Humbled


Have you signed Dr. Frederick Banting's birthday card yet?

I did, first thing this morning. On the card (you'll see it when you click the link above to sign it) there's an area to write a personal message. I wrote, "Thanks to your work, I have an amazing teenager." 

Before Dr. Banting and Dr. Best made their discovery of insulin in 1921, people with Type 1 Diabetes died. Their bodies wasted away. It's humbling to consider.

In 2002, on a crisp December morning, we rushed my daughter to the hospital, and by mid-morning she was receiving insulin. She's now a thriving high school student who is looking forward to this weekend's school play, college in a couple of years, and a career in education.

Had she been born less than 100 years earlier, she simply would have died. Probably by Christmas, only a few days after we'd called the local doctor to stop by on his rounds to examine her.

I'm thankful to Dr. Banting, and his colleague, Dr. Best, for making insulin available so that my daughter can be alive. And I'm thankful for all of the discoveries and inventions that ensued, including modern synthetic insulins, increasingly accurate technology for glucose monitoring, and insulin-delivery tools that have come a long way from regularly boiling and sharpening the one syringe in the household.

Dr. Banting's birthday, now World Diabetes Day, helps put life with diabetes in perspective. There was no life with T1D before Dr. Banting. It's still a daily challenge, and the dangers aren't completely gone, but my daughter is here, and thriving. I couldn't be more grateful.

Happy Birthday, Dr. Banting.

Trick-or-Treat


It was 8:45 on Halloween. The doorbell hadn't rung for almost an hour. And then it did. We paused Survivor, and my daughter got up to greet the trick-or-treaters. She had enjoyed her door-answering responsibility all night, and I was glad to let her get up one more time.

Peeking through the living room window, she recognized a life-long friend at the door, dressed as Kim Kardashian.

She opened the door, and I could hear another voice, in addition to my daughter's and Kim's. There was a little chatting about the nice weather and what the girls had acquired in their travels. "There was a house handing out apples. Honeycrisp ones though, which are amazing, so I guess if I wash it I can eat it?"

My daughter then offered as much of our loot as the girls wanted to take. We didn't have as many kids as usual, and so generosity was in order.

"Are you sure? Thanks so much," Kim Kardashian exclaimed.

"Ugh, my mom won't let me eat most of it anyway," replied the other voice, which I was still trying to place.

"Take the airheads" was my daughter's quick response. "They're great for low blood sugars!"

Now, of course, I was able to narrow down which friend was accompanying Kim Kardashian on her rounds.

"Ha! Yes- I will! My mom buys terrible glucose tabs at Costco. I can't stand them."

Now Kim Kardashian's friend has a nice stash of airheads for her low blood sugar needs.

Who says Halloween and diabetes can't go well together?

Another Wait


The Dexcom G6 finally arrived last week, after a wait which was entirely too long.

And yet, we've decided to put off using it.

There are still 3 Dexcom G4 sensors here, and we've decided to use them up.

The wait is, in most respects, really hard. It's like getting a new toy on Christmas morning and not getting to play with it until February. Why would we torture ourselves like this?

We have our reasons:

We are grateful for what we have, and don't want to waste the G4 sensors. We're certain that once the switch is made, there's no way my daughter will want to go back to the G4 for a few weeks to use up the old supplies.

We feel much more comfortable with supplies in reserve. By waiting a couple of weeks, we build up a few extra G6 sensors in the supply closet for a rainy day.

We want to take the time to start it and to set it up right. Because of our family's marching band commitments, time is at a premium in October.  We're waiting for a quiet evening, or weekend morning, to sit and learn the minimal but important basics of insertion and sensor start-up, download the apps and software, and learn how to use them. That might not be until November.

And the most trivial reason? The Dexcom receiver fits perfectly in the tiny pocket of the marching band uniform jacket, and my daughter's phone (which will be her new receiver) does not. Waiting until next year to solve that problem, which will likely involve some stealthy sewing, feels easier.

So we wait, the box of G6 stuff taunting us from the corner of the dining room.

