Choosing Your Next Pump

For the past few weeks, I've been doing research on purchasing my next Insulin Pump. My only experience is having diabetes for 30+ years, but I'll write all of this as if it's gospel without the standard disclaimers (most of the time).

I've blogged several stories about my Insulin Pump sagas. If you are interested you can do a search for insulin pump in the upper left hand corner of this page. It should show you all the stories where I mention my insulin pump. You can, of course, search for anything you want. All of my wonderful postings have been carefully indexed for ease of searching.

For those of you still reading and completely unaware, I'll give you a short lesson on insulin pumps.

Insulin
Insulin is a hormone secreted by the islets of Langerhans. Insulin's primary goal is to convert sugar into energy. You can do more research on your own, but basically, Type I diabetes is thought to be caused when your immune system attacks these islets. With Type I diabetes you are producing no insulin so you must somehow inject it. Type II diabetes is a little more complicated. It can be caused by your body's inability to use the insulin efficiently. It can be caused by the islets simply not producing the proper amount. I don't think anyone knows exactly, but suffice it to say with Type II diabetes, you're not getting enough insulin for one reason or another. Type II can sometimes be managed by diet and exercise. I have Type I.

Animas
I've tried insulin pumps in the past and I didn't like them. About 5 years ago I tried one that stuck (heheh literally). It was an Animas pump. I liked it because of the "color display" (which is riding a fine line of false advertisement -- there might be 2 colors) and because it was "waterproof" (which is also riding a fine line of false advertisement -- I've had 2 of them quit working after leaking occurred). It stuck because of the support team. I had three different nurses all calling me on a regular basis to set up what they call "the basal plan". It tries to mimic the body's natural secretion of insulin when you are not eating.

The Basal Plan
Some of this is based on fact. Some of it is based on me. A subject for another blog, but I'll summarize here for this post. I discovered the other day that I make intuitive leaps which become fact (in my mind). Over the years, I don't remember if I actually read this somewhere or it's just an "intuitive leap".

Even when you are not eating, you need energy. Your body has various ways of putting sugar into your bloodstream. Therefore, your body is always producing insulin. When getting a pump, your first goal should be establishing your fasting basal rate. If you could survive without food, how much insulin would you need?

It gets a bit complicated because your basal rate on the pump is measured in units of insulin per hour, but it can change throughout the day. Did you know your liver dumps sugar in the morning to help you wake up? My basal rate in the morning is 0.6 units per hour. During the day it is 0.375 units per hour. At night it is 0.275 units per hour.

I obtained these numbers by fasting for 8 hours at a time and checking my blood sugar levels every 2 hours. If my sugar levels stayed normal, the basal rate was good. If my sugar levels were too high my basal rate was adjusted up for that time period. If my sugar levels were too low, my basal rate was lowered for that time period. It's a bit of a guessing game and you don't want to do anything drastic, but like I said, I always had an expert going over the numbers with me.

Once you feel confident that you can wake up in the morning with a blood sugar level of 100 and it'll be very close to 100 when you go to bed, then you can move on to Boluses. From researching various pumps, it seems that the Basal rate setup is about the same on all of them. It doesn't seem to be a big selling point. Boluses, on the other hand, are entertaining because their various implementations commit one of my pet peeves: unnecessary complications.

Boluses
Every time you eat anything with carbohydrates that aren't fiber, you need insulin to do something with that sugar. Boluses allow you to add additional insulin when eating. They also allow you to correct for times when your blood sugar gets too high.

Two important numbers come from this: the insulin to carb ratio and the insulin to blood sugar ratio. How many carbs will one unit of insulin cover (ICR is Insulin to Carb Ratio) and how many points will one unit of insulin lower your blood sugar (ISR is Insulin to blood sugar ratio). For me those numbers are 13 and 60 respectively. Except for some reason in the mornings I have to lower that first number to 10. Theories abound.

