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!).

Wednesday, July 31, 2013

Oh, say can you see…


I think it’s no secret that most of us use the backlights on our D-gear to find the bathroom at night, but so far as I know, the Snap is the first diabetes Swiss Army knife to come equipped with a genuine flashlight.


 A bright LED bulb is built into the controller, and is powered from the AAA battery that’s said to live inside the disposable body. If you turn on the flashlight from the main menu, it stays on for 15 seconds. How far from your bedroom is your bathroom? Of course you can turn the light on as many times as you want to, the down side being too much flashlight use eats up the battery.

Uh…. Would that be the same battery that delivers the insulin?

Why, yes. Yes it is.

No fear.  Well, no fear, according to Asante. They say that the Snap system is designed so that if you gobble up too much juice illuminating your world, the flashlight will be disabled, still leaving enough juice to finish up the whole keep-you-alive-by-delivering-insulin thing. Hmmmmm….

The flashlight also comes on automatically during the body/site change operations to help you look for the drops of insulin at the end of the tubing. Nice feature.

But how useful is the flashlight in the real world? Personally, in the dead of the night, I find it too bright, or at least brighter than I need to navigate piles of dirty laundry, toys, cats, and other barriers to bare feet between bed and bath for nocturnal pit stops. I just use the Snap’s backlight for this nighttime navigation, like I’ve done with all my other pumps, and it works just fine. By the way, t:slim is just barely bright enough for this operation, so Snap trumps t:slim in this regard, too.

On the other hand, I do find the built-in flashlight useful as a beacon to help locate dropped test strips at 3am. I don’t know about you, but for me the pump or CGM backlight—while fine for avoiding large objects, furniture, or walls—is not cut out for finding dropped strips. It probably doesn’t help that I’m using VerioIQ strips, which are gold, and have tan carpet, which turns out to be the prefect Verio camouflage. And while I haven’t personally used it in this way, I suspect it would be handy for lighting up keyholes on doors late and night, illuminating the menu in dim bistros, finding the frickin’ candles in a blackout, checking on the baby, or locating the whiskey bottle in the tent when camping. Basically any operation you’d use a small flashlight for.

People with more interesting lives than mine could also use it to swap phone numbers in dark night clubs, locate drug dealers in dark alleyways, or to unwrap condoms. Yes, Asante is certainly lighting the way for us.


Tomorrow: A post-modem on a dead body


Tuesday, July 30, 2013

When film ruled the world


♪♫♪♪♫ So Mama, don’t take my Kodachrome away…♪♫♪♪♫
--Paul Simon, 1973

Readers half-way through their statistical lifespans, or further, likely owned a film camera at one time or another. For you younger readers, back in our day, things were different. Our objects didn’t multitask. Rather than having an iGadget that did everything, we used typewriters to send mail, phones plugged into walls to make calls, pocket calculators for math that was beyond our mental abilities, watches on our wrists to tell the time, and our contact lists sat on top of our desks in circular filing cabinets called Rolodexes. Yes it was all very primitive, but we got by just fine. And to take pictures we used a camera that was only a camera. Its sole job was to make images on this stuff called “film,” that you had to take to a camera shop, who then sent it to a big lab somewhere to be processed. It took us a week or more to get our pictures back after a big event.

The King of these cameras, used by pros and avid shutterbugs alike, was the SLR. That stood for Single Lens Reflex. These were heavy metal beauties that took a range of interchangeable lens. You would have a wide-angle lens, a normal lens, a portrait lens, and a variety of telephoto lenses. Oh, and if it was dark—defined as not outside in bright sunlight—you needed a flash, too. Back in the day, photography required lugging some serious gear.

The great innovation of the SLR, over the cameras that came before it, was that you could hold it up to your face and actually see through the lens that was taking the picture. Prior to that, we had cameras you held at waist-level and looked down into, or ones that used a view finder that never quite let you see the same thing the camera was seeing. The technological marvel of the SLR was accomplished by using a mirror and a large glass prism to bounce and flip the incoming light around. (Camera lenses see the world upside down from they way your brain does, but that’s a subject for someone else’s blog.) It was this pyramid-shaped prism, sitting proudly dead-center atop generations of SLR cameras that gave them their distinctive look—a look that became so iconic that it can only be described as cameresque. For decades before the digital era, if you said the word “camera” to almost anyone in the world, they would picture in their mind’s eye the iconic pyramid profile of the SLR. I bet you could even have gone into the heart of Africa with a deck of flash cards, and if you showed a clip-art drawing of a SLR to the bush people there, they would have known exactly what it was.

And just what the fuck does this have to do with the Snap insulin pump? Why, everything, of course. Because buried inside the Snap is a prism that reminded me of the cameras of my younger days.

OK, granted. It’s a lot smaller. And plastic. But still…

So what is it doing there? Surely there’s no film in the Snap. Well, I don’t actually know that there’s no film inside a Snap, as I’ve yet to dismember one (don’t worry, it’s on my “to-do” list). And, come to think about it, that description is less than accurate. Technically, the Snap prism isn’t part of the pump. It’s part of the infusion set, built into the tubing connector. Here, look for yourself:


 Remember when I told you that Snap infusion tubing was unique? That you couldn’t use the left over Luer lock sets from your Animases, Cozmos, Spirits and pre-Paradigm Med-T pumps? Right. The part of the Snap tubing that connects to the pump is unique, proprietary, and not compatible with the closet-full of horded infusion set supplies you’ve been jealously guarding just-for-in-case you lose your health insurance.

Sucks to be us.

