LifeAfterDx--Diabetes Uncensored

A internet journal from one of the first T1 Diabetics to use continuous glucose monitoring. Copyright 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014, 2015, 2016

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Location: New Mexico, United States

Hi! I’m William “Lee” Dubois (called either Wil or Lee, depending what part of the internet you’re on). I’m a diabetes columnist and the author of four books about diabetes that have collectively won 16 national and international book awards. (Hey, if you can’t brag about yourself on your own blog, where can you??) I have the great good fortune to pen the edgy Dear Abby-style advice column every Saturday at Diabetes Mine; write the Diabetes Simplified column for dLife; and am one of the ShareCare diabetes experts. My work also appears in Diabetic Living and Diabetes Self-Management magazines. In addition to writing, I’ve spent the last half-dozen years running the diabetes education program for a rural non-profit clinic in the mountains of New Mexico. Don’t worry, I’ll get some rest after the cure. LifeAfterDx is my personal home base, where I get to say what and how I feel about diabetes and… you know… life, free from the red pens of editors (all of whom I adore, of course!).

Sunday, November 25, 2007

Life, the Universe, and Everything….

…is too damn much sometimes.

So I’m still overworked. And depressed. And Thanksgiving, as expected, totally wrecked my BG control.

I’ve had good luck selling everything I own on eBay to buy drugs; sadly, not the recreational kind. But, boy, it’s a lot of work. Shooting pictures, writing descriptions (which I find to be a lot like blogging, actually), and answering the swarm of questions that come in on each one. How much to ship to Paraguay? To France? To China? To (fill in the blank). Is it really black? How many inches wide is it? Will you take half of the minimum bid and give me free shipping? No. Go to....

I’m exhausted. Totally. But I also know this pre-Christmas season is the best time to sell. So I gotta do it.

Finial decision: I’m going to take a break from blogging. Not a vacation. More of a sabbatical. And just for a little while. I’ll still post as things come up I need to share; but not everyday. Not for a while.

Love you all, see you again before too much time passes.

Friday, November 16, 2007

A telegram from the trenches



See you all next week.

Thursday, November 15, 2007

They came, they saw, they conquered

Young and old. Men, women, children. The D-Folk and their loved ones.

They came.

As a group we set out, the pace matched to the slowest of our number. Some with canes. Some with walkers. One in a wheel chair and one in a stroller.

We walked. The strong supporting the weak.

It was a beautiful day for a walk. Especially this walk.

I had a happy D-day. I hope you did too.

Wednesday, November 14, 2007

Happy WD-Day

I guess this is our First Birthday as a world power! Happy World Diabetes Day everyone. What? You have nothing to be happy about? Hmmmm… look deep inside, this curse gives all of us a silver lining. If you haven’t found it yet, look harder.

Meantime, I’m off to our “celebration” at the local National Park. The team and I put together a nice little event. Not exactly lighting the Eiffel Tower with blue lights, but my budget is pretty limited.

We’re going to have a group health walk around the grounds. We’ve got some give-always. We met with the owners of all the local restaurants, reviewed their menus and picked D-friendly foods and got ‘em to donate samples.

I have no idea what kind of turn out we’ll have. I’m hoping for 200. I fear we’ll have two. I’ll let you know.

Now, go out to your local event. Show the power of our voice.

Tuesday, November 13, 2007

A1C road show

Stethoscope. Check.

Blood pressure cuff. Check.

Glucometer. Check.

Test strips. Check.

Disposable finger lancing devices. Check.

Looks like we are ready for a round of home visits. It is a beautiful autumn day. Not hot. Not cold. A taste of impending dry winter is on the breeze as we load up my assistant’s metallic-coffee colored Jeep Wrangler Safari Edition. Such a nice day for a road trip. What’d ya say we skip the home visits and go to Starbucks in Santa Fe? I get a very serious scowl in return. Sigh.

What are we forgetting?

Oh yes. I forgot the A1C machine.

What? You ask.

I pop back into the office and crawl under J’s desk to unplug it. Yep. Our brand-new DCA 2000+ is going on it’s first road trip. The machine is a hair smaller than an traveling typewriter (for those of you under the age of 30 a typewriter is a manual word-processing device that we all used before computers; back when we rubbed two sticks together to made fire to cook spaghetti) and half as heavy. In short: imminently portable.

I tuck the machine under my arm and head to the jeep. Let’s go.

We arrive at our first stop, a licensed day care center. The woman who operates it works longer hours than we do, so it is impossible for her to come to the clinic. Parents drop their kiddos off pre-dawn on the way to work and pick them up after dark on their way home. In such cases, we bring the clinic to the patient. The kids run to great us, “The doctors are here, the doctors are here!”

After getting the mandatory hugs, listen to my hearts, and do I have a fever todays out of the way, we can finally attend to our real patient. I plug the machine into an outlet under her kitchen window and set it on a chair. It flashes the software version on the screen and starts making all its little warm-up noises.

I check our lady’s blood pressure and begin to review her BGL log. I’ve also brought along a Levemir flex pen sample and a script; I might or might not add a new layer of therapy today. Depends on the A1C and sugar log, and of course, the patient’s level of compliance with the original plan.

She starts off with a “confession.” She hasn’t been remembering to check her blood sugar very often. Oh, yes, and about half the time she forgets to take her pills. She’s just soooooooo busy. In three weeks I have seven blood sugar checks. Growl.

OK, here’s the deal. I know you are busy. But how much time does it take to take a pill? What, maybe 15 seconds? And I want you to take two blood sugars tests per day. Now how long does that take? What, maybe 20 seconds? So I’m only asking for ONE MINUTE of your time out of each day to take care of your diabetes. How many minutes are there in a day, anyway? About 1400? I’m not asking for much here.

With a beep the A1C machine tells me she’s ready to go to work. I open the foil package that holds a test kit. Then I open the wrapper to a cartridge. I twist the baby-blue top off of a Johnson & Johnson lancet and hold it lightly to her fingertip. Even the “soft touch” disposable one-shot lancing devices can be pretty aggressive. My favorite two fingers are becoming callused from all the demo blood testing I do at the clinic. If you hold too tightly you’ll hurt the patient; too lose you don’t get blood. Older people have softer skin, but reduced capillary response. Manual laborers have thicker skin. Children have sensitive little fingers and bleed easily. You need to personalize your touch. Her hands are dry and smell like Dawn soap. Did you just do dishes? I snap the trigger. She doesn’t flinch. I put gentle pressure on her finger and a bright-red drop of blood wells up. I touch the capillary tube on the cartridge to the blood drop. In a flash it fills. I wipe the edge of the tube and hold it up for her to see.

