Dexcom musings - a month in

With this sensor still going strong, soon entering it's 14th day, by now I've had my little device for about a month. I've learned a lot about it, about myself, and about our interaction. Here are some thoughts:

1) it almost sounds strange, but I want more granularity. Right now I get a reading every 5 minutes; while that's eons better than anything I've ever had, between missed readings and the display limits (see below for further discussion on this), I am occasionally desperate for more granularity. Every 2 minutes or even a minute would be great. I'm not sure if this is possible with the current Dexcom technology - it may run through the transmitter too fast - but if they move to passive transmitters (a notion I've presented in a post a little while ago), this should be easily attainable.

I think the Navigator does every minute, and that will be a big - huge - competitive advantage.

2) to further elucidate on this issue, the Dexcom has allowed me to "prove my brittleness" to a degree I never anticipated. My 100 mg/dl drop in 15 minutes was scary, but it was great seeing it on the Dex.

Thing is, I didn't actually see it develop, because the drop was too fast for the Dex (which can only display a rate of change of 15 mg/dl per 5 minutes), and it has no directional indicators. I saw the start and end points, and confirmed with my meter. Thing is, these kinds of events are exactly when I want my Dex to function best. And it isn't. That sucks. With more granularity in the tests, I am almost certain I'd have seen a few "in betweens". But other indicators could be valuable, too.

3) for example, if the Dex could at least display a directional indicator when blood sugars are moving too rapidly for a reliable result, that would at least tell me what's going on to a great degree. In the situation above, I would have loved to have had some indication that the Dex is thinking I'm dropping real fast even if I don't have a number attached.

While I (think I) understand the reasoning behind not wanting to display rapidly changing readings (due to differences in measurements between meter and Dex, suspicion of malfunction etc potentially leading to mistreatment), I think I'm smart enough to act appropriately even with potentially suspicious data. Maybe some sort of advanced mode where I get the numbers and trend anyway, together with a "use at your own risk" indicator?

Give me data. I can work with it. Don't hide it from me. Don't use the least common denominator. Shoot, I'm an early adopter, I sure as heck do not need babying. It's not like I could have found out about this if I wasn't intelligent enough to seek it out in the first place, you know what I mean?

This also holds true for the way Dexcom is choosing to hide raw data values. I'm already 95% of the way to getting them anyway - I know what needs to be done and how to do it, I just don't have the skills to code for it - but dang it, why should I go through all that trouble? if you don't want to make it "generally available" then just put a little software tool in the software directory, don't announce it to anyone, but put it there. Trust me, I'll find it. Or just make it available by request.

4) I wish my Dex had the ability to show the last "reliable" measurement somehow, instead of the "???". So you can't display a number - fine. But give me a way to know what the last data point was. Otherwise, you are pretty much forcing me to look at the screen every 5 minutes. That's OK in the first couple of weeks when I do it anyway, but otherwise it's just annoying.

In fact, I wish the "???" would provide indication of why it is there. Is it processing? complaining about signal unreliability? indicating too rapid of a change in blood sugars? again, don't hide data from me, please.

5) speaking of "???", I'd like some indication - like a less obvious vibration - of a series of missed readings. For example, if the "???" appears 5 times in a row, let me know. NOW. I hate peeking at the Dex in the middle of a meeting and suddenly seeing a blank 1-hour graph. It makes me anxious. And what I can't do is start fiddling with it, because the buttons click way too loudly and it draws a lot of attention. Speaking of which, can't the buttons be designed to be less "hard" and noisy?

6) I'd like a "quick reset" mode for when I am simply trying to reset with an existing sensor. The 2-hour gap really isn't needed for this instance, as the sensor is well saturated. This feature will be particularly useful at the 7-day session threshold.

Yes, I understand the 7-day limit comes from the FDA's approval. But I doubt having a "quick reset" mode will violate it, especially considering that a reset is sometimes needed for other reasons, and Dexcom support admits that in those cases it would be helpful to have it happen sooner. In other words, it's a useful troubleshooting technique.

7) That 2-hour gap is a psychological killer. Yeah, I know I'm being ridiculous here, but I become irritable when it takes place on a new sensor placement. And it's more than 2 hours, you know; it's the 10 minutes it takes to replace them, the 2-hour calibration, then the 15-20 minutes until I get the first number. That's, like, 2 1/2 hours. And it feels like 2 1/2 weeks.

8) The transmitter/sensor array in itself has interesting psychological implications. I find that I keep touching it ever so often. I am always aware of its presence. I do a lot less roughhousing with my kids now, because I'm afraid it will get ripped out. I just can't seem to "forget" about it. I wish I could.

9) when all is said and done, I am absolutely addicted to this technology and device. With all its shortcomings, it has become a central, leading elements in my diabetes management. And it has done some amazing things for me; I am controlling my blood sugars way better now (as evidenced by my long terms graphs, especially peaks and valleys), and as a result I feel better. I am not afraid of spending long hours in "good" territory now (my "fear of 100"), and weather changes can be handled a lot more effectively. I haven't seen a single 300 since I've started using this - I used to see them 2-3 times a week before.

The list goes on. If you are thinking of getting a CGMS, stop thinking. Get one.

Happy new year.

Longer time, new sensor record (for me)

Realized today that my current sensor has been installed and working great since tuesday, 12/18, around noon. This means it's already into its 11th day, and it exhibits no signs of decline whatsoever.

I wonder how long this one will last. It has also been the most comfortable thus far, both on insertion and use. I think that's because I am getting better at choosing the sites and going through the insertion process.

The shrinking gap of inequality

Yes, I said shrinking.

Read this, then come back.

I've recently become a subscriber to the Economist, and boy, do I love the magazine. This particular piece hits the nail right on the head; it's why all politicians who focus on "poor vs rich" don't win as many points as they think they should. How could they? people live differently than what the particular set of numbers they are looking at indicate.

I have been ruminating about this subject recently, so the article really hit home. The context? my new Dexcom. Think about it. I am not a rich or wealthy man. We are middle-class as they come (also by the real definition of middle-class, being the professional class). And yet, I am able to purchase and enjoy the benefits of a new, radical medical technology without assistance and on my own as an early adopter, because technology in general costs a lot less these days.

This dramatic increase in lifestyle equality is what's driving luxury items' prices and popularity so much in recent years; the rich simply don't have much to spend on anymore that really distinguishes them. When a common man can drive something akin to a supercar (take your pick: Porche Cayman, Corvette, Lancer Evolution, pretty much any AMG car), what can a rich man drive? a $430,000 Maybach is somewhat special, but to really flaunt it, he'd need to spend over $1.5 million on a Bugatti Veyron. And the difference in experience? minimal. Is it a wonder that $1 million cars are becoming almost common these days?

I love that I can afford my Dexcom. I love that I live in a world where it's this easy for me to own one without having to be extremely well-off. I think we don't congratulate ourselves enough on how amazing this state of affairs is, and how different from what it used to be even 50 years ago. We are very fortunate to live in this age, folks.

American is getting better

No, seriously.

It's a long article, but worth skimming through at least. It may surprise you.

Gloomy

Not sure why, but I'm feeling a little gloomy going into christmas this year.

Almost beaten down, even if nobody's fighting me.

