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    New Toys!

    Yesterday, I had an appointment at my diabetes clinic. In addition to all the normal aspects of a clinic visit, such as getting my A1c, I was expecting to sort out some unresolved details regarding my pump and CGM funding. Chief among these was that I'm still using a loaned pump and need a replacement Real Time pump for the sensor funding to be of continued use in future. What I wasn't expecting was Christmas to come early.

    I left the hospital weighed down by boxes including:

    Paradigm Real Time
    A brand new Paradigm Real Time System.
    Pump!
    I've switched back to a clear 722. The main reason for using a 722 rather than a 522 is because I'm lazy, and I hate filling reservoirs!

    To be honest, I was a little taken aback at the ease with which they opened up the cupboard and dished out a new pump from their plentiful stock. Giving away glucose meters is standard practice in the UK, because the manufacturers make their money on the strips. But giving away insulin pumps when the funding for them is still pending? This was a new one on me, and just seemed far too easy. If anything it made me feel even more frustrated about how much of a struggle it was to get considered for funding for CGM in the first place.

    I was expecting the next one:

    MiniLink
    MiniLink CGM transmitter
    Inside the box

    And then I got one of these:

    Contour Link

    A Bayer Contour Link blood glucose meter

    This is the first blood glucose meter that communicates with the Paradigm pump to be available in the UK. The technogeek in me loves the idea, but my initial impressions actually aren't all that favourable. A proper review will come when I've had more chance to fairly evaluate it, though.

    And theeeen.....

    Nothing to do wth diabetes: My new TV!

    Well, no 'and then' really. This one has absolutely nothing to do with diabetes, and I didn't pick it up myself yesterday as that would have been pretty tough to do. I've been desperate to replace my old 18 inch CRT television, that shrinks movies on DVD to the size of a postage stamp in the centre of the screen, and cuts the sides of broadcast programmes because it can't cope with widescreen, for a long time.

    So the last one is my present to myself.

    Have a great weekend!

    CGM Approval: The Funding Finish Line

    This is a landmark diabetes year for me. My quarter century: Twenty five years of living with the highs and lows, quite literally that type one diabetes brings.

    Things have changed a lot in that time. From the type of insulins I use through the regime in which they are administered to the way they are administered. From beginnings of animal insulins in clunky syringes, I've now been using an insulin pump for more than six years.

    And the changes in monitoring of blood glucose levels have made what we used to do back then almost unrecognisable. Back then we couldn't have conceived of monitoring systems designed to be worn continuously. This past Monday, though, marked my two year anniversary of using just such a device.

    I'm still as committed to, and impressed and amazed by, CGM as I was back on that balmy July evening when, fresh out of hospital with a diagnosis of Addison's Disease, I got hooked up for the first time. I remember the feeling of blinkers being lifted away as I could see for the first time the direction I was heading in.

    I'm not sure if I can claim that CGM has improved my A1c and I'm certainly not convinced that I can claim it's saved my life, but it has made an enormous difference. A difference in the number and severity of my low blood sugars. A difference in my confidence to work in the occupation that I do, without putting myself or my patients at risk. It's made a huge day-by-day difference to the quality of the life that I'm living. That is important, because if life must be simplified and stripped bare in order for me to live it healthily, then I can't really see the point. I want a full life and a healthy one.

    It didn't take me long to decide that CGM was a tool that I wanted to be a permanent part of my diabetes management system. The problem? This technology is expensive.  I've been very lucky to experience incredible generosity and have had the necessary hardware, a  Medtronic 522 pump, loaned to me (not directly from Medtronic, I must add). But that pump is not my own, and sooner or later will need to be returned. I've also had to pay out of pocket for the sensors from day one. Here in the UK, the original sensor price was a whopping £50 a pop (roughly US$100 at the time). Although there have been price drops since, sensors still remain a significant cost. So I turned my attention to getting it funded by the National Health Service (NHS).

    Contrary to what some may think, the NHS is not a free service. Like any other nationalised service, we contribute to the cost through taxation. Essentially, the more tax you pay, the more you contribute and I don't mind admitting that I'm a higher rate tax payer. There are several people who've suggested to me that that fact alone means I must be able to afford to pay for my own CGM. Well, yes, if I really have to - and I have been doing. But it means giving up something else - maybe a hobby, or a holiday, that if it weren't for the chronic health condition I have, I would be able to do. Aside from that,  there is a principle at stake. I've already contributed significantly to the NHS. I work for the NHS, for goodness sake. And finally, if I can't keep my low blood sugars to a minimum and keep myself in reasonable control, I won't be a higher rate tax payer, or working for the NHS in a high-demand field, for very long. I'll be sitting at home, drawing benefits from the state and contributing nothing.

    I always knew that I'd have a fight on my hands. I got my original insulin pump prior to centralised guidance on when the NHS should, or should not, pay for an insulin pump, issued by the National Institute of Clinical Excellence, or NICE. Insulin pump funding used to be decided on a case by case basis, demanding that each patient prove they had good reason to benefit. So I tackled CGM the same way. I showed my diabetes team data comparing hypos requiring assistance, ambulance rides and hospital admissions whilst on and off sensors. I showed them how, in my hypo unaware state, CGM caught the majority of lows sooner, made them less severe and more quickly reversed. I talked repeatedly about the difference it made to my life. How it meant I could go to work, and do the job that I love, safely.

    I may as well have been talking to a wall. Sure, people seemed impressed with the figures I was giving, but this was "new technology", "unappraised technology", "of no clinical benefit."

    What? Had they really actually been looking at my data?

    My frustrations mounted with each unsuccessful attempt to get funded. I became unwilling to have periods off the sensors in order to keep showing the difference that it made, and I stopped taking the numbers along to hospital visits. I would end up in tears as new doctors I'd ever met before said things like "Well you know, diabetes is my job, so if you just brought along three months of records, I bet I could fix it. I do it every day. You don't need CGM."

    They may meet people with diabetes every day, but they don't live it 24/7. I flared with internal anger at the arrogance that he could change everything in 5 minutes when I'd been failing to change it after months of effort.

    Finally, three weeks ago, I got the opportunity to see the top professor at the university hospital where I'm a patient. And she did something none of the others have done. She listened. Really, really listened.

    Fresh from the ADA Scientific Sessions, she told me the problem - current clinical studies aren't showing a measurable benefit from CGM.

    "But", she said, "that's almost certainly down to patient selection." Her attitude was: "Show me what it can do for you."

    So I did.

    I showed her graphs of my blood glucose on sensor and off. How off sensor the numbers varied much more wildly, there were more lows, lower lows and lows that lasted longer. I showed pie charts that detailed the umber of readings that were high, low or in range comparing a week on sensor, and a week off. We talked about my hypoglycaemia unawareness and the attempts I'd made to improve it. We went through the number of times I'd needed glucagon (several) while off sensor vs on (attributable to steroid crisis). We talked about the lows that I needed assistance to treat. We talked about the three times paramedics have been called to me in the last year and how each time I wasn't wearing a sensor that particular week. We talked about the effect on my work and how I must run myself higher which doesn't fully alleviate the stress of the potential of lows, but increases the stress about the damage I'm doing to my body. I made it plain that  knew all about the inconvenience of wearing the sensor, the problems with accuracy, how it doesn't make diabetes vanish.

