The Art of Control

Yes, that is a direct and intentional plagiarization the Art of War by Sun Tzu. But he's long, long, long dead....so it's OK. But I chose to knock off the title for a specific reason. BG control is a war of sorts. A war that needs to be won with an artful approach, rather than a purely scientific one.

We now have a very important new weapon in the war to control our BG. One that requires new strategies and tactics, and a new mind set to use it to its fullest potential. So without further ado, Wil Print Tzu brings you: The Art of Control.

The first principal: Watch the flow of the water, not the stones in the stream. Don’t think about BG numbers; think rather about the motion of BG. Direction. Speed. Duration.

The second principal: Know that your house is built on sand. There is no true BG. It cannot really be measured and doesn’t need to be. BG does not matter. Only changes in BG matter.

The third principal: Use the crystal ball. Be proactive in your thinking. You can watch the flow. Now, you can think ahead. Plan ahead. Be ahead. Avoid surprises.

The fourth principal: Be a red state. In this case, it really is better red than dead. Use conservative alert thresholds. An alert means to listen. It does not mean you have to act. This means a high low and a low high. You’ll need to read that twice to get it, but you will.

The fifth principal: Calibrate in safe harbor so your readings are accurate in rough seas. Don’t calibrate your monitor when you are way out of your normal range or when your BG is shifting rapidly. For one thing, your test strips aren’t as good here, and for another the delays between you finger stick, your entry, and the calibration process all add up.

The sixth principal: Think deeply sometimes, think shallowly always. You should always be alert to your BG, but do not obsess 24/7. In your daily life stay aware but don’t micro manage. By the same token, set aside a hour or two per week to sit down and really study all the information that is available to you. Think about it deeply. Learn from it.

The seventh principal: Celebrate defeat. Even with the best technology has to offer, bad days will happen. We count carbs wrong. The infusion tubing tangles. The wind is from the west and the moon is in Leo and your BG does a mystery dance. Don’t be angry, sad, or frustrated. Take joy in being human with all our frailties and uncertainties. This is a game of averages, a bad day that doesn’t end in a coma is not the end of the world, and it won’t even screw with your A1C. Be right most of the time and you get to keep your toes and eyes.

The eighth principal: In this modern warfare we need fewer soldiers. In the new world order there are only three uses for test strips: Test strips are for insulin. Test strips are for emergency sugar. Test strips are for calibration. Other than these three times, they have no further use and are otherwise obsolete.

The ninth principal: Walk the field of battle after the fighting ends. Be the Monday Morning Quarterback. If you keep good records you have a great opportunity to learn from both your victories and your mistakes. Review battles lost and won. Read the map. Look at your traces. Search for patterns and connections. Use that information to plan for the battles ahead, for this is a never ending war.

The final principal: Be the lion tamer, not the lion. Control your D. Don’t let D control you. We’ve been managing our condition in a knee jerk fashion. We are reactive. Now we have the opportunity to take the reigns. To be proactive. To see what is coming, to plan, to manage. The Guardian is more than a Watcher. It is a Seerer. It can let you put two and two together. You eat the Egg McMuffin. You take the insulin. You watch the BG, first slowly snaking upwards, then suddenly shooting towards the sky like a rocket to the moon, now leveling off, begging for more insulin....With continuous, real time feedback you can see what is happening as it happens, take action with the flow of information, and stay on top.


A final note. This new technology, this new way of thinking about BG, this new way of treating ourselves: it will be a revolution. We stand at a moment in time where everything is about to change. And change for the better. I believe that in twenty five years most diabetics will carry some sort of advanced descendant of the Guardian, just as most of us carry our little BG meters today. The technology is good now and will only get better; and it carries a promise of a whole new approach to managing diabetes. Not just to treat, but to truly manage and control it. Short of a cure, what more could we want?

Farewell, minus one.

Yep. Tomorrow is going to be my last post. Oh stop your blubbering. You’ll all do just fine without me. You’ve got Amy for info, Kerri for emotion and poetry, Allison for the glass half full and Scott for the glass half empty and deep thought. And you have so many others in the OC. There is almost too much to read!

I’ve decided to wrap this up because I’m running out of things to say. I’m sure I could go on a bit longer, but I think it would be redundant.

I've covered the reasons for wanting a Guardian and the adventures in acquiring one. I've covered the nuts and bolts in great detail and the discovery process of getting to know the system. I've showed what daily life is like living with her. I think I've shown how incredibly valuable a Guardian can be, and what a pain in the ass it can be at the same time.

Mission accomplished? It seems to me there are a healthy supply of excellent "life with diabetes" type of blogs out there, so there is no need for this one to evolve in that direction.

What? Ah, Ok. Well, I must wrap this up for today. Rio wants Daddy pancakes. Daddy pancakes are a tradition in my family for three generations, well four if you count Rio. They originated with my Dad's Dad. On the maid's day off Grandfather had to cook for the youngest son (Grandmother was killed in an accident when my father was little). Yes, I did say the maid. My family has gotten poorer with every generation for at least five generations. If Rio doesn't turn this trend around we will have de-evolved from leading citizens to trailer trash.

The story goes that my Grandfather asked the little boy what he wanted for breakfast and Father asked for pancakes. Grandfather got out a cook book and found a crepe recipe and made them as pancakes.

I grew up on them as a weekend staple. The are very thin, and golden brown. You put a light coating of butter on them, a thin veneer of maple syrup, and then roll them up like a burrito using only your knife and fork. Well, except for my Mother. She uses her fingers. That's OK. Different gene pool.

The two main ingredients in the original recipe are flour and powdered sugar and then you cover them with maple syrup. All around this just doesn't seem to be a good idea for diabetics. But one day, determined to make the old family recipe diabetes friendly I subbed Splenda for powdered sugar. I had my doubts, but Splenda is pretty fly away...

Any way, it came out great. Eaten in reasonable quantities, served with high-fat sausage and sugar-free syrup, it treats my BG pretty well. Deb and Rio have put their own mark on the family favorite by adding a generous dollop of various jams before they roll them up.
Serve with a cup of very dark coffee. But I digress....

Where was I? Oh, yes. I’ve felt really good about being able to provide a pile of important information to the diabetes community about a new product that we all had such a thirst for information about, but I think it is time to close up shop and move on to other challenges.