Five million of your red blood cells, I tell her. Then I snap the cartridge into the test kit, swipe the kit down the reader track so the machine can read the bar code, and with a thunkkkk lock the kit into the testing well. I pull the silver foil tab to start the test and close the test well door.

The machine starts making happy little coffee-grinder noises. We’ll have our results in six minutes. In her kitchen. This is sooooooooo cool!

On our way out after we were done, I see a huge flat screen TV along the wall. It stops me in my tracks. The picture quality is amazing. Was that here before? She blushes, “no my husband got it. I hate BestBuy!” Huh. It’s beautiful, I allow. “Well, the kids like it,” she mutters.

And A1C machine cradled gently in both arms, I head down her stone steps to the jeep. We’ve got more people to see today. Accurate, on site A1C testing. It doesn’t get any better than this.

Monday, November 12, 2007

Is there a doctor in the house?

So as a kid I was called Willy, which I hated. As a young man I was Wil, with one “L,” just to be different. When I came to New Mexico, the place I worked at already had a Bill. My boss felt it would confuse people to have a Wil and a Bill and asked me to use my middle name. My middle name is my Father’s name. It seemed waaaaaay to weird to use it myself. “So pick a name,” I was instructed. How about Liam? (The Irish diminutive of William). “Never heard it. We’ll just call you Lee.” And so it was.

So my family calls me Wil. My wife Lee. And when I worked at the hospital my name tag said William and everyone shortened it to Bill with out asking me. Bill is my cousin. I got introduced at the clinic as Lee, so that’s what I’m called there.

In short, I don’t know what the hell my name is, and people shouting any of my names as I cross a parking lot are likely to get no response out of me. Probably how that rumor I’m deaf got started.

At the clinic we have these cute little appointment cards, that have a small sticker that can be pealed off an put on your calendar that says you have an appointment with Dr.________ on such a such a date and such and such a time. The front desk fills these out for my patients. So you have an appointment with Dr. Lee on such a such a date and such and such a time.

When I was first at the clinic I was always careful when meeting people to emphasize that I’m not a doctor, nor a nurse, but just one of them with knowledge and experience to share. I think I’m formally classified as a Health Educator. My business card says “Diabetes Coordinator” and my name badge says “Diabetic Educator.”

After I’d been there a couple of months the front desk girl gave me a heads-up that patients were calling and asking for appointments with Dr. Lee. She thought it was a riot. I groaned, resolved to stamp this out, and worried about how my boss, a real doctor, would react to all of this.

It took me a while to realize that the appointment cards were the cause of a lot of the trouble. I also knew that a middle-aged white guy who wears a stethoscope and works at a community health center that serves a minority population was bound to be mistaken for a doctor. (That actually happened a number of times before I worked in Health Care….I must have a doctor-like look. The clerk at my wife’s favorite shoe store once asked me a medical question. I have no idea. “Aren’t you a Doctor?” No, I run a photo lab. “Oh… (greatly disappointed), I thought you were a Doctor...”

So much for my macho globe-trotting photojournalist self image.

But back to our regularly scheduled story….

One day Juanita (nothing like her real name), one of my senior citizen patients, came for an appointment and brought along her five-year-old grandson. She introduced him, “I’d like you to meet Dr. Lee.” The boy peaked out from behind her legs, “Hello, Dr. Lee.”

Crap! Ok so here’s the problem. I work in a Hispanic society, so there are certain rules ya need to follow, even as an assimilated outsider. Manners and respect to elders are a really big deal here. I chose not to correct her because I didn’t want her to look foolish in front of her grandson. I bit my tongue, crossed the Rubicon and let it go. I extended my hand to the boy and said simply, you can call me Lee.

I’ve stuck with that line ever since, with considerable guilt and overall lack of comfort.

Since that time, even patients that know perfectly well that I’m not a doctor have started calling me Dr. Lee. Some to tease me. Some out of respect. Some just ‘cause everyone else is doing it. Yikes. What a mess. One time recently I tried to correct a woman who should have known better. I’m not a doctor, you know. “Oh well, you know so much you ought to be. They should just make you one.” Ummmm…. I pretty sure that it’s one of those things you have to work hard at for a long time. No field commissions in the medical ranks.

I’m thinking I should get an on-line PhD in underwater basket weaving just so I don’t feel like some sort of…. counterfeit? …charlatan? …Imposter. That’s the word. I feel like an imposter. The Unintentional Imposter, good title for my autobiography.

So last week I was meeting with a new Dx. He’d gotten very sick and had gone to ER where they found his blood sugar was like 800 or some such. They kept him for a day or two and sent him home with vials of insulin and scanty instructions.

Hi, I’m Lee. I understand you’ve had a crappy week. I want you to know it’s all uphill from here on out. Soon you’re going to be feeling so much better you won’t be able to believe it. You can live with this, and it really isn’t that hard.

“Everyone in town has been telling me I should come see Dr. Lee for my diabetes,” he told me, “but I was expecting an Oriental Gentleman.”

Friday, November 09, 2007

A mission for the tribe (the D-tribe that is)

I was trying to get my tie on right. First the front was too long, falling well over my belt. Then the back was too long, dangling down, showing behind the wider front. Now the knot is too large. Now too tight to slide up under my collar.

As you can see, I don’t wear a tie very often.

I have a flash back to junior high school, when I stood in front of my mirror with my old Cub Scout manual on my dresser. I had been invited to a De Molay meeting (a youth auxiliary of the Masons). My father had been a member, so it was a honor of sorts. Grandpa was a 33rd Degree Mason. I never stuck with it, but I do remember trying to get the tie on right. When I eventually got there one of my friends told me, “Thank God for my Cub Scout manual, I’d never figured out this tie…”

I don’t have my Cub Scout manual anymore, but I do know the theory by heart. It’s just putting into practice that’s the problem.

At work, my boss requires us to “dress down.” Jeans and casual shirts are the rule every day of the week. It is a poor area, he doesn’t want to risk creating a class barrier by how we dress. I’ve noticed, however, that many of our patients do put on their “Sunday best” to come to the clinic. They must think we are a bunch of slobs.

