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!).

Wednesday, November 28, 2012

Voices in the night

“If a sales rep suggests to you that if the alarm is too low you can set the monitor to vibrate, then set the CGM on a mirror next to a glass of ice water at night (true story!), you know the frickin’ alarm is not loud enough.”

--Beyond Fingersticks

If I’ve said it once, I’ve said it a thousand times: Your CGM alarms must be loud enough to wake the dead so you don’t join them.

So that begs the question: Will the Dexcom G-4 get you any Zombie action?

Well, it’s a hell of a lot better than the Med-T Guardian or their Revel (unless it’s talking to the mySentry, which is delightfully loud). And in many ways, G4 beats Dex 7, but sadly, not in every way.

The G4 comes equipped with what Dex calls “alert profiles.” It’s called a profile, because each of the five options you can choose from applies itself to all alerts, alarms, and prompts. It’s easy, but you can’t mix and match, and you don’t get as much choice as Dex marketing materials might lead you to believe you do. On the bright side, each alert, alarm, or prompt has its own unique sound. The manual says, “This lets you easily identify each alert and alarm and its meaning.” I say, it speaks a unique language you and your family can learn.

But before we get to the profiles, we have to talk about the gorilla. What? You didn’t notice him over there in the corner? How could you miss an 800-pound gorilla in the corner? Yes, the G4 shares a fundamental design flaw with its predecessors: The first alert is vibe only. If you acknowledge it, little Bo Peep never makes a sound. That’s nice for staff meetings, but not so great for 3 a.m. The vibe-first design all but guarantees you’ll miss the first warning late at night. What does that really mean? Well, let’s play a game.

Let’s assume you’ve left your G4 set at the factory defaults, so your low threshold is at 80 mg/dL. Never mind for the moment that there’s a good chance your sugar will get ahead of the CGM readings and you’ll already be below 80 when the alarm goes off. When the system detects an 80, it will vibrate. The audio alarm won’t go off for five more minutes. How low will you be by that time?

Well it depends on how fast you’re dropping. The G4 recognizes two speeds for its optional Advanced Alert for falling glucose—more than 2 mg/dL per minute, or more than 3 mg/dL per minute. At the “slower” rate you’ll be down to 70 mg/dL the first time your Dex squawks at you. At the “faster” rate you’ll be down to 65 mg/dL. Does anybody but me have a problem with this? Does anybody but me think the ice is a little thin under our feet at 65 mg/dL at three fucking a.m.?

Well, this is nothing new, you say. True. Dex Seven was just the same. But the Dex Seven vibe alarm was seismic. It’s hard to describe, but even though it was silent, it was robust enough to wake me up 95% of the time. A week or two ago, I wondered and worried if the new G4’s vibe would wake me from my slumber. I’ve now had enough nocturnal lows to report that, sadly, it’s not. I sleep through almost all of them. On the bright side, the G4’s voice is loud enough that I’ve not yet joined the dead. (It would be pretty creepy if I had, and was still able to blog, huh? I guess I’d have to change the name of the site to LifeAfterDeath—the Zombie Chronicles.)

So why not just move the alarm threshold upwards to a higher number to compensate, you ask? Well, I’d love to, but… Here again, we’re dealing with one of the few short-sighted aspects of the G4’s grand design. I only get one low threshold to choose from. If I choose 90 at night, then I’m stuck with 90 all day, too. And that sets me up for pack of nuisance alarms. Why not reset it every day? Because that would be a frickin’ hassle. I’d forget half the time to change it back when I got up, and forget half the time to change it again when I went to bed. Our devices should serve us, we shouldn’t have to serve them. I wish they’d designed the G4 to go straight to audio at night.

So the vibe sucks, compared to its predecessor. How’s the voice? In a word, charming. One nice feature is a preview function, so you can tentatively set a profile, then run through all the alarms to see what they’ll sound like, and decide if they’re right for you.

The alert profiles are: Vibrate, Soft, Normal, Attentive, and Hyporepeat.

In the Vibe mode the G4 remains silent, signaling you with Morse Code the nature of the alarm. Three short vibes is a low. Two long is a high. And so on. This same pattern of vibes extends across the spectrum as the first alarm in all of the profiles. If you have a “fixed low” at 55 mg/dL (the break-glass-in-case-of-emergency alarm that cannot be disabled) in the Vibrate profile, the G4 will give you four short vibes and then switch to audio in five minutes if you don’t acknowledge it. But let me be clear: It does not do this for garden-variety lows, only for the ultimate “fixed” low. By the way, I think they really missed an opportunity here. Instead of four shorts, I think they should have used three shorts, three longs, followed by three shorts. Yeah. Morse Code for S.O.S.

In the Soft profile (not to be confused with soft-core porn) we get the same vibes plus low beeps after five minutes. How low? Actually, about twice as loud as the almost-impossible-to-hear Medtronic “loud” tones. At the Library of Congress, you’d most definitely hear them. In the subway? Not so much. The tones associated with highs and rises are a higher octave beep than the ones associated with lows and drops, which feature a deeper tone.

In the Normal profile the beeps are louder. These tones are particularly annoying to cats, as it turns out. The alpha cat (a Siamese who likes to cuddle up against my back at the top of my desk chair as I write) just finished tearing my back and neck to shreds as I tested the tones for this column. So hypo cats may be the next big thing. The Dex manual defines the beeps as being either “low” for the Soft profile or “medium” for the Normal profile.

My G4 is set to the Attentive profile. I still get the same set of vibes we’ve seen across the board, but now instead of beeps and tones, I get music. Well, not music so much as melodies. The sounds are fun, spunky, entertaining, and highly communicative confused with communicable). And by that I mean that the sounds Dex has created fit the circumstance. A rise is greeted with a rising sound effect. A fall by a falling sound effect, and so on. They run respectably long, about four seconds each, a much longer commotion that you get out of Soft or Normal beeps; and the volume is pleasingly loud. It wakes me up and night. But, since there are no subways in New Mexico, I can’t tell you whether or not you can hear it on the subway.

The last profile is the Hyporepeat. Don’t get too excited. This mode is merely Normal plus. It uses the medium beeps and adds the “feature” of alarming every five seconds if you drop below 55 mg/dL. The people at the morgue will find this highly annoying.

I think, overall, the G4’s voice and voice options are a huge improvement over the Dex Seven. But I’m still disappointed that the best ever CGM alarm system was way the fuck back in 2005. The original garage door opener Guardian RT had the longest, loudest, fun and funkiest alarms of all.

I thought that technology, like fine wine, was supposed to improve with time.

Wednesday, November 21, 2012

Packing for disaster

“Few things wreak havoc on your blood sugars more than travel does. Your body clock unravels when traveling across time zones, sleep patterns change, eating habits get blown out of the water, and the assorted stresses and excitements that travel provides all add up to destroy even the best controlled blood sugar. You need your CGM when traveling. American Express and CGM. Don’t leave home without them.”

--Beyond Fingersticks

Actually, I’ve never had such a boring trip. Blood sugar wise, that is. I only drank one glucose bottle the whole time, and I’m not even sure I needed it. My CGM was coasting nice and level at 115 mg/dL while the nice lady from American Airlines was telling me that with the holiday travel in full swing she didn’t know how many days it would be before I could get home. I started to feel lightheaded. It might or might not have been a hypo, and I didn’t want to take time for a fingerstick.

Other than that, like a sober driver, I was right between the lines pretty much the whole time. Everyone kept asking to see the new gear, then would stare at it in disappointment and make comments like “Is it broken?” or “But I thought you had diabetes?”

It’s not broken. I do have diabetes. I’m only eating salad and meat while traveling.

But one thing I wanted to talk about is being prepared when you travel. I like to travel ultra-light, mainly because of my fucked-up back. I took a carry-on bag and my “Go-Bag,” and that was it. I did discover, however, that a well-appointed sport coat is as useful to a man as a purse is to a woman. And if it’s cut well, you get many an admiring gaze from flight attendants and traveling females. So it really doesn’t get any better than that. And the Dex G4 is slim enough that you don’t have any bulges where you’re not supposed to have them.

But here’s the thing. If you’re going on a three hour cruise or a three day trip, do you pack a spare seven day sensor? Do you pack the charger? Every ounce weighs you down. So why take anything you don’t need with you?

Because sometimes three hour tours lasts three full seasons. And sometimes a three day trip lasts four days. Or even longer. It’s ironic, because about a month ago I was asked by the School of Medicine to present a didactic—that’s a fancy word for lecture with a PowerPoint—for primary care docs on emergency preparedness for insulin-using patients. This was before Sandy. To keep it lively, I chose to take a play on the Spanish words for very small and very large: Poquito and Grande. My theme was that a poquito emergency can advance into a deadly diabetes disaster just as assuredly as a grande emergency can, so that it is best to be fully prepared for any outcome at any time. Right after Sandy, my dLife editors asked me to write something on the subject for my column over there, too.