Not all insulin pumps support the above two numbers. My new pump has to. I like the feature. When programming my pump I almost never tell it to give me X units of insulin. 99% of the time I tell it that I just ate X carbohydrates and my blood sugar level was Y so how much insulin do you recommend? It does calculations based on my ICR and ISR and my IOB. IOB is Insulin On Board. I have mine set at 1.5 hours, but it's adjustable. Literature says humalog insulin (the kind most pumps use) is normally absorbed and gone in about 2 hours (give or take). IOB is a calculation of how many units of insulin are still working in your body when you get ready to perform another bolus.

Two basic types of boluses exist. Based on your entries for the amount of carbs and blood sugar level, your pump may recommend 5 units of insulin. You can choose to take it all now (which I never do) or you can tell it to give you some now and the rest over a specified duration. For example, I can say, give me 1 unit now and the remaining 4 units over the next hour. If it gives me a dose every three minutes, it'll do 1 now and then every three minutes do 0.2 for the next hour.

Every pump I've ever seen defaults to the "dumb" bolus. You scroll to the bolus option, click it and the first choice is Normal Bolus. Just enter how much you want and hit go. This irritates me to no end. They need to make these things customizable for gods sake.

Even if you get past the "Normal Bolus" and get into the "Wizard" that lets you compute the bolus, it still comes back to the dumb screen after the wizard is done. It'll, for example, say, "The wizard recommends 5 units, hit go do deliver. But, if you prefer, change this option over here to combo or expert or square or dual or whatever this particular pump manufacturer calls it, hold your head slightly to the left and carefully caress the go button".

Finally, you arrive at the "expert" delivery screen and here it gets ugly again. The Minimed pump says you can do a Square Wave bolus (give the entire 5 units over a duration) or a Dual Wave bolus (give part of the 5 now and the remainder over a duration). This is the ultimate in overcomplication.

My Animas pump specifies a percentage now (which can be 0% and a duration). It accomplishes the same thing as the Minimed but with a simpler nomenclature. 0% now is a "Square Wave", anything greater than 0% and less than 100% is a "Dual Wave".

However, let's simplify further. Let's not have normal, combo, dual wave, expert or anything. All boluses are an amount, a percentage and a duration. All of this naming and additional screens is completely unnecessary. A "Normal Bolus" is 100% now (duration would be ignored). The idea of having two bolus screens (one for the experts and one for the normal) is overcomplicated.

If they'd just make all of these devices use a well defined Bluetooth protocol I could write my own bolus app on my mobile phone.

Tandem t:slim
I had high hopes for this little guy (the t:slim). However, last week they released a video of someone giving themselves a bolus and my dreams were crushed. It's odd being excited and then horribly disappointed by an insulin pump (medical device), but I was. I am still in line to get one because it does seem to be a little ahead of the curve. At least it looks more like a smartphone than a pager.

Ah, the video. Basically, it shows someone doing a bolus. The t:slim came up in the "Normal Bolus" mode and you have to touch a little slider button to switch to "Combo". And I reiterate: Normal and Combo are exactly the same things! Don't make me hit a slider button and then adjust the percentage when adjusting the percentage is the only thing that is necessary. It's utterly stupid. Some other people who actually were given a chance to play with the pump have commented on its customizations. You can probably change the colors. If they'd let me unnecessarily make all Boluses default to Combo that would be something.

None of the pumps allow you to have two "Combo Boluses" active at the same time. You have to cancel the previous to do a new one. This should be customizable. I can understand the safety risk of over medicating yourself, but for those of us who know what we're doing, it's just a pain. Pizza, for example, can take an hour or more to digest. If I eat a slice of pizza at 20 carbs and do a combo bolus for an hour, then, thirty minutes later, I decide I want another piece I'm screwed. I'd have to do some kind of miraculous calculation about how much of the previous insulin was given and how much of the previous pizza was digested so that I could cancel the previous bolus and do another one. It should just allow me to do another bolus over time (BOT is my new acronym)!

Maybe I should get into the Pump Programming business.

T:slim advertises less buttons to accomplish the same task which is obvious because there are no buttons. It's a touch screen. I think there might be some marketing folks who need to be shot. It's also "rechargeable". I'm kind of curious if I'm going to have to sit next to an electrical outlet for an hour while it charges... That would be fun.