But when I’m out in the rest of the world representing the clinic I always wear at least a sport coat, and often a tie. I figure if you are at the capital they really don’t know what’s happening out in the rest of the state.

On this day I carried my title from the clinic, but I was actually representing all of us. Let me tell you the story. Here in New Mexico, like more than half the states in the union, diabetic children are NOT allowed to carry their own testing supplies or insulin. They are kept locked up with the school nurse.

OK, so you feel a hypo coming on. Now you need to walk to the school nurse’s office. Seriously. And it gets worse. I know of at least one case of a remarkable teenage T-1 girl. She was Dxed at age five. Her mother tells me she’s never given an insulin shot to her daughter. The kid insisted on doing it herself from day one. Then, years later, comes high school. Where the powers that be take this perfectly self-managed child and set her years back by forcing her to get her shots and tests from the school nurse.

Now let me tell you some things about school nurses. Over worked. Under paid. Under staffed. Not, generally, experts in diabetes care. They are the first group who will be inundated by the rising tidal wave of diabetes.

Many of them, I’m sure, are wonderful people. I just haven’t met any who are yet. Their national organization is even worse. I can prove it.

An enlightened medical doctor in our state Department of Health, having become aware of the situation, decided that youth in our state need the protection of law to ensure they may test and self medicate, assuming they are sufficiently mature and capable of it. And if they are not, she wanted to create some sort of universal training for adult volunteers who could help out in the classroom: parents, foster grandparents, teacher aids, even the teachers themselves. Seems like a simple, good idea that benefits everyone, right? Wrong.

The school nurses fought this tooth and nail. It became an ugly, down in the mud fight. Does that surprise you? At first it did me, until the agenda of the school nurses became clear. They want a school nurse in every school. Who doesn’t? It’d be great if we could have a doctor in every school too. But the fact is, we don’t have enough teachers, books, or supplies, much less the money for more school nurses. But the school nurses see diabetes as a way to force in increase in their numbers.

They are bank robbers holding a pistol to the heads of our hostage children.

I was a charter member of the task force that tried to work out some sort of reasonable compromise between the competing interests. The ADA even got involved, their lobbyist told me she wasn’t afraid of the nurses, “I’ll fill a room with crying mother’s and they’ll look like monsters.” It got so nasty I dropped out. Yeah, chicken shit of me, but I didn’t have the energy. That was at the first of the year.

But then last week I got a personal call from the Doc who started it all. There was a public hearing on the law. Would I come speak? Of course. I had my assistant call and cancel and reschedule all of my patients for the given day. That night I got an email from the ADA, please come. Wear red to show your support.

Red? I thought we’d all agreed on UN Blue as our international color. What the hell, I got out a red shirt. It looked pretty good with the only sport coat I own that still fits, a rust colored micro-suede. Dark grey Dockers completed the ensemble. I really need another sport coat. By now everybody in the state who does anything in diabetes has seen me 20 times in this coat. Maybe I can find something on EBay……

Once I got the damn tie right I grabbed my traveling stainless steel coffee mug of home-brewed Starbucks and set off for the hour-and-a-half drive to the state capitol in Santa Fe. It is an insanely beautiful drive.

The hearing was lightly attended. I recognized many of the faces in the crowd, people who should be our friends, but were our enemies: the school nurses.

I sat in the back and bided my time. I listened to two parents, one grand parent, and the remarkable teenage girl I mentioned earlier testify. That was the extent of our voice. It didn’t look good for the home team.

Then the nurses started. To their credit, most of them supported the law—with some changes. Standing clearly, and loudly in total opposition was the state head of the school nurses organization and one other. The rest, I think, could sense how bad they could look had the absent press showed up. They circled their wagons around three issues: insulin administration and “assessment.” They also were against the non-licensed volunteers. They, to their credit, actually supported the part about letting kids test in classrooms.

Assessment is an important concept for nurses. It is a key nursing skill that takes time, education, and practice to develop, and according to our state’s nursing practice act can not be delegated. So far, I can go along with that. Also, we need to bear in mind that if a nurse delegates something to someone else and there is trouble, it’s her (or his) license on the line. They really tried to play up how complicated and dangerous administrating insulin was. Hmmmm…..

All of that said, I don’t think there is any assessment needed to administer insulin. What’s the current BGL? How many carbs? When was insulin last given? Was the child more or less active today than usual? These things don’t need to be assessed. These things are facts. Once any even moderately trained person has these facts, they can look at a plan drawn up by the health care provider that will instruct how much insulin to give. By the way, the proposed law states the parent has “veto” power over the selection of volunteers that are tasked to work with their T-Kiddo.

I waited until the very last to speak, seeing which way the wind was blowing, taking mental notes. When at last, the hearing officer asked, “Is there anyone else who would like to comment?” I rose and approached the microphone.

I introduced my self by name, title, and clinic. Then I told the hearing officer that I was also a Type-1 diabetic. “So today I speak with two voices,” I said, “both as a health care professional, and as a person with diabetes.”

I don’t recall everything I said, but I pointed out that my clinic served the population of 1,000 square miles with a small staff and that I could assure him that we had no shortage of diabetics. I told him I used trained volunteers in virtually every capacity with excellent results and that I felt the state would find persons with diabetes a willing, knowledgeable, and eager-to-contribute work force.

I told him that if we made some one who was experiencing a hypo walk somewhere else to be tested we’d be up to our asses in malpractice law suits, and deservingly so.

I told him that taking away control from the patient, at any age, was making my job harder. I told him that diabetes is a unique chronic illness where the ultimate outcome is in the patient’s hands. I told him that it was my job to teach those self management skills, and that anything that short circuited that process was a crime in my book.

I told him that well managed, there was no reason a diabetic can’t live to be 100 years old with great-grand children romping at their feet. But that poorly managed it will kill you most terribly. Then I told him my tiger analogy.

“The best way to think about diabetes if you don’t have it, is to compare it to a tiger,” I said. “You can live with a tiger in your house if you feed it, and groom it, and never turn your back on it. No problem, it can be your pet. But if you neglect it, and turn your back on it, it will pounce on you and rip you to shreds.”

I said that I respectfully disagreed with the nurses. Giving an insulin shot wasn’t rocket science. In fact, the vast majority of people who give or take insulin shots every day are not licensed medical professionals.