    And then she said the magic words: "You've more than convinced me."

    So finally, after nearly two years of trying, we have a concrete plan. I've spent the last couple of weeks collecting more data on my lows without a sensor on. I've filled out a whole bunch of questionnaires to quantitatively assess the impact of lows on my life and assess my hypoglycaemia unawareness. Next week, I'll return to the hospital and I'll begin 3 months of fully funded sensor use. At the end of the three months, we'll compare the data looking for an improvement. If the improvement is there, I should be in line to get the funding permanently.

    I know there will be an improvement, because I've already seen it for myself.

    Whilst I'm not counting my chickens just yet, I finally feel like I'm on the home stretch.

    CGM Reflections

    Tomorrow, it will be exactly 18 months since I first got hooked up to Medtronic's original Guardian RT and I got to learn for the first time what truly amazing things my blood sugar could be doing while I wasn't looking.

    Back then, the device looked straight out of the 1980s. The monitor was cumbersome and heavy and had a tendency to make a death leap from my waistband more than once a day. The numbers were real-time, but the graphs weren't. To figure out the trend, the true value of this device, you had to scroll back through the last dozen or so numbers and draw a mental picture of where you were going.

    But compared to fingersticks alone, compared to what I'd had for the previous 23 years, this thing was a revolution. The drawbacks of irritation from the adhesive and the size of both the transmitter and the monitor were easily outweighed by the information it gave me. And the timing for me could not have been better, coming just days after the diagnosis of Addison's threw a huge spanner into the workings of my diabetes.

    From the get-go, I didn't want to not have regular access to this technology ever again. I couldn't see that I'd ever really want to be without out. That still holds true, but I cannot believe it was only 18 months ago. Things have come so far since then.

    After starting up with the Guardian I cycled between that and a loaner 722 until I got my own 522 pump which I've been using for the last 14 months. The real-time graphs were as much of a revolutionary step-up from the numbers alone as the numbers alone had been from fingerstick data. We've all heard the analogy about it being like driving with the windshield uncovered for the first time. It's true.

    CGM really has made an enormous difference to me. Right back at the beginning it was the biggest single thing in helping me retrieve my confidence, bruised and battered as it was from  countless episodes of severe hypoglycaemia  as my cortisol deficiency went undiagnosed.  It was the major reason I went back to work so soon and makes a regular difference to my working life now.

    As a dentist, I cannot afford to be hypoglycaemic on the job. For my patients' safety. For my safety and the safety of the people who work with me. Even if a high-speed drill in hypoglycaemic hands weren't dangerous, how would I be able to do a good job, a job up to my high standards, if my brain were fogged by a low? I couldn't, plain and simple.

    Previously, my only defence against lows was regular fingersticks, prevention and relying on my symptoms to alert me to quick drops between tests. With my hypoglycaemia awareness shot by recurrent lows and so many years of diabetes, I lost that weapon. The only other way I could see to cope was letting myself run higher, much higher, during the working day. That would have meat trading the immediate risks for the long term risk of my practicing life being cut short by complications such as retinopathy and neuropathy, as well as making me feel awful.

    I do run looser targets at work, for safety's sake and because my mind is very focused on the job and not always so much on diabetes. But with my CGM in pocket to alert me when things are amiss, I feel safer. Without the worry of diabetes I stay focused and my patients get the best of me. And the targets are still tight enough that I haven't had an A1c over 6.6 in the last 18 months.

    And outside of work, it makes innumerable differences too. I've written before about the difference between a blood sugar of 5.5 that is stable versus one that is going down or up. More than 50% of my bolus calculations are now influenced by the information about where I'm coming from and likely to be going to. Travelling across time zones, working out at the gym and living alone are all helped by the numbers from my CGM.

    Of course I can, and did, do all these things without that information. Many people lived with diabetes long before even fingersticks were available. Anyone who strives for good control wouldn't dream of doing that now, and I'm beginning to feel the same about CGM. After all, a healthy body knows where it's at at all times, why shouldn't I?

    There are drawbacks, of course. A recurrent problem is irritation from the transmitter rubbing on my skin, although I've recently begun placing a piece of gauze under the transmitter, which seems to help. I've written before about accuracy, and while it's true that I have few problems and I find the trend is almost always right, screwy sensors do happen.

    I can get burned out by it too. Rob recently described my pump/CGM combo as a little bit like being permanently attached to a Tamogotchi pet, and it was a good analogy. When the fifth or sixth alert of the day starts up, I sometimes want to kill it! Sometimes when my numbers stay consistently above the high target range I get frustrated much more easily than I would by a series of fingersticks showing the same trend.

    The bottom line though is that I still love it. The breaks I take these days are mainly for financial reasons. Eighteen months on, I'm still no nearer securing funding but the longer I go on using CGM, the happier I am about choosing to forgo something else and instead spend the money on sensors. I can't really give it a much higher endorsement than that.


     

    How much glucose can a glucose sensor sense?

    It was Kerri that got me  thinking about woodchucks chucking wood. It was that which gave me the silly title for this post.

    And it was a new comment on an old post that inspired the topic. Adil asked:

    How long can the sensor actually last?

    What surprised me most about this question is the fact that I've not answered it explicitly before. Or rather, that I've not answered it here. I've explained countless times to other folks, on mailing lists, in comments on other blogs and in person, how I prolong sensor life and what my sensor life cycle is, but a quick check of my archives confirms that while I've mentioned it briefly, I've never really explained it here.

    So, first the "official answer'. The sensors are designed and approved to last three days. Now that is out of the way we can get in to the real world.

    There are several reasons why three day use doesn't cut the mustard for me, not least of which is cost. I'm still not getting any financial assistance for the cost of sensors. I'm told there has been a recent price reduction although I can't confirm as I haven't ordered any sensors recently. I'm working through several "expired" ones I obtained from an acquaintance. [Shh, they are working fine. *knock knock* (on wood).] Previously the UK price was working out close to 50, yes fifty, pounds each. For those of you in the US that is a whopping US$100 per sensor. Every three days? Yeah, I don't think so either.

    Admittedly if you have funding or insurance coverage, there isn't the financial incentive to prolong sensor life. But there is another very good reason.

    Like a fine wine, sensor accuracy appears to improve with age.

    This is purely anecdotal, but it is an observation shared by other CGM users, bloggers included.  I find the first three days of sensor data the least accurate of all and so pulling the sensor out every three days would be somewhat counter-productive.

    So the unofficial answer to the question is a little along the lines of how long is a piece of string. Personally I use my sensors for two week stretches. I restart* the sensor at days 3 and 6 and it gets up and running again within 15 minutes. On day 7, I disconnect the Minilink and charge it up, leaving the sensor in place. This typically takes 10-20 minutes. On reconnecting there is two hour initialization period and I'm then good to go for another 7 days, restarting on days 3 and 6 again.

    But as with everything diabetes, your mileage may vary. Some users have gone much longer. Others stick to shorter time frames. I know one woman who cannot get any usable data past nine days. I stick to two weeks because by that point I'm usually getting the very beginnings of skin irritation. Who knows whether the length of time that I go is damaging my tissues below the surface Sadly the decision on sensor life for me is in a large part economic.