Ironic that a month later I am stranded at an airport. Hardly an emergency. But what if I had only packed enough insulin for my short trip? Then an annoyance could have elevated to an emergency, and possibly even a personal diabetes disaster.

In this case I took a spare sensor. I didn’t need it. But had it. I took spare insulin, which I did end up needing. After some back and forth about the charger, as the new receiver holds a charge so well, and there’s always a risk of losing a charger when traveling, I decided to take it along just for in case. I didn’t need it either, but had I been marooned a day longer than I was, I would have.

Shit happens when you travel, to places far and near.

So like all diabetes supplies, you need more CGM stuff with you than you think you’ll need when leaving home. Oh and speaking of CGM, this is post number 30 of 30 days of posting about the G4. I’m not quite done with the story, but I’m done in. Going forward, let’s get together one day a week for a while. What do you say to Wednesdays with Wil? We’ll start next week, after Thanksgiving. Have a good one.

Tuesday, November 20, 2012

Airport adventures

“If you were an airport security screener and had never seen one of these before, would you let it on an airplane?”

--Beyond Fingersticks

Last week I traveled to the 2012 DiabetesMine Innovation Summit at Stanford. It was awesome. We had clinicians, patients, designers, device companies, money guys, and the FDA all coming together to talk about the needs, challenges, and barriers around innovating diabetes tech.

I also got to hang with some of my diabetes buddies and make some new d-friends, too. It would have been a perfect event if I’d been able to get home again. Let me tell you the tale…

It started, like most mis-adventures do, rather boringly. I grabbed a Canadair jet out of Santa Fe. The Santa Fe airport is small, and is served by only two flights per day: one from Dallas/Ft. Worth and one from LA. As I was headed to Palo Alto, jumping over to LA and then up the California coast seemed to make the most sense.

Because we’re only served by two puddle-jumper jets a day, the TSA is hardly going to invest in much for security. We still have the old-fashioned metal detectors. Well, that’s a lie. We have one old fashioned metal detector. Anyway, I wondered if the new much-larger Dexcom G4 transmitter would set off the metal detector. Nope. It didn’t. And the receiver ran through the X-ray machine along with my wallet, belt, watch, medic alert, cell phone, iPod, glucometer, insulin pen, and shoes without a hitch. You realize it’s only a matter of time before they make us fly naked, right?

The plane ascended to cruising altitude, the captain turned off the engines, and we coasted down into LA. When we landed we taxied twice the amount of time it took to fly there. In fact, I think we taxied half-way to San Diego. At the very far side of LAX is a car-port where the small planes are parked. I had to take a bus back to the terminal. No shit.

From there I boarded a 737 to SFO and took a “limo” service to Palo Alto. I never had to go through security but the one time back in Santa Fe. But my luck was about to change for the worse on the way home. The long way home.

After a night of heavy drinking with my dBuddies old and new, an intense day of agenda-rich talks, panels, networking, and more, and a second night of heavy drinking with my dBuddies old and new—I found myself back at SFO again. Hey, I’ll sleep when I’m dead.

And the (first) time I tried to make it through a back-scatter scanner I was busted.

Now I’ve been through a dozen or more with the old Dex transmitter and it never caused a stir. But this time, when I exited the machine, two guards were waiting for me. Step over here, sir. There seems to be something on your arm we need to inspect. Polite Gestapo smiles.

Then I was wanded, patted, and swabbed. On the bright side, I was able to give a mini-lecture about CGM technology. Finally, being deemed not a threat to national security, I was let go.

My advice: tell them you have an attached medical device before you step into the machine. Also, look for the “liquid medicines” line at the airport. They’re more up to speed on d-tech. And you might want to avoid placing your CGM site on top of any radical tattoos you might have. At least if you’re trying to look respectable when traveling.

It wasn’t too bad, really. It would be my next time through a TSA screening point that would prove to be the adventure worth telling.

I made my way toward my gate, dead-tired after too much drinking and excitement, too little sleep, my $100 pre-dawn cab ride, and the TSA delay. It took my bleary eyes a few minutes of starring at the flight monitors to realize that my flight had been seriously delayed. I would miss my connection to one of the two planes that would land 150 feet from where my Jeep was parked back home.

Uh oh. Now what?

You know what? Why bore you with the details? Just know that for the next 18 hours SFO was my home. But I learned some things. I learned that the best smoking area is between terminal one and the international terminal, under the CalTran tracks.

I learned that the best food is in the employee cafeteria. That the most interesting display was the Pan Am artifacts from the 1950s, with the history of bicycles and 100 years of board games coming in a close second and third. And that there’s a cool tile mosaic in the basement that looks almost like fabric.

The key to surviving this kind of misfortune is to get out of victim-mode and bask in castaway-mode. Life is what you make of it.

And I can tell you that in the back of the international flights terminal there’s an airplane museum that closes at 4:30 in the afternoon. I discovered that at 4:45 in the afternoon. Damn it.

The museum gift shop, however, never closes. And thus we need to talk about dogs before we go any further. Last month we were up in Denver and happened to eat at the Old Spaghetti Factory (which has a very edible gluten-free pasta). It was a Friday night, so the balloon man was there. He boasted he could make any creature we could want. Rio chose a aardvark and the balloon man rose to the occasion. My niece, however, asked for a wombat. It serves the balloon man right for asking an obvious trouble maker like my niece what she wanted after bragging he could make anything.

The balloon wombat didn’t look much like a wombat.

Anyway, this event turned Rio onto balloon animals. His mom found him a kit with the balloons, a pump, and the directions for how to make the classic balloon dog. And only the classic balloon dog.

Rio has since made a veritable pack of classic balloon dogs.

The only problem is that they last a short period of time. Even if the cats don’t get them. Hey, it’s a cat eat dog world out there.

So at the museum shop back at the airport I stumbled onto the ultimate classic balloon dog. It’s a solid, heavy, life-sized sculpture of the classic balloon dog. Time proof. Cat proof. I knew I had to get it for Rio. Here’s a pic of the two of them together when I finally got home and was able to give it to him:

And I say finally, because if you think the TSA hates insulin pumps and CGMs, just wait until you hear how they feel about classic balloon dog sculptures.

The second time I went through airport security in my nearly day-long stay at SFO I told them about the G4 transmitter and they both peered at it, and one said, “So it’s sort of like an insulin pump?”

Yeah, I replied, too tired to give a second lecture on the wonders of CGM technology.

They waved me on. Then I waited for my carry-on to come out of the X-Ray machine. And waited. And waited. And waited. And waited. Then I noticed a small crowd of uniformed agents begin to gather around the X-Ray monitor. There was much finger pointing and whispered discussion. Finally my bag was brought out. “Is this your bag sir?”

Uh oh.

I was made to stand behind a barrier. To keep my hands where they could see them, but not reach out toward my bag. Everything was taken out and individually swabbed for explosives. The bag was X-rayed several times. Swabbed again. Oddly, they never asked me what was in it. Nor did they open the box the classic balloon dog sculpture was in. But that turned out to be the item of interest.

I guess, in their defense, it must have looked pretty weird on the X-Ray machine’s screen. We’ll never know for sure, but I’ll bet the conversation went something like this:

X-ray screener: Dude, look at this!

Guard: It looks like a classic balloon dog.

X-ray screener: It can’t be. It’s solid.

Guard: Shit! Do you think it’s a bomb?

X-ray screener: Shaped like a classic balloon dog?

Guard: Maybe it’s drugs.

X-ray screener: Call a supervisor.

Supervisor: It looks like a classic balloon dog.

X-ray screener: Except its solid.

Supervisor: Oh. Right. I wonder if it’s a bomb? Or drugs? Maybe we should strip search the bag’s owner.

Guard: But I was about to go on break.

Supervisor: What? Oh. Well, OK, then, Swab it for explosives five times, X-ray 20 times, and if the guy starts to sweat just shoot him, OK?

And I thought traveling with CGM would be hard! That’s easy compared to trying to smuggle a solid classic balloon dog sculpture through security.

Monday, November 19, 2012


“All things being equal, diabetes-wise anyway, I much prefer to travel by car, bus, or train. Flying in the post-9/11 world is a pain in the ass.”

