Bolus-worthy Bunny



 
 
 
 
As my daughter looked through her Easter basket yesterday she remarked,
 
"My friends all get chocolate bunnies from CVS. I'm glad mine is always homemade dark chocolate. It makes it so much more worth eating it."
 
The Easter Bunny's reasoning (as far as I understand it, though we've never met) is that if your basket is not going to be filled to the brim with candy, the candy that's in there should be worth eating... 'bolus-worthy' as it were.
 
So nestled among a few silly Easter toys, a package of baseball cards, a couple of  EOS products, an i-tunes gift card and some marigold seeds there's always a really good chocolate rabbit the Easter Bunny has picked up at a local candy store.
 



What We Know


My daughter got a new pump a couple of weeks ago. It's her fourth Animas pump.

We know there are other options out there. The new Medtronic pump with it's built-in glucose-responsive CGM technology is by far the closest to the ultimate goal of a closed-loop system. The slim and durable Tandem has some nice user-friendly touchscreen and Bluetooth features. The tubeless Omnipod would be convenient with exercise clothes and on the beach.

We briefly considered all of the options.

In the end we decided not to undertake the challenge of learning to use a whole new insulin delivery system. We decided to stick with what we know.

 
My daughter has been attached to an Animas pump since fall 2004, 24 hours a day, seven days a week. It's as close to a part of her body as an electronic device can be. Replacing it with a new brand of pump would, we think, require an extraordinary amount of learning, thinking and adjustment. Which seems unnecessary since we're perfectly happy with the results we've had.
 
We use several of Animas' unique features to our advantage. My kid has very low basal rates during certain parts of the day, so the tiny basal adjustment increments the pump offers are great for really fine-tuning her doses. The meter remote is a huge quality-of-life feature because it allows my daughter to program a bolus without extracting her pump from underneath a dress or a marching band uniform.  We have a good feel for the current insulin-on-board set-up, and for how the bolus calculator takes her blood sugar into account so that we can easily factor that knowledge into dosing decisions. We've rarely had problems with our pumps but when we have, we've consistently had good experiences with Animas' customer service department. After 12 years of the same pump I'm able to do site changes, battery swaps, and cartridge changes under almost any circumstances. My kid can program a bolus and have a conversation or keep an eye on the baseball game at the same time. Using this pump has become second nature.
 
In four years, or maybe sooner, our decision making process may be different. There could be some amazing new technology on the market by then, like an honest-to-goodness artificial pancreas or at least something much, much closer than the current options. For that we would certainly switch brands and learn something completely new. Until then we'll stick with what we know.

Endo Day


As I started to write about yesterday's endocrinologist visit the words felt familiar. I looked back and found a post (which you can read below) from 2013. The only difference between the old story and yesterday's visit was the added visual aid of a Dexcom graph which showed that the average range of blood sugars was about 40 points higher than we'd like it to be. "This whole graph just needs to move down an inch or two," was our doctor's assessment of the issue. The rest of the conversation was about the same as this one four years ago:

We visited the endocrinologist this week. 

In the weeks leading up to a visit, I am usually motivated to keep a more detailed log and to scan through the meter's averages and graphs.  I try to identify any major issues we need to discuss.   Sometimes I am able to fix a few things or at least narrow down the issues to a few really tricky ones.  I do this so that we can spend our endocrinologist time on issues I really need help with.

This time I tried to think about it.  I really tried to weed through all of those numbers and find the places we needed to change things.  I didn't know where to begin.  I gave up.  It turns out my confusion was warranted. The doctor's initial impression?

"She needs more insulin...like most of the day."

Her A1C was up, only by .3, but after going down a couple of times in a row it wasn't great news.  It wasn't surprising either.

Many things had changed since our last visit.  She'd added height.  She'd added weight. Yet she was missing a sufficient quantity of a key ingredient.

So we added insulin to almost every basal rate.  We added insulin to almost every carb ratio.  We added insulin to the correction factor.

We've been doing diabetes for ten and a half years.  I'm able to tweak a basal rate here and there, or recognize when the correction factor is no longer correcting.   I'm a person who, given sufficient knowledge, tries to solve problems on my own before asking for help.