    * To restart the sensor at day 3 or 6: go to Sensor --> Sensor Start --> New Sensor and then press ACT. Don't wait for it to ask you for a Meter BG. Just go straight to Sensor --> Enter Meter BG. It will tell you the sensor isn't ready, but press ACT and put the number in anyway. The sensor will pick it up and use it and it stops it alarming to ask for the number a couple of minutes later anyway.

    For more about my CGM experiences, see the archives Knowing My Numbers - CGM

    Examination Questions

    Next Monday I'm sitting an exam that will count towards my first post-graduate qualification.

    And I'm nervous.

    The English school's examination system, coupled with my high desire to achieve and my choice of degree programmes means that I'm no stranger to exams. In fact, they were a summer ritual for eleven straight summers in a row. The moment the weather started warming up and the scent of fresh mown grass and barbecues started drifting in through the windows, I'd know it was time to get my head down into my books. I'd emerge pale, pasty and blinking like a mole several weeks later to enjoy the rest of my summer.

    This, though, will be my first exam in three years and that is definitely a contributor to my nerves. The ritual of revision and preparation seems strange, alien almost.

    But there is more to it than that.

    There is diabetes.

    Being diagnosed at such a young age, diabetes has undertaken every exam with me. I'm glad to say, it has rarely been a problem (the odd French and German spoken language exams aside). But then, I've always been in a secure environment. At school my diabetes, and the adjustments that may be necessary to accommodate low and high blood sugars, were common knowledge.

    Even at university, where some of my exams were sat in vast, impersonal halls with a thousand other students, my diabetes, my pump, my need for testing supplies and snacks were all listed in my record. Even if an over zealous invigilator should question what the little silver device - my Freestyle meter - on my desk was, as normally happened, I knew it would get straightened out without problem. I never felt that my sitting an exam would be jeopardised by diabetes.

    Diabetes being an unregistered candidate for this exam didn't occur to me until I received the candidate information letter.

    There it is, towards the bottom:

    "mobile phones or any other electrical device are not permitted in the examination hall... Use of any electronic device is not permitted during the examination and regular checks of the hall will be made."

    My pump, CGM and testing kit are suddenly prime candidates for getting me kicked out. Even after putting in a call to the examination office, I still feel uneasy.

    As if the stress of just trying to  pass the exam won't have a deleterious enough effect on my control!

    So the question is, will trying to hide my pump, given that I may want to pull it out to deal with CGM alerts, end up drawing greater unwanted attention than having it "out-there". And would I be foolish to try and rely on CGM alone for the 3 hour paper? Your thoughts are welcome and appreciated.

    The number, the whole number and nothing but the number

    Imagine, for a moment, an adult attempting to explain to small child, in appropriate terms, where babies come from. Or how Santa Claus makes it round the whole world in a single night. The course of the conversation will doubtless be punctuated by frequent buts, whys and hows on the part of the child. Small children have an uncanny knack of seeing straight through any confustication and sadly the skill of explaining complex things in simple terms is not widespread.

    Imagine, then, trying to explain not only the concept of blood glucose values but also the information CGM and/or knowledge about past and future food and activities adds to those values, to the uninitiated. A comical situation rather like that between a father and his small son could easily ensue. In most areas of daily life, mathematicians aside for a moment, a number is just a number. If someone asks you for three pounds/dollars/groats, three is what they want. But a number in diabetes? Is a number ever just a number?

    So let's start with the real basics: Under 4 is low, requiring sugar. Over 8 is high. Or sometimes over 7, or even over 12.  What's that? Why? Well it just depends. Different people have different needs and different situations require different targets. Yes, it is a bit like shooting. We're aiming for a target. Yes, that's right, it sometimes moves.

    But anyway, high numbers need insulin. Got that?

    OK.

    Whats my number now? Well, yes, 3.9 is low and yes, normally that means sugar. But hold on, I just ate 10 minutes ago and look at this line on my CGM - it shows I'm going up. So yes it's low, but no I don't need sugar.

    You want me to test your number? You're at 3.5. No, no. That doesn't need sugar either. You see, you don't actually have diabetes, so your body will take care of your numbers for you.

    A little later...

    See - I came up just fine. I'm 8. No 8 isn't high today. Yes, I see from the graph that it's going up, but I'm just on my way to the gym. So 8 going up very slowly is just fine today.

    Later still...
    What's that? You want to know what my number is now? Hold on...

    Oooh... 5.5.

    Yes, yes... I think you understood the basics and yes, that is a normal number. But look, my pump says I still have one whole unit of active insulin from what I gave earlier and look how far my CGM graph has dropped in the last hour. So I'm normal, but actually I need to eat.

    What do you mean you think I' making it up as I go along? I'm really not. It's quite simple and logical when you look at it. We have low numbers and high numbers. But we also have normal numbers that can act like low numbers if we are falling, and normal numbers that can act like high numbers if we are rising. And a high number isn't always a high number, for example if we are about to drive a long way or do something where it is really important we don't have a low. And a falling number is...

    What's that? You just want to know where babies come from? Now that's a much easier question to answer...

    I can't do it on my own

    You know that cheesy mantra about there being "no 'I' in 'team'"?

    Well when it comes to my diabetes care team, sometimes I feel like it's much more of a diabetes care tiim. I feel like the 'I' and I'm doing it all myself.

    On the surface at least, my last clinic visit, on July 31st, wasn't so bad. My A1c was unchanged and I got to spend a good 45 minutes discussing various issues with my diabetes consultant - who is essentially a very good man. But that is where it started to get not so good.

    The issues are multiple. I hadn't taken along any recent blood glucose records, which meant that my consultant was working somewhat in the dark. Obviously I fully accept that the responsibility for providing my records lies with me, but I have my reasons. Holidays was one of them. Not having access to Carelink owing to the fact that I don't have a copy of Windows to run on my Mac, certainly don't want to fork out for a copy of Windows (else why would I use a Mac?) and wouldn't want to use IE7 even if I had Windows. Carelink would be by far the simplest solution for me to log data and share it with my care team right now, but Medtronic have made that impossible for me. Yeah, I'm damn mad about this. My chronic medical conditions dictate or influence enough of my day to day lifestyle choices. I won't have my medical conditions dictate what kind of computer hardware and software I should use.

    I digress.

    The real downside to the appointment came when I finally admitted that yes, things are not good. That yes, I'm still experiencing a high number of severe hypos at night, some involving seizures. My consultant was pretty appalled. Not at me, and my lack of control, more that I hadn't asked for help.

    His words were "I can't let you keep having this number of serious hypos."

    So why have I not asked for help?

    Well, in one way I have. I've be fighting for over a year now to get support to get some financial assistance for CGM sensors. I know this sounds like a cop out to the very many people who aren't lucky enough to have access to CGM at all. But whilst there are very few patterns in my control at present, the consistent pattern is that things are far worse when I'm not using a sensor. I do have enough records to prove that. Various changes in my personal circumstances, including being unable to get sensors at US prices any more, mean that I've not been using them as regularly. But despite the fact that my clinic have assisted some people to get financial support, I'm repeatedly met with a blanket "no." And my PCT won't even consider a direct application without consultant backing.

    I digress again.

    On why I haven't asked directly for more practical help then: because it is so damn difficult. Especially in my line of work.

