December 16, 2010

Insulin Pumps/Medical Devices and Airport Security

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Passing this on for travelers with pumps:

From :

Insulin Pumps/Medical Devices and Airport Security

We have conducted official testing on the effects of the new full body scanners at airports with Medtronic medical devices. Since the new scanners include X-ray, remove your insulin pump, Guardian monitor, sensor, transmitter, meter and remote (refer to the User Safety section of your device user guide) before going through the scanner.

If you do not wish to remove your Medtronic devices, ask TSA personnel that your medical devices cannot go through the scanner and alternative (pat-down) screening is needed.

As a reminder, it is safe to go through the airport metal detectors with your Medtronic devices.
Taking of CGM Transmitter sounds a lot easier than I think it will be in practice. Good luck travelers.

Editors note:
Sara - Thanks for the comment. I called Dexcom. They don't have a similar press release / statement. They have not done testing. They have not had negative comments from users or staff that have traveled wearing a Dexcom sensor. They pointed out that taking the transmitter off sensor has a fairly good chance of dislodging the sensor wire - YDMV.

Dear Kerri - We used a pumpkin

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 Kerri asks,  "Who learned injections with an orange?" We did and we also used a pumpkin. Here's our first dx story written ages ago for the Thank Shoe Section of BadShoe.com.



Connor was just starting to learn the saxophone. His first public performance was in a school talent show.  I think he played Peter Gun. We went out to dinner, something Connor typically enjoys. 

He had a soda or two, used the rest room and felt crummy. He didn't eat. We figured it was stage fright. The next day he moped around drinking OJ and complaining he didn't feel very well.  So Mrs BadShoe took him to the doctor. They called for some blood work so the next day I took him to Quest for a blood letting first thing. 

They tried and tried to get blood and it took both arm to get what they needed. It was early on a school day but Connor didn't feel up to school. So we put on the Star Wars trilogy (the real originals with Harrison Ford not the stupid prequel movies.) Connor was semi conscious, drinking juice and going to the bathroom. 

I figured that if the doc sent us to Quest it was no big deal and we could wait for the results. Mrs. BadShoe and the doctor's office started feeling otherwise. Finally that afternoon she decided to take Connor to the local hospital ER. His blood sugar was off the chart. He was borderline conscious in DKA. He was shipped out to Children's Hospital of Philadelphia as soon as they could get transport.

So not a whole lot of hours after his first ever saxophone performance Connor was diagnosed diabetic. So it turns out it wasn't nerves about performing that had him feeling funny before hand.

Connor (Mom & Dad) needed some help learning what to do. Melissa was our nurse / trainer when Connor was at CHOP. She was very cool teaching us how to get started with Connor's treatment. She was more than happy to turn over the needle to Kim & I so we could stick it to Connor. She also was very good about helping him learn about what was going on. 
As you can see below, Melissa is the type who enjoys her work. 

Particularly when it is sticking needles into loud children like Connor.

It was a rough time at first. Connor was hooked up to this machine as they put fluids and insulin into him. He later came to mock it, and if you look, you'll see he stuck the pumpkin.

Melissa was very good about helping us not only the mechanics of what we needed to do but also how to go about it with a smile. As Connor picked up his louder than life sense of humor returned and found a happy audience in her. She was serious but not solemn and that was a big help.



Connor awarded her a BadShoe Pin and she went straight to looking at her shoes. Lots of laughs Melissa that is another part of the family web empire and your shoes seemed like you could walk on them all day - you pass.

Thanks Melissa. Melissa is part of the Children's Hospital of Philadelphia Empire. The scope of this operation would put Darth Vader and Emperor Zurg both to same. It is everywhere it is everywhere. I also seems that every where CHOP is it is an outstanding operation.

December 13, 2010

Robin Hood and Diabetes Meter Accuracy

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WARRING:  This may be boring. In fact it may only be the first a series of boring posts. Sorry about that. I’ll do what I can to keep it moving hence all the Robin hood references. I am going to try put it into a larger context of care quality... aka happiness in Sherwood. 

That said parts of this are gonna be as dry as the deserts of the crusades from which Robin returns. Feel free to skip over and see what Kerri is writing about I’m sure it will be more interesting. Come to think of it - I may join you.

Accuracy in the context of quality care to me means the measurements needed to obtain great glucose control - kinda wordy - happiness in Sherwood sounds better. It means testing enough to manage blood sugar levels. It means those test are a good measure of the actual blood glucose. It means there has been education on effectively using the blood data. It means actually acting from that data and education. It means there is good food nutrition information, regular activity and insulin and insulin delivery that is predictable, stable and reliable even if your diabetes is unpredictable, unstable and unreliable.

