The first time I learned about the efforts of the International Diabetes Federation's Life for a Child program, I watched one of their videos where they described what it is like for a child with type 1 diabetes in the developing world.
I cried as I listened to them talk about families being forced to choose between the cost of feeding their 4 non-diabetic children for a month or buying a bottle of insulin for child number 5. Child number 5 does not come out on the winning end.
In many parts of the world, news of a diagnosis like that which my parents received when I was 10 years old also comes with preparation for an inevitable and tragic loss. Most children with type 1 die within the year.
You know, 8 years ago today, my husband met me for our second date with a bouquet of small dried out purple flowers and baby's breath filler. He handed it to me sheepishly and apologized that it was the best the supermarket on the way had to offer. Flowers have never been his strong suit.
This year though, he can save the stress of that supermarket stop. We've chosen to spare the whole dozen. For $60, we are providing the means for ONE child to have ONE year worth of insulin.
Insulin here costs a lot more than that, yes - $150ish a bottle, but because IDF can do a lot with a very little, they aren't asking a lot.
Our contribution is a start, but because there is more than one child out there in need, I'm asking you to search your hearts and take a glance at your bank account and consider whether you've got just a handful of hope to hand someone, too.
1 rose = $5 = 1 month of insulin for that child.
A dozen roses = $60 = 1 year.
Think of the parent who holds their sick, suffering child for the last time, knowing that a bottle of insulin would have saved his life. It makes me heartsick.
Valentine's Day is about LOVE. Not flowers. I choose love.
I'm frequently asked how I have the opportunity to try so many insulin pumps. The answers, briefly, are (1) having an endo who trusts me enough to allow me to experiment, (2) having a husband who will financially support and encourage an "early adopter" mentality, and (3) paying for some of it out-of-pocket so as not to tempt fate with my insurance company.
In this particular case, Asante actually approached me about their 30-day trial in mid-2013 and I had the opportunity to start the trial in November. Because they were soliciting my feedback, they also offered to let me keep the controller portion of the product if I wanted to start using their system. What worked to my benefit was that my insurance covers the monthly supplies and that my endocrinologist was happy to write me the prescriptions I needed. I am Asante's first customer in Texas.
Somewhat related to my decision was that I am being forced onto Humalog in 2014 by Express Scripts International (my insurance plan's Pharmacy Benefit Manager) and Snap is currently Humalog-only (with plans to design a Novolog version), so this was something I felt I could move forward with.
I always have anxiety about switching to a new pump. What if I don't like it? Asante is so confident about their product that they will let you try it for 4 weeks. That really piqued my interest. I tried it and I liked it. And the startup price is so low that, even if they hadn't offered to let me keep a controller, I would have been able to manage the low out-of-pocket costs to switch to the device.
I don't have much more to report about the device than what I reported in my initial review after my first week on it. I felt the same at the end of my trial as then. I really appreciate how little I have to think about the pump itself.
I will echo what Kim said about Snap's lackluster accessories. Much like the Dexcom G4 leather belt holster, I am certain they were designed by and for men. I don't like the options for a case or clip that Snap came with, but I don't usually like belt clips or leather holsters on my pumps (or my phone either). Maybe it's because I don't wear a belt and I often have a kid on my hip that knock those things off.
I prefer drop clip cases that hang from a beltloop and stay out of my way - like the Clip n Go that I used with my Cozmo and the Tallygear G4 case I use for my Dexcom. Fortunately, however, the Tallygear Dexcom case (of which I own three) is perfect for the Snap and I'm loving that I can see the full pump face and control all the buttons without fishing it out (though I do have to remove it to use the handy flashlight). The pump is visible, accessible, yet protected.
I love how quickly I can change out my site and that I don't have to change the tubing unless I'm changing the whole pump body. I just change the site every three days.
And on Day 6, I can change the insulin cartridge and pump body and tubing in under 2 minutes and did it in the dark the other night when I got the low insulin alert before bed.
I love how little I have to carry around with me. I'm carrying a tiny purse that holds my wallet, phone, keys, glucose tabs, meter/strips/lancet, syringe, 3mL pre-filled cartridge, slim pump body, and site. I love tiny purses and women with diabetes never get to carry them! (I was the only 5th grader in my class with an old lady handbag.) And now I have an itty bitty zippered barrel bag.
I don't love being back on Humalog. I'm not going to lie. My highs do seem to drag on for longer. It's not as peppy as Apidra, but it's a battle I was willing to fight only so hard (more on that later). If I'm going to be on an insulin I'm not thrilled about though, I love that I get to use these awesome little 3mL vials and I don't have to worry about compromised insulin or air bubbles and that I get the whole 300+ units from it. I can continue pumping on Snap down to the very final .05u of the vial.