Now, when Med-T did this a while back, I cried foul. I saw, and still see, no technological need for the Paradigm ® Tubing Connector. (Seriously, is there anything these people haven’t tried to patent, trademark, or copyright?) To me it seemed like they replaced the Luer lock to make sure no one else’s infusion sets would work with their pumps. It was a monopolistic marketing move that provided no technological improvement. Bastards. Hell, even the highly innovative t:slim pump uses the standard Luer lock infusion pump connections, making it fully backwards-compatible with your supply closet. Although, in the case of t:slim this is a mixed blessing, because it created the bizarre “pig tail” connection that people either love or hate.

Now, just to be clear: the body-set end of the Snap infusion set is compatible with old gear, but the tubing and connector are not. I suppose you could use up some old supplies by just reusing the Snap tubing and connector with surplus body sets until the needle that pierces the penfill of insulin gets so dull that you can’t force it through the top membrane anymore…

But I digress.

The prism is actually part of the Snap’s occlusion detection system. For you pump virgins, (that sounded a lot worse than I had intended it to) an occlusion is any blockage in the insulin delivery system. Often occlusions are caused by kinked tubing. Just as twisting a garden hose can cut off the water flow, a twisted infusion tube can cut off the life-sustaining flow of insulin. At other times occlusions are caused by bent or twisted cannulas inside the body. And sometimes occlusions are caused by biological fouling—basically, the cannula gets plugged up by fat, dead white blood cells, or whatever.

Pumps are designed to detect occlusions and alert the pumper to the risk, hopefully before the lack of insulin puts the pumper through the roof blood sugar-wise, or into the ICU in a coma. Pumps do this by monitoring the pressure of the system. Too much pressure indicates that the insulin isn’t getting through, and an alarm is triggered. Realistically, if the problem is a blockage during basal delivery, most pumps won’t warn you in time. There’s just not enough insulin being delivered to build up a high enough pressure. Accordingly most occlusion alarms happen inconveniently during an attempt at meal delivery, and your food gets cold while you try to trouble-shoot the problem and then worry about what percentage of the failed bolus really got into your body.

Sucks to be us.

Now, truth be told, I’m not really sure how other pumps detect occlusions, but I know how the Snap does. It uses Kodachrome.

Well, not quite. But it uses a cousin of the good ol’ SLR technology to ferret out occlusions. The prism on the hub is installed above an ultrathin sheet of material that lies against the tubing. The hub, when attached to a Snap body, and when the body is snapped onto a controller, fits snugly down inside of the pump:


 The prism is mated to a window on the controller :


 This window sends out a light beam that travels through the prism and back into the window again. So long as the light is sent and received, all is well. However, if the pressure builds up too much in the tubing, the light is blocked off as the expanding tubing pushes the ultrathin material upwards. If the pump can’t see either one lamp or two, it knows the British have already gotten to Boston and captured the church. It doesn’t really matter if they came by land or by sea, the shit has hit the fan. When the pump can’t see the light, an occlusion alarm goes off. All thanks to the little prism built into the infusion tubing connector. Very clever, Black and Decker. (’Cause very clever, Asante don’t rhyme.)

The Snap may not take snapshots, but it has camera technology under the hood.


Next time: The light of your life



Monday, July 29, 2013

Time for a change


Tomorrow: Live in concert, Paul Simon rocks the Snap!



Friday, July 26, 2013

They ain’t twins

There’s something funny about a box of infusion sets from Asante. Here take a look:


 How many differences can you count between the two labels? (I’m told that these find-the-differences games are all the rage).

OK. See you next week. I’ll post the answers on Monday.





Juuuuuuuuuust kidding! Each box is 50% infusion sets and 50% cannula sets. Huh? OK, so here’s the deal. A proper infusion set is made up of an inserter needle, a connector hub with a cannula that has sticky tape to hold it on the skin of a person with diabetes, and a length of tubing to connect that same person with diabetes to a reservoir of insulin inside a pump. Although not technically part of an infusion set, we often include the pump reservoir and fill needle in our minds when we think of these things. So in the vernacular, an infusion “set” is all the disposable supplies needed for the pump site change that generally happens every three days.

But, you need to remember that Snap is different from every other pump in this regard. Thanks to the insulin being in a glass penfill, you can legally and safely (more on that in a bit) use it longer than you can legally and safely use insulin in a plastic reservoir. Bottom line: You don’t need a traditional full infusion set every three days; nor do you need to replace the tubing every three days. You only need to replace the part on your skin every three days. The rest of the rig you can wear six days. Or longer. I’ll talk about stretching that envelope on another day.

Back to the box of infusion fun. Asante gives us two things: what they call “Infusion Sets” for the complete changes that happen once a week or so; and “Cannulas” for the changes that happen every three days. The full Asante infusion set has the tubing and the special connector that mates with the body and the penfill of insulin. We need to talk about that device in a separate post, but they smartly realized that we don’t need tubing as often as we do with other pumps. So you get half a box of traditional infusions sets and half a box of tubeless infusion “sets,” or what I’ve decided to call Infusion Lite. ®™ by me!    ;-)   Those of you who worry about landfill overfill will appreciate this lack-of-waste approach.

Now, as promised a moment ago, I’ll address the issue of how long insulin can stay in a pump. Any pump. Is this week-in-a-pump thing of Asante’s really all that special? Maybe. Maybe not. There’s a good reason insulin comes in glass vials. It holds up better that way. Insulin does degrade in plastic, but how fast it really does so is anybody’s guess. The pumps with plastic reservoirs are approved for 3-day wear. Is that the best that they can do, or did no one bother to pay for the studies to get FDA approval for 4 days? Or five?

Asante didn’t need to do that because the glass penfill already has a longer use indication.