In short happiness in Sherwood is a myth.

Diabetes care is complex as this bit points out:



The first step in accuracy is to test often enough to get actionable numbers and then to (and this is the really sophisticated part) act on them.  Lee Dubois speaks to the challenges of getting enough strips via medicaid. Even more drastic Jeff Hitchcock points to a Washington State study that suggests that type 1 kids don't need more than one strip a day. 

WilI and Jeff draw attention to the simple fact that access to strips is a critical part of accurately managing blood glucose.  I don’t care if those strips are as spot on as a lab reference Yellow Springs Instrument if there isn’t sufficient number to do the testing needed manage diabetes there can’t be quality care. Robin Hood needs arrows for happiness in Sherwood.

Once a patient has enough strips they need to get results from the meter that contribute to quality care. Many of us in the diabetes world talk about meter accuracy. Those conversations are frequently based on often repeated assertions that amount to whipper down the lane lack instead of being based on a solid underpinning. Accuracy is enough of an issue that the meter companies produce white papers to clarify their accuracy positions. I have read a lot of these. Typically 2 - 4 pages with a few charts and graphs and a bunch of footnotes. Sadly they are typically not the solid underpinning we can base informed conversation on. My view is the papers exist to make users feel comfortable that a given meter is accurate without any actual context. I may not go as far as to say they are Prince John’s minstrels singing his praise but it is a very tempting bit of thematic puffery to toss in - so there it is.

I have however found some good pieces. Thanks Google Scholar. One of the best that I have read is by Barry H. Ginsberg, M.D., Ph.D. (M.D. and Ph.D - that is like Doctor Squared!) Factors Affecting Blood Glucose Monitoring: Sources of Errors in Measurement is a nice little ten page run through the forest of meter accuracy issues. If you are interested in the topic this is a great place to start - unless you are looking for some kind of a score card of which meter is best. It is a great primmer on meter accuracy, it is not a betting form for the big archery competition Prince John is sponsoring. (Hint: Double down on Mysterious Stranger!)

Think of your meter as an archer at that competition. If it shoots a bunch of arrows at the target that are evenly distributed up down left and right, on average it is on mark but not precise.  Said archer it isn’t getting any attention from Maid Marion.

If all the arrows hit a spot all clumped together in the lower right side of the target - well it is precise but not accurate and still not getting any love from yonder fair noble woman.

When Robin Hood... err.. Mysterious Stranger, steps up, his arrows are all smack in the bulls eye, accurate, precise and for show, this is Marion's favor we were talking about - showing off matters, splitting the prior arrow right down the middle.

We want our meters to be Robin Hood. Barry (can I call you Barry? No! Ok... Sorry.) Dr. Ginsburg writes of four specific sources of influence that can throw off our archer’s aim. These source of meter inaccuracy are: variances with the strips, physical factors, patient issues and pharmacological problems. I strongly encourage you to read the good doctor’s paper and not solely trust the woefully inadequate analogies I am about to draw for these four horsemen of error. Here goes and remember these are the Saturday MatinĂ©e version:

Strips: Just as Robin Hood needs some serious quality control in his arrows to shoot straight, strips need to have their component parts straight and true. Strips need the right amount of the magic enzymes, in the right size little lollypop pool for blood and enzymes to react in and the tiny electrodes in the pool need to be the right size too. Olde Robin’s arrows may warp as they get schlepped around the forest so temperature, humidity, altitude, exposure and well you know the drill just about everything can effect the conditions inside that little strip.

Physical Factors: Just as the strip can be influenced physical factors aka temperature, altitude oxygen etc so can the test process itself. Mr. R. Hood has to shoot through the air and that air influences the arrow’s trajectory. Yes altitude and temperature have an effect. Alternative site test when it is cold can see even more of a lag to actual BG than normal condition.

We the Patient: We play a roll in accuracy. The good Doctor squared has a nice little chart that includes the impact of Chips Ahoy residue on BG. That is one of the more humorous thing I have seen in a scholarly discussion of meter accuracy and yes  washing hands has an impact. You think Robin Hood could shoot straight when he had grease from a slab of mutton on his fingers? There is more too, patients can miscode just as the outlaw may mistakenly use a duck feather arrow when he thought he was aiming with a goose feather arrow.  In addition to patient/archer technique a blood check may have variations due to the cellular composition of the victim’s blood. For example the red blood cell count aka hematocrit may be off. That can mess up tests. I am struggling for an analogy to the band of merry men in Sherwood forest for that one - how about: If they haven't poached one of the King’s steers recently they feel a little anemic and can't shoot. I do now I am struggling to understand why my kid’s meter doesn’t read when her hematocrit is off but I know it doesn’t. The honorable Dr suggests a GDH-PQQ or WaveSense meter and we have switched to the former as the later is the one that wasn’t working. 

