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!).

Thursday, April 30, 2009

Fear, media, and Flu

I’m bored. And I don’t deal well with boredom. I had a full schedule today when I got to the clinic. It is now 2 o’clock and I’ve gone home early. Not one person showed up, and the rest cancelled or rescheduled.

At first I thought it might be free-all-you-can-eat-desert day at the Indian Casinos. Then I thought it might be Spring Fever, as this is the first summer-like day we’ve had this year so far.

It wasn’t until my boss asked me to change the sign in front of the clinic that I really understood what had happened. I was to take down the announcement of the impending “shots for tots” campaign and replace it with the toll free FLU HOTLINE number.

Ah. Swine Flu Fear. My patients aren’t doing the all-you-can-eat chocolate cream pie. They are not lying in the sun, or drinking beer and playing horse shoes.

They are locked in their homes afraid to come to a place where sick people are likely to be.

OK. I understand. I can live with that.

But should we be scared?

That’s a good question, so I guess if it is a question at all, it is OK to be scared. As I write this my state is yet to have a confirmed case of Swine Flu. That may change by tomorrow as today we had a young Mexican girl who is visiting family come in. She had a high temperature, body aches, and respiratory distress. We did a rapid flu test on her and she was positive. That means she does have some kind of flu. Could be Asian. Could be Swine. Could be Bird, Hippo, Mongoose, or Rattlesnake flu for all we know.

The Swine Flu, lucky for everyone, will give you a positive for strain “A” run-of-the-mill flu on a rapid test. To determine if she has Swine Flu will take tests more sophisticated than we can do in rural non-profit medicine. In fact, many metro hospitals probably can’t do it either. But her blood is off to the powers-that-be and we may be on CNN before you know it.

How bad is Swine Flu? Remember that I don’t work for the Centers for Disease Control, but here’s my take on it, for what it’s worth.

Garden variety flu kills somewhere around 36,000 Americans every year. That’s why we are always telling you to get your fricken flu shot. It tends to take out the very young, the very old, and the chronically ill. That would be you and me.

36,000? Good Lord, by comparison, 31,000 Americans were killed last year in traffic accidents. You are more likely to die of garden variety flu than behind the wheel of your car.

Swine Flu has taken out somewhere around 200 folks. Probably. Maybe. And on top of that unknown is the larger unknown: we have no clue what-so-ever how many people were infected. That’s where fear comes in. Does this new flu kill 1% of those who get it, or 4% of those who get it? With a new bug for which we have no immunity and few tools to fight it with, even differences of a half-percent can make a huge difference in global body count.

Swine Flu also seems to strike the middle, folks ranging 20-40, rather than the young and the old. Odd. But we’ve seen this before. Right after World War I. Spanish Flu, which also hit the young and strong, killed about 50 million people worldwide. The morality rate has been estimated between 2.5% and 5%. That’s a pretty wide gap because no one really knows how many folks were infected.

The same is true in Mexico City, which is a very, very, very, very crowed place. One of the most crowded in the world.

If I had to put money on it, I’d guess that Swine Flu is no worse than the average flu of 0.1% because, to my way of thinking, if it were a killer like the Spanish Flu we’d have a lot more bodies in Mexico.

This is a vivid demonstration of how dangerous Mother Nature can be when she’s pissed off. Spanish Flu spread to every corner of the globe in an era of steam ships, wood and cloth bi-planes that could hardly carry two people half way across a state, and at a time when most folks still traveled by horse and buggy. Now we travel so freely, so fastly that we may as well be blood cells in one giant global body. The gene was out of the bottle before anyone even knew the bottle was found.

All of this said, let us not forget the pain and suffering even a single death brings to the victim’s loved ones. Each and every single death is a tragedy, a story unfinished, a painting not yet complete.

I don’t think we need to live in fear of Swine Flu, but with any flu, we need to live in caution. Wash your damn hands. Go to your doctor if you feel sick. Don’t share drinking glasses. Cover your mouth when you cough. Basically, live your life like you were in kindergarten.

Kindergarten rules. Also good rules for a civilized and healthy society.

Saturday, April 25, 2009

No Zebras here today

White. All I can see is white. I’m floating in a cloud, seeing nothing, feeling nothing. The surgeon’s voice, however, is clear. He’s lecturing. Enjoying the audience “…now this is the base of the epidermis. Below that you can see the dermis; and this is the start of the sub-q tissue….oh yeah, this is a deep one…”

“This is sooooooooo cool,” says my mate. She is really digging this. Uh-huh, just when -- after 20-years -- you think you know someone. Having two turbo-charged vehicles at her disposal has brought out her inner-wild woman. Now it also turns out medicine turbo-charges her mind. What other delicious surprises await me?

God, I love her.

Then, feather light and warm, I feel her touch on my hand. Then, more pressure on my left cheek. The surgeon is pulling, cutting, pulling some more. The lidocane has removed all sense of detail. Something is going on, but I have to rely on the disembodied monologue for clues. My senses have been removed, I’m flying blind…..

It all started about two weeks ago, when my face blew up. Literally. The entire left side of my face looked like it belonged to a man a hundred pounds heavier. There was much discussion where I work on what had befallen me, as nothing quite added up right in terms of color, speed, and shape. I couldn’t even follow nine-tenths of the conversations. The doctors I work with sometimes forget I’m about 800 times stupider than they are on every medical subject in the world except diabetes….and having one’s face blow up isn’t a common side effect of diabetes. Or even an uncommon one, for that matter.

One end of the spectrum was “zit gone bad” and on the other end was “mumble, mumble” no eye contact and, “let’s just wait and see.” Translation: some sort of cancer. So began the ping-pong ball game of go see this specialist and go see that specialist.

I didn’t care what was in my face, I wanted it gone. Right now. It was the enemy. It did not belong.

Once my face began to shrink to its normal size, I had a huge mass in the middle of my left cheek. It felt hard, was about the size of a shooter marble, and it was resting against one of the spider web of nerves that crisscross the face. Every time I laughed or smiled I got shooting pain that whipped across my face and around my head.

I had no idea I laughed so much.

I was fucking miserable.

The young doctor who recently joined our clinic told me, “In med-school they taught us the Zebra Principal. If you are walking in the woods and hear hoof beats, it probably isn’t a Zebra. That assumes, of course, that you’re not walking in the woods in Africa. It was a way of reminding us that, sure, some really exotic and rare condition might afflict a patient; but most often, the most likely explanation is generally the correct one.”

That very night, convinced that I had some rare cancer he hadn’t even considered, I went on eBay and bought a Zebra Xing sign. Just to rub his nose in it.

In a week it was agreed we needed a surgeon to remove it. Whatever it was.

“Oooooooooo! Your face will be even more sexy with a scar!” said my favorite deluded female friend. She’s the only one who finds me handsome. Even my wife doesn’t find me particularly handsome; or if she does, she never mentions it. My deluded friend wonders why I’m not beating off adoring female fans with a stick. I don’t have it in my heart to tell her that she’s the only one whose eye I appeal too. That’s why I keep her in my circle. Everyone needs a little ego boosting now and again.

“Take a look,” said the surgeon. In his blue-gloved fingers he held oval piece of skin a little larger than a pinto bean. Complete with salt-and-pepper stubble. Below that some fat. Then the enemy, and below that red-colored tissue. All told, more than a half an inch thick, looking like a diagram from an anatomy 101 text book. “Got it out completely intact,” said the surgeon, justly self-satisfied. “Now we can cut it open,” with a quick flick of the bloody scalpel he bisected the garden variety sebaceous cyst. Not a Zebra.

And the adventure was over. So uneventful as to be a non-event. And it was only 9:15 in the morning. So Debbie and I went to brunch.

Over a steaming fish-bowl sized cup of rich dark coffee deep inside the La Fonda, I regard my mate carefully. Debbie’s dark eyes are bright with an inner fire, “oh my God, you should have seen it! His hands were rock-steady. I’ve never seen anything like it, and his suturing…it was like watching a ballet!”

After a breakfast burrito, eaten carefully so I wouldn’t bite myself we headed out to see my PCP doc. I feel like I just came from the dentist. My face is numb and feels even bigger that it did before, but now I can reach up and stoke my hand across a reassuringly flat face. Whew!

My doc asked what the surgeon had given me for pain. Nothing.

She rolled her eyes, “Surgeons!” and reached for her Rx Pad. She prescribed Lortabs. I’ve got way too many patient’s hooked on these damn things. I swore to myself I wouldn’t even bother to fill the script. Forty five minutes later I was begging my wife to drive faster. Where’s that fucking Walgreens??

I missed an entire week of work, taking Lortabs and Advil. Some sort of pain killer every two hours. And I was not in pain. Nor could I function. I’d be a piss poor junkie. I think I’ll stick to being a drunk.

At least I can write drunk.

Friday, April 24, 2009


OK, so I know that it is not traditional to have an intermission in the middle of a gun fight, but I was never much for tradition.

This picture of my arm was taken five days after I removed a Navigator sensor. No, it doesn’t hurt as much as it looks like. It hurts more. The other arm is much the same. I had wanted to wear Navigator non-stop for the full run of the shootout, but my body insists otherwise. There is also the fatigue factor of the multiple jobs, long days, and commutes. I’d forgotten how hard it is to post nearly every day.

Not to worry, I’m not throwing in the towel. Just slowing down a bit. We still have much to talk about, but not every day.

I’m also involved in what is turning out to be a fun and exciting project. Red Blood Cell Books has gotten many requests for both Kindle (e-book) and Audio (like books on tape, but higher tech) versions of The Born-Again Diabetic. At first I resisted the e-book, ‘cause I’m a book freak. Books are supposed to have pages and covers and stuff. And important books have hard covers, by God. That said, the message is what matters and I came to realize the e-book folks probably don’t buy real books and vise-a-versa. I gave that project my blessing and it is moving forward with little need for input from me.

The Audio book was trickier and became more interesting. At first I had thought it would just be someone reading the book; but the way I write is designed for reading. It doesn’t always work so well spoken out-loud. As various ideas were kicked around, then kicked some more, it began to dawn on me that this was not just a different way of publishing a book, this was a whole different media.