Of course, lots of people extend the use of insulin-in-plastic inside their pumps for reasons ranging from economy to necessity, with laziness in the middle. I myself had some supply issues with t:Slim cartridges recently and ended up not only having to extend them, but even to re-use some. That’s strictly off label. How did the insulin hold up? Geeez… I wish I knew. My life has been so… umm… stressful lately that my BGLs suck. A lot. Pinning down the true cause of that suckiness is no easy task, and on top of that, I’ve had more than the normal number of cannula issues lately, on both the t:slim and the Snap. Check out this blood-filled Snap cannula, for instance:


 But, infusion sets aside, as to age of the insulin in my (temporarily?) retired t:Slim pump, sometimes on day 5 or six it seemed that the insulin wasn’t doing its thing: my BLGs were running high and corrections were sluggish. But on other days, I’d see the same thing on day two of a reservoir. And at yet other times I was sailing along just fine on “old” insulin. Heat can also come into play. Just keeping insulin in glass is no help if you are spending all day playing tennis in 108 degree heat or canoodling with drug reps in a hot tub every day at lunchtime.

Not that I’ve ever had that opportunity!


Monday: Invasion of the Body Changers, a graphic novel
(or as they are called south of the border, a Photo Novella)



Thursday, July 25, 2013

Oh, snap! I’m unsnapped!

Just as I walked into the new clinic’s 1,000-square-foot pharmacy, the alarm went off. It was a wailing noise, not as loud as the Walmart shoplifting alarm, but with the same kind of “Freeze, sucka!” authority. Oh crap, what did I do this time? I asked the pharmacist.

He shrugged one shoulder, “It’s not us. I think it’s your pants.”

Oh.

How embarrassing!

That’s the funny thing about noise. Sometimes it’s hard to know where it’s coming from. I quickly grabbed the infusion set tubing from my beltline and reeled in the pump. All that came out of my pants pocket was the pump body. The controller wasn’t there. It was missing. Gone. My pants continued to say WeeeeeeeWooooooWeeeeeeeWoooooo…

Oh snap! I’ve become unsnapped! How on earth did that happen? How long have I been unsnapped, with alarms of lesser authority that I did not hear, before this nuclear-meltdown alarm went off? I dug my hand into my pants pocket and fished out the screaming controller. I silenced the alarm with one button click, then dismissed the alarm with another click. I quickly snapped the pump back together again, and retreated to my office where I could hide amongst the cardboard boxes from our fresh move and die of embarrassment in solitude.

Later, I realized that had I thought to ask it by going to the status screen, the pump almost certainly could have told me how much insulin I had missed. If you suspend the Snap, it helpfully tracks missed basal delivery, and once you wake it up again, it will tell you how much you missed while it was snoozing. Sadly, there’s no provision to deliver that missing insulin with a simple press of a button. You have to go into the bolus menu and program the delivery manually.

On the bright side, I think it’s a good thing that this alarm was loud enough to embarrass me. The alternative could have been ketones before I realized what had happened. By the way, this is no ordinary alarm. One of the pump’s designers described the last-ditch alarm to me as “highly annoying,” but that’s an understatement that doesn’t do justice to its engineering. It’s more than just volume; it “sweeps” through sound frequencies from low to high, and then from high to low again—the theory being that if you’re deaf to certain frequencies, at some point the pump will find one you’ll hear.

Sounds like an innovation that would be most excellent for CGM integration in the future.


Tomorrow: Asante’s strange box of infusion sets


Wednesday, July 24, 2013

Temporary insanity

I’m annoyed at the location of the temporary basal rate menu in the Snap, but I don’t know if this will bug anyone else. You see, I use temp rates a lot, which means either that I’m a “super user” or that my pump programming is less than perfect. (The truth probably lies somewhere in between.) But anyway, I frequently use temp rates during CGM drops, and always use them to shut the pump off in a low. Yes, yes, yes. I know. I know. You can suspend a pump when you are low, but then you have to remember to turn the little fucker back on again. When I have a hypo, I follow a simple three-step battle plan. First, I set a temp rate of zero for 30 minutes, as there’s no point in throwing fuel on the fire. Second, I consume 16-18 carbs. I usually use Dex 4 liquid at night and Nipro’s Shot during the day. The Shot has 400 IU of vitamin D, as well as glucose, to help me recover the physical energy I lose from the low. I don’t care if I’m peppy or not after a nocturnal low, but during the day this really helps me get back on my feet quickly. Third, I use colorful, explicit language about food, diabetes, insulin, technology, and how the sucky universe is in general.

This procedure works well for me.

Now, it was not my intention to spend the next month doing nothing but comparing t:Slim to Snap, but I’m sort of forced to. It’s been years since I wore the OmniPod, and talking about the extinct Cozmo is moot. Of course I wore a Revel last year. Well, that’s not quite accurate, is it? As veteran readers will recall, I actually wore five of them over the period of a few months. All the gaps in between these pumps were filled with pens and syringes… and what the hell, I think most of the reader interest out there is in t:Slim or Snap… so I guess I’ll just go right on comparing. If you don’t work for either pump company and you get sick of it, let me know.

So on the temp rate front, t:Slim mops up the floor with the Snap. Once either pump is turned on and at the main screen… Hold on a second. We need to clear something up before we go on. To wake up the Snap takes a single button press—unless you have the optional screen lock on, and why would you? To wake up the Tandem, it takes four button presses. But please remember that unlocking the t:Slim isn’t hard, is kinda fun, and it becomes very automatic, so it’s not the pain in the ass that it sounds like. But to try to keep the playing field level, I think I’m going to start counting steps from main menu. Just try to remember that getting to the main menu on either pump is a quite different operation, OK?

Now where the hell was I? Oh, yes. I’m dropping like a stone because the Amaretto Sour had a lot fewer carbs than I thought it did, so I overdosed myself with insulin. How many steps does it take to get to the temp basal control screen on each pump? Tandem: two. Snap: six. I find that really annoying on the Snap. And of course, I’m trying to do it quickly, because I’m low. And neither pump will remember the last temp rate I ran, damn it. Once you get there, the Snap requires some scrolling, and the t:Slim some typing.

