Worst sensor so far

Sometimes my CGM is off by a few mg/dL and sometimes it is off by a lot more. It makes me feel guilty to see the large number on the CGM. Then I check my BG and see the reality....

CGM sensor wounds

The last time I put in a new Enlite sensor, it hurt quite a bit. When I pulled out the stylette (the needle part of the apparatus) I noticed it was bleeding quite a bit. I did my usual 360 sweep of IV Prep (the sticky swab) and when I went under the adhesive that sits under where the transmitter would sit I even got blood on the swab. I applied gentle pressure for a few minutes and (because previously, in error, I have attached the transmitter too early and had huge discrepancies, which eventually led to "bad sensor" and "change sensor" alerts) I did not attach the transmitter for a good 2 hours or so.

Overall this may have been one of the more accurate sensors I have used. Maybe because it was getting some blood readings in addition to interstitial fluid, or maybe just luck. Anyway, I pulled it out by accident on day 4 and realized that the adhesive does not stick as securely when there is any blood on it!

Check out the great bruise I have. If you look closely you might see the outline from the transmitter in red irritation lines too..

So today I went to put in a new sensor and decided I would be as gentle as I could (Maybe I had bled the last time from pursuing to hard?) So I just placed the loaded inserter on my skin without applying any pressure, except to keep the insertion device flush against the surface of my skin. Very little pain (except for the force of the insertion device; that thing is quite forceful and leaves a slight stinging sensation) so I thought I had had success. However,  I don't recommend anyone try this light and gentle technique! When I removed the device, I had some of the adhesive around the electrode+needle sticking and no needle or electrode in my skin! I wish I had got a photo but instead I panicked and pushed the electrode+needle into my skin. I think I was successful at getting it in since the transmitter did flash upon connection. But who knows? I just hope I don't have to pay too much in the next couple months on sensors since most insurance companies won't pay for more than 1 every 6 days. I've already pulled out 2 (by mistake) around day 4 or 5. I guess I should use up the leftover sof-sensors (the previous Medtronic model, for those who don't know) I have "hoarded" before they expire in May! I would really rather not. There was a lot more bleeding when I used those inch long buggers!

Take care not to bruise yourselves like I did!

25 Year Award!

This arrived today. My real diabetes anniversary is March 10, so it's a little early.

Really simple application process if anyone else is "celebrating" 25, 50 or 75 years on insulin: http://www.lillydiabetes.com/Pages/lilly-diabetes-journey-awards.aspx

Enlite sensors - week 5

I have been using the new Medtronic Enlite sensors for a little over 5 weeks now (since January 7, 2014). I wanted to share some of the problems and happy moments I have had. 

Was it worth the switch?
Yes! I did have a lot of problems with the older Medtronic Sof-Serter sensors and I have similar problems with the Enlite sensors but they are so much more comfortable and less aggressive on my skin and tissue, it was still worth it. It means less scar tissue and more space to use for future sensors and infusion sets! 
I used my abdominal area a lot for injections before getting my insulin pump. My abdominal tissue is already so much better after 4 years of not doing injections 4 to 5 times a day. Some day maybe you might not even know I'm diabetic from the way my belly looks! ;)

A year ago I was not wearing my CGM (Continuous Glucose Monitor) all the time. When I first tried wearing it I was having so many alarms, errors and inaccuracies I wouldn't wear it for weeks at a time. When I did wear it, if I had a false low alarm at night (the CGM would indicate I was low, but when I checked my meter BG it would be normal or sometimes even high), I would turn off the low alarm completely. It prevented me from being woken up every 20 minutes by the alarms, but it also meant that I when I was unaware of real lows I completely slept through them--a great danger to my health. Then I would be dealing with rebound highs the entire next day.