I’m behind on my reading: both photography/lab and diabetes; and I’ve been neglecting my friends over at Diabetes Talkfest where this all began. There are also new blogs for me to discover and read. So many talented writers out there! Does diabetes cause good writing or does good writing cause diabetes? Hmmmmm.....

A word on writing, I've had two photography books published and two text books, but I got to say, this has been by far the most satisfying writing experience I've ever had. I think bloging is so cool, 'cause you get feed back from your readers.

But I've also got two other writing projects that are wallowing (not to mention bike ridding!). I've got a three-quarters written novel, my fist foray into fiction, that I personally feel is the best stuff I've ever written. Need to get that puppy finished.

I've also been asked to review software for one of the diabetes websites, and the first product to be victim of my pen is lying on my desk. Waiting, waiting, waiting....Don’t worry, David, I promise I’ll get to work on it right away!

I'm sure the one question left on everyone's mind is: after wearing the Guardian for three months, would you recommend it to others?

Yes. Absolutely. Double absolutely. Triple absolutely. OK, I've had my ups and downs as you’ve all seen. But I think that the ups far, far, far out weight the downs. I think a lot of the “downs” have had more to do with my expectations, miss-understandings, and ignorance about the technology.

Once my brain grasped the possibilities and how different continuous monitoring is, once I matured in my understanding of how the system could be used, I really started to benefit from it. I truly wish that all of you could have one too.

The girl has been promoted from flashy mistress to partner. At first, I viewed her as nothing more than a easy finger stick and an expensive alarm system. Sigh...what a waste in hindsight. I wasted too much time obsessing over the percentage difference between any one given finger stick and the Guardian reading at the same time. Now I realize that is so feeble and unnecessary.

Once I woke up, shifted mental gears, stepped outside of the box and realized the possibilities things all fell into place. And my health is better for it. My crazy BG’s have stabilized.

For me at least, there is never any going back. Rio’s new “word” is Never. He draws it out like this: “Neeeeeeevvvvver!” He uses it like most three-year-olds use “No.” I think it is cute. My wife less so, but she hears it more than I do.

Come on, Rio, time for a bath. “Neeeeeeevvvvver!”

Let’s get dressed. “Neeeeeeevvvvver!”

Put away your toys. “Neeeeeeevvvvver!”

Dinner, time to go, time for bed: “Neeeeeeevvvvver!”

You get the idea. If he really wants to add emphasis he’ll add “Ever, ever, ever.” to the end.
So will I ever live my life without continuous monitoring? Neeeeeeevvvvver! Ever, ever, ever.

Not until the cure.

Tomorrow I’m leaving you with a final gift: a users guide of sorts. My most important thoughts on how to use continuous monitoring.

New Adventures Exploring the Amazon & the Ghost of the Fat Man

I recently visited Skytor’s site (http://www.skytor.blogspot.com/) and got quite a shock. He had posted a meter download of his BG. It looked like the graph of an earthquake. Sharp, jagged lines, like horizontal lightning bolts.

I’ve gotten use to the organic meandering lines of the continuous traces. What at first seemed un-orderly to me has now become natural and normal, and the striaght mechincal lines I used to love now look artificial and strange. Funny how quickly we humans adapt, isn’t it? These traces, which seemed so alien to me at first are now so beautiful to the eye.

So I’m trying to figure out why a man who only owns three pairs of pants has no room in his drawers. At first I had suspected an intrusion of overflow female clothes from you-know-who. But that is not the case. It turns out I own three pair of pants that actually fit. It turns out I own a significant wardrobe of descending sizes that no longer fit. Thank God for $9.95 jeans at Wal-Mart, or I’d be broke! My current, and slightly baggy pants are 36. I can wear a 34, but not comfortably yet. So I guess my waist is actually a 35. The largest pants still in the drawer are a pair of 48s (relaxed fit at that!). I try them on, just for fun.

Oh. My. God.

Was I ever really big enough to fill this mountain of cloth?

I can’t remember if I’ve even told you this story, and I’m too lazy to re-read the whole blog, so if I’m re-telling this I apologize. When it was finally settled that I was, in fact, a very late to the party T-1, I started reading up on T-1s. I found over and over that T-1s are typically described as thin, angular, ectomorphic if you like. So I asked my Endo, so why am I the only fat T-1?

Just wait, she told me.

Sure enough. I melted. Like magic. No real effort on my part. I don’t know if the disease ate the fat, or if the carb counting and healthier eating did it, but 60 pounds went away in about ten months.

Now my wife and her family worry and tell me I’m too skinny. (My medical team says they won’t worry until I lose another 20 pounds, so I don’t think that I’m really all that thin, just so much thinner than people were used to seeing me). But last night as I was walking past a mirror I caught a glace of my reflection. I had to stop and stare. Yeah, there I was standing there in front of the mirror, checking myself out. Like most heavy people, I’d learned to look in a mirror and comb my hair and trim my beard without really looking at myself.

But now I’m looking. Wow. I gotta tell you, I like what I’m seeing. I like this being thin. I’ve been heavy most of my life. Well, I can’t recommend the D-diet, given all else that comes with it, but at least I’ve been given one perk.

I used to be a fat, out of shape middle aged man. Now I’m a skinny, out of shape middle aged man. My new goal: to be a skinny, in shape middle aged man!

I’m loving the bike, but, yikes! It has really shown me how pathetically out of shape I am. My current work out (don’t laugh): I ride the long way to work. About 600 yards. Up and down and around rocks and cactus, but more or less flat. Then I do another 600 yard loop at “lunch.” And a final returning home at the end of the day. I’m getting slowly better, but that 600 yards leaves my heart pounding and me panting for breath. Pathetic. Lance Armstrong is laughing his ass off right now. Oh well.

Hey, Lance, no prickly pear on the Tour de France!

By the numbers

Let’s re-visit the subject of the number of calibration sticks. We haven’t talked about this for a while now. My current thinking is three on most days. The system requires two, twelve hours apart. But think about it. If I do 7am, then I need to do 7pm. Not good. In the morning it is calm water, but in the evening it would be right after dinner. What I’ve been doing is either three or four per day.

I always do a wake up stick. By the way, this is a new stick for me. I use to just wait an hour and hit it at breakfast. But this is a good time to give the girl her first cal stick. Sometimes I do a noonish stick, but usually I wait until late afternoon, and then again at bed time.