And then I was done and the hearing was over. I guess I did well. All the mothers came and hugged me. The teenage girl flashed me a “thumbs up” (thanks, kinswoman), and various doctors and non-school nurses shook my hand.

Then, my duty to our tribe discharged, I took off my tie and I went to Trader Joe’s for macadamia nuts.

Thursday, November 08, 2007

Fiddlesticks, a morning of many fingersticks

I put the last sensor in the box into my leg this morning. It went in with no trouble. No pain. No blood. A pleasant change from recent experiences.

Ten minutes later I get a sensor error. Then a second. Then it shut down.


I carefully pealed off the IV 3000 dressing, unplugged the transmitter, and plugged it back in.

Of course I already have the next box of sensors. I keep one box ahead. MedT’s recent supply problems make life terrifying for the sensor dependent like myself. Back orders on sensors are running upwards of three weeks for current users and 6 to 8 weeks for new starts.

I guessing MedT is having some issues up-scaling their production. But, so far, I’ve only had one batch that didn’t run as well as I expect. I’m hoping that MedT doesn’t become the victim of their own success. I got to visit the original manufacturing site quite a while back. At that time the damn things were pretty much made by hand one at a time. It gave me new respect for the then $45 each price tag. Automating that process, I sure, has turned out to be a huge challenge.

After I re-plugged in the transmitter, I kept an eye on the ISIG, which you find in the Sensor Status menu. The ISIG is the raw signal coming off of the sensor. Mainly the NoHelp Line uses it, the manual doesn’t shed much light on it, but I can tell you a few useful things that I’ve learned about it over the years.

The system takes the raw signal and, using the magic of math, compares it to your calibration sticks, applies a bunch of fancy priority algorithms, and translates it to a SG number that you and I can understand. I can’t remember the exact number (should have written it down) but I think if you multiply the ISIG by 8 you get the approximant blood sugar. But don’t bother. There are a number of reasons this doesn’t always work.

When you first plug in a sensor, during the warm up period while it is settling in, you’ll see 250+ ISIG numbers. Of course your blood sugar isn’t really 2,000 BGL. That would be fatal either from the sugar or the heart attack you’d have when you were told that’s what your sugar is. By the time she’s ready to go the ISIG is commonly in the 15-25 range.

All you really need to know is that if the ISIG is in that range you’ve got a pretty good sensor set. In time the signal will degrade. The human body is an extraordinary hostile environment for foreign objects like sensors. I find that the monitor can compensate for ISIGs down to 8 or 9. After that, you’re gonna get a CAL ERROR. The signal has gotten so weak that the system can’t reconcile the data being transmitted with the blood glucose number you are trying to feed it. At that point it is end of the road for the particular sensor.

If a new sensor is running below 10 ISIG, you’ve got a bad set. Maybe it got bent going in. Maybe it got hit by cosmic rays. Maybe….

Guardian sensors are FDA approved for three day wear. Many users wear them for longer periods. I won’t say what I do. You gotta find your own way. I know of many people who wear the sensors 6 days to a week. I heard of a guy who wore one fourteen days. I don’t think I’d want something “in” me for that long. Infection risk goes up with each day. I’d also think that in most folks the signal strength would be pretty weak by then. Oh well, your mileage may vary.

I kept an eye on the ISIG. It was running 55.75 Then it dropped to 4.32 Then jumped to 42.88, then back down to 5.33. This is very strange. It should start high and gently settle down. Something is wrong with this sensor. Meanwhile, in the ocean with out my life jacket, I’m doing fingersticks every 15 minutes during this prolonged period of no CGM coverage.

No CGM. Worse than leaving the house without your cell phone. I feel totally naked. And not like the having fun kind of totally naked. More like those nightmares well all had in third grade, you’re giving a book report in front of the entire class, when all the sudden you realize you forgot to put clothes on before you came to school. Then you wake up in a cold sweat. So hence forth we could say cold-sweat naked and you’d know we were not talking about the good kind of naked.

I fought with cal errors, sensor errors, and shifting sands on when I’d be allowed to actually try and get the first cal stick in for eight hours. It was clear this sensor was not going to work.

Damn! May the fleas of a thousand camels infest the arm pits of the person responsible for this piece of crap! No, wait a sec. Might be my fault. Best to be careful with your curses. A highly placed researcher once told me that ALL sensors functioned perfectly in the lab. It was just in that annoying human body that they had trouble. He seemed insulted that his perfect sensors had to go into us. Hmmmmm….I’m thinking he’s missing the point on the purpose of his creation…Well, brilliant folks don’t usually have both feet on the ground, after all.

With extreme disgust and a sense of longing for the twenty-dollar bill the sensor set me back, I peeled the tape off and pulled the sensor out of my leg. Ahhhh…the things I could have done with that twenty. I could have taken the family out for a simple meal. I could have bought a pipe on EBay, or a couple pairs of interesting ear rings. Or ten cups of Starbucks coffee. A small drop of blackish-red blood oozed out of the hole. The sensor wasn’t bent or kinked in anyway. I stared at it’s dull gold glow, but nothing seemed out of the ordinary.

Well, in the greater scheme of things, there are more important things to worry about. I put in a second sensor. And got a sensor error. After taking five blood pressure pills I went on with my day.

The senor ran “hot” during it’s entire warm up period. When it signaled it’s willingness to be calibrated it was above 35. Very strange. Right after calibrating the SG curve shot up, gave me a high alarm, and kept climbing. That’s odd. I haven’t eaten much….

Fingerstick. Wasting a lot of strips today for a guy with CGM. Guardian has me at 245. I’m at 150. The ISIG is still raging like a bonfire. I’ve never had this happen to me before. I consider feeding the unit a few more fingersticks to reign it in, but the worst thing you can do is over-calibrate, and the stupid machine still thinks I’m on a rise. If I give it sticks while it’s in “motion” I’m asking for trouble. I need to be stable, it needs to be stable. That gives time for all the math to happen. Having just pissed away twenty bucks, I’m not to keen on double or nothing. I decide to keep pissing away test strips instead, hoping the site will settle down.

First days are often the worst when it comes to sensor performance. The key is not to stress out in the first day. I think several things happen after the first day. After the first day the sensor has a greater “bank” of calibrations to really on, and I think your body settles down around the sensor in a good way. After all, you’ve torn thousands of cells asunder putting that monster needle in.