If we want to use the power of sound as strongly as we’ve used the power of the written word, we’ve got to do things a little differently. Just like turning a novel into a movie requires a screenplay “based on the book by……”; I’m finding that I need to adapt The Born Again Diabetic for it to be as good an audio book as it is a written book. So I guess instead of a screenplay, I’m writing a speakerplay. As you might expect, it will not be what you expect. I’ll keep you up to date, but I’m totally jazzed about this project.

CGM wise in the coming weeks I’ll cover downloads, software, highs & lows, and even a Navigator family photo album. It’s all still coming, the Navigator Experience: Good, Bad, or Ugly?

Thursday, April 23, 2009

The six million Peso diabetic

I was moving dishes off the table and into the dishwasher. One of our favorite pastimes is the classic dinner party with just a few close friends.

“Good Lord,” said my friend Laura, “what is all that crap on your belt? You look like the bionic man.”

A few days before, I had a quick snack with one of my diabetic sisters. She looked the Navigator with interest, but flatly stated she’d never wear one. “Look at the size of that thing! It’s a monster!”

Leaving the restaurant, a cell phone sales man stopped me to ask what the heck it was. He’d thought it was some sort of GPS and Phone. Actually it is sort of a GPS, it tells us our Global Position in our blood sugar.

Well, the device is big. And it is a pain. Literally. I’ve got a bruise on my stomach from the top of the cleaver articulated clip. I’ve worn Guardian for years, both with a pump and pumpless with no trouble.

Navigator: 0. Guardian: 1.

Wednesday, April 22, 2009

An intimate moment—not

The girls have interrupted my fun, and now I’m sitting at my computer in the grey pre-dawn hours of my day off waiting for the second round of 15 carbs of glucose to take hold. Or to see if I need 15 more to live to see the sunrise.

Everything has gone horribly wrong somehow. Everything but Navigator and Guardian, that is.

It has been a really strange week. Monday I had a film crew following me around instructing me to just “act normal.” OK, I’ll get right on that. It’s for a documentary on diabetes care, specifically on how technology can help bridge care gaps in rural settings. A worthy cause, but it evolved from “can we interview you?” to “can we film you in action?” It turned out OK, but it was a bit embarrassing be the focus of so much attention. Pardon the pun, my blood sugar is in the 50s as I write this, so my IQ is not far behind.

We drove though a blizzard getting home last night after a drug-rep dinner. Families usually can’t come to these things, but we both work for diabetes care centers now, so we were both able to go. Winter hasn’t quite given up yet. It was nearly midnight by the time everyone was settled down and Deb had a chance to get her “Bejeweled” fix on the computer.

Deb fell asleep on the living room couch with Rio. That’s pretty much the daily status quo. At some point in the night she migrates, as when I wake up she’s usually with me. Today it was closer to dawn, I guess, because I was in that nether land between wake and sleep when she slipped under the covers and snuggled up for warmth. Her skin cool to the touch.

I absentmindedly stroke her skin to warm her up and in the process wake myself up more. Her shoulders tense, I rub them gently, and more asleep than awake she makes contented Mmmmmmmmmm noises. Of course being male my first instinct is to try and turn this situation to my advantage. Of course being a nice guy and knowing she’s been short on sleep…

So with the little miniature Wil with wings and a hallo on one shoulder and the little miniature Wil with a red cape, horns, and a tail on the other shoulder the night was shattered with Teee! Teee! Teee!


So I need to be clear about the fact that Navigator is on my shit list at the moment. Last night the bread basket was right in front of me with the most amazing array of carbolicious creations you can imagine. I actually clocked at 525 mg/dl with my super-awesome carb counting skills. Oh, and the Cabernet Sauvignon was especially smooth too.

Guardian faithfully followed this clusterfuck to the best of her ability, finally just reporting “above 400” and still showing a rise rate arrow. Navigator is blissfully ignorant of my impending DKA, blithely informing me that my sugar is stable at 270 something.

I’ve said it before. I’ll say it again. Abbott Navigator is worthless above 200.

So shortly before bedtime Navigator buzzes, demanding a finger stick for calibration. I give her one, but noooooooooooooo, my BGL just isn’t good enough. I am too high. Try later.

OK fine. It is the last cal stick on the current five day run. That means I’m supposed to have an wide window to give it the stick. But she still alarms every fifteen minutes. Now wait a minute…. what moron developed this program? The machine knows it won’t take your finger stick at a high BGL, it also knows your glucose is high, and yet it alarms every fifteen minutes? I can mute for an hour, but I know I’ll still be high and she’ll wake me up.

On the verge of yanking her batteries out and throwing her in the corner, it occurs to me at the last minute that I can just turn off the system alarms.

So now in the predawn hours with something other than diabetes on my mind, I’m not inclined to believe her. Then I hear another noise. Bzzzt. Bzzzt. Bzzzt.

Ut-oh. I think the you-know-what has just hit the fan.

I un-tangle myself from my slumbering mate and pick up the Navigator from the night stand. She’s got me at 80 or so, calling for a low. I reel in the Guardian (clipped to the Cozmo). She’s higher, but is predicting a low too. I fumble around for the Blood-red Presto. Appropriate color for its job. I’m at 75 mg/dl. I do 15 grams.

In 15 minutes I’m at 55. The predawn air is filled with Teeeping and Buzzing.

So much for sleeping in.

Bottom line: both systems predicted the low, albeit late, within a minute of each other. Pretty damn good work, ladies.

The drop was sharp. Spectacular. I sure as hell didn’t get my 20 minute warning, but the predictive alarms did their real job: they outsmarted the inherent delays that are the nature of interstitial fluid and the sampling systems. Both gave me a heads up when my real sugar was 75 and dropping. Plenty of time to turn it around and live to see another sun rise. Technology rocks.

But then, just when I’m feeling pretty good about these systems, Navigator shuts me out. I’m in a crisis and all I get is a “- - -” and a blood drop icon. I’ve exceeded my calibration window apparently, and now I’m screwed. I know that lows or rebounds are the worst time in the world to try and calibrate a CGM.

So there you have it, contrary to her name, Navigator is the over-protective parent while Guardian gives us maximum freedom.

Ironic. Just fucking ironic.

Tuesday, April 21, 2009

Vulture update #3: Will the real 850 pound gorilla please stand up?

If we didn’t tar-and-feather George W. Bush for the mess we are in now, I don’t think we should do it to Med-T for trying to drum up a little insulin pump biz. OK, I never thought I’d come to Med-T’s defense, but I think they are being unfairly flamed for their recent “jump ship” offer to Cozmo users.

Now, there are several important things to remember here. For those of you who use other pumps the best way to understand us Cozmo pumpers is to just think about Apple Mac users. Yep. Loyal, a little bit fanatical, and possibly even irrational about our gear.

Part of this is mystique. Part of it is what you are used to, if you started pumping with a Med-T you are used to it, and it beats the hell out of shots, and you really don’t know what you’ve been missing, and…Ooops, a little bias slipped in there. But part of this is vastly superior pump, from a purely medical perspective. Here is what makes the Cozmo rock: a real insulin on board computer.

Last night, my buddy Rick and his wife Alice came over for dinner. He’s a tech guru (see? I was careful not to say “geek”!) and brought everything we needed to get started on the Audio version of The Born Again Diabetic; you know, for you ‘books on tape’ lovers. Anyway, he also Type-1, and also wears a Guardian CGM and an OmniPod.

As we were installing software and testing headsets, our mutual BGL followed an amazingly identical excursion path from Deb’s low-fat-diabetes-friendly-gluten-free dinner (Julia Child’s Hell). At about 250 or so, Rick was contemplating a correction. He plugged the numbers in and OmniPod suggested something in the neighborhood of 3.8 units to bring him back down to target. “What do you think?” he asked me.

I think you’ll kill yourself, I said. I checked my IOB screen and saw that I had 7.3 units in my body with a duration of action at right on three hours. My pump pays attention to all insulin. OmniPod, Ping, and Paradigm all assume that if you took insulin for food you counted right. In their minds, scissors cut paper, rock breaks scissors, and carbs cancel insulin. In my mind, even the best of us never count our carbs right. I like seeing the whole picture.

Interstinly, although not necessarily actually true, I was told by an Insulet insider that when they were developing the OmniPod they surveyed Endos about which method of counting insulin on board that they preferred. 51% preferred the Med-T way (carbs cancel meal boli) and 49% preferred big picture. Why this wasn’t made a user-selectable option is beyond me. Maybe that would have made FDA approval a nightmare.

So, as you can see, the Cozmo method of looking at insulin and corrections is quite a bit different from the rest of the pack; and for me anyway, is a major key to good control. Cozmo also features the ability to have a pre-programmed basal rate for weekends that kicks in automatically, a disconnect feature that tracks lost basal while you are in a hot tub with groupies, a hypo manager that looks at your BGL, your insulin on board, and your carb/insulin sensitivities and recommends a precise number of carbs to save your ass in each individual hypo situation, rather than having to trust your luck to the rule of 15 (eat 15 carbs, wait fifteen minutes and see if you are dead or having an excursion). It also lets you pre-program a curve to increase the insulin needed for correcting highs by percentages. In most folks, the higher you go the more insulin you need to knock it down. Anyone who has taken multiple corrections on an Animas, Med-T, or OmniPod knows this. Cozmo lets us say “well, if the BGL is over 300, please increase by 15%. If I’m over 350 please increase by 18%. Of course, you can use whatever numbers work for you.

I’ve got a kid at the mid-school on a Med-T pump under my care that frequently forgets to bolus. If he were on a Cozmo I could instruct it to alarm if no meal bolus happened between 11:55am and 12:10pm, right when he should be in the cafeteria pushing buttons on his pump and eating a less-than-healthy-for-anyone public school meal.

(Rio’s mother is cooking brunch. Rio just came into the library to tell me “this restaurant is really busy today. The President and Michelle Obama just walked in.” God, I hope not, I’m wearing and lint, dust, and grease covered shirt from crawling behind our clothes dryer to try and fix the damn hose. Anyway, no question which side of the family he gets his active imagination from).