Yet once in a while, particularly with a growing child with diabetes, the time comes for a major overhaul. In many ways, it was freeing to hand that whole pile of 'undesirable' numbers over to the endo and say, 'please fix this.'   Now we'll watch and see if he did, and hope he at least got close enough that I can trouble-shoot the rest from there.

I don't imagine all of yesterday's adjustments will work perfectly. We'll be following up with more tweaking in the weeks to come. But I'm grateful for yesterday's major overhaul so that we can get back on track, an inch or two lower on that Dexcom graph.



Different Every Time


Airport security experiences are like snowflakes- they're different every time. Fortunately this week's travel was different in a good way.

Our journey began at a huge, busy international airport.

My daughter's boarding pass was marked pre-check. The procedure was shoes on, metal detector only. She approached metal detector and said to the TSA agent, "I'm wearing an insulin pump which could set this off."

"Try it," the agent replied.

My kid walked through metal detector, and did not set it off. She looked at the agent who gave a friendly wave. "Have a good trip!"

On the way home, at a smaller airport, the procedure was different:

Our boarding passes were, once again,  marked pre-check. Upon arrival at the first security checkpoint we were informed that because the boarding passes were printed at the hotel and not on site at the airport, the authorization was not valid and would not scan in their system. We were ushered to the full security, shoes-off, body scanner line.

My kid approached the body scanner with her disconnected insulin pump in hand. "This is my insulin pump. It can't go through the luggage x-ray or the body scanner. It needs to be visually inspected."

She was instructed to hand it to the agent behind the luggage scanner. As she did so, she reiterated that it could not go through the luggage scanner. He smiled and nodded, and seemed familiar with the issue. "Yup- I'll meet you on the other side."


The agent walked away with the pump (a little unsettling) and my daughter went through the scanner. The pump was handed back on the other side, as promised, and we continued on our way.

A couple of notes on our experience:

-On past trips I've been the person to speak to the TSA people, but I asked my daughter before we left if she'd be willing to be her own spokesperson through security. Eventually an opportunity may come for her to fly without me and I want her to be comfortable with the process. We talked quite a bit ahead of time about what could happen and how she would respond. She handled both experiences well.

-We're often tempted not to mention the insulin pump and just go through the metal detector hoping for the best. We certainly do that at museums and other more minor security checkpoints. But for some reason the pump occasionally does set off the metal detector. Also, because my daughter is on the smaller side, the pump is always visible in her pocket or on her waist band so it's immediately obvious that she hasn't followed the instructions to empty her pockets. For those reasons, when we're at TSA security or touring a highly secure location like a government building, we've always mentioned the pump first with the goal of heading off suspicion before it can begin.

-People make a variety of choices about going through the full body scanners and about putting their pumps through the luggage scanners. Some leave the pump on and opt for a pat-down, after telling the TSA agent that they want to avoid the body scanner altogether. Some send the pump through the luggage scanner and hope for the best despite many pump manufacturers' recommendations to the contrary. Some wear pumps through the body scanner, which is also not recommended for my daughter's brand of pump. To us the option of asking for it to be visually inspected seemed like the safest, easiest, least intrusive, and most efficient solution.

We don't fly often, but thus far we've had no two TSA experiences which were alike diabetes-wise. Sometimes the carry-on's contents have been called into question. Sometimes she's patted down despite the insulin pump being the obvious reason for the metal detector alarm. This week's TSA experiences were our smoothest ever. Maybe we've finally hit the sweet spot on the security learning curve. Maybe the voices, including my own, of people who've been reaching out to the TSA requesting common-sense security measures for people with diabetes are finally being heard. Or maybe the TSA is finally realizing there are more important things to worry about than a 15 year old girl with an insulin pump.



New and Sparkly



We fired up my daughter's new insulin pump over the weekend.

Our four year warranty was up and, while the pump still worked, its appearance led us to believe it might be living on borrowed time:





The screen protector was peeling off.

And so was the paint.

It was still effectively giving insulin, but the idea of having no warranty was making us nervous.










