Sleep-over

This week is gonna be a big milestone. My hail-battered, broken-windshielded, bald-tired, old Honda Accord is going to roll 200,000.

Of course, watching a car “roll over” is not as much fun as it used to be. I can remember my Dad packing Mom, Debbie and I into his car for a 25 mile detour so we could watch his Subaru roll 100 K. In the last half-mile we all unbuckled and leaned forward to watch the odometer, nobody in the car paying attention to the road. The numbers slooooowly crawled and all those nines rolled lazily over into zeros. We cheered.

I’ve got a digital odometer. I imagine that one second it will be 199,999 and in a flash it will be 200,000. Actually, knowing me, I’ll probably have my head up my ass and I’ll miss the whole thing. I’ll look down about Tuesday and be at 200,499. Damn!

So speaking of driving, around the forth of July I was reading on the AP that a year previously gas had been $2.98 per gallon. I was tanking up then at $4.09. Yesterday up to $4.14. Gas went up over a third. In one year.

Are you making a third more that you were last year?

Yeah, I thought not. To their credit, we all did get a 3.5% inflation raise at the clinic; which under any sane set of rules might actually keep up with the rising cost of things. Reminder: nothing sane about the world we find ourselves in now.

I work four tens. I get up at six in the morning. Shave, take my basal insulin shot and my thyroid pill, turn on the coffee pot, and take a shower. Then I check in with Amy’s blog over low-carb yogurt. Amy’s is the place to go everyday if you never want to miss anything in the world of diabetes. I mean, no point in my going to work today if they cured it, right?

OK. No cure today. So I get in my little white car and drive the sixty miles to the clinic. Now some folks think I’m crazy to take on a 120-mile daily round trip commute. First, let me remind everyone that lots of people spend an hour getting to work. Most people just use that hour traveling a much shorter distance. I also have to point out that my drive is probably the most beautiful you can imagine. I go from the mesa lands where I live into the foothills of the Sangre de Cristo mountains. I watch wild weather, breath taking sunrises and sunsets. I see deer. Road runners. Coyotes. And state cops. Damn! Gotta be careful with the ol’ lead foot on the wide open interstate.

My house sits in the open mesa land at right at a mile above sea level. My office at the clinic is about 2,000 feet higher, around 7,087 feet. Sometimes I leave my place as the sun is peaking up over Apache Mesa in a short sleeve shirt and arrive an hour later, sun full up at work and in need of a jacket.

The only real downside of the commute is it turns my day into 12+ hours away from home, so there isn’t too much family time left, me needing to sleep and eat, and all. But that is balanced by the four day work week, which gives us three-day weekends together.

I was OK with the commute. Until I couldn’t pay the electric bill. What the fuck happened? Well, electricity went up in cost. As did propane. And groceries. Oh my God did groceries go up. And gas.

Sixty bucks to tank up. I found my self not thinking in dollars per gallon, but hours per tank. How many hours of work did this fill up cost me? Even in my 33 mpg Honda, a huge percentage of my income was spent getting to work. It used to be that meds were my biggest single line item on the family budget. Now it is gasoline. At what price per gallon are you losing money going to work at all? I love my job, but would I pay to do it?

My boss asked me why I didn’t move closer to the clinic. Well, because I own my house free and clear and I love where I live. Changing any of that would cost more than I would gain. At least until gas hits….

So desperate times call for desperate measures. My solution?

I now live in my office.

Well, one day per week for now, two in the fall.

So I have to take a detour here to give you some background. For years now I’ve been trying to increase my education in my new chosen field with no luck. I’ve looked into several flavors of nursing school, I’ve researched two physician assistant programs. I even looked at dietician training. Nothing is set up for working folk, and as the sole income provider for my family, taking three years off for school wasn’t an option.

I’d all but given up when the email arrived. A fiend at Department of Health tipped me off to a new program starting at one of our state’s universities: a Master of Public Health (MPH) in Community Health Education. It was to be totally online, designed for folks already working in the field. I’d only have to go to the University one time. I’d take two graduate classes per semester, three semesters per year, for three years. The information meeting was that very night.

I called to find out if it was a sales meeting or a required meeting. I’m already sold, I told the program director, just tell me how to apply.

