Minimed Guardian

The Dexcom 7 trial was awesome.

Despite some of its shortcomings, the accuracy of information gleaned from the Dexcom 7 was invaluable.  Within 2 days we were able to set a much lower target BG for Cadence's bedtime as we noticed that she doesn't drop significantly in the middle of the night.  This does usually require a small breastfeed at about 3 am and a correction dose (.5U) of humalog for those carbs but she is sleeping from 9pm to anywhere between 6:30 and 8:30 in the morning.  I'm up and gone for work before 6am so I miss the sleep-in (bummer!).  This tweak alone takes out Cadence's high nighttime BG's.  Last night, she slept soundly and hovered at 5.6-8.0 mmol/L for the whole night.  This has been so nice to see.

Some huge pluses for the Dexcom:  

 - small insertion needle

 - no dangley bits on the sensor, everything is affixed securely.

 - seven days of wear (sooo nice)

 - good software program

 - menu's are simple

Some downsides:

 - It's been said before, that damn sync cable and choice of only the Onetouch Ultra.  

 - awkward receiver size

 - not able to scroll backward on the receiver to see past data (love this about the minimed)

 - no 24 hour trend screen

There are some other hassles but those are the majority.  Overall we were extremely satisfied with the Dexcom 7 system.

When we tried the minimed paradigm 522 pump/CGM earlier this month I always felt like we didn't give it a fair opportunity to show us what it could do.  Admittedly the sensor wasn't secured as well as it could be with the tegaderm.  The clamshell/sensor interface was right at the top of the diaper, we calibrated during times of not so stable sugars, etc.  We are now testing the Minimed Guardian system, which is the stand alone CGMS for minimed.  It's essentially a 522 without the pump in it.  The CGMS has quite a few more features than the 522 does.

The sensor insertion went MUCH better this time than our last go-round.  Using some of the mistakes that we made last time, Cadence did fine with it.  The sensor went in easy, we covered everything securely with tegaderm, and she was playing happily within minutes of the event.  The startup and calibration went off without a hitch and the data through the day yesterday was very accurate.  A nice change from our experience with the 522.

The Guardian has "predictive alarm" capability which already has come in handy.  Cadence and I were out with Spokes, the family airedale terrier for a walk yesterday.  About 3/4 through the walk I heard an alarm from the Guardian, checked it and it said "predicted low alert", so i did a blood sugar check and sure enough she was dropping quickly but still in an ok range.  So, I gave her some fruit bar to chew on and we marched back to the house.  As we approached the house I heard another alarm and the Guardian said LOW.  I got everyone into the house and checked Cadence's blood sugar, it read 3.4.  That's getting a bit dangerous so I quickly grabbed some banana and soy milk and we had some snacks.  In checking the "Real-Time" BG reading, the Guardian showed her as 4.5 with 2 arrows dropping (very quick).  So, that's the 15-20 minute delay that exists.  The BG reading is not accurate but the trend is, we knew it was going to be lower.  

So, this predictive alarm is fantastic...except at night.  We were up a bunch last night to turn off the predicted low alarm as Cadence was 0.1 mmol/L under our threshold but holding steady.  This isn't a knock against the feature, it's doing exactly what it's supposed to do, but we will now turn it off at bedtime and set her low threshold a tad higher.  After I turned that off, the night went perfectly.

So, we'll spend the next 6 days or so testing the Guardian before we make our final decision on which device we will use and will keep things updated here.

On a side note, we had a meeting at the Diabetes Clinic yesterday and our nurse asked me "how are you doing?"  It wasn't a casual, looking for a canned answer, kind of question.  She was referring to how I was dealing with the experience of my role with Cadence in the hospital.  I was the one who held her down while the ER docs drilled into her shin to get fluid into her, looked in her eyes and saw the fleeting life, fear, pain, and panic.  I held her down when the phlebotomist came into draw venous blood as she would soil herself in panic.  It haunted me for months, and still does I now realize.  I guess I sort of repressed it a bit through alcohol and focusing on other things.  I feel like I'm on the other side of those habits though.  Her question really brought back some difficult feelings and flashbacks, but also a significant question:  

Would I trade the experience of being there for her through those moments vs. not knowing the panic that she went through?  Would it be better if I didn't see it?

It didn't take me more than a millisecond to decide: Not a chance...I feel lucky that I was the one to be there to try and comfort her, I hope she in some way remembers that I was there.  So, yes I struggle but I wouldn't trade it either.

b.

Dexcom - day 5

We are dexcom day 5 with Cadence.  What a great little device, which has already paid for itself in spades after a scary low on the weekend.

We were cruising through a showhome in our 'hood looking to

 steal some decorating ideas for our little hacienda.  Cadence was ripping around the house, up and down stairs, jabbering at all the other people milling about in there on Sunday afternoon.  We heard the chirp from her Dexcom CGMS and the warning that she was dropping low.  We sort of expected her to go down a bit as a result of her activity, so we casually picked her up, went over to the kitchen table in the showhome and did a quiet fingerpoke.  The number on the blood glucose meter said 2.2 mmol/L (35 md/dL).  That is a severe low and a very dangerous one for a 15 month old.  The worst part is that she had no idea...  confirming our suspicion of "hypoglycemic unawareness".  Cadence doesn't feel her lows, where as most diabetics feel horrible during a low, it's their safety net.

