Novolog

Housekeeping

002Sure T Insulin at Connector Site002

Before I publish a lengthy manifesto on the pros and cons of insulin pumping versus injections in regards to my recent switch over to shots, there are a few long overdue housekeeping details that I would like to highlight for those interested.

1.)  Meeting of the Diabetes Minds

Around Halloween, I had a big appointment with an insulin pump representative and my nurse.  My doctor also sat in during her lunch break.  I know that it was around Halloween because I brought a bag full of insulin pump supplies as well as Halloween cupcakes coated in frosting (see above) as sustenance for those who were kindhearted enough to meet with me on their free time.  So, it was a meeting of the multifaceted diabetes minds, fueled by large amounts of sugar for those with properly-functioning pancreases.

We went through every scenario, including a live insulin pump site change.  They all nodded their heads in agreement when I showed them how Humalog bubbled up quickly in the reservoir.  We were all baffled as to why the Sure T infusion sets continued to pool insulin at the connector site.  And so on.  Basically, we knew there were problems, and we had to try to tackle them each individually.

2.)  Sure T infusion sets

Regarding the Sure T, I have said it before and I will continue to say it: I like Medtronic.  Their pump rep nurses were as gentle as possible when we did the “human pincushion” trial and error game of inserting into different sites during appointments over the past two years.  Those days were not easy for any of us, on a mental and physical level, but their confident reassurance that it was going to be okay is something that I will always carry with me.  Medtronic’s customer service is timely, polite, and helpful.  One manager in particular has logged dozens of hours on the phone with me while we documented and troubleshooted what we believe to be a rare Sure T product defect.  Medtronic has sent me various lot numbers of Sure Ts to try, and I have sent them back my problematic sets for analyses, the results of which are still to be determined.

In a nutshell, we have tried repeatedly to make the Sure T work for me, but maybe the Sure T doesn’t like people with very light, no sugar coffee orders.  Sure T might perform better for a different diabetic coffee enthusiast on a different day.  You tell me.

The recent product warning sent out by Medtronic is believed to be unrelated to my issue.  See image above; note that insulin droplets pool at the connector site and do not get into my body.  The proof is in the sugar-free pudding: after many site changes, subsequent ketone spikes, stubborn high blood sugars, and droplets of insulin falling out at the site, we have decided to hold off on using the Sure T until new lots are manufactured in the future.  Although I like the steel needle aspect of the Sure T, as bent cannulas cannot occur, if/when I transition back to the insulin pump after doing multiple daily injections for awhile, I will most likely give the Medtronic Quick Sets another try.

Whenever I switched a Sure T site out, I always ate low-carb for a few hours afterwards in case the insulin was not getting into me.  My fear is that someone who is unaware of this risk might consume a big pasta dinner and have an infusion set failure unbeknownst to that person, leading to a very dangerous situation very quickly.  I disclose this information so that you are at least aware of this potential problem if you also use Sure Ts.

Note: If you experience any insulin pump problems, please contact your respective pump company so that they can document the issue and investigate safely.

3.)  Bubbles in insulin pump reservoirs

I detailed this extensively in Broken Record, but to summarize briefly: These were more than champagne bubbles, they blocked proper insulin delivery, and they caused blood sugar to stagnate at high levels until the problem was identified and the reservoir changed out.

A Facebook user recommended that I pre-fill a reservoir a day before an expected site change, let it sit undisturbed to allow big bubbles to settle, and then prime those bubbles through the tubing on the day of the site change.  For some reason, letting the reservoir sit for a day helped immensely.  I also found that Novolog produced bigger bubbles which were easier to eradicate than Humalog’s millions of feisty bubbles which had a knack for procreating over time.  Get a room, Humalog love birds!

Please note that this trick is not recommended by pump companies, as insulin has been shown to lose efficacy over time in the plastic reservoirs.  However, given the frequency and degree of problems I encountered with pump site changes, I found that pre-filling the reservoir was a risk I was willing to assume, and I was always cognizant and on the look-out for problems related to this risk.  So far, the benefits have outweighed these risks.

I hope that this update is helpful to anyone who was curious about the possible solutions identified for my insulin pumping problems.  Thank you again to all who offered encouragement and advice along the way.  More to come soon with a post chronicling the transition back to insulin shots.  Yeehaw!

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Keep Calm and Novolog On.

I owe you a detailed description of this week’s meeting with the insulin pump manager and my health care team, but that may have to wait until the weekend.  (If running on grad school vapors was a thing, it would definitely be “my thing.”  Real life beckons at the moment).