At bed time I needed to give it a fingerstick, as I didn’t want her waking me up at 3a.m. My BG was fine, but she didn’t think so. The two numbers were over 150 points apart. I knew what was going to happen next.

Sure enough. CAL ERROR. I trudged, dejected into the library, where Deb has discovered the internet (you know what I mean). This isn’t going well babe.

“Hmmmmmmmmmm?” distracted, looking for the near impossible to find CD musical sound track of Rome Adventure, apparently only released in Japan a few years ago. She’s not looking for a DVD of the movie, but just a CD of the music from it. If you know where to get one, let me know.

I tell her I’m anticipating another CAL ERROR. I had a light dinner, no desert. My BG is stable and there is little or no Humalog fast-acting insulin “on board” (meaning in my blood stream). There is a forest service sign near the clinic. Smokey Bear holds a sign, Fire Danger Today: X. And every morning some poor ranger has to change the sign. The fire danger varies from Low to Medium to High to Extremely High. Hypo Danger Tonight: Low. Thanks Smokey.

If the thing craps out on me, I’m going to turn off the monitor but leave the sensor and transmitter in place over night. Maybe it will settle down and work right tomorrow.

She doesn’t hear me. The magnetic field from the computer no doubt interfering with her hearing.

I feed the fingerstick to the Guardian and tuck my feet under the three blankets I have on my bed to fend off the night cold (hey, it’s a desert, but we are right at a mile above sea level in my living room). I get my head adjusted right with two pillows so I can read for the fifteen minutes it will take to either calibrate or fail. I pick up the Flinders Petrie bio and take up where I left off. The year is 1890 and Flinders and I have just returned from a miserable season in Palestine and we are sure glad to be back in Egypt where the workers aren’t so lazy and we are more accustomed to the culture. I really do get into a good book!

Absorbed by the artifacts we are digging up, time slips past me and after a half an hour my eyelids are drooping. I gotta start getting more than six hours of sleep each night!

But there has been no calibration error. I put the book on top of the three-foot stack of books by my bed side, set my glasses on top, and turn off the light.

The dawn is cold. It is 66 degrees in my bed room, according to my HoMedics indoor/outdoor thermometer, alarm clock, and white noise machine. I do my dawn fingerstick. Within ten points of Guardian. Now that’s more like it. I check the ISIG and find it still running hot and high at 36.68, very strange.

But the algorithms are in harmony once again and Guardian is giving me an accurate picture of the dance between my defective endocrine system and my blood sugar. Today far fewer tests tips will be sacrificed on diabetes’ altar.

Wednesday, November 07, 2007

The family tree

So I was reading that scientists have unraveled the cat genome. This matters not so much for pet cloning, which is inevitable, but because cats can have over 250 disorders which are “similar to genetic pathologies in humans,” according to the findings published in the journal Genome Research.

Among other things, cats can get a version of AIDS, eye diseases, and of course, diabetes. Unraveling the genes is the first step to new medicines for cats and their not-to-distant cousins: us.

So good for us and good for the estimated 90 million house cats in the United States.

Now, one hundred million years ago we and cats and dogs and monkeys and presumably whales, all had a common ancestor. I’ve been spending a lot of time studying a cat at close range these last few months; and I’ve come to the conclusion that we humans are more similar to dogs than cats. In lots of ways, but especially in eating habits.

If you turn the average dog lose in a dog food factory over night you will find it dead in the morning. Dogs will eat until they are out of food or until they explode. Just like most humans. Cats, on the other hand, just eat what they need. You can leave a huge bowl of cat food out and the cat will graze as needed.


How do we become more like the cat branch of the family?

Tuesday, November 06, 2007

A solution that was too expensive

So I got this guy who is the poster boy for Brittle Diabetics. Ok, ok, ok, ok. I know. I know. Now-a-days there isn’t supposed to be any such thing as brittle diabetics. But like the Loch Ness Monster, Big Foot, and little grey aliens—if you see one in the flesh it really doesn’t matter whether they are supposed to exist or not, right?

For those of you who just arrived at the party, “brittle” was a term used long ago to classify someone who’s BGL is nearly impossible to control. Weird spikes with no cause. Unexplained crashes. Wild swings that make no sense.

In reality everything under the sun has an explanation. It may just to too obtuse to be obvious. Mercury is in retrograde, the moon is in Leo, the wind is from the east and the barometric pressure is rising so the poor guy has a hypo.

Hey, the human body is a complex environment and our best tools and medicines are stone knives and bear skins compared to the elegant complexity of a properly functioning endocrine system!

I’m somewhat brittle myself. I think, in reality, I’m just hyper-sensitive. Especially to anything with even a decent amount of carbs. I can just walk past The Old Spaghetti Factory restaurant in Denver and my BGL will spike. Probably the carb molecules in those wonderful smells wafting through the air…..

But back to the Poster Boy. His sister brought him to us a year or so ago after he survived a hypo-induced car crash. At that time he was on old-school mix insulin which was very poorly suited to his life style. Also, he was under huge stress, his wife of 25 years having left him for her boyfriend. An extraordinarily vicious divorce was underway.

To make a long story short (did I hear a collective snort from the blogosphere?), I have tried virtually every combination of diabetes drugs under the sun on this guy. We finally ended up at a modified Multiple Daily Injection plan. We had tried garden variety MDI with poor results. Side note: I’ve had good results putting T-2s on MDI, a treatment that historically is only used for T1s. Further proof that 1 or 2, we are all really the same tribe. He’s just not cut out for carb counting, and he’s very insulin sensitive. I had thrown in the towel on proactive use of fast-acting. I had him taking basal, trying to eat reduced carb and then correcting any screw ups with sliding scale. I wasn’t really happy with either the approach or the results. His morning fasting numbers might look like this:






…and so on. The only pattern being there was no pattern. I wasn’t very happy. Did I also mention that he commutes about 80 miles to come see us? And that his boss is a total ass hole who gives him a ton of grief about taking any time off for medical appointments?

Anyway, recently, after studying his latest BLG download in Co-Pilot, and after consulting my Ouija Board, and after praying for divine inspiration, I finally decided that the key to our trouble was the postprandials (after meal BGL readings and surges). I convinced myself that if we could fix the postprandials we could tinker with the basal insulin and everything would work out. Turns out I was right. But it did me no good, as you will soon see.