How odd.

Confirmation

So for years I've known that severe weather changes cause my blood sugars to go haywire... it's just that I could never prove it conclusively with solid data.

Well, now I can.

This last week the weather has changed considerably where we live - sharp drop in temperatures, lots of rain, etc. Almost immediately, I went into the "weather ritual", which happens 3-4 times a year, in which my blood sugars become very difficult to control and impossible to predict.

However, with the Dexcom I can do a much better job at controlling, and am beginning to get a sense for predicting. It used to take me 2-3 weeks of terrible blood sugars to regain control, suffering in the meantime from the effects of seesawing numbers, which are physically exhausting, not to mention damaging. Well, now it took me less than 2 days - and even that only because I was over-reacting to trends. And that's the first confirmation for something I knew for years: during weather changes, my body's reactions are in general more extreme (when it gets colder). I suspect I will get confirmation for the other side of the equation (less extreme when it gets warmer) in summer.

In technical terms, it appears that my trend slopes become steeper when the weather gets colder, and I assume they will get smoother when it gets warmer again.

And I also have a wonderful little example of this from the trend graphs. I think I mentioned it before that, as a brittle type-I, I can drop 60 points in 15 minutes with no idea it's happening. Well, I apparently never realized the obvious - that if my body's reaction become more extreme, it will impact this as well. Examine this:



Wow. That's a drop of ONE HUNDRED (100) mg/dl in 15 minutes.


No wonder it's more difficult for me to control my blood sugars in weather changes. And thank heavens (again) for the Dexcom.

Getting Dexcom raw sensor data

So a couple days ago I decided to try and figure out if I can extract the "hidden data" that is part of the Dexcom Seven data objects. Specifically, I would like to find the Dexcom equivalent of the Guardian's ISIG readings - the measurement of electronic pulses that the sensor utilizes to determine blood sugars.

Anyhow, I started by trying to figure out where stuff is stored. The Dexcom software is a ClickOnce application, so it's structure is a bit different. I found that the data files are under C:\dexcom, and the program files under C:\profiles\username\local settings\apps\2.0

I then looked at the data files and found that the actual data is compressed. It is also signed with Sha1, but it is not encrypted.

I just figured out that the compression library used for the data objects is ICSharpZip, which is one of the default libraries available with C# (or .Net). The DLL is part of the program files, so there is no mystery there.

Here is the problem: I am not a programmer. Can anyone point me to how I can use this library to decompress the portions of the data files that are compressed? I know visual basic is "part of" Excel and such, at least to a degree; can anyone give me a sense of how to write a simple call to make this happen?

Cooliris

If this little plug-in doesn't get you over the hump to using Firefox instead of Microsoft's horrendous Internet Explorer...

Nothing will.

If you haven't made the switch yet, install Firefox now, then install the Plug-in. No need to thank me later.

Life with the Dex, part Deux

Another thing I have discovered, now being on my third sensor, is the "2 days have passed and it is starting to itch" phase.

It happened with every other sensor. Sometime on the day after my second night with it, the area where the sensor is located starts itching a little. Nothing major, but it's distracting, and of course, you can't scratch the itch - or even close to it, because of the adhesive tab.

Interestingly, it more or less passes after 24 hours. I wonder if it has to do with the adhesive more than the actual sensor. It doesn't affect readings in any way, and it could conceivably also be entirely psychological. But that it always happens around the same time makes that unlikely.

I haven't read anywhere about anyone mentioning this, so it might also be unique to me. Statistically, though, that is also unlikely.

Speaking of psychological impacts, the sensors do carry some. One is the constant worry that they don't get hit, and more importantly, shoved or scraped hard. The main difference for me is with my kids. I used to roll around with them and rough-house a bit regularly. Now I'm a little sheepish, because I keep worrying about the sensor getting ripped out by mistake. I'm not sure how to solve this problem. I'd love more education around how well they handle bumps and grinds - are they designed to withstand this sort of thing? does a sensor's performance get impacted by a hit? a scrape? a twist? does it continue to work normally as long as it's in, or is it sensitive to "re-seating" that might occur because of jostling? I can't find any information about all that.

Dexcom catches a hypo... again

I just can't get enough of what this thing does for me.

I was cruising along nicely after dinner in the high 100's for a while, which is fine considering I just ate. I was reading some stuff, and going over some other stuff, and at some point I took another look at the little screen.

OK, who am I kidding? I look at it at least every 10 minutes. Isn't that what it's for?

Anyway, I get a very suspicious looking "???". A couple minutes later it gets confirmed - 101. I just dropped over 60 points in 15 minutes and hadn't even realized it. No Dexcom, no treatment; I would have hypoed before I even knew what was going on. Then I would have rebounded, had a terrible night, woke up with 300+, and screwed up at least a half day following. Been there, done that.

Not now, though. As soon as I saw this I went and downed some OJ and honey, a bit of candy. Result? I went as low as 72 before bouncing. No hypo, no liver release, and I'm guessing a much happier me for the next 12-14 hours.

My blood sugars used to play "Catch me if you can". Well, now I can.

Whodathunkit?

I just took the - somewhat tiresome, but certainly intriguing - "choose your candidate" test on Washington Post.

Imagine my surprise when I was done and it became very clear that one candidate stands head and shoulders above the rest in terms of my agreement with their platform...

Joe Biden.

Well then. Time to rethink things. Does he even have a chance to win the nomination?

Later edit: having read a bunch of his stuff on his website, I just sent $100 to his campaign. My first political contribution ever, too. Go Joe!

New sensor

Oh well... it was good while it lasted.

I just replaced my sensor with a new one. While I am not absolutely certain the old one was dead, it went into a perpetual "another blood sample" mode. I reset it but even after the 2-hour/2-calibration process, it simply wouldn't wake up again.

Overall it lasted roughly 9 days, which I suppose isn't bad. Anyhow, new one in and counting. Between the resets, I'll be almost 5 full hours with no CGMS by the time I get it back, and I'm getting anxious.

More on A1C

My last post got me thinking...

I trust that you all know by now that A1C is not a straight average - rather, it is weighted towards the most recent results to a great degree. That is, the most recent week "counts" for an order of magnitude more in the A1C result than the oldest.

I think the main reason why healthcare professionals don't tell this to patients is twofold: it's confusing, and also it points to a way to "cheat" on the A1C: simply wait for a "good" period of a week or two, then test. Even if the former 8-10 weeks were horrible, the A1C score will tend to reflect the most recent weeks much more strongly, resulting in a score closer to normal.

Anyhow, so we know the A1C is somewhat pointless as a 3-month average, even if that's how it's treated by so many. In fact, it is only useful as a 3-month average in people who have rather stable blood sugars - which means mostly type 2, not type 1, and certainly not brittle ones like me.

Now I'm beginning to wonder if even this limited usefulness is useful. In other words, what if because of my ability to manage my sugars more pro-actively through the use of a CGMS, I can have an "A1C of 7 that is more like a 6"? in other words, if the A1C is a weighted average of sugars in the blood, but those reflect more peaks and valleys than what is happening in my cells, then is it possible that my "effective average" is actually lower?

Oh, the possibilities!

Now this is interesting... receiver/meter interaction

So I wake up this morning after a nice solid night spent in the 130-140 range.