    Take this example: I call the specialist nurse with a problem. She'll be busy with a patient, or an education course or just generally doing her job. So I leave a number and request a call back. The call back comes a little later by which time I'm elbow deep in a surgical extraction of a wisdom tooth, or halfway through delivering an inferior dental nerve block injection or just generally doing my job. So we miss each other.

    And when this has happened multiple times, then as hard as carrying on without support is, it is easier than keep struggling to work the system. I know I could get more support, but it seems like too much hard work to be truly worthwhile.

    Towards the end of my appointment came the real crunch. My consultant insisted that I must come in again in 3 months. He seemed receptive to the fact that allowing 6 months to elapse between appointments adds to my sense of abandonment. But when he tried to request an October appointment he was told that the October "pump clinic" was "full". So the next available is January.

    "Don't worry" he assures me. "We'll sort something out.  We just have to fiddle the system and you'll get an October appointment sent out to you shortly.You need to be more supported professionally. "

    So why, three weeks later, am I sitting here without an appointment? Why do I feel more abandoned than ever?

    I can't do this on my own, but I can't find a way to get the professional support I need either. I don't have the energy it seems to require of me.

    MiniLink Has Landed: CGM Updates

    I'm still using the Paradigm REAL-Time system, although I've switched from my clear 722 to a charcoal 522.

    I still love continuous monitoring.

    I still very, very lucky to have the opportunity to use it everyday.

    Yes, I agree it has its problems an it can only get better.

    Personally, I have very few issues with accuracy and even at the times when the numbers are not right on, I have never seen a trend be wrong. Since this thing is all about treating the trend, that is more than good enough for me.

    And yes, it is expensive. I didn't have to purchase my own hardware, but I do self-fund my sensors.  If I was using one every three days that would be more than I could manage. But I'm not. I now routinely use each sensor for two whole weeks. When I remove them there is little more than a tiny red bump on my skin.

    I've personally managed to avoid alarm burnout too. I use tighter or looser alarm thresholds depending on the circumstances I'm in and I even turn the alarms off completely from time to time. At first sight, the ability to do this may seem strange, but if you're not sure ask a Dexcom user. There is a fixed on low alarm on the Dexcom, and a funky sensor can lead to no end of lost sleep. I also defend this feature since, after all, the original CGMS collected data for three days that you couldn't even see until afterward, nevermind have alarms for, and yet that was still a very useful tool.

    And the Paradigm system is getting better: The MiniLink.

    It actually arrived a couple of months ago, during my blogging hiatus. But this little critter is just too cool to go totally unblogged.

    Why?

    Because this thing is truly tiny:

    P1000044_3

    Especially when compared to the original Gen 1 Transmitter, which not only has the wire to connect to the sensor, but is also considerably thicker than the MiniLink.

    P1000060

    It isn't without it's drawbacks though, the biggest one being its lack of flexibility. The wire on the original was irritating, but at least it meant that once the sensor was in, you had some choice about where exactly you stuck the rest of its bulk. With the MiniLink once the sensor is in, there is only one position for it to go, dictated by the sensor position. If you end up with the MiniLink digging into you every time you bend forwards, or showing trough your favourite outfit, there is no way to change it without having to trash the (expensive) sensor.

    Also - notice the dressing over the sensor and MiniLink in the pictures. Medtronic have advertised the MiniLink as being adhesive free. For all those of us who suffered extreme irritation from the adhesive patches used to hold the old transmitter in place, this was a great selling point. Sadly, it's a no go. The MiniLink itself can easily get caught, pulling the sensor out with it. And if you want to extend your sensor life, the little bit of adhesive on the sensor itself isn't going to hold all that long, especially with bathing and swimming. Originally I had trouble covering the MiniLink with just one IV3000, but I've since learned that a diagonal angulation does the trick, which is a plus.

    Two other things I've learned about the Paradigm system:

    1. You can get around the day seven "Lost Sensor" alarm.
    With the (original) Guardian RT, you could continue restarting the new sensor every three days for as long as you wanted. Well within reason. The only drawback was that you had to wait for a 2 hour initialisation every three days. When I moved on to the Paradigm REAL-Time it was great not to have this. Just select new sensor  and be good to go again in fifteen minutes.

    Until day seven, that is.

    Without fail, a "Weak Signal" alarm, followed by a "Lost Sensor" alarm will occur on day seven, and no amount of restarting will get it to go again.

    For several months I continued under the misapprehension that you couldn't get around this; that Medtronic had somehow built in this feature to stop sensors being extended beyond seven days, and so improve their revenue from sensor sales.

    Oh cynical me.

    Turns out if you just disconnect the sensor from the transmitter/MiniLink and reconnect, you can go on for another seven days, albeit with that two hour initialisation period.

    Sadly, this is another drawback of the MiniLink. It won't reconnect to the sensor at day seven if it isn't charged. Charging is remarkably quick. You plug it in to a little blue pod that holds a AAA battery and within 10 minutes or so, the charge is complete. The drawback is if your sensor end occurs when you are miles from your charger.

    Just another bit of kit I now carry pretty much everywhere!

    2. You can get going again even quicker at the day 3 and day 6 restarts

    Initially, when I restated the sensor at day three, I would wait patiently for it to ask me for a calibration meter reading. This itself could take five - ten minutes and data readings followed 15 minutes later. The typical gap in data was 15-25 minutes.

    One evening, after restarting, I realised I had not been asked for meter reading. When I checked the screen I saw that data had been coming through for a while. It then dawned on me that I had sent a calibration reading to the sensor a few minutes before it ended, having forgotten its time was due. The system had used that calibration and had skipped just a single data point.

    Obviously you can't always get a number in just before sensor end, but what you can do is input a number immediately after restarting. You'll get an on-screen message saying the sensor isn't ready and the value won't be used, but ignore it, it's lying!

    I now typically have just 3 missing data points at restart, and don't have to hang around waiting to be asked for that number.

    You can probably guess, I won't be giving up my Paradigm REAL-Time anytime soon.

    Guardian RT vs Paradigm REAL-Time System

    The Paradigm REAL-Time system really is the Guardian RT all grown up. My experience on switch day notwithstanding, I'd be lying through my teeth if I said it didn't have big advantages. A whole lot of advantages.

    But there is one major drawback:

    I can't hear it!

    The alarms on the Guardian RT are sirens, without understatement. Low or high alarms going off at night have woken people sleeping in the next room to me! Added to the fact that you can have 'beep' and 'vibrate' alerts simultaneously (and this is a hearty up-'n-at-'em shake-itself-onto-the-floor kind of vibrate) and you'd be hard pushed to ever miss an alarm or alert.

    In fact, I didn't.

    By contrast, the 722 alarms are very quiet. Even the vibrate is pretty mild, and there is no option to have both alert types simultaneously. Whereas the Guardian RT awoke me as soon as an alarm went off, the 722 has taken between 10 and 18 minutes to wake me up at night. Yes EIGHTEEN minutes. A fast moving low could do a lot of damage in that time.

    I'm still working on solutions to this, but it is early days yet, since I'm (fortunately) not getting many overnight alarms right now.