I had been toying with the idea of dropping the pre-breakfast stick and just using the wake up stick as I’m usually eating breakfast within 45 minutes of getting up. However, I’ve noticed that there is often quite a lot of changes going on in that first 45, so I’m still doing pre-breakfast. I don’t enter any of my pre-meal sticks on two theories: one, I’m about to pump insulin and two: I’m about to dump sugar into the system. I figure either one could start things moving pretty quickly and that could throw off the calibration process. Of course there are other finger sticks during the day that don’t go into the machine as well, like responding to an alert, but overall my test strip usage is way down.

Another number: I’m trying two IV 3000s under my transmitter. I’m still getting some localized rash on my skin from the transmitter adhesive. I guess it’s working its way through the IV 3000. That now means I use five each time I change a sensor. What was that sound? Oh...just the sound of Smith & Nephew sock going up 5 points. Lucky for me that with these modern windows computers my readers can go buy stock without having to close me down!

The best new number yet: fewer hypos. I've noticed looking over my data that not only do I have fewer hypos, I'm spending less time "in the basement." I've also clocked less high time too. My sugars have settled down considerably. I’ve had very few alerts the last several weeks, and almost no real hypos. I credit the Guardian for this. I think now that I've "mastered" the work flow of using the system to keep tabs on where I am, my control has improved. I'm heading trouble off at the pass. I'm preventing trouble. I’m being ProActive Man! (Readers Vote: what color of cape should ProActive Man have?)

But most important : I feel safe again.

I'm boss now, well me and the girl. So it is sort of like a marriage that way, I think I’m the boss, but we all know who’s really in charge....

But not the specter of hypo, that’s for damn sure. During the day I'm on top of things. As bed time rolls around I don't have to resort to taking a finger stick, looking at my IOB (if any) and winging it, like I did in the old days. (New view of the morbid child’s prayer: Now I lay me down to sleep and if I die before I wake...I sear I will never teach that prayer to Rio!).

Now at bed time I can see the rate, speed, and direction of change before hitting the hay. I'm in control. In the pilot's seat. But it is good to know that I have a co-pilot, just in case. If something unexpected happens during the night, the girl is on the job and will wake me up.

For what it is worth, I had expected many "false alarms" when I cranked up my alert thresholds, but that has not turned out to be the case. The last few weeks I've only had a fraction of the alarms that I had in the beginning. Again, I think this goes back to good control, and the opportunities for good control that constant feedback bring.

This leads me into one last point that I haven't spent enough time on. The name of the system is Guardian RT. The RT stands for real time. Of course we know it isn't, but it is close enough. Even though the data is delayed by as much as five minutes, it lets you take action in real time. Think about that. No, really think about it. Is a test strip real time? No, it is slice in real time. That's not the same. I've come to appreciate that the most powerful element of the entire system is the recent history that can be accessed by checking your now, then scrolling backwards a few clicks.

Tonight, two hours post sugar-free Klondike Bar: 104 now and going back wards: 104, 104, 105, 106, 108. Dropping, but slowly. According to the pump the IOB is 0.4 units. Looks like we are cleared for landing! (In bed that is).

Miscellaneous musings:

If you don’t have your shit together, and most of us don’t, you can forget that it is sensor change day. If you space it out, here is what the Guardian does to you: 72 hours after insertion you get an alarm telling you to replace the sensor. And then it shuts down!

Yikes!

That’s right. No more data. This is as insidious as Abbott's smart strips that won’t work one hour after their expiration date. If I were designing this system I either give a pending sensor replacement alarm in advance, or allow a six hour extension of operation after an alarm.

Can you imagine if your pump shut down after its “time for a new site” alarm?

Speaking of which, I have a window in my Cozmo that lets me look and see when the next site change is. Hmmmmm....Is that going to be tomorrow, or am I confused again? Well, let me see...oh yes next site change is ___________ (fill in the blank).

Why am I grousing about this? Well, I was out to lunch, in the intellectual sense of the word, on a recent sensor change. I forgot all about it until I was shut out. Unfortunately, It was right after a big, badly bolused meal. You can’t just plug back in. It takes two plus hours to spool up. That put my first cal stick on a steep slope above 300. Not the best footing to start out a new sensor. The unilateral shut down didn’t let me plan the best time for insertion of a new sensor.

Speaking of carbs and insulin, I forgot to tell you folks that a while back I adopted a new short cut. The Guardian has a way to enter both a carb value and an insulin bolus amount. However, it is almost a complete waste of time. Note that I said "almost," not "total" waste of time. The reason? The data isn't incorporated in any useful way by the software.

If you log in a meal, it will show up on the daily graph in "UnSolutions" (as I like to call it); but only as a graphic element. That's nice 'cause it says "at this point you put something into your mouth and took some insluin." Or, at this point you took a correction bolus. But....and there is always a "but" with UnSolutions...it is an act of Congress to find out how much insulin or how many carbs are involved. And we all know how slow Congress is, right?

Is there anything I like about UnSolutions? Hmmmm....Well, yes, as a matter of fact. The desk top icon. It looks like a miniature Guardian monitor. Very cute graphic. But that's about where my affection for the software ends....still better than nothing, and I do use it nearly every day. I spend a lot of time looking at the "traces" of the BG over a 24 hour period after I down load them. I just wish I had more flexibility in what I did with that data and how it is displayed.

But back to carbs and insulin, the data is there lurking under the surface of the software, but hidden and not readily available. First you have to close the graph; and second you have to open the log book, which takes foreeeeever to spool up. Then of course, you'd have to close the log book to re-open the graph. As there is no way to read the data while looking at the graph, I find it easier to just look in my food diary or pump log instead. That being the case, why am I wasting my time entering all this info in yet another place?!

Now, I do like having the little logo on the graph so I can quickly see when meals and insulin doses happened. My Solution? I just always enter the same insulin and carbs. That forces the software to leave me a logo, but takes me almost no time to do. The Guardian remembers the last entry so for a meal I just go to events press the ACT button five times and I'm good to go (once to confirm, once for insulin, once for insulin amount, once for carbs, and the last time for carb amount). If it's a correction bolus, same drill but three clicks instead. Maybe a few more buttons and a few less stacked menus would be a good addition to the next generation monitor.

By the way, as I predicted it would happen almost three months ago, the monitor's AAA batteries finally ran down. Readers who've been with me for a while will recall that one of my early bitches about the system was the lack of a battery strength indicator (which almost every other battery powered device on the planet both cheap and expensive have). Instead the Guardian gives you an alarm six hours before the batteries kick the bucket. I predicted this would happen in the middle of the night.