Where Have You Been All Week?

No, I wasn't cruising. Well, not on a ship.

This has been my darling eldest child's last week of "mandatory education". I have high hopes for her "voluntary program", but it's interesting watching the kids squirt out on their own like an unsquishable jelly-like thing. Anyway, it keeps ones mind on things that aren't necessarily for the viewing public.

Her mom and I bought her a laptop for her birthday, which happens to coincide nicely with her graduation (birthday is May 26, last day of school was May 24).

I was going to get her a DSLR camera for her photography dreams. But, I've decided not to purchase one until she's enrolled at a university. Yes, I learn from the federal government. I hold back on necessary funds until my demands are met.

On Monday, I went to get my "gum surgery" to keep my teeth from falling out. Before the surgery I had to go get 3 prescriptions: a mouth wash, pain killers (with Hydrocodone) and antibiotics. The surgery was at 2:30 PM. It lasted until 3:30 PM. It was mostly uncomfortable. At about 5 PM, I popped my first pain killer. At about 6:30 PM, the "cute doctor" herself called me to ask how I was doing!

Being on pain killers, I quickly replied, "I'm fine, thanks, how are you?" It's part of my instant response training to alleviate my social awkwardness. Of course, I assume she was really calling to make sure I wasn't bleeding or any of that nasty stuff that can happen after open mouth surgery. However, the pain killers were encouraging me to think that maybe she thought I was cute!

Next morning, after the drugs had worn off, my paranoid personality disorder took over and I began to wonder if she called everyone or just the ones she messed up on.

Nurses and Doctors and X-Rays, Oh My!

An odd thing happened today.

It started Wednesday.

Actually, it started several weeks ago, but if you've been following along, you'll know this.

My ongoing hip drama has taken a wincing turn to the left.

Yesterday, that day being Wednesday, also known as the day after Tuesday. I should probably pause here and mention that I've recently hired an attorney to do my will. I've been reading legal documents for a few days now so some of this may sound kind of legal (like that first sentence). I don't know why I tend to mimic my current reading assignment. I'm like a mockingbird.


Yesterday, I decided to be a squeaky wheel and try to determine why no one had called me concerning my imminent Labral Repair and Osteoplasty.

Doctor Scheinberg's "assistant" answered my original squeak and exclaimed, "We haven't received any referral concerning His Excellency's, The Great and Powerful Gar's imminent hip repair." To protect the innocent, we'll call this assistant Wanda. I picture Wanda as a brunette with long hair and even longer legs.

Anyway, Doctor Evanich's "assistant" answered  the second squeak and exclaimed, "They haven't received it yet because we haven't sent it yet. The transcriber has been on vacation." What I heard was, "We kind of forgot about it and now I'm going to describe something that makes no sense so you'll forgive me and my lovely blonde curls." We'll call this assistant Becky. I've met Becky. I think she's blonde.

My last appointment with Doctor Evanich involved Becky calling Wanda to setup my appointment. I was standing there and remember Becky telling me that Wanda couldn't setup an appointment until Doctor Scheinberg reviewed my files and considered me a candidate for the procedure. Thus, the reasoning for my two weeks of patiently waiting for everything to get mailed to Doctor Scheinberg.

This morning, or the day after I made my squeaks, Wanda called me! She said, "We've received your files and I'd like to setup your appointment. The first one I have available is June 11 at 8:30 AM."

"Sounds good to me," I say. I figure the first appointment will just be a fifty dollar consultation so I can ask the doctor if we can delay the surgery until late autumn.

She then gives me instructions on their website and how to fill out the forms and get them sent to the correct place, etc.

Then she says, "Could you make sure and bring all your radiology discs including the X-Ray."

It gave me chills. I told her I didn't have the X-Rays, that Becky wouldn't give them up. Wanda said they'd make more.

If you don't understand, you'll have to go back here and read a bit. It's short. The post is short. Jeez. I mean the blog is not very wordy.