Oh yeah. Did I mention he’s also nearly stone-deaf? Our appointments are full of shouting, wild gestures and lots of scribbled notes. I find shouting into his left ear works best for me. His sister shouts into his right. Really, one of his appointments looks like a scene right out of a sit-com. Being a traditional polite Hispanic, he always nods, smiles, and pretends to hear me. I now make him repeat to me any critical instructions.

So about four weeks ago I’m sitting at my desk fiddling with my pen, desperately trying to come up with a solution when I remember we’ve just received Januvia samples. I’m pretty sure we are the last clinic in the world to get samples. No, wait, I think there is a one-man clinic in southeastern Paraguay that doesn’t have it yet. I’m pretty sure Kakistan is totally stocked.

Januvia is a somewhat new Merck diabetes drug. It belongs to the broad category of incretin drugs, the latest frontier of diabetes treatment. Merck reps caused quite a stir when it was first released by telling Docs that Januvia was “oral Byetta.” Which is not true at all. Byetta and Januvia both come at the same general problem, but from opposite sides.

OK, time for Incretin 101, the latest online diabetes treatment course from your hosts at LifeAfterDx (It’s high end reality internet!). In a nut shell, with T-2s, insulin resistance isn’t the only thing going on. Two incretins (hormones), GLP-1 and GIP are the air-traffic controllers of the pancreas. They help with insulin release and action. They also hold the liver in check so it’s not adding sugar to the problem. The Gs also play a role in hunger signals and digestion speed. Anyway, there is nothing wrong with GLP-1 and GIP in Type-2s. The problem comes in from a nasty little critter called DPP-4. It’s job is to mop up the Gs when they’ve done their job. Problem is, DPP-4 jumps the gun in most T-2s.

So there is a complex dance between GLP-1/GIP and DPP-4 that just begs for intervention. The choices boil down to adding more GLP-1 or slowing down the DPP-4. Either approach should work.

Byetta (the lizard spit drug!) was the first incretin drug to hit the market, and it took the supplement approach. It is correctly called an incretin mimetic. What that means is that it is an artificial incretin, much like analog insulins are modified versions of real insulin. Byetta is, in essence, supplemental GLP-1. It is a runaway “best seller,” and for good reason. Byetta is an amazing drug, one of the most effective diabetes meds for T-2s I’ve ever seen. The problem is, it is hard to get insurance companies to pay for it; and for some reason insurers view it as a drug of last resort rather than the first line defense it ought to be. Byetta actually restores first-phase insulin response. If you put all pre-diabetics on Byetta, full-fledged Type-2 diabetes would virtually vanish. As that makes a lot of sense, it will never happen.

Januvia takes the opposite approach, to “inhibit” the DPP-4 (we’re really gonna need better names for these incretins). Even Merck’s own studies don’t exactly blow the doors off of the competition, showing less than a 1% A1C drop. The Byetta crowd has really tried to trash Januvia, but a couple of folks in the biz that I have high respect for have reported good results to me, so I was open minded. I want every tool I can get my paws on.

In summary, both drugs focus on postprandial blood sugar. And everyone agrees that the T-2s can benefit from more GLP-1 after a meal. Byetta gives extra. Januiva inhibits the DDP-4 so that the native GLP-1 can do its job. Byetta is injectable. Januiva is a pill. Byetta has the delightful side effect that most patients lose a ton of weight. Januiva is weight neutral, meaning that most people neither gain nor lose. Just so you know, most folks put on weight when put on insulin. Some debate about whether or not this is caused by the medication or the fact the people feel freed up to eat what ever the hell they want to eat….

So desperate for a solution, and having nothing to lose, I gave my guy two weeks of Januvia samples and told him to only use the Novolog if he topped 300, which I fully expected him to do.

In two weeks he had not touched his Novolog. His sugars were actually stable. We needed to make a small adjustment to his basal, but he was in near perfect control.

I was impressed.

And pleased.

So we sent him on his way with a script and I closed the mental door on a difficult chapter. Now I didn’t need to worry about this guy any more.

Until the phone rang.

It was my patient’s sister. The patient had gone to his pharmacy. The co-pay for Januvia on his Blue Cross was $96 per month. She said he couldn’t afford it.


I went to our pharmacy guy to see what the wholesale cost of the drug was. Now we need to take another detour here. There is no one single wholesale price for any drug. The wholesale price depends who you are, and how much you buy, and whether or not you paid for hookers for the drug company executives. Unfortunately, we didn’t get our grant funds for hookers this year, so….

We have a unique pharmacy at my clinic. We don’t take insurance, it’s all cash-pay. But, as we are a federally funded non-profit (more accurately federally partly-funded) we get our meds at one of the federal rates. We are required to add an administrative handling fee, but do not make a profit of any sort on the drugs. Consequently we can sell some drugs to patients very cheaply, especially generics, and others… well….

And Januiva? The pharmacy guy reports that it starts at $400 for a month’s supply of the lowest dose, and goes up from there.

So my guy is screwed. If he were a welfare bum I could get him free drugs through patient assistance programs (PAP). If he were a rich oil executive he could afford it, or more likely he’d have a better Blue Cross policy that would have him only paying $15 for the med.

But he’s working class, and there is not a worse class to be in when it comes to your health care. So back to the drawing board. We’ll have to take him off the only medication that has worked so far.

So like Moses and Martin Luther King, Jr.; my patient got to see the promised land, but won’t get to go there.


Monday, November 05, 2007

Once a year….

That loud THUMP was me falling off the blood sugar control wagon. On the bright side, the vampire bat that bit me Halloween night went into an immediate comma and died from the high level of glucose he sucked out of my neck.

All week long I had been brave. My boss put out a candy bowl about the size of a hot tub, full of Hershey bars, Crunch bars, Snickers, Ressese Peanut Butter cups, Kit Kats, Three Musketeers and a couple of others. The bowl was a symphony of color.

As the week drug on it became increasingly monochrome. By Halloween day it was brown and blue. Only the Hershey bars and the Crunch bars remained, apparently the least favored among our crew. It didn’t surprise me that the Heresy bars were left (borrrrring), but crunch bars? Come on!

I happen to love them…

They are really small.

How much harm could it do?

Bad error of judgment on my part. Once the gates were open the carb barbarians plundered the city. My sugar went through the roof and my judgment went through the floor.

I left work early on Halloween to take in the costume parade at Rio’s kindergarten. Sooooooo cute! 128 five-year-olds in costume! Fun, fun, fun. Rio was a bat. His mother made him a clever top with wings he could flap by flapping his arms.