Other features of the rudely retired Cozmo pump include fancy combo and extended boli, simple temporary rates; and a few things I never use like a basal testing system, a custom meal function, and food data base. Cozmo was revolutionary in its time for a simple, plain English menu system, but frankly, OmniPod has beat the pants off Cozmo on this front.

But the party is over. Unless all of us Cozmo users can band together to buy the pump from Smiths, we are all screwed sooner or later. I’m absolutely tickled to have what may be the last Cozmo sold. With my black sense of humor, I’ve decided to name it “Custer.”

So I know that in four years I’ll need to choose something else. I also know that in four years we won’t even be able to recognize the insulin pump market as things are changing so quickly. I love my Cozmo. So do all the other Cozmo users. But in a decade from now it would like owning a Radio Shack TRS-80 personal computer when everyone else has super computers. It would be like sticking with 8-track instead of CD, or BetaMax instead of Tivo.

Back to the vultures. We all must change. Some of us in four years. Some of us tomorrow. We all need to get in a life boat before the ship sinks and set out for an island. At this point there are three islands to row towards: Med-T Shoals, Animas Atoll, and OmniPod Isle. The Hilton at all three islands has the red carpet out. And there is really nothing wrong with that.

Med-T simply moved the fastest. Kudos for nimbleness, given the size of the company. But at this point, even though very, very, very few Cozmo pumpers need to do anything, all three other players in the insulin pump market have something in the order of a 90-day come join us deal. They vary from firm to firm, but they all want you. So let us be clear here: Med-T showed up on your door step with flowers first, but now all three major pump players are wanting to marry you and have “upgrade” offers on the table. They are all putting some pressure on you by making you choose soon. Making you choose before you need too.

So should you change? If your warranty is almost up and your insurance will buy you a new pump: yes, you should change. If you really don’t like your Cozmo, you should change. Some folks like the idea of the tubeless Pod approach. Some folks like the sound of using the Ping to control a traditional pump without taking it out from under clothing. Some folks need integrated CGM. (I would, however, say that it would be better to wait if that is your motivation.) It won’t be long before all the other pump folks have CGM working with, talking too, part of their pumps. Before the ball drops in New York this year I expect to see more than one new CGM enabled pump. This more than anything else, is probably why Smiths lost their nerve. They saw the future. And it was expensive to get there.

So why do so many people harbor the kind of hostility for Med-t that is usually reserved for Microsoft? Because they are viewed as the 850 gorilla in the diabetes biz.

But I am here to reveal a secret. They are not. Animas is. By a long shot.

In 2008 Med-T rang up 2.81 billion dollars in sales. Yep, billion with a “B.” Remember they make artificial hearts and all kinds of non-D stuff too. They’ve got about 17.4 billion in capitalization; the equivalent of money in the bank.

J&J, who owns the Animas pump, rang up 17.75 billion in sales with capitalization of 41.37 billion. J&J made more in one year than Med-T is worth. J&J’s pockets are deeper than most medium-sized countries. Lucky for us they don’t have an army.

No wonder Smiths, an English company with ’08 sales of only a hair over a billion dollars was feeling ill-equipped to get into a row with these two.

That said, tiny Insulet Corp, makers of OmniPod has to use the ‘M’ word instead of the ‘B’ word. They rang up only 20.81 million in 2008 with capitalization of 108 million. If they can kick Med-T’s ass without an established, loyal, and fanatical customer base; you’d think that Smiths could have made a better go at it. They weren’t even losing money; they just didn’t want to spend anything to go to the next level.

Anyway, the point is, in all of the David-and-Goliath drama, don’t hate Med-T for being big. Med-T isn’t the big player.

It is Animas that casts the long shadow.

Monday, April 20, 2009


Yeah. It is true. I gave my intern fleas.

Well, I didn’t personally do it. But the flea bitten buck stopped on my desk. Yet another hazard of rural health.

You might, or might not, recall BabyDoc--the second-year medical student who worked with me this last summer. BabyDoc just loved home visits; where we go out into one of the 16 small villages that line the river and bring medicine to the folks who can’t get to us.

For the most part, despite the crushing poverty in our service area, homes are neat, clean, and welcoming. I’ve been in adobe homes with dirt floors that were so clean we probably could have done brain surgery in them, no problem.

But other times….well, other times you get fleas. Both BabyDoc and my full-time assistant got chewed to pieces at this one place we visited. Somehow I escaped. BabyDoc took it in stride. Every breath of life is a great adventure for her. My assistant is still suffering post-traumatic stress syndrome.

But what reminded me of this notorious home visit is the fact that I’m feeling flea bitten today. The tape that holds Navigator in place really is making my skin itch. Scratch-scratch-scratch-scratch. I dig my fingernails into the clear bandage around the base of the transmitter; but like wearing a cast for a broken leg, I can’t reach the part under the frame where it itches the most.

The Abbott tape is unlike any other I recall. It isn’t porous like IV3000. So the skin can’t breathe. It has no soft cloth-like lining like you get on all infusion sets. And it is BIG. I’ve entombed a patch of skin more than three inches long and two inches wide. That’s what? Six-square inches of itching skin? Barbaric.

For me at least, it seems to hold pretty much like super-glue. After removing the first one, I had a bright-red oval on the back of my arm for days.

Well, unlike fleas, at least tape doesn’t lay eggs.

Saturday, April 18, 2009

Bonus post: Papa Bear, Momma Bear, and Baby Bear

My little Type-3 is quite overweight, and this causes me some worry, given what I do for a living. When he was real little, he use to come to me and ask me to check his blood sugar all the time. Now that I actually want to check it, I can’t get near him with a lancing device.

It was my friend Fox who came to my rescue. When we had lunch together a month or two back she mentioned she had a limited number of Presto meters in colors other than blue. I got quite excited about this as both Deb and I use the Prestos so that the family has universal test strips; but we are always mixing up meters. For me, that doesn’t matter so much as I download the CGM stuff to see what’s going on with my Diabetes, but mixing some of my T-1 readings in with Debbie’s T-2 downloads gives her a heart attack.

So after a minimal amount of pleading, begging, groveling, and so-forth; Fox gave me a couple of Red meters so we could have his-and-hers meters. Yep, we are one big happy chronically ill family here.

A couple of weeks later it occurred to me that my son is a remarkably possessive person. He doesn’t share well, won’t ever throw anything away, and basically reminds me of a mythical dragon sitting on a hoard of gold coins and gems. I thought that maybe if he had a meter of his own, like ours, but different, he’d want to use it. Then I could keep an eye on his blood sugar now and a again and reassure myself that he isn’t developing diabetes.

I emailed Fox with my dilemma. She had shown me a beautiful metallic white meter. It glowed like a giant pearl. Just what every fire-breathing dragon needs. Fox only had the one, and wasn’t really too interested in parting with it. In the end I applied a guilt trip that would have made a Jewish Grandmother proud. She caved and sent Rio the meter and the sweetest note. She told him she was a Type-1 like his Daddy and that this was one of the few White Prestos in the whole country. He loved it.

After dinner Rio brought me his shiny new White Presto. He got a strip out of the vial by himself, got it in the meter correctly and then asked for help with the "poker."

I set the lancing device to "1," kept gentle pressure, and lanced the side of this thumb. We got a nice size blood drop, more than needed.





GASP!!!! BGL 395!!

I don't think either Debbie or I could breathe for minutes.

Rio is asking "Is that a good number, Daddy?"

Well, that's a little high baby. Wash your hands really good and let's re-test.

Big frown from R.

"Can you use the other thumb? This one is still recovering."

You bet.

Snap. Squeeze. Damn. Drop is a little too small. Don't want the lance the kid a third time, but we HAVE to know.

I gently massage his finger, I know I'm mixing in interstitial fluid. Will the fancy hematocrit counting Presto meter compensate?





BGL 117. Thank God.

Debbie quickly crosses herself.

Daddy needs a drink. Maybe two.

So WTF? Where did the breath-takingly high number come from? I have a theory. Rio had just eaten a hamburger with ketchup. Seven-year-olds can be somewhat messy eaters. Ketchup is chock-full of sugar. I’m betting / guessing that he had ketchup on his thumb and the 395 reading was more about the amount of sugar in the ketchup than in his blood stream. Still. It was a hell of a moment, and lord only knows how many years it took off my life.

But it is a good reminder to us: a clean test is a good test. Failing all else, at least suck on your finger for a quick moment before testing; and any time you get a number that seems out of line, test again.

Friday, April 17, 2009

Low down dirty dogs

1649 hours.

! Predicted low glucose. Arrow 45 degrees down.

Ah ha! Despite quite a few lows and highs (me: great tour guide, not such a great role model) since the shootout began, this is the first predictive Navigator alarm. I had already decided the predictive system wasn’t worth a shit. Guardian’s is nearly flawless.

But Guardian, right now is show smooth sailing at 116. Hardly an emergency in the making. I get my Red Presto out of my cargo pants.

Click, snap, slurp. Holy crap! 71. I’m wearing two fricken CGMs and a hypo just snuck up on me and whapped me upside the head. So much for technology. I should get one of those hypo-sniffing service dogs and the hell with all the gear. It could sniff out patients too. I’ve had two diabetic patients “go hypo” in my office this week.

I down a bottle of glucose liquid.

1657 hours.
Presto 79. The sugar is doing its job.
Navigator 84 with 45 degree down arrow.
Guardian 104.

1707 hours.
Presto 96.
Navigator 79 and level. She never reached the low threshold at 75.
Guardian, late to party, predicts a low. Current SG 90.

And I bet dog food would cost less than these damn sensors too.

Next time: with dogs come fleas

Thursday, April 16, 2009

Transmitter troubles

I can see myself in the very corner of my computer screen, and I look like an air traffic controller. I’m in my comfy desk chair at the clinic, a large professional-looking headset covers my ears. A boom microphone sweeps down from the left ear, parking a foam-covered disc in front of my mouth.

United two-niner-four, turn east 120 degrees, maintain two-thousand-feet, watch for traffic….

But of course this has nothing to do with airplanes, damn it. We are actually talking about heroin.

