Opsite Flexifix

For the first time since Arden began wearing a CGM we are using a third party product to aid with adhesion. Back in December I realized that the adhesive on the new DexCom G4 sensors wasn't as resilient as it was on the prior version of the device. I tried for a few weeks to be sure that we weren't just having a bit of bad luck, but after a few attempts my suspicions were validated. As others started to experience the same lack of longevity the Internet became littered with folks saying that the new DexCom G4 adhiesive just doesn't stick like it did with the 7+.

I knew instantly that I wanted needed to add a third party product into the mix and I began to search online for options. All of my research led me to want to try Opsite Flexifix first so I ordered a roll on Amazon and waited for the UPS driver to arrive. 

I later found a post on the D-Mom Blog that explains, step-by-step, how Leighann prepares her daughter's Flexifix to work in conjunction with a CGM sensor. I co-opted Leighann's plan for how she cuts the center hole and made one small change. Instead of a significant overlap, I cut the Flexifix just slightly larger than the DexCom's original adhesive (image below).

Tomorrow will the twenty first day since the sensor above was applied.

Opsite Flexifix, write it down.  

Update on Thursday, February 7, 2013 at 10:16AM by Scott Benner

Here it is Shelley.

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.

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 Monday, December 3, 2012 at 11:19AM by Scott Benner

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

Seven. Point. Five.

 

I've never said the actual number here before. I've never had the nerve to say Arden's A1c is 8.5 and no matter what I do I can't seem to get it to go lower. Back in February when Arden's A1c was at it's lowest point ever, I still couldn't tell you that it was 7.8. We had a .7 reduction in February, the biggest single leap ever, a sign that we had cracked the code and still... I couldn't say the number out loud. As proud as I was of the 7.8, I couldn't bear the thought of you adding .7 to it and realizing that her A1c was 8.5 just three moths prior.

A1c is funny. Everyone tells you not to measure yourself against the number, yet it's the only number that we measure to examine the job we are doing managing type I. I understand why I shouldn't measure myself, but if not with this, how? How do I know if we are doing okay, better, worse?

I tried, just as I always do, to not think about what Arden's A1c was going to be as we walked into her Endo appointment yesterday. I was doing a good job too because I was so focused on the fact that Arden was filling out the pre-visit form on her own for the first time. It made me think back to the first time we brought her to this office, she was two years old and this whole thing seemed like a bad dream. In those days the A1c results made me nauseas. One time, back when the tests took much longer, our NP caught me in the lobby as we were leaving to say that Arden's A1c dropped .2 to 8.7. I cried right there in the lobby when I heard the news and the NP hugged me because I was so inconsolable, so happy, eminently relieved. 

I cried because each point felt like more life, like better days. Forget the notion that we are doing something right or not, I just want Arden to live as long and as healthy a life as possible. Ironically, I want the same thing for all of the people that I love and I'm probably making far worse life choices for myself and others then I do for Arden. Diabetes is the catalyst that makes me pay attention to this degree, it is a curse and a blessing in many ways, this is one of them. Now it's six years later, Arden isn't two, and I'm not new to this diabetes thing. "It does get better", I thought as I watched her write her name on the form. Maybe not easier, but better.

You'll get better, I got better, good things are coming.

So yesterday when the NP told me that Arden's A1c was 7.5. I just smiled and said, "great". Sure my eyes tried to fill up a time or two as she praised Arden for her hard work. I was so proud of Arden that I didn't have time to make the connection between the number and Arden's health. I never thought of it like it meant more days, no arbitrary feelings that we did something monumental or did something that meant the literal difference between having a tomorrow and not. It just felt like an accomplishment, no different then if I had completed an exercise goal or written a blog post. I set out to do something and got a good result. Simple. If next time doesn't go our way, then we try again much like hitting a baseball. Just because you don't always get the result you desire doesn't mean that your approach is wrong, only that you are doing something that has so many variables that it is not reasonably within your control. Your job is to win the ones that you can and not let the others slow you down. 

I think I'm finally past the part where I think of diabetes so fu@&ing literally ever second. Yesterday, I felt happy, not relived, not like I just pulled Arden from the jaws of certain death, just happy. I think one day, if you already don't, you'll feel the exact same way because it gets better.

It was a long road from 9s to 7.5 and we aren't finished yet. The NP asked me what my short-term A1c goal was and I said with some confidence that I think I can get it to 7.1. I've identified two times of day with CGM graphs where I think we can do a better job of pre-bolusing and making better food choices. Those changes should move the number toward 7.1. I'm going to start by trying to effect those moments and see where we are in three months. I'll strike out once and a while, but I bet that by the time another three months goes by, I'll have more hits then outs. This is how, in my opinion, you should measure yourself. Simply by being able to say that you are trying with every ounce of who you are. By understanding that you aren't trying to win and that it's not possible for you to lose. As long as you don't give up, you're doing perfect!

I want to take a moment to list a few of the factors that I believe have the biggest influence on Arden's A1c results. When the NP asked me what my secret was I flippantly said, "Apidra, DexCom and not sleeping", but there is more to it then that. 

Support - Love and support from family, friends and teachers is huge.

Insulin Pump - Being able to give insulin quickly and unobtrusively for meals, snacks and high BGs.

CGM - Arden's DexCom is a window to the past, present and future of her BGs and I couldn't make the pinpoint adjustments that helped us get to this new level without it. It's sad to me each day that the FDA doesn't approve it's use for young people.

Over night monitoring - Arden is sleeping almost half of each day, if you can control the night then a few bumps during the day don't hit the A1c average so hard.

Apidra - Arden's BGs are move stable on Apidra then they ever were with the other insulin she was using in the past. Make sure you are using the insulin that works best for you... not just the one some sales person gave your doc.

D.O.C. - You all give me strength to do these things when I otherwise feel like I can't. It's knowing that one of you is awake, sad, crying, happy or running around out of your mind like me that makes me realize that I'm doing okay. 

As we walked through the lobby yesterday on the way to our car we saw a teenage girl filling out the same form that Arden had just written her name on one hour before. This girl was just on the verge of being a woman and that almost made me cry... but it didn't have anything to do with type I diabetes. It does go so fast, just like they say.

Arden's A1c is Seven. Point. Five!