Walk to my office, take a calibration test. Meter says 118. Interesting, I think to myself. Maybe this is an indication of a soon to fail sensor? no longer reading well?

I calibrate anyway.

Less than 5 minutes later, the receiver vibrates and tells me in no uncertain terms that my meter is an idiot. Well, alright, it displays the blood drop.

Of course, I obey my new master, and take another meter test for a new calibration.

144!

The receiver was right all along!

And it knew it, too.

Fascinating.

This is the clearest example yet of something I've been noticing for a while, which is that from the perspective of how my body reacts, the Dex results make more sense.

Example: I've always wondered how I could get a hypo reaction from my liver when my blood sugars never drop below 90; well, the Dex is showing 60 following a rapid drop so it makes sense. My liver simply reacted fast enough the blood sugars never got to full hypo territory. This has happened to me by now, folks.

Another one is a bit more complex but has happened a couple times too. The Dex insists that I never rise over, say, 230, even though my meter claims as high as 280. Note that when I started rising, I would take insulin, and "catch" the trend before it realizes its full potential. Here is the thing. I feel quite different at 230 and 280. I used to be so well attuned to high blood sugars that I could normally guess to the nearest 10 with deadly accuracy, at least meter-wise. The thing is, it never crossed the line into feeling like 280.

Now comes the big question: from the perspective of long-term damage, what matters? blood sugars or "cell" sugars? (the Dex measures interstitial fluid) has anyone explored this topic? because if I were to take a guess, I'd say the latter more than the former. And if I'm right, then a little gizmo like the Dexcom can have an absolutely tremendous impact on long-term health of a diabetic - if properly managed by the patient. And it may also mean that the A1C is somewhat pointless when discussing finer granularity (that is, it can give you some general indication but may easily be useless at a full percentage point). Now I'm really curious.

Still holding up

My 9-day old sensor seems to still be doing just fine... although it does seem to do better if I calibrate a bit more often at this point (4-5 times a day seems about right).

I wonder how long it will ultimately last. My guess right now is 11-12 days or so.

Beyond a week

So... my sensor just got to the end of its proscribed 168-hour session.

Still, it is functioning just fine, so I reset it instead of getting rid of it. We'll see how long it will last. I'm quite curious about this question.

Travel

Bernard raises a good question in response to my last posting, which is worth repeating:

What impact does the Dexcom system have on travel?

There is no way on earth that I will be removing or discarding a $60 sensor just because I have to fly somewhere. But I do need to travel quite frequently (the only reason this hasn't been an issue yet is the time of the year).

I guess there are two questions here:

1) is there an issue with airport security?
2) is it safe to let the Dexcom go through the metal detector and the scanner?

If anyone from Dexcom would like to respond here, please do.

Easy to forget... Dexcom UI issue

So a little time after lunch today my Dexcom suddenly showed the big blood drop signal, indicating the need for a calibration. While it was a little strange since I had just calibrated it only about 7 hours before, I gave it one. It cleared the screen to the normal screen... but then the blood drop stayed there.

So I gave it another calibration. No go. The blood drop at the top right refused to move.

I called support. First of all, I want to note about Dexcom support: they really WANT to help. Some of them are better than others, surely, but they are NOT the typical call-center guys. In any case, the lady asked if I could upload data, which I couldn't because I didn't have the sync cable, but she did remind me something that I had forgotten:

If the Dexcom shows the big blood drop signal in the center of the screen, DO NOT automatically calibrate again. Instead, press "c" and see what the top right image shows. If it's showing "???", then calibrating will just mess things up.

Anyway, I got home, got my data synched, called and uploaded. I was speaking to Brad (who deserves a good word, he was great) from Dexcom support, and he offered to replace the sensor (thank you!). However, I refuse to believe all these uber-expensive sensors can go bad so frequently, so I delayed accepting (yeah, OK, I'm a dumb consumer), and asked what else could be done.

Then Brad said a couple of things which are worth repeating:

1) the data collected from the receiver includes additional information than just glucose values, that is not represented in the software. By looking at this data, Brad was able to tell that the sensor's sensitivity was being reported as too high - explaining the receiver's refusal to present readings.
2) he suggested I try another calibration and see what happens. It worked; everything went back to normal. Apparently all that was happening was that the heightened sensitivity was causing the software to not trust its own interpretations of the signals, and (this is my conjecture) it is designed to not show readings until things stabilize instead of potentially endangering the patient with false readings.

Oh, and the sensor isn't really bad or going bad. In fact, it appears that had I just pressed "c" when the blood drop showed and ignored the request, none of this would have occurred.

Brad also admitted (OK, I'm paraphrasing since he was far too professional to say all this) that most patients just don't care enough, they want to tear the sensor out and get a new one. I'm sure this is especially true in this case, as my sensor was about 5 1/2 days old, just below the free replacement threshold (that is, if it actually works 1 more day it will have "worked as advertised"). But I'm also pretty sure that these sort of "real world" troubleshooting events are worth their weight in gold to Dexcom, and in the end, to us as users. Thus, while it would have been wonderful to get a free sensor out of it, I'm really happy that we were able to troubleshoot this and get to the core of the issue, which is:

1) the user interface is confusing; the big blood drop signal should indicate one thing and one thing only, "do calibration". It's too much to remember that it might mean different things at different times.
2) the user in this case was a moron.

Something else which is really interesting and is a direct result of this system: I now occasionally compare CGMS, Onetouch Ultra, and Freestyle Flash. Right now I had an interesting sample:

Dexcom 172
Onetouch 216
Freestyle 248

(both the meters used the drop from the same prick)

How's that for variance? I know the Dexcom was "catching up" to a rising trend, and we already know it lags on those. But one would expect the meters to be closer. Fascinating stuff. And not the first time this happens, either.

Flattening the curves

I am working today with my partner, and he just took a look at the Dex, and looking at the 3-hour graph (which has me dropping very slowly from 150 to 130 over the 3-hour period) said something interesting. His words: "I have never seen you so flat before". He's right. I can now have flat stretches for hours on end.

And that, boys and girls, is what it's all about.

Finally! This is how music should be sold

At least to old codgers like me who are completely disinterested in iPods and their ilk. MP3 players? not for me, thank you very much. I carry enough junk around anyway (just the diabetes gizmo's alone are enough) to think that carrying yet another one just so it could help me become oblivious to my surroundings just is not appealing. People are finding more and more ways and reasons to disengage from other people, and MP3 players are a supreme enabler.

Anyway, that was a little rant there. Sorry.

I just found out that Walmart.com offers an absolutely fantastic service called "customize your own CD". It finally delivers on the promise I heard all the way back to 1995 - that one could go to an online store, build one's track-list, have the store burn the CD, package it, and send it to one's home address.

I'm not sure how long Walmart has been offering this, but considering my recent Country addiction, I was thrilled to find this existed.

In other words, I just spent $20 on a CD and felt great about it. Why? because the $20 are very well spent; I got 20 songs of my choice, put in the order I desire, on a single CD I can put in the car and enjoy on my long bay-area commutes. And they aren't some low-quality MP3's, oh no. They are the actual digitally mastered CD tracks. And of course, since this is a regular CD, there's no DRM and all that crap. If I want, I can transfer them to my laptop, or another CD to listen to at home, or what have you, and not be in any danger of violating any moronic copyrights protection act. Heck, I can MP3 the suckers for my own use if I really want to, but alas, I have no MP3 player.