In the meantime, for those of you who reached out to offer help and to commiserate upon reading Broken Record, first of all I want to sincerely thank you again.  Your words of encouragement, sharing of the blog post, and overall viewership of that piece really helped to keep me afloat and to work to fix these problems.  And you also taught me that if I do not fix the pump problems, that is okay, too.  Life will go on, and I will adjust accordingly.  Many of you have done so already; thank you for paving the way.  I felt your virtual hugs for many days, and that support is something that I will carry in my heart for a long, long time.

Until I can write a lengthier post, I do want to provide updates, especially for those of you who are going through what I am/was with the insulin pump recently.  The following are just a few positive things to consider if you are/were in my shoes with the pump:

1.) Try switching insulin types in the pump.

Novolog has made an enormous difference for me.  I am not sure why my body/pump decided not to get along with Humalog recently, but it was a very nasty divorce process.  There were lots of tears and the neighbors definitely give us weird looks when we walk by now.

Sometimes just testing the waters with something new can give your body and mind the break that they need to re-group. I have witnessed a very positive difference in my blood sugar numbers since the insulin swap-out.  And mentally, even if the insulin type switch is solely placebo effect, I will take any positive change at this point.

2.) Bubbles

Novolog has some bubbles, too, but not to the same extent as what I witnessed with the millions of tiny, feisty, stubborn Humalog bubbles. Novolog’s bubbles are bigger and fewer, allowing for the insulin in the reservoir to continue to do its job and to squeak by the bubbles.  This is just my experience at this point in time, but so far, so good.  More to come in a future blog post…

3.) Ask and you shall receive.

I asked for the doc’s help regarding my issues, and I was blown away by their feedback. I also semi-harassed Medtronic and my health care team to troubleshoot with me, and, to their credit, they heard me out.  They set up meetings quickly, they yielded multiple phone calls, they read lengthy emails, and they all agreed that something had to be done.  In the past I spent my hours and days wallowing in the idea that “Life might just have to be like this on the pump.”  Then I saw many of you living well with diabetes and realized that I was horribly mistaken.  You were living with diabetes, and you were doing so gracefully and successfully given the rebellious nature of a major organ.  I, on the other hand, was stuck in the mud with my wheels spinning, living without direction in my diabetic journey.

Once I admitted this, acknowledged that what was going on was not okay, and asked for assistance, the burden did not feel so heavy and so lonely. As of today, I am in the “icing my back” stage, rehabbing from carrying the cumbersome load of previous insulin pump issues.  But I am standing a little taller, my head is held a little higher, and my heart is definitely bursting for having you all to bear witness to the struggle and to cheer from the sidelines along the road to getting better.

I will forever be humbled by all of the hands in the health care pot that reached in, without hesitation, to help in my time of suffering.

Thank you…

Broken Record.

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Disclaimer: Before we really dive into things, you should know that this is a lengthy post, and it may not be all rainbows and sunshine.  Read at your own risk.  I personally hope that you are feeling a bit adventurous as a reader today, though. 🙂 

When my mother was in second grade, she was running through the auditorium and accidentally dropped her Bambi record on the ground.  It shattered into tiny pieces, and the janitor swept them up and gave them to her in a plastic bag.  She walked home sobbing and was heartbroken when gluing the pieces back together did not make the record work again.

If I told that story to a child today, she would laugh in my face and say that my Mom should have used an IPod instead.  Fair enough…

Well, I have become a broken record myself.  I know it and everyone else knows it.  I don’t even want the attention.  I just want the simple act of screaming my lungs out when I’m angry, and it usually comes disguised as some sort of social media rant about stupid drivers on the way to work or something else that is irrelevant.  I have lost friends over it, and I say this to my doctor all the time: Although diabetes is to blame for many bad moods, at the end of the day, I still have to answer to God and to the people in my life.  Diabetes isn’t a good excuse, then.  I can still be a respectful human being despite diabetes-induced mood swings and frustrations, and I need to work on this. I’m trying, which has to count for something.

But it is also very difficult to describe to people what stubbornly high blood sugars feel like and what a physical and emotional ass-kicking it is when nothing you do works to solve the problem. This is my reality on many days, and I imagine some of you reading this understand exactly what I mean. I hate to say that this type of suffering has changed me, but in some ways, it has. I am always on edge about how I will prevent and treat these highs, and I don’t remember the last time I just let my guard down and enjoyed the moment- probably because I was nursing a high blood sugar back to health in the background of that moment, with everyone around me remaining oblivious.

Many people have “yessed” me to death in regards to my insulin pump struggles, including family members. “Are you really just going to say ‘I know’?!” I scream on the phone with Mom. I get upset with this response, but I also understand it from a psychological perspective. There is really not much that others can do to help. They are not the ones up all night changing pump sites any more. They do not have to go to work exhausted and seeing spots because of high blood glucose. As much as they try to “get it,” they can’t completely comprehend what it feels like.