I do like Omnipod still, but it's just never going to be my favorite pump. Its idiosyncrasies are often maddening. I didn't ever experience the frequent pod errors people complain about - on the old or the new versions of the systems, but my occlusion rate was always very high. Maybe once a week. And pods would fall off. Occupational hazard of having little feet climbing all over me, I guess. And the PDM was so often still in my purse or on the kitchen counter when I'd be in bed with a sleeping toddler on my arm and want to bolus. I do like wearing the controls on my person. That's probably the best testimonial for a tubed device. I want it right there with me.
I am optimistic about Snap. I think Asante is a confident and capable new challenger to the existing pump market and I love how responsive they've been to me. I am 10 days in with my new RED controller (thank you for allowing me to exchange for the color I wanted, Asante) and, knock on wood, I'm problem-free.
Well...at least as far as my insulin pump is concerned.
I am currently trying the Asante Snap insulin pump for 4 weeks. (This is going to be a thorough first look, folks. Go potty now.)
Watching their ads, I'd shrugged off their emphasis on how quick the pump is to change and prime in much the same way that I shrugged off Omnipod's "we've got no tubes!" angle. Big whoop. Having worn Omnipod off and on for 5 years, I find tubelessness to be a pleasant feature, but it's not life-altering. What else ya got?, I often ask the companies who tout a single major design innovation.
But Asante may actually be on to something. As I close out my first week on Snap, I am finding that my favorite thing about Snap is how little I have had to mess with it. I'm on Day 6.
No cartridge change (I finish up my 300 units today around dinner time)
No tubing change
No priming
No battery to mess with changing or charging (the controller charges its small backup battery off your disposable pump body battery)
Just a site change so far.
The prefilled 3 mL pen-style cartridge? I got an Rx and a box from my local pharmacy with 5 cartridges. That's about 30 days for me. I'm still on my first one. I haven't touched it. Same pump body (what the cartridge slides into). Because the insulin is not compromised by plastic cartridge or bag chemicals as it can be in other pumps, it sits happily in its original glass vial/cartridge, tucked safely away (I can see it through the viewing window - been missing visibility since switching to tslim and Omnipod), and I don't even have to change my TUBING until the cartridge is empty. Fresh insulin is coming through the tube straight from the sterile vial. (Snap's pump body is currently specifically designed for Humalog cartridges, but Novolog is coming next, they say - it will take designing an alternate pump body due to cartridge length and diameter. So, if you're a Novolog user, you'd order the pump bodies specific to Novolog cartridges.)
Breakdown of the components (3min):
But back to how much they've cut out... I changed my site on my third day. That's it. Just the site on my skin without the tube. That's all I've done. It's still ticking away on day 6. I'll use the last of my 300(+)u cartridge today and change to a fresh pump body/cartridge/tube today.
Snap weighs less than these, but is longer.
Also, I have a ridiculous number of insulin pumps.
I had a really engaging visit to their office and talked at length about what I love and hate about the many pumps I've been fortunate enough to have the opportunity to try.
from left to right: Omnipod UST400, Cozmo 1800, Snap, t:slim
Ken El-Sherif, their VP of marketing, explained Asante's philosophy to me about their wanting to help patients think less about their pumps. I met with Mark Estes, Chief Product Architect, who answered many of my concerns specifically. Who better to ask about design features than the chief designer?
What I loved about the tslim is the carb calculator that totals the carbs as you enter different foods, I'd say. We've got that, said Mark.
Video of me programming a bolus (~2min) while using the carb calc feature:
What I loved about the Cozmo was that it would keep track of missed insulin if I told it I was disconnecting, I said. Snap does that, he showed me. (It doesn't yet prompt you to ask whether you would like to take it. I look forward to future iterations perhaps populating the prompt with the missed basal value and asking if I'd like to take it and then not counting it against my IOB. For now though, it's enough that it tells me I missed 0.3u in the 19 minute shower I took. I likes keeping up with my basal, people.)
I also love that the folks at Asante have developed a relatively simple occlusion detection system where the tubing meets the cartridge rather than relying on back pressure at the infusion site like a traditional pump. Anyone who has had as many occlusions as I have (again, thinking of tslim and Omnipod) can appreciate detection earlier in the delivery process. This is a huge selling point for me. I want to know that the pump detects that it can't deliver insulin - not that it may or may not have partially delivered what I asked it to before it realized something was amiss.
An interesting feature for those moving to Snap from other pumps is that Snap calculates your IOB however you and your healthcare team prefer. Do you like the Minimed/old Omnipod model for IOB where only correction insulin is considered? Done. Prefer the Animas/Cozmo/Tandem/new Omnipod way of including your mealtime insulin? Done. It's in the pump settings.
In many ways, the menus feel Medtronic-esque. As I haven't been on an MDT pump in 6 years, I find myself thinking, where would ___ be on a Paradigm? And there it is. I had been enjoying more screen since leaving Medtronic for Cozmo/Omnipod/Tslim, but Snap uses their small screen efficiently. It's clear to read, low resolution (my husband explains to me that this saves their device a ton in battery), and I can read it fine in broad daylight. Still, the low res screen is NOT sexy. And the colors of the controller (currently dark blue, black, or a light red) don't excite me either. I'm told some brighter colors are coming our way (green, magenta, etc). I've done a decade on black pumps. Give me something that will whistle back at my pink Dexcom.