On my computer screen, like the old Hollywood Squares game, I see my colleagues from around the state. A diabetes educator from the far southeast has a worry. She was helping a new dx learn to take insulin shots when the patient’s helpful girl-friend piped up with the advice of “it’s just like shooting up, only you use your stomach rather than a vein.”

Initially dx’d as a T-1; that diagnosis is in doubt. You see, when a T-2 gets really, really, really high (say 800 or 900 BGL) they suffer glucose toxicity. The beta cells in the pancreas, in the words of my Endo-friend Dr. Colleran “freak-out,” and shut down. Temporarily. Once the sugar is down they fire up again.

This guy is from a heavy T-2 family, and he is quite obese. His diabetes educator, pretty convinced he is a T-2, and worried about the “shooting up” reference, is asking for thoughts from all of us. Should she move him to orals? She’s worried he’ll shoot heroin with his insulin syringes.

I listen to this nonsense for as long as I can stand it and un-mute my mike. And, why, exactly, would we want him not to have clean needles? I ask. There is a collective embarrassed silence. Instead of cutting him off from needles if you think he’s shooting up, I think you should give him twice as many as he needs.

Then my belt vibrates. Bzzzzzzzzzzzzzzzzt. It is Navigator phoning home with some sort of system alarm.

! Tx Battery Exhausted

You’ve got to be fucking kidding me, I mutter to myself, making sure I have re-muted my mike. It is day two of the sensor. When I put it in, I checked the battery level first.

Main>System>Status>Transmitter status> TX Battery 75-100%.

Now I’m dead in the water. Becalmed. Rudderless. Navigator refuses to navigate.

Like a toddler, my Navigator has gone from full speed to fast asleep in the middle of the living room floor, butt in the air. That, in a Navigator monotherapy environment would leave my butt in the air too.

Of course, I have not bothered to put a spare 357 button battery in my Go-Bag. Not that it would do me any good. The sensor is now “officially” dead and needs to be replaced. Of course I also do not have a spare sensor with me either. Are you kidding? Do you know how big those suckers are? No? Well, I’ll tell you. Five-and one-half inches long, five inches wide and nearly three inches thick. They are big.

Not something I’d want to lug around all day everyday just-for-incase.

And what good would it do me? If I put on a new sensor I’m still faced with a ten hour wait. I’ve never, ever, ever had the rechargeable Guardian battery crap out on me and it only sits in its charger about 15 minutes every six days.

So I’m pretty disgusted right now.

To add insult to injury, the damn thing continues to alarm every fifteen minutes for the rest of the work day to remind me that the fucking transmitter battery is dead.

Hey, I’m not working. Yeah, I know.

Hey, I’m not working. Yeah, I know.

Hey, I’m not working. Yeah, I know.

Hey, I’m not working. Yeah, I know.

Hey, I’m not working. Yeah, I know.

Hey, I’m not working. Yeah, I know.


Daddy needs a drink.

As this sensor wasn’t on the job for very long, Deb and I decide to try and fire it up again. OK. So the transmitter is supposed to lock into the plastic concrete form that is glued onto your arm. The be-careful-you-don’t-break-it arm slips through a little hole in the frame through a hole on the computer-chip like sensor, to help hold the whole array in proper alignment. At the back/bottom side of the transmitter is a little nub that sits in a hole on the frame. If you can hold the frame down against your skin while lifting the base of the transmitter you can slide it back off the frame, boot it back up again telling the system that it is a new sensor and you can keep running it for another five days.

It is nearly impossible to do this yourself if it is on your arm. You need a spouse.

I screwed around with in for almost 20 minutes with no luck. Deb got it off in 20 seconds.

I pull out the offending battery and toss it in the trash, and put a new one into the grey plastic club cracker. I slide the transmitter up the rails of the concrete form and snugly push it into place. It is a soft connection. No reassuring snap or click to tell you everything is good with the world.

Navigator vibrates in my hands, telling me a new sensor has been detected. I feed her the lot number and…

…and I get the hour glass. The ten-hours begins.

Ha! Tricked the system. Take that Abbott. Take that FDA!

Thump-thump-thump-thump-thump. Helicopters? At this time of night?

Ut-oh. FDA SWAT team on the roof….

Next time: low-down-dirty-dogs

Wednesday, April 15, 2009

Ups and downs

So speaking of dropping; I was very impressed with the bottom end of the sensor performance of the Navigator. On the first sensor I was once in the 70s and the Navigator was on the ball, and not even late to the party. During a deep, fast drop it kept up with the frequent Presto finger sticks really well. I can’t say, at least not yet, if the sensor is actually better than Med-Ts. The Guardian does lag quite a bit on steep drops. This is partly because of the time lag between interstitial fluid and capillary glucose (true of all CGM systems) but also because of sampling lag. Guardian updates every five minutes. Under normal circumstances, that’s more than enough. But if you are dropping fast, you can go a long way in five minutes. This inherent defect in the system is brilliantly addressed using the slope and predictive alarms. Nonetheless, this seems to be the issue that pisses people off the most. Navigator, on the other hand, updates every minute, and I think that this is why she tracks so much better during a drop. I guess 240 seconds makes quite a difference.

Either way, whether by sensor design or sampling speed: Navigator more accurately reports during a steep drop. Navigator one. Guardian zero. In the same vein, Navigator more accurately reports rebound recovery following a hypo. Guardian will frequently show you continuing to drop after you’ve taken on your fifteen carbs; you could over correct with this “information.”

CAUTION: the observations above are based on one sensor only. Time, and more sensors are needed to know if this is the exception or the rule. I’ve got six more sensors in my stash, hopefully that will be enough to reveal the system’s dark side if she has one.

I also found that the Navigator was pretty much worthless above 200. The higher I got the more she lagged, sometimes by a stunning amount; and the less likely she was to be correct about change in glucose. Going up pretty rapidly, according to Guardian (confirmed by Presto finger sticks) Navigator still showed me flat and level. Guardian reports faithfully on highs. I guess I care more about lows, but I still found it odd. Now again, in fairness, I have a confession. My first Navigator sensor is an expired one. I had to scrounge what I could get. Some of the sensors are older than others. I started with one of the oldest just in case I screwed it up on the first insertion. It “expired” six months or so ago. Still, it was damn impressive on the low end. I wouldn’t want to drink milk that was six months old. So I’m curious to see if the current almost-in-date sensor will behave better in a brownie-laden environment.

Navigator also gets high points for easy insertion. On my second shot at it (pardon the pun) I found it very easy. The first time I covered the entire affair with the largest IV3000 bandage I’ve ever seen. It was the mother of all IV3000’s. This time I’m going without and hoping the tape on the sensor tray holds up OK for me.

So despite generating a significant amount of trash, the Navigator insertion is superior to Guardian. Navigator one. Guardian zero. Navigator is a much smaller diameter sensor probe, and it goes into you at a 90 degree angle. It is minimally invasive. But is it as secure? That is the possible downside for highly active folks. Guardian is a whopping 18 gauge needle.

It can be painful. The angle is 45ish degrees, and it is long. It can tag muscle tissue in lean folks, which is very painful. Having worn them for many years I can attest to the fact they are destructive enough to cause some built up of scar tissue (also true of the much smaller infusion sets). Sometimes inserting a Guardian sensor can be very painful. Other times not at all. Putting in a Navigator is pretty much the same as putting in a pump infusion set if you use one of the inserter devices. More of a pinch sensation than pain, per se.

Especially for kiddos, I think the Navigator would be better. Of course, the system takes up more skin landscape, and the receiver is bigger too….so….

One nice thing about the Navigator alarms is that they are at least decently loud. On the high setting they’d probably wake most folks up. I’d still like a higher option for heavy sleepers or winter coats. What bugs me about alarm volumes on these devices is that we can CHOOSE. So why not give us a decent number of choices? Why only Baby-bear, Momma-bear, and Poppa-bear? Someone out there wants Mouse-bear. I want T-Rex-bear.

Next time: transmitter trouble

Tuesday, April 14, 2009

Last of the Mohicans

After six months on the current Pres insurance plan, and five appeals it finally happened. I got a brand new pump of my very own.

With Smiths on the rocks, I had to make a decision to either go home with the girl I brought to the dance, or….

It was not an easy call.

I’ve worn OmniPod and liked it a great deal, but I’m a klutz and kept knocking pods off. I lost three in one day and my wife reminded me that in all my years of tethered pumping I never pulled out a single set. I also had some issues that I think were caused by the two wireless devices. I’d lose telemetry between pod and PDM. It shouldn’t matter, you don’t necessarily need to have your PDM with you; but in my case it would lock up, crash, and I’d have to reset everything, including date and time, and put a new pod on. It was a pain in the ass. That said, I’ve got quite a few patients on Pods and lovin’ them.

Animas looks pretty sexy. Nice shape. Color screen, not that you need one on an insulin pump. I like the Ping concept. Tethered pump, but controllable from the glucometer. Kind of best of both worlds in terms of no pod problems but off-the-belt control. You could even wear the pump under clothing. But I’ve never worn one. I have asked at least three times to try one out… but it never happens. Not going to commit myself for a life-time to something I haven’t road-tested. I’m told by my various spies that insurance plans are increasingly starting to refuse to replace out-of-warranty pumps. As long as it works, you are stuck with it. That also means when you break down, and you will, you’ll be pumpless for quite some time while you fight with your insurance for a new one. Animas wise, I was also worried that while Pres would probably pay for the pump, they would not cover the strips (One Touch) that would make the Ping so much fun to play with.

Med-T is too big a pain in the ass to use, and the CGM features I adore from the Guardian aren’t part of the package yet. If the next-Gen pump ever comes out and has Guardian-like features I could happily learn to deal with any shortcomings to have one box on my belt; but at this point it is not worth it.

And bottom line, the Cozmo pump rocks. It is the only pump that calculates insulin on board in an intelligent manner. It has the awesome disconnect feature that replaces missing basal while unhooked. It tells me how many carbs to eat to get out of a hypo without rebounding when the shit hits the fan. It is reliable and rugged. The menus are simple, clear, and direct. Even though it is an endangered species, I love it enough to take the last one. I know that I’ll be fully supported for exactly 1, 460 days. And then I’ll be on my own. Maybe some smart lean little company will come along and manufacture Cozmo pump cartridges for us until the last duct-taped Cozmo bites the dust. Who knows? I may be Cozmo pumping for a decade. Maybe until the cure, but I doubt it.