For me, this is music heaven. I'll reserve full judgment until I receive the CD and listen to it, but assuming it all works well, I'll be ordering a few more of these moving forward. The convenience factor is overwhelmingly positive, and ability to browse and listen to samples is fantastic (although I do so wish they would put in longer samples than 30 seconds), and it's just the perfect way to buy music.

And by the way, I would never, ever have bought any of the related albums. The music industry needs to realize this is the right approach; while it doesn't allow them to charge me $20 times the number of albums, it does allow them to get me to pay $20 they would otherwise never see.
And you bet it will lead me to spend more $20 increments like that. Sure, crap songs don't get sold as they do in the current bundling model; but why should they?

Anyhow, my first country CD, my mom would be so proud. Here is the list of songs I chose:

Sunshine & Summertime, Faith Hill
Before He Cheats, Carrie Underwood
Because of You, Reba and Kelly Clarkson (wow)
Anyway, Martina McBride
Moments, Emerson Drive
Lucky Man, Montgomery Gentry
Harper Valley PTA, Jeannie C. Riley (I love her rendition)
Never Wanted Nothing More, Kenny Chesney
Tequila Makes Her Clothes Fall Off, Joe Nichols
Honky Tonk Badonkadonk, Trace Adkins (if this is Honky Tonk, I love Honky Tonk)
Online, Brad Paisley (how could I not?)
Little Bitty, Alan Jackson (oddly enough, my favorite Alan Jackson song)
Good Directions, Billy Currington
Watching You, Rodney Atkins (the song that "got" me into Country)
Our Song, Taylor Swift (ohhh... she's good, this one)
Teardrops on my Guitar, Taylor Swift (her second on my CD, and not the last)
Take me There, Rascal Flats
So Small, Carrie Underwood (I don't even watch American Idol, but you have simply got to watch the video. Makes me cry)
Tim McGraw, Taylor Swift (clear winner, 3 songs in this collection, I really like her)
Give it Away, George Strait (feels so... genuine)

So there you have it. Can't wait to get it!

Life with the Dex

So now that I'm a veteran of this system - almost a week! - I figured I'd tell you a bit about living with it, instead of my various pathetic attempts to impress the world with my supposedly fabulous instinctive grasp of the thing.

Hey, self-promotion is all the rage these days.

Oh, and note I'm calling it "the thing". There is reason for that, because it has by now taken a life of its, and it is controlling me, guiding my thoughts, running my life...

What would you expect from something that has such a huge say on how I manage my diabetes anyway?

I think I mentioned it before, but the best way I have to describe the thing's profound
impact is this:

It allows me to make many small accurate corrections instead of few big less accurate ones.

As any type I who is also brittle and using short-acting insulin (that is, me) will tell you, our life is this constant diabetes management hyper-course. Thing is, because you could never really tell where your blood sugars were headed unless they were headed there at a pretty sharp clip, you'd develop these ideas about how your body does things. With me, and my chronic fear of hypos (not unusual amongst our tribe), it was always the fear of going under 100. Because I can easily drop 50 mg/dl in 15 minutes, and would do so regularly. So 100 was always a scary number, because it meant 50 was just around the corner, and 50 ain't good.

So if I found myself at, say, 100 an hour after lunch, I'd immediately correct up, no matter what. Now, sometimes that would work well, and I'd catch a hypo before it happened. But sometimes it would be too late, and I'd already hypoed and rebounded and hadn't noticed it, meaning my correction was simply adding to an already rising trend, resulting in a nice, fat 400 on my meter an hour later. And sometimes it would be an unnecessary reaction, because I in fact got the ideal combination of bolus and food, making it so I managed to flatten my post-meal blood sugars due to the combination of glycemic indexes and amount of insulin taken at just the perfect time. It does happen. Thing is, when you hit this ideal the last thing you want is mess with it, and my "correction" would inevitably mess with it.

In other words, I lived in constant fear. Fear of the unnoticed, unmitigated hypo that would send me plummeting to the floor in the middle of a meeting, or make me completely incoherent in front of a client, or what have you. The same would happen after dinner, when the fears intensified, because I was going to be asleep soon.

In retrospect, it's practically a miracle that I had managed to keep my A1C's down around 7% for so many years. I did it by pricking my fingers 15+ times per day, trying to make more and smaller corrections rather than big ones, but doing quite a poor job at it because, well, I could never test as frequently as I needed to all the time. It's just not practical.

And then came the thing.

It's amazing what that little trend graph does. I can look at it and at a glance know where I stand, and figure out where I will be in 10, 20, 30 minutes. Extrapolating is easy as pie. There is no guesswork involved; it's all visual, it's all right there.

And the immediate result? I'm not afraid of 100 anymore. I'm not afraid of 90, or 80, or even 70 for that matter. Case in point: yesterday night before going to sleep I was dropping, and feeling it. Before the thing, I'd have tested myself at some point to see I was around 100. I would then react severely, stuffing myself with a bunch of quickly digestible carbs, test again 30 minutes later and see myself at somewhere in the 160-200 range, and say "OK, great, no hypo tonight" and go to sleep. I'd sometimes wake up high anyway, not sure what happened along the way.

Not now, though. This time I had data, real data. First of all, I was dropping slowly, at a constant rate of about 3.5 mg/dl per 5 minutes. That meant I had time to let the trend establish, because I was only dropping about 42 mg/dl per hour, enough time to react calmly. So I ate something small, and waited. I went down to 90, then 80, then 70, which is when I drank some OJ and ate a bit of honey. As expected, the honey and OJ "caught" about 15 minutes later, just as I hit 60, raised me to 130 or so, and kept me there. Never triggered the liver to release glucagon, never went too high, never over-reacted.

Woke up in the 150's after a nice stable night. Beautiful.

This keeps happening; my ability to make these smaller, measured fixes "just in time" is almost beyond belief. The calming effect this has is also a benefit, even if not easily quantifiable. And it sure keeps me flatter through the day because I can anticipate as well as react better.

The downside to all this is not having it around or working properly. At this point a major reason one would want to prolong the sensor life is not because of cost, but because of the simple fact that replacing it means a whole 12 hours of somewhat unreliable readings. Argh! I think it's pretty much a given that one should do sensor replacements at night. When my first sensor was going bad, and then the second one was refusing to work properly after insertion, I was literally depressed; we went to a party that evening and I must have been annoying as all heck to everyone, because all I kept doing was looking at the receiver and willing it to work, dammit!

Maybe I'm in a honeymoon period of sorts. Maybe I'll get disillusioned. I've read blogs from people who have. It's not a fully mature product or technology, by any means. You have to be patient and willing to work through some minor hassles. But it's definitely mature enough to work, and when it works, it's like a different world.

It's alive... and more interesting information

What a day it was... I inserted the new sensor yesterday around noon after giving up on the old one, waited two hours, did the calibration... and it didn't work right out the gate. Similar behavior; "???" most of the time, gaps with fingersticks, etc.