Now I'm not worried about the surgery at all. I'm worried about the X-Ray! And what did Wanda and Becky discuss which made my X-Ray so important? I feel like a cheap porn star.

Update on My Deterioration

I've had a host of concerned citizens ask me about the status of my ongoing physical deterioration.

Okay, not really.

Today, I've got an appointment with a Periodontist. Her name is Dr. Hsu and she comes highly recommended. She's also rather cute. I don't know how I feel about a nice looking woman poking around in my mouth. It seems like that should be a job for some wicked witch type person who heckles and has a lazy eye. Or perhaps a nondescript man who doesn't laugh and has a steady gaze.

My cool doctor has determined, via a trip to the radiologist for an MRI Arthrogram, that I have a labral tear. I think it sounds worse than it actually is, but apparently I've got a little bump on my hip bone and over time the bump has torn my labram.

A couple of months ago I was going to physical therapy and my physical therapists said, "I think you've got a torn labram. You should probably make an appointment with Doctor Robert Scheinberg. He's one of only two surgeons in the Dallas area who can fix that kind of thing."

I, of course, mostly ignored her and made an appointment with my own hip doctor. Two months, an MRI and $100 dollars later, my cool doctor tells me, "Well, it looks like you have a labral tear caused by a bump on your hip bone. There are only two surgeons in this area who have experience with that sort of thing and I would recommend Doctor Robert Scheinberg."

From doing Internet research, I believe the procedure is called: Labral Repair and Osteoplasty. Feel free to look it up. Recovery involves lots of physical therapy. Four weeks without putting weight on the leg. Two weeks no driving. Six weeks on crutches. I'm not at all happy about it.

I am wondering how fast it will degrade. I'd probably prefer to get the surgery done at the end of the autumn rather than the beginning of summer. But, if they recommend surgery ASAP, then what to do? I've been doubling the amount of pushups I do every morning to strengthen my arms for the coming crutch fest. I've never had to use crutches before. I may beg for a walker. I'll have to remember to get one of those temporary handicap mirror hangers for the car. And tennis balls.

They sent the MRI results to Doctor Scheinberg and basically said, "He'll call you after he determines that you are a candidate." I haven't heard from him yet, but it's only been two weeks. I don't know how long I should wait before calling. I don't think I've waited long enough.

A Work in Progress

Since I started this little blog, I've been working on my communication skills. It's really amazing how therapeutically helpful it is to write everything down for the world to read. Granted, a small portion of the world actually reads any of this, but the practice is in writing it down to begin with.

I've discovered I don't explain things very well. I literally have tidbits of sporadic thoughts storming through my head all the time. When I'm in a room with quiet people, I'll sometimes spout one off just to see what kind of reaction comes out of it. But, these are usually carefully mulled over one-liners. If I have to explain anything all bets are off.

For example, I know, deep down in my heart, why the concept of "health insurance" is a bad idea. I just know it to be true. But, I've tried to blog about it at length and no one understands it. Does this mean I'm wrong? I don't think so. I just can't articulate my idea adequately.

I've recently been thinking I might try my hand at writing a computer programming book. People are always asking me how to write programs. I figure it's a curiosity thing and for some reason they think that I have a magic bullet so when I say, "You do it this way," it'll suddenly just make complete logical sense. For me programming is easy, but I've found that I can't explain to people why it's easy.

My first job out of college involved writing server programs on a Tandem Computer. To me, it was easy. I turned in my first assignment and the manager said, "You can't do this. It doesn't work." I loaded it up, ran it, and showed him that it did exactly what he wanted. He said, "We've been trying to do that for years and no one could get it to work." When I tried to explain how I did it, I got blank stares. I'm just not capable of explaining. I'd get irritated because people couldn't get it. One of my more empathetic managers took me aside and explained that not everyone was like me.

Since I started my little blog, I occasionally decide through months of internal agonizing that I have, perhaps, finally gotten better at explaining things. Then Durango comes along and shoots me down. He doesn't really do it on purpose I don't think, but he does it with alarming clarity and eerily coinciding with my sudden confidence.

