Insulin Pump

The First Three Years on an Insulin Pump.

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Today marks three years since I first began using an insulin pump.

I can still remember just how excited I was for that initial clinic appointment. I had the feeling of somewhat ‘joining the fold’ with so many other pump users in the DOC. I also knew that I had so much riding on this, feeling as though it were my last chance to get on top of diabetes.

I initially wanted to go on a pump because I wanted better numbers. I felt like I owed it to myself to at least try it. I was also tempted by the promise of more even basal coverage. I never felt as though I could get my Lantus dose quite right.

In hindsight, I wasn’t really putting a lot of thought or effort into my (spontaneous) food and insulin dosing decisions at the time. I didn’t have a very good understanding of how insulin works. When I started on my pump, in some ways I was also learning some of what I should have learned a lot sooner.

There were a lot more variables in play when I started using a pump. Basal rates need to be configured, carbohydrate ratios need to be set, infusion sets replaced and insulin cartridges refilled. In many ways, moving to a pump was like learning diabetes all over again. I definitely lost my patience and got overwhelmed more than once.

The results didn’t come overnight. It probably took me three months to become completely comfortable pumping insulin, and at least six months to see my first sign of improvement. Three years later I never seem to stop learning new things when it comes to diabetes.

It is much, much easier to go low on a pump. Insulin needs to be adjusted or carbs consumed for something as simple as a walk around the block. I distinctly remember having to completely change the way I thought around insulin dosing during physical activity, or else I’ve found myself going low, low, low.

Pump breaks are okay. I’ve taken three lengthy breaks from memory over the past three years. Those breaks stemmed from a mixture of pump fatigue, and also from frustration when diabetes wasn’t playing along as nicely as I’d have hoped. Diabetes is extremely monotonous, and those changes to the way I managed were extremely refreshing.

The same level of management can be obtained using Multiple Daily Injections. It wasn’t until I began pumping that I truly began learning about blood sugars and insulin, and moving away from the spontaneously-eat-and-guess-the-insulin-dose. After transferring those skillsets to MDI during my pump breaks, I now know that the same level of management is possible.

My insulin pump has to work for me. My pump works for me when I know that I don’t have to constantly babysit it, or live in anticipation of something going wrong all the time. It works when I’m using manual infusion sets that don’t require insertion devices. It works when I’m using angled sets, that don’t kink so easily on my lean body. It also works because I can largely see what’s going on through the tubing and around the infusion site on my skin. If it didn’t work for me, I wouldn’t still be using it today.

I can still remember my diabetes educator stopping me in my tracks three and a half years ago and telling me that an insulin pump would not make managing diabetes any easier.

Today, a pump offers me more convenience as I go about my day. I like being able to give my insulin at the push of a button, without having to stop and lift up my shirt and pull out a needle and put it away again. I like having basal rates and profiles that can be customised around my life: such as when I want to eat, when I want to get to bed, when I have to go to work and when I want to go for a walk. I like that added level of precision.

While a pump has definitely helped me to ‘realise’ my potential, my diabetes educator was right. A pump hasn’t made diabetes any easier. It’s not a substitute for all the hard work I’ve put in to get the results. Today, I quite honestly see an insulin pump as my preference in insulin delivery.

A preference that’s definitely improved the quality of my life.

Filling a T:slim Cartridge: The Idiot’s Guide

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I must say that one of my ongoing issues with the t:slim has been filling those little pesky black insulin cartridges.

The empty cartridges still have some residual air trapped in them, which needs to be drawn out with your syringe prior to filling with insulin. I know from experience that when I haven’t properly drawn air out of the cartridge, my blood sugars run high and insulin delivery from my pump has been compromised.

I’ve had several moments over the past few months where correction after correction hasn’t been able to tame my blood sugars. There have even been some moments where I wake up high at 3am and in a ‘lightbulb’ moment realise that my cartridge needs to be replaced. Of course, I know I that I won’t be able to lay still until the problem has been fixed.

To my understanding, the empty black cartridges have two components: the chamber at the top of the cartridge which you can see, and an invisible plastic bag inside the cartridge where insulin is stored. When I caught up with the friendly team at AMSL Diabetes in March, I was shown a demo cartridge where I could see that the plastic bag inside was vacuum sealed. So no air in there. Which meant that the air that needed to be released was actually trapped inside the chamber at the top of the cartridge.

With credit to the T:slim Users Australia and New Zealand Facebook group, I’ve learned to fill my syringe with 50-100 units of insulin, draw the air out of the cartridge and then top up the syringe with additional insulin as desired. It’s far easier to withdraw air with an emptier syringe than a full one. I’ve also tried drawing air using a completely empty syringe, but I’m a bit paranoid and prefer to actually see the air bubbles come out.