Eventually I spoke to Dexcom's Christine again (who has been tremendous but must be getting tired of me by now) and she suggested what I already knew - restart the sensor. I did so, and lo and behold, it started working normally!

Two things about this:

1) it goes to show how addictive the system is. I was literally depressed friday night and yesterday when I couldn't use it, and became quite irritable. Once you get on it, it's very, very difficult to consider not having it.

2) there is an important distinction to be made between weird behavior on the first 12 hours and after them. Apparently, although the symptoms were similar, the first sensor was indeed failing. The second, however, did not fail. Instead, what was going on is that it didn't get fully saturated during the first 2-hour period, leading to the messy readings.

When this was explained to me, I could immediately correlate it to something else. The first sensor I put in felt comfortable in 20 minutes or so. The second sensor, maybe because I put it at an odd angle or was struggling too much after insertion or whatever else, still felt a little awkward several hours later - I could feel the little needle, quite easily if I pressed lightly on the transmitter. That feeling eventually went away sometime before I did the rest. Related? maybe.

The business of insertion and removal

Now for something a bit different. I'd like to write about the whole experience of putting the sensors in and taking them out. The former is mentioned occasionally, the latter I haven't seen anyone posting about. I think both of these are important to those of you considering buying the system (which you should do, no doubt about it, failed sensors or not).

Please note that I am writing this tongue-in-cheek. It really isn't bad, especially not considering the benefits.

Insertion: first of all, let me say that insertion is, oddly enough, easier than removal. I'll explain why later on, but the insertion process is fascinating. I won't go into the details, but you're essentially using an injector to push in an insulin needle at an angle that will then reside in your body. It pricks a bit for sure, but that goes away quickly. The process is as fool-proof as they could make it, but it can be a bit freaky because removing all the attachments requires you to jostle the inserted sensor around a lot. Why? well, attaching the sensor unit is easy enough, as is removing the safety tab and pushing the injector in. Then come three steps that require manual dexterity and some effort:

(1) pulling back the injector. In the commercials you see someone grabbing the pulling lever between two fingers, and simply compressing upwards, all the while smiling heavenly to the tune of an angelic orchestra. In real life it goes like this: you put it between your two fingers, and try to compress towards your thumb. You need to remember to pull up while pushing down but pull up more than push down, because otherwise, you'll feel the needle. Of course, don't pull too hard the other direction so as not to feel the needle pulling out... ouch. I swear I'd have pulled my liver out too if it wasn't for the adhesive. Then, you will realize that the lever action is two-step; it goes up, stops, and then you have to compress it again. Trust me, this thing is not smooth.

I think the psychological impact is the most difficult; I keep worrying I'm breaking the needle in my body, or bending it, or pulling it out, or a host of other imaginary stupidities that have nothing to do with reality.

(2) now wipe the sweat of worry off your face and concentrate. You need to squeeze those two little tabs at the bottom, then roll the injector forward. Easy to do - on a hard surface. Thing is, at least my body doesn't count as one. So you're gonna be squeezin' and pinchin' and turnin' and gruntin' but the darn injector just will not... move... forward. And when it finally does, it will do it in the middle of your darndest effort, which means it will be flying, which means you'll be pulling on the back side of the sensor and consequently angling the needle straight into your abdomen. At least in your thoughts, anyway.

(3) Now you have to put the transmitter in - easy - then break off the tab. Did you think you were worried about turning the sensor around too much? you ain't seen nuttin' yet. See, this little plastic tab is good at what it does, and what it does is be part of the bigger plastic unit. It really likes its little home. It doesn't want to go away. So you'll be sweating full of worry again until you hear the thing snap, because guess what, it's not a demo on a table, it's in your friggin' abdomen that all this is taking place.

Removal: so now you've had this little buddy in you for (I am assuming) 7-10 days. You've gone through the whole getting used to it period, the constantly touching it to make sure it's there period, the (I'm assuming again) bumping into things and suddenly remembering it's there period... and now it's time to take it off.

Thing is, in order for it to stick around like that, it has to stick. Know what I mean? Now this is a nice, solid adhesive. Just like the little plastic tab, it doesn't wanna leave home. here's a tip: never, ever, ever even consider putting it anywhere with hair.

Now get ready, because this is gonna hurt a lot more than the insertion. You need to peel this little sticky sucker off. The problem? it's attached to a needle that's inside your abdomen. I don't know about you, but keeping this in mind, the "quick peel" method simply doesn't appeal to me very much.

So I wanna be careful. To me that means peeling all around the sensor/unit first, then carefully removing the rest... which is still attached with that adhesive in the bottom. In other words, you don't get to peel the adhesive then carefully lift the unit out of your abdomen. Oh no. You peel around and then pull it off - hopefully at an angle that somewhat approximates the angle of the needle in your body.

I swear, the psychological pressure of this process is a killer.

So you've removed it? good. Now breath deeply, and wipe that sweat off your face...

It's time to insert another one.

Failed sensor and some new info

I am happy to report that Dexcom will be sending me a new sensor to replace the failed one. This procedure certainly serves to explain the high cost of the sensors; if the failure rate is relatively high, then it would drive costs higher overall.

To look this up I searched the performance information which is available at the back of the user manual. Indeed, it appears that 13% of sensors fail within the first 3 days of use (page 133, bottom right). That's a bit less than one in seven.

In fact, the chart indicates a 25% total failure rate on the first six days, and 19% on the first five. I don't know what the policy is at Dexcom for sending replacement sensors, but let me assume for a second they will send one if the current one fails during the first five days. Also, because of the cost of these things, some folks will try to take advantage of the system and drive the replacement rate slightly higher; let's say an additional 2-3% percentage points.

This means that practically, they are sending a new sensor out to replace a failed one once for each box of sensors. If the policy is six days, it gets even worse.

That's a terrible way to run a business.

My suggestion to Dexcom: if this is more or less right, and if the distribution of failures is more or less even, save yourself a lot of trouble and tons of admin and support costs and send an additional freebie sensor with each box by default, at least until you get a handle on the production side. Make sure it is clearly communicated that this freebie sensor IS the "first replacement" for a failed sensor, and track that internally per receiver. The communication side is going to be really critical here, you will need to make sure customers understand the change and what it means for them (while they are getting 5 sensors for the price of 4, it also means that when one fails, they don't get a new one shipped unless they have already used the freebie as a replacement).

While this will not entirely eliminate sending replacement, it will most likely reduce it by 80% or so; my guess is that the savings on admin and shipping costs would more than offset the cost of the extra sensor added to each box.

One thing for other users to note: if you tossed your packaging when you put in the sensor, and then it fails, and you are for the lot and serial number, remember that (1) the lot number is identical across batches (so all four sensors in a box have the same lot number); and (2) the lot and serial number are printed on the sensor itself. When you take it out, look on the inside and you'll see them in tiny black letters.

Something else that turned up as I was going through this issue. Apparently, recalibrating the sensor more often when it has trouble reading the signals is just going to confuse the system more. It's not only not helpful, it's a contributing factor to faster deterioration of its performance.