Hey girl, did your standard deviation fall from heaven or do you just have great control?
Speaking of playing nicely with integration, it's in the future, as with all their competitors. The graph screen that is currently kind of useless - overwhelming with symbology and axis information that I'm likely never to access - is a great placeholder for integrated CGM data. On the software side, they are first focusing on programs that clinicians will use to upload data in an office setting - programs like Diasend. I'm hoping that they make good on their talk of interoperability so that patients can find software that will provide useful data and, more importantly, be user friendly.
Graph of...monster teeth?
The pump is indeed feature rich in terms of operations and doesn't lack any smart pump features that I can think of beyond perhaps bolus/temp basal presets. It's also operable, however, for people who might want much less in a pump. Since you can choose to have the shortcut key function operate EITHER an audio bolus or prompt your "smart bolus" (bolus wizard), it seems designed for either the crazy calculators like myself or the set-dose brand-new-to-pump crowd. You can choose to bypass smart bolus (bolus wizard/calculator) capabilities and just do a "now bolus," too. But I was able to easily run a combo bolus for my correction plus BBQ burger and fatty onion rings (over a 3 hour period) the other night and also still layer a now bolus during its run to accommodate something else I ate. I think the hardest part for me so far is remembering each company's fancy term for their boluses (now/timed/combo vs standard/square/dual wave vs...).
I've grown accustomed in the last year to having my IOB in my face. Tslim and Omnipod both show you IOB on your startup screen as soon as you wake the pump and respond to the key sequence or confirmation screen, respectively. I'd like to see Snap's IOB more obvious. I have to wake the pump from blank screen (just like with other pumps) but then click status and then click one more screen (screen 2 pictured below) to see my IOB. If they could cut that by a button press or two, I'd be happy.
Taking you through the status screens.
Since I have been trying to log my data more (using MySugr), I find myself using the logbook screens often as I go back and add my recent temp basal or boluses to my app. The logbook doesn't currently remember your position if it times out. I'm hoping they can extend the timeout screen for this feature. I'm a slow data entry monkey. A data entry...panda.
Temp basaling is easy. No, it doesn't have presets (also no bolus or carb presets). It uses a positive percentage method for temp basal and calculates and presents what the rate is actually changed to. If I go in knowing that I want to run approximately 30% of my .95u/hr basal, I can make changes down to .05u, so it allows me to choose values like 37% (.35u) or 32% (.30u) or 26% (.25u). On my status screen, I can see time remaining. To cancel the temp basal, I go back into the basal menu. (I keep wanting to find it in the stop menu.)
I really like the alerts that Snap offers. My favorite is that, if you turn on BG prompt in your setup, it will ask you if you'd like to be prompted to check BG in the time you chose when setting up the device. Unlike what I remember with Minimed or Cozmo, it won't just automatically remind you at the ___ hours past bolus mark every single time you bolus. If I'm correcting a fasting in the morning and plan to bolus for my breakfast about an hour later, I don't need a prompt for three hours from now. At lunch however, a reminder to check in post-meal during that long stretch of afternoon is handy. So I can just click yes or no when it asks if I'd like a reminder. Too annoying? You can turn the feature off entirely.
Key beep volume is adjustable, alert tones are pleasant and designed to be heard in a range of frequencies. Innovation alert: The pump will actually alert you if it detects that it has suffered damage from a drop, from water seeping into the housing, or if the controller and pump body are separated. Also, expect a persistent (and growing in volume) alarm if the cartridge is empty.
And if you need a replacement controller (the non disposable portion), you can save an old pump body and instantly program your new controller with ALL of your settings just by - yeah, you guessed it - "snapping" it on.
Snapped and Unsnapped.
Waterproof? Always a big question. It's accidental dunk proof, but not recommended for submersion. With my tslim, I never felt comfortable taking it in the water. Cozmo, I've showered with, but honestly, it's my personal preference to disconnect. I lost a pod in the ocean in the Bahamas on our cruise in October and remembered why it's nice to have my pump tucked safely away in a beach bag or cooler.
Bren Kern, Asante's Director of Manufacturing, gave me a tour of the rooms with the gadgetry where people smarter than I put the devices through extreme conditions and make adjustments. I saw their production lines, their post-production testing area, and from a distance, their sterile areas for assembling their infusion sets (6 or 9mm cannula, short or long length tubing, angled or straight insertion options). I'm a 9mm, short tube, straight set girl. (And I like my coffee with Splenda and cream.) They make all the parts in house and ship through their distributors.
Oh, and it has a flashlight on it! Its purpose is to illuminate the infusion set to see that the pump indeed primed itself in the time it takes to screw on the cap. But it's also good for finding lost toys under my nightstand.