Which brings me to my next dilemma. Last week I must have wasted at least half an hour drawing seemingly endless air bubbles from my syringe, leaving me feeling downright paranoid and wondering what I was doing wrong.

After a chat with the team at AMSL Diabetes, I’ve been told that it’s not possible to draw all of the air out of the cartridge, and that one pull of the syringe and a few big air bubbles is sufficient. I’d also add, with credit again to the t:slim Facebook group, to make sure that the needle on your syringe is screwed on tightly enough.

If you look closely at the cartridge on the right, you’ll see a fair few air bubbles in the chamber at the top. I replaced that cartridge at around 3am a couple of weeks ago after it was causing untame-able high blood sugars. Perhaps this is also a result of me over-drawing air from the cartridge. Sometimes I like to settle my paranoia by simply popping off a loaded cartridge just to confirm that there’s no signs of air.

I don’t like having to babysit my diabetes devices, when I already have my blood sugars to babysit all day every day. So I’m crossing my fingers and toes that this is the last of my issues with filling these cartridges. Because I really do love this pump.

Lesson Learned: Don’t Overfill Your t:slim Cartridges

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Yesterday morning after breakfast, after I could no longer ignore the vibrations coming from the needy insulin pump in my pocket, I swapped out the cartridge on my t:slim.

I slowly drew insulin from my penfill cartridge into the syringe, filling it all the way up to its 3ml capacity. After tapping and priming the air bubbles from my syringe, I stuck the needle into my black t:slim cartridge and began to slowly inject the insulin in.

As I tried to continue pushing that last bit of insulin from my syringe into the cartridge, I was met with a little resistance. The cartridge must have been nearing full.

I knew I should have stopped then and there. Except that I didn’t.

After pushing a little more in, I pulled the syringe out and slid the cartridge into place on my pump. I was feeling a little hesitant, but figured I’d be able to pick up on anything weird soon enough.

I had lunch a little later on, and found myself at 10.6 when I checked my blood sugar afterwards. Which felt plausible, given that I had also eaten ice cream with my lunch. I can never seem to bolus for ice cream quite right.

After some correction insulin, a walk and nothing more than a coffee that afternoon, I was still lingering around the 10 mark.

After loads of corrections that evening, I don’t know why I didn’t just replace my insulin cartridge before I went to bed.

I guess a part of me was seeing the 200+ units of insulin in the pump, and didn’t want to be wasteful by throwing it away if there was actually nothing wrong.

After a full correction at bedtime that had little effect by the time I woke up at 5.30am this morning, I hauled myself out of bed and made a dash to the fridge. I swapped out my cartridge for a fresh one, this time only filling to around the 2ml mark on my syringe.

Yes, Frank was told to put less insulin into his cartridges when he got set up on his t:slim a few weeks ago. But Frank also didn’t like to be wasteful and wanted to get his money’s worth from the cartridges that he paid for with his hard earned money. Frank also doesn’t like not being able to reuse these cartridges like could with his Animas pump.

Anyhow, lesson learned.

Don’t overfill your t:slim cartridges. It just feels like your insulin isn’t working.

Frank’s First Week on the t:slim!

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Frank still can’t believe that he has a t:slim tucked away in his left pocket.

It feels so surreal.

(In his determination to get a t:slim, Frank has even began referring to himself in the third person in his own head, which he really should stop doing now).

As trusty and reliable as my late Animas Vibe was, it was definitely outdated. Quite frankly, it looked like a game of tetris from the ‘90s. It wasn’t particularly attractive. The skin quickly began to peel. It wasn’t particularly easy to navigate, when compared to the smartphones we use today. Animas had failed to throw research and development at that pump to bring it into the 21st century, which is likely a big part of why they decided to exit the market.

I know all of these things may sound superficial, but when you’re talking about a $9,000 device that is attached to my body 24 hours a day, it really does matter.

I’ve only been using this pump for a little over a week, but quite honestly the transition has been seamless. The t:slim combines the features that I’ve come to rely on in my Animas Vibe, with many enhancements that I’ve been longing for in quite some time.

The bright touch screen on the t:slim is so much more convenient and sophisticated (although not exactly easy for oversharing bloggers to photograph). I am no longer reliant on up or down buttons to navigate through the pump. I no longer need to scroll to reach my desired number to input into the pump. I can simply touch the menu item on the screen, and type in my numbers.

Another feature that is proving useful is the basal profiles. Within each time segment, I can also set custom carb ratios and correction factors. So when I’m on my feet at work at 9am on a Monday morning and more sensitive to insulin, I can set a custom carb ratio to reflect that, rather than having to manually adjust every single time. Thoughtful little things like that really do make a difference to my life.

