LifeAfterDx--Diabetes Uncensored

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

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Location: New Mexico, United States

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

Sunday, September 09, 2007

Evolution or revolution?

Apologies to all of you creationism nuts…err….folks; but evolution is a beautiful thing. My new girl is amazing compared to my cave-man original guardian.

Remember those illustrations in out-dated physical anthropology textbooks that show the progression of evolution over millennia? First comes a monkey type critter, then walking in front of him is an ape, who follows a hunched over human with a brutish looking forehead, who is following a naked Mel Gibson carrying a spear?

I’m envisioning a new poster for Continuous Glucose Monitoring. First comes the original MedT “Gold” system. It was hard-wired. You wore the monitor on your belt and connected it to the sensor by a cable. It was your silent partner for three days. You had no idea what your numbers where. The box stored them and you took it back to your doc for a download and printout at the end of the study. It was quasi-continuous (like all CGMs, none are really “continuous”); but not real time.

Next would come my beloved wireless garage-door opener Guardian, then the ParaPump, and then, at the top of the evolutionary ladder, the handsome Adonis of CGM: the Guardian Real-Time. I’m drooling on my keyboard thinking about what the nextGen Guardian on MedT’s drawing boards must look like. Ahhhhhh, to be a fly on the wall of a certain lab in California…..

Back to our evolution poster. We should plug the GlucoWatch in on the poster somewhere, an evolutionary dead end like Neanderthals. Other cousins on the family tree would include the DexCom branch: the original, then the one you could download, now the one you can wear seven days. Each of these tinny evolutionary steps requiring a fossil expert to tell the subtle differences between the models.

We should also include Abbott’s Mythical Navigator. Kind of like Sasquatch, we keep hearing reports of it, but there seems to be no scientific evidence that it exists. For years Abbott’s web site as had different images of the device. It seems to be evolving without living in the market environment.

With two major exceptions my new Guardian completely fulfills and even exceeds my wish list that I drew up after using the original for six months or so.

The most important thing that I wanted and got: a visual graph ‘cause I’m a visual guy. The original Girl gave me a number every five minutes. It’s been a while, but as I recall I had to press a button to get even that limited information. In some ways, this was really just a fast BG meter, and I bet a lot of folks just used it with that mind-set. To many, it was just a self-monitoring BG meter with some back-up alarms for when the shit hit the fan. Treating a CGM this way is a bit like using a microwave oven to just boil water, and cheats the user out of the real power of CGM. That said, the design of the device made it a lot of work to get the most out of it. That’s not true anymore.

Now I can just slip the new Girl out of her clever plastic holster (another improvement) and pressing no buttons whatsoever, I can take in my blood sugar environment with a glance. I want to stress my choice of words here. I didn’t say I could check my blood sugar with a glance, I said I could take in my entire blood sugar environment. Let me digress about this a bit.

Accuracy without context is worthless. I recently enjoyed a DVD of a movie called A Knight’s Tale. It is a harmless medieval tale of a commoner who poses as a noble to participate in jousts. The opening scene rocks, literally. Set to the tune of Queen’s hit rock song We Will Rock You we are treated to a marvelous re-interpretation of a jousting match. The scene is accurate in appearance and costume, but the crowds do the “wave,” have their faces painted to match the colors of their favorite nobles, dance, and otherwise act pretty much like modern Americans do at the Super Bowl. In an instant, I got it. I really understood the flavor of the joust in a context that made sense to me. All the sudden I could understand the past through the filter of my own time. Naturally, historians freaked out.

But who cares? If we sent a time machine with a camera back to the 14th Century to film a joust we just wouldn’t get it. We could watch in perfect accuracy and with no understanding whatsoever. Director Brian Helgeland should be given an honorary Doctorate in History from Oxford for his success in making medieval sports relevant in a way we can understand.

Likewise what the hell good is it to know your blood sugar is 147? Is that a good number? A bad number? That depends on the context doesn’t it? If you just ate a Fudge-fudge Walnut Brownie at the Elephant Bar in the interest of science, well, then a 147 is pretty fricken good. If you wake up at 147 after sleeping for 11 and a half hours, well, that’s not so good at all.