--Beyond Fingersticks

What did the stupid rabbit say in the 1951 Disney version of Alice? “I’m late! I’m late! For a very important date! No time to say hello, goodbye! I’m late! I’m late! I’m late!” In the actual book he apparently said: “Oh dear! Oh dear! I shall be too late!”

God only knows what Disney will do to my writing when I’m dead (hard to imagine, isn’t it?) and apologies to Lewis Carroll’s ghost, but I actually think I like the Disney version better on this quote.

So I’m late to post today, and some of you were probably wondering if I’m marooned on a deserted island, or what. No, the truth is both more interesting and more frustrating. I’ve been marooned at San Francisco International Airport. Better than an island, but no Ginger and Mary Anne to keep me company—vote by comments men and lesbians—which Gilligan’s Island co-star would you rather have been marooned with? Oh and I didn’t ask you ladies and gay men, because there’s only one clear choice among the male stars for each of you.

From Alice in Wonderland, to stuck at an airport, to sex. All in under 200 words. Damn, I’m on a roll this morning.

Anyway, I’ve got a travel story or two for you about the Dexcom G4 and airport security, but it’s not written yet. That will have to wait for another day or two while I catch up on the millions things that didn’t get done while I was off on my travels. The problem with working 80 hours per week is that if you go somewhere for three days and get stuck somewhere for another day in route home, getting caught back up with your various responsibilities is nearly hopeless.

So today, I invite you to visit Diabetes Mine, where Amy just posted my summary review of the G-4 to date. It’s a bit more of a global look and there’s no sex or swearing, so you can even read it to your kids. The post summarizes what I think the strong, weak, and pointless points are, and answers the most important question: Should I get out my wallet?

Sunday, November 18, 2012

Sign of the times

Check out this snazzy sharps container from the women’s bathroom at a rest stop near Trinidad, Colorado:

Being both diabetic and a healthcare worker, I’ve seen a lot of “sharps” containers—those trash cans for syringes—over the years. We had them in the ICU, of course, when I worked at the hospital. And we have them in every treatment room at the clinic. Hell, I even have one on my office wall.

But it’s only over the last few years that I’ve noticed them cropping up in public places.

I first noticed them at Indian Casinos. In the bathrooms. I don’t know about the rest of you, but a public restroom is pretty much the only place in the world where I will not take a shot.

Then I started seeing them in restaurants. Now at rest areas.

Huh. It’s not like there’s an diabetes epidemic, or anything.

Oh. Wait. That’s right. There is a diabetes epidemic. We should really do something about that.

Like buy stock in companies that make snazzy sharp’s containers.

What was I doing in the women’s room? Well, that’s a story for another day. But it’s neither as interesting or as kinky as you’re thinking it is…

Saturday, November 17, 2012

Diabetes: The theme park

“But in those of us with diabetes, our non-working bodies depend on crude corrections from outside. Our blood sugars become a roller coaster caused by things both within and beyond our control. Our bodies are not stable. They’re in flux. Up. Down. All around. It’s all dynamic, changing, flowing.”

--Beyond Fingersticks

Some days have their ups:

And some days have their downs:

Friday, November 16, 2012

Hidden treasures

“Transmitters either use those “button” batteries, rechargeable batteries, or are a sealed battery/transmitter package guaranteed to last a certain time period. This last style requires you to buy a new one with it runs out of juice.”

--Beyond Fingersticks

The map is tattered and yellow, the edges burnt. But the directions to “X marks the spot” are still clear. You press the button twice. Scroll down to “settings,” press again, then select “device info.”

Here be treasure.

Of course, without the treasure map, you’da never found it in a million years. Hidden in this backwater alcove of the receiver’s menu is the day and time your inserted the current sensor, and the time of the last calibration fingerstick.

It’s not quite as helpful as Med-T’s menu that tells you when your next calibration is due, but it’s better than nothing, and you can work it out from there yourself, if you have to.

Interestingly, the same screen also shows the status of the transmitter. Mine says the six-month transmitter is “OK.” That’s right, like dragon flies, dormice, house ants and voles, Dex G4 transmitters have lowered the bar in the wrong direction. They are the shortest-lived transmitters in the seven-year history of real-time CGM systems.

Hmmmmmmmmm….. But no indication of just how OK it is. Does the transmitter really report its full status? Will that change to “So-so” and later, “Kinda Crappy?” And is this the real deal, or not, in the first place? Is it really reporting signal strength, or did a six-month count-down timer start automatically the first time I booted it up, like the stupid check engine lights on my car that turn on at set mileages on the odometer? I’d expect that kind of nonsense out of Med-T, but not from Dex. But we won’t know for six months.

According to the 210-page insomnia-curing User’s Guide that came with my G4, one week before the transmitter gives up the ghost, the receiver is supposed to give me a low transmitter alarm. I’m to call Dexcom Sales Support as soon as possible and order a replacement. You just know I’ll be snowed in with no hope of being reached by a FedEx truck for a week when that happens.

But what happens in this status screen? Does it quietly change to “not OK?” Will it later morph into a battery icon showing how much life is left? I don’t know, and the User's Guide is moot on the subject.

Maybe we’re missing a corner of the map, after all.

Thursday, November 15, 2012

The big event

“On top of long commutes, multiple jobs, shopping, getting the kids here or there, and all the daily grind of life, we must contend with counting the carbs of every bite we eat, taking insulin, checking our blood sugar, dealing with lows and highs… And you want us to punch all of this crap into yet another device? I don’t think so.”

--Beyond Fingersticks

I always forget that CGMs have a helpful feature to let you add yet more information to your download. Because, you know, there’s not really enough to look at when you pull up two thousand blood sugar readings for the week.

I always forget about it because I’ve never really use this feature, but like the last few generations of CGMs, the G4 lets you place event markers into the system. But let me be clear: the info is buried. You can’t see it on the receiver.

And as if it weren’t inconvenient enough to actually enter event markers into any CGM, Dexcom has not made it any easier by requiring a minimum of six button pushes to even get into the events screen. (They probably know none of us will ever use it.)

But just for fun, what if we were gonna try? What kind of events do the Dex folks think we engage in? Well, events that could affect our blood sugar, anyway.

The broad categories are Carbs, Insulin, Exercise, and Health.

When you open Carbs, the default is 50. Interesting choice. I almost never eat 50 carbs in a sitting, but I guess that’s the non-diabetic average carb intake. On the bright side, the system remembers the last value you entered. For fun I had put in 29, and the next time I opened the carb screen it was at 29, rather than 50. So if all of your meals tend to be about the same, your scrolling will be limited. But here’s the rub—isn’t there always a rub? Once you enter the carbs, you’re next taken to a day and time screen. What the fuck is up with that? Ya gotta press a couple of more buttons to enter the current day and time. Or you can enter a carb count from two years ago with only a few more presses of a button, although why you would want to is beyond me.

Although… I just had a great idea for a spy novel where secret information is smuggled in a CGM receiver as retro-active carb data.

Now in theory, it might be useful to record your food and insulin at every meal. It would allow you to really see what a given carb load and insulin bolus does to your blood sugar. Many CGM-enabled insulin pumps have this kind of data reporting, and it can be amazing for nailing down insulin to carb ratios, correction factors, and more. So for an insulin-pen user like me, entering carbs and insulin into a CGM could really help me see if I’m on my game or not. But already my food is getting cold just getting the carbs into the Dex, and I haven’t even calculated my bolus yet, much less taken it, much less entered that info into the fucking CGM, too.

And just how hard is it to enter insulin? Well first you gotta make eight button clicks, then you scroll your insulin up or down to the right number, first in full units, then arrow over to tenths—no shit. My eyesight isn’t that good, even if my syringes and pens were. And I can’t see a pumper bothering with using this.

Oh and you better stay on the ball. If the screen times out, you have to start over.

And just like food, you have to set the time and date for your insulin bolus. Even if you just want to use RIGHT FUCKING NOW as the time and date, it takes two button presses to enter it, and get this, yet another button click to confirm the entry.

It’s as frustrating as an insulin pump, but all it’s doing is placing a data marker on the CGM’s download. Once the data is in, you can’t even see it from the receiver (which might be useful to some people for tracking of insulin, and avoiding the stacking of insulin). But these are just dumb markers. No power, no visibility. So why make it so hard to do? If we had real-time insulin onboard tracking, which would be an awesome addition to a CGM receiver, all the checks and balances and safety screens would make sense. But all of this just to add an icon to an already over-crowded graph?

Anyway, the next type of event is exercise. You can choose between light, medium, and heavy. Then you have to choose how many minutes, and then—you guessed it—you have to choose the time and date, any in history that appeals to you, and then you have to confirm that you really meant it. Just for fun, I tried to go back to V-J Day to enter some heavy kissing-of-nurses action in Times Square, but as a time machine, the Dex G4 really sucks.