    It has led me to think about the names of the devices and I couldn't help but wonder whether the Paradigm REAL-Time System is simply more of a Real-Time monitor providing data, whereas the Guardian is just that: A Guardian. Something extra to watch over you and wake you from your sleep should the need arise. It is daft that there should be any difference in the use of the systems. But then, it strikes me as pretty daft that one should be so LOUD and the other so quiet.

    So, what are the other major differences?

    To begin with the obvious:

    Carrying one device vs carrying two

    Hpim1057 If you are using a pump and a continuous monitor it makes sense to try and combine them. Even leaving aside the bulk an unattractiveness of the Guardian RT monitor, to me it is a great advantage to only have one unit to clip to my clothing and carry around, one unit to worry about damaging or losing, one unit to explain to airport security personnel. And one unit that is the exact size of the pump I would wear anyway, no less.

    Trend Graphs and Trend Arrows

    722status_3 The graphs showing three hour and twenty-four hour trends are great. I'd got used to drawing a mental graph with the last dozen or so numbers from the Guardian RT, but to have it there on the screen without having to think about it is great. A word of warning though: the screen size is very small - the same as any other Paradigm pump. I think the samll size of the graph can give some false impressions about exactly how stable the glucose level is since a reading of 6 mmol is not that far removed from one of 9 mmol giving the impression of a much flatter line than may be there in reality.

    This in itself could be a reason for the inclusion of the trend arrows, but to be honest, I don't actually find them much use. Perhaps this is because I got used to mentally calculating the trend whilst using the Guardian RT, or perhaps it is because my levels have been pretty stable anyway over the last week (I have yet to see a double arrow, indicating a change of more than 2mmol in 20 minutes, in either direction). However, it strikes me that the trend arrows seem in themselves to be very much a response to single values, which is obviously ridiculous. They are basically a comparison of a pair of values taken twenty minutes apart. I've so far seen a down trend arrow when the current reading is actually higher that the previous one, and vice versa. Take the following as an example:

    15:40  7.1
    15:45  7.5
    15:50  7.2
    15:55  6.8
    16:00  6.2  *No arrow*
    16:05  6.4  *One down trend arrow appears*

    The arrow appears at 16:05 since this value is >1mmol less than the value recorded at 15:45, despite the fact that the reading has gone up since 16:00. No arrow appears for the lower reading at 16:00 since this is not greater than 1mmol different to the reading at 16:40. The biggest drop in this data series, between 15:45 and 16:00 is not considered as these two reading do not make a twenty minute pair!

    I'm not knocking trend arrows per se, I just think this feature could use a little more work to maximise its value!

    Calibration Warning

    Both the Guardain RT and the Paradigm REAL-Time System need to be calibrated by entering a fingerstick result a minimum of every 12 hours. On the Guardian RT, the time the next calibration is due can be accessed by pressing the up arrow once from the home screen, and the time and value of the last calibration by pressing 'SEL' twice from the home screen to get to the 'Meter BG' screen. The pump would also emit a small beep and/or vibrate at six hours since the last calibration/until the next one amd the word CAL would appear on the home screen. To be honest though, I got a lot of 'Enter BG' alarms where I had reached the 12 hour mark without remembering, and these were accompnied by a 15 minute skip in data.

    The 722 allows you to set a 'CAL Reminder Alarm' to alert you anywhere between 5 minutes and 4 hours before the calibration is due. It also records the date, time and value of at least the 28 most recent calibrations (my 722 currently has 28 values, but it may store more.) Remembering to calibrate is also easier since each time a blood glucose value is entered into the Bolus Wizard, to calculate a bolus dose, (so at least every time I eat) it asks you whether you want to use that value to update the sensor. Before anyone asks, yes, this is better than the pump automatically using it to update since calibrations performed when the blood glucose is changing rapidly tend to throw things out of whack.

    Sensor Restart

    If you haven't heard that extending the three day life of the sensors is possible, then this must be the first thing you've ever read about about CGM technology, bar the official company info!

    With the Guardian RT re-using an existing sensor requires treating the old sensor exactly like a new one. So you have to disconnect the sensor and transmitter, then search for the transmitter and then reconnect the two. Bingo! The monitor thinks your old sensor is a brand new one. Drawback? You have to wait for a complete two hour initialisation. Not only does this mean a gap of two hours in the data, but it also has to be timed so that you won't get woken up to input a meter calibration at the end of the initialisation, and ideally so you don't end up needing to calibrate soon after a meal when glucose levels might be unstable.

    Timing it would be easier if there was better warning of the sensor end time. If you don't make a mental or written note of the day and time of your last "new sensor" the Guardian RT will only warn you after you have entered a meter calibration less than 12 hours before the end of the sensor life. The screen which shows when the next calibration is due (see above) changes to 'Replace' with a time, when the 72 hour life will be reached before the next calibration is due. But if a Calibration isn't required or entered until 71 hours of sensor life has already passed, you could find yourself with only a one hour warning. And even then, it is a warning you have to seek out and check for yourself!

    With Paradigm REAL-Time System, you can restart the old sensor as a new sensor, and provided you don't disconnect the transmitter from the sensor first, it will be ready to begin giving data again in just 15 minutes. The fact that there is only a 15 minute gap in data makes it more acceptable to delay the restart if necessary, to wait until glucose levels are stable enough for a calibration. In addition, the exact life of the sensor is recorded in days and hours on the status screen, so you know exactly when it will need to be replaced.

    Hpim1053_5

    Synchronisation and Missed Data

    The Guardian RT accepts missing a single data value. This value is then retrieved along with the next value. If two successive points are missed, the Guardian RT will begin to search for the sensor. Provided it is found within five minutes, when the next data point is due, all three values are retrieved and recorded. Three data points seems to be the maximum the transmitter can store without passing them to the monitor, so a loss of synchronisation between transmitter and monitor of greater than 15 minutes causes a break in the data data. If the transmitter still is not found after 8 minutes, the unit will alarm with  'No Sync' alarm. It is then necessary to start another search manually, ensuring the transmitter and monitor are well within range.

    The Paradigm System, on the other hand, can accommodate much more missing data. You can select how long you want the unit to wait before alerting you to the loss of Sync, referred to now as 'Weak Signal' to between 5 and 40 minutes. I'm told, although I've yet to confirm this personally, that the unit can retrieve the full 40 minutes of data. This would obviously be a big plus in situations such as going swimming, as it would be possible to leave the unit well away from the water, but still look back at a full set of data later to see the impact of the swimming session.

    My experience over the lat week suggests however that the 722 tends to lose the signal more readily than the Guardian RT did. This is difficult to gauge exactly, since the 722 is for the vast majority of time attached to me by my infusion set and I'm unlikely to leave it very far away from me. The Guardian RT would quite happily continue to pick up data when I was actually in the next room, whereas the 722 will sometimes show 'Weak Signal' when I happen to have it on the opposite side of my body to the transmitter. It really isn't a great problem though. As I say, I'm unlikely ever to get that far away from the 722, and the fact that it picks up so much missed data is a definite plus. So far the only days on which I have not had a full set of 288 data points recorded at the end of the day are those when the sensor has been restarted. The Guardian RT, on the other hand, would often have gaps - including, of course, those where I forgot to calibrate on time!