Pharmacological: In short if Robin is on drugs it may impact his arrow accuracy. Various medications can influence how our meters work.

Strips, physical factors, patients and pharmacology - YDMV.

In summary, and I will be personally shocked if anyone reads this far, accuracy is about facilitating quality care. That means first and foremost sufficient checking done and acting on those checks to inform care.  So checks need to be sufficiently precise to make for quality care. Robin Hood is a myth but a serviceable metaphor for the many things that can make our meters vary. After watching the MatinĂ©e here at YMDV it is a good idea to read something more substantial.

December 8, 2010

Little Help - Can Anemia Mess Up Diabetes Blood Glucose Readings?

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Doh! I feel like Homer Simpson asking that.

Someone out there should probably hit me with dope slap upside the head.  Of course {fill in the blank - including anemia} has an impact on blood sugar. What is the name of this blog again?

How does it mess with meters?

Diabetes plays games and one is to make me feel powerless. This is one of those times and I need a little help.  I am curious does anemia mess up glucose meters? I would love some experianced feed back.

It is more than just the readings - does anemia stop the frogging meter from working at all? Does it make the meter throw off used strips like beads from a Mardi Gras float with nothing to show but error messages?

We use WaveSense Jazz meters at school. Over the past few weeks our school nurse reports increasing instances of meter errors. As in it takes 2-4-6 up to 10 strips to get a reading. This is an experienced nurse and kid with 6+ years since type 1 diagnosis. They have literally thousands of blood test between them. They know the ropes of finger pokes.

The kid had lingering cold. That with exposure to whopping cough led to a doctor visit.  The visit in turn called for a blood draw that showed nothing but low iron. Which in turn led to a more detailed blood test that isn’t back yet.

Meanwhile the nurse is getting a more and more checks that just fail to give a reading. 2-4-6-8-what don't we appreciate? Using boat loads of strips to get a single Meter Readings! Yeah BG!!

Oh and some consistency between readings would be cool too. Three days ago after a bunch of errors the nurse got a BG reading of 22. That seemed suspicious given the circumstances (a word that hear means: a lack of hypo symptoms factored in with prior tests that day, the amount of insulin on board and time since eating.) So being familiar with such circumstances, they tested again. Three minutes and another bunch of strip later the low transformed into a 308. I don’t think anyone wants to confuse a 22 and a 308. Certainly not our nurse. She is tip top.

She called and sensibly but timidly asked for another meter. I love her. No worries I could swap out one from home with fresh strips in minutes. Guess what? - That replacement had the same issues and more the next day.

Could this explains some of the resistance to checking we are seeing at home? Gee I don't know - finger pokes are not that much fun to begin with so yeah maybe having them not work could be frustrating.

So I dragged a Tru2Go ninja meter up to school today when they called (3rd day in a row!). Would a different blood electrochemical process make any difference? Yes - No problems giving a reading, we'll see what tomorrow brings.

Now I for one don’t think a kid should have to poke her finger 5-10 times to get a reading. Also all in all I would prefer not to burn through strips at a rate of 2 to 8 errors for each reading. And lastly and I know this is being really picky of me I would prefer not to see 280 point swings between hypo and hyper in three minutes.

I asked the 800 number if they were aware of any issues. The operator at the call center was sure it is temperature. I know the environment well so I know it isn't about temperature. I called WaveSense directly, they said they 'wanted to support' me in the use of their product but little else.  Nothing about low iron and strip issues. 

I can find academic articles on the subject: Error Rates Resulting From Anemia can be Corrected in Multiple Commonly Used Point-of-Care Glucometers and Anemia causes hypoglycemia in intensive care unit patients due to error in single-channel glucometers: Methods of reducing patient risk.  I guess is a very scholarly, Yes - anemia can mess up numbers. But it isn’t much more helpful than my opening Doh!  

How about any of you out there in the big wild blue yonder of the DOC? Does anyone have experience with low iron and meter errors? If so what did you do about it? (Other than cursing - Kerri says we can’t curse. I may have forgotten that.)

December 3, 2010

Views of Diabetes Online

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Those of use living with diabetes and who connect online see ourselves as a community. Heck we casually toss about the term DOC like anyone has a clue what it means other than the few of us in the club. 

I had the privilege of listening to one of my heroes, Christel Marchand Aprigliano, challenge a few of us in the diabetes blogging community to think about the 95% of the people who could benefit from the Diabetes Online Community who do not even know that community exists. I have been thinking about that challenge ever since.