You may think I’m crazy. But I’m happy take that last Cozmo pump, thank you very much.

Monday, April 13, 2009

Shot through the heart with the TRU arrow

“Shot through the heart,
And you’re to blame,
Honey, you give love a bad name.”

--Bon Jovi

So I can safely say that so far, what I hate most about Navigator is the long spool-up time. The thing I hate the second most is the lack of user-adjustable snooze alarms. If you are high or low she’ll pester you every fifteen minutes, until her batteries run out our your BGL recovers. But for a change of pace let me talk about what I DO like about the system.

In no particular order, as I have not infused enough caffeine yet today: how do I love thee, let me count the ways….

With apologies to Huge Heffner (who even at, what, 102 years old? is more of a “man” than I): three girls in bed with me is just too many. I’ve got Guardian, and Cozmo, and now Navigator. Oh, and on rare occasions, my wife. That’s four girls in bed with me. I’m too old to enjoy that. So one thing I discovered and loved is that Navigator will work on my nightstand. She seems to have a more robust signal strength than Guardian.

Officially she has a ten-foot range, but my experience, in medical devices that use wireless the rage is always much less than the published figure. I suspect radio range is tested in large empty warehouses by naked people. Probably Heff tests them for the FDA. Guardian will not work for me on the nightstand, she loses telemetry. In fairness, part of that may be my choice of sensor location. I wear Guardian sensors on my legs. I have for years and years, since the original Garage Door Guardian.

I get much better sensor performance and accuracy with Guardian on my leg than on my stomach. I tried to place one on my arm a month ago and it went….badly. I still have a bruise. It went in with no trouble but preformed badly and starting hurting. I pulled it out the next morning to a hell of a gush of blood. Our white porcelain sink looked like a murder scene. Oh, that’s your tip for the day, if you’re gonna murder someone make sure that there is no white porcelain around. Damn hard to get blood off of. I was late to work. When my boss asked why I was running late I said Oh I was having a hard time cleaning up a murder scene. She just gave me the “why do I waste my time asking you anything” look and went back into her office.

But once again, I’m off track. Because I wear the Guardian sensor/transmitter package on my leg, it is both further from the night stand and buried under more blankets and so-forth than the Navigator sensor, which I have on the back of my upper arm. Might or might not have a thing to do with it. I suspect that Navigator has a more powerful transmitter than Guardian, but I wanted to present all the evidence to be fair.

OK, now this is embarrassing, as I spent quite a bit of time trashing the TRU arrow…but…I like it. Yep, I confess, this is one of those things, like calamari, that you really have to try to appreciate. In fact, the entire Navigator “dash board” is much more user friendly than I had given it credit for. The read out is large and the screen contrast is excellent, especially with the back light on. Tied in with this, I don’t recall if I talked about the belt-clip/holster discovery yet. On first looking at it I bitched about how thick the clip was. It turns out this is an articulated clip, allowing you to quickly angle Navigator perpendicular to your body. Think boy scout with compass on belt.

The bottom line is air-plane style information.

When you are flying a plane it is a really good idea to spend most of your time looking out the windshield so you don’t hit stuff like other airplanes, cell phone towers, or mountains. So the instrument panel is designed to deliver information to us in an instinctive and graphical way, just like a quick glance at a traditional watch can tell you the time with no brain power. Now no one has developed a fuel-gauge-style blood-sugar-level graphic (but it is a good idea). But maybe we don’t need it. From the day we are given our first glucometer (hopefully the day you were dx’d) we have to think about NUMBERS.

Not only do we learn numbers, we learn to obsess over them. “Good” numbers make us happy. “Bad” numbers make us angry, sad, or in need of a stiff drink. Or cake. Neither of which will make the bad numbers better. Of course a number is only a number. You can’t take it personally. Easier said than done, I know. Numbers are no more than information. I say rejoice in bad numbers because it is good information.

CGM gives us numbers in a new dimension. Before CGM numbers were two-dimensional. Flat. Isolated. Poured in concrete. A fuzzy, grainy snap shot of one single second in a day that has 86,400 seconds. CGM allows these numbers to jump into the world they really exist in. Paintings become sculpture. Photos become movies. The flat two-dimensional number becomes a living, breathing, three-dimensional object. The value of the information sky rockets to the tenth power and beyond.

Is a BGL of 104 good? Sure, if you just woke up. No so much so if you took 14 units of fast-acting insulin an hour and a half ago. Is a BGL of 278 bad? Maybe. Maybe not. If you were are 392 a while back and you are dropping nicely it should be considered “good” as you are improving on target.

So the TRUTH about the TRU arrow is that it works. Well, damn. I hate being wrong. But there you have it. Navigator’s compass rose arrow is damn handy. Picture me driving home from the clinic. Some evil bastard has left home-made brownies on the carb table at work. I resist them until 3pm when my energy wanes along with my will power. I scarf and bolus, but it is too much sugar for my poor little pathetic diabetic body. Fast acting insulin really isn’t fast enough. Before leaving for home I’ve hammered away at the high with two correction boli. And being a control freak…err….enthusiast… I even add a little to each bolus. I’ve probably stacked my insulin. This could have a bad outcome.

So I’ve got the radio cranked up. The cruise control set at 80 mph. Did I say 80? I misspoke, I meant to say I had the cruise control set at the speed limit of 75 mph. I’m smoking a Falcon pipe and enjoying the fact that the sun is still up. Not long ago I was driving home in the dark after sunset.

To check my “sensor glucose” I have two recipes.

Guardian. Without taking eyes off road, each down, quick flick of finger frees her from the holster (yes, I’ve dropped her on the floor of my car a few times). Next press SHIFT and the DOWN arrow at the same time to turn on the back light. Guardian backlight is that eerie green that reminds me of the night lights my Aunt Dora had in nearly every plug in her house. Guardian (and Navigator too) have Liquid Crystal Display screens. These tend to be low contrast and in some lighting conditions impossible to see. Shit…err…Shift and Down at once is a two-handed operation. No problem. The car practically drives its self and I can clench the pipe in my teeth. I keep Guardian on the six-hour screen, so I get a number and to the left a trace that allows me to put that number into perspective. I also have some arrows to warn me if the changes in the last few readings are happening pretty fast. I generally hold Guardian on top of my steering wheel so that I can more-or-less keep the Pt Cruiser in one lane or the other while looking at the sensor glucose numbers and studying the graph while also more-or-less looking out the windshield to make sure I don’t hit other cars, cell phone towers, or mountains.

Navigator. Without taking eyes off road, reach down and flip unit upwards with cleaver articulated belt clip. Next, by feel, press the Down button followed by the Right button. Glance down. Navigator’s report of your sensor glucose number is BIG. The screen backlight is a blue-grey that is really high contrast. I also think that Navigator’s screen is higher resolution as things don’t look quite so “bit-mappy” as they do on Guardian. So you have this BIG ASSED number and then you have this BIG ASSED TRU ARROW that tells you the direction and speed of the flow of your glucose. Slow lazy and flat; moving up or down faster than is strictly healthy; or the shit is hitting the fan fast.

Oh. I’m at 110 and dropping like a fucking stone. The TRU arrow is pointing straight down. As she’s on my belt the arrow is pointing at my stomach, threatening, all set to eviscerate me. I’d better do a fingerstick….

Two cherry slices got me home alive.

Next time: ups and downs

Saturday, April 11, 2009

Bonus Post--A bittersweet goodbye

Like the arms of a lover wrapped around my body, she comforts me, welcomes me home. For a time I feel great peace. But then it hits me. This isn’t welcome home, this is goodbye.

Great sorrow washes over my body and soul like water. Sorrow mixed with relief; and guilt for that relief.

It is the final day in the lab. For two decades this operation supported us. Toiling under the orange glow of safelights is a mix of work and play. A blend of precision and creativity.

Celtic music wafts in the air. The looming shadows of the giant enlargers cast their ghostly negative images onto the light sensitive photo paper. The hum and vibration of machinery. The gurgle of water. The acrid smell of fixer.

I first walked into a darkroom when I was 13, that was thirty-three years ago. Now I have to walk out. Darkroom work, endangered by the digital revolution to the point of near extinction, is like nothing else. It is one-third art, one-third science, and one-third technology. It is magic.

Today, I thank God I developed diabetes, as it gives me purpose. I cannot imagine the dark place I’d be in at this very moment with the lab gone and no purpose in life. I love my new life. I love the fact that I can have a hand in making someone healthier every day. I love my co-workers, my patients, my D-kinfolk far and wide. I love the power of the written word to reach those I cannot touch directly. But it is hard to let go of the old life. To know this is the end of a great book. To have to close the cover and set it aside.

There was a time when I was a master B&W printer. One of the best. But I did it every day, for hours and hours and hours. Skill at that level is like body building—you won’t win the Mr. Universe title working out four hours per month. I know I’m not as good as I used to be. Not by a long shot. I’ve gotten fat and flabby sitting on my metaphorical couch. There is simply not enough printing work left to be done for me to stay sharp. An era has past. I’m the best damn flint knapper in the history of the human race at the time when bronze spear tips have come onto the scene.

Today I also feel just a hint of what it might be like to have Alzheimer’s. I’ve not been into the lab for about six weeks. I let the final orders piles up. Maybe I couldn’t quite face the final act. All my life I have done this work. This very darkroom has been my home for over a decade…and yet…and yet while nothing has changed my hands can’t quite find what they reach for. Tasks that were as automatic as breathing before now leave me scratching my head. What’s the processing time for T-Max? Ummmm…. Was the warm-tone paper on the right or left side of the paper safe? Why am I having trouble loading the film onto the stainless reel? Crap. I can’t believe I forgot to turn on the paper processor.

Skills not exercised grow rusty. Knowledge not used is lost. The hands, as well as the mind, have memory. But only for a time. What we do not use, we lose. Tasks I was once the master of I can now barely accomplish at all.