Actually, once I do eventually get there, I prefer the Snap’s way of getting the rate programed and set: I just hold down the left button for about five seconds to scroll it to zero, and hit next. The pump does not advise me (and make me acknowledge) that I have set a temp rate of 0.0 u/hr. and basal will not be delivered for the duration of the temp rate, like some other pumps do. Next, on the Snap, I scroll for time. The pump’s default temp rate time is one hour, but it scrolls in 15 minute blocks so it takes only two left button presses to set my half hour. I don’t recall if 15 minute intervals is the pump’s default, or if I set it up that way. Hit the middle button  (labeled Start) and you’re done. A screen pops up to tell you the temp rate has started, but you don’t have to acknowledge it. You can just drop the pump back in your pocket. When it times out in a few seconds, it will return to the main menu.

Now on the t:Slim, the default settings on the temp rate control menu are 100% and 15 minutes—two settings that no one on the planet will ever use. So that requires you to access both menus separately and enter numbers. If you are low and shaky, you’ll be amazed by how hard it is to get your fingers to press the right part of the touch screen to enter the numbers you are after.

I must confess, however, that I’m sort of old fashioned. I’m a steam gauge and button kind of guy. I really prefer analog displays over digital. Debbie’s new used car, Duke the Juke has a digital gas gauge that just doesn’t “talk” to me. It’s too fancy-pants. I’m always getting myself into trouble and don’t know it until the low gas alarm goes off. My trusty old Jeep, on the other hand, has a needle that drifts between “F” and “E” and a quick scan of the dashboard tells me all I need to know. I also prefer buttons that really press over these touch screen things. I admit, they are kind of cool, and our house does have several of them, but I’ll take a button over a touch screen any day. Especially on a diabetes device. If you are younger, and grew up with this technology, you’ll probably feel the reverse of how I do.

Anyway, so the bottom line here is that I actually like the Snap’s control interface for temp rates much better than I like the t:Slim’s; but I hate where Snap buried it in the menus—temp rates are much easier to get to on the t:Slim—a fact that may come from the crowd-sourced design model that developed the t:Slim menus.

And there are a few menu items that are just in plain stupid places. But I’ll save those for another day.


Next time: The difference between unsnapping someone’s bra and unsnapping someone’s pump


Tuesday, July 23, 2013

Not a pump paradise


So in many ways the Snap is pretty Snapalicious. What I like about it best so far is that it lets me do something that I love to do quickly: eat. As we covered yesterday, the Snap is practically a speed demon, compared to other modern pumps, in this regard. To recap, there are a minimum of steps involved in getting the BGL and Carb info into the damn machine, so that the insulin can get into my shitty body, so that I can eat the frickin’ food.

Now, for you non-dFolks, the reason this matters to us is that by the time we’ve figured out our carb counts in the first place, our food is already cold and the rest of the dinner party is starting dessert. Adding any slow-down on the pump end of the business makes eating practically not worth the effort.

I also like the fact that the Snap requires fewer oil changes than my old car. And by that I mean, of course, that I enjoy the fact that I only need to slap an infusion set on my body every three days rather than do the whole fill-the-pump/fill-the-tubing thing every 72 hours. But that leads us nicely to the first thing on my list of things that drive me batty about the Snap. Asante’s menu design slows down one of the fastest feature of the Snap.

Just for the sake of argument, let’s say that you’ve had a back-alley encounter with a sword-wielding Japanese mafia hit man who’s just cut your infusing tubing while trying to eviscerate you. Hey, it could happen. And it’s just about the only scenario I can imagine where you’d even need to fill your tubing using a Snap pump. Recall that when you assemble a pump body, penfill, and tubing set every week or so, the tubing fills itself.

Of course, the pump still has to have a tubing fill menu because we dFolks do sometimes encounter Japanese mafia hit men, sharp doorknobs, playful cats, dropped razors, and insulin pump tubing-eating seatbelt latches. So in an emergency, you do need a way to replace the tubing without sacrificing the pump body or the expensive insulin penfill inside it. Try that with an OmniPod or t:Slim. So there is a tube-fill menu, and I’m glad to have it, but it really should be at the bottom of the glove box.

But noooooooooooooo….. It’s high up on the menu structure, while on the other hand, buried below it, is the menu that lets me fill my cannula: an operation I need to do every three days. So on a Snap, every three days you need to scroll past the tube fill menu you’ll probably never use, to get to something you use all the frickin time. It’s not that big a deal, but it’s an extra button press. And extra button presses add up to God only knows how many hours/days/weeks/months/years of my life that I’ll never get back.

I have a low tolerance for extra button presses. Life is short and I have better things to do.

And this is an unnecessarily bone-headed extra button press. Someone at Asante should have realized that we almost never need to prime our tubing, but we have to fill the cannula every couple of days. What happens most often should have priority in the menu structure, while what happens almost never should be at the bottom of it. I suspect this is a legacy of engineers thinking inside the old pump box, not outside it where they created this baby. Back in the day you always had to fill the tubing before you could fill the cannula. Still, you’d think someone would have noticed how stupid this is. Maybe Asante doesn’t have enough dFolks on staff. Maybe they should hire some more. I urge all of you to fill their inboxes with your resumes.

But Snap’s exacerbating features don’t stop there. Chief among other things that piss me off about the Snap is how damn long it takes to correct a high blood sugar. Getting to the place to correct an unexpected high is a Snap, but then you need to scroll in your blood sugar. Yesterday Debbie brought me a diet cherry lime from Sonic Drive-In. Well, actually, that’s not correct. She ordered me a diet cherry lime. She brought me a regular one. I couldn’t taste the difference, but my CGM sure could. In no time, I had two arrows up and the sensor glucose was rocketing past 350. Guess how long it took to scroll from the default setting of 100 mg/dL to 350 on a Snap?

Twenty seconds.

Assuming one snap per second, it took 20 snaps. So it’s hardly a snap to fix a high.