Today, I saw a Facebook ad that is trying to attract the attention of some part of that 95%.  A part that is a very clearly defined segment of a marketing machine that sees the people looking for diabetes information online as a target. A group to track, refine and package as it “offers pharmaceutical companies an opportunity to develop relationships with individual consumers using sophisticated data-mining tools.” [http://www.democraticmedia.org/files/u1//2010-11-19-FTC-Pharma-Filing.pdf]

You know what? It is OK with me if pharma wants an individual relationship. That is fine. They have an important roll in health care.  I want pharma to be part of the community if they take a seat, join the conversation, listen and participate openly, honestly and with respect.

It is just that I don’t see this ad as open, honest or respectful.
 




What do you think?

Zen and the Connected Type 1 Diabetes Devices Don’t Exist

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I wish they did. I have a radically different view of the technological future of diabetes care. It isn’t as much a Artificial Pancreas as it is a peace treaty between armies of robotic healthcare devices fighting over our data for their proprietary sales gain.

This treaty would make diabetes data available to, and this is the really radical part here, patients. The data will be presented in ways that would facilitate using all the information to help individuals understand how each little bit represents one of the variables that makes any type of diabetes vary.

The treaty would also facilitate patients picking the equipment and using the every day devices they already use to manage their diabetes. Now that may not sound radical but it is the opposite of what happens now. Our every day devices don’t help manage the whole of life with diabetes as our tools don’t share the little bit of information on our lives that they know. In fact they tend to guard our data as a hostage to the continued use of a given device.

I should talk about what prompted this version of my ongoing diabetes information rant. I have a RSS feed for Continua Health. Continua is, in theory, a means of connecting medical devices. Diabetes has been part of the Continua marketing line from its earliest days. Big diabetes firms are part of the Continua Alliance. Diabetes care keeps popping up in the press stories about Continua. Recently Med Gadget had a post about about a health data router for home heath care devices that said “One can imagine this device as being a central control unit for continuous glucose monitors.”

Not if one has ever used a CGM they can’t. Getting past the hurdle that no CGM is bluetooth enabled or Continua certified why would a CGM user want device with less functionality than the CGM’s own receiver? By less I mean less ability to interact like calibrating the CGM. Why would they want to carry Yet Another Device Already. (YADA)

Insulin users carry something to deliver insulin, a pump YADA, a pen YADA , a syringe YADA. They carry a meter YADA. Increasingly folks wear a CGMs YADA. Being normal every day folks they probably carry a cell phone YADA. It sound like a Seinfeld bit - Yada Yada Yada.

In case anyone is wondering those things for the most part don’t talk to each other very well. The solution isn’t Yet Another Device Already. Sadly the trend is to make for more devices and or less choice. Some may say, ‘Our pump displays meter and even CGM readings.” OK but only if we use the proprietary combination of strip meter, CGM and pump. Notice that the marginally usable food database left the pump and went into the meter with one pump so if you want the food data you gotta now carry YADA. Oh and for fun, to get the data out of any device requires proprietary software, running though a special cable, to a desk top PC, running a old operation system you probably don't use anymore.

The solution is that all the devices need to talk a common language. Continua is right about that part. Then the data can be combined to make something that resembles sense. Meter data by itself only has value in as point in time. CGMs are good at stringing those points in time together and making trends. Knowing the amounts of insulin taken would help make sense of those trends as would what was eaten (and a lot of folks enter that into a bolus wizard on their pump.) The data exist it just needs to play nice. Set the information free! Common language is the start of a treaty.

In a glorious world somehow activity, stress, hormone cycles and a partridge in a pear tree. Oh and a button to just reject freak events would be handy too.

The Continua model is data is collected sent to an electronic health record and via some mysterious process (using YADA above) doctors will have the time and be compensated for looking it over and making recommendations. If that happens, and that is one big ass if, I am sure the doctor will be using some kind of data collection device with logic tools that sift out relevant data and trends.

Why not keep that local? People living with diabetes are there own primary diabetes care giver. Cut the loop short. Get the logic into the users' smart phones. The phone they choose to use not some goofy medial phone.

Artificial pancreas fans are saying OK - why not just make the whole thing automatic? Make it all just work without any patient input. My answer is that there is value in knowing. There is value in being cognizant of the implications of what specific choice and events do to the individual. As in, wow that really work well maybe I should try to do that more often or opps that wasn’t so great how can I avoid doing the same thing again or wholly crap six hours after a really physical work out I crash and burn like the Hindenburg.

More awareness of how one live life is better than less. I think that is true on the purely physiological level and that the physical has a big impaction the emotional and spiritual levels too.