Then it was time for trick-or-treating.

Locally, families take young kids to pillage the business district. Although the local businessmen and women take it in stride, I’ve always felt it was wrong to take advantage of businesses you don’t patronize. Most of those people only set foot in these establishments once per year, and that’s just to get free stuff for their kids, then it’s off to Wal-mart to spend their pay checks.

We vowed to only take Rio to businesses we did business with, plus his various Tias (Spanish for Aunties) and of course his Nana.

I can’t fucking believe that sooooooo much candy came from so few places. By my best estimate Rio took home eight-hundred-thousand-four-hundred-twenty-seven carbs of candy from a mere 12 locations. The problem with patronizing places you patronize is that they are generous in return. And for a family brimming with T-2s, Rio’s Tias bought him an insane amount of goodies. Oh yeah, and he brought home several bags from the school to… eye-yi-yi….

To her credit, his Nana (Deb’s Mom), came up with the most sensible collection including raisins and granola bars. One of his Tias gave him bags of nacho cheese Doritos because she didn’t want him having too many sweets. I bit my tongue.

To his credit, Rio doesn’t have much of a sweet tooth; but this was about accumulating wealth. He was after a high body count. The winner is the one with the most tonnage.

He was the winner.

I was the looser.

Yeah, right good plan. Let’s take the heroin addict and lock him in a room full of bags, and bags, and bags, and bags of heroin. Does heroin actually come in bags?

Of course once my blood sugar went up, my hunger went up with it. The more I ate the higher I went. The higher I went, the more I needed. The vicious cycle had begun. The insulin shots became a blur of injection after injection and the roller coaster ride began.

Once the flood gates were open, it didn’t stop with the candy. I was into the pound cake I had watched my T-3s eat with no temptation just days before. But it didn’t stop there.

I put vanilla ice cream on the pound cake.

And chocolate sauce.

And whipped cream.

And walnuts.

Where the hell are the maraschino cherries?

I didn’t die in the night, but I’m sure I was flooded with ketones.

The next day I was into the pasta.

On the third day I finally got a hold of myself while surfing EBay. Huh. I wonder what the link between high blood sugar and addiction is? Excuse me while I delete all of these snipes at eSnipe.

Ok, now I’m back. But even after I stopped eating, it took days for the sugar to get out of my blood stream. Like fallout from a nuclear detonation, the residual radiation of the sugar binge stuck with me. My body strived for homoeostasis at a blood sugar level of 225.

I felt like crap. Oh well it’s only once per year.

But then there is Thanksgiving.

Followed by Christmas.

Followed by Valentines Day.

Followed by Easter….

Followed by…..

Friday, November 02, 2007

An assortment of temptations

My visitor breezed in on high heals; quite rare in rural Northern New Mexico. She was blonde, thin and busty. Cute as a button. She brought a mocha-chocolate cake from the Chocolate Maven in Santa Fe, complete with chocolate covered strawberries on top.

Well, it had been a while since I had a visit from Lucifer.

Yep. My poor Exubera rep, feeling guilty about Pfizer’s leaving the few, but happy, inhaled insulin users in the lurch, bought cakes for all her providers that had scripted out the doomed product.

For what it’s worth, Pfizer is going with a scorched earth policy the like of which hasn’t been seen since the Huns swept over Europe.

They’ve officially dropped the product, only filling scripts for 90 more days. They’ve shut down the factory. They’ve laid off the workers. According to Amy’s blog which she calls Diabetesmine and I call the New York Times of Diabetes, Pfizer is taking a 2.8 billion-with-a-B dollar loss; the largest in pharma history as far as anyone can recall. My spies tell me the company “only” made 12 million on the product last year.

Of course, to be fair, it would take the company 233 years to break even at that rate.

Back to scorched earth, Pfizer has even gone so far as to prohibit their reps from giving the samples in the trunks of their cars to patients already using the product. Instead of ending up in the lungs of diabetics, these very expensive packets of insulin will end up in a land fill somewhere.

I called around to my various contact in the medical world. No one could recall a FDA approved med, that is under no apparent pall of suspicion, being made to fall on its sword due to lack of sales.

More strangely, Pfizer reportedly had just contracted with a third party to develop a new, more compact inhaler for the medication that was to look less like penis enlarger.

I had only one patient on Exubera. It dropped him from an A1C of 7.5 to a “perfect” 6.5 with virtually no hypos. He loves it, and is feeling very abused and abandoned. He wonders why Pfizer would react so violently. Why not just marginalize the product and let sales slowly grow, he wonders.

I wonder too. The billions have already been spent. Pfizer is in desperate need. They’ve got no block-buster drug in their portfolio once Lipitor goes generic in a few years. One would think that every 12 million dollars would help when your back is up against the wall.

…..boy what I could do with 12 million…. Can you hear the seagulls and the waves lapping against the beach?

Of course I have no earthly idea how much it actually cost them in terms of payroll, electricity, shipping, etc. to make the packets that brought in the 12 million; but I’m betting that, development costs aside, they were actually making a cash-flow profit on the drug.

I never for a minute expected Exubera to be the block buster that Pfizer deluded themselves into believing it would be. One wonders at the lack of connection to reality in America’s board rooms.

By the time 95% of D-folk need fast-acting insulin, they are already taking basal insulin. When I presented the massive six-story inhaler in one hand vs. another insulin pen in the other….well, you know what happened.

Now, had Pfizer developed an inhaled basal insulin first; then they would have had unstoppable run-away sales. Until they’ve had their first shot, most new insulin candidates are terrified of “the needle.”

All of that said, I thought Exubera was a nice little niche product. I like having every possible arrow in my quiver and I’m sorry to see it go away. It’ll be interesting to see if the other inhaled insulin players will try to jump into the void left by Pfizer’s departure; or if they will quietly close the books, take the development as a charge against their profits for the quarter and move on to the next act in the diabetes drama.

Thursday, November 01, 2007


Dateline—Las Vegas National Wildlife Refuge
One hour after sunrise

They crept through the long grass, low to the ground, single file. I braced my field glasses by resting one elbow on my knee and slowly adjusted the focus knob.

I counted.





Five of them.

The same pack I saw yesterday. The same fascinating behavior. The Alpha was leading the pack across an open field. They strung out like beads on a necklace, spacing themselves thirty feet apart. They are lean and strong with long snouts, alert ears, and bushy tails.