1:47 am last night... err... this morning. Yep. Damn, it's a burden always being right. ;-)

By the way, once that alarm goes of the back light no longer works, so if it is in the middle of the night you can't see what all the commotion is about.

Any way, quick process to change the two AAA batteries. I use the "Bunny Batteries." Energizer. I have no complaints. That was my original set. I got damn near three months out of them. And I use the monitor a lot, and most of the time with the back light too.

Oh well, replacing batteries by moon light four times per year won’t hurt me any....

Eight O'clock and all is NOT well

It was a morning of many electronic crickets. First the girl gave me a low threshold alert. Then my alarm clock went off. Then the pump alarm, reminding me it is site change day. I lay in bed for a minute, eyes half open, recovering from this electronic assault.

Not likely to be a real hypo at this time of day, but the girl needs her calibration stick anyway. Last strip in the vial. I slip the strip into the port, check the lot number, stab my finger and touch the strip to the drop of blood. The pump vibrates almost immediately. Ut-oh. This can't be good.

24.

No way. But...wake up, babe. I just clocked a 24.

My wife, who doesn't wake up fast under any circumstances is on her feet in flash. We need to re-test, but just in case I really am super low, extra exercise seems a bad idea. She fetches a fresh vial of test strips for me.

I retest and clock in at 91. That's more what I would have expected, but to be on the safe side I take a "tie breaker" finger stick. It clocks at 71.

This would not be a good time to check my blood pressure.

I need to give the girl a calibration number and I've got two finger stick readings that are nearly 22% apart.

I break out the back-up Precision meter. It reads the situation at 82. Pretty much right in the middle. A final Freestyle stick places me at 79; and that is the number I use to get the girl on track for the day.

I swear it is a conspiracy to sell more test strips....they are getting back at me for telling all of you to sell your test strip stock yesterday!

Kiss the post-meal finger stick good bye!

This is my foot. This is my post-meal test strip. This is my foot kicking the test strip to the curb. That's right, I've cut three test strips from my daily routine forever. Your freaking out. I can hear it from here. I'm killing the sacred cow? Damn right, and I'm gonna barbeque it's ribs too!

The post meal finger stick is one of the corner stones of diabetes management. But I've decided I don't need it any more. It is an antique. Obsolete. Past its prime and time. Adios, sucker!

No, I haven't lost my mind. I've got something better. We use to look to this stick to judge how well we bloused the meal. The idea is to be under 150 two hours post. So if you score a 148 you go off feeling pretty smug. Until your pre-dinner stick when you find you self at 210. Wouldn't it have been cool if the test strip said "148, going uuuupp!"

Even if you are too high at two hours, it is probably too soon to take a correction. And unless you really, really, really muffed it, unlikely you'll be border line hypo yet. So our most sacred finger stick is actually our least useful from an action perspective, isn’t it?

Now I still do a two hour check, but I use the girl and I don't just look at one number. I look at the recent history and think about it, plan ahead. A quick scroll shows what's going on. I always hope for a number around 150. Scrolling backwards I'm happy to see a slow decent from the 170s or 180s. That is if all is right with the universe.

But when all is not right with the universe I can make an action plan. If I'm high or still rising I know that I didn't use enough insulin. A correction will be in my future. I can ride the wave and knock it down at the crest. If I'm lower than expected or dropping fast some more desert will be in order.

Like finger sticks, at two hours post there is not a hell of a lot I can do with the Guardian info, yet. But unlike finger sticks, I can see clearly where I've come from and I can make a reasonable prediction about where I'm going. Very, very, very cool indeed.

So I didn’t just kick one test strip to the curb. I kicked 1,095 of them to the curb in this year alone. Printcrafter’s stock tip of the day for test strip companies: Sell.

What the hell is it about Home Depot?

Have you watched Forty dollars a day with Rachel Ray? Fun show. Of course our intrepid host doesn’t have to deal with a $40 sensor, that in this case lasted only one day. If I’d been with Rachel on this day it would have been no food for Wil. Here is my tale of woe.

It's been a bad week for me and sensors. You recall the tale of the bent / painful sensor, right? So with some trepidation I moved my sensor site back to a stomach set to replace it. It seems less likely that I'd bend one there. The transmitter-tape induced rash on my stomach has cleared up, but now the skin on my stomach is different colors. I have perfect light brown transmitter-shaped patches where the pigment of my skin seems to have changed color. There are several of them. I have no idea if it is permanent or not.

Now I'm a middle-aged married guy, so the only person who sees me naked is my wife, and she's long past being interested enough to look anyway. But if I were female, or a young man who liked to go shirtless in the summer, I'd bet this would be highly distressing.

My advice--use a IV3000 on the bottom.

So this was....hmmmm, must have been Friday morning. All day long the sensor didn't behave really well. Off. Mostly reading low. Then the damn thing alarmed, err, alerted every 45 minutes all night long. At each point I did the finger stick and found the sugar holding steady in the low hundreds. At one point the girl reported my BG at 54. The finger stick clocked me in at 117. Looking at the signals menu, I see that the signal strength is very low. I don't enter calibration sticks, hoping that the signal will recover. If it does, I don't want it to over-respond and run too high. For the rest of the night I just canceled the alarm and rolled back over to go to sleep each time. Every 45 minutes. All night long.

For the first part of the morning she was acting OK, but then began to drift lower and lower. We were headed home from Denver when we stopped at the Elephant Bar for lunch at Colorado Springs. At that point the difference was 52 points. (Printcrafter’s restaurant rating: four and a half stars for food, five stars for decor and atmosphere. Also nice that Rio's drink and desert are included in the price of the kid's meal.)

We stopped at Home Depot in Pueblo, retaliation for my buying a bike without first getting spousal approval. I don't remember the exact details of events, but I think I had a low alert, way off. I fed it a cal stick. That led to a cal error that lead to another finger stick that lead to an alarm that the sensor had failed and needed to be replaced. It had been in service about 26 hours. Bummer.

Now have you ever seen the men's room at a Home Depot? This is one place that I am no way going to use to stick a needle into my self.