I could only go back to 2009. I guess that’s when they wrote the software. I could be wrong, but I don’t think anything overly memorable happened on August 14, 2009 in Times Square. On the bright side, I can go as far forward as 2029, so I’m guessing that Dexcom is planning to support this product for many years to come.

Health events sounded like they might be more interesting. Or so I had thought. From a social anthropology perspective, this should tell us a lot about what device manufacturers think we dFolk do with our time.

The choices are…. drum roll… Illness, Stress, High Symptoms, Low Symptoms, Cycle (presumably a female’s period), and Alcohol. Congratulations. There’s your life summarized. At least your life according to Dexcom.

When you navigate into each Health Event, you jump straight to time. You can’t say how much stress. How bad your High Symptoms are. And Low Symptoms… you know I’ll have to slap you if I find you’re taking the time to enter these into a CGM rather than fixing the problem, right? Under Cycle, we are not given the option of saying who’s period is causing our blood sugar problems and you can’t even record how many drinks you had after being ill, stressed, high, low, and dealing with someone’s period.

But at least you can record them from 2009 to 2029.

Wednesday, November 14, 2012

Dexcom Worst Case Scenario—part 1

“Trust me, there are much worse things in life than living with a CGM.”

--Beyond Fingersticks

When the shit hits the fan, which Dex will serve you better? The old Seven Plus or the New G4?

Lost in Sahara: Dex 7
(easier to read in bright light)

Lost in coal mine: Also Dex 7
(brighter light can function as flashlight)

Lost at Star Trek Convention: G4
(you’ll fit in better)

Lost at Apple Store: Also G4
(they won’t know you’re lost, you’ll fit right in)

Lost in the woods: G4
(longer battery life)

Lost at a corporate board meeting: G4
(leather case camouflages with urban wardrobe better)

Lost at school: Dex 7
(looks more like a medical device than a music player)

Lost at sea: The CGM from the Other Guys
(neither Dexcom is water resistant)

Post your Worst Case Scenario via comments and in part 2 I’ll give you my thoughts on which Dex will better McGyver you out of the pickle you’ve proposed.

Tuesday, November 13, 2012

Pushing the envelope

“But the reality is, the human body is not entirely happy having stuff that doesn’t belong there in its tissues. From the moment you tear your cells asunder putting the sensor in, your body is trying to figure out ways to get the damn thing back out again.”

--Beyond Fingersticks

Back in the “Right Stuff” days of jet airplane development, pushing the envelope was a term for taking an airplane beyond it’s designed capabilities. Higher, faster, tighter turning than it was designed to go or do.

Sometimes that ends badly with little bits of airplane scattered across the desert.

When it comes to CGM, pushing the envelope is using a senor longer than our noble FDA has approved it for. It’s more like drinking milk a week past the expiration date than it is like driving a 1.5 Mach certified jet at 2.3 Mach.

But there are some risks involved in pushing sensors too long. First and foremost, if you use it too long, it won’t work right. And if it’s not working right you might not get an alarm when you were supposed to. And if you don’t get an alarm when you are supposed to, and you are hypo unaware like me, you can die.

So there’s that.

And the longer you wear a sensor, the greater your risk of infection, at least in theory. I mean, it is a hole in your epidermis. Plus, your skin can get pretty damn unhappy being trapped under a sticky pad for day upon day upon day; and lastly, if your body hair grows at all fast…. Well, you know.

But all of that said, in the interest of science, I rebooted my first sensor, as you’ve read about in the not-half-naked-with-a-nurse post. How’d that work out? I ended up running my first Dex G4 sensor for 13 days. Why 13? Did it crap out on me? No, the performance was spot-on the entire time and I have no doubt at all—that at least for that sensor on my body—it could have run a full 14 days, twice the approved wear length.

I pulled it after 13 days because I wanted to get back on schedule for changing the sensor on no-travel days. Running all the way to 14 would have me changing it at the clinic again, so I pulled it a day early.

Now, the most I ever got out of a Seven Plus sensor, on my body, was an extra three or four days. I never got one to last two weeks for me. So based on a sample of one, I’d say there’s been a significant improvement in sensor life. BTW, the G4 sensor wire is supposed to be 60% smaller than the Seven Plus’ was. Here’s the new one, fresh out of my body:

It’s always hard to judge 60% smaller when it comes to fish line, but one thing I did notice was the change in appearance. The new sensor is smooth. The old ones had a coiled spring-like look to them.

For an encore performance, will I try to run the next one for three weeks? No fucking way. My skin is pretty damn unhappy over the extra six days. I’ve got a big red splotch on my arm. It looks like an octopus give me a hickey.

I’ll leave the envelope pushing for those who have the Right Stuff.

Monday, November 12, 2012

Role reversal

“Do you really want your CGM to get its picture of the world based on one reading from your frickin’ fingerstick meter?”

--Beyond Fingersticks

I wish I could use my CGM to calibrate my fingerstick meter.

As you may recall, I’ve been unsure how good or not-good my health insurance mandated meter is, so I’ve been doing dual fingersticks. Not all of them, just ones for the CGM calibrations.

And you know what I’ve discovered? The little bastards are quite a bit off when I run two readings back-to-back. More so than with the iBG Star or the Presto I used before it. But here’s the ironic part: The G4 is always parked right between the two Nano readings.

Too bad I can’t use the G4 to calibrate the Nano, instead of having to use the Nano to calibrate the G4.

I’d be a lot better off.

Sunday, November 11, 2012

On not being in first place

Just yesterday, I got an email from Amazon telling me I’m the 174,618th best-selling author on the site. Umm… I’m not sure if that’s something to be proud of or not. I guess it depends on whether they have two million authors or 174,619 authors.

Still, the number tickled my fancy so much I celebrated by making a trip to CafePress:

Saturday, November 10, 2012

Stone knives

“And of course, if the maker decides to stop manufacturing the sealed transmitters in the future, you will be forced to upgrade and your monitor will become an expensive paperweight.”

--Beyond Fingersticks

In college I had a cool job. I ran the darkroom for the anthropology department. Mainly, I spent many hours printing B&W photos of stone knives and spear points. Each picture had to be to scale. There was a little ruler in each photo. I had to run the massive Omega D2 enlarger up and down its silver track to get each negative to just the right height so that the prints would be to scale.

If you’ve never had the chance to play in a darkroom, I pity you. They’re extinct now, of course, but they were wonderful, magical places. They were bathed in dim orange light, like the rising harvest moon. Water gurgled like palace fountains. The machinery hummed. It was soothing and peaceful and wonderful. And when the pictures formed from white sheets of paper… to dull grey whispers… to ghosts… to pencil-like drawings… and then matured to stark back and white images in the developer tray, you feel god-like for making it happen. Even if the images are only of stone knives.

What drew my mind back thirty years? Well, today I changed my sensor and I decided to snap a picture of the new G4 transmitter next to several others for scale. The resulting image, on my computer monitor with no orange light, no gurgling water, and no ancient magic, reminded me of those anthropology department prints I spent so many hours making all those years ago.

It kind of makes me wish I’d thought to put a little ruler in the picture!

Left to right: the Abbott Navigator’s transmitter;, a Med-T MiniLink; Dexcom Seven Plus transmitter; and the new Dexcom G-4 transmitter.

Friday, November 09, 2012

Here’s looking at you, kid. Or maybe not…

“CGM monitors display “trace” graphs, a plot of recent CGM readings. It is a map of your recent blood sugar river. And just like glancing at a wrist watch tells you the time, glancing at the CGM trace tells you the context of your blood sugar.”

--Beyond Fingersticks

The new Dex G4 reminds me of Times Square on New Year’s Eve. It’s a crowded place. The receiver screen has a lot of data squeezed into it, and frankly, I really don’t like the layout all that much. Not that I have any practical suggestions, but I’m pretty good at bitching about what I don’t like, so I’m just going to have to go with my strengths today.

The G4’s receiver’s screen is one and three-quarter inch left to right, and one and a quarter inch top to bottom. That’s actually very close in size to the Seven Plus’s screen size. Both devices feature an x/y type of graph, with changes in time displayed horizontally, and changes in blood sugar levels displayed vertically. Every five minutes a dot is added to the graph. Lots of dots make up a trace line that shows where your blood sugar is, where it was a while ago, where it was a while before that, and so on. The shape of the line gives you a good clue as to how fast your sugar is changing. Flat lines mean not much is going on; while sharp ups and downs indicate rocky going.