Darkroom work is a solitary task, and over the decades I’ve spent countless hours working by myself, but never feeling alone.

But that is not true today.

Today I feel more alone than I ever have in my life.

Friday, April 10, 2009

Vulture update

Just learned Cozmo refugees can jump ship to Omnipod for $49.99 for both controller and a month supply of pods.

My take on this is the same as the Med-T offer. If you have more than half of your warranty left and love your pump don’t do anything. If you’re itching to be un-tethered or if your warranty is counting down, this is another damn fine offer.

Random thoughts on the first week

So the gunfight at the DM Corral has started. Bullets are flying everywhere. The blue-grey gun smoke is so heavy I can’t tell who’s still standing, who’s been injured, or if anyone is lying in the dust bleeding to death.

As I write this I’ve had five days of Navigator CGM under, well on, my belt and I’m now cooling my heels for ten hours waiting for the second sensor to fire up. Luckily I have my “first wife” CGM still with me, watching over me, protecting me. Without Guardian on the job I’d be plowing though one hell of a lot of test strips right now.

Guardian is ready to fight in about two hours while Navigator sits useless after a sensor is inserted for at least full ten hours. The official bullshit line from Abbott (Taken from “Healthcare Professionals: Frequently Asked Questions”):

“Abbott Diabetes Care is committed to making its products safe for the user. Soon after the insertion of a sensor, there are physiological processes that happen as the sensor and the body equilibrate. These processes are part of the body’s natural response to a foreign object.” They go on to say the amount of time this takes varies from person to person and time to time. “We have found through our research and studies that it is not always easy to accurately measure glucose in the body when this equilibrations happens.” Abbott’s bottom line, a better safe-than-sorry time period.

Hey, in the first ten hours Guardian isn’t at her best, but at least she is on the job. At least she is giving trend info. She’ll alarm if you start dropping like a stone. I think the two hours it takes Guardian to spool up is too damn long.

Ten hours for the hypo-unaware is a life time.

Or a death.

Both the first time, and last night, I put Navigator sensors on at night. Now real world, if this was my only option, no way would a be putting on a new sensor at this time of day. But I have Guardian to watch over me at night and ensure I wake up. If Navigator were my only CGM I’d hook up in the morning and test like the dickens for the ten hours in the daylight. Better to die awake than die in your sleep, I always say.

You cannot pre-insert your next sensor and let it equilibratize. Pity, that would totally solve the problem; both from our perspective and Abbott’s. You could put one in the day before you need it, hold it in place with a dummy transmitter and when you were ready to rock it would be ready too. The idea probably never even occurred to them.

I guess if you were Bill Gates rich you could buy two Navigator systems and wear them to over-lap by 24 hours. I’m not Bill Gates rich. Sigh. Oh, speaking of money, this is a great time to remind you to buy my book. If you already have please disregard this plug and accept my thanks.

Living with Navigator is like having a tiny little TV screen on your belt, both in terms of size, shape, and quality of its blue-grey light. Of course it only gets one channel; all blood sugar, all the time. I like it. It would have blown the doors off of Garage-door Guardian, which it was built to compete with. But while Navigator languished at FDA, Med-T leapfrogged ahead of Abbott. Navigator is good, but Guardian blows the doors off her in term of features and options.

Both systems do what you need most. Monitor your blood sugar all the time, warn you when the shit hits the fan, and give you tools to better understand and control your diabetes. Either would be better than neither.

To be totally honest, there are things I like better about Navigator and things I like better about Guardian. If I could throw them in a blender and turn them into one device I probably love it. If I could add the Cozmo to the mix (Taps playing in background) I’d be in heaven.

Navigator insertion is easier, but the whole design of the plastic frame for holding the transmitter is awful. It takes up a lot of skin. Guardian, even though the sensor probe is larger, takes up a quarter of the space on your body that Navigator will.

Navigator is LOUD. I like that. I wish she had personality like the Old Guardian did. (Note: modern Guardian uses a “bee, Bee, BEE” tone for high alarms and a “BEE, Bee, bee” tone for lows; each an octave up or down from the previous, but they are so short and low in volume as to hardly be noticeable. I use the vibe alarm instead.)

Test strips. Boo-hisssss to Abbott for locking the door so that you can only use their strips. I’m sure someone in marketing thought this was brilliant, but I causes barriers. Anyone on Fucking Presbyterian will have a hell of a more difficult time getting covered for Navigator. Which is actually ironic, as Pres has been one of the better insurance companies to have if you need CGM. They have been pretty good about accepting it as a benefit, especially for the hypo unaware (just God help you if you need a name brand drug or a pump). But Pres, at least in my neck of the woods, will only pay for Accu-chek strips. Period. And what if strips get lost?? What if meter craps out??? Abbott was being greedy. They could easily have had both the built-in meter and a way to enter a stick from any meter just like insulin pumps. Hmmmmmm….maybe Abbott is wearing the black hat.

And speaking of black hats, who ever designed the alarms for Navigator is not diabetic. The alarm designer for Guardian probably is. Navigator alarms every fucking fifteen minutes as long as an alarm condition exits. I guess the Abbott team has nooooooooo idea how long it can take to turn a stubborn high around. Even with a heavy bolus, three hours or more might pass. The only solution Navigator offers is a one hour muting of ALL alarms. That would include your low alarm to. Great. Just fricken great. And, to add insult to injury, there is no way to un-mute the muted alarms. Once you choose that option you can’t un-do it. Navigator will be silent for one hour.

Guardian on the other hand, lets you independently set a variable “snooze alarm” for both highs and lows. For instance, I set my high snooze at three hours. If I go high then it tells me and I take a correction bolus. But that high sugar is not going to go down right away. Why be pestered by more alarms? If I keep throwing insulin at the problem too often I risk “stacking,” which leads to low alarms. Lows on the other hand spook me. I let the Girl tell me every 20 minutes if I’m still low.

So we rode in to town on the stage coach this week. Me, Cozmo, Presto, the new kid, and Guardian riding shot gun. What are the odds that the whole crowd could agree on anything?

Well, it may surprise you, but every once and a while the two CGMs read exactly the same. When I was a kid we went on a family vacation “back East.” Amongst other places we went to Gettysburg. I remember seeing a beautiful metal flower at a museum. It was created when two bullets hit each other head on. What are the odds? Well I guess if you have an infinite number of monkeys on an infinite number of word processors one will write Shakespeare by randomly typing, right?

Next time: arrow to the heart

Thursday, April 09, 2009

Here's looking at you, kids

So I went into Photoshop and rescaled downloads from CoPilot, CareLink, and ZeroClick. I distorted them so the X and Y axises would be close to the same and then lined them up by time as well. The upshot, as we are comparing apples, oranges, and lemons--I wanted to try to get all the fruit on the same page. It was a huge pain in the ass, so we won’t be doing this little exercise again anytime soon.

Top is Navigator from day one, about 12 hours worth. Middle is Guardian from the same time period. Bottom is Presto. That’s my clinic presto meter, so it doesn’t have the late afternoon or early evening readings.

So a couple of things to point out. First, Guardian is exhibiting a very noisy trace. This happens sometimes, but is pretty rare. This particular sensor on this particular day was really acting crappy. As speculated yesterday, I could be RF interference from the other CGM. Navigator’s trace is much smoother. Of course, they might polish the data during the download, but it seems to me that both traces are accurate presentations of what I experienced with the devices on that day.

But in spite, or despite this, but the CGM curves are pretty much the same shape. We have a drop from early morning to noonish, a hospice-pizza spike, a decent to base line that is pretty rapid and then a leveling off.

The connect-the-dots Presto control strip also mimics the overall shape of the curve too.

So bottom line. Both systems, from a large over-all trend perspective work.

But which is better in the trenches for day-to-day use and survival? Ah, it is too early to tell. The real-time shootout has just begun.

Next time: a summary of first impressions using Navigator.

Wednesday, April 08, 2009

A day of much data & few conclusions

Ten hours came. Ten hours went. And still the Navigator only showed me the hour glass. No clue as to when it might calibrate. Or why it wasn’t.

Eleven hours came. Eleven hours went. Maybe my blood sugar is changing too rapidly. I’m still recovering from a correction for a nocturnal excursion triggered by Pizza Hut meat lover’s pan pizza and the new Premium M&Ms. Navigator is like an over-protective parent. It won’t let you calibrate unless conditions are perfect. Great. Just what we need. A CGM that only works when your blood sugar is perfect.

Guardian will let you calibrate at any time. Of course, if you choose a bad time your accuracy goes to hell. Still, at least this allows the flow of some information. Trend, direction, and speed. It is better than flying blind.

But I am late to work, so I fly out the door. Driving across the mesas, the rising sun at our backs, my belt vibrates. But who is talking? Guardian, Navigator, or Cozmo? I got a lot of gear on today. It is Guardian, with a fall rate. The correction boli is cleansing me of my dietary sins of the night before. Penance and forgiveness for the pizza orgy.

Now a different vibration, more baritone. Ah ha! Navigator speaks. It is asking for blood. We pull to the side of the interstate and I dig around in my cargo pockets for my vial of precious FreeStyle strips. My commuting buddy looks on with a mix of professional and personal interest. My life-support gear is the source of endless fascination for my co-workers.

I find the vial and fish out a strip. I slide navigator out of her home on my belt, and rotate her around in my hands looking for the corner that has the strip port. I find it and insert the b&w strip. They always remind me of the old “cow” boxes Gateway computers used to come in. The Navigator’s screen lights up and gives me a chance to dial in the right strip code number. Navigator uses “old style” test strips, not the newer FreeStyle Lite self-coders. It takes a long time to get through FDA.

Ready for blood, I’m now grateful for the dual-side-loading design of the FreeStyle strip. Easy to maneuver the device to the blood drop on my finger from pretty much any angle. Slurp!

Then a clock graphic appears. I am informed that the Navigator is “processing.” It seems to take a long time. 210. The Navigator asks me if this is a Control Solution. I tell it no.

Then nothing happens.

“Did it work?” asks Eve.

I don’t know.