I decide to go Guardian-free for a hour or so. I've got my eye on the handicapped restroom at Colorado City’s Cuerno Verde rest area. I used it once when the men's room was being cleaned. I recall that it is a cell-block sized room for one. It has a toilet, sink, towels, and a long countertop along one wall. I can lock my self in and do what needs to be done.

Deb takes Rio to play on the rocks and I dig though the trunk. Under the jackets, under the new bicycle wheels, under assorted bags at the very bottom (of course) are my pump and Guardian supplies. Lucky for me that I'm superstitious and brought a spare sensor in the ice chest.

I gather up all my stuff and head for the restroom. They've got a coffee bar set up in the lobby. The elderly hostess glares at me as I head into the handicapped restroom. Hey, there's all kinds of handicaps, lady.

First up, I gotta pull the dead sensor. I've left it in place since Pueblo, just killing the power for monitor. I strip off the IV3000 covering the sensor / transmitter joint, and uncouple the two by depressing the teeth on either side of the sensor. I give the transmitter a quick tug and it pops right off of the IV3000. I get a hold of a corner of the dressing and peel it up. It crumbles into nothing, like a spider web. I'm always amazed that such a large bandage can crumble up into such a little piece of nothingness. Next I have to take out the sensor. I'm yet to establish a protocol for this that I'm totally satisfied with.

With my infusion sets, I just whip them off. But the sensors are a bit more substantial than the canaulas. They've also got a much more aggressive tape. Most of that tape is on the IV 3000 under it, but some is on the skin around the hole in the dressing. After some twisting, pealing and a quick yank, I'm free of it.

Instead of the shiny gold they usually are, this one is dark red. It is coated with dried blood. I guess I just solved the mystery of why it didn't work right. There is a deep, black bruise on my skin where the sensor was injected. Looks like I hit a capillary. I hadn't seen any blood on the bandage, so this comes as a surprise.

I take my hole punch to a new IV3000, punching nine times to create a quarter-to-half inch square opening. I lay in on my skin to the left of the bloody bruise. Next to it I lay down another one for the transmitter. I smooth it into place and pull off the liner.

I slip the sensor into the Sen-serter, pinch up some skin, line everything up carefully, glace away, and push the trigger. I look down. Nice clean insertion. Some times they don't go in all the way and I gotta give them a push with my finger.

I attach the transmitter pad to the back of the transmitter, peel off the backing paper and push it onto the IV3000. Time to hook up. I turn the monitor back on, scroll to "Search" and press ACT twice. The eight minute countdown starts.

Holding the sensor with two fingers, I snap the transmitter cable into place. "Success" says the monitor, then something strange happens. I get an alarm. "C-60. Service." What the hell is that? Then the initialization countdown starts. Well, that's good, but what is this Service thing all about?

I gather up all my goodies and throw them back in the bag. I truck in my shirt, pulling my pump's infusion set tubing down into my pants. I put the monitor back on my belt. I grab the trash can and sweep multitude of paper envelopes, plastic bags, and slippery bandage backings into the trash. We diabetics are not good for land fills.

Back at the car, after another glare from the coffee lady, I make a call to Medtronic 24 hour help line. I get one of the customer service folks who's helped me in the past, and she remembers me. I tell her what's going on. Do you have a minute, she asks? Yeah, but not much longer, I'm roaming. You can hear that vacuum cleaner sound, money being sucked out of your checking account.

Turns out it can be two things: low battery on the transmitter ($400 please) or....

(you're holding your breath, aren't you?)

....or a "false positive" caused by the hook up being not too smooth. If the batteries have run low 11 months early I'll get another alarm at noon tomorrow, and another each day for a week.

(Note: I won't make you wait. All is fine with the batteries, there are no more alarms over the next few days).

On being a cheap SOB

I'm hobbling around like a cripple this morning, barley able to walk. I've got no one to blame but myself for my predicament. I've often commented, sometimes rudely, that diabetics are the cheapest SOBs in the universe. I have no doubt at all that right this very second, out there somewhere, is a guy who is pulling apart his test strips and trying to clean them out for reuse.

But I've always thought that I was IMMUNE to diabetic cheapness. Wrong.

When I put my last leg set in it hurt. Hurt a lot. Hurt bad. Hurt so you forget to breathe for a minute. Sharp, like a bee sting. But then the right brain kicks in. That's a $40 sensor. Be a man. So I left it in. Wrong call. It hurt some off and on. Never quite enough to signal a definite problem; but always enough to signal that things weren't quite right too. I rode it out for a couple of days. This morning the pain was dull, throbbing "pay attention to me" level. Finally common sense ruled the day. I pulled the set early.

The sensor was bent at a crazy angle. Looks like I hit something inside the leg. Muscle maybe? Then, with all the assorted bandages and tapes off I could see clearly that the leg was very swollen. It is an area about the diameter of a tennis ball. Raised almost an inch above the normal level of the skin. At first it hurt more with the sensor out than in, but now it's getting better.

Printcrafter's tip of the day: don't be a cheap SOB. If it hurts like hell when you put it in, take the sucker out. Screw the $40. You'll be able to walk without limping.

Next time ask for a side salad

I'm getting really good at flipping and scrolling. I slip the girl off my belt about every half and hour, flip the case open and check the current trend. I in traded Click. Giggle. For Click, click, click, click, click. Hmmmmmm....

I probably need to be more clear about that. What I'm saying is that when the girl and I were first together I'd click and look at A reading. I was using her like a finger stick. OK, a fast and painless one; but a finger stick none the less. I was looking at a moment in time. A single piece of information.

Now, I never look at a single reading. I check my NOW number and then quickly scroll back in time using the down arrow button. Five minutes per click. I usually glace at a half an hour. Then, instead of just being pleased with the simplicity, I think about what I'm looking at. Direction? Is the BG going up or down? Or is it fairly stable? Speed? Speed I'm not always so good at, 'cause that takes mental mathematics, which is my weak spot. That said I can get a rough idea of how fast things are moving.

On the way up to Denver we stopped at Denney's in Raton. OK, Denney's isn't the best food in the world, but its pretty good. They also have one of the better kids menus. Very flexible. Choose an entree from the list. Choose a side from the list. Would you like another side? Nice vibrant color photos of all the options. Easy for little ones to study the possibilities. Rio's choice, Mac and Cheese (no surprise) and a firm announcement that he wants the cheese pizza the next time we come. It'll be month from now, but he'll remember.