Any way, very long story shortened: finical aid was a nightmare. In the end the clinic decided to pay for the lion’s share (talk about feeling appreciated!). Getting transcripts, some of them over 20 years old, from the six colleges and universities I’ve taken classes at on short deadline was a greater nightmare.

I was excited and scared.

But it all worked out.

So the plan is to use my two overnights, which will be school nights for Rio anyway most of the year, to be my school nights too. I’ll study my butt off after the last patient leaves and hopefully keep the weekends free for family.

I’ve got a T-1 line in my office. I’m in the “annex,” as I renamed the leaky-roofed-broken-down construction trailer at the end of the parking lot that houses our program. So basically I’ve got a sub-compact mobile home. I have my own a/c and heat. I’ve got a bathroom. What more would I need?

I bought an air mattress, brought a microwave from Big Grandma’s estate, and too old for roughing it, I bought two bottles of Carnet Sauvignon for my insulin sample fridge.

A bottle opener. A poly-carbonate wine glass. A tooth brush. Pipe tobacco. All set.

Ready for my big new adventure.

Oh, and the 200K? I didn’t miss it. E and I swerved all over the road 200 yards from the clinic, eyes glued to the odometer waiting for the big minute.

199,999

199,999

199,999

199,999

FLASH!

200,000. We cheered.

Re-priming the pump

As most of you already know, I’ve been working my way down the ladder of success for several years now. More the American nightmare than the American dream.

Even without diabetes my income would be waaaaaaaaay down, given the economy and the planet-killing asteroid called digital imaging that hit my old industry. I’m not too bitter, for the most part, because I am a better person now. A happier person.

But lately, I’ve been having a problem with Dawn. Nope, she’s not a co-worker, boss, or patient. I’m talking about Dawn-Phenomena (sounds sort of like a stage name for a stripper, doesn’t it?).

As the sun creeps towards the horizon my internal rooster, in the form of circadian rhythms, sends a lethal cocktail of hormones coursing through my blood stream. My liver kicks into overdrive in the pre-dawn light. My alarm goes off and my blood sugar is 248. Crap.

No amount of creative use of pen syringes will counteract Dawn. If I set my alarm clock earlier to try to beat her to the punch she catches on, clever parasite that she is, and she sets her alarm even earlier. I find myself fighting a re-guard action. Burning the bridges as I retreat from the enemy. Humalog to knock down the highs retroactively.

Pumpers don’t have this problem.

I didn’t used to have this problem.

That’s because I used to be a pumper.

A quick recap of the sad tale: it’s all the fault of insurance. I used to have good diabetic coverage on a personal policy that cost a fortune, and got more expensive every year. Ultimately, it was unrealistically expensive. The year I threw in the towel, they raised it 45% to something around $660 bucks per month. At that time I had been working at the clinic for about a year and felt like I had found a home. But it was scary. I had been self-employed for two decades. Taking insurance, and being T-1, I was setting myself on the path to permanently “working for the man.” It was more than scary, it was terrifying.

But it had to be done. I closed my eyes, took a breath, and prepared to jump off the cliff. But at the last moment I grabbed the phone and called the lady who over-sees the clinic insurance instead.

She “researched” and called me back a week later, assuring me pump stuff was fully covered and that I’d only have to make a $15 or $20 med co-pay. I was elated and jumped off the cliff.

To the jagged rocks below.

She is apparently an incompetent boob. Like most plans, I later learned, pump stuff is considered Durable Medical Equipment. WTF? OK, I can see that the pump is durable, but what the fuck is durable about an infusion set you wear three days and then pitch?

Well, no one ever said life was fair. The clinic’s DME coverage was 50%. I actually got approval for the CGM sensors, but they too are considered durable. That means I still pay half of retail, so I wear them longer than would be strictly smart to do so because I simply can’t afford to do otherwise. The pump stuff was just too much to pay for what with gas, and food, and electricity, and phones, and car insurance, and taxes, and…

I had to pack my pump up in a box and go back to shots.

At first I was outraged. Then I enjoyed being un-tethered. Then I got in control. Then I spun hopelessly out of control, thanks to Dawn.