    Snooze Features

    As I explained to Bernard here it is possible to turn both the high and low alerts on the Guardian RT off, as well as select the interval at which the alerts repeat to allow for the fact that both high and low levels take time to correct, and you don't want to be bugged by alarms every five minutes until you are back in range. That would be enough to test the patience of a saint! The Guardian RT also has the rather curious 'Snooze' feature for high alerts. This can be set independently of the repeat interval to prevent you being alerted to another high value for between one and twelve hours and applies only to high levels, not lows. I did use this feature a couple of times overnight, where I really wanted to get sleep and chose to chance staying on the high side for a little longer without being woken up if my first correction didn't fix things. Setting it was easier than going and changing the interval in the setup screen.

    On the Paradigm System this feature is gone. You can still choose to turn either or both the low and high alerts off and each one has what is referred to as a 'snooze', which is the same as the repeat interval on the Guardian RT. The 'High snooze' can be between 5 minutes (??! - Anyone discovers an insulin that works that fast to correct highs, send some my way will 'ya?!) and three hours. The 'Low snooze' can be set to between 5 minutes and 1 hour. If you want longer than that, you'd have to turn the alert off. I guess the advantage of the 'snooze' on the Guardian RT is that the alerts will resume themselves after the set time, rather like the resumption of basal delivery after a temp basal of 0.0 u/h vs remembering to restart the pump after a suspend.

    Transmitter Size

    Transmitters_1 Tiffany has written here about the problems of concealing the transmitter under fitted clothing and this isn't helped by the fact that the 522/722 transmitter is actually bigger than the Guardian RT transmitter. It is slightly bigger all round and, significantly, around 30% thicker. This may be extra waterproofing. It may reflect that extra data storage the Paradigm transmitter seems to be able to handle. It may also be explained by the fact that the transmitter now emits beeps when connected to or disconnected from a sensor, and so must contain some sort of speaker. Overall I think that if you're prepared to accept the size of the Guardian RT transmitter, the difference is not that big. I sometimes find the thicker profile more uncomfortable if I end up lying on it, but to be fair, the clothes issue is not a biggie for me as it doesn't seem to show, unless you're really looking, under any of my favourite outfits!

    Software

    The Guardian RT comes with 'Guardian Solutions' software, which enables you to download all the data from the Guardian RT onto your computer. There is nothing flashy about the software. It gives you a graph for each day, as well as a 21 day overlay (but no options for different numbers of days, or to restrict it to weekend or weekdays only, for example). Beyond the daily high, low and average reading, there are no other stats either. However, the graphs are extremely useful for spotting trends (See here for an example) even without any other statistical analysis.

    And I really miss those graphs right now.

    I don't currently have any way to download data from my 722 pump. This is partly because I still have it on loan, and was not given a download cable. However, even if I had the cable, I'm not convinced I could use it. The Medtronic Carelink web-based Therapy Management System is not available to users outside the US or Canada. But aside from Carelink, there doesn't seem to b any other software to use with the 722 - or at least Medtronic haven't been able to tell me that there is.

    I think this is a serious drawback. The on-screen graphs are great, but their small size limits their value, as does the fact that you can only see back to the last 24 hours, so you can't easily compare consecutive days, or any days for that matter, to spot patterns. Without the ability to manage all the information that continuous monitoring gives you, it loses so much of its value.


    So there you have it. I recognise that much of this information is probably somewhat redundant to people making a choice of monitoring system, as I understand that the new improved version of the Guardian RT - the Guardian REAL-Time System is about to become available. Since I still have decisions to make about my long term choice of system, I've been looking into this one with interest. So for the next instalment: Upcoming features of the Guardian REAL-Time System!

    And after that, an end to the obsession with CGM technology??!

    Continuous Monitoring: In a Sentence

    This post comes from the category of "posts that never quite made it..." since the information in it and the intention to knock it into shape, has been hanging around for quite a while, but somehow it never quite happened. The original title would have been "Guardian RT: In a Single Sentence".

    I guess, it has never been my intention to discuss the Guardian RT or continuous monitoring in great depth since so many others have already made an admirable job of this task: Life After Dx (of course!) discusses use of the RT, Tiffany over at Candid Diabetes has done a fantastic job of describing her experiences with the Medtronic 522 integrated pump and sensor, and Amy at Diabetes Mine  is recounting her experiences with DexCom, following in the footsteps of the Insulin Factor's Matt Vogel. In short, there are plenty of capable voices out there.

    I still wanted to take the opportunity though to try and sum up my perspective on the Guardian RT, which I used for just short of two months before my switch on Monday to the 722. This really is my perspective and my opinions and experiences. Continuous monitoring is definitely an area in which your mileage may vary. But, if I had to use just one sentence to describe this thing it would be:

    The Guardian RT is a device that gives you prompts to test your blood sugar.

    There is obviously more to it, but ultimately that, for me, is what it all boils down to. The Guardian RT has been able to replace some of the prompts that my body has no longer been giving me since my experiences with severe recurrent hypoglycaemia.

    Low and High Alarms, or a series of readings that indicate I am trending sharply up or down are things that prompt me to do a traditional finger stick and treat as appropriate. The Guardian RT doesn't have the on screen grpahs and trend arrowns that both the 522/722 and Dexcom have, but scrolling back through the numbers and drawing a mental picture of where my blood sugar was heading was a frequent prompt to act. I couldn't tell you how many times in the last two months I've tested at times I would otherwise not have, particularly in the absence of prompts from my own body in the form of hypo symptoms, and I have found lows needing treatment and highs worthy of correction.

    I've tended to find that the Guardian RT is spot on with my finger stick readings more than 90% of the time when the reading on the Guardian lies between 5 and 8 (90 - 145). Even at lower levels the correlation is great, provided that the lower levels have crept on slowly. Otherwise there will tend to be a lag of around 10-15 minutes.  When my blood sugar is above 9 (160), the Guardian RT tends to be almost permanently off the number. These things reinforce that fact that the Guardian is best as an indicator of when to perform a traditional test. A conservative low threshold - around 5 (90) - leads to a test before the Guardian can get too far behind, and hopefully before blood glucose can get too low. Even if the Guardian and a fingerstick are spot on at that time, looking back over the trend on the Guardian and checking the next couple of readings, along with knowledge about active insulin on board and recent food and activity can help decide how to proceed. And knowing that a number of 9 or more is unlikely to be spot on is a definite prompt to test.

    But, for anyone who finds that somewhat disheartening, there is more to it: The discrepancy with high numbers appears to be consistent. That is, the discrepancy is almost always the same. Between 9.5 and 11 (170 - 200), it is around 2mmol (36mg/dL) too low, above 11 (200) around 3-4 mmol (55 - 72mg/dL) too low [Bear in mind I haven't has that many readings in this range] This is really significant, because it means I can predict what my finger stick reading is likely to be based on the Guardian reading. The finger stick is needed to check, but the numbers aren't quite as useless as they may appear.

    In fact, a good way to view the RT, or any interstital fluid continuous data, is removed from the numbers entiriely. The scale it gives out could be in pink elephants for all it matters, as long as you know what the numbers mean for you, and you know how you need to act and when you need to test based on them. Also, in my experience, even if the numbers are a little out of whack, the trend is almost always absolutely spot on.

    I'm happy with that approach right now.

    I totally agree with many of the statements out there - that continuous monitoring is not a magic wand to transform control. It is simply another tool, another layer of information that we can use in our quest to stay healthy.