♪♫♪ Scroll, scroll, scroll, your pump gently down the (blood) stream…♪♫♪ But there’s nothing fucking merrily about how long this takes. I think the Snap is the slowest scrolling pump I’ve ever worked with, and infinitely slower than a linked meter or the t:Slim that lets you enter a blood sugar as simply as dialing a phone number. Well, simpler, actually. When was the last time you called a three-digit phone number?

Why on earth don’t these pump companies set the blood sugar correction scrolling at 5mg/dL intervals? The damn meters are so inaccurate in the first place, it’s not like there’s a real world difference between a blood sugar of 273 and 275. But like the movement to remove the penny from US currency and just round sales up or down, I suspect many people would cry foul if a pump scrolled in fives. But it should at least be an option.

Do my complaints stop there? No.


Tomorrow: How the temp rate menu drives me temporarily insane



Monday, July 22, 2013

Let’s eat. NOW!


You’ve been staggering around, lost in the Sahara for four days, ever since your plane ran out of fuel high above the dunes and ditched in the arid sands. Luckily for you, the good folks at Hilton have just opened the Moroccan Sands five star resort, and, stomach growling, you stumble into the all-you-can-eat buffet.

By some miracle, you’ve kept your insulin cool all this time and it’s still good. Wanting to maintain that stellar A1C that made your crusty old endo smile, you take the time to enter a bolus into your pump before you dig into the mountains of mouthwatering food that await you.

Trivia question: Just how many steps does this take on a Tandem pump vs. how many steps does it take on a Snap pump?

Are you fucking sitting down? Tandem: 14 steps. Snap: 6.

What???? Yep, that pretty, shiny, high-tech t:Slim makes you go through more than twice as many steps and “are you sure” screens before you take your first bite.

Maybe the Snap really is a snap, after all.

Now, because the flamers are cracking their knuckles and saying, “No frickin’ way,” let me bore you with the steps to prove my point.

Tandem:
1.) Wake pump up with silver button on top.
2.) Touch target 1.
3.) Touch target 2.
4). Touch target 3 (the pump is now unlocked).
5). Select Bolus.
6). Press Add BG to enter your BGL (or you can do carbs first, it doesn’t matter).
7). Enter your BGL. Although this probably takes three key strokes, I’ve counted this as one step.
8). Press Done.
9). Tell the little fucker that, yes, of course you want to correct your blood sugar, if you didn’t why would you embarrass yourself by telling it what your sugar is in the first place??).
10). Select Grams to enter your carbs. Now, I again counted this as one step, even though there is no saying how many key strokes it could take. You can also use the “+” key to enter multiple carb-counted items that build your meal. If you do, you must now however press “total” to add them up.
11). Select Done.
12). Select Next.
13). Confirm your request. If you choose to do a combo or extended bolus you’ll add a few more steps here.
14). Press Deliver.

Snap:
1). Press the bolus shortcut button, the one on the far right, to wake up the pump and take you to the bolus screen.
2). Enter your BGL. This does require scrolling, which depending on your BGL may or may not take as long as typing a blood sugar value into the Tandem. The higher your BGL, the longer this takes. Bear in mind that neither system has a meter that “talks” to it. Yet.
3). Press Next.
4) Scroll in your carbs. Note that you can also add the components of a meal. Just like with the Tandem, all you need to do is hit the Next key again and the Snap keeps a running total. Unlike the Tandem, however, you don’t need to press yet another key to total all the numbers.
5). Hit Next again. The Snap shows you the total insulin bolus. If you want details, you call scroll to the side to see them, but it’s not required.
6). Hit Start to deliver. And that’s it. It’s time to eat.

What? The Tandem user has fainted from hunger at step ten? OK, let me eat one more lobster tail, then I’ll go help him.

Now, the Tandem people have been telling me that all the “are you sure” and “are you sure you are sure” screens were required by the FDA under the new pump guidelines, and that, going forward, all new pumps will be designed for the stupidest diabetic on the planet. But… wait a sec. The Snap is approved by this same FDA, under these same new guidelines… Hmmmm…

I suppose some of the extra steps might be because of the Tandem’s innovative touch screen (certainly that’s true of the first four steps), but I wonder if Tandem was being straight with me. Even without the touch screen unlock, the t:Slim would have four more road blocks between me and my insulin than the Snap does.

Today I’m liking Snap a lot. She’s not as pretty, but she loads fast and lets me eat faster. But the honeymoon has just begun.


Tomorrow: Are there things I DON’T like right out of the gate? Oh, yes. Yes, there are.


Friday, July 19, 2013

Prime time meets primetime


I cannot tell you how long it takes to prime my 43-inch infusion set tubing on the Snap. My reflexes simply aren’t good enough to time it. I can’t even reach for my iPad timer before it’s done. I think the Snap charges the line in around one second. It might be half a second. It might be a second and a quarter. But for all practical purposes, it’s instantaneous.

That would be amazing compared to any pump, but it’s especially amazing compared to my slower-than-molasses t:Slim with its six-minute tube-fill time. The t:Slim fill is so vexingly slow in filling it’s tubing that while it’s doing it I make coffee, check the weather, get dressed, eat breakfast, see if anything new has showed up on eBay or Etsy, and still have time left over to surf for porn. Now, like Emeril Lagasse, Bam! The tube is fully charged with insulin as soon as I attach the tubing to the pump. The damn Keurig hasn’t even warmed up yet. My morning routine is now shot to hell.

How’d they do that?

Damned if I know. But I don’t care. I love it.

Getting the Snap ready for action gave me visions of those old war movies where the Marine recruits are blindfolded and fieldstripping their guns while the instructor times them. I think that happened in the sub on its way to the pole in Ice Station Zebra, and during training in The Boys in Company C. Or maybe it was Full Metal Jacket.