Back to Insulin One


A change in insurance has led to a change in insulin.

We've used up our stash of Novolog, and the first cartridge of Humalog in several years went in the pump 3 days before back to school.

Some people say they experience no difference at all between the two insulins. Some think Novolog withstands heat better. Maybe Humalog sticks around in the system longer. Humalog could be more likely to clog infusion sets. We switched to Novolog a few years ago because it was reported to kick in just a little bit faster. Some of the differences are detailed here, on T1D Living.

The key difference to us is that insurance will pay for Humalog now, and it won't pay for Novolog anymore.

There are too many variables here for this switch to serve as a scientific experiment. The change coincided with an already established need to make some pump setting adjustments. It also coincided with back-to-school, and with the hamster wheel which is marching band season. A couple of things do seem obviously different, despite the chaos.

What we've noticed for sure is a greater need to pre-bolus breakfast. That aspect feels familiar to me from our switch from Humalog to Novolog a few years ago. Breakfast, after which my daughter's bg had spiked significantly almost every day since diagnosis, became more manageable with Novolog. The Humalog is a little more sluggish.

I'd also agree that Humalog sticks around a little longer. It's hard to see during the day, but I'm noticing that the Dexcom graph's downward slope continues longer on the last-before-bed bolus, or for any overnight corrections.

Because we're changing basal rates anyway, based both on feedback from our last endo appointment, and on the schedule changes from the start of school, it's hard to tell what other differences there are. It won't be until we finish tweaking that we can see, for example, if the total daily dose went up.

Given my druthers, I'd say Novolog is probably a snappier variety of insulin, and that it would be nice to go back. But in accounting for Humalog's more sluggish nature we're making adjustments that are working.

Humalog and NPH were the first insulins prescribed when my daughter was diagnosed. The glass-half-full part of me will note that Humalog's challenges are minor and manageable compared to the nightmare that was NPH.


The Edgpark Order that Won't Die


We placed our initial Edgepark order in March. The details of that ordeal are here, if you'd like to read the beginning of this story.

I returned two of the three items in that shipment on April 11th, using the return label sent to me by Edgepark, because they were not items my daughter uses, nor were they the items prescribed.

I subsequently received a bill for the Verio Test strips I'd returned. When I called, the representative said to disregard the bill. Edgepark was in the process of 'billing the return' with our insurance.

Ignore it I did, along with a couple of subsequent, identical bills I received in quick succession.

Mid-summer, after another bill, I called and was told again to disregard it.

Fast forward to the beginning of this month. I placed an order for a new Dexcom G6 system.

I then received an email telling me I had an outstanding bill. I called and was told once again to disregard it.

Two weeks later, I followed up, since there'd been no word on the G6. They'd just processed the order with the doctor's prescription, I was told, and it would be shipping from the Ohio warehouse within 24 hours. It would be at my house by Friday via FedEx. It was very specific information.

I then received another bill, for a higher amount than the previous ones, and a subsequent email warning me that no further orders would ship until I had resolved my delinquent account with the Edgepark billing department.

So I called. Yes, I was told, they had 'billed the return' and refunded my account $63.60 for the test strips. I acknowledged that as a good start, but then noted that I had paid them $288, and that they were now sending me bills for over $400. It was an unproductive conversation which ended in the representative telling me she was sending March's whole order and subsequent billing back for a 'full review.'

So, did that mean my upcoming order would be cleared to ship? "Oh- yes - that wouldn't have been on hold anyway."

Today, still no word on the Dexcom, so I went onto the patient portal to check the status. There were 'urgent alerts' posted warning me that no further orders could be processed until I paid my outstanding bill of what was now two hundred-something dollars.

An hour phone call, piles of explanation-of-benefits and bills reviewed, and lots of math later I agreed with the billing representative that the current number was correct. In (very) short, the original billing on the one item I did keep (Dexcom G4 sensors) was also incorrect, not in my favor, and that error was reflected on a subsequent explanation of benefits in July. After the whole day's bills were sent back for review, my account was credited with the rest of the Verio money Edgepark owed me, in order to pay for part of the cost of the Dexcom sensors. I still owed the balance for those supplies.