    To me, it certainly gives peace of mind. It is another pair of eyes to watch over me... prompt me to act. And it clearly shows patterns in a way the snapshot finger sticks can never do.

    And the drawbacks...

    Of course there are plenty.

    In the case of the Guardian RT and the DexCom there is the inconvenience of carrying the bulky monitor around, and the risk of losing that monitor if you set it down somewhere away from home.

    Continuous monitoring gives an awful lot of data and as Allison  has pointed out, there is a tendency to get information overload. Some of the data may even be very surprising. I was totally floored by how little my blood glucsoe spikes after certain foods, having always assumed a spike was there. It takes time to shift the ingrained mindset for dealing with data from finger sticks, even the large number of fingersticks that many people seeking good control perform. There is a very real risk of becoming somewhat obsessional about the numbers and continually checking them out and following them. This in turn can easily lead to frustration when the flat line you aspire to in your mind's eye fails to become a reality. (Get real here: even people without diabetes don't get completely flat lines!) Not all the actions made based on continuous data will turn out to be the right ones and sometimes it is easy to regret intervening in a downward trend when it subsequently spikes up, or vice versa. But then, not every decision made based on any data will be correct.

    On the other hand, there is a risk of becoming over dependent simply on the alarms, instead of listening to your body and remembering to use common sense and judgement. Oh, and checking out those trends!

    Plus... the biggie... despite my discussion of accuracy issues above, things can go awry from time to time and the readings will go out of whack. This may be temporary - related to rapid changes in blood glucose levels not matched by changes in the interstitial fluid, or related to performing calibrations at a time when things are not stable. (I had a tendency in the beginning to want to tell the Guardian that it had got things wrong. "Damn you, stupid monitor. Look, my blood sugar is actually thiiiiis high." This is a mistake. It only confuses the unit more and sends things further out of whack.) Sometimes the sensor in use just seems to be a bit screwy. Either way, you know the solution: test,test, test.

    There is no hiding from it.

    Continuous monitoring won't reduce the number of finger sticks needed.

    Hell, it may even increase the number performed!

    (Coming up: Watch out for my High School Science essay standard 'Compare/Contrast'  on my experience of switching from the Guardian RT to the 722)

    Is the Grass Not So Green?

    Yesterday I swapped the Guardian RT for a Medtronic 722 pump. This is a temporary change as I currently only have the 722 on a finite trial arranged between my hospital and Medtronic. Even so, I've been looking forward to this. Since discovering at first hand the value of the Guardian RT and continuous monitoring I've become a total addict. And I was looking forward to a bunch of features that the 722 offers over the Guardian RT.

    Like 3 hour and 24 hour trend graphs right there on the status screens.

    Like the ability to restart an old sensor after the 72 hour cut off with only a 15 minute skip in data, rather than a full two hour initialisation.

    Like only having one unit to carry around, which apart from obviously being easier will also surely simplify matters on flights I am scheduled to take.

    But had I not already been a convert to continuous monitoring, had the 722 today been my first introduction, I think I might have thrown it out of the window and given up. And even as it was, I certainly began to wonder if things weren't better back with the Guardian. If the grass wasn't greener over here with the new pump.

    After starting up the new sensor on the pump, I patiently waited for the two hour initialisation to end, and the pump to ask me for a calibration fingerstick result.

    'Beep beep beep CAL ERROR'

    Ok... let's try again. 15 minutes pass...

    'Beep beep beep CAL ERROR'

    And then: 'BAD SENSOR'

    Gaaaah... Admittedly there was a likely reason for this: Unfortunately the timing of picking up and starting on the new pump, plus the timing of an important meeting I had on in the afternoon that meant I couldn't delay or skip lunch, the first calibration request fell just an hour after I finished eating. Cal Errors are the pump's way of telling you that it is confused because the data it is receiving from the sensor doesn't tie up with the data you've given it. Bad sensors can cause Cal Errors, but far more likely is that the blood glucose level is changing rapidly and so does not correlate well with the interstitial fluid glucose measured by the sensor.

    No matter. Without disconnecting the transmitter, I selected 'New Sensor' to restart, and just 15 minutes later (i.e without the full two hour initialisation) it asked me for another fingerstick.

    'Beep beep beep CAL ERROR'

    Ok, I was annoyed now, because this fingerstick was within 0.5mmol of the previous two. So over the previous half an hour or so my blood glucose hadn't been changing that rapidly. I angrily punched in the value again.

    Finally, a few minutes later I started getting readings and seeing the trend graph appear.

    Great.

    The values on that graph? Not so great.

    Stress of my meeting notwithstanding, my blood sugars yesterday afternoon were horrible! I consistently hovered around the 12-13 (215-235) range. The pump painted an even bleaker picture though, shooting up to the graph limit of 17mmol (306) and staying there. So much for seeing trends. All I was seeing was a thick black bar dragging across the top of the screen.

    When my meeting was over I took what I guess with hindsight was a bit of a rage bolus, and fell from 12.5 (225) to 4 (72) in under an hour. Whether it was the rapid change or not, something was irking the 722...

    'Beep beep beep BAD SENSOR'

    "Ok... chill, I can deal with this" I said to myself. Restarting as I perused the menu at the restaurant we'd settled on for dinner.

    Right around the time my first margherita arrived 'Beep beep beep BAD SENSOR'. And to make matters worse I kept hearing little alarm beeps but with no accompanying alarm message.

    I guess having already used the Guardian RT was something of a benefit. If I hadn't experienced a couple of bad sensor alarms with that, and realised that the sensor is usually anything but bad, I would almost certainly have pulled the sensor out at this stage, if not long before.

    And probably followed that up by throwing the whole assembly against the nearest wall, or through the nearest window.

    As it was, I switched the sensor feature off, but left the sensor in place, enjoyed my dinner and a hot chocolate fudge brownie sundae for dessert.

    It was only when I got home and examined the sensor carefully that I realised that somehow the transmitter has come partially disconnected from the sensor. The "alarm beeps" I'd kept hearing were actually coming from the transmitter itself as the end engaged and disengaged slightly with pressure. I've never had this experience before, and the connection was tightly covered with IV300 so I still don't understand how it happened. The transmitter beeps are a new feature not present on the RT transmitter, so I wonder if this has been a problem for others and those beeps have been added as a warning system.

    Later, after reconnecting and initialising, and allowing enough time for that sundae to quit messing up my readings, I was good to go. Calibrated first time and normal service resumed. Since then I've had great accuracy and I'm very much enjoying not having two units to carry around.

    Oh yeah... and checking out those graphs. This is what I like to see...

    722status_2

    Perhaps I'll reserve judgement on the colour of the grass for a little while longer...

    Low and Alone

    Guardian_rt_graph_10_08_06_2

    I'd intended on an early night last night. I was exhausted from those ridiculous highs, caused by a failing infusion set and prolonged by my stubbornness - choosing to rage bolus rather than take a shot or change it at around 1am. I gave in at 5am when I met that second peak, along with a bunch of ketones and I spent the day with a tired, hungover feeling.

    But the early night never happened.