As you can see by now, I will try any pump. And I will try to find what I don't like about it. So far, what I dislike the most about Snap is that there is no quick way to put the pump back into its offscreen/sleep/blank screen position. If I've followed a menu series down a rabbit hole, I might have to click exit, exit, exit, exit to turn off the screen to slip it back in my pocket/the leather case/the belt holster.
Leather Holster vs Pump Clip - both w/ vertical/horizontal options
That reminded me of Medtronic - Act and Esc. While the tslim frequently put itself to sleep even when I didn't perform the double tap that turned off the screen (way too sensitive, I pressed once, I swear!), and Omnipod's power button is buried under 12 feet of plastic (why you be so hard to press, Omnipod?), I do love the buttons on this device. Punchy and plastic like my microwave display panel. A little like Verio IQ. Responsive. And re-assigned according to the on-screen menus like the Omnipod where they have different functions depending on where you are. The left and right buttons either scroll you through menus or +/- your BG/carb/dose values as necessary. The three horizontal buttons usually offer some kind of Act/Esc yes/no select/back binary option unless the far left button is needed for a third feature. They don't have the hardness of Cozmo buttons or the great rubber buttons of the Animas, but they scroll quickly, stop on a dime, and feel good. (I think about buttons a lot. Do you know how many freaking buttons I press in a day?)
Snap and the One Touch Verio IQ
What I like best may very well be the ease of changing that I poopooed. Break out the pump body, snap a cartridge in, screw on the cap, and boom, your pump is already primed. No fill needles, no cartridges, no priming.
Cartridge change procedure explained (42sec):
Low profile packaging (unlike Tandem and Medtronic) means less to carry, too. And a tiny glass vial that I can easily draw from with a syringe in an emergency? Again, awesome.
All you'd carry with you would be a spare cartridge,
spare set, & spare pump body (clockwise at 12, 1, and 2).
I'm going to enjoy finishing out my trial of this device (probably 24 days all told with my insulin usage). I think this company is doing some innovative things with design and certainly breaking me out of my paradigms (pun intended) about pumping with asking me to do so little to keep it up and running. They also don't want to make customers wait for their newest/latest/greatest. If they improve the pump controller (the only non-disposable part) or update the software or offer a bold new color, it's $99 to get whatever the new version is. (That's a philosophy that ought to please still-angry Podders.) It's also a very low startup cost with higher supply refill costs, much like Omnipod.
I plan to subject Snap to Thanksgiving dinner on Thursday. Oh the boluses. I bet that 300u cartridge of Humalog runs out sooner next week than it did this. :)
If you're interested in doing a trial like I'm doing, it's as simple as going onto their website and filling out a trial request.
Sometimes the pieces fall in front of you in a way that shapes your path.
Being a sedentary adult had nothing to do with my diagnosis as a child with Type 1 Diabetes of course, but diabetes with the accompanying fears of hypoglycemia and the stress of managing glycemic control during exercise has everything to do with my being a sedentary adult.
The Diabetes Hands Foundation's community TuDiabetes.org helped me understand that I was not the only one struggling with my diabetes when I joined the social network in 2008 and has much to do with my two successful pregnancies and my outlook on diabetes today.
DHF's program Diabetes Advocates has allowed me to become a voice for patients and those touched by diabetes, and my blog Sweetly Voiced has allowed me to extend my reach and tell my story.
But something has been missing. I've still been afraid of exercise. I make a lot of excuses. I am afraid to do it alone, clueless as to how to accomplish being active while caring for two kids under the age of 4 at home alone all day, and always confused about how to manage the delicate balance of insulin and activity.
DHF has another program though - the Big Blue Test - which has proven to me that just a FEW minutes of activity can lower my blood sugar. Type 1 diabetes is incredibly challenging, sure, but if I could take a little less insulin, I'd have fewer hypo excursions. And if I could make my body just a little more efficient, I could have fewer hyper excursions. Just a little.
For the next 5 weeks, I commit to walking 10 MILES a week. Though it will likely be a well-worn route to and from a local park with my little ones, it will be an emotional journey, a physical challenge as I avoid hypoglycemia (while pushing a double stroller) and as I learn what does and doesn't work in my planning, and it will be the very first time I've done something else - ask for your support. Yes, you.
As I walk these 50 miles, I'm asking my friends, family, and acquaintances to help me reach my goal of raising $1,000 for the Diabetes Hands Foundation. For every dollar I raise, that's another dollar that we at the Foundation can put toward reaching more people who used to be like I was, helping more people who are just like me, and amplifying the efforts of those who are committed to making the world a better place for people who are struggling.
Will you help me put some miles on these bad boys?
When you have type 1 diabetes and your blood sugars run high for a short period for no discernible reason, you have a checklist of troubleshooting tasks you have to tend to:
Am I sick? Getting sick?
Am I taking a medication?
Am I stressed?
Am I more sedentary than usual?
Did I overtreat a low blood sugar?
Did I underestimate the dose I last took?
Did I forget to initiate that dose?
Did I even receive the dose I initiated?
Is my pump malfunctioning?
