Basal Adjustments

I was asked on FaceBook to explain how I made the adjustment to Arden's overnight basal rates that resulted in the graph above. I'm sorry that it took me so long to write about my (less than technical) process. Here's how I did it...

Somewhere around the second week of overnight lows it became obvious to me that I was dealing with a trend and not an anomaly. Something had changed about her physiology and I was going to have to adjust - basal adjust.

I'm not going to lie, I didn't do any basal testing. I have the procedure around here somewhere, the page or so of directions from Arden's endo that explains how to do basal testing - but I tried a more, let's say, personal approach. Luckily CGM technology lends a distinct advantage and unless we are averting a low, Arden doesn't eat at this time of night so trend graphs are a perfect way to understand where we have too much basal insulin.

I broke out the stupid PC laptop that we had to buy, because the damn device manufacturers refuse to port their software over to OS X (Apple), then I downloaded Arden's DexCom data. It only took a moment to see what time of night that her blood glucose was drifting lower.

Arden's overnight basal rate was .30 per hour, all I did was dial it back to .20 starting one hour prior to when her BG was beginning to fall, not terribly scientific I know. The possibility that this adjustment would be too little or too much wasn't a huge concern, because let's face it, I'm awake anyway.

As you can see in the image above, the slow drift that was beginning around 4 am leveled off nicely. The picture you see here shows that there was room for a little more basal insulin. I waited two more nights to verify that this graph was accurate and then I moved the basal to .25 an hour. That adjustment caused a slight dip and so the next night I staggered the hourly rates .20, .25, .20, things have been golden since.

The reasons that I like handling basal adjustments myself are simple. Waiting until Arden's next endo appointment to discuss this doesn't feel like an option - too long. Continuing to live with lows would have not only taken the rest of the precious little energy that I have left, but also it would leave Arden in danger - not doing that. People living with diabetes will always need to make adjustments like this. Their bodies, like everyone else's, are constantly going through ebbs and flows. My pancreas doesn't secrete the exact same amount of insulin every hour and it makes sense that Arden's pump shouldn't either. Arden's body has needs, ever changing needs - I have to keep up with them.

We all have to be comfortable making decisions like this autonomously at some point. As parents we don't always have the time to call for an army of help and our children's bodies shouldn't have to wait days or weeks for balanced control. Don't get me wrong, I wouldn't make a grand change to Arden's care without our doctor and I don't chase every night that doesn't go perfectly, but basal adjustments when they obviously are needed... We can do that!

If you are going to make basal adjustments please don't forget to write down your old numbers in case you have to switch back. Actually, if you don't already have that information recorded somewhere, take a moment to do that. Write down basal rates, IC ratios, alarm thresholds and all of the other personally inputted data that your pump and glucose monitors retain, just to be safe.

Later this week I'll be talking about Pre-Bolusing, Arden's latest A1c and more... stop back, like Arden's Day on FaceBook or follow the RSS feed to stay in the loop.

Good luck getting those basal rates where they need to be and then enjoy the huge difference in your BGs!

DexCom G4 Platinum: Follow Up

It's been three months since I first gave my impressions of the new DexCom G4 Platinum CGM and two months since I published a Second Look piece. Today it's time for a follow up...

Overall I am quite pleased to say that everything that I previously reported to you about the G4 still stands as true. Signal distance is vastly improved, insertion is less of an issue from a pain standpoint and accuracy is often spot on. What then you ask prompted me to write a follow up? I wanted to share my experience with DexCom customer service and how they handled my call to tell them that the thumb pad on Arden's receiver was breaking.

Before I get to the thumb pad I want say that not long after we began to use the new G4 I noticed an odd video noise on the screen when the receiver transitioned from screen to screen. It happens mostly when entering a BG, a garbled image appears as the receiver switches from one screen to the next. I never noticed a decrease in the receiver's accuracy so I assumed that the video noise wasn't a critical issue and decided not to call CS over what I deemed a cosmetic glitch.

A few weeks later the thumb pad began acting up. The thumb pad is basically five buttons, up, down, left, right and center. The donut shaped disc handles the directional clicks and the small nub in the middle, selects. Our unit's disc began to not go back into place after selecting down. The disc would rock as it should toward the down selection but then never fully return to it's starting point. I felt like it was only a matter of time before the disc became worn further. I imagined that soon instead of just getting stuck in the down position the disc was going to pop out. I let things go for as long as I could and then I called DexCom this past Saturday morning.

I explained that the thumb pad was loose and getting worse. The kind woman on the phone asked politely if I had dropped it, we hadn't. She verified my address, apologized that it wouldn't be able to ship until Monday and explained how I should go about making the switch once the new unit arrived. The entire call took less then five minutes. It was very pleasant.

It seems that I timed my phone call almost perfectly as nine hours later, as we were preparing to eat dinner for the first time at Harold's in Edison, NJ, (you may have seen the picture on FaceBook of Arden with our "slice" of cake) the thumb pad fell out completely. I used a piece of packing tape to hold everthing in place until Tuesday. Here's what the unit looks like when the thumb pad comes off:

 

Initially I wanted to be annoyed that the receiver had issues after such a short time, but instead I took a more reasonable position. New technology is prone to issues like this, early adopters take a risk in my opinion. As long as the manufacturer stands behind the product and doesn't make its replacement a headache, I'm okay with stuff like this happening. I wish it wouldn't, but I understand. I hope that my issue is either isolated or promptly addressed by DexCom. Who knows, maybe it already has been in more recent runs of the product.

If you are seeing this issue with your unit, It's my opinion is that you can expect it to eventually become a problem that will need your attention.

Please Test

I need this post to accomplish two distinct and important goals. The first one will be simple. I want to thank my wife Kelly and my daughter Arden for both being so amazing. You'll see why in just a moment...

Second and maybe more importantly, I want to take this opportunity to remind everyone that while CGM technology is fantastic, it isn't foolproof. Because of that sometimes ignorable fact, we always have to test. Normally when we speak about this topic it's in response to the notion that you shouldn't bolus based on a CGM number. While bolusing without testing is something that we should never do, most of us probably have... but we shouldn't becasue CGM technology is designed to be used in addition to testing, not in place of.

Tonight while I was with my son Cole at his baseball practice (yes I know it's January) Arden's CGM alarmed and reported, "101 arrow straight down". Kelly, being the D-mom rock star that she is, tested.

Please test because sometimes, not often, but sometimes, 101 is actually 36. The DexCom CGM technology is so wonderful that it's easy to forget that it isn't perfect. I've been as guilty as the next person of leaning on it too much when I know that it isn't always spot on. It's difficult not to, especially after the sensor has been on for days and consistently reporting numbers that are so close to our tests. Next time that I'm inclined to think that way, I'm going to remember something that Arden and Kelly told me when I got home and I hope that you will too.

Kelly later said that she tested Arden because Arden said that her eyes "felt funny". Arden told me the next morning that it felt like she had been looking, too long, into a computer screen and then suddenly turned away. "My eyes were getting dark" she told me, with no inclination for how her words were breaking my heart. 

I gave her the bolus a few hours before at dinner that caused this low... and her eyes got dark.

Most moments with type I diabetes are uneventful. Our vigilance gives us the sense that we have the disease under control, but that's a foolish notion. It's only under our control until it decides that it wants to run away. When diabetes decides to run you can't stop it. Your best hope is to chase after and keep it in sight until it gets tired of running. Then you can stand next to it again, pretending that you are partners.

We're vigilant because we can't predict when diabetes will take off running, that's why we test. You aren't taking the test, it isn't you that's being judged. It's a test of diabetes, an indicator for whether diabetes is going to stand next to you and play nice or run away.

Please test.

Pooh. Gilly. Bear.

Arden has been fighting off a cold for the last week and her BGs have been low overnight as a consequence. We've used up more juice boxes this week then in a literal year of overnights prior. I'm beginning to drag a little bit from the experience but Arden, despite her distaste for drinking juice when she isn't thirsty, is taking it all in stride.

I can't seem to avoid these lows, I've tried everything. By the time this story happened I had resolved myself to the fact that we would be dealing with low overnight BGs until her cold passes.

But anyway... last Friday we went to the movies and saw Monsters, Inc. Many hours after the movie ended in the wee hours of the morning, Arden's CGM alarmed and woke me. I checked her DexCom receiver and saw that her BG had fallen well below the low threshold, so I tested. Arden needed to drink a juice.

I was able to wake Arden with very little issue and she began to drink. I held my left hand behind her back at one point because she was having trouble holding herself up. When she finished the juice she handed me the empty box and said, "Thanks poohgully bear". Her words seemed without meaning, I was startled by her jumbled communication. Perhaps her low blood glucose was more severe then the Dex and meter indicated. I was worried that she was becoming incoherent. I asked her, "what did you just say?" and without missing a beat, she smiled and said again, "Thanks poohgully bear". I responded this time, "Arden, I'm sorry but I don't know what poohgully bear means. It sounds to me like you are saying, Pooh Gilly Bear".

"No, not poohgully bear", she said. Then she spoke the words again only slower saying, "Poohgully bear". In this instant Arden and I had slipped into an Abbot and Costello routine. I was sitting on her bedside saying, "pooh gilly bear" and she was responding with words that sounded, to me, exactly like what I was saying. Finally I realized that everything else about our conversation, sans poohgully bear, was very coherent so I stopped worrying that her BG was much lower then indicated. We agreed that I wasn't going to understand her message and we said goodnight. I told ther that she could go to sleep, adding, "I'll be back to check on you in about fifeteen minutes".

Before I walked out, I couldn't help it, I asked one last time "poohgully bear?". Her little voice answered back in the darkness, this time very, very slowly, "pooh gully bear". I laughed and said, "Arden I'm hearing pooh and bear but I just can't make out the middle word... are you saying gilly?" She answered only, "Never mind" and then giggled. I left the room expecting to never know.

Her BG leveled out some time around 3 am...

The next morning Arden and I were making breakfast together while Cole and Kelly slept in. I brought up our conversation because I wanted to know, even though I imagined that she wouldn't remember. "Any idea what 'thanks poohgully bear' means" I asked.

Then Arden said this, "Remember last night we saw Monsters, Inc., it's what Celia calls Mike... poohgully bear".

I laughed so hard that I thought I was going to break a rib and then replied, "do you mean Googley Bear?".

"Oh, is that what she calls him... sounded like Poohgully Bear to me".

We smiled at each other and then I couldn't help but to walk over and gave her a big hug.

Most low BG stories aren't any fun, but this one, this one needed to be shared.

Click the image to hear Celia

Update

on 2013-03-19 01:46 by Scott Benner

My new book, "Life Is Short, Laundry Is Eternal' is available now - Amazon/Kindle - Barnes&Noble/Nook 

Update

on 2013-03-19 01:46 by Scott Benner

My new book, "Life Is Short, Laundry Is Eternal' is available now - Amazon/Kindle - Barnes&Noble/Nook 

DexCom G4 Platinum: Second Look

Arden modeling her G4 tucked into her pocket.

Arden has been wearing the new DexCom G4 Platinum CGM for every second of the last month. I initially wrote a 'First Impressions' piece about three weeks ago - let's see how things have gone since then.

Sensor Life:

The worst kept secret in the DOC is that the DexCom sensors can be restarted at the end of their seven day life and often gain accuracy as the days go on. The package insert indicates that you have to change your sensor site at the end of those seven days, I am in no way suggesting that you should ignore that direction. I'm merely sharing how we do things... Many times in the past the DexCom 7+ would happily restart twice and would still be going strong as the last bit of adhesive was holding on for dear life. So far we haven't gotten a G4 to a second restart, but I'm not giving up on getting one into the three week range. Having said that, two weeks is really very good.

Adhesive:

Not as long lasting as the 7+. The G4 is not weathering showers like that 7+ did even when covered. I wonder if DexCom changed the adhesive, maybe I'll ask.

Form and style:

The reciever is a huge inprovement in both size and shape. I've heard a few call it 'unsturdy' or 'light' but we don't have that feeling. 

The sensor is slightly taller then the last generation. I've asked Arden multiple times if the size change is annoying and she has always answered, "no". Mindful that I don't wear the product I read about what some others have said and I did find a few adults that aren't happy about the increase. Again, Arden is unfazed by the change.

Signal Range:

I have for years been unable to let Arden sleep on the sofa during her sleepovers becasue I wouldn't be able to hear her CGM. Once I even slept on the floor so that she and her friend could 'camp out' in our family room, but that was so uncomfortable that since that day sleepovers are confined to the bedroom. Until last weekend that is. On Saturday night Arden had a friend over to spend the night, she asked just as she always does if they could crash on the sofa, I said yes without hesitation becasue of the G4. Our family room is underneath of our master bedroom and the G4 cruises through walls, floors and ceiling like they aren't there. 

As the parent of a PWD this new feature trumps any other and makes the Platinum a winner in my book. Here is my Instagram picture of Arden's G4 sending a signal through the floor of her bedroom and into our kitchen. Kelly and I were watching 'The Walking Dead' on AMC while Arden slept soundly in her bed. In the past, we would have to pause the show while I ran up and down the stairs like a loon. Now we just listen for the beeps.

@ArdensDay on Instagram

The Sensor Wire:

The insertion of the sensor wire seems less painful but the real win of the wire being smaller is that Arden doesn't seem to notice it under her skin anymore while she is wearing it. It the past with the 7+, Arden would sometimes be bothered by the wire if she moved the wrong way. 

Pound the Alarm:

The alarms on the G4 are louder then the 7+. Additionally, you can vary them if the one you are using ceases to get your attention. So far the default sounds are waking me from my slumber, though Arden never hears them when she is sleeping. DexCom has samples of the alarms on this page of their site (scroll to the bottom), if you'd like to give them a listen. 

Freedom:

With the new signal range comes freedom. In a movie theater I can hold the CGM to give Arden a break. When she gets home she can take it off and roam the house without fear of dropping the signal. Arden sleeps upstairs, we live our life downstairs. I wish you could have heard the lilt in Arden's voice when she gleefully told me, "I just peed without my CGM", she was seriously thrilled that she left her receiver in the kitchen while she used the powder room, thrilled! Connected but frequently untethered is a major advancement in my opinion, it gives back some of Arden's humanity and releases burdens. 

Wrap:

I know of a couple people who have experienced build quality issues, for example Stacey's thumb pad fell off. So far we haven't had any such isues, but be sure that I will tell you if we do. 

I've always been an early adopter of technology that I believe in. I expect a few bumps along the way and take the chance on something new when I think the chance is a good bet. So far, the G4 has been a terrific bet. Wait until you see the signal range and how it changes your life.

Be Well!

Update on 2012-12-03 16:24 by Scott Benner

This post is a follow up to First Impressions: DexCom Platinum G4 which can be found here.