So the number is nothing. Actually, that would be a good add slogan for a CGM campaign: The Number is Nothing, know what your sugar is doing all the time in real time. No need to pay me for that one, MedT, just give me a couple year’s supply of your wonderful sensors and we’ll call it even. :-) It is the context of the number that matters.

Some of you know I used to be a Commercial Pilot (thanks a lot, diabetes). The instrument panel of an airplane is a wonderful thing. The first time you sit behind the yoke and strap yourself in you think, holy crap, I’ll never learn what all these gauges, switches, levers, and dials are for! But in reality the cockpit is elegantly simple. Most of the time you just look out the windshield and make sure that you are not about to hit anything (like other planes or the ground); and every minute or so you glace at the instrument panel and in a second or two all that cleverly designed visual information tells you how your plane is doing. You don’t even really think about it. Visual stuff connects to our brains in some sort of Zen like way that pure numbers don’t. If something is out of whack you’ll notice it. Trust me.

The graph on the new guardian is like a miniature aircraft instrument panel, but instead of telling you how a plane is doing, it tells you how your diabetes is doing. With a glance. Wouldn’t you like a diabetes cockpit of your own?

When you look at the display, you still get the old-fashioned number. Mine’s 176 right now. Nothing to be proud of, regardless of context. But this number is not floating in space either. It has context. The instrument panel is showing a six hour graph. I can see my OK, but not great, morning fasting number, and then my post-breakfast excursion. The hump is passed and my sugar is dropping back towards it’s target. If I’m dropping kinda fast I’ll also have an “down arrow” to alert me to that fact. If it’s dropping really fast I’ll get two down arrows.

Because we now have context in an instant, we can easily bring the power of CGM into play in a realistic way in our lives. We can monitor and intelligently, accurately, and proactively with minimum effort; and control our diabetes.

And, like an airplane, the new Guardian features an auto pilot of sorts. Should you neglect to remember to look at the instrument panel because maybe you are sleeping through a electronic medical records training or something like that, alarms go off if you start losing altitude too quickly. I really love this machine.

Other things from my wish list that I got: an option to leave my screen on all the time. Sometimes I don’t even bother to take the girl out of her holster. I just tilt her a little and glace at my waist. Ooops! Going up!

I can vary my thresholds depending on the time of day. Of course, like the original, I can choose what those thresholds are.

I’ve got a battery strength icon now! The old Guardian gave you no clue until it set an alarm off with the last sip of electricity, usually at 2a.m. The new girl is a battery hog, burning through a AAA in a week to ten days, but as she gobbles up the battery she keeps me in the loop about how much food is left on the table. This is the price that I pay for having my screen on all the time. I’m happy to pay it. If I didn’t already mention it, don’t go to bed with the icon on one bar. Bad news.

Back when dinosaurs ruled the earth, our CGM transmitters looked more like the thingies that soccer mom’s use to unlock their mini vans. The transmitter was expensive, short lived, and connected to the sensor with a short cable. It took up a lot of landscape on your bod. Now we have a sexy, small, and rechargeable transmitter. If all other things were equal (which they aren’t), this would be the reason enough to choose the MedT product over it’s competition. There is nothing evolutionary about this part of the system at all. This transmitter is completely revolutionary. The first time I saw it, I thought I was hallucinating.

It’s worth mentioning that I also have better telemetry with it as well. “Lost Signals” are much rarer with the new transmitter.
The software is drastically improved, which isn’t really saying much as the original was so completely abysmal. Still, it looks like the computer guys at MedT have really been trying to make some improvements in this arena.

Some seemly minor things that really are worth their weight in gold include a back light (yeah, the original didn’t have one, I slept with a red-lens flashlight on my night stand for a lonnnnnnnnnng time). I also now have a reminder that a sensor change is impending. Trend alarms for quick drops or surges have been added. The unit is water-resistant, which the old one was not. Water proof would be even better, not to nit-pick. It downloads it’s data way quicker. Getting Garage Door Guardian to download was a project that required packing a picnic. It is also lighter. For smaller folks, a 10 pound brick on their belt is annoying.