Navigator didn’t say anything. It isn’t showing anything. Very mysterious. I check the CM status screen under “reports” and the various checklists say “OK,” but there are no details. Not much help.

I return to the main screen and there it is. Glucose CM 210. We are live!

So right off the bat, there is one thing I don’t like about Navigator. Ya’ gotta press a button to find out what your sensor glucose is. Now long-time readers who have been with me since the beginning might remember my delight with Garage-door Guardian at being able to press a button to see what my blood sugar is. But now I am soooooooo spoiled.

Modern Guardian can stay on all the time. I can glance at it and see my glucose; like glancing at a watch. Would you want a watch that made you press a button to check the time? Oh, wait. They used to make those back in about 1979. They were called LED watches. Funny. You don’t see them anymore. Probably because no one wants to have to press a button to do something that for years you could do by glancing at your wrist without pressing a button.

Of course being on all the time eats up your batteries more quickly. But that is a choice I’m happy to make. Guardian can be set to stay on or shut off. I wish Navigator had done the same.

Oh, I need to update you on the Navigator’s fat belt clip. It turns out it is a flip-clip. You can flip it perpendicular to your body to view sensor glucose…..I kinda like it….

Click-click-click-click-press. (Navigator) 166 with 45 degree down arrow.
Click-thunk. (Guardian) 214 with one arrow up.
Well….that can’t be any more different, now can it?
Snap-slurp-beep. Presto says 189. Of course a meter can’t give me trend, can it? We’ll have to wait and see who’s right.

What?! Who’s buzzing? Oh, must be Guardian, I’ve got Navigator set to squawk most of the time to see if her voice is louder (I only set Navigator system alarms, such as time to calibrate, for vibe).

Now, just a few minutes after the no-one-is-on-the-same-page checks, Guardian is alarming a fall rate. So the two CGMs agree the blood sugar is dropping. Or do they? Now Navigator shows 154 but no arrow. So…..where the fuck is the TRU arrow? Is it not being True to Me? Guardian only uses arrows when you are changing rapidly. But I thought the TRU arrow was the Navigator’s compass rose: it is always supposed to point some direction.

“The skipper he stood beside the helm,
His pipe in his mouth,
And he watched how the veering flaw did blow,
The smoke now West, now South.”
--Wreck of the Hesperus,
Henry Wadsworth Longfellow


8:45 a.m.
Guardian predicts a low. She’s at 138 with dual arrows down. Navigator shows 148 with a 45 degree angle down. The horses are at the starting gate. The race is about to begin. Presto shows 164. Hmmmmmm….too much technology can definitely drive a man crazy.

Guardian is bouncing around a lot today, which is the second day of the sensor in question. It should be running stable and clean. Yesterday, it preformed like a champ, but I was having a pretty good day with stable BGLs. We’re on a wilder ride today and Navigator only has the benefit of one finger stick while Guardian has had several. The first round goes to Navigator. I’m impressed.

I decide to access the Navigator’s graphs. Right click. Down twice. Line graphs. Select two hour. And I get a sweet little graph showing a steady drop from the starting point of 210 down to the current 145. I have the choice of 2, 4, 6, 12, and 24 hour graphs. The screen stays live long enough for me to study, but when it winks out, I’m back to the main screen again and I find myself wishing that Abbott had seen fit to let me choose my time-out time. As I’ve only been “live” a short time, the two hour graph is the only sensible one to look at. Guardian’s graphs display on a rectangular screen, Navigator on a square. Unless the rate of change is radical, I’ve always found Guardian’s 3 hour to be worthless. It is so stretched-out that it looks flat most of the time. I like the Guardian 6 hour screen a great deal. Twelve is OK too, but the 24-hour is worthless as the screen is too small for the amount of information in it. It will be interesting to see how Navigator’s screens compare.

It is now 9 a.m. Guardian shows me at 96 and still dropping like a stone. Navigator shows 136 with minimal change. Presto, always the tie breaker shows 146. (It is worth pointing out that Presto is a hematocrit compensating meter, so while closer to a lab reading, is commonly slightly higher than a conventional test strip like FreeStyle. Navigator is calibrated with the FreeStyle. That said, Guardian is calibrated with the Presto so she shouldn’t be so damn far off. Right now, Navigator is performing much better in a state of rapid change. But this is only the first hour of the shootout. Too soon to jump to conclusions (or jump ship).

9:30 a.m. Guardian, predicting a low 15 minutes ago, now gives a rise rate alarm, followed by a high. She’s showing 174 with two arrows up. Navigator shows steady at 120. Presto shows 130. Guardian seems to be having a nervous breakdown today. Is she jealous that I’m courting a new CGM? Women!

Or….I’m wearing two wireless devices. Could one be somehow interfering with the other? So I don’t know what the fuck is up with Guardian today, but Navigator is showing a very nice Cozmo-driven correction bolus from this morning.

9:45 a.m. My belt buzzes. Bzzzzzzzzzzzzzzzzt. Long and steady. Guardian is more like a wood pecker. Bzzzt. Bzzzt. Bzzzt.

Yo hablo Medtronic. Yo hablo Abbott. I am learning.

Navigator wants a BG test for her second calibration. Has it been two hours? I guess so. Out comes the white vial. BG on built-in FreeStyle meter is 121. Navigator shows 115 with flat arrow. Presto calls the game at 133. Guardian, still freaking out, shows 182 with one arrow up. Now I’m set on Navigator calibrations for 12-20 hours. I’m past the worst part, timing wise. I have a wide field to choose my third cal of 4 needed over the five day run of the sensor.

10:21 a.m. Navigator 98 and stable. Guardian 164 and stable. Presto 116. Fresh cal given Guardian.

Bzzzt. Bzzzt. Bzzzt. 10:45 am. Guardian speaks up with fall rate and low predicted. She’s got 104 with two down arrows. Navigator has been silent so far today. I rotate the clip upwards (I’m really beginning to like this feature) and wake her up. I’m showing 85 and level. Presto has 103. Hmmmmmmm….

11 a.m. sharp. Bzzzt. Bzzzt. Bzzzt. Guardian calls a low at 74 with two arrows down. Navigator is steady at 83. Presto calls the game at 88. My fingers are really taking a bruising today. The sensor ISIG on Guardian is really low.

Navigator 76 level. (coasting very low, but as of yet, no predictive alarm).
Guardian 112 one arrow up.
Presto 91.

Navigator. Teee! Teee! Teee! Three brief sharp Soprano tones. High pitched, but with authority ! Low Glucose. 74 level.
Guardian 118 stable.
Presto 83.
Took sugar, 15 carbs.

Navigator 71 level. Low alarm repeats.
Guardian 114 level.
Presto 94.

Then hospice came. Well, not for me personally (thank God). They brought pizza for an in-service.


13:20 hrs.
Bzzzt. Bzzzt. Bzzzt. Guardian High predicted with two arrows up.
Navigator 127, 45 degree up arrow.
Presto 199.

Navigator seems slow to catch a rise.

Guardian 190 High Alarm two arrows up.
Navigator 137, 45 degree arrow up.

Guardian 198 two arrows up.
Navigator 140 level.
Presto 234.

Guardian 244 level.
Navigator 186 level.
Presto 251.

None of these fucking CGMs work right….

Fall rate alarm. Guardian 202 two down arrows.
Navigator 193 level.
Presto 313.

15:18 hrs.
Teee! Teee! Teee!
! High Glucose. WTF? Why didn’t I get a projected high alarm first? I double check to make sure the projected alarms are turned on. They are. Hmmmmmmmm….same tone for high as low. Bummer. I had hoped she’d have a separate voice for each occasion.
Guardian 266 one up arrow.
Presto 371.
Cozmo advises 5.15 unit Novolog correction.

When I next look, I’ve lost telemetry. Crap. I’m told I need to reconnect. Not a scary as it sounds. I don’t need to pull the transmitter out or anything. Main>System>Reconnect>Select.
Wait 70 seconds. Beep-Beep. Up and running again. Guardian will automatically hook back up following a signal loss. Guardian also stores a half an hour or so of data in the transmitter for upload to the receiver if telemetry is lost. Navigator does not.

As the day winds down I’m disgusted with CGMs, blood glucose meters, and diabetes in general. I down load the devices and without looking at the images, send them all home to view over a glass of wine.

Next time: here’s looking at you.

Tuesday, April 07, 2009

Hooking up

I peel open the vacuum packed container. Kinda like getting a microwave dinner ready to cook. I lift out a blue-grey-and-yellow handle; it looks like the controller for a video game.

Game on, I say.

We are gathered around the large mirror in the master bathroom; Rio, Debbie, and I.

It is time to hook up and head out. Time to put in the first sensor. The Navigator’s manual resting on the edge of the sink, open to the “sensor” tab, I review the directions. It seems like an appalling amount of gear compared to holding a tiny Med-T sensor, which is the general size and shape of a guitar pick.

I peel the backing paper off of the bottom of the video controller, exposing an Saran-wrap thin clear adhesive tape. We consult the copious diagrams on pages 32 and 33 of the manual. The “top” of the sensor has little vertical lines like a radiator. These need to face my shoulder. A quick argument ensues about whether or not I have it upside-down or right-side-up. My arm is raised above my head to expose the underside of my upper arm. This means to face my shoulder the top of the sensor faces down.

“Tell me if it hurts,” says Rio.

I push the video game controller firmly against my arm. Now what? I’m afraid to let go. Online, I’ve read the tape that holds the sensor on is “crap.” While maintaining pressure, I reach up to the yellow key on the top of the “sensor delivery unit,” the video game controller. I’m to twist it 1/4 of a turn in either direction.

I feel like I’m arming a bomb.

I gently twist.

The yellow pin falls free and lands in the sink. Clink! Debbie gasps, “was that supposed to happen??”

Yeah, don’t worry about it, it is just the safety.

“The safety just fell in the sink?” she asks.

Step 12. Insert sensor. The manual warns me: “Caution: do NOT press the button until you are ready to insert the sensor. Doing so may cause unintended results or injury.” Well, I’m ready….

My finger rests lightly on the trigger. Two sets of steady brown eyes regard me, unblinking. Gently I increase the pressure of my left index finger on the trigger not knowing what to --


I freeze. I feel….nothing.