Is my cannula (catheter) kinked?
Is my tissue at that site not absorbing the insulin?
Do I have an infected site?
Did my insulin go bad?
If it did go bad, is the whole glass vial spoiled or did it go bad in the pump cartridge?
Are these my unlucky socks?
It's a ridiculous list. And there are times when you run through each point and find half of them that could be the culprit.
I removed this insulin from this pod, but which of them was the culprit? I'll never know.
I propose that insulin manufacturers consider providing us with some kind of control solution or litmus test to evaluate the efficacy of our insulin.
It would be so easy to prime a drop or two from my pump onto a strip and see evidence that my cartridge insulin was compromised. It would be so easy to draw up a small amount from the glass vial and test it against a control that would allow me to see that I need to open a brand new vial.
They're all essentially wrong. My plasma glucose was 104.
And they're mostly within FDA's acceptable variance range. The one on the far left was -22% off, but the other four performed within the +/-20% allowance.
Meter companies and the FDA worked together to set these (arguably loose) standards. And they're thankfully petitioning for tighter standards (+/-15%) in line with international recommendations. The PROBLEM is:
1) More than 25% of blood glucose meters already fail to meet current standards.
2) There is no post-market regulation of these meters or their strips. Once released into the wild, subject to weather or age or drug interactions or, I don't know, Tuesdays, there's no one checking to see if they continue to meet standards.
3) New Medicare laws will bring low-cost, low-quality meters and strips to millions of people with diabetes. Without a regulatory process in place, people will get hurt.
4) I take a different amount of insulin depending on that number. Not enough insulin can kill me. Too much insulin can kill me. I play Russian Roulette every time I take my dosage. In the above example, I was about to drive a car. On a highway. I had to make a decision about taking insulin for the 124 or eating a snack for the 82 before I got behind the wheel. It's the kind of decision I make 6-8 times per day and I'm usually basing it on that number.
Okay, I'm not a lumberjack. Because I'm in no way, shape, or form...a logger.
As patients, we're constantly scolded for showing up to doctor's appointments without logs. We're accused of being too far removed from our data. It's assumed that we don't log because we're not paying attention. We're not thinking about our diabetes. We're not doing our part. We don't take this seriously.
Yesterday, as I was changing my pod due to an occlusion that resulted from slamming my pod arm against a door frame two hours prior, I realized why I don't log. I realized why I can't find a logging app that I like. I realized why I can't even create a form I like even with my mad spreadsheet skillz.
There is just too much to log.
Whenever I've tried to create a form with the fields I think I need, I feel fairly satisfied until the first time I find information I need to log that I can't fit into a tidy space.
I've often said of Omnipod users that you hear from us only when there is a problem.
This is why you haven't heard from me about the new system in the last month.
It's awesome.
The pods are so lightweight and unobtrusive that, twice, I've put a new pod on and accidentally worn the old pod on my arm an additional three days without noticing. I've had to run diagnostic checks just to see which pod is active because the adhesive holds so well that I can't remember which one is where.
I haven't had an error, a kink, a misfire, an unexplained high...or anything.
My numbers are excellent. My 7-day, 14-day, and 30-day BGs according to my Dexcom graphs are 123, 128, and 130, respectively. My standard deviation is in the mid-50s.
Today's Prompt: Learning. Share something you learned from another Health Activist (that everyone should know!).
First of all, I am not a licensed medical professional. I'm not trained to give advice on anyone's diabetes but my own.
That being said, I want to share a revelation that I picked up online that changed the course of my diabetes. It changed my blood sugar spikes. It lowered my A1c. I credit this piece of advice more than any other in getting my body ready for pregnancy. It changed everything.
It matters when you take your insulin.
Online we call it pre-bolusing.
The last few years, continuous monitoring has taught medical professionals a lot about how insulin works in the body. When the newest fast-acting analogs came to market, we were told we could take them right on top of meals. When my doctor started me on Apidra just after it was approved by FDA, we thought it would help me because I usually bolused after meals and this insulin would supposedly accommodate that habit.
Fast-forward to the days of continuous monitoring.
We now know that the "fast" insulins are not as fast as we thought. When taken on top of (or worse, after, meals), Humalog/Novolog/Apidra miss the post-prandial (post-meal) spike entirely. They should be taken earlier. I won't give advice on how early, as I think it can vary from person to person, but I know how many minutes before the first bite of food works for me at most meals.
The pushback I get from most people when I suggest pre-bolusing involves one of the next two arguments: 1) But what if I go low before the meal? and 2) But who knows how much little Timmy will eat? It's easier to bolus afterward.
Today's Prompt: Sharing Resources. Create a “care page” – a list of your best resources that someone who is newly diagnosed could go to when starting to advocate for themselves or a loved one. Remember to include sites that lead to successful self advocacy!
I could tell you all about advocacy resources…or I could tell you a funny story and still manage to throw in some truths about advocacy.
We all know what I'd rather do.