Last thing, and some will argue with me on this, I think it definitely looks cooler. Of course, like the software, they had no where to go but up hill on this front. That said, you could hardly say it is a cool looking device. This is no I-Pod. But is does look cool in a no-nonsense medical kinda way. All Guardian Real-Times come in dark greenish-grey. Maybe that’s called Smoke. I’m not sure. I’d rather have silver myself. But you can always doll up your CGM monitor with a host of skins that are now available to fit any mood, personality, or wardrobe. I do actually have a Zebra skin on my desk, but I’ve not gotten around to putting it on to see how it looks. Maybe the next time I go to the Elephant Bar I’ll dress for the occasion.

New Guardian also features a number of interesting on-board statistical functions that let you get an overall view of you control over time without downloading. This is far, far, far beyond the “BG Average” feature of most blood glucose meters. This is complex and interesting enough that I’ll hold off and devote an entire post to it in the future.

Things I never even thought to want include the sci-fi predictive alarms that actually work. I can’t tell you how cool this has been. In a million years I never thought we have CGM devices that would accurately predict the future. Talk about taking pro-active to the next level!

I did say there were two things that I didn’t get, and what upsets me most about these, is that a couple of steps backward in evolution we had them. Maybe evolution isn’t always progress. Garage Door Guardian was LOUD. Probably to be heard over the roaring of dinosaurs in those pre-historic times. It could also vibrate and squawk. I like ice cream with my cake. I don’t like to choose. There are times you will feel a vibe when you can’t hear. There are times you’ll hear a noise when you can’t feel a vibe. New Guardian will let you choose, but there is a lot of button pressing involved in changing, and odds are you’ll choose wrong no mater what situation you plan for.

Garaged Door Guardian’s alarms were also loooooooooooong. Real-Time’s alarms are dainty and short. Shake the earth. Wake up the neighbors. Our lives could depend on it. Actually, our lives do depend of it. We won’t be looking at our sexy instrument panels while we sleep: either at night or in training seminars. But over all, natural selection has delivered a wonderful new member of the species to us.

Now if we can only get the fuck-wads in the insurance companies to wake up and see the value of CGM we’ll be as good as we can get short of a cure.


Blogger Bernard said...


Thanks for a both funny and informative post. Speaking as a creationista [Sic], I loved it.

Can I just request a few photos? I'd love to see that diabetes dashboard and the new transmitter.

10:46 AM  
Anonymous Anonymous said...

Thank you for the information - all the humor! I was laughing so hard, the people in the desks next to me probably thought I was going insane! I love your analogies too. Keep us posted on your progress. I would love to read more about your adventures with the sensor.

4:38 PM  
Anonymous Anonymous said...

Hi Wil,

I'm a new reader and have been enjoying my time going through your posts today. Love your perspective! I've been T1 since 1983 (I was 12, I'm now 37) and on MDI of Humalog & Lantus. I too neglected myself as a teen/young adult but now my A1Cs are pretty consistently in the high 5-low 6 range. With luck (and the hard work we all know so well), I've avoided any complications to date.

My husband got his private pilot's license last year and sometimes I use your cockpit analogy to try to explain my routine. He never heard anything but scary stories about diabetes, so I still have to calm him sometimes when I have a low/high BG and he thinks I'm going to fall apart. It seems to help a little though. The 'losing altitude' line really resonated; that's exactly what a crashing low feels like for me.

I'm really intrigued by continuous monitoring, but not sure my insurance will cover it. I feel most of my lows, but like you I've hit the mid-30s (usually in the middle of the night) without warning. To date my doctor's well-meaning but fruitless advice has been to time my Lantus dose differently; she insists there is no 'peak' action. I have to argue that but oh well...we'll see what happens.

Thanks for all your work, I look forward to reading more!

1:22 PM  

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