June 2013, I was recovering from ankle tendon surgery and I was able to go for hikes at the park near my house for the first time in years. The extra exercise was making my bloodsugars plummet. I figured I needed to wear the CGM if I was going to know what was going on, and where to make changes (not to mention the insistence of my endocrinologist to wear it as well). The Sof-Serter sensor is approved for use for 2 to 3 days. My insurance only covered 10 for 60 days. If I tried to get them more frequently I had to pay $400+, but I wouldn't know if it was covered or not covered until I got a bill 2 months later. I found I could wear the Sof-Serter longer if I: 1) exercised consistently, 2) ate well (no high fat food, no snacking) and 3) didn't expose the sensor to too much moisture (water, sweat, etc). Basically you have to be "a good diabetic" to use a CGM effectively. My average time with 1 sensor was around 8 days. Every 3 days, my pump required me to reset the sensor (in essence, you make the pump think you've connected a new sensor), which somehow takes less than 10 minutes instead of the normal 3 hours. Most of the time, however, this happens at the most inconvenient time: I just tested a few minutes ago (too long ago to be accurate enough) or I had just eaten a meal.


Shortfalls of the CGM in general
Which leads me to general problems I think all CGM have by design (please let me know if I am wrong: I've only ever used the Medtronic system).

• Blood glucose and interstitial glucose will never match. The CGM is excellent because instead of several readings throughout the day as with just doing meter blood glucose readings (once before each meal/snack and bedtime, and ideally two hours after each meal) it shows what is going on in between. 
• You should NOT calibrate when there is a large difference between CGM and meter readings. There is always going to be a time difference between rises/drops in blood glucose and rises/drops in interstitial glucose and when it comes to calibrating your CGM (which is required a minimum of every 12 hours with the Medtronic system) it is only going to calibrate well when blood and sensor readings are as close as possible. If somehow the "planets align" multiple times in a day, you should not calibrate more than 4 times in a day.
• Something I learned from the Medtronic training in January: a bad calibration can take a minimum of 5 good readings to get the sensor working properly again. There are times when a sensor just won't work.  I hate getting that "BAD CAL" Alert on my pump. When I know I can't calibrate because there is too big a discrepancy between my meter reading and my CGM reading, I try waiting. Sometimes I will turn off the sensor and reconnect as a new sensor. I could wait an hour, put in a reading, but if it is off, I get another "BAD CAL" Alert. If it's really unhappy I could get "BAD SENSOR" or even "CHANGE SENSOR."

This is actually what happened today. Even though I had the sensor in for only 4 days (What a waste!) and the trainer said you can call the Medtronic hotline and they will troubleshoot with you, I decided to pull it out (see photo below) and realized the sensor was not cleanly inserted.

You may notice there is also a significant amount of blood. Probably not a good idea to hit a blood vessel with the sensor. This happened almost every time with the old Sof-Serter sensors but it is the first time this has happened for me with the Enlite sensor. Probably wasn't good that the electrode got bent too!

Enlite sensor problems

Insertion device is unreliable
This is the scariest thing about these sensors. On Sunday, I was ready to insert a new sensor. I prepped my skin, loaded the insertion device, removed the pedestal and adhesive, placed on my abdomen, pressed the button and let go and...nothing. The interior part of the device did not move, click or do anything. I tried 3 times. I pulled the adhesive portion forward and tried to find a release mechanism or some way to pull the sensor out so I could load a new sensor--no luck. I hit the insertion device lightly against the counter, then harder. Though it is a very durable device, it did not help to release the sensor. Pushed the button and released in the air several times. Smacked it with my hand, jiggled the sensor with my fingers, pushed the mechanism in more while pressing and releasing the button repeatedly. I called the 1-800 number for Medtronic and after 10 minutes on hold, I gave up, went out to lunch.
2 hours later I came home, dialed the Medtronic help line again and decided to try pressing the insertion device button (without putting it against my skin: at this point the sensor was not sterile anymore!) and released, and out popped the sensor! I spoke to the Medtronic rep within a few minutes and explained what had happened. They had me use another sensor to test the insertion device and it worked immediately. They also said they would replace the sensors I had wasted and the insertion device, but only if I returned the insertion device I had. Since there didn't seem to be a permanent problem with the insertion device, I decided I would keep the one I had. The rep said I could always change my mind if I had more problems. I am going to test the insertion device a few times before loading a sensor from now on.