But snapping your tubing full of insulin is so fast you wouldn’t even have time to get the blindfold on.

Bottom line: Getting the pump’s tubing ready for the week’s run is… well… a snap.



Next time on LifeAfterDx: A real-time meal time shootout. I compare the number of button presses between me and my food on both the t:Slim and the Snap. That’ll be on Monday. Same time, same channel. Be sure to tune in.


Thursday, July 18, 2013

First impressions


Wow. This thing is light. When I first held the Asante Snap in my hands, I thought they had handed me a mockup, like one of those hallow plastic husks they put under glass at diabetes trade shows, not an actual unit. But this was the real deal, and as insulin pumps go, it’s  feather light. Fully loaded with a week’s supply of insulin, it tips my Slater kitchen scale at a hair under three ounces, fully 25% lighter than the Tandem t:slim.

In your pocket, weight-wise, it feels like you forgot your pump. But it’s thicker than the highly-pocketable t:slim, and longer to boot. Your diabetes educator might ask you, “Is there a Snap in your pocket, or are you just happy to see me?”

In shape, thickness, and build quality, the Snap is reminiscent of a TV remote—which doesn’t sound very impressive—because it isn’t. While light weight is good, I confess that this thing feels cheap-ass in the hands. But you have to remember that I’ve been pumping the Appleque t:Slim for over six months, so that’s warped my expectations. The t:Slim is handsomely made, solid, sexy, and sports a bright color-touch screen. If I had picked up the Snap with a Med-T Revel on my belt, would I react differently?

I think maybe so.

The Snap’s screen is a blue-backlit LDC… which seems rather 90s to me. But for such a small screen, the Snap is… well, a snap to read. All the letters and numbers are big, and the resolution is sharp, even high-res compared to, say, the Med-T pump’s rather cubic pixilated screens. So while the Snap screen falls far short of modern sexy, it’s highly serviceable. A few years ago, it would have blown the doors off of everyone.

But it’s not a few years ago.

That said, I don’t find that that backlight blinds me at night, and outside in direct mile-high New Mexico sunlight it can be read just as clearly as it can be anywhere else. You can’t say that about the t:Slim, which requires you to cup it in your hands for shade if you’re using it out of doors. Bottom line, the Snap is as easy to read as a Kindle.

Ergonomically, although it shouldn’t matter, I think it’s a right-handed pump and I’m a lefty. Every time I pull the damn thing out of my pocket, I’ve got it upside down. Oh… wait a sec… I just figured out why I do that. The tubing exits the t:Slim on the right-hand side, while it exits the Snap on the left-hand side. I’ve just gotten into the habit of flipping the pump a certain way based on where the tubing is. I need to re-train my hands. Never mind.

Anyway, when you hold the Snap, it feels a bit like a game controller (but I doubt that Diabetes: The Video Game will become a best seller). If you hold the Snap in two hands, your thumbs fall comfortably onto the buttons on either side of the screen, and can easily reach the three buttons across the bottom.


I find I’m all thumbs using this thing, but in a good way. Operating it is as easy as texting with a pre-smart cell phone. We’ll talk more about this some other day, but I’ve found that there are a number of operations—taking a correction bolus for instance—that are easily done one-handed, but on the other hand(s), there are some common functions that take waaaaaaaay too many button presses. Again, a discussion worthy of its own post, so stay tuned.

The buttons themselves are sweet. They take a little authority to press, reducing the risk of a butt bolus (there’s an optional screen lock, but that adds extra steps between me and my insulin so I’m not using it), but the buttons aren’t overly difficult to engage either. All things being equal, I’d describe them as delightfully springy. Sounds more like the description of a new laundry soap than in an insulin pump, huh? Now available in Delightfully Springy and Country Rain scents…

For now, I’m carrying the pump in my pocket, as I already have the frickin’ CGM and a meter case on my belt, and enough is enough. But the pump did come with two belt cases. One is a handsomely made leather job, with a rotating belt clip for vertical or horizontal wear, complete with the Asante logo deeply embossed into the front. It has a magnetic closure and no window. That means it’s a slip-out belt case; you cannot operate the pump in this case. With the pump in the case it’s nearly identical in size to the Dexcom G4 in its own case, but nearly twice as thick. I can’t see myself using it, even if nothing else were on my belt. Plus, it doesn’t come in tan. (I’m going to keep harping on this until one of these diabetes device companies gets me a case that matches my frickin’ wardrobe!)

The second Asante-supplied case is a high-tech-looking gripper clip that holds the pump close to the body and lets you operate the pump from your waist. I could see myself using this one, and might test it out before we are through. Actually, I kinda wish Dex would make one like this. Again, the clip rotates and I suppose it could be used either as a belt clip or a dress pants pocket clip (to keep the pump from dropping to the bottom of those sometimes overly-deep pockets). Like the pump, however, this clip-case looks a hair flimsy. Well, that’s not quite fair. The clip itself is military grade, no doubt about that, but the arms that hold the pump to the clip look like they might snap off in a light breeze. I’ll have to test it out in a light breeze, then I’ll report back.


 So those were my first impressions, many of them aesthetic, and you need to remember that I’ve been carrying the ultimate aesthetic pump in my pocket for half a year now. And while good aesthetics are nice, they really aren’t the name of the game here. I don’t want an ugly pump (and the Snap isn’t), but performance and ease of use are the real deal makers and deal killers. Or should be. Yeah, I know of a couple of kids who chose the Ping just because of how it looked. But if we want the BEST pump we should really be looking at performance, ease of use, and user interface.

When it comes to pure looks, t:Slim has everyone beat. But as pretty as she is, she can be a huge pain in the ass to use. She’s loaded down with safety and warning screens to the point that many daily operations are slow, slow, slow.

How does Snap compare in this regard?