What I personally like about Denney's is that they have extensively published carb data on their menu items. Not just a few here and there, but everything---even deserts (although I refrained today).

I ordered a Philly Beef & Cheese hogie-type sandwich on chiabatta bread, hold the mushrooms. No fungus for me, thank you very much. Good thing, my waitress informs me, as we are out of mushrooms today. It comes with fries. I hesitate a moment, knowing that fries are likely to give me trouble but my brain locks up and I can't come up with any alternatives. Twelve hours later it occurs to me that they would have subbed a side salad for me with no quibbles. Had I done that my day might have been very different. But that's Monday morning quarterbacking.
By the way, the Printcrafter rating on the sandwich: Five stars. Yum.

Sandwich: 53 carbs
Side of fries: 57 carbs
Diet Coke: 0 carbs

Bolus: 5.5 units of insulin. Let's eat! The damn fries are wonderful and I eat every last one, being careful to use minimal ketchup, the stuff is packed with sugar.

Following the meal I keep an eye on the BG as we snake our way up Raton pass and over the New Mexico / Colorado line. Unlike the terrain we're cruising through, my BG is staying really, really flat. I'm thinking there's gonna be hypo in my future.

Quite the contrary. As we near Colorado city a steep rise kicks in. We're about two hours post bolus at this point. We stop at the Cuerno Verde rest area at Colorado City. Rio has important business here. First we play on the rocks. On the West side of the rest area, between the overflow parking and the restrooms, are eight BIG rocks laid out Zen garden style on a bed of sand. It is our tradition to stop here both coming and going. Rio scrambles to the top of each. Two of them are designated jumping rocks. He always does them in the same order, over and over and over and over and over as many times as I'll let him. Today we have an advanced pact. It is dark, very cold, very windy. One time is the deal. He keeps up his end of the bargain then runs to the bathrooms as fast as his little legs can carry him to see the map.

Inside the building that houses the woman's room, handicapped restroom, and men's room is also a generous lobby with a magnificent two story bank of curving windows. In the center is a large rack of brochures for various sights and things to visit. And on the wall is a giant map of the state, including a wee bit of our home state.

Rio points to the map. This is were we ate lunch. And this is were we are now, and this is Grandma Jean's house. And these are the mountains. And what's this? I bend over and squint at the large purple splotch on the map. Ft. Carson, I tell him. Where the army practices with their tanks.

So while Rio studies the map of our Journey, I study the map of my BG. Rio's looking at were we've been, where we are, and where we are going. Likewise, I can see where I've been, and where I am. Where I'm going is trickier. So I've got a quickly rising BG. In an hour I've jumped from 125 to 237 and I know a correction bolus is in order but I've got a radical new theory to test. Well, radical for me anyway.

To be honest, I can't claim full credit for this idea, but I can't recall either if there is just one person who deserves the credit or if this is something I synthesized from various conversations and readings. So if I stole someone's pet theory, I apologize. But here is my own personal take on it.

Ride the wave. That's right, I'm going to try to let this spike reach it's apex before I do anything about it. Before I tell you why, a quick comment that is important. Most of the time my high BGs are below the mid 250s. High BG is not really where I have trouble. I do spike into the 300's sometimes; and I've clocked a 400 or two in my life, but it is not common. The two times recently that I've spent considerable time in the stratosphere didn't even rate me one tenth of a blood ketone. Not that I'm complaining. I'm just pointing out that riding a high wave to its crest is less dangerous for me than bunging jumping off a bridge. Which I've never done. Why survive something that will scare the hell out of you only to be killed by your wife for doing it?

Obviously, if you are ketone prone you should not try my new approach.

This is why I want to ride the wave: I'm trying to avoid Serial Correction Boluses. (there's a new one for Kerri's diabetic dictionary). SCB's always happen to me. When I get a wild sugar ride I find I'm taking correction insulin every two hours. The reason I now realize is this: I'm taking them on the up-slope. The sugar on board has not run its course. That being the case, the various magic formulas in the pump software can't work.

Third grade math example: let us say that we've got a spike that will top out at 300. If I intercept it at 200 and take insulin, the pump is not going to give me enough juice to knock down a 300. Instead, it will flatten out the curve. I'm still going up, but just not as steeply. When it hits 250 the same thing will happen again. Eventually, four or five boluses later I may end up over correcting and end up in the basement.

On the other hand, if I wait until the spike reaches it's high, where it will stay unless I do something about it, then I have some simple facts to deal with. It takes "X" units of insulin to Lower "Y" points of BG to target level of 115. OK, maybe that is more seventh grade than third grade, but waiting maximizes the efficiently and effectiveness of the correction bolus. In theory at least. This little experiment can also serve to help nail down a precise correction bolus ratio.
Point is, if I let it ride to the peak I should be able to knock it down with one correction not five. And that, again, in theory, should leave me high for a shorter period of time. Minimizing your high time is the name of the game for a A1C that will make your heart glow.

Now determining the peak of a spike with finger sticks would be a pain in the finger tip. But with continuous monitoring, this is very easy indeed. It doesn't even matter that much if the Guardian and the BG are not quite in sync, and they probably won't be with a fast rise. You'll still need the finger stick for the insulin, but you can use the Guardian by herself to tell when you've reached the top and leveled off. At that point you take your finger stick and figure out how much insulin is needed.

I get two readings in a row that are the same before we leave the rest stop. I know the peak is near, but I'm not sure we're really there yet. We drive on and I stop near Pueblo, once I'm sure we've leveled off. My readings show: 273, 277, 279, 279, 279. Looks like the crest of the wave to me. I take a finger stick and get a reading of 348. I don't trust freestyle readings over 300 so I do a second stick and get 327. I diecide to split the difference and correct for 337. Furstratingly, the pump stubbornly refuses to let me over ride the most recent finger stick so I correct for 327. Oh well, that's erring on the side of caution.

We hit the road again. I periodically check to progress of my therapy by balancing the monitor on top of the steering wheel, scrolling with my right thumb, driving with my left hand, and keeping one eye on the road and one eye on the monitor.

Damn, she's going up again. So much for science.

The BG keeps going up until Colorado Springs, then noses over nicely. 294, 291, 286, 278, 270, 265, 262, 260.

When we get to the Colorado Blvd. exit of I-25 in Denver I'm at 252.