In addition to the graph itself, the G4 receiver screen displays the telemetry status of the transmitter, the battery status of the receiver, the current blood sugar (or more correctly, the current sensor glucose reading), a trend arrow that shows the relative speed and direction of recent changes in blood sugar, and a blank spot for urgent messages—like calibrate now, or I can’t find your sensor.

The Seven Plus also displayed all this info, plus one other tidbit. So which does a better job? The old girl or the new girl?

Ummmm…. Neither? There are things I like better about the old screen and things that I like better about the new screen. And there are things I don’t like about either screen.

Note: for clarity, I stole these image from the Dexcom website. The shiny surface of the receivers makes shooting them in the wild quite the trick!

There are major differences between how the new and old screens are laid out. On the G4 the x/y graph extends fully from right to left, and the icons that deal with the receiver status are displayed on a small ribbon along the top. This gives us a slightly more rectangular glucose graph than the older model, causing the image to be stretched out a hair. Slopes will appear ever more slightly gentle than they did on the Seven. By comparison, on the older Seven, the graph extended fully top to bottom instead, and the receiver status icons were displayed on the right-hand side of the screen.

Speaking of the graph portion of the screen, there are two major changes in how it’s displayed on the G4, compared to the Seven. The first is the location of the blood glucose scale. Pretty much every x/y graph in history since Professor Euclid in ancient Alexandria had the vertical scale on the left. A convention that became a tradition. The G4 breaks with this tradition and moves the scale to the right side. Why? Well, it’s actually more user-friendly for a CGM monitor. A CGM trace line (or row of dots) travels from left to right. The left end of the trace line shows the oldest information. The right end shows the newest reading. It looks weird at first, but it makes sense to have the glucose scale next to our latest readings. I just don’t know what to make of that; we d-folks aren’t used to medical devices that make sense!

The other significant change in the graph is the G4’s addition of a time index across the bottom. The Seven just had hash marks to signify hours. The new one has the actual time of the readings. You still can’t scroll back across the old data like you can with Med-T CGMs, so I’m not sure how much use this is to us. And sorely missing from the G4 is the Seven’s label of which of the five glucose graphs you’re looking at. The Seven labels each graph clearly: 1 hour, three hour, six hour, etc. I actually find the loss of this tidbit of info from the new G4 to be highly annoying, and the way the time scale works (always three readouts on each reporting screen, with a progressively larger span between the numbers, rather than adding more numbers to the bottom) is no help in this regard. Frankly, it takes some brain power to figure out if I’m looking at the six-hour screen or the twelve-hour screen, and I don’t really have any brain power, or time, to spare.

New devices should make life easier, not harder, damn it.

Going back to the display of the receiver status icons, I can see why any designer might think the Seven was wasting precious screen space by using up nearly a quarter of the right hand side of the screen with the data that relates to receiver status. But I find the G4’s data ribbon along the top overly small, and overly crowded. The telemetry icon and battery status are right on top of each other. On the real machine, they actually touch (the image from the Dexcom website is making it look better than it looks in the real world).

And hey, and what the fuck happened to the current time? I used my Dex Seven as a back-up watch. Why didn’t they put the time on the G4 anywhere? Oh. Wait. There it is. Hidden waaaaaaaay down in the far right-hand bottom corner, almost invisibly small. You can mistake it for part of the time scale.

Both devices suffer from wasted space in the hyperglycemia portion of the graph. Hopefully, most of us don’t really spend much time above 300 mg/dL, so the top quarter of the graph is blank space most of the time. It’s too bad that space can’t be used to display current glucose level and trend arrows largely when the landscape isn’t in use.

Another major difference between the old Seven and the new G4 is purely one of aesthetics. Or maybe not. In this case, fashion has an impact on function. The old Seven’s screen was black on white. The new G4’s is white on black, what printers call a reversal. Well, actually the old screen was more of a pale blue-grey background with dark grey writing. The new one is black background with mainly white writing and some use of color, which I’ll talk more about tomorrow. The G4 is prettier, but hard to read in bright light. Did I say hard? Actually, in some cases it’s impossible, especially if you’re wearing sunglasses.

Now at night, I like the G4 better in some ways and worse in other ways. A nocturnal CGM check with a G4 is not hard on the eyes. So that’s nice. But I also used to use my Seven as a midnight flashlight. I’d use it for lighting up a pitch-dark fingerstick (I wish all meters had test strip port lights like the Flash meters). Or: Oh crap, I just dropped a test strip on the floor, can I find it? Or: What is that cat up to now? G4 doesn’t cast enough light to use as a flashlight or to signal a train that the bridge is out. Hey, it could happen.

Lastly, I need to talk about the dots. There are two ways to display data on an x/y graph. Each data point can stand alone, or you can just connect the dots into a line that’s sometimes called a trace.

Both old and new Dexs use dots. Sorry. I don’t like dots. I like lines instead. I know dots are more scientifically accurate, and all of that. But I prefer lines. They look cleaner and make it faster to interpret the information being displayed, which is the whole point. With a line there’s nothing to slow down the eye or the mind. It’s the direction and flow that matter in CGM. The collective movement of sugar. The aggregate picture. Individual data points are meaningless. The less we obsesses over individual numbers, individual readings, the better we do with CGM. To me, dots harken back to the bad old days of fingersticks where we tried to control our diabetes by looking a snap-shots, brief moments in time, not the real life ebb and flow of our blood sugar as it really is.

That said, the G4’s new dots, for some reason, are more appealing that the old Seven’s dots were. I think it’s because they’re cleaner and smaller. Maybe the spacing is better, too. Oh, and the old dots on the Seven are actually little crosses. The new ones are perfect little circles that look like stars in the night sky—forming constellations of your health. Very appealing as dots go. It also probably helps that with the improved transmitter range, there are less missing dots. On an old Dex Seven, not only did you have these funky crosses, but there were always some missing. With the G4, I’ve yet to lose a single data point—knock on wood. So my closely spaced dots are more line-like.

But I still like lines better.

So there you have it. Crowded. Colorful. Black with city lights. The G4’s monitor screen is very much like Time’s Square, indeed.

But unlike the new year, I just can’t decide whether to celebrate the new G4’s screen or not.

Thursday, November 08, 2012

My kids are driving me crazy

“It all sounds so simple in the manual that came with your CGM. You calibrate your CGM the same way you feed squirrels in the park. Or maybe it’s ducks you are supposed to feed. I don’t know, I don’t spend much time in parks. The manuals tells us that all we need to do is enter a fingerstick reading into the monitor every now and then and press a couple of buttons to keep our sensor on course.

True. But not true. Because the devil is in the details.”

--Beyond Fingersticks

Fat Dex is always reading slightly lower than little Nano. Skinny Dex is always slightly higher than little Nano. But little Nano is being used to calibrate both girls, so what’s up with that? I’m not convinced that the Nano is as accurate as my iBG Star, but I don’t really have any evidence for that. Some of it may be I’m just feeling sorry for myself that I can’t use the iBG Star any more… so I might be focusing too much ire on the poor Nano.

But even if it is inaccurate, so long as it’s consistently inaccurate, the CGMs should track closer to each other. Right?

Now, I’ve noticed on a couple of startup cals, where I need to do two fingersticks, that the two Nano readings were quite a bit more off than they should be from each other. Bad luck or bad meter?

So I’ve resolved to do dual fingersticks on the Nano for a while, at least for every calibration stick, just to be sure the Dexs are getting the best possible guidance in their travels through the jungle of my blood sugar.

Stay tuned.

Wednesday, November 07, 2012

Play it again, Sam

“How long can you wear a CGM sensor? you ask. Before I answer, let me ask you: Are you asking me how long they are FDA approved for wear; how long people are actually wearing them; or the maximum time one could theoretically be worn?”

--Beyond Fingersticks

A Dex G4 sensor is FDA approved for seven-day wear. How long you actually can wear it is a whole ‘nother kettle of fish altogether. And frankly, how long most CGMers wear their sensors is directly correlated to their poverty index. The poorer you are, or the poorer your insurance is, the longer you wear your sensor.

That said, as bad as my insurance is (no choice of test strips, not enough of the ones they will cover, and—no shit—they will not pay for my insulin) they at least do cover my CGM sensors, and my copay is a big fat Zero. As I also have sensitive skin, I’ve been wearing the Dex sensors the FDA-approved seven days. Besides, it’s convenient to have a sensor change day on the same day every week. It’s easy to remember, and I can do my two-hour warm up when I’m not on the road.

But I only have one box of the new G4s, and I want to stretch my review as long as possible, so I decided to reboot the first one and see how things went.