Accuracy
Despite improvements in my own diligence to be a "good diabetic" (which really helps everything), I still have fair to major discrepancies between my blood glucose and CGM readings. Sometimes this is advantageous, such as with "false lows." I have noticed that even if my meter glucose reading is not low, the CGM indicating a low could mean I will eventually drop. Particularly at night, when I am motivated to not get woken up again, I am now in the habit that if it tells me I'm low, but my BG is low normal or low, I will take eat or drink 15-25 g of carbs. So far this has prevented the extreme rebound highs I was tending to have in the past.




Good things

• Stays in consistently for the full 6 days. As long as I don't have more issues like bending the electrode or hitting a blood vessel, the adhesive on these sensors is quite impressive at continuing to stick through quite a bit of abuse. There have been a few times clothing or pump tubing has got caught around the transmitter half of the CGM and I am sure that I've pulled the sensor out, but when I look the adhesive around the electrode continues to hang onto my skin. The "O"-shaped tape they include in the Enlite box also sticks much better than the IV-3000 adhesive ever did. However, I do wonder why they include extra pieces of these. It is very difficult to remove this tape: you have to remove the tab from over the transmitter, disconnect the transmitter (which resets the sensor!), cut the "O" tape from around the adhesive under the transmitter, carefully remove the "O" tape from on and around the sensor without pulling it out and then place a new piece perfectly over top. Not a simple procedure. I would not want to try it in a public restroom and I doubt I'd have the equipment (i.e. scissors) to use on a vacation, or day trip.

Look at that adhesive pulling up my skin (after 6 days)

• CGMing has given me a great sense of relief. The more I wear my CGM, the more I enjoy interpreting the data. Data collection is a diabetic's best friend. I've already been able to adjust my overnight basal rates to nearly eliminate overnight lows which has improved my sleep quality tremendously. Now I just have to figure out how to adjust my temporary basal rate for exercise. Overall I'm very happy.

New pump and CGM! :D

Just in time for 2014, I got the new 530G Medtronic pump and Enlite sensor (for continuous glucose monitoring). It is always fun to get new things and see all the new features available on such a piece of technology. Unfortunately, now that I have the pump and I've done all the reading and training to use it, I don't know if I will actually be able to use all of the new features. So what do I have? A fancy, upgraded (*and purple!) version of what I had before. Don't get me wrong. As a tool for my diabetes and getting closer to my A1c (average glucose) goals this should be beneficial and I'm glad I got it. I'm just not as excited to have it as I was anticipating receiving it. It is supposed to be more accurate and at least I don't need to pull out the user manual and I can clear an alarm without looking, but I feel like that is part of what makes new things fun.
In contrast, I got a FitBit for Christmas and I am constantly looking up tips and hints on their Help site! The new pump just went in my TummieTote (which is my favorite pump accessory by far!) and I more or less forgot about it. Not one part of the dimensions, buttons or general appearance has changed.

Let's break down the good, bad and things I'm indifferent about.
 Pros:

• I can dial in basal rates and boluses in much smaller amounts with up to 3 decimal places (which I might not necessarily need, but my doctor wants me to try).
• I can flag events under "Capture Event" such as exercise, food (without bolus), and meter BG (without bolus or calibration) so it will show on the pump software reports my doctor sees instead of having to match up a separate record. That is, as long as I remember to "Capture" at the time the event is occurring. (If only it had NFC capabilities...)
• Threshold Suspend - this is the most hyped feature of this pump, which Medtronic chose to title an "Artificial Pancreas" feature. When turned on, the pump will suspend all insulin delivery for 2 hours if I do not respond to a Low Glucose Alert. This is only beneficial if the CGM is accurately calibrated, i.e. I truly have low blood sugar when the sensor indicates. Also this will have a loud, obnoxious, continual alarm during the entire time the pump is suspended. If I am unconscious then hopefully this will mean that someone (probably my husband or a coworker) will come to my aid. When not properly calibrated (which could happen in random situations), this could mean a lot of disturbed sleep.
• Overall accuracy of the sensor should be improved.
• Size of sensor electrode is smaller in length and gauge. It is much less painful on insertion too. I was shocked by how little I felt (I inserted my first Enlite sensor on Jan 7, 2014 at a pump training session so will be doing my second insertion by myself, probably tomorrow!). I also don't have to pinch or look for fattier areas to insert the sensor or worry about significant bleeding which I think will improve accuracy. I can put it in less fatty areas with less scar tissue and better circulation (of glucose to interstitial fluid from the bloodstream and vice versa). Hopefully insertion will continue to be easy, since I have read reviews saying otherwise.
• Sensor has been approved (and will continue to work without the 3 hour restart period) for use for 6 days. Since I used the old sensors for as long as possible (despite them only being approved for 3 days) and on average got about 8 or 9 days out of them, this is not exceptional for me. With the minimal taping advised and my fear that the sensor will pop out, especially with summer activities, I really hope the majority of sensors last for 6 days.

Day 2 (Jan 8, 2014)

Day 5 (Jan 12, 2014) Surprised the sensor is still in

Day 5 (Jan 12, 2014) There is no way to replace this wider tape, and it is all I can use to hold the sensor half of the CGM down. Water freely flows under parts of it (what will happen if I go swimming?) and last night my pump tubing got caught under the transmitter side (which hurt!).

 Good things (Beneficial, but not fantastic):

• The reservoirs, infusion sets and overall set up, buttons to press, etc are the same.
• Menu is much more user-friendly. It uses titles like "Reservoir + Set" and "Fill Cannula" instead of the more general term "Prime". Once an Alarm is cleared, the pump displays the part of a menu that would come in use for that alarm.
• Low and high prediction Alert.
• Trending high or low Alert. This would be extremely irritating if there is no significance to the increase. For instance, if I increase from 130 to 100 over 10 minutes, it doesn't matter to me as much as a situation where I go from 100 to 70 in 10 minutes. However this feature does not discriminate between the two situations.
• Missed bolus reminder for those who forget to bolus during a certain time period. This is useful but it requires a person to eat at the same times each day. I love the flexibility of having a pump because I tend to have a different schedule on any given day. I will soon get "alarm insensitivity" if I used features like this. It would also be a hindrance if I am speaking with a client at work and my pump keeps vibrating. I also hate having to explain these sorts of things to strangers.

 Cons (mostly my concerns):

• When I have the option for Low Alerts turned on, I also have to have the High Alerts turned on. It might not be intuitive, but I don't really mind having high glucose. I usually test my glucose every 5 or 6 hours or look at the number on my pump. At minimum I test before each meal and/or snack. If I have high glucose, my basal rate will take care of it or I will catch it in plenty of time to compensate. Luckily, I can set the high alert to alarm every 3 hours instead of every 20 to 30 minutes as I usually set the Low Alert. Low glucose, especially when I am having a "good BG day" is much more important to catch asap.
• The instructions in this pdf document are the only backup I have for preventing moisture (sweat, shower, pool water, etc) from getting under the adhesive holding the sensor in place. I do not feel confident about this staying in place during a day at the waterpark or just a day outside in humidity of a Virginia summer. My pump trainer said that if we use the entire IV3000 transparent dressing over the sensor and transmitter together (which I found worked the majority of the time with the old sensors) it will buckle and cause the sensor electrode to pop out. This is unfortunate because she also claimed that most insurance will not cover extra sensors. Meaning: I'm probably going to be wearing the sensors for more than 6 days to compensate for those I might lose. I'd say that I would minimize the number of showers per week or the amount of activity I do in my pool or outdoors during the summer, but that's not going to happen!
• This pump only works in mg/dL and my brain works in mmol/L. I didn't even ask about that because my old pump had both units (apparently people are bad at selecting units and picked the wrong one and messed everything up...argh...FDA..). So after nearly 25 years (in March 2014) of using mmol/L from living in Canada, I have to adapt to new units. And after probably 15 years of One Touch meters, it looks like I'm going to be switching to Contour (since the Contour Next syncs with the pump, which is pretty cool). I have already made the mistake of overcompensating insulin correction instead of letting the Bolus Wizard take care of it.