Very cool. At this point we stop at Noodles, where we've arranged to meet my mom for a late dinner. So we'll never know if this correction would have been picture perfect, but it sure looked good for the home team. By three hours after the meal I'm below 100.

For me, for now at least, I'm going to ride the waves.

Three inches of snow

I think the state should give me an award for single-handedly ending the drought by buying a mountain bike. I got up early this morning, eager to take the "long way" to work on my new mountain bike. It was grey but OK when I got out of bed. By the time I was out of the shower the snow was flying. We got a little over three inches by noon. But now the sun is out and it is in the 40's so maybe tomorrow....

Adrenaline rush

Ahhhhhhhhhhhhhhhhhhhhhh!!!!!!!!!!!!!!!! I'm flying across the desert, way too fast, totally out of control and half scared to death, half thrilled. As cacti, trees, and rocks zoom past it occurs to me to wonder: is this really the sport for me?

Yes, it is my first ride on my new mountain bike. Well, my first ride off the nice, flat, strip mall pavement where I test drove it. Where everything was in control and I thought, well it is true: You never forget how to ride a bike. Of course it now dawns on me that the problem is that I never knew how to ride one of these puppies in the first place. The bike is an Iron Horse Warrior. A chrome and black dual suspension bicycle with rugged, thick, 26" tires. It is designed to go where no bike has gone before.

I careen madly down a slope that never looked that steep when I walked it a hundred times. Things are moving way, way, way too fast. Where the hell are the brakes? This is ridiculous! I'm not even peddling!!!

I had not ridden a bike since I was 16, not one without a motor that is. I wrecked two motorcycles when I was in my 20's. I figured the third time would be the charm and I'd end up dead, so I gave them up. It would be OK if everyone rode motorcycles, but the problem is most folks are in cars, and for some reason people in cars don't tend to see motorcycles. Or, in some cases, they see you just fine but have nefarious intent.

So what would posses a 42-year-old man who hardly ever gets any exercise and has not ridden a bike for over 26 years to run out and buy a mountain bike? It is very simple: it's my brother-in-law’s fault.

He and my sister and her two youngest stayed with us for a few days around new years. One morning we were sitting at the kitchen table in front of the wide glass doors that lead out on to the back porch. Spread out in front of us is, I gotta brag, an incredible desert panorama. Our house sits on top of a hill and has a commanding view of the valley below, mesas and hills stretched out for miles, then the distinctive shape of Starvation Peak about 20 miles off, and in the background the Sangre de Cristo Mountains 50 or so miles distant. Starvation peak is so named because, according to local legend a band of Hispanic settlers escaped to the top after being pursued by hostile Indians. The warriors besieged them and they all staved to death up on top. Another version of the story has the Hispanics besieging the Indians and the Indians starving. Probably no one has ever starved up there, but it is a great story either way.

Tim and I are in no danger of starving as long as Deb is the cook. Today we're having a companionable cup of coffee. Well come to think of it, I'm drinking coffee, heavy and rich (my wife would say motor oil) and he is drinking green tea. He's on his Apple lap top and I'm on my Compaq. We're enjoying the view, sipping our drinks, and half heartily surfing the web when he says to me "with all this land you have out here you should buy a mountain bike."

Well, one thing lead to another and after a little on-line research it was clear that I didn't even have the right vocabulary to even understand what I was reading. It was clear I'd need to go to a bricks and mortar store and look and bikes and talk with bike people in person.

I hadn't planned on looking at any in Denver, but we took Rio to the Downtown Aquarium the day after Mom's B-Day. Printcrafter’s rating: Five Stars. We loved it so much we got a membership so we can get in free every time we are in Denver. Plus half off on parking. And the restaurant, run by the Landry’s Sea food folks, is actually really, really, really good. Very cool place. Anyway, very nearby is the flag ship store of the REI chain, a seller of outdoorsy stuff. The store is one of the most fantastically beautiful places I've even been in. Too bad the staff doesn't match.

I tired to talk to the guy in the bike department, but it was worthless. I don’t think he’d ever seen anyone my age before. I got no where, and learned nothing.

On Friday night in Denver while out running an errand, I take a wrong turn and end up face to face with a bike shop: Performance Bicycle. Three hours later, my wife convinced I'm dead from a hypo, Gene (a newly minted school physiologist who is still working at the bike shop that put him through college while he looks for a career) has patiently explained every component of a mountain bike to me and showed me the differences between the various sub-species and price classes. He gets me a helmet and arranges for me to take one out for a spin in the parking lot. I'm very shaky at first and can barely stay upright. But soon I get my balance and I'm having a blast. It is a warm evening (in Denver? in January?). I'm flying around the mall's parking lot, jumping curbs and speed bumps and having the best time I've had for years.

I ride four different bikes. It's kind of like Goldie Locks and the Three Bikes, err, Three Bears. One is too big. One is too hard, One is the right size, but too hard, and finally one is Just Right. It comes home with me in the trunk. My wife is not amused.

I'd planned to ride down the road to the back meadow for the first trial, saving the rougher terrain for later once the bike and I know each other better. Now I abandon that plan and head for the flatter ground near the fire circle. I'm thinking if I can keep from breaking my neck, a leg, or the bike I'll be happy to just get back to the house alive. Thank God they have a 30-day money back guarantee.

I get the speed under control, get turned around and make it almost back to the house, where I'm able to stop and get off. I walk the bike back up the drive way. I'm winded, gasping for breath and muscles in my legs that I didn't even know I had are screaming in pain.

I stumble in, throw my helmet on the couch and sit to catch my breath. Then a funny thing happened. Like a man possessed, I went out and did I again. And again, And again. And again.
Throughout the day I'd go ride one loop, about 600 yards or so, then come in, do some laundry or some such, and go out again. Each time I got more comfortable, happier, faster, and more confident. I'm bouncing over rocks, artfully dodging prickly pear cactus, laughing, and enjoying the rush of shooting over the rough ground. Bottom line: this is FUN! And good exercise too. My endo will be thrilled that I'm getting some exercise. Finally, my butt gives out before the rest of me. Time to call it a day. I won't be exercising my 30 day return on the bike. I won't be exercising it on the Guardian either. She's part of the family now.

And what of the Girl? She seems to like bike ridding too, and reports that the BG is more or less stable. It seems that the adrenaline and the BG burn are canceling themselves out.

