Choosing Health Insurance

For the first time, either in a really long time or possibly ever, I have a choice as to what health insurance I will use.  When I was first diagnosed with T1 I was already enrolled in Aetna while working at Brown Brothers and there was no way I was going to try and change insurance plans.  At Darden my coverage with Aetna continued under their student health plan and really it was either use that plan or go it alone and try and buy something off the street (not really an option).  However, now that I've FINALLY FOUND POST-MBA EMPLOYMENT (more on my dream job later this week) I need to figure out which insurance plan to go with.

The choices:

• Anthem Blue Cross PPO - $20 co-pay
• Kaiser Plan 20

The most important part of my coverage is prescription cost.  The Anthem plan will have me paying $15 for generics (does Novolog even come in generic?), $25 for brand name with a $250 annual deductible.  Kaiser's cost structure is $10 for generics, and $60 for brand name at a 100 day supply through their mail order service.  

Does anyone have experience filling Medtronic or Dexcom orders with these plans?  Anne of annetics.blogspot.com loves her Kaiser plan but its a different one than what my future employer (unveiled later this week) is offering.  Not sure what else I need to look out for - any advice would be awesome!

The Little Things

NPP and I have been getting along very well over the first week of our relationship.  My blood sugars have been incredibly steady and my bolus ratios actually work like I expect them too again; I fear that OPP was on the fritz for the better part of a year.  I really wish there was a guide book for all the little things that a diabetic encounters during the course of their disease.  Most of the daily adjustments we make become second nature, but every so often I am reminded of how much thought and practice it took to get accustomed to this new way of life.

Tuesday evening after physical therapy I met my sister out for dinner at Suenos, a tasty Mexican restaurant in the Chelsea area of Manhattan, for taco night.  We started the night with some guacamole and then split a delicious trio of taco meats and we made our own tasty delights family style at the table.  With the massive amount of corn I was about to consume I started plugging away on NPP to pump up the bolus.  I figured that my meal would be about 160 grams of carbohydrates, but for the life of me couldn't figure out where my dual wave bolus function went.  I also could not fathom why my pump kept locking me out of administering a regular bolus saying I had exceeded my mass bolus limit!

Now a step back, due to all the medical regulation required for medical devices the device pretty much has to be error proof.  Additionally, tons of children use insulin pumps so there need to be a ton of fail safe mechanisms so a 5 year old does not inadvertently give themselves 20 units of insulin.  So on each pump there are settings that open up more menus for a higher level of customization of insulin infusions.  It's kind of like unlocking a secret level on a video game except in this case it lets me eat, not just spend more hours getting callused thumbs.

After staring at NPP for a good 3 minutes I finally remembered that it came with factory settings - not Ed customized settings!  With that realization I began beeping away expanding my max bolus from 10 units to 25 units and unlocking the magic menus of square and dual wave boluses.  Had those two functions not been available to me there was no way I could have eaten the meal we ordered.

Over the past month I have gotten just a small taste of what blood sugar management must have been like prior to pens that could give you lantus or novolog in micro-adjustments or insulin pumps that can change the level of insulin in your body at the push of a button.  The advancements in medical technology have made it possible for me to eat a carb-riffic meal of tacos, compete in Ironmans and go about my day like any other 31 year old would.  And the amazing thing is, it's not the big advancements that have helped totally change blood sugar management, it's the small things that let insulin calculations become more precise.  I know that the advent of insulins that react differently in the body (i.e., lantus v novolog) revolutionized care but the incremental changes to deliver that insulin more precisely has provided alot more freedom.  From a 30,000 foot level we all manage this disease pretty similarly but when you get down really close to individual management you see how unique this disease is for each person who has it.  The past few weeks have made me realize how much all those little things add up and reminded me why it's so important for our collective experience to be shared.

Re-Birth! The New Purple Pancreas Arrives

I anxiously waited by my front door on Tuesday morning hoping to see Big Brown making its way up the hill my parent's house is on.  I sat by the door like an anxious puppy with my head turning at each passing car.  After less than 24 hours I couldn't handle shots anymore.  I had bruised my stomach twice, had a rapidly escalating blood sugar and overall just felt lousy from the worst control I had over my blood sugars since day 1.  My knight in shining brown could not get here with my package fast enough.