A coyote pack.

Now I’ve lived in the southwest most of my childhood and all of my adult life. Coyotes are part of the territory. I, myself, have rather fond feelings for them. But I’m not a rancher. While I enjoy the beauty of their design and the sense of wild freedom they represent, my neighbors reach for a gun with a string of expletives.

But for me, this was a new experience. Coyotes aren’t generally considered pack critters. They run solo. Very unusual to see even two together. Much less three. Or four. Or five.

And I thought I knew a thing or two about coyotes.

About 200 years ago, when I was still in my late teens, I was a Colorado Licensed Fur Trapper for Ft. Lewis College. I was part of an animal behavior project. The idea was to catch a coyote, put a radio collar on him, or her, and track the critter’s movements for the summer. The goal was to determine movement patterns, size of home range, night vs. day movement and all that kind of thing. It took us all summer to catch one of the damn things. It’s apparently quite easy to kill a coyote, quite another thing to catch a live one. By the end of the summer, having been outwitted by the wily beasts for weeks and weeks and weeks and weeks and weeks and weeks I became convinced that in the real world, the damn Road Runner would not have stood a chance.

We finally got one two days before the end of the project. It slept off the tranquilizer the entire two days. We never recorded even one foot of movement.

As to why I’m now observing coyotes again, it’s my Mom’s fault. She and Dad were avid “birders,” people who learn to recognize various species and sub species of birds, and then keep track of what they’ve seen. The first time you see a given bird it goes on your “life list.” Serious birders will travel hundreds or even thousands of miles to spot rare birds to add to their life lists. There are whole web sites dedicated to this stuff (I guess that’s true of any subject under the sun). My eldest sister also took up birding. Every year she and Mom compete to see who gets the most birds in the year. Most years my sister blows the doors off my Mom. This year it’s a dead heat.

Like the sports gene, I did NOT get the birding gene. Sports just don’t interest me. I don’t even watch the super bowl. I only knew the Rockies made it to the World Series ‘cause my Mom lives in Denver and its all she talks about. Must be something in the water up there.

So what I know about birds, before today, can be summed up right here: if it can stop in mid air with no horizontal movement it is a humming bird. You can find a bald eagle on most American currency, but Ben Franklin advocated for the wild turkey as a national symbol instead. It was native, smart, and wiley. He thought a bird of prey sent the wrong message. Seems like, right now anyway, it’s a pretty accurate symbol of our international policy. Some birds have color: blue, yellow, red. Vultures fly in circles above anything in the desert that is dead or nearly dead. That’s about all I know about birds. Oh yeah, and when Robbins show up it’s spring and don’t let your cats out at night: great horned owls find them a tasty snack and cats are under the mistaken impression that they are at the top of the food chain. (Don’t panic, Khaki is fine.)

Anyway, back to the dead heat. Mom is down at our place to deliver a carload full of glass. She has her mother’s collection of antique glass and has been paying to store it for many years. She’s decided to sell it off, but most of the glass shops in her area have been victims of an economy that leaves most citizen precious little in the way of disposable income after paying bills. I suggested EBay might reach a wider audience and as you might expect, I’m now going to be listing all the glass for her….

Anyway, we live about half an hour from one of the nation’s premier national wildlife refuges. Like most locals, I confess to giving it very little thought in general. Mom hits it a couple of times on each visit. As Rio has to be to school before sunup I offered to drive Mom through the refuge after we drop him off.

I now know a lot more about birds and birding. Each equipped with stainless steel coffee mugs of home-brewed Starbucks, field glasses, and warm jackets; we slowly cruised the empty two lane road windows down, seat belts off looking for, God help me, birds. Every fifty feet or so we’d spot something, stop the car, kill the engine and bring the glasses to bear on some flying mass of feathers.

The first day I was just being a good sport. But once my brain got tuned in, I found my eye was sharp at spotting birds. On the second day I got into it.

Now I can tell the difference between a golden eagle and a hawk. And I can tell you that anyone who thinks they can tell one type of hawk from another is probably kidding themselves. The differences are subtle and individual animals vary in appearance as much as humans do. Even with a bird ID book in my lap it was hopeless.

On our second outing we spotted and IDed 30 different species of birds. Mountain blue birds twittered around our car. A Merlin buzzed over us. A great blue heron, as improbable a flying machine as a bumble bee, flapped his giant wings to escape us. I sat in the window of our CRV, feet on the driver’s seat, with my elbows resting on the roof, staring at distant ducks to figure out if they were pin tails or what the hell. A raven flew so low over us we could hear the wind swhooshing through his feathers with each powerful stroke of his wings.

We saw a bald eagle perched majestically in a dead tree. I got so close to a juvenile hawk, that didn’t yet have the sense to be scared of me, that his face filled my field glasses. I stared into his yellow eyes and detected an intelligence quite different from ours. Smart but cold. I saw a mole, digging a new tunnel, throwing dirt out with this body shovel-like. He was a cute little sausage of fur with no visible ears or tail.

Being out with nature. Highly recommended.

But back to the pack. I first saw them on day one. One was just off the road. He froze when we approached. It was then that the Alpha, far across the field, caught my eye. He made a dash. Then, to my shock, I realized there were three more coyotes between the first I saw and the runner. Number two also bolted. The three close ones stayed frozen, totally motionless. I was blown away by the group strategy. The most distant and hard to catch were distracting attention from the closer, easier targets. Hmmmmmmmm…. Smart little bastards. And smart as a group too, not just as individuals.

On our second day we were walking a loop trail in hopes of spotting some sort of rare owl. Far to the east I heard the iconic lonesome howl of a coyote. Then something different happened. A chorus of voices joined in. Howls. Yelps. Laughing hyena-like noises that chill the blood. Then to the west and south a second chorus came in reply. Two packs. Gossiping or challenging? No way to know.

It was the group to the south and west of my location I was able to spot with my Mom’s field glasses (having left mine in the car in favor of carrying my go-bag with insulin and all that other crap that keeps me alive and well). The pack was in about the same location as they had been at the day before, but they were running ahead of schedule.

They were far distant, I was having trouble getting an accurate count. I knelt down, one knee on the cool morning earth.

I braced my field glasses by resting one elbow on my knee and slowly adjusted the focus knob. The coyotes crept through the long grass, low to the ground, single file….

And I began to count….