“Well?” demands Deb.

I think it is in.

“How do you know for sure?”

Ummm….Well… I don’t know….

Now I squeeze the two blue buttons on either side of the tower and it falls off in my hand. All that is left on my arm is a grid of smoky grey translucent plastic. It looks like a miniature concrete form.

Danger: construction zone.

The sensor looks nothing like Med-T’s wicked little golden rocket-needle. This thing looks like a computer chip. It is square. The manual tells us that if it is in right we’ll see “the tip of the sensor is inserted under the skin” and the sensor is supposed to lay flat in the top of the concrete form. There is a picture showing us.

The manual also tells us that if it is in wrong we “will see that the sensor is not flush against the top edge of the sensor support mount.” OK……

Well…. I’m not sure what we are seeing. Rio, bored and disappointed that no pain was involved wanders off. I squint in the mirror, squint at the manual, and squint in the mirror again.

Debbie squints at my arm, bends over to stare at the photos in the manual, then scowls at my arm again. “So is it in, or not?”

I poke at it gently. The computer chip is flush against the mount, but at a crazy angle. When I poke at it gently I feel a spike under my skin, tugging at the flesh. I guess it’s in. Well, we got nothing to lose by hooking up the transmitter.

Ah, but for that we must go to the next chapter.

Following the text and pictures we slide the battleship grey club tracker up the rails of the concrete form. I expect the transmitter to snap snugly in place. It does not. I’m staring at the directions, skimming the text and looking at the drawings. I’m clueless. Of course, a real user would probably get some training.

I pick up the receiver and start skimming through the menus when it vibrates in my hands. Working my way backwards to the main screen I find a email waiting for me.

New Sensor Detected.
Have you recently
Inserted a new sensor?

Hell yes.

It asks me for the sensor code from the micro-wave dinner box. I enter the code and then…

Nothing happens.

Not one fricken thing.

Then I see it. A tiny little hour glass. The system is waiting

It will be a long wait.

Next time: late to the party

Monday, April 06, 2009

Test strip woes

I was ready to rock. Then a rock fell on my head.

Navigator is out, batteries are in, she is all programmed and ready to go. Transmitter is out, battery is in, she is linked to the receiver and ready to go. I have a sensor package on my desk. I’m doing a last minute read-though of the insertion-and-hook-up processes.

OK. OK. Yep. I think I got it.

I glance ahead to the calibration chapter to double check times and procedures. Then it strikes me. I haven’t read a word about manually entering a fingerstick. With increasing alarm, I shuffle back and forth though the User Guide. Next I fool around with all the menus and buttons. You gotta be fucking kidding me.

It is true. You cannot use any meter to calibrate other than the one built-in to the Navigator’s Receiver. And it takes FreeStyle test strips. The old manual-coding kind. The kind I have no access too. You cannot even turn on the blood sugar testing mode of the Navigator through the menus. You have to stick a OldStyle FreeStyle strip into the port on one corner of the receiver to turn on that mode at all.


We haven’t carried OldStyle strips since FreeStyle light was introduced, what, almost two years ago? Coding errors are the bane of diabetes education. We threw away all the OldStyle meters and replaced them with the self-cal models.

Ironically, and further proof if you needed it that God as a wicked sense of humor, just last month I was given a couple of hundred OldStyle strips which I promptly re-distributed to an Un-insured OmniPod user I know whose keeping alive out-of-pocket. Definitely not someone you can be an indian-giver with.

So I call Charlotte. She’s one of my Peer Educators and she job-shares with Debbie at the private practice clinic I wrote about recently. Charlotte uses a Cozmo pump. In fact, I pushed it through her insurance and trained her on it. As she has Lovelace, she’s able to use the attachable Cozmonitor meter ‘cause they are better sports about letting patients choose the test strips that are right for them. I’m “covered” by Presbyterian who doesn’t give a rat’s ass what’s right for me.

Yep, Charlotte’s little stick-of-gum-sized meter uses OldStyle strips. That means she has exactly what I need in her medicine cabinet.

I whip out my PDA to look up her cell phone number. I dial her up on my circa 1930s rotary phone. Zzzzzt. Click-click-click. Zzzt. Click-click. Zzzzzzzt. Click-click-click-click. Zzzzzzzzzzzzzzzzzt. Click-click-click-click-click. I love the sound those old metal dial phones make.

Hey, ummmm, sorry to bother you, but could I borrow a cup of sugar?

Next time: hook up and hang out.

Saturday, April 04, 2009

Bonus post—Vultures

The single set of tracks stretched for miles across the arid desert, stopping abruptly at the collapsed figure. He lay in the scorching sands, not dead yet, but not truly alive either. With no water, and no energy to go on, it was only a matter of time before the end.

High above came a screeeeeeech and the rustle of hot wind through feathers. A vulture arrived, circling, waiting. Then another vulture arrived, and then a third.

Strangely, all three vultures were different types. The first on the scene was the most common vulture in the world: the Cathartes Medteeas. They are large and slow, but tough. The second vulture was a Cathartes Animaisis, who for reasons scientists can’t explain have been experiencing a population boom. Baby birds of this type have the unusual ability to change the direction of their mother’s flight by calling out. Last on the scene was the small, nimble, and fast-flying Cathartes Ominpodus.

Yep, my fellow Cozmo pumpers, the other three want you to join their families. I got an email from Med-T on Friday explaining how they want to help out the poor abandoned Cozmo pumpers. Quoting from their Media Advisory: “In an effort to lend a helping hand to individuals affected by this decision, Medtronic Diabetes has launched the Medtronic Cares Program.”

How noble and selfless. OK, seriously, here’s the deal; and for some pumpers it is actually a very smart move. For others, not so much. Read on.

For a limited time, send in an in-warranty Cozmo pump and two box tops and they will give you a Med-T pump at no cost what-so-ever. It won’t be brand-spanking new, but will be a refurib with a two-year warranty. They will also throw in the first month’s supplies.

The only catch is you have to fill out four customer surveys over the first year. Small price to pay for an insulin pump.

I’m guessing that the first thing that jumps out at folks is that this offer is for a refurbished pump. You know, this doesn’t bother me at all, as most Cozmo users are walking around with refurb pumps in the first place. Anyone who had bought a model 1700 had the opportunity to trade it in for free on a model 1800 refurib. It didn’t re-set your warranty clock. It wasn’t a new pump, but it had all the new features. As the 1700s flowed in they were rebuilt as 1800s and sent back out into the field.

So who do I think should seriously consider switching to Med-T? Anyone more than half-way through their warranty that’s who. If your pump is only a year or two old and you love it, don’t worry. The big bad Federal Government is our friend for once. Smith’s has to keep the clinical support people there for you until the very last warranty runs out. Of course the support folks will be out on their asses the very next morning, so as time goes by morale might suffer. Smith’s also has to continue to replace in-warranty pumps as needed for that time too. The Cozmo has a much lower failure rate than the other folks, but all man-made devices can and will fail at some point. In the last year I’ve seen a couple of cases of Cozmo pump shells developing serious cracks. I’m betting some kind of problem in the molding process; but each time I called about a patient a new pump arrived next day by FedEx.

The bottom line with Smiths pulling out of the pump biz is that even if your pump craps out at three years, 364 days after you bought is; you’ll still get a replacement. That said, when your warranty is up, be it in a month, six-months, a year…then it is all over. You’ll have to chose a new pump to love. Med-T is offering you a chance to make a smooth transition right now.

As a Cozmo user will you be happy with a Med-T pump? No. Probably not. But duct-tape will only take you so far. Four years from April 26th you will be hard pressed to find insulin cartridges for your beloved pump. Sure, you could use them twice and hold out for a while. You could watch eBay like a hawk to scoop up every last cartridge you can find. But ultimately you will have to choose a new pump. It will be traumatic, like a divorce you didn’t want. But ultimately you’ll find a new mate and fall in love again.

Med-T is asking you out on a first date. They even brought flowers.

The most cynical amongst us will say Med-T, losing new Rx market share to OmniPod and Animas are desperate to get all the Cozmo users on board. I can’t recall where the hell I read it, but I saw a statistic recently that estimated that Med-T is only pulling in 3 out of 10 new pump scripts. That’s not enough to feed an 800 pound gorilla.

But today, tomorrow, or next year, your choice is going to come down to Med-T, Animas, or OmniPod.

OmniPod is awesome and creative, but not right for everyone. If you like traditional pumping you’ll realistically have to choose between Med-T and Animas.

I’ve not used the Animas pump, so I’m hard pressed to say how it compares. They keep promising to loan me one to test-drive, but it has yet to materialize. All of these remaining pumps calculate insulin on board in a way that will be traumatic for Cozmo users to adjust to, but beyond that there are things to love about all the systems.

Med-T: a pump that can receive signals from a CGM (although only the most basic of alarms, not the full Guardian-style system); and a free-standing meter that transfers your BGL to the pump. They also have a damn fine infusion set.

Animas: with the Ping you have the option of controlling insulin delivery from the freestanding meter. Pretty cool idea. I mean, ya gotta get the meter out anyway; so why not just leave the pump on your belt, in your bra, or wherever.

OmniPod: tubeless pumping and a controller with a built in meter.

Animas is being a little lower key (so far) about scooping up Cozmo users, but on their home page there is a picture of a Cosmo pump with the bold headline “A special message for Deltec Cozmo pumpers.” You click on the link and the first thing they tell you is that their infusion sets are compatible (true, but all non-Med-T sets are luer lock and interchangeable). The insulin cartridges, or future lack thereof, will be the dagger in the heart of the last die-hard Cozmo pumper. Animas also assures us that “we are here to support you during this time of transition.” No upgrade offer at this time.

I’m told that OmniPod is scrambling to come up with a very low or no-cost switch over plan like Med-Ts, but the details are pending.

So the Cozmo ship is sinking. We’ve hit the berg. We are going down. Nothing can stop that. But it could be worse. There are plenty of lifeboats and three rescue ships just waiting. It is the end of a era, but hardly the end of the world.

On Monday: back to Navigator Adventures