Tomorrow: The fastest gun in the west


Wednesday, July 17, 2013

Snapping up a Snap (and a disclaimer)


Asante is rolling out their new pump starting in the Northeast. They tell me they hope to be nationwide by the end of 2014. Anyone with diabetes who lives in an area where the pump is currently offered can get a 30-day free trial of the pump, just for asking.

What?!

Yes, you read that right, there’s nothing special about me as far as Asante is considered, other than the fact that I have diabetes. Look, even the box I scored says “Trial Kit” on it.


 So by the end of 2014, pretty much no matter where you live, you’ll be able to do what I’m doing. Are they crazy?? Maybe. But whether they are crazy like foxes or crazy like lunatics, only time will tell. One thing is for damn sure, they must be pretty confident that PWDs will love their product.

Now there’s much confusion about where New Mexico is, with many people—and sometimes UPS and FedEx as well—not even realizing that we’re even part of the United States at all. [Special Alert to victims of America’s public education system: we’ve been a state since 1912.] But most people are pretty clear about the fact that New Mexico is definitely not in New England. So how did I get a trial kit? I pulled strings as a high-profile diabetes writer, of course. Actually, I had hoped that Asante would just box one up and send it out to me, but they, or their lawyers, felt the need to train me in person on the device. As I wasn’t planning to be in the Bay Area anytime soon, Asante flew me out for training on their dime. So now I get to the disclaimer: I’m not on the Asante payroll. They are not paying me to write for them, they have no influence over what I write, and they don’t get to see the posts in advance. They see what I’ve said the same moment you do. Asante did cover my travel expenses to their HQ for training, but didn’t provide me with any prostitutes, further proof that un-certified diabetes educators have less clout than doctors.

Hopefully, all of you who read me realize by now that I’m not the kind of person who can be bought off, and certainly not by a quick trip on Southwest Airlines and one night in Sunnyvale, Californian (which you should put on the bottom of your list of places to see in the Golden State). In fact, rather than having any influence, they are probably scared shitless about what I many say about the Snap, given I have a reputation of being hard on diabetes gear.

And frankly, I have no idea what I’m going say. Time will tell, and that’s one of my principles when it comes to gear reviews—it takes time. A new piece of gear is like a new wife, it takes some time to get to know her. Sometimes the honeymoon is wonderful, but it goes downhill from there. Other times, the honeymoon is rough, but you come to love her. I’ve found you need to spend some time with a device to get to know her true personality. I also believe in sharing that journey of discovery in near-real time, sharing my experiences, thoughts, and feelings about the gear as they happen.

Beyond that, we humans are creatures of habit. I find that once we get used to something, either good or bad, we can’t help but compare the new to the old. So when you change insulin pumps, there’s a risk that you’ll be unhappy with the new one simply because it’s different from the old one, even if the old one was stupid. We get used to things and it takes time to shake that off and judge a new piece of gear on its own merits. I find a month is enough time to get to know a piece of gear and forget its predecessor.


Tomorrow: My first impressions



Tuesday, July 16, 2013

So WTF is a Snap?


The Snap is the new-kid-on-the-block insulin pump. It’s also a whole new kind of insulin pump. Which, I guess, means I’d better review the old kinds of insulin pumps to get everyone on the same page.

A traditional insulin pump is the world’s most expensive insulin syringe. It’s a box that holds three days’ worth of insulin and enough computing power to fly three guys to the moon and back half a dozen times. The devices cost thousands ($6-10K) and have a wide range of features that most users never use. That’s the “durable” part. Inside the pump is a short, fat, motor-driven syringe that’s filled with insulin. The syringe, often called a cartridge or reservoir, is connected to thin plastic tubing. The other end of the tubing is connected to a person with diabetes. Every three days or so, you pull out the reservoir and throw it away, along with the tubing. You then must fill a new reservoir, usually by sucking insulin out of an old-fashioned glass vial. The filled reservoir must then be inserted into the pump, new tubing attached and filled with insulin, and you are good to go for another three days.

It isn’t as bad as it sounds.

The pump has only fast acting insulin in it: Apidra, Humalog, or Novolog. The machine covers your basal insulin needs by a slow, constant, automatic drip of fast-acting insulin that can be customized throughout the day to match your body’s needs. When you eat, you tell the pump how much you are going to eat, and the pump crunches the numbers to figure out how much insulin to give you. But it’s no artificial pancreas. A pump is dumber than a stump. It’s the ultimate garbage-in, garbage-out system. If you eat more than you tell it, your blood sugar will go high. If you eat less than you tell it, the pump will over-dose you and you’ll go low.

Still, with some small effort, you can accomplish awesome diabetes control on a pump.

For the longest time, all pumps were like this. Which is to say, tubed. Then a number of years ago the “patch” pump was introduced. The tubing was eliminated, the insulin was moved from the device to a pod that stuck onto the user’s body, and the whole system was controlled with a wireless handheld. Suddenly, we had two types of pump systems to choose from.

Like anything in life, there are ups and downs to the two systems. Insulin pump tubing has an amazing ability to snag on passing doorknobs, and cats just love to wrestle with this most-important of lifelines. While both of these problems were solved with patch pumps, the patches are easily knocked off, are uncomfortably large for some users, and as worthless as a glued-shut Swiss Army knife if you accidently leave your controller on the bathroom countertop in your haste to get away for a romantic weekend at a Five Star resort. Most resorts have got you covered if you forgot your shampoo, razor, deodorant, condoms, or comb. Forget your insulin pump controller? Sorry. Your screwed.

The Snap is a traditional tubed pump, but it’s not like any tubed pump we’ve seen before. First, instead of having a reservoir that needs to be user-filled, it uses prefilled pen cartridges. Second, the electronics dock with a disposable base unit that holds the insulin and has a throwaway motor and power system.

Here are the parts:



The flat thing with the buttons on it is the controller. It’s the brains of the system and the user interface. That’s the part you keep.