Durango comes across as really mean spirited and I get defensive and crotchety. He thinks I'm overly crotchety, but he doesn't ever realize that the timing of his zings is impeccable.

My new challenge is to make Durango understand something that I write. I'll know I've accomplished it when his degrading comments make sense. Currently, every time he writes one of his belittling little diatribes, I find myself scratching me head and thinking, "Did I write that? Where did he get that idea?" Even if I don't win the argument, I'd at least like to feel like he's understanding my "flawed" point of view.

Currently, I understand what he's saying, but I don't know how he got the idea that I feel the way I do. It's like if I were to write, "The sky is blue." And he comes back with, "Stupid little Gar, everyone knows the sky is not purple." His argument is clear, but it makes no sense to me in my comprehension of what I wrote. Obviously, in real world examples, my verbiage is more complex (kind of like this long winded post).

They Could Always Suck Harder

In case you haven't seen the Time Cover yet:

I debated on whether or not to even mention it, but I've been watching "Game of Thrones" Season One on DVD.

I remember it being kind of funny reading the books because George R.R. Martin (author of "Game of Thrones") goes out of his way to describe this spoiled brat of a kid whose mom is certifiably insane and on the short track to completely nuts. He sits on the throne with his Queenly mom while casually sucking on her breasts. He even throws the occasional temper tantrum when no boobies are available.

The way George describes it makes you feel kind of disgusted and sorry for the kid at the same time. They showed it, in all of it's glory, for the HBO Series. It kind of made me feel vulgar watching it on TV. Granted, the kid in the book, I believe, is supposed to be 5 or older. I have no idea what kind of CGI was involved to pull off the act. The kid pictured above is only 3.

I don't hide the fact that I believe the government should give us more freedom to live our lives the way we want. I draw the line at children. If the government needs to protect anyone, it's the children.

The question then becomes: when does the sucking hurt? Why do you never see moms with their 3 year old girls standing up on a stool? Would that be too much? Please send your pictures here. I jest. Ew.

I really can't see any way this is good for the children. Or their mammaries. What happens when you are 13 and going through puberty and you see photo albums with pictures like the one above? Nope. No good can come of it.

Brainless North Carolinian's

I heard about this today.

Apparently a majority of people voting in North Carolina have agreed they are unable to think for themselves. I could hardly believe it.

They have decided that the government should tell them who they can marry. It's incredible! I've heard several people opine that India is bad because they have "arranged" marriages. I assume the marriages are arranged by the children's parents, but I'm not an expert.

However, in North Carolina, it's up to the government to determine who you can marry! Happy days. I guess your parents can still try to arrange it for you, but if the government doesn't agree then it doesn't count.

Why oh why oh why? The government has no business dictating matters of love, relationships or marriage. None, zero, zilch. That's a very personal thing. We should not allow the government to tell us what to eat, what to drink, or who to marry.

The fact that in some states they vote for the government to dictate who they can marry is crazy! Why do you want to give the government that much control?

There's no need to waste time debating about the merits of gay marriage. If you want to get married, by all means, get married. It doesn't hurt me in any way.

However, in North Carolina, you'll need permission from Beverly Purdue, the current governor. The only time she should be involved is if you'd want her blessing to marry one of her sons. Even then, it's just a blessing.

Nerdgasm Extraordinaire

Back when I was a small pup, I played Dungeons & Dragons. There was a group of guys I played with regularly and one in particular. I'll not list their names to protect the innocent. However, in no small way, AD&D helped me survive my teenage years as a misunderstood scrawny adolescent.

This Sunday, a virtual goldmine of Dave Arneson's "gaming" stuff will go up for auction on eBay. Read all about it here and enjoy yourself a personal nerdgasm. I know I did. My personal favorite was Dave's briefcase from the 1970's. I have a briefcase from the 1980's that has my "Catacombs of Laromy" design in it. I don't remember the combination and mine is black. Really. And it wasn't just my design. There was a partner in crime.