Now somewhere in my head I had the idea that you needed to pop the transmitter off of the Dex Seven sensor and re-set it to run a sensor a second time. And that was going to be a problem. You can very easily remove a Dex transmitter from an implanted sensor; you just need to pull both the wings at the base of the transmitter off to the side simultaneously. But that takes two hands. And as I’m wearing the sensor high up on my arm, my two hands can never reach the sensor unless I’m in a horribly disfiguring accident.

But either I had it wrong, or something changed along the road, because two days ago my Seven Plus expired. To double check what I was in for, and to compare the two systems, I told it that a new sensor was in place and it booted right back up again—with no other action on my part. But that didn’t mean the new G4 would be so accommodating. I’d better have a plan in place. I was going to need a partner in crime.

The G4 reboot would happen at work, as I inserted the first G4 sensor at the clinic, rather than on one of my “safe” days when I’m home writing. Realistically, that meant recruiting one of the nurses to assist me.

First thing in the morning I plopped myself down next to one of our RNs at the nurse’s station. Hey, wanna get half-naked with me? I asked her.

An arched eyebrow. Dark eyes studying me intensely. “That depends on which one of us is half-naked, and which half you’re talking about,” she replied in a deadpan voice. Then a hint of a giggle escaped. I guess they’re all used to my sense of humor at this point. Can’t get a rise out of any of them.

I explained my problem. “No problem,” the nurse told me, “call me when you need me.”

Later in the morning the little girl tugged on my belt:

And after lunch, the stoplight turned red and the flow of blood sugar information screeched to a standstill.

I navigated to the main menu and selected “start sensor.” The warm up screen and the green count-down pie logo appeared. And that’s all there was to it. Kinda anti-climactic.

Two hours later I was in business. Now, how long—and how well—she’ll run beyond seven days I can’t say. Yet.

But if your poverty index requires you to stretch your sensor wear, you can do it with a couple of button pushes. No help from a nurse needed.

Pity. I was kinda looking forward to getting half naked with one of my favorite nurses.

Tuesday, November 06, 2012

Power to the people

“If you have a rechargeable system, you need to have both your charger and a wall socket handy when you get into trouble. Pine trees don’t have power plugs, as one of my Native American patients discovered when she and her boyfriend went camping in the wilderness. She had packed her power cord but it hadn’t occurred to her that there would be nowhere to plug it in.”

--Beyond Fingersticks

One of the things that pissed me off about the Dex Seven Plus was more a matter of philosophy than a functional real-world annoyance. Back when it was first FDA approved, we had the first ever seven-day sensor with a receiver that could only make it three days without recharging. WTF?

It really wasn’t that big of a deal to plug her in while I was sleeping every three days, but it still bugged me. It was the principle of the thing. A seven-day CGM system should be able to run seven days. Right?

Naturally, with the addition of a color screen, I had very low expectations for the G4 in this department. Given how quickly my iPod runs through its battery, I had expected the G4 to be even worse than the Seven Plus. I expected to be charging it’s skinny little ass every two days.


On day seven my battery icon was still at half-mast.

Of course, I know that batteries are fickle. As they age they lose their ability to keep a grip. And temperature affects them. And they are affected by how many times we turn the device on. And a host of other crap.

But out of the box, the new seven-day system from Dexcom will last for more than seven days.

The universe is in harmony.

But of course, we d-folk are never satisfied and endlessly curious. I got what I wanted, a receiver that lasted as long as the sensor. My wish granted. But instead of rejoicing, I immediately wanted to know just how long can it last?

I decided to keep driving. To wait for the metaphorical “low gas” light on the dashboard.

And on day 10 after the first charge, around noon, the little girl tugged on my belt and said:

And of course, I didn’t have the frickin’ charger with me. And I was surrounded by pine trees.

(Picture dark clouds of doom on the horizon. The wind rattles the windows. A streak of lighting shatters the night. Trouble is coming.)

How far can you drive a G4 with the needle on empty? Luckily for me, as it turns out, well over 10 hours.

Oh, and speaking of charging, the charging cable is s-h-o-r-t. Super short. I’ve seen licorice ropes longer than this cable. Both Dexs (or as my wife calls them, your curvy girlfriend and your skinny girlfriend) sleep between our pillows at night—old habit from the days of limited telemetry range between the transmitter and the receiver. I used to charge old Dex where she lay, about every three days.

But the new cable wouldn’t reach skinny girl where she slept. Damn.

Now understand, I have the world’s smallest nightstand. And not only is the landscape limited, but a lot of stuff lives there at night. The infernal Nano meter, with its lovely FastClix lance, and giant test strip vial; my insulin pen; my iPod with the insulin tracking software; two bottles of Dex4 save-your-ass glucose fluid; a skinny jar for collecting used test strips; and of course a clock and a lamp.

I had to move things around a bit to make room for skinny girl with the rest of the nocturnal diabetes tools.

Anyway, first thing this morning I checked her screen. Not one lost dot. Despite my usual turning, spinning and trashing about in the night, she never once lost telemetry. Not exactly a scientific test of the boasted-about new range, but a good omen at the very least.

Power in distance. Power in time.

Power to the (d)people, indeed.

Monday, November 05, 2012

To sleep, perhaps to dream

“…an awful lot can happen in four minutes and 59 seconds when the shit hits the fan.”

--Beyond Fingersticks

When someone tells me a new CGM is better in a low, the first thing I think of is improved accuracy in reporting a low blood sugar as it happens. But I haven’t had my normal number of lows recently (what’s up with that?), so I found myself not really being sure if G4 was better in a low or not. Which, perversely, is rather frustrating, as that’s what everyone is dying to know about.

But then I got to thinking about the other half of the low blood sugar coin. Accuracy in a low also means not reporting lows that aren’t there.

You might need to read that two times to wrap your brain around what I’m saying. Here let me help you out: Accuracy in a low also means not reporting lows that aren’t there. Accuracy in a low also means not reporting lows that aren’t there.

In short, being accurate in a low entails screaming at you when you are low, but not crying wolf the rest of the time (unless, of course, you know… there really is a wolf).

Nothing vexes me more… well… actually quite a few things have been vexing me recently…

Let me try again: One of the things that vexes me most is when a CGM “coasts” a hair low all night long. Let’s say for instance that my BGL is cruising at 88—flat, stable, steady all night. But let’s say the CGM is a bit off. It thinks I’m at 78 instead. Not a big difference of opinion, really. Unless your low threshold alarm is set at 80. Then you get alarms. Every 15 minutes. All night long. Sometimes, no matter how many calibration fingersticks you feed the little bastard (and you really shouldn’t overload cal sticks), you just can’t get its head above water.

I can’t begin to calculate how many nights’ sleep I’ve lost to this kind of thing over the last few years.

But I just realized this morning that I haven’t had this happen on the G4. So improved low performance includes not crying wolf. And that gives me more sleep.


Sunday, November 04, 2012

Honey… sauce?

We interrupt our regularly scheduled program for this Health Alert…

We were late. We had far to go still and no time left to waste. A fast lunch was in order so I pulled into a combo Taco Bell and KFC place just off the freeway.

Does fried chicken and Mexican food strike you as an odd marriage? I guess they’re both southerners, as far as American cuisine goes… but still…

Anyway, Mom chose a burrito, Deb went for a fried chicken breast with fries and a biscuit, and Rio elected for a chicken sandwich. I choose a pair of crunchy tacos which are getting cold while I: Look up their carb count in the Calorie King App on my iPod—twelve carbs each for a total of twenty four, minus the collective six grams of fiber for a net impact of eighteen carbs; get the infernal Nano out of my cargo pants pocket, unzip the case to get access to all the various parts and pieces to take a BGL check; pop open the massive test strip vial, fish out a strip and put it in the meter, lance my finger, squeeze out a drop of blood, touch the tip of the strip to the blood drop to get a reading; go back to the iPod and enter the fingerstick into RapidCalc by sliding the blood drop logo to the right until the proper reading is entered, then slide the hamburger logo to eighteen carbs to get the bolus and log the shot for insulin tacking to avoid stacking; put all that crap back away; get out my Luxura pen, dial up the dose, uncap the pen, unsheathe the needle, roll up my sleeve, slip the needle into my arm, click-click-click-click the injector button down to deliver the dose, and hold the needle in my arm for ten seconds.

One-one thousand… Two-one thousand… Three-one thousand…

Camouflage be-decked hunters eye me suspiciously. They don’t like long-haired tattooed hippie people with earrings shooting up at the table at their Taco Bell/KFC restaurant. I pull out the pen, re-sheath the needle, re-cap the pen, and slip it back into my pants pocket.

I’m finally ready to eat, and my family is nearly done. I pick up my taco for the first bite when Deb asks me, “Honey, would you go get me some more honey?”