Being an advocate doesn't have to be anything grand. The first time you speak up for yourself or your loved one, you've joined the ranks of advocate.
For a person with diabetes, maybe it's when you asked your well-meaning relative to stop policing your dinner plate. Maybe it was when you stood up to your boss because he told you to get back to work when you were taking a minute to check your blood glucose and treat a low. Maybe it was when you told that rep with the insurance company that you absolutely needed more test strips than 4 per day and that she should honor your physician's orders.
It starts small. But it starts. It has to.
As I've said before in a post on resources for workplace rights, I like to think of myself as an advocate for the next person you'll meet with diabetes. If I conduct myself responsibly and prove that diabetes doesn't stop me, you'll think twice before you size someone up on the basis of their diabetes. You'll be more understanding to your employee with a child with diabetes. You'll consider dating that guy with diabetes.
But...sometimes it's easier to slide back down that patient activation scale and just take care of your own.
Since many people are curious about the additional confirmation screens on the Omnipod, I thought I would post a video and a few screen shots of said screens.
Video of a Blood Glucose check and Meal Bolus on the new Omnipod system:
I started today on the newest Omnipod Insulin Management System, the UST400. (For an update on how I'm doing on the new system after one month, click here.)
For those following my ongoing pump parade, I had left Omnipod last year after over 3 years on their UST200 PDM and original pods because I was frustrated with kinked cannulas and occlusions. From there, I jumped back and forth between my out of warranty backup pump (the Cozmo 1800) and my brand new shiny Tandem tslim (that hasn't worked out for me).
And through a strange set of circumstances, I found myself back at Insulet's door just weeks after their new, smaller Omnipod system had been released. Right as my original Omnipod system warranty expired. Right time, right place, and hopefully an improved user experience.
I started pumping on the Tandem t:slim in October 2012, less than six months ago. Let me begin this post by saying that I consider myself extremely fortunate to have access to expensive medical devices like touchscreen insulin pumps. Not everyone is so lucky and not everyone has good insurance.
My endo reminded me today with a smile at my quarterly checkup that I had begged her to let me try this pump. I had high hopes. So it is with frustration, embarrassment, and a heavy heart that I put this pump back on the shelf.
I loved the innovation. Loved the employees with whom I have interfaced. Loved their responsive customer service. I won't tell you not to get this pump. I hope your experience is incredible.
It was not the right choice for me.
I've blogged here regarding the fact that Apidra insulin cannot be used in the t:slim. Cannot. Be. Used.
When I last blogged, I stated that I would be trying Apidra on a 48-hour rotation to see if I could have a functioning pump for that short of a cartridge lifespan. By hour 30, my blood sugar had skyrocketed. By hour 37, my insulin was spoiled. Cloudy. Gray.
There's a phrase in German for when you can't pick between two people you love - "zwischen zwei Stülen" or between two chairs, meaning that you have to pick a seat if you're going to sit down.
I'm in a room of empty chairs.
I love my old, use-it-when-I'm-frustrated-with-everything-else-in-my-life, 100% dependable, out of warranty Cozmo insulin pump. They're out of business now. I have been wanting to move on. She's been there for me. When I first got my A1c into the 6s. At the end of two pregnancies when my Omnipod couldn't hold enough insulin. She's my ugly little workhorse and I love her, but being out of warranty, I'd really prefer her to be my safety school. Not my primary path.
UPDATE: Please see updated information at the end of this post. I think that I misunderstood the tubing interior. While what I state here about Apidra being the cause of my occlusions is likely still true, as I've not had a single occlusion in the 2 months I've now used a different insulin (Humalog), I do not believe now that what I pulled out of my tubing was solidified insulin...
I started on the Tandem t:slim insulin pump in October, a little over 8 weeks ago. In that time, I've experienced an alarmingly unusual number of occlusions - blockages somewhere in the insulin delivery that causes the pump to alert the user with an alarm. From my third cartridge to now, I would say it has been 1-2 out of every 3 cartridges that I've had to change early.
All of these occlusions have resulted in extremely high blood sugars for a number of hours while I troubleshoot the problem, change everything out, and take a manual injection of insulin.
Two of these occlusions have happened while I was sleeping. The alarm did not wake me. I woke up a couple hours after the pump detected the problem, so several hours after the problem probably began, and only because I was feeling very sick. A high blood sugar makes me feel nauseous, sluggish, sleepy, unreasonably angry (rage hormones, cortisol), and very thirsty.
Anyway, like a good PWD, I've attempted to isolate the problem. I have spoken with the same two people in Tandem's (impressive) customer service on at least a weekly basis. I've spoken with my diabetes educator over the phone.
I changed cartridge and infusion set lots. It wasn't the cartridges or the infusion sets.
Tandem offered to send a new pump. I accepted. Three cartridges of insulin later, two of those three had occluded. It wasn't a faulty pump.
Tandem Tandems
That leaves one possibility - the insulin. It couldn't be the insulin, I thought. I've used Apidra fast-acting insulin since 2005. I've used it in pumps from Medtronic, Cozmo, and Omnipod. It couldn't be the insulin.