 To anyone considering upgrading: if insurance will cover it, I highly recommend doing it. I don't know how this pump will be for me over the next 4 years, but I figure the more up-to-date I can be, and call me crazy, the closer I will be to having the correct calibrations and preparations for the true Artificial Pancreas that is on the horizon!

Most recently: HbA1c: 7.4%, 140.5 lbs; left ankle mild peroneal and Achilles tendinitis, calf cramping. Have not worked for 5 weeks and doing physical therapy twice a week. Exercise: stationary bike, stretches. Calorie counting with FitBit.

CGM data

I have had a Medtronic Minimed Paradigm and RealTime CGM, since December 2009. It was rough to get used to it and how to work all the technology but it is pretty fantastic.

Nothing brings things into perspective like watching your pump plot its CGM (Continuous Glucose Monitor) graph throughout the day. I used to think getting more than a pre-meal blood glucose meter reading was bad for my ego: my 2 to 3 hour post-meal readings left much to be desired (especially by my doctor).  Now that I get a sensor (interstitial fluid reading, calibrated to be a close as possible to blood) reading every 5 minutes it offers a bigger picture that doesn't always reflect how I feel I'm doing. In fact, it often hyper-accentuates the extremes when, overall I feel like I'm doing well! It gives room for the doctor to tell me I lack control whereas all they used to have was my A1c reading and 3 to 6 meter readings throughout the day. Trust me, nothing is worse than being basically told "you suck" by a doctor. Even if I'm not getting into car accidents or fainting or going into a coma, the doctors still consider highs and lows a "failure."

July 10-July 16, 2013

 
Despite all of this, I am pretty pleased with my CGM graphs from this week (see below). I have been working very hard at staying below 8.0 mmol/L (144 mg/dL) and lowering my glucose so that I am not high for more than 1 hour. There were bad times here and there, such as the dinner out that turned into 1/2 a hotdog and a basket of fries, but I believe I'm going in the right direction toward achieving my goals!

Sept 17 - Sept 23, 2013

Look at all the time I spend in the green (goal area) versus on the graph above! It makes me giddy! Hopefully my doctor will be happy too!
 

Most recently: HbA1c: 7.9%, 144 lbs; left foot mild plantar fasciitis, blisters!

Beginning the balancing act: my diabetes goals

I have had Type 1 diabetes for almost a quarter century. During this time I have tried, mostly unsuccessfully, to maintain tight blood sugar control. I have reached a point where I want to be successful at this balancing act or I will suffer some life-threatening consequences.

I recently spent several weeks recumbent and incapable of working or getting around on my own recovering from foot surgery. It gave me time to enjoy life and the things around me and forced me to realize that working is not all there is to life. I realized years ago that we spend more time at work (or school) and sleeping than we do with loved ones and enjoying our hobbies and interests. I wouldn't call it my "biological clock" but something similar told me it is time to think about bigger things: my legacy.  My husband and I have decided we would like to start a family. We would prefer to do so by traditional methods, and it is going to take a lot of effort on my part.

I hope I can help others, and get advice from those who have been through it, by keeping a log of my endeavors.


Most recently: HbA1c: 7.9%, 146 lbs; left ankle pain, mild plantar fasciitis 

Goal 1

Decrease HbA1c to 6.0 or below

Goal 2

lose 20 lbs

Goal 3

minimize highs and lows

Goal 4

get the ok from my endocrinologist!