Why not? It’s not like I’ve started eating my lunch or anything. I set the taco down and make my way across the tiled floor to the condiment table. In addition to the hunters, a group of downs-syndrome patients are out on a field trip with their officious matronly caretaker, and their looking-for-a-better-job bus driver. Most of the patients have staked out personal territories, at separate tables, and are poking at their food and glaring at each other. There are also two of those ultra-conservative religious cult families that dress their women from head-to-toe in drab clothing, hair bound tightly to their heads, sans makeup; while their men dress like peacocks and flirt with the hapless cash register clerk.

I grab several packets of honey and return to my rather ordinary-looking (to me) family. As I toss the packets on the table, the label catches my eye. I have just fetched three packets of “Honey Sauce.”


So what on earth is Honey Sauce, and how does it differ from honey? I mean it looks like garden-variety honey, the stuff made by bees. The back of the packet is clear. I squeeze the plastic bag. It moves like honey. I adjust my tri-focals to read the fine print:

Off on the lower right, the package boasts that it’s “7% real honey.”

You’ve got to be fucking kidding me. So what’s the other 93% of Honey Sauce made of?

Are you sure you really want to know?

By volume, Honey Sauce is: high fructose corn syrup, normal corn syrup, sugar, then honey. It also has fructose and trace amounts of caramel color, molasses, water, citric acid, natural and artificial flavors and malic acid.

It’s packaged exclusively for use by KFC and its franchisees, thank God. I’m thinking the less Honey Sauce in the universe the better. But I also can’t help but wonder why Honey Sauce is even necessary in the first place. I know there are problems with colony collapse disorder, but I had not read about any honey shortages. I don’t recall people wailing about the cost of honey at the hive pump. So why did the Colonel choose to go with fake honey?

I was too lazy to email their corporate media contact and ask, and if I had bothered, I doubt I’d get the real answer. And what is the real answer? There can be only one reason to use the end product of Iowa farmers over the end product of worker bees: money.

And even though honey is hardly a luxury item, corn syrups are no doubt cheaper. If KFC could save one penny per packet by switching from honey to Honey Sauce, it’s a nice little dividend at the end of the year, given the size of the chain. I couldn’t find out how many meals KFC serves globally every year, but for perspective consider that they have 17,000 outlets in 105 countries, making KFC second only to Mickey Ds in scale. As a side note, KFC is owned by Louisville, Kentucky-based Yum! Brands, who also hold Taco Bell and Pizza Hut in their portfolio, hence the marriage of the two unlikely fast food chains under one roof. Combining all three chains, Yum! Has 38,000 restaurants in 120 countries, more than any other restaurant company, and employs more than a million people. But, apparently, very few honey bees.

Still, even with some extra money to be had, it’s hard to imagine anyone dreaming up the entire concept of fake honey in the first place. I mean, who on earth, sitting around a board room table was first to suggest, “Hey, do you think we could save any money by developing artificial honey, rather than buy the real thing?”

It makes you wonder what other counterfeit foods are lurking in our food chain. On second thought, maybe I don’t want to know.

Oh, and by the way, Honey Sauce has about 10% more calories than honey, and arguably has less food “value” than real honey. In my book, another product that should not exist. Is it good for anything? Well, I guess if you didn’t want it on your biscuit, you could always carry a few for insurance against low blood sugar.

It’s messier than Skittles if the packet breaks in your pocket or purse, but at 8 carbs per packet I guess under the right circumstances, Honey Sauce could become Rescue Sauce. But does that thought take the sting out of the product?

Saturday, November 03, 2012

Royal Visitor

Joe College stuck his head around the corner of my office door. “All clear, or are you with a patient?” I waved him in and spotted it at once. That style-killing belt case with the funky bonus strap could only be one thing. Oh my God! Another Dexcom G4—in the wild—in the flesh!

Hey, I pointed to his waist, you got a G4 already! I pulled mine off my belt and flashed it at him like a government ID badge.

The rep’s smile faded a megawatt or two and he sighed. “One of these days I’ll surprise you and get something before you do.”

Probably not.

He’d been wearing his for two days, and so far, was pretty happy. Naturally, we compared notes. And the first thing we talked about wasn’t accuracy, or range, or alarm volume, or sensor life, or the control layout—but color.

The color of the receiver.

“Obviously,” said Joe College, who’s got that athletic team-type-1-look that makes the rest of us look bad, “I couldn’t go with Tickled Pink.” (No kidding, that’s the official Dexcom name for the pink-colored unit.)

Me either. But I’m glad it’s an option. In fact, I personally know two girls who’ve ordered pink ones this week. One girl is six. The other girl is forty six. Tickled Pink. Universal chick appeal.

Personally I ended up choosing black, called Classic Black by Dex, as it matches everything, and I was afraid I might get sick of the blue. If I could have had any color in the world, what would it be? African Safari Khaki. Why? Because devices just don’t come in shades of tan. It would be both different and subtle. Hard to notice.

Anyway, of the three we have to choose from, my visitor decided to take a chance on:

“It’s not quite the color I expected from the website,” he said. “What would you call it?”

Hmmmmmmm….. I held his receiver in my hand, bending it back and forth to catch the shafts of light pouring in through my office windows. It’s blue. But not any blue you’ve ever met before. Dex calls it Ocean Blue. I’d say it’s not quite Superman blue, too dark. Not quite royal blue, too cool. Not quite navy blue, too warm. Not quite storm blue. Not twilight blue. Not blueberry blue. Not Egyptian blue or even ultramarine blue. I think if you set your mind to rich midnight indigo, you won’t be too disappointed. It’s not so vibrant as it looks online.

For fun, we compared Dex Ocean Blue to my meter line up, and it didn’t come close to any blue ever used on any blood glucose meter before. Ever. Which is pretty amazing, as blue seems to be the number one color for meters. Well, blue and silver.

I snapped a pic of the two Dex cousins together. Joe College noticed that the color shifted on my digital camera. He shot a pic with his iPhone and the same thing happened. So this magical Dex G4 color changes when you shoot it, and Lord only knows what your monitor’s profile will do after that.

Still, if you’re on the fence between the blue and the black, I can tell you this. My black shows fingerprints something fierce. The entire front of the receiver, except the big round button, is as shiny as an iPad, which is completely unnecessary, as the screen is not touch-controlled. I noticed Joe College’s Ocean Blue G4 showed fingerprints less than my Classic Black one does. Something to think about.

But after color, we talked about accuracy, range, alarm volume, sensor life, and the control layout; right?

Ummmm…. No. Next we bitched about the case and speculated on what the fuck the extra little strap-loop is.

What would work better? Joe College slipped his Animas pump off his belt and dis-engaged the heavy duty metal clip. Having used an Animas pump only ever so briefly myself, I tend to forget that they make the best pump clip on the market. He held the clip to the back of the receiver. That would have been the perfect solution. Just the machine and the open air. Vertical like I love it. Nothing to unsnap. No clear vinyl to make it hard to see the screen. No layers of leather making it hard to press the buttons. No looking like a dufus with a sunglasses case on my belt.

Too bad Dexcom didn’t think of that as an approach, or as an option. In theory, you could use industrial-strength epoxy to glue a clip onto a receiver yourself, but I’d be a nervous wreck: It might fuck up the machine; or it might fail and you’d end up at home at the end of the day with a clip on your belt and the receiver nowhere to be seen. Ack!

“It’s not so bad with my work clothes,” Joe College told me, looking at his case sadly. As a pharma-type person, Joe College wears a rather citified wardrobe not typical of northern New Mexico. Think pin-stripe pink dress shirts and dark grey suit pants, accessorized with shiny shoes. If I didn’t have diabetes radar for pumps and CGMs, I’d never have noticed the Dex case on his belt. After all, its slick black leather and shiny black button snaps give it an urban look. Joe College set the case down, “But I don’t know what I’m going to do the rest of the time. Maybe I’ll try carrying it in my pocket.”

Now pockets are fine for what I call “reactive” CGM use. You wear the sensor. Carry the monitor. If it squawks at you, you do something about it. But if you’re a “proactive” user (or are currently in pro-active mode, we all tend to go back-and-forth) you’ll want to be looking at your machine more often and having it out on a belt is hard to beat.

The Dex case is functional, and I’ve actually gotten rather fond of it, at least until I catch a glimpse of myself in a bathroom mirror, or see my reflection as I pass by a window or glass door. Then I really hate it because I can’t stand the way it looks. Even the same case in a tan leather would be better for my wardrobe. I mainly wear pale browns, tans, and greens. Desert pastels. A black case really stands out with this color palate. It says, HEY LOOK AT ME!