Meanwhile, my boss started searching out better insurance. Looks like next month it could be a whole new world-order for me. I got to thinking about pumps again. At a trade show I talked to the Animas folks, who had one of their pumps in a fish bowl full of water at their booth. I was wearing a “professional” badge so they nearly soaked my shoes with drool.

Rep: would you like a case of info packs for your patients?

No, I’m not going to recommend a pump I haven’t tried. Can you get me a loaner for a month?

Rep: Absolutely, no problem, we’ll make it happen.

Then they discovered I’m not a CDE. Only CDEs get such perks, apparently. To add insult to injury a Nurse Practioner friend of mine invited me to a lunch meeting with an Animas Rep. My friend wanted to hire me to be the pump trainer for her practice, as a side job now-and-again on my days off.

Animas: can’t be done. He’s not a nurse.

Now my friend could be a certified pump trainer. All she had to do was watch one pump training session and they’d rubber stamp her. “That’s just plain crazy,” she told the rep, and pointing to me, said “I don’t know even 1% of what he knows about pumps.”

Animas: that’s just the way it is.

The same thing happened with Dex Com. Not being a nurse, what could I possibly know about continuous glucose monitoring?

Accu-Chek has promised a Spirit Pump for me to test drive. We’ll see. It has brilliant software and the best designed infusion set I’ve ever seen; but it requires both a separate meter and a PDA to run the system. Seems like quite a few boxes to me. One thing I do like is that they give you two pumps.

What? You ask.

All the other players in the pump market will FedEx you a replacement pump if yours craps out. But that’s a long 24 hours, don’t cha’ think?

Accu-Chek’s solution (mainly a marketing ploy, but a good one) is to just give you two pumps from the get-go so you have a spare on hand just-for-incase. Now, before you get too excited and plan to share your spare with an uninsured friend, Accu-Chek is a step ahead of you. Sorry. The spare pump is like the little tape machine from Mission Impossible. It is designed to self-destruct. Not in five seconds, thank goodness, but in 180 days.

They also, like Med-T have skins to personalize it, and the display can “flip” so you can read the pump right-side-up no matter how you position it. Oh, and they also have a really creative set of assorted cases, straps, and so-forth for wearing it.

Their super-slick and creative info kit has so many healthy-looking obviously non-diabetic models in it that I actually threw-up.

That said, I’m yet to use the system, so I can’t really report on what it is like in the real world.

About the same time that all of this was happening, the new kid on the block sent me a post card. Insulet Corp wanted to know if I’d like a dummy pod to wear for a few days to “experience” what it would be like to be a I-Corp pumper with their OmniPod.

What the hell? I sent it in. Or maybe I went to their web site. I don’t recall. But it sure came fast. And this was just to me as a diabetic patient. They had no clue what I do for a living.

Actually, I found the whole OmniPod concept fascinating from the very start. I-Corp, as I’m sure you all know, has unplugged the pump. It really is thinking outside the box. You wear a disposable “pod” on your body that has all the mechanical parts of an insulin pump, while the brains of the system are in a PDA-type device that you can stash anywhere on, or around, your body.

The pod has the insulin, infusion set, etc. Amy over at Diabetes Mine was one of the first high-profile folks I knew of who got one. She went on a quest that bordered on a crusade to get it. I think highly of Amy. Amy thinks highly of OmniPod. Hmmmmm…

But still, that pod looks pretty big to me.

So my sample pod came earlier in the week. I opened the box and it looked HUGE. They also sent me a cute little CD disc that was cut-out into the shape of the PDA-type device. Huh. This must have cost them a fortune.

Anyway, it was a crappy, busy week. So the box sat on my desk. Then, on the weekend I got it out again and took the pod out of the wrapper. It felt heavy. Yuck. But still. I really like being un-tethered, but I miss the control of the pump.

This might be the way to have my cake and eat it too. Oh, and then I could bolus for the cake with the push of a button again. Oh yeah.

The OmniPod “demo kit” box asks “Where will you wear yours?” in ghastly puke-green and baby blue letters worthy of Med-T. Hmmmmmmmmm…..Where will I wear mine?