We've had very few issues with Animas pumps over the past 12 years, but when we have, having one under warranty has unfailingly led to an overnight replacement.

That's hugely reassuring, especially considering how long it took to order a new one from scratch.






Granted this wasn't an emergency since my daughter's pump was still perfectly operational, but it took about six weeks between my first call to inquire about a replacement and its arrival on our doorstep. The process began with two different phone calls with questions for me, then doctor's orders, insurance authorization (which was the longest process), another phone call to discuss our copayment and the shipping details, and then actually getting it shipped out.

The possibility of reverting to multiple daily injections for even a fraction of that time is not appealing to us.

The new pump is silver, and sparkly all over, with no chipped paint. The screen protector is intact and clean.


And we expect to have a reliable source of insulin delivery for four more years.

 


 

Reading is Fundamental


My daughter had a few late afternoon and evening lows last week.

When she's out and about, she carries juice boxes, glucose tabs and smarties. When she's home she prefers something different. There are occasional seasonal choices in the fridge like fresh apple cider or high-test lemonade leftover from a cookout. Usually, though, the home juice of choice is orange juice. She pours four ounces into her pink sippy cup and waits for the low to turn around. Nine times out of ten, unless she's under 50 or been exercising heavily, those 4 ounces bring the low up within 15 minutes and life goes on.



Last week, not so much. The lows seemed slower to respond. If it was dinner time and she hit 70 after 15 minutes, we'd eat and subtract some bolus insulin. Otherwise, she found herself adding more juice, or a little snack of fruit or crackers to make sure she came all the way up.

A couple of seemingly sticky lows in one week was weird. And a nuisance, especially at dinner time. What was going on? Maybe it had to do with impending full moon or some other such mysterious and passing variable. Or maybe something had changed and my daughter's new normal involved closer to 20 carbs per low.

Then I walked into the kitchen as she poured the last of the orange juice into her cup:


I accidentally bought low-carb orange juice. I don't drink it and my husband hadn't noticed when he slugged it down still half asleep in the mornings.

I read a lot of labels: cereals, snacks, bread, starches and countless other packages are fully assessed before they're consumed. I missed this one. Which explains why those lows wouldn't come up.





No Diabetes In There


Yesterday was the dreaded eye doctor day. Dreaded for several reasons:

   -Making time for any appointment is a challenge with the busy high school schedule.

   -Most of the homework had to be finished prior to the appointment since she expected to be blurry afterwards.

   -While we truly appreciate the thorough exam and attention to detail we receive at this office, we've learned that an appointment there is an hour and a half commitment.

   -And, of course, the diabetes what-ifs.

The plus, in addition to liking this doctor, is that the office is less than a mile from home. So a few minutes before five we hopped in the car with the last of the homework in hand. We arrived, signed in, and took our seats in the waiting room. After half an hour of reading for history class and watching a series of increasingly unsettling segments on the 5:00 news (Car crash! Bomb scare! Everything could kill you!) we were ushered into the exam room.

The doctor started with the basic vision tests, which came out about the same as last time. My daughter has 20/20 vision in one eye, which she apparently uses to compensate for astigmatism in the other. No glasses yet but probably some day. Then there were the eye drops- which she hates but which she took like a champ.

Next up was the visual field test. Our doc usually gives this once, as a baseline in kids. But because having diabetes isn't enough of an eyeball challenge, my kid also has an 'it's probably nothing but we're going to keep an eye on it' issue going on with her optic nerves. So into the dark room she went to squeeze a clicker every time she saw a light flash in a machine. She did great, just like last time, so we put this concern off for another year.

Round three involved the actual looking into the eye part. The part when the fingers get crossed and the breath gets held. The doctor used a couple of different instruments to look into the eye herself and, after that, took the retinal photograph. She then pronounced,

"They look great- perfect. There's no diabetes in there."

Which is kind of a peculiar way to put it, but the exact words don't matter. My kid, despite still being a kid, has had diabetes for 14 years. That starts to get into the potential collateral damage timeframe.

So far so good. All the ophthalmologist had left to say was, "See you next year."