Just before 10:30 am I was in my driveway to go pick up my Dad from the auto-mechanic shop where he had dropped a family car off for new brakes.  As I opened my car door I heard a rumble at the end of the driveway - Big Brown had finally arrived!  I signed for the package and called out for my Mom, I couldn't wait, it was time to put my tail back on!

Giddy with joy I opened each box, removed my remarkably similar new pump (there was some anticipation that there would be some distinguishing characteristic).  I had hoped for a slightly different colored "ACT" button, maybe a slimmer profile, but NPP looks identical to OPP - I guess while OPP was not original in looks he was original in spirit.  I take solace in the fact that on my belt NPP is OPP's twin.

I found my settings on my Minimed Connect site, loaded them into NPP, felt the oh so familiar sting of inserting an infusion site and was off to pumping again!  By the time I had NPP up and running my blood sugar was up to 279.  To manage my blood sugar while tail-less I set my alarm for 4am so that I could get some mid-sleep fast acting insulin into my system.  At 4am my blood sugar was in the 250s, I took in 3 units of insulin and woke 3 hours later with a blood sugar of 215.  At 8am I took in another 3 units of insulin but by 10:30 am without any breakfast I had hit the 279 mark.  With my pump attached I bolused away but my blood sugar was still on the rise.  Due to the lack of insulin in my system my bood sugar continued to climb into the 300s until I had enough insulin in my system to reach a homeostatic state.  Around 5pm I finally had control over my blood sugars again.

Over the past few days I have noticed that the control I have over my blood sugar levels has been much tighter than what it was with OPP.  During OPP's final few months I had to fight off low after low and often encountered an unusual high that made no sense.  Foods that I would bolus for one day under the exact same environmental factors (exercise, temperature, etc) would require a totally different insulin amount the next day.  I probably should have called Medtronic as soon as I noticed my blood sugars doing weird things because it was probably a warning side that OPP had gone crazy.  NPP has worked like a champ and my bolus calculations have returned to what I expect them to be and my blood sugars are reacting like they should.  I guess I'll take this as a lesson to never be too cautious when it comes to my blood sugars and when I notice something is repeatably out of line to take action and find out what's up.

Obituary: Original Purple Pancreas

On August 16^th at approximately 4:10pm on the 5^th floor of 60 East 56^th street in Manhattan the Original Purple Pancreas experienced a fatal button error. After numerous attempts to revive the Original Purple Pancreas through a series of battery changes, rapid button pushing and the seldom effective slap on the side, Minimed Paramedics called time of death.  The Original Purple Pancreas was born on June 12^th, 2007, lived a full life and is survived by 6 boxes of infusion sets, 5 boxes of reservoirs and 17 needle marks on Ed L’s posterior.

The Original Purple Pancreas truly gave life to all those he came in contact with.  The Original Purple Pancreas was a warrior insulin pump having survived two Ironman triathlons, including one in the pouring rain, five half-iron, 2 Olympic and 1 sprint triathlon.  The Original Purple Pancreas was no stranger to foreign cultures having visited Costa Rica, Sweden and Denmark as well as spending time in no less than 15 US States.      

OPP three times survived extensive security screenings at airports and was known to perilously detach himself from the safety of its belt clip to dangle life and limb from nothing but an infusion site tube; OPP was truly a thrill seeker.  OPP with a series of beeps, calculations and corrections was always fond of low glycemic foods but gave its best to counteract the sugar spike of the occasional pizza. OPP unfortunately never was able to achieve its life’s dream of testing its carbohydrate counteracting abilities versus Wylie Dufresne’s molecular gastronomy however. OPP’s last great triumph over blood sugars was at Jonathan Waxman’s Barbutto, 6 days before OPP’s passing.

OPP will sorely be missed by those he supported and allowed to thrive.  On countless bike rides, through questionable placement during debaucherious pursuits, and steadfastly fighting the fight against type 1 diabetes OPP was always there.  He will be most fondly remembered for his remarkable ability to face carbohydrates and allow those he supported to live their life to the fullest. 

Tribute to Original Purple Pancreas will be paid during his long lost twin brother’s first priming on June 17^th, 2010 at 10:30 am in Upstate NY.  Sarah McLachlan’s I Will Remember You will be played during priming simultaneously on all connected Itunes libraries at that time.