Speaking of the Guardian I've got a basket full of adventures for you. But they are hastily scribbled on restaurant napkins or exist as half-written posts on my lap top. I need to pull them together and dole them out to you a few at a time. Also, it is back to work tomorrow after a few weeks off, so time to get the lab brain working again and get the studio ready for the big bridal show at the end of the month. Will I be able to post every day this month? I don’t know, I'll try, but no promises; besides, I gotta make time to ride my bike!

But does it brew coffee?

I was intrigued with my visiting brother-in-law's new cell phone. Well, I'm not sure it is fair to call it a cell phone. Here is what this tiny marvel can do. It can check email. Or mobile web sites. It plays MP3's with tiny little stereo speakers or with a head set. It has a built-in digital still camera and a video camera. There is an alarm clock, a calendar, and a calculator. He can text message and download videos from the internet. There is a flashlight, GPS capability, games and Blue Tooth. Did I mention you can make phone calls on this thing? Wow. It is like Buck Rogers’ Swiss Army knife! A blend of phone, PDA, and lap top. Everything you need to survive in the modern world. All in the front pocket of his shirt.

It does not, however, pump insulin.

My mother turns 80 tomorrow. So we kids, spouses, and off-spring are converging on Denver to celebrate. I'll be off line until next weekend, too much hassle trying to find wireless Hot-spots and I don't even know how to configure my lap top for Mom’s dial-up AOL connection.

I know a few of you will probably get withdrawal, so here's a suggestion. Go to the November Archives and read the whole thing again. That should take you until the weekend, and then I'll be
back. ;-)

So I'm heading north, but leaving you with a brief preview. I've been doing some more deep thinking about the role of test strips, hyper management, and other goodies in the new continuous universe. I've got some stuff that you just do not want to miss, but I haven't quite got it "on paper" yet. Ya' gotta promise to come back. See you either Sunday or Monday.

The new adventures of ProActive Man

We went walking after lunch. My sister, her husband, my niece, my nephew, and Rio. Up and down hills. Scrambling over lose rocks on the talus slopes. Inspecting petrified wood. Squeezing between Juniper trees. I was able to casually check my BG trend every ten or fifteen minutes by glancing at the girl's screen. Well, I thought I was being casual. Not casual enough for my poor sister, who had been designated as the most responsible adult. I'd given her the short course on using the Glucagon Emergency Kit before we headed out on the day's adventure. Every casual glance on my part brought a quick, "Are you feeling alright? Is your sugar OK?" complete with the concerned mother-like frown.

But it was a great day for me and the girl and the rest of the crew. Today, for the first time I realized that I not only have a warning system with me the entire time, I also have a simple, quick, and efficient way to keep on top of the situation. The more I work with the Guardian system, the more I appreciate it, and the more I learn how to best use it for my benefit. I don't have my black belt yet, but I feel like I'm starting to master this Continuous Monitoring thing!

For one thing, I'm getting more relaxed. When I first had the system, if I'd take a finger stick and get, say 145 and the Guardian said 135 it bugged the shit out of me. The damn thing is wrong, I'd curse to myself. Now I'm beginning to get perspective. No one is going to want to hear this, but there really isn't a difference between 145 and 135. Either could be correct, neither could be correct. Our entire house (diabetes management) is built on shifting sands. The truth: BG can't really be "measured." The good news: it doesn't need to be. Don't freak out on me people, stay with me a little longer and I'll explain.

In the old world order we took finger sticks. We became obsessed with individual numbers. We, not surprisingly, became micro-managers. We don't need to think like finger sticks any more. We can now watch the movement of our BG. Think about that for a minute.

It doesn't matter if the BG is 145 or 135. What matters is which direction the numbers are flowing and how fast. The number by itself is meaningless and probably wrong anyway, whatever system is used to "measure" it. The Guardian lets me see the motion of the BG. That is so amazing that I'm only beginning to truly understand the power and potential of this kind of info.

As we hiked I was able to “see” my blood sugar was dropping, but very slowly. That's a good thing, as I was walking off a double patty cheeseburger flame-broiled on our back porch propane grill. Oh yeah, and one of those mini-bags of Fritos.

I was able to enjoy our hike, walking and exploring and enjoying family, with no worries--secure in the knowledge that my BG was dropping very slowly. No pauses, no finger sticks. No hassles. Did I know exactly where my BG was at any given minute. Maybe not. Did it matter? No way. I knew I was in safe territory and that my BG was changing very slowly. That was all I needed to know to enjoy the day.

I'm getting really comfortable with the "work flow" of checking the BG and scrolling through the last half hour's readings. It is not much more bother than glancing at a watch. What a great way to keep in control. I am being ProActive Man, not Reactive Man.

But the alert features are still wonderful too. Once we were back from our adventures safe and sound, we were sitting around the kitchen table chatting about what we'd seen and searching the internet on our lap-tops to try to find the identity of a new critter we saw (a Tiger Salamander as it turns out, who knew there were dry-land salamanders?)

I had not been checking the Guardian since we got back in. It seemed there was no need. No exercise. No worry. No food. No reason to check. Lucky thing the girl is always on the job, even when I'm being the absent-minded professor's son.

All of the sudden the air raid siren goes off. "High alarm, high alarm!" shouts Rio, delighted, jumping up and down and clapping his hands. Well, he gets half of it....He's only three.

A high? How on earth? I find my self the center of attention, all eyes on me. Are you really high? Dunno. Maybe the machine is having an episode. I glace through the history. It shows a steady rise over the last hour since our return. That is very odd. I take a finger stick. 206. The girl called the game right. But how on earth? It is a Twilight Zone high. There is no reason, cause, or rational for it at all. No explanation. Nothing to have caused it, but there it is none the less.

I shrug and take more insulin to correct it than I did to cover the burger in the first place six hours before. The human body is a mysterious place. Twilight zone highs and lows happen. But between ProActive Man and the Guardian Angel we've got the situation under conrol!

From the mouths of babes

Rio and I are washing dishes. Well I’m washing. And drying. But we are together and enjoying each other’s company. All of the sudden the Guardian pipes up: air raid siren. A high threshold alert.

Rio turns sharply towards me, his big brown eyes wide, and says,
“Ut-oh. A high alarm!”

I’m totally blown away. I had no idea he even knew what the alerts were all about, much less that he’d learned to tell the difference between the alert tones.

Wow. Kids are so amazing.

Happy New Year Everyone!

Copyright 2006 by William Dubois