In practice, this means that when your sensor starts acting weird, for whatever reason, showing scattered reading that are less accurate, adding a few calibrations for good measure is in fact a bad measure. Instead, reset the sensor and see if things get smoother. The reason for this is that the system uses the last six sensor readings to compare against the meter calibration test, and when there is trouble reading the sensor (showing "???"), there are less data points and therefore diminished accuracy. Since I presume there is a statistical model hidden in there somewhere, the impact would be exponential, not linear. Thank you Keri from Dexcom for this piece of advice.

Thinking about this, I will also venture to add that calibrating during a strong trend (rising or falling) may also not as useful as during a stable period, as the trend in itself introduces increased variance (inherent in the rate of change in readings). This may be flushed out if the model is strong enough, but since I don't know the model I can't really say.

To keep each post more or less on topic, I'll end here and move on the next post, in which I will discuss a couple things that I haven't seen talked about much elsewhere.

Dexcom support

Based on the suggestion I received, I did call Dexcom support and indeed, they have an oncall person.

She suggested I monitor this throughout the day to see what happens.

Well, I'll tell you what's happening: it's become completely unreliable. The gap between meter tests and Dex measurements is ridiculous - in the space of 20 minutes I had a meter 129/Dex 188 and a meter 119/Dex 198.

I do indeed hope they replace the sensor. In the meantime, I am going through the restart procedure (tell the receiver I tossed it, then tell it I put a new one in). I'll see if that makes it work again. If not, then bye-bye sensor (a bit disappointing for it to go bad in under 3 days).

Reliability

My Dex has gone weird on me.

Sometime yesterday - it started around 6PM or so - it suddenly became a whole lot difficult to actually get a reading consistently, for no apparent reason. I kept the receiver right on my body as I have been for the previous 2 1/2 days, but I'd keep getting a "Y" every two or three readings, as it it were out of range.

Then it got weird. The readings literally started jumping up and down.

Here is an example from last night:



Notice the gap on the left? that's when the range thing started happening. Also note that subsequent to that, the readings are not "always there".

Then look what happens around the middle of the graph. Up-and-down, down-and-up, I didn't know blood sugars could even do this. I really don't think they can. The most incriminating evidence is the little red dot, though. If you look, it is taken at the same time that the Dex is reporting the blue dot much higher above it - in fact, the Dex was claiming I was in the 250's, my actual result was 190 or so... as the Dex itself reports immediately following the calibration. I had calibrated the device previously at 3PM.

Also note that even when the downtrend gets established, the Dex still seems to want to do this up-and-down game; look at the little clusters.

It became much worse during the night:















Again, we get "mini-trends" or clusters, but the overall pictures is strange. Also note - again - the significant gap in a calibration result on the left.

What's going on? My biggest problem right now is that I don't know whether I can continue to trust the Dex, which kinda defeats the purpose. Is it a sensor problem? a transmitter problem? software issue? something going on with my body? is it simply that it doesn't function very well when blood sugars go way out of whack?

And the worst part? it's the weekend (of course). I don't think I can call anywhere for help.

If you're going to buy the Dexcom...

... please remember that it uses the Onetouch Ultra as its sole calibration tool.

I just had a chat with Christine and she mentioned I'm not the only one who wasn't taking this into account as part of my routine. The problem? I had just refilled the strips prescription for my regular meter (Freestyle Flash) a week before I got the Dexcom. Result: no strips for me until the next roll-through refill period.

Yes, they do tell you that, but it gets lost in the general excitement... it just needs to be stressed more, as in (hypothetical conversation between potential client and Dexcom rep):

Potential Client: so this gives me 288 tests per day? cool!

Rep: yes, indeed, isn't that nice? by the way, please remember that you are going to switch meters to the Onetouch Ultra, and must get your prescription changed to get those strips instead of your regular ones.

Potential Client: and I can shower with this, right?

Rep: oh yeah, it's water proof. Plus you should remember that you're switching away from your current meter to the Onetouch Ultra. Make sure to speak to your doctor about a new prescription for strips.

Potential Client: will it give me an alarm when I go high or low?

Rep: Absolutely. It has a fixed low blood sugar alarm, plus user-configured alarms. But there's one general alarm you can avoid if you make sure to have your prescription changed for your strips for your meter, because the Dexcom can only be calibrated by a Onetouch Ultra.

Potential Client: Wait, what? Onetouch Ultra? but I use ACME Uber-Meter II!

Rep: *sigh*

Well, I guess since the Dex will allow calibrations by any meter in a few months this is somewhat of a moot point, but still... I thought it was worth noting.

By the way, kudos to Dexcom who had come through for me with a few extra strips until I could get them switched with my insurance. But one cannot rely on that.

More trending

I mentioned this in passing before, but I now have enough data that I think it's worth a post of its own.

If you see the "???" entry hitting your Dex screen after a trend gets established, and see that there are actually two of them in a row, YOU ARE PROBABLY MOVING TOO FAST FOR THE DEX TO SHOW THE NUMBERS.

Oddly, this is the single most powerful indication it can give you.

At that point, use your meter.

Suggestion to Dexcom folks: have some software indication for this particular point to urge a meter test.

Second night

So last night I put the receiver under the pillow. Worked a lot better; while it still missed readings here and there, I got most of them.

I was for the most part stable all night so I didn't get any interesting data, but at least I know I WILL get it when things go wrong.

Cool.

More Dexcom Joy

So I eat my dinner...

First I have a minor trend established going higher. Since it's a minor slope I can determine quickly how high it will reach, and provide a small correction.

Later on, as a reverse trend suddenly gets established, I realize that my small correction was comparatively large because of the lowered carb intake. But the down trend is easy to notice on the Dex, and instead of realizing I'm hypoing when I hit 80 or even 70, I catch it at 140, eat something small, and it all sorts itself out before I go under 100. I am now stable at the 130-140 range, which is where I feel comfortable before bed time.

This is brilliant. Instead of making few big adjustments I get to make many smaller adjustments, which is a much more flexible and ultimately accurate way of managing things.

Christine gave me another good tip, which I am hoping to put to use tonight: apparently, the receiver unit functions better when it is higher than the transmitter. Thus I will put the receiver in an elevated position next to me and see if it has less missed readings.

Tickled Pink

So I just had a quick conversation with the wonderful Christine, the Dexcom trainer.

Anyhow, as we're talking I mentioned to her I was writing the blog, and that I wrote this thing about this interesting element of the Dex that I was noticing about its behavior. I was a little sheepish when I said it had to do with trending...

She says: "it lags when going high and leads when going low".

I was right!

She then told me why this happens, which while not exactly what I was thinking, is rather close. Basically because the Dex is sitting subcutaneously it looks at cells rather than blood, and thus when changes occur they occur first in the blood (as sugar starts building up) when going high, and in the cells when going low (as sugar gets pulled into the blood stream). Thus the predictive trending.

I must admit that I am extremely tickled by having both noticed AND figured this out after only 12 hours of usage. I mean, imagine that! I get the sense that I'll be deriving serious benefit from this little gizmo, as I keep figuring other things out over time.

First night, first shower, and more thoughts

First of all, the trending thing I was mentioning still seems to be holding true, whatever the reason. I do realize the Dex doesn't measure blood levels but electrical currents, but I think it would work more or less the same way I described. Anyway, it has for the 24 hours I've been on it *smile*

I have now had the first couple of major glitches with the device:

1) around 9PM yesterday night I tried a new calibration test. Dex took it fine it seemed. Went to sleep. Around 3AM I was woken up by an alarm - the Dex wanted me to provide a new calibration test. Huh? I thought the 9PM one should be sufficient to carry me through to the morning.