The top five suggestions from I-Corp:

(1) Arm

(2) Abdomen

(3) Back

(4) Leg

(5) Other. Other? Like, what? Your forehead?

Can you guess where I chose?

Arm. Why? Well, I don’t use them for anything anyway, so it seemed logical to me. I grabbed my beard trimmer and shaved my right bicep. I pulled off the sticky pads and slapped it on my arm. Then I jumped back into bed and rolled around to see how annoying it would be to sleep with.

You don’t really notice it. Once it is on your skin you don’t feel the weight. It reminds me a little of the transmitter on the first and second generations of the Med-T CGMs; before they stole the Roswell Alien sea-shell transmitter that I love so.

I might just like this pod approach. A lot.

On the radical fringe (again)

“My plumber said I should ask to see your tattoo,” said my elderly patient. (Man, does news ever travel fast in small towns!) I set my aluminum clip board down on her kitchen table and extended my right arm to her, wrist up.

She studied my new tattoo for a while with keen eyes, then gently ran a wrinkled finger over the design “did it hurt getting it?”

Nope, not worth mentioning. A finger stick hurts more.

“Do you think I should get one?”

Ummmmmmm………………

FLASH BACK: 48 HOURS EARLIER

Richard and I were sitting in a tattoo parlor called Shades of Grey in central Albuquerque. In some ways it was pretty much what I expected. In other ways, it wasn’t. The shop was located in a very ordinary strip mall in a very ordinary part of the city.

I guess I had expected it to be in a rougher neighborhood. Like sandwiched between a biker bar and a crack house, across the street from a XXX video shop; instead of between The Vacuum Doctor and Albuquerque Bridal Formals and More.

Inside the door, it was more what you might expect. A pool table dominated the lobby and the walls were covered with drawings of busty naked tattooed women. With vampire teeth and high heels.

The owner, Orlando, looked like what I envision Odysseus must have looked like. Slightly small of stature but sturdily built. A thin Greek beard. Penetrating brown eyes. Square, solid jaw and a thick chest. Of course, I doubt Odysseus was covered in tattoos. Inked flames licked up Orlando’s arms from his wrists. His biceps were covered with assorted designs. Large block letters dominated each finger, violating my Mother’s advice to me thirty-years ago: if you are going to get a tattoo, put it where you can cover it up if you ever need to get a bank loan. Sorry, no bank loan for you, Orlando.

“So you’re my Uncle’s Doctor?” he asked.

Slight flush of embarrassment. I’m not really a doctor, my patients just call me ‘Dr. Lee’ out of respect. But I help your Uncle keep his diabetes in check.

He nodded OK and asked, “So, are you ready to get started?”

FLASH BACK: ONE YEAR AGO

For the life of me, I can’t recall where I first heard the idea of medical alert tattoos; but my crew and I had been talking about them for months before someone emailed me an ABC News article on the trend. Apparently amongst young D-Folk, medical alert tattoos are the rage. We even kicked it around several times at team meetings in the spirit of, yeah, someday I’d like to get a medical alert tattoo. Sort of like saying, yeah, someday I’d like to go bungee jumping. Surrrrrrrrrrre you will.

Anyway, I always wear an alert bracelet. Except when I forget to put it on, which is about half the time. But I always wear my necklace. Except when it bothers my skin. Or breaks.

Which is about half the time.

So I don’t recall how it came up that I mentioned medical alert tattoos to my mother, but I did, and she jumped all over it. My mother who is NO FAN of tattoos offered to pay for one. She enlisted my wife to the campaign. Both my mother and my wife insisted that they would feel better if their hypo-unaware T-1 loved one, who was out in the world half the time with no alert jewelry, had a medical alert tattoo.

But what design? And where to put it? And how on earth does one go about finding a tattoo artist that is skilled and clean?

As it turns out the middle question was the hard one. There was really only one design to consider: the caduceus, the winged staff entwined with two double helix snakes that has become the universal symbol of all things medical in our modern world. Finding the artist was fate and fortune. One of my patients came in one day with an eyebrow ring. Hey, I see you’ve got a new look. “Yeah, my nephew owns a tattoo parlor in Albuquerque and he was like, ‘uncle, let me give you a new tattoo’ but I have enough tattoos (editor’s note: very true) so I got this piecing instead.”