    Instead I became mesmerised by tracking the progression of this flat line low, that saw my blood sugar stay under 4.0 mmol/l (72mg/dl) for over six hours, as I shovelled carbs into my mouth until I thought I would surely burst. For the first time since I started using it, I wanted the Guardian to be wrong, to be misreading the numbers and misleading me. I made my way through more than 10 test strips in my quest to catch it out. The Guardian just wailed sweetly at me, the technological equivalent of a smug smile. If it wasn't for the fact that it was actually doing me a favour, I'd have hurled it against the wall.

    I didn't want to go to sleep until I could see an end to this. I pulled back my basal rates dramatically and watched trashy TV, waiting for the carbs to hit, and the decreased basal to take effect. Eventually, a little after midnight, a finger stick yielded 8.3 (150) and then I must have drifted off.

    I was awoken around half an hour later by the insistent alarm of the Guardian. I was back to 3.9 (70)

    Lying in the darkness, the window open just a little, I could hear the distant screaming of sirens. An ambulance, perhaps, racing across London's streets. Of course I was thankful that it wasn't coming to me, but at the same time I was acutely aware that even if I had needed it, it wouldn't be coming. Because there was no one else there to call it. Just me, on my own.

    Twenty minutes later the Guardian stirred to life again. As I simultaneously reached with one hand to silence it, and with the other to my testing kit, I couldn't help but wonder if there would ever be anyone there; if I will ever find someone who will happily tolerate these rude awakenings; who will sit with me as I eat my way through the entire contents of the kitchen in a single midnight feast; who will share a bed with not only me, but also my pump and all the leftover crumbs.

    I know that there are so many people with diabetes out there who have successful, supportive relationships. In fact, I wasn't going to share any of this here, feeling it may be somehow a step too intimate. Until I read Kerri's story tonight and found myself overwhelmingly unable to hold back the tears.

    Even I am shocked by the intensity of my emotion. I've never felt before like I needed someone so much as I did last night. I've always been a very independent person, who likes my own company. I have a good network of friends, but despite spending the evening with several of them, I've been unable to confide any of this, because that isn't what I'm looking for. I need more than I can ask my friends to give.

    I feel again now like I did last night as I continued to lie in the darkness listening to the distant sounds of a city that never sleeps: that finding what I'm looking for might just be an unreachable goal.

    I Guess Everyone's A Suspect

    I was travelling on the Northbound Jubilee Line, being watched. At first it was furtive, surreptitious glances, out of the corner of her eyes. The sort of glances that are pretty commonplace on public transport. But they soon progressed to an unabashed stare and eventually she was virtually craning her neck to look at me.

    I peered down at myself, to check that I hadn't accidentally left the house wearing my breakfast down my front or, worse, wearing my underwear Superman style. I wasn't.

    Less than a minute passed. She turned to the girl travelling with her. "What is that?" she said, quite audibly.

    This wasn't a curious 'Well isn't that strange, I wonder what it could be' enquiry. The edge to her voice betrayed that she wasn't asking her companion a question; she was confiding her fear.

    The travel companion's eyes flashed at me with a slight panic that was also evident in her voice as she said "What, that thing under her clothes?"

    A couple of other heads in the carriage whipped round to look.

    I knew what they were thinking.

    The train rattled noisily into my station. I diffused their panic by slipping off.

    When I got home I stood in front of the mirror. I saw my pump in my pocket, a loop of tubing going to my tubeguard and tubing snaking from there up under my clothes. On my arm the Guardian sensor was just visible, its grey wire feeding up under my sleeve. The outline of the transmitter on the back of my shoulder was clear through my shirt. The Guardian monitor was clipped into the mesh pocket on the side of my backpack. I reached into my backpack to look at it...

    It doesn't really surprise me that people were suspicious. The terror threat has been dragged brutally back to the forefront of everyone's minds - not that it was ever far away - by today's foiled terror plot, the banning of aircraft hand baggage and ensuing airport chaos and the raising of the UK threat level to critical.

    And I clearly remember how just over a year ago, after the 7/7 bomb attacks and subsequent Stockwell shooting, a friend told me, with genuine concern, to make sure I kept my pump well concealed and most importantly without the tubing hanging out while on public transport.

    Because, I guess, these days everyone's a suspect.

    Changing Buses at The Elephant

    Travelling on London's public transport in the 35 degree heat we had last week is not fun. None of London Transport - with the exception of a few of the modernised suburban rail links - is air conditioned. The tube in particular is a nightmare. Would I be being too graphic if I described being packed in like a sardine with your nose in some unknown sweaty commuter's armpit, and the risk of getting stuck in a tunnel at any time? Probably, so I'll gloss over it. But that is why I choose to travel by bus in the summer as often as possible.

    But then, so does half of London.

    And changing buses at the The Elephant is bad enough at the best of times.

    Elephantandcastle

    For starters, seven different routes use my stop. There are so many chances to miss the bus I need: It flies past a line of those already stopped, not realising I want to get on; it stops right at the back of a long line of waiting buses and pulls away before I've reached it; oh, and half the other people at that stop want my bus too, and there simply isn't room for all of us.

    Changing buses at The Elephant in 35 degree heat whilst on crutches is particularly bad.

    Changing buses at The Elephant in 35 degree heat whilst on crutches and hypoglycaemic is impossible. It's a proven fact.

    And you know, sitting down on London's pavements isn't a good idea. I love London, but you only have to visit any other city in the world to realise how dirty it is. Yes, especially The Elephant - if you visited the link above, don't be fooled,  it is currently little more than a giant tatty roundabout, with a hideous red shopping centre at its heart.

    Perhaps I looked a peculiar site sitting there with the Guardian periodically wailing like a banshee and tears of frustration - at being low again, at being unable to accomplish the simple task of getting on a bus to go home - streaming down my face, throwing the contents of my bag into a heap in a desperate search for glucose tablets.

    The only good thing about The Elephant is that anything goes.

    So I'm sure nobody really batted an eyelid.

    Guardian Angel

    Last week  may have been a nightmare in many ways but it did, at least, have a positive ending.

    Thanks to the unbelieveable generosity of an acquaintance I met at a London meeting of members of Insulin Pumpers UK, since about one hour after after my discharge from hospital last Friday evening, I have been watched over by a Guardian: A Guardian RT.

    Guardianrt_1 After a week of intractable hypoglycaemia and being reduced to the point where I've lost all hypo signs, nevermind warning signs - I'm currently concious or I'm not, that is the only distinction - it is great to have an extra pair of eyes watching my blood sugars.

    It is fantastic to have some additional piece of mind.

    Best of all it is great that I have so quickly become abe to trust the RT where Low Alerts are concerned. With  very conservatively set alert level, it hasn't missed one yet and I am now able to catch up on much needed sleep to combat the fatigue caused by a combination of Addison's itself and time in hospital, without having to set my alarm for every 90 minutes just to check I haven't dropped below 2 again.

    Right now, this was just what I needed.

    For the record: I have not deprived anyone else of their monitor - the lady concerned has just upgraded to a 522. And the other good thing? I'm able to get the sensors from the US at $40 a pop - roughly £22. The UK price is £52 - roughly $95. The prohibitive cost of the sensors is the main reason I can't currently get my own Guardian RT, or consider the 522/722 as an option when it is released here soon.

    The biggest drawback: I'm going to miss this thing when I have to give it back.


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