So, I sprinted out of the showhome to grab whatever carbs we had from the car, while Nic put Cadence on the boob.  I grabbed fruit bars, soy milk, anything really, and ran back into the showhome to the surprise of the salespeople there.  So with about 25-30 people moving in and about the showhome we treated Cadence's second lowest glucose reading since her diagnosis.  We had carbs, a sock, and bloody test strips layed out over the kitchen table...in the middle of the showhome.  Sometimes you just have to make due LOL.  Once recovered, we continued the tour through and upon exiting she showhome manager says "that must have been some diaper change!  By the way, is that a GPS on your daughter?"  :)

Now, onto the Dexcom.  What a great little device, and proven so in the above story.  We are on day 5 and the finger stick readings comparative to the dexcom trends are very close if not bang on.  If there is a difference, it's usually as a result of taking a reading at the peak or valley of of change in glucose levels.  Otherwise, the dexcom is usually well within 10 points (mg/dL) of the meter reading, a huge plus.  With the minimed system we had values that were absolutely nowhere near what her blood glucose reading was, even at times of stable sugars.  So the question begs:  What's the point on putting a "real-time" blood glucose reading on your display if the user is amazed if and when it's accurate?  The trending bars are invaluable though.

We are still undecided as to which technology we are going to invest in but the Dexcom appears to be a better product.  If only they could pay one computer programmer for 3 hours work and make some rate of change arrows (like minimed's) and have an option to use mmol/L or mg/dL, it would be the giant killer of Minimed product.  For the price of these "next generation" units it's amazing that a handheld poker game from the airport has more display and computing capability than these devices.  We're going to give the minimed another shot next week though and see if it can stand the test.  

With Cadence's hypoglycemic unawareness, it appears that we don't have much of a choice of not going with a CGMS.

The Dexcom experiment has begun

I was able to secure a Dexcom 7 unit during my last trip south.  We have engineered the rare opportunity to test both the Minimed CGMS system and it's competitor Dexcom.  Dexcom is not available in Canada unfortunately.  Through several conversations with many people in the US  I was able to get one for her.

A couple problems with this system already is that it still is only capable of communicating with the OneTouch Ultra meter which IMHO is a POS.  Further it needs to communica

te through a cable.  Why this was deemed to be a good idea vs. manual calibration with whatever meter you like to use is beyond good reason and stinks of corporate collusion between Onetouch and Dexcom.  

Dexcom has plans to change this but it hasn't happened as yet.  Also, the Dexcom CGMS system was designed only to use the US mg/dl scale and cannot be programmed for

mmol/L, again the rep has said this is to be updated soon.  

I greatly appreciate the 7 day wear and smaller needle insertion size (26 gauge Dexcom vs. 23 gauge Minimed) and the insertion of the Dexcom was definitely easier with Cadence.  When we did the Minilink sensor Cadence cried hard and grabbed at the area for a few hours afterward, anytime we tried to inspect the area she was quite upset by our efforts.  The Dexcom in

sertion however was absolutely easy, no tears, completely unbothered by it, and in fact immediately after sat in her highchair and had dinner, sitting on the sensor.  Pretty amazing difference and definitely a +1 for Dexcom.

The insertion device is good, I would say a bit better than the Senserter (Minimed's) but the sensor latch/tab...the little doo-hickey to snap the transmitter in place is goofy in the way it must be broken off.  Cadence, didn't like that part to be sure.  Both units, Minimed and Dexcom, could be greatly improved...easily.

We are in the middle of the 2 hour calibration period and will report more tomorrow once we see readings.  

so far so good!

brad.  

P.S. - I find the google ad beside this post about how to reverse your diabetes oh so comical...if only :)

Gadgets rule - The Continuous Glucose Monitor

Really interesting last few days. We finally generated enough courage to put Cadence on the Medtronic Minimed Continuous Glucose Monitor.

The CGMS system is designed to give "real-time" reading of Cadence's blood glucose readings. The problem is that it reads the glucose content of the interstitial fluid, the glucose meter that is used for finger poking measures actual blood glucose. The interstitial fluid is about 15-20 minutes behind. This may not seem like a bunch of time, but it does make a difference.

This little do-dad has a huge scary needle for insertion. In fact it took us 4 days to gather enough courage to do it. We finally decided that yesterday was the day. We numbed the insertion site with Emla cream, bent her over and using the "senserter" I jabbed the 23guage needle into her butt cheek....and it didn't go in...crap. Blood came out though and the crying ensued. A little panic by the parents and we decided to tray again. So, we grabbed the senserter again, reloaded and into the flesh we went again this time with success and actually no bleeding.

The readings yesterday were all over the map, we had a significant low yesterday afternoon that the CGMS completely missed. It did show a large trend downward though, so we had an idea that it was happening and that seems to be the value in this device. You can't trust the number and you're happy if it's close but you can watch to see if a trend is developing instead of finding out what's happening late.

We've only been hooked up to this thing for 24 hours now but I can already say that it's really a valuable tool in terms of seeing trends. The problem with point in time blood glucose monitoring (finger-pokes) is that you have an absolute value but no idea in which direction and how fast that value is changing. We did a poke with Cadence yesterday and she was 11.8, relatively high but the CGMS monitor showed a significant downward trend. Why is this important? Well, she was heading for a nap, if we had given a dose of insulin prior to that...the low would have been severe. Without a correction, she went down to 2.9. Now mind you, the CGMS missed the low but showed us it might be happening. We did a fingerpoke and caught it before it was too severe.

The big question is: Is it "WORTH" 6000 dollars a year....that's one that's hard to wrestle down.

I ordered the Dexcom 7 competitor unit last night as well to try it out. Many of the CGMS debates out there minimed vs. dexcom are based on an insurance coverage mindset of which we don't have. That puts us in a situation of being able to decide between the two based upon their merits.

Overall, very interesting experiment thus far.

b.