Hmmmmmmm......... I might have need of a tattoo artist. So my patient gave me Orlando’s card and I went online and the guy’s work is awesome. So that took care of that. As to avoiding Hep-C, his shop has a hospital autoclave for sterilizing all the gear and a brand new needle is opened in front of you and is used only on you.

So I walked across the field to the ambulance base and visited with two of our Paramedics about where a medic alert tattoo should be. Their first choice was on the neck on the carotid artery. No. Violates Mom’s rule of tattoos.

Next choice was at the wrist, but which one? What followed was a long discussion of which arm would be more likely to be ripped from my body in a wreck. This is why I generally avoid spending too much time with Paramedics.

In the end the right wrist became the favorite choice for several reasons: I wear a watch on the left and on the top of the left arm is a tattoo from my youth. D-folk generally wear alert bracelets on the right. In the end the consensus was it really didn’t matter (so long as my right arm wasn’t ripped off) because ambulance folks would “tune into” the caduceus.

So, everything in place, I got out the business card and called the tattoo parlor. I chatted with the receptionist. I said something like, Orlando’s uncle said I should call…and 20 seconds later the guy was on the phone with me. I outlined the project. He told me he was generally booked solid for three weeks out. I looked at my calendar and in three weeks I had to be in the city for a D-training all morning. We made an appointment for early afternoon.

I emailed Orlando about 20 low res thumbnails of various caduceuses (caduceusi?) for him to get a feel for the image. I know better than to try to give an artist too much direction. I just told him I wanted it to have an edge of attitude, it had to be recognizable as a caduceus and, of course, it had to say ‘diabetic’ on it somewhere. I closed my email with: the tattoo’s main job is to alert Paramedics that I’m diabetic. As it get to wear it the rest of my life, I want it to look cool. That said, not too wild as I work with patients of all ages and races.

Then I waited. And waited. And waited. And waited. And waited. And all of you know how much I hate waiting.

Two days before our appointment, just before bed, this arrived:

My first reaction was one of shock. My artist had taken one of the oldest and most used symbols on the planet and had done something unique with it.

Rio was at my shoulder when I opened it. “It’s perfect, Daddy!”

I called Deb. She leaned over my shoulder and stared at it for a loooooooooong time and said, “it’s magnificent.”

I stayed up waaaaaaaay past my bedtime, holding my wrist up to the monitor and trying to envision the design on me.

I analyzed what Orlando had done. The caduceus always has the top of its wings parallel to the horizon. He swept them upwards, and separated them a bit from the staff. A bit like angel wings, a bit like Harley Davison. A bit like arms raised in prayer. The snakes pull back from the staff more than usual. They are wicked looking, don’t tread on me ‘kinda snakes. With fangs like the needles we poke ourselves with. The orb on top of the staff floats free. Hope for the future? A symbol of the concentration and dedication it takes to stay healthy? You choose. Maybe both. The ribbon behind the staff and wings gives the entire emblem a bit of a military feel to the logo. Diabetes storm troopers. We must fight. Every day.

All said, it was everything I could want. For a guy who doesn’t have diabetes he really packed the image full of elements that go to the core of our disease. Two days later it was done.


My co-workers love it. My wife loves it. My mom loves it. I love it too. And I feel safer with it.

So, anyone else out there have a D-Tat? Email me an image and I’ll post ‘em. If not, and you want one, my design is Open Source. Help yourself. Just send my guy five bucks for coming up with the design.

And what if they cure diabetes, you ask? Yeah, right. Well if in two years or twenty they find a cure and actually make it available then I’ll go visit Odysseus again and have him add the word “Cured” above diabetic on my arm.

Another sign of the times

How many diabetics does it take to screw-in a light bulb?

Post your best answers via comments. But a more interesting statistic might be: how many diabetics have to keel over in a national park before we rate our very own sign:


No kidding. This is a REAL sign near the mouth of Carlsbad Caverns!

Wrong rainbow

I'm turning Japanese
I think I'm turning Japanese
I really think so Turning Japanese
I think I'm turning Japanese
I really think so…

--The Vapors, 1980


When I was in First Grade in the late 1960s we had a crayon color called “flesh.” It was quite horrible, and not, as far as I could tell, the color of anyone’s flesh. It was gross, pinky-peach. Over-ripe fruit gone bad.