Now, there are plenty of anecdotal reports that Apidra seems to become ineffective on the third day in a pump. And any insulin begins to break down after it's removed from the glass vial. Apidra has never been problematic for me. Or at least I've never been able to blame any third day highs on bad Apidra. Apidra is technically contraindicated in pumps for over 48 hours, yet I've always gotten 72-80 hours out of a reservoir. Most people report no issues, so I've always just proceeded with cautious optimism.
from http://www.apidra.com/faqs.aspx
The representative from Tandem's Customer Service told me that the t:slim was tested and approved specifically for use with Humalog and Novolog, and, while preliminary testing with Apidra showed no concerns, the majority of calls he personally was receiving regarding frequent occlusions all seemed to involve Apidra users. And diabetes blogger Sarah from Sugabetic mentioned to me on Twitter that she had heard people reporting Apidra turning to gel in the t:slim.
So, I had to get a-cutting. I split my occluded tubing from yesterday with a pair of scissors to find this crystalline substance inside it.
That's not part of the tubing. That's Apidra.* - please see update below
Alas, something about the t:slim cartridge and micro delivery chamber seems to age my Apidra to the point of a hardened substance. Like a pliable thread.
A piece of split, unused tubing looks like this:
sliced in half
My tubing looked like this, with an interior thread:
I've bent the tubing halves down like on an ear of corn.
So is this a piece of insulin in my hand? A PIECE OF INSULIN?*
I took great relish in taking a hammer to the opaque cartridge to get a glimpse at the interior reservoir bag. Upon impact, liquid insulin splashed all over my hands. This is what the bag looks like:
t:slim cartridge interior
The bag still has liquid in it, which at least verifies that it's a process occurring - insulin slowly turning to crystal as it moves through the system.* Perhaps it's aged by the materials with which it has come into contact. Perhaps it experiences some kind of catalyst from pressure in the microchamber. I don't know. I'm a shoddy scientist.
At the urging of Tandem customer service, I am switching to another insulin effective immediately. My CDE (diabetes educator) gave me a bottle of Humalog and a bottle of Novolog to try. I started with Humalog (an insulin I took from 1998 through 2005 and am familiar with). I've never tried Novolog, but I'll give it a go next. I don't expect them to differ.
The 3 Fast-Acting Insulins
I am just still in shock. I didn't think it could be the Apidra.
UPDATE: I have some facts wrong and need to issue a retraction. After cutting through additional tubing - both empty and with Humalog insulin inside it, I can state that the thread I saw is NOT crystallized Apidra as I originally believed. Inset tubing DOES INDEED seem to have an interior tubing piece that may be what I was seeing and pulling out. I had originally believed that inset tubing wasn't double-walled, but other pieces of tubing have proven that it depends on how one cuts the tubing. I apologize for the confusion I caused!
I was disconnected for longer than I intended this morning (forgot to reconnect after my shower), so I checked my blood sugar and took a correction bolus. And I did it all on video. Spooooky.
Okay, not spooky. But it's Halloween and I had to acknowledge it. What will be spooky is my post-trick-or-treating-barbecue-feasting-with-friends blood sugar tonight.
UPDATE: I am no longer using the t:slim pump. It wasn't the right choice for me after all. I had issues as an Apidra user and had concerns about inconsistent basal delivery and worsening control. I understand I'm part of a small but significant group who had trouble, but Tandem is listening to the handful of us with problems and hopes to resolve them. Anyway, here was my initial review.
I started pumping this week with the new t:slim insulin pump from Tandem Diabetes Care. I have been watching and waiting for this pump to come to market for years and can hardly believe it's ticking away on my waistband as I type this.
This is not me typing this.
Many of you have been asking me how the t:slim compares to the pumps I've used in the past.
Here is the t:slim pictured with the three pumps I still have in my possession: the Omnipod first generation PDM, the Omnipod UST200 PDM, and the Deltec Cozmo 1800 (my 3 Medtronic pumps went the way of trade-ins). It's slimmer than any pump I've used before - about half again as thick as my iPhone 4S in its Speck case. Not THAT much slimmer than a Medtronic or Animas pump, but still thinner. (I compared it to my student's Paradigm and it was only barely so.)
I know - he's delicious.
My favorite part so far is that they moved the luer lock connection further down the tubing so that there is no stress on the tubing where it connects to the cartridge. I've had a baby or a toddler on my hip for the last couple years. When wearing a tubed pump, I frequently poke them with the luer lock cartridge port on my Cozmo. Not now. Clearance for those yummy chubby thighs.
Insets, IV prep, Verio IQ, cartridges/syringes/needles
t:slim box, charging cable, adaptors, cartridge remover keyrings,,
and the user guide is a business card thingy w/ USB input - wow.
The supplies take up more room in my meter case than I'd like. Your set change and cartridge implements are essentially in four separately wrapped pieces - 1) whatever infusion set you choose (I'm using the Animas inset, my favorite), 2) a flat black cartridge, 3) a fill syringe, and 4) a capped needle similar to the Omnipod fill needle. They package the latter 3 implements in one small black and white box, so that's nice. I just have to make sure I grab one of each item. Consolidation would have been nice.
I am always critical of pump clips and the t:slim delivers nicely on that point. A swivel belt clip with a soft felt lining to help the cased pump slide in and out. I'm looking forward to the t:clip, too - a case+clip in bright colors being developed by Myabetic.
Charging Cables and Assorted Tech Gear
Charging cables. I have a bone to pick with Tandem about charging cables. The t:slim's revolutionary lithium polymer battery requires a charge once every 7 days and does well if topped off for 10-15min every day. They send you a USB wall charger and a USB car charging adaptor (for a cigarette lighter) - and only one cable. One.
Luckily, I keep a spare micro-USB cable in my car for my husband's Samsung Galaxy series phone and it easily topped the battery off while I was driving today. But why send only one cable? Isn't the point of having the car adaptor in case I need to charge it on the go? Do they really want me lugging a cable around in my supply case or my purse? Have you seen what I do to headphones?
Thank you, Samsung. Apple, why you gotta be so proprietary?
Touchscreen. Oh my heavens, it's lovely. The glass and the colors (which denote different information types and whether or not it's a value that can be changed by the user) are crisp. It's not exactly like using an iPhone, but you can quickly adapt to the required pressure for button pressing. The touchscreen input means that you can pair it with any blood glucose meter you prefer to use. No scrolling up and down to input blood sugar values. Just a quick keypad input for BG and for carbs.
Touch me.
Carb calculator. This was the feature that surprised and stupefied me. There is a calculator for inputting your mealtime carbs. Sandwich was 28 and chips 17? No problem. Press "28 + 17 =" and hit Done. I'll never do addition again.
6th grade math teacher: You're not going to have a calculator
on you everywhere you go. Ah, how far we've come.
I LOVE that they have delivered on a failsafe for insulin overdose. There is essentially a holding chamber that they call a micro-delivery chamber in the cartridge that can hold less than a unit of insulin at a time. You're not ever at risk of a pin or plunger suddenly delivering the entire contents of your 300-unit reservoir into your body. Whew.
Loading the cartridge. There are three little idiosyncrasies about the way you fill the cartridge and tubing for the t:slim. 1) The cartridge is inserted before you fill it with insulin. 2) The fill syringe needle is very long, yet only the very tip of the syringe is inserted into the fill port. You feel a little pressure and stop. How many people will break a needle attempting to jam the whole thing into the fill port? Very odd. 3) When priming insulin into your infusion set tubing of choice, prepare for a wait. I'm a 23" tubing length user myself (short length) and in the time it took to fill the tubing completely, I could have gotten up and made myself a cup of coffee. Or gone to check the mail. It takes that long. Hmph. Update: I timed a prime and it came in just under 02:30. =\
So much makes SENSE about the way this pump works. If you time-out on a screen and go back into the pump, it remembers what screen you were on. It pulled the best features from the Cozmo pump (a site change reminder every three days, a missed meal bolus reminder) and the large reservoir capacity previously offered only by Cozmo and Medtronic.
The best feature, hands down, of the t:slim is the way it presents your settings to you.
With the other pumps currently on the market, the user is able to set multiple basal insulin profiles (for work, for weekends, for differently scheduled school days, etc), but you can't create multiple profiles for your correction factors, your insulin:carb ratios, or your target blood sugars. Those are stuck. When I was preparing to go into the hospital to give birth to Dibbs, I could quickly switch to a post-partum basal profile, but I had to go in by hand and change all of my settings in the other screens.
The other pumps split this data into multiple screens, embedded in different areas in the pump.
Omnipod
Cozmo
On the t:slim, it's all in one place. One place. ONE SCREEN EVEN. I can create (and even duplicate and then edit) profiles that are displayed based on time of day. I can look at a glance and see if my correction factor may be overcompensating for my basal rate being off. It's all in one location.
These settings were set by my Evil Genius CDE in regard to my
personal blood glucose trends. Please do not make adjustments
to your regimen without consulting your physician.
From the lock screen, I can see the time, date, battery life, insulin volume, and my insulin-on-board amount and time remaining.
Easy as 1, 2, 3.
And if I go into my History and click Delivery Summary, I can even get a visual breakdown of my usage for the day or over different specified periods (7 days, 14 days, etc).
Rock me, Amadeus.
This baby seems to have it all. I'm excited to see where this company is headed with their future iterations of the t:slim and I'm thrilled to have another competitor enter the market to push their rival companies to keep innovating for the end user.
I have consistently said two statements over the years when talking to people with diabetes about our available choices in regard to insulin pumps: "There is not a bad pump out there; they all get the job done." And "No one pump has everything I'm looking for."
I'm optimistic that I might be able to stop saying the latter.
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