Of course eventually Joe College and I got to accuracy, range, alarm volume, sensor life, and the control layout.

And then, as my visitor was set to leave, I realized that our cases were both on my desk. Whose was whose? One was a bit scuffed up and my uncharitable thought, as I put his Ocean Blue G4 into the damaged case, was how on earth did this guy manage to scuff up his case so much in two days? But when I tried to put “mine” back on my belt, the clip was tight. I realized my mistake and switched the cases.

I’m the one with the scuffed-up case.

I’m generally pretty careful with gear that keeps me alive. I have no idea how I did this:

But it probably doesn’t say much for the enduring quality and longevity of the stock G4 case. Hopefully the third-party accessory makers will be rolling out product soon.

And maybe they’ll make one with a rotating clip in tan leather or African Safari Khaki.

Friday, November 02, 2012

G4 Platinum: What I hate most so far

In my former life I was a newspaper photographer. Actually, a damn good one. That was a long, long time ago and the technology we used back then was primitive compared to what we have today. I racked up a lengthy list of Associated Press awards using cameras that didn’t even need batteries to function.

No auto focus. No auto exposure. The machines I used for covering the news were mechanical. But oh what machines they were. Precise. Solid. Brass and gears and steel and glass. Heavy, but with movements as smooth as butter. And when you pressed the shutter, you got the image your eye beheld. Exactly. Precisely. What the famous shooter Henri Cartier-Bresson called “the decisive moment.”

When the world went digital, my photography skills went to hell. Shutter lag was the bane of my existence. You no longer got the exact split-second image. The momentary lag it took for the digital camera to capture its image gave me a very different image from the one I wanted. The lag has gotten better and better as camera improve. But it’s still too long for me, at least in the most recent digital camera I own. That ever-so brief extra breath the digital camera takes is long enough for a facial expression to shift, smoke to drift, light to change, or flying sparks to die.

The decisive moment is lost.

And why am I talking about this today? Because the G4 acts like an early digital camera. You press the button to find out what your decisive blood sugar is, and nothing happens.

Not a damn thing.

You press again. And again. Is the little fucker broken? Already? Then, like a sleepy child opening one eye in protest as she’s being woken for school by an insistent parent, her screen flickers to life.

Dex Seven woke up when you pressed the button. Like a film camera, on the job on demand. But the G4 is like a digital camera. I’m not quite sure how long it takes, about three seconds by my reckoning. Long enough to drive me crazy. Is this the price of having a color screen? I don’t think so. My iPod has a color screen and it springs to life.

Does it matter? Damn right it does. I take a lot of pictures of my blood sugar every day.

Thursday, November 01, 2012

Best night ever

Today’s CGM Primer: “Could you hurt yourself trusting a CGM? Sure. But you could just as easily hurt yourself trusting a fingerstick meter. Diabetes is a dangerous business.”

--Beyond Fingersticks

Cigar smoke wafts gently upwards towards the two-story high ceiling of the Churchill Club. I’m sitting in a wing-back leather chair. A glass of dark, rich whisky in front of me. Heavy glass ashtray to the right. I’m a lefty, so I drink left-handed and smoke right-handed. At my back, stack after stack after stack of bound copies of the Pacific Review from 1928 tower over me. My view forward is of a massive oil painting larger than an Imax screen. The Sultan’s Dream. Naked nymphs try to lure the sultan off his boat and into the water. The spires of Constantinople are behind him.

The club is mainly populated by men, but not exclusively. In fact, seated at my table is one of the most stunning brunettes I’ve ever met. My evening is looking up.

I take a slow drag on my cigar, the tip glows angry orange, and a faint crackle reaches my ears. Ahhhhhh….. The cigar is new to me, called Eileen’s Dream. An easy name for me to remember, because just like the real live Eileen I know, the cigar is tall, skinny, and blonde. The wrapper hails from Cameroon, the filler from the Dominican Republic. The tobacco is infused with Irish Crème and White Chocolate Truffles. I ordered from the leather-bound cigar menu because the description was sexy. The cigar did not disappoint; it, like both its description and the real-life Eileen, is sexy. The taste is mild, smooth, exotic.

Suddenly voices are raised. The pack of cigar- and cigarette-smoking men two tables over have broken into a heated argument, “You just shut up!” shouts one, a small, powerfully-built man with 1973 NASA engineer glasses. “That type of defeatist attitude is why this country is going to hell! Don’t even put negative thoughts into to the atmosphere! Don’t you know that kind of thinking can cause bad things to happen?!”

I look toward the brunette. She raises one eyebrow and mouths “Politics?”

His tablemate, a chubby black man, holds his hands up in defeat, “OK, OK, I’m sorry. Don’t get upset. I take it back. Anything can still happen. It’s only the top of the eighth.”

I suppress a laugh. It’s not the presidential election they’re worried about. Not the fate and future of the country. It’s the fate and future of the Giants and the Tigers. They’re arguing about the World Series, playing on a screen that (thankfully) I can’t see, and which (double thankfully) is muted. I like bars, but I loathe sports bars. I like quiet and sophisticated bars where I can have a conversation. Hear and be heard. Flirt if there’s someone flirt-worthy, like tonight.

There’s a gentle tug on my waist. The little girl wants my attention. I unsnap the origami case and drop it open. My blood sugar is now 310 and rising. The trace line shows a steady line of yellow dots, like marching army ants, ever upwards. The blood sugar readout has turned from white to yellow. A warning. The trend arrow, like a wind vane, is pointing up at a 45 degree angle.

The scones and sweets from this afternoon’s High Tea at the Brown Palace are kicking my ass. It’s a self-inflicted wound, I grant you, but that was… Oh. About four hours ago… Wait. That makes sense. The boatload of insulin I took to try to cover it has worn off. Time to throw more troops into the fray.

I angle the G4 so the brunette, who’s now sitting quite close to me, can see it. She takes a sip of her amaretto sour, and licks her lips seductively. “That’s so cool,” she says, voice mildly husky. G4 Platinum: Chick Magnet. Who knew?

I slip the iPod Touch out of my new corduroy sport coat’s inside pocket. I’ve lost more weight, so none of my old clothes fit. I’ve got several other trips coming up this year, so I sprang for a new wardrobe. The coat is a cool sand color, and ever so soft to the touch. Funny thing about corduroy. Sometimes it’s as rough as sandpaper, other times as smooth as silk.

I press the iPod’s “on” button with my thumb and then sweep my thumb across the arrow on the screen to unlock it. The screen flashes momentary, then dims itself for the subdued lighting in the cigar bar. That is so fucking cool. I slide my finger along the blood drop icon in RapidCalc until the readout matches the 310. The App advises three units. I take the heavy metal insulin pen from the back pocket of my new blue jeans and hesitate. I’m wearing a skin-tight forest green turtleneck under the jacket. I’ll never get it pulled up high enough to shoot in my upper arm like I usually do. I don’t want to un-tuck my sweater and shoot in the stomach in front of all the other cigar smokers.

There’s a 4mm BD Nano needle on the business end of the pen. The sweater’s kinda thick. It would probably get into the skin, but why take a chance? I shrug, pull up my sleeve a little, rotate my hand, palm up, and inject right into my wrist, in the middle of my medic alert tattoo. A man at the next table nearly drops his cigar in his lap, but says nothing.

Although not FDA approved for it, and even though the legal team at Dexcom says we shouldn’t do it, the G4 is clearly good enough to dose insulin from without a fingerstick. At least in some circumstances. Like when you are making progress with a hot brunette, are half way through a good $6 cigar, and have left your glucometer in your hotel room.

“I really like this place,” the brunette tells me, “ I’m not a smoker, and I’m glad I never started, but I like how happy and relaxed all the men in here are. The place has a good vibe. I feel at home here.”

Truth be told, I say to her, I’d totally forgotten the cigar bar was here. My son reminded me about it. He’d like the old-fashioned vibe. At first I was kind of bummed he couldn’t come with me… but… My eyes sweep up and down the brunette’s curves. Sometimes some adult time is indicated.

Her dark brown eyes, almost black, twinkle. “How very true.” She leans in towards me, lips gently parted. I set the cigar in the glass ashtray and turn to her. Our noses nearly touch. “Speaking of adults,” she whispers, her lips brushing across mine with a flickering, teasing touch, “do you think our son is driving your mother crazy by now?”

I kiss the brunette, my Debbie, on the tip of her nose. After 25 years the hottest woman I know. Exotic, stunning, and still full of surprises after all this time.

Nah. Let’s stay for another cigar and watch my blood sugar come back down.