I paid the bill then and there on the phone.

My daughter's Dexcom G6, the third person in so many weeks told me, is on its way. She's, once again, really looking forward to getting it. It seems highly unlikely to me that there isn't at least one more phone call involved in this. And then, of course, the next set of bills...

Stay tuned.

And if you have a choice to get supplies from someone other than Edgepark, do.

You Know What To Do


We visited the endocrinologist a couple of weeks ago.

My daughter's A1C was up a smidge, which isn't unusual at her end of summer visit. We do better keeping her blood sugar stable when her schedule is more predictable, as it is during the school year.

The numbers downloaded at the beginning of the visit from the pump and Dexcom covered the prior two weeks of blood sugars. One week was from vacation and the other was from the youth group mission trip. Both involved strange meals at strange times, late nights, periods of heavy activity at all different times of day and night, and at least during the second week, a few moments of stress.

There seemed to be a couple of patterns, but they could just have easily been a pattern of what happens when you follow a heavy, late lunch with a busy afternoon, an unusual dinner, a walk, and no 9 p.m. snack.

After talking things over, the endo said something like this:

Look- it looks like you need a little more insulin in a couple of different places here. You could tweak a couple of things now, like maybe this after-dinner spike, but maybe you don't want to do too much yet. Why don't you wait a week- get through band camp where you don't want a bunch of lows, and then once school starts look at these patterns again and make the adjustments. You know what to do. And hopefully by then you'll have the G6 which'll make it so much easier.

Band camp was, predictably, another week of unusual eating, busy schedule and extreme heat. It felt safer to run a little higher than what we'd ordinarily consider ideal.

School started last week with a weird schedule for the first day and an unexpected half day on day 2 due to a heat advisory, which was followed by a takeout lunch with friends. Friday night was the first marching band performance at the football game, preceded by a 4:30 p.m. dinner. This week will be slightly more predictable, so we'll see if some basal tweaks we made over the weekend make a difference. And we'll add more insulin for dinner. That was the one change we did make after the endo visit but it isn't doing the trick yet. No G6 yet either- more on that another day- but we've been managing T1D in a growing, changing child since long before any CGM at all.

We'll keep watching and adjusting. We know what to do.

Piecemeal


We talked technology at last week's endocrinologist appointment. My daughter is using an Animas Ping pump and a Dexcom G4 CGM. The Animas can be serviced or replaced for another year before we'll have to switch to Medtronic for the last two years of its warranty. The Dexcom version we're using is almost obsolete, so we have to change something, but the question is, how much?

We could close our eyes and jump headfirst into a full switch to all things Medtronic. We would likely be transitioned to their 630G model which works with their Guardian brand CGM system and a Contour meter as a meter remote. This pump would suspend insulin delivery when low blood sugar is detected by the CGM sensor.

The low glucose suspend feature would be reassuring, especially for those few nights per year that my daughter spends away from us. On the other hand we've heard mixed reviews of the Medtronic sensors, in terms of accuracy and calibration neediness. We hear they're improving with each version, which is incentive to wait a while. There is already a more current Medtronic pump, which adjusts the basal rate every few minutes based on feedback from the CGM.. We wonder if we wait a year if we'll have the option of switching directly to their most recent version, whatever that is at the time, which would surely have more bells and whistles than the current offer.

Our other option is to keep the Animas pump for another year and upgrade to Dexcom's G6 CGM. The G6 requires no fingersticks for calibration, and can be worn for 10 days before changing the sensor. The CGM data can go straight to my daughter's phone, and be shared with us from there, or we can choose to use a receiver. The reviews of its accuracy are stellar.

My daughter is comfortable with the Animas pump, and super-excited about the Dexcom G6. So the plan is to move forward with those for the next year.

It feels like a piecemeal solution. But it's not a perfect world. Insurance and corporate deals dictate the diabetes choices we can make. We are destined to be Medtronic people.

Just not yet.