2) I lost so many readings through the night that the data is almost meaningless. I don't necessarily think it's directly related to transmitter range (see point 3). However, something IS messed up here, and if I can't get good night-time graphs, that will immediately reduce the efficacy of this as a control tremendously. Any suggestions on how to make this work properly during the night? I was sleeping with the unit next to the bed, which is really just a mattress on the floor right now (our furniture mostly staged in our old house which we are trying to sell). Then after it woke me up at 3AM I put it literally next to my body on the bed, and it still missed most readings. In other words, it was never more than 2 feet away. Am I doing something wrong?

3) Had my first shower with the sensor/transmitter today. No problem. It also raised an interesting point about range; I left the receiver in the bedroom and for at least 20 minutes was more than 20 feet away from it - AND I was in the shower. Receiver kept registering measurements throughout. So the night-time problem is not strictly a range issue. I'm wondering if it's somehow related to the way our body functions in sleep?

More empirical evidence

My little theory is being put to the test...

Ate dinner. Blood sugars were rising (as expected, post-prandial). Dex was showing a rising trend, then started tapering off. Meter showed 243. Dex kept rising for several more minutes (lagging indicator) up to 221 before quickly reversing. Now it shows 177, my meter is still showing 230 (starting to drop though). I'm betting Dex is being a leading indicator again on a lowering trend.

This is fascinating. I just need to figure out how to really work with this.

More impressions

A few more things I've noted... and this is just my first day!

1) The Dex seems to be a lagging indicator when a trend goes HIGH, and a leading indicator when a trend goes LOW.

What I've noticed is that the Dex lags behind the meter when a rising BG trend gets established. By the same token, it leads the meter when a dropping BG trend gets established.

I have a theory about this, which is most likely complete and utter nonsense, especially considering my highly limited understanding of this field. I'll share it anyway so you can all make fun of me. It goes like this:

The Dex is subcutaneous whereas meter is blood, and the way the body works is that sugar in the blood gets broken down, then enters the cells through the layer in which the Dex sensor is embedded. This process takes a bit of time. Now see what happens:

In a rising trend, too much sugar is in the blood stream, and the rate of breakdown to glucagon is essentially too slow; thus, it takes it more time to filter through the "Dex layer" and show on the Dex screen. The end result is that the Dex reacts a little slower in confirming this trend, as the breakdown activity "catches up" to the rising trend.

As a side note, if this is right, then it could very well be that the Dex will never be able to show blood sugar levels when no insulin is active whatsoever (such as pre-diagnosis).

In a dropping trend, the reverse occurs. As blood sugars drop, the cells get starved even faster, because too much insulin is breaking down too little sugar much too fast. In a sense the Dex becomes predictive because of its location as a middleman between blood and cell.

Again, if I'm right then people who generally have stable blood sugars will see overall a much higher degree of "accuracy" when comparing the Dex to their meter than those who have bigger and more rapid changes in blood sugar levels. It would also suggest that the Dex on its own will be less useful in times of, say, sickness, when blood sugars get messed up. But it would be more useful if used in conjunction with a meter than a meter alone; see point 2.

Enough pseudo-science. If anyone has some ideas around this I'd love to hear them, and again, what I say above could be and is entirely likely to be complete and utter hogwash.

2) The combination of Dex and meter is extremely powerful in allowing the PROPER reaction in the proper TIMING once a trend gets established. Why?

When its trending lower, the Dex will tell you two things: (1) a hypo is coming even if your meter hasn't caught up to it yet; it might be just enough of a lead to avoid an actual hypo altogether; (2) that your corrective action has succeeded in staving off the hypo when the Dex is still claiming low blood sugars but your meter is already reflecting the future increase (reversing the trend).

It's a little more difficult to explain when the Dex is trending higher. Basically, the velocity of the change on the Dex can give you a good guesstimate of how high you'll go, when compared to the actual values as measured by your meter. In other words, the meter becomes a predictor for the Dex, while the Dex provides an indication of when the rising trend is tapering off (and thus the rise will stop). The combination of both results can provide a pretty tight window estimation of just how high you are about to get and how to correct.

Think of it this way. The Dex is trying to play "catch up". It will therefore hit its highest "slope" on the graph when your actual BG's are still rising. However, the graph will being to taper off when your actual BG's have more or less stopped rising, because the catching up must become more accurate. You can then use your meter to see where you actually are and have a pretty solid indication that you won't rise much anymore. Sure, the Dex may take another 15-20 minutes to get there, but you get to act NOW, and get to act APPROPRIATELY.

I've used both of the above analysis successfully today, in staving off a hypo before it happened and stopping a rise in a manner that avoided what would previously have resulted in a follow-up hypo.

3) Can someone tell me what the deal is with the stupid transmitter? first of all, the range is dismal. But beyond that, why the heck are they even using an active instead of a passive unit? wouldn't it be a lot easier to use a dynamic RFID chip which is then read by the display unit? it would surely make the cost of what is today the transmitter unit a lot lower, because a passive unit is a lot easier to build let alone make waterproof. It would also allow it to be a lot more compact. Am I missing something here?

My first few hours on the Dexcom Seven

First impressions:

1) Dear god, this thing is addictive. I can't stop looking at it. I really really REALLY wish there was an option to just keep the LCD screen on all the time, even if it means I need to be diligent about recharging it daily (which I'll be doing anyway, just like I do my phone). Another UI comment: an option to have the reading itself in very large font superimposed on only the graph would be nice, for those times when I want to catch the number and general trend at a quick glance without being distracted (such as when driving).

2) The trend graph is even more important and useful than the actual readings. I can react so much sooner to sudden changes. Interesting point is that the receiver will indicate a gap in readings if there has been a change more rapid than around 15-20 mg/dl between any two 5-minute readings; just that in itself is a powerful trend indicator!

3) How I LOVE being able to download the data and play with it in a spreadsheet. And this is just after a few hours. I can't imagine how much fun I'll have with several days' worth.

4) Accuracy DOES improve over the first few hours. The first couple of readings were Dex 154 meter 185. An hour after I got the sensor in I had one reading where the Dex said 136 and my meter said 207. An hour afterwards it was Dex 187 meter 221, an hour after that 161 to 180, just now 98 to 103.

5) Another UI nitpick: the graph should START on the left and advance towards the right, as opposed to starting on the right and PUSHING to the left. I was terribly confused for the first 10 readings when it seemed like the graph was advancing right-to-left with newer readings on the left. It's not. But it seems that way.

6) Keep between the lines: you got it, Dexcom. That's the game now. Keep between the lines. It's a simple and obvious goal. And it's a heck of a lot easier.

7) Interesting observation: I eat lunch, graph trends lower during he first 20 minutes during lunch. Thus I know to eat my bread first, salad after. THAT kind of distinction I NEVER could have had before. And directly because of that I caught a hypo before it happened. This was followed up with the typical post-prandial rise, but because of the trend graph, I was able to quickly get a sense of how QUICKLY I was rising and inject a correction bolus that was ACCURATE rather than over-reacting. Again, I could never, ever do this with a meter. And it has nothing to do with the readings themselves and everything to do with the velocity of change in readings, or in other words, how steep the trend graph was. It's like the first time you get exposed to level-2 information when you trade stocks. A new dimension. Wowza.