African Americans where the first to protest, and about the same time the first black Barbie’s came out, the flesh crayon disappeared from history. Or so I thought until last week.

I was telling all of you about the visual aids for the school program recently, remember? I have a little 16” anatomical figure in my office called Madeline. She’s there partly so can show people where their pancreases are, but mainly to make my office look more medical and to make me look more smart and better trained than I actually am.

All of that said, kids of patients coming in for diabetes education just love to take Madeline apart and put her back together again. A couple of weeks ago a first-grader pulled out her lungs, heart, liver, stomach, and intestines and then peered into her abdominal cavity. “Are these the kidneys?” she asked.

Yup.

“What are these things on top of the kidneys?”

Sharp kid. Those are your adrenal glands.

“What are they for?”

They are for when you are being chased by a tiger.

“What?!!”

Hey, it could happen. It was right there and then I decided our school health ed program needed a life-sized anatomical figure. So I went to the internet on a mission.

Well, I’m here to tell you there are quite a variety in terms of size, detail, number of parts, and cost. I’m a big believer in if you’re going to do it, do it right. Top of the line are the models by Denoyer-Geppert. They are truly works of art, in fact, each is signed by the artist who details it. They are also priced like works of art. Works of art at really trendy galleries. 6K is more than my whole budget for several years. So that was out.

I surfed the web for several weeks, comparing offerings from a dozen makers before settling on a dual sex unit from Lippincott-Williams. I ordered it from the eBay re-seller with the lowest price. It came promptly, having been dropped shipped from the maker.

I struggled to get the large box through my front door, stepping on the cat, tripping over Rio’s toys, banging my elbow and pulling out my back. I eagerly opened the box and was instantly disappointed.

It was flesh colored. Yeah. Like the crayon. Revenge of the flesh.

It also didn’t look anything like the photos online. Clearly they had made one real good one for the photo shoot then had Chinese political prisoners paint the rest of the inventory. In haste.

I was totally bummed. Even at the lower end of the spectrum of anatomic figures this had set us back three-hundred bucks, the single largest budget item. And it was the color of the flesh crayon.

After a couple or three stiff drinks, because everyone knows that when you are depressed the best thing you can do is drink more depressants, I started studying the pieces. The lungs looked so great in the online photos, but in person where flat and boring. I turned the two lungs over and over in my hands. Hmmmmmmm….so why does the left lung have three lobes, and the right lung have two? What was God thinking with this design? Sure, you need room for the heart, but still, that doesn’t explain it…

The Italian-tile pattern of the surface of the lungs was actually molded in superior detail, there was just nothing done to make it pop. Maybe I could wipe some black paint into the cracks? I picked up a ball point pen and started filling in the cracks with black ink. Deb came by half-way through the job. “Hey, that looks great!”

With a critical eye we began to dissect Justin/Justine as we named our hermaphrodite anatomical. The detail in the molding was really quite outstanding, only the paint job was pathetic. Debbie sat down with a set of colored markers and began to work on the intestines.

As the internal organs shaped up, the integumentary system (skin) bothered me more and more. It was about this time that my cultural sensitivity training kicked in. Eighty percent of our kids are Hispanic. Even if the figure was the proper color for Caucasian skin, they wouldn’t relate. I decided to give Justin/Justine an ethnicity overhaul.

So in the dark of the night my mate and I began our program of evil ethnicity transformation. We mixed assorted brown and tan paints left over from various home improvement projects until we had a pigment that looked like a cross between my chili-growing neighbor and Debbie’s uncle. Or so we thought.

In the morning it was clear we had transformed Justin/Justine not into a Hispanic, as planned; but into a Pilipino. With malaria.

Back to the drawing board.

We actually got it right the second time. If our alchemy had been able to bring him/her to life and add legs and arms he/she’d blend right in walking down the dirt-main street of any northern New Mexico small town.
So internally perfect. Externally appropriate, all we were missing was some humanity. A spare temporary tattoo from Rio and a pair of sunglasses and we were good to go!