The Nutrition Protocol Drawing Board

My attempts at exercise starting at a lower initial blood sugar has been going on for about a month now.  At times the process has been tremendously frustrating, like getting to the pool parking lot with a blood sugar of 75, sitting there for 15 minutes and then realizing a swim just isn't going to happen.  Or going out for what you hope will be an 8 mile run and having your blood sugar drop into the 40s during the first 20 minutes of the attempt.  However, I totally expected this to run into some really frustrating moments as I attempted to tweak my nutrition.  After a month I've noticed some trends and am getting more comfortable taking insulin before I workout.  Also, thanks for some of the great suggestions with my last post on this topic, please keep the ideas coming!

Thus far swimming has been the easiest thing to change my nutrition protocol for.  For swimming I can take in more insulin than for biking or running pre-workout and my blood sugars seem to be more stable for the duration of the effort.  It also seems I need a lower level of initial carbohydrates for swimming than I do for the other two disciplines.  Not sure how that will play out in a race but as a stand alone the new protocol is helping alot.  In the past I would start a swim with a blood sugar upwards of 220 and that number would continue to rise throughout my warm up.  During the early part of my main set I'd often be dizzy or just not feel that great.  Now starting at a blood sugar of 140 - 160 allows me to feel much more fluid in the water, concentrate to a higher degree and feel much stronger at the end of my set.  I've been taking in about 35 grams of carbohydrates pre-swim with 1 unit of insulin compared to 60 grams of carbohydrates pre-swim with no insulin; the protocol still needs some tweaking as my blood sugar is dropping into the 70s or 80s if I swim for more than 1,500 yards but at least I am avoiding the massive blood sugar spike post swim that I had encountered in the past.

I have only been on my bike 4 times since IMCDA but 3 of those times came in the past week.  My physical therapist wanted me to hold off on biking as we've been working on my back but having made some progress I was comfortable enough to get back in the saddle.  Last week had mixed results for blood sugar management on El Bastardo.  Monday I threw my bike onto my trainer and was set for an hour long effort.  I took in 1.5 units of insulin for a clif bar about 40 minutes prior to my workout.  20 minutes into the ride my blood sugar dipped to the 60s which required a 20 minute break before my blood sugar came back up.  Thursday I attempted the ride again this time taking in 1.1 units of insulin for my clif bar and was able to hit the ride out of the park.  Confusing the issue has been a major basal/ bolus rate problem I've had since diagnosis. Almost everyday sometime between 4pm and 5:30pm I know I'm going to go low.  No matter what I do, what I change, what I eat, I go low.  A future post will feature that issue since I have no clue what the heck is going on in the afternoon.

The run has been by far the most frustrating part of the nutrition tweaking idea.  I know for certain taking in insulin greater than 1 unit in the 40 minute window prior to running will make my blood sugar go way low in over the first 2 miles of a run.  I have also realized that when I run with a blood sugar between 130 and 150 I feel freaking awesome, especially when compared to running with a blood sugar near 200.  The stomach issues and cramps that I normally associate with a run are absent when exercising at a lower bs.  There is a really delicate balance between insulin intake, carbs or board and running duration to my blood sugars though and I just don't have it dialed in yet.  I'm getting closer - on Saturday I headed out for what I hoped to be an 11 mile run (bonked at mile 9.85, fitness has left the building!) by mile 4.5 my blood sugar was in the 90s and I felt a little low - in the previous attempts I'd get that feeling around mile 3.  I was able to recover my blood sugars quickly and continue the run with a stable blood sugar in the 120s.  There however is a huge mental hurdle to get over to have the confidence to run at a stable 120 when you have spent 3 years freaking out if your blood sugar was below 160 for a run.

The quest continues; a few more weeks of this and I'll hopefully have everything locked in.

Dropping Knowledge About My Dexcom

I still need to finish my long overdue full review about my Dexcom.  But honestly the thing has been amazing and well my long self-directed job search has been taking up the bulk of my time.  While I know that going the off-grounds route for my post-MBA job will prove to be incredible rewarding does not make networking my butt off on a daily basis any easier.  But enough of the whining, onto some knowledge about the Dexcom.