The funky plastic part that looks like a miniature version of those big foam fingers fans wave at the Super Bowl is the body. It’s disposable, and holds the insulin penfill and the power supply. It also has the motor that drives the plunger that delivers the insulin. And yes, it too, is disposable. I can’t wait to dissect one of these to see what makes it tick!

And the last item is the infusion set. It’s not a standard infusion set, which means that you can’t use the closet-full of sets left over from your previous pump. But unlike some pump companies who have made proprietary infusion sets to control the market, the Snap set has some unique features that were needed to make the system work.

To put it all together and make a working pump, you slip the penfill into the body, attach the infusion set, snap the controller on, and you’re ready to rock and roll. Is it really that simple? No, of course not. And we’ll go through the whole process together soon. We’ll also talk about all of these parts and pieces in great detail before we are finished, but for now, how does all of this come together? What’s innovative here?

First, by using penfills as pre-loaded insulin reservoirs, the whole process of filling up the pump is dramatically simplified. How simplified? You’ll just have to wait until my next change and I’ll walk you through it. It also dramatically reduces the risk of air bubbles in the system.

Second, because the insulin is in a glass vial rather than in a plastic reservoir, you can carry it around with you a lot longer. Twice as long, in fact. So now, instead of complete site changes hitting you an average of every three days (by the book), you only need to change your insulin and tubing once a week or so. Of course, the body site still needs a fresh cannula every three days, but this dramatically reduces the ongoing headaches of pumping.

Third, your battery or plug days are over, o-v-e-r. The disposable body charges the pump for an insulin run—usually a week, depending on your daily dose requirements. How does that work? Each disposable body has a AAA battery sealed up inside of it that powers the motor and the attached controller. We’ll talk a lot more about this in the future, but for now, all you need to know is that if you are Snapping, your days of carrying spare batteries (or a cord and keeping one eye out for a wall plug or unused USB port on someone’s laptop) are over.

Fourth, the pump has both drop and water-invasion sensors that warn you if the pump sustains a damaging shock (like when it falls out of your underwear at 2 a.m. and smacks into the Saltio tile floor at 122 miles per hour); or sustains internal water damage from being in a bubble bath too long with a pair of identical twin super models. Hey, it could happen.

Fifth, it’s cheaper. Maybe. At least it’s cheaper to get started with. A controller sells for between $600 and $800 bucks, depending on the supplier. That’s about 10% of the cost of a traditional pump. In the long run, since the consumables are more expensive, it can actually cost you more, but depending on how your insurance is set up, it could still easily be the best deal in town.

And finally sixth—and this is getting waaaaaaaaaay ahead of ourselves—for the first fucking time ever, we can choose what method we want the pump to use to calculate our insulin on board (IOB) instead of being forced to use the method the pump company thinks is best for us. That’s just so cool that I had to mention it and I think we should all send “Thank You” cards to Asante for doing this. Mine is in the mail.

As soon as I can find a frickin’ stamp.


Tomorrow: How I snapped-up a Snap


Monday, July 15, 2013

Oh, Snap!


I couldn’t have made this up if I tried: About 15 minutes before the start of the clinic all-staff meeting last month, as our crew was gathering, one of the docs was venting about her changing role in the world of medicine. “I used to actually practice medicine,” she was saying, “You know, actually make people healthier. Now my job is to click. That’s my entire job description. Just to make sure everything gets clicked in the right place and right time.” To illustrate the point, she made mouse clicking gestures with her index finger.

She was complaining about the new burdens of electronic charting. The same ones I vented about in these pages a little while back.

“Well,” said one of my coworkers, helpfully, “I read yesterday that ‘click’ and ‘snap’ are now the two most commonly used words in the English language.”

The lady doc considered this for a moment, her finger still raised in the air, then replied dryly, “I don’t know which is more depressing: My new job description, or that tidbit of information.”

I suppressed a grin behind my coffee cup.

“What does ‘snap’ mean?” asked another staffer. “I’ve never heard it used before.”

There was an embarrassed silence as my peers struggled with the best way to define what’s apparently one of the two most commonly used words in the English language.

Being the resident wordsmith, I stepped into the void. It’s urban slang for ‘Oh shit,’ I said. The New American Oxford English Dictionary according to Wil.

It was about a week later that I arranged to take a test drive of Asante Solutions, Inc.’s new Snap insulin pump. Remembering the conversation about the word ‘snap,’ I wondered what bonehead would name his company’s new insulin pump the “Oh, Shit!” pump. Must’a got his MBA from Waterloo, Trafalgar, or Agincourt U.

Of course, if we delve deeper into the linguistics of snapism, we realize that, just like “oh, shit,” snap is nothing if not flexible. It can be used with a positive or a negative connotation. Consider:

Oh, snap! I left my wallet at the nudie bar. Not that I ever have.

Or…

Oh, snap! This is good whiskey! Not that I ever drink.

And often “snap” is used when making fun of oneself, not unlike Homer Simpson’s forehead-slap and “D’Oh!”

But back to the Snap pump. This being Asante’s opening bid on the American diabetes tech market, I can’t help but wonder, will investors end up saying, “Oh, Snap! I invested in Asante!” Or will they laugh all the way to the bank? Will the device take the diabetes world by storm, like the slang word it’s named after, or will it be another Homer Simpson moment in diabetes tech history?

I’ll let you know in a month, because I’m actually snapping away right now, as I write this, and I’ll keep snapping right on for the next thirty days. Yep. Welcome to another LifeAfterDx in-depth test drive. Over the next month, I’m going to post daily snapshots of life with Snap. At the end of that time, I’ll let you know just what kind of Oh, Snap! we have on our hands.


Tomorrow: What makes a Snap a snap

Saturday, July 06, 2013

Houston we have a problem…





Why does it take us so long to check for the most obvious?