8) Is there a way to look at the most recent "available" reading in cases where the Dex has some problem? (like when the "???" is displayed). Would seem an obvious option but I can't find it.

I love it.

I can summarize it this way: I've had one major, significant event in my life as diabetic over the last 23 years, and that was 11 years into the disease when the doctor I had just hired privately spent two meetings over three weeks with me and fixed the most terrible problem I was suffering from: hypo unawareness and frequent night comas due to low blood sugars. Apparently I was allergic to the specific insulin that I had been given previously, to the point where my liver would not respond to hypos normally (by releasing stored glycogen) because its reaction was suppressed by my particular allergy. He changed it from Human Regular to Lispro, and the problem disappeared practically overnight (even if it took me 3 years to believe it). The most amusing part in retrospect was how he thought it was the most obvious thing in the world. For me, it was a life-changing event. Suddenly I could live alone, and not worry about the 3-4 times a year where I would end up in a hospital with temporary or permanent damage to various body parts due to massive night-time hypos. I had taken EEG's that show conclusively that I have some major scars in my brain because of some of those events. It was nice not to have to gain any more, nor broken limbs, nor further damage to my teeth and jaw, nor a tongue so bruised from being bitten down on so hard that it was raw and in constant pain for weeks at a time.

This feels on the same order.

I'm wired!!!

For several minutes after the trainer left, I could hardly breath without tearing up...

The Dexcom sensor is in. Still can't see anything as I am in the 2-hour initial sensor period, but it's in and doing what it's doing. Sometime in the next hour or so I'll get a vibration to tell me to do the meter calibrations...

This is going to be one long hour.

Dr. Faustman

So how come I never hear about these things?

Go, Dr. Faustman, go!

The executive summary for those of you who don't like to click on random links: looks like this lady has been showing repeated successful results in reversing type I diabetes in lab mice, and is ready to move to human trials in 2008. She's proven that the pancreas has an ability to regenerate beta cells on its own once the destructive T-cells - those that originally destroyed the beta cells, and that apparently continue to do so - are removed from a diabetic's blood. No autoimmune suppression necessary, no implants, no stem cells, nothing but a tightly controlled 40-day treatment and you're healthy again.

I may start praying soon. Anyone has a deity they want to suggest?

To Die in Jerusalem

So I finally got to watch this documentary.

Interesting concept, fascinating results. It also validated for me something I've been saying for years in explaining the overall Israeli-Arab conflict in the middle east.

The one single most important thing that Israelies, by and large, lack to a degree that makes it practically impossible for them to ever have a decent dialog with Arabs is respect. That is, showing respect, or deferment. We are big on honor, but we maintain our honor by never really giving in, by always providing an image of strength. That's why our discussions are loud, our body language borderline violent, and our facial expressions exaggerated. It is telling that there is no hebrew word for gracious.

If you look at Abigail's body language, tone, and facial expressions throughout the conversation with Um Ayat, it is hard (for an american anyhow, and even then I am guessing since I've only been in the US for 8 years) not to be deeply offended, regardless of her words. The raised finger, the raised chin, the eyes half downcast as if she is looking down on her rivals. For a typical american, my guess is that it would be practically impossible to even try and decipher her intent, or recognize any concessions she might make (as indeed she does throughout the film). It's not just her, of course; if you examine the gathering in her house, where they speak about her plan to meet Um Ayat, just examine the body language, tone and facial expressions of almost all of them when the discussion gets heated. We all do this, and there is nothing to it; this is how we communicate.

In other words, our culture is one of honor through superiority.

Now, I can't say for certain that I'm right, but it has been my impression that while Arab culture is also about honor, it is not honor through superiority. Rather, it is honor through respect or deferment.

What do I mean by that? I mean that in all my numerous encounters with arabs growing up, in Israel and outside of it, and even in the occupied territories before everything went to hell 15-20 years ago, I have seen one constant theme in which even sworn enemies always followed a certain code of conduct, and have always deferred to each other even when arguing heatedly. In fact, as an Israeli it was difficult not to instinctively interpret this deferment as weakness (something that encourages the tone of superiority we all learn at a young age). It gets worse. Since we think in terms of superiority, having someone allow us our aggressive posturing while still maintaining their convictions must mean that they are lying to us.

Examine Um Ayat's (and Abu Ayat's) body language throughout the film, and even when she gets very upset, it still is not aggressive. Her tone gets high, but it is explanatory, not inflammatory. Go to a mosque once and you will see where it comes from; even when the cleric sings about the worst horrors one could imagine, he sings them piteously. Her convictions are strong, but she, too, is making concessions. It's just that Abigail can't hear them (to which she admits towards the end) because they are delivered in a way that confuses her; they are strong words delivered with a somewhat exaggerated show of respect.

Thing is, we're both fighting about the same thing - honor - but our communication style is horrendously incompatible. We continually insult and condescend to them. They continually irritate and confuse us. We all have the same good intentions and even share the same goals, but it gets lost in the delivery. And never the twain will meet.

I have claimed and will continue to claim that an Israeli leader who can speak to Arab leaders in their language - not the words, but the delivery - will have an easy time of settling differences. This film just reinforced my opinion. Yes, it has to be an Israeli leader, because Israel IS in a position of power. Thus it has to make the bigger concessions, and has to rise above itself further. Yes, they will have to find their match amongst arab leaders, to a lesser degree. But it CAN happen. Will it ever?

Wednesday, not thursday!

It was a complete surprise to me to get home tonight and find that the Dexcom had arrived... I called the trainer and was able to reschedule to Wednesday morning.

It's amazing how saving an extra 30 hours seems so important considering I've waited 23 years for this.

Three days, one hour... and counting

Had a chat with the Dexcom trainer this morning, and we have a date set up for Thursday at 4PM. The kit should arrive tuesday or wednesday - assuming they sent it Friday morning like they said they would - which means I will have 24-48 hours of building up my excitement before I get "fitted".

Not sure if this is a good thing. I think I'll have to ask my wife to hide the sensors from me so I don't try to do it on my own.

On another front, seems like I started losing weight again. Got the first 20 lbs off (from 237 to 217) over several months, then plateaued for several more. Checked again this morning about 3 weeks since last time and I'm down another 5 to 212. 20 more to go! I fully attribute this to my recent shift towards a lower-carb approach. While I still eat carbs, what I've done is limit most of my carb intake to one meal a day, trying to mostly stay off them for the other meal (I rarely eat breakfast), thus effectively reducing my overall carb intake by about 40%. Seems to work, and it's also eminently sustainable. I'm also grazing more but it's largely carb-free (olives, pickles, tomatoes, a bit of cheese, that sort of thing) and it doesn't seem to hurt. Interestingly, my overall calorie intake has stayed roughly the same, so something else is going on.

Now if this thing gets created...

... I may finally get an insulin pump.

For years I've been opposed to the notion of getting a pump - for many of the reasons detailed here.

But if this system gets created... I may just change my mind.