My one big frustration with my Dexcom has been its uncanny ability to wake me up at 3am proclaiming that I'm about to go into a hypoglycemic coma with nothing but an announcement of LOW on the screen.  The vibrations and beeps are enough to wake the dead; the tones are especially nice when I accidentally hit the Dexcom next to my pillow while I sleep.  Now if my blood sugar was in the 40s or 50s each time the alarm went off during prime sleeping hours I'd be ecstatic.  However, alot of the time the alarm is going off even though my blood sugar is somewhere in the 110 to 130 range.  Getting woken up at 3:30 for no reason = not cool.

Then during a run the other day I had an epiphany.  My blood sugar started to drop quickly and I could feel some of the symptoms of a bad low coming on so I plopped my butt on a bench.  Since I was looking at my Dexcom every 30 seconds waiting for the trend arrow to change (it takes 7 minutes btw) I decided to clip it off of my shorts and put it on the park bench next to me.  Even though I was just inches away from the Dexcom the out of range icon popped into the status box.  Hmmm..... weird.....

At that moment I realized that the sensor for the Dexcom is probably on the back of the device (I have no official knowledge of the engineering specs for the CGM).  So that when the back of the device was laying flat on a solid wood park bench and my sensor site was above the receiver the transmission got lost in space.  when I flipped my Dexcom face-side down it quickly picked up a signal again somewhat confirming my hypothesis.

It then dawned on me that the same thing is probably happening while I sleep on my mattress.  My big ol' butt is making the sensor site higher than the receiver and if the receiver is face up its receiving nothing but transmission from my mattress.  I've noticed when the Dexcom picks up an intermittent signal it can start to do wacky things - which is what I believe was happening each night.  Now that I keep my Dexcom face down on my mattress I'm getting an "illegitimate" low maybe every 3rd or 4th night - way better than being startled awake up to 3 times a night for false lows.  The small change did the trick and now I'm getting much better sleep!

MacGyver Like Diabetes Management

Each year my Uncle throws what he calls the "Sweeney Bass Tournament," at his lake front cottage just North of Albany, NY.  The origins of the name are a bit confusing, in the 20 or so years that the family BBQ has been going on a total of zero bass have been caught and well I'm not sure anyone has actually seen a bass in the lake, ever.  But I guess Bass Tournament sounds alot better than Sunny Tournament.  The family get together was held this past Saturday and marked the first time I was able to make the party in about 3 years.

Besides some great highlights, like my sister's boyfriend and 2 of our cousins flipping the canoe over in the lake, my first match of can-jam and running the fastest 3.5 miles and longest distance (7.5 miles) I have run since prior to IMCDA, one diabetic incident almost soured my day.  In my temporary stay at my parent's house during my quest to launch my ideal post-MBA career my diabetic supplies aren't in the nightstand I normally keep them in; since the stand is in storage.  So, about a week ago my Medtronic Inserter fell into the vortex of lost things in my parent's house forcing me to put my infusion sites in by hand.

The Medtronic Inserter makes putting a silhouette infusion site in way easier than putting it in by hand.  The "gun" controls the speed and angle the needle punctures your body at creating an optimal insertion.  When inserting a site by hand I never know how hard or deep to push or what angle I should ultimately put the needle in at. Plus, the "gun" is considerably less painful than putting a site in by hand.  With that history, on Saturday I had to change my infusion site by hand and hoped that I had put it in at the right angle.

When I finished my 7.5 mile run on beautiful country roads up at the lake house I hopped in my Aunt and Uncle's shower. When I removed my running shorts I looked down to see a bloody infusion site hanging at my waist - it had completely fallen out of my butt.  I quickly showered, got dressed, and then found my Mom to say "ummm, I have a problem."  Normally I bring an extra site with me when I travel but for whatever reason I didn't have one in my bag of blood sugar doom.  I then tried to call Medtronic to see if there were any reps in the area I could grab a site from but after 20 minutes on hold with no answer I went to plan C.

I had remembered sometime ago reading on another diabetic's blog that they used their pump reservoir as an insulin source and inserted their novolog with a syringe.  With that faint memory my sister and I headed to CVS to pick up a package of syringes.  Once in the car I took the reservoir out of my pump, tried to calculate 2 units of insulin on the 50