I’m also really happy with the wearability of the pump. When I’m at work, it truly is slim enough to tuck into the waistband of my trousers, leaving my pockets completely free. While it is a little heavier than my late Animas Vibe, it’s hardly noticeable thanks to its size and sleekness.

A big shift from Animas is the rechargeable battery. Unlike a smartphone, I have been told that I do not need to worry about damaging the battery with my charging patterns. I’ve been plugging it in before I jump into the shower every day. It charges super fast, and so far that ten or fifteen minutes in the bathroom keeps the pump battery topped up at close to full capacity.

I’m really happy that I can continue to use the Animas sets that I’m most comfortable with, so no massive adjustment needed there. The nobbly luer lock connection, which was concealed on my Animas pump, is a little annoying when I go to tuck the pump line away or pull it out again. But it does guarantee me lots of options should I need to switch infusion sets in the future.

Filling an insulin cartridge is a little different as well. Insulin is basically drawn into a syringe, and then injected into that little white hole at the top of the cartridge (next to the line). Given that I can’t see inside the black insulin cartridge, the key is making sure there are absolutely no air bubbles in my syringe. I’ve only filled a cartridge twice so far, but it seems simple enough.

I also like that the cartridge can hold 300 units of insulin, which conveniently uses up a whole penfill cartridge in one sitting. Although apparently I’m only supposed to be filling three days’ worth to minimise the risk of insulin spoiling? I’ll leave you to guess what I’m doing with that one…

Most of my bolus deliveries take a good minute or two to complete, due to a back and forth motion happening inside the insulin cartridge that slowly infuses bolus deliveries. It’s just something to be mindful of when delivering a larger bolus.

The one thing I dislike about my t:slim is the pump clip, which I have been unable to use. The clip is attached to the rather chunky t:case, rather than the pump itself. This doesn’t exactly make the t:slim all that slim!

Another irritating thing about this pump is how demanding it is. The screen blacks out with three mis-taps. I’m frequently alerted when I don’t complete a bolus, or if I’ve been running a temporary basal rate for a prolonged period of time. While these may be helpful to some people, my pump should be able to realise how switched on I am.

While pump data can be uploaded to Diasend for review, I’m also looking forward to the t:connect app eventually launching here in Australia. Just like wireless blood glucose meters, it’ll be great to wirelessly sync my pump data to my iPhone for instant review.

It’s still early days, but it’s hard for Frank to find much fault in his t:slim.

It’s nice to finally have an insulin pump as modern as my smartphone and the other devices that I use to manage my diabetes.

#TslimForFrank!

Disclosures: AMSL Diabetes bumped me up to a priority transition to the t:slim after seeing all of my cheeky #TslimForFrank comments on social media. As an existing AMSL customer using an in warranty Animas Vibe, I was eligible for a free upgrade to the t:slim as per their transition program. The upgrade was treated as a replacement for my late Animas Vibe, which I was required to send back. I have not been asked or paid to write about the t:slim, and these opinions are entirely my own.

Dawn Phenomenon, Spring Style.

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My levels have been a bit of a mess over the past couple of weeks.

A few weeks ago, I began to notice my blood sugar levels slowly but steadily rising through the night. I found myself waking up to blood sugars of 8 or 9 at around 2am and giving a correction, only to find it had little effect by the time morning rolled around.

After I had ruled out any after effects of afternoon snacking or evening meals, I began increasing my overnight basal rates until I had curbed that steady rise.

But I still hadn’t quite managed to clean up the spill.

To add to my woes, the FreeStyle Libre sensor I’m wearing at the moment to fine tune those rates has been producing long flat red lines through the night – the kind of ‘LO’ readings that make me a walking talking miracle. Thankfully, multiple finger prick readings quickly confirmed that Libre is at fault, and not me.

I’m usually quite tuned into carb counting, protein and how I bolus for my meals when I’m on my feet at work. Yet morning after morning, I would bolus for my breakfast and find my blood sugar spiking into the teens. Those highs would carry through into my morning tea and lunch.

Eating is something that I can’t really afford to be skipping at the moment. I’m working on packing more into my meals to fuel my active days so that I don’t feel so dreadfully exhausted and limping into bed at night. I’m a better person for it.

As I was setting up the basal profiles on my brand new tslim over the weekend, a mental lightbulb flicked on in my head.

If I had increased my basal rates through the night to cover my dawn phenomenon, why hadn’t I increased them to cover my insulin resistance the moment I wake up?

I have been tinkering my overnight basal rates back and forth since I began pumping insulin two and a half years ago.

I have a theory that the lighter mornings during Spring and Summer enhance that insulin resistance in the wee hours of the morning, compared to the darker days of autumn and winter.

After upping my waking basal rates by 25%, in line with what I had done through the night, I’m hoping I have a better week in store for me.