Some others have told me to toughen up or that it’s in my head, including fellow diabetics. I have a much more difficult time swallowing humble pie at that point. That advice adds nothing to the equation; it is the same as telling a depressed person to simply be happy. If life were this easy, there would be no depressed people, and there would be no sick diabetics. This is a “cop out” sort of commentary. It is much more beneficial to the friends, patients, coworkers- whoever is struggling- if we assure them that we believe them and that we are hopeful that they will find solutions. Dumbing down the problem by dismissing it as “it’s in your head” only angers that person. And guess what? It’s probably not in his or her head, especially if the person involved is a type 1 diabetic. We know our bodies better than most people do, and we know when something is awry. If you are a type 1 diabetic who has been lucky enough to avoid insulin pump problems, well, please cut us some slack that we have not been as fortunate.

Anyway, this is the blog post that I’ve owed you all.  I am BEYOND frustrated.  Forgive the length of this post, but I have to get all of the information out there. Bear with me while I go over the details, and then I really, truly need your expert advice, especially before I meet with a pump representative and my nurse for a troubleshooting appointment in two weeks.  I pinky promise that if I can ever help you in return, I will do whatever I can to pay it back, or to pay it forward. If you’re participating in the DOC, then I already know that you’re an expert, so please, please chime in here if you can help.

I am 26 now, and I went on a Medtronic MiniMed insulin pump about ten years ago while in high school.  It immediately changed my life for the better.  No more shooting up insulin doses in the bathroom stalls, no more limiting my food intake, and so much more freedom.  As my nurse would say, I had “virgin skin” that had never been pierced by insulin pump sites, and my absorption was great.  Once in a blue moon I would experience a technical issue, but this happened twice a year or so.  (I understand that an insulin pump is technology and it is not perfect.  Although if I could go back in time, I would erase the failed pump site on the one day of my life where I decided to try an iced mocha sugary drink thingy from Dunkin’ Donuts…).

Anyway, while in college, after my body experienced some wear and tear from the pump, I started to have site issues more frequently. On my twentieth birthday, I indulged in a pizza dinner with friends and had some ice cream for dessert, only to discover a bent cannula afterwards and a blood glucose reading of over 500 mg/dL. It’s my party, and I’ll cry if I want to. I also experienced some severe lows in which the whole world felt like it was falling down around me.  I was spooked- by the highs and the lows.  I had to figure out a way to stay between the lines- not too high and not too low- easier said than done with type 1 diabetes, as we all know.

According to my doctor, I literally experienced trauma from the “extremes,” the severe highs and the severe lows. This mental trauma has changed my reactions to things, has made me live a hypervigilant life in order to survive.  My brain was in fight or flight mode when these adverse situations happened in college.  I flew away from carbs.  If I ever have a kinked cannula again, at least I won’t make the mistake of eating pizza on top of it (as if anyone knows when they have a kinked cannula). If I eat salad and protein instead, maybe my sugar will be 300 instead of 500 if that happens.  And so I lived, for many years.  Until my body started to scream that it needed fuel, and it burned fat in place of carbs, and I saw ketones quite often.

I still struggle with working an adequate amount of carbs into my daily diet and with taking a more liberal amount of insulin, but I am trying. I have a phenomenal doctor who doesn’t make me feel stupid about my fears.  In fact, she makes me feel brave for showing up at her office to fight those fears.  There are some days where we are literally high-fiving and prancing around the room because I ate a half of a sandwich when my sugar was already 250 and I took quadruple the amount of insulin that I would normally take, which is usually still not enough.  But it is one giant leap for Ally of Very Light, No Sugar, so we celebrate those moments heartily.

What is making this process even more complicated is the fact that the majority of the time, I experience some sort of problem with my insulin pump and we cannot trust in the delivery mechanism for insulin. So, not only am I petrified of highs and lows, but I am constantly questioning whether the pump works or not.

I want to go on the record and say that I really like Medtronic MiniMed as a company. In my ten years of experience with them, the customer service has been top-notch.  If I need a supply, it is at my door within a day or less of placing a phone call.  Their phone representatives yield calls at all crazy hours of the night.  Their PR team does a great job of answering questions.  Angie, in management, has spent hours on the phone helping me investigate my pump issues.  I will not forget how she moved me to tears with a simple question a few weeks ago: “If you’re putting the pump site in your back, and you’re already on the thin side… well, doesn’t that hurt you…?”  Um, yes.  That part of it gets lost in the shuffle when you just want to absorb the medicine going into you, but the human connection was there.  She was clearly upset that I was in pain.  As was the Medtronic representative at my diabetes clinic who helped me with various sites last year and was a wealth of knowledge regarding all aspects of insulin pumping.  I’ve said it before and I’ll say it again: Medtronic doesn’t like bad pump days just like I don’t like them.  We are all in this for the greater good of living well with diabetes.  Alas, we have to fix these issues, for the sake of my health and for the sake of current and future insulin pumpers who may experience similar issues.

Anyway, I started off with the Quick Set infusion sets years ago, but had to switch off of them due to kinking cannulas. The Silhouettes, which have a larger cannula, worked slightly better, but my sites were so irritated that a nurse, upon seeing a picture of one site in my phone, in no uncertain terms told me that I was never to use them again.  I was allergic to some of the material, making absorption of insulin questionable due to the agitated areas.

The Sure T site, which uses a stainless steel needle that inserts into the skin and looks like a thumb tack, has been useful in that it has cut out the kinked cannula problem. Because the needle stays under your skin and you need to be able to disconnect the pump for various activities like showering, there are two attachments to the Sure T.  See photo above; disregard “love handles,” please.  One long tube connects to the reservoir in the pump.  There is a small needle at the end of this tube.  This small needle clips into a connector site, which is attached to a smaller tube running down to the needle under the skin.  To remove the pump, you detach at the main connector site.  I have had a few bizarre occurrences where the sites were snapped together but insulin was pooling at the connection instead of going through the smaller tube and into my body through the needle, causing me to spike high ketones.  Medtronic promptly replaced all of those lot numbers for me and is investigating the issue.

I am also relatively thin, so it is hard to find areas with enough fat for the sites. I never used to experience much pain with site changes, but now I feel significant shooting pains, sometimes lasting for days and making me nauseous.  My health care team has retired my stomach for sites to give it time to heal.  I sometimes use my sides and have experimented with the lower back but have not had great results so far.  Upper butt works okay but tends to be quite painful.

I feel like I have seen the whole spectrum: from pain-free, easy site changes years ago to painful, troublesome sites in recent times. I know that I am not crazy, that I am experiencing problems that are really disrupting my quality of life.  With each bad site change, I am often on the couch chasing ketones away all day and taking manual injections on top of changing out problematic pump sites.  It is no way to spend one’s mid-twenties on a weekly basis, and I want this to change so desperately that I am willing to try pretty much anything.

I would like to continue pumping because of the fine-tuning that the pump allows. I can take my mini-bolus at the beginning of dinner and bolus more ten minutes later if I go back for seconds.  I can tweak my overnight basal rates, etc.  While I do not remember seeing ketones often with multiple daily injections (MDIs), I do not like the thought that once that insulin is in you, it’s there for the day.  And if you need to bolus, it is a bigger deal to get the dose right on the first try so that you do not have to take more shots later on.  Socially, it is simpler for me to press a few buttons on a pump while in grad class late at night than it is to go to the bathroom to take a shot.

My final issue is not with the pump itself, but with the insulin. I have used a pump for years; there are usually a few pesky bubbles which can be flicked away and forgotten about.  But lately, it’s like the insulin is feisty before it even gets inside the reservoir.  See photo above.  Millions of tiny bubbles shoot around my Humalog bottle.  I have tried new orders of Humalog, attempted using different bottles, etc.  Nothing changes the presence of these bubbles.  When I fill the reservoir, I flick out the big bubbles, but usually a few tiny culprits hang out by the top of the reservoir and refuse to move.  Over time, they expand, blocking proper insulin delivery or causing some air, instead of insulin, to be delivered.  My sugars will run high for hours until I figure out the issue.  I recently gave Novolog a try, but the first two attempts yielded big bubbles as well and my sugars were high for days.  It is as if the bubbles compromise the efficacy of the insulin, and it is so not cool.

As noted earlier, I am meeting with my nurse and a Medtronic representative in a few weeks to go over all of this and to walk through the process with them to see if we can identify the issues. In the meantime, I ask for your prayers and your advice.  Some of you have reached out to me about the bubbles and you have made me feel so much better in knowing that I am not a lunatic, although I truly wish that none of us had to suffer through these circumstances.  A lot of times people are quick to blame the user.  Maybe there is user error?  If so, I’m willing to admit it and move on.  I just want to feel healthy again and to regain the quality of life that the pump originally afforded to me.

I apologize for the broken record-ness, but I am fighting for my health here.  It is disheartening when you are making big strides in your diabetes management to tackle your fears, yet something as simple as a few air bubbles is wreaking havoc on your control.  I am incredibly concerned about the toll that this is taking on me physically and mentally, and about the burden it is placing on my family and friends who want to help but don’t know how.  Perhaps you hold the answer, DOC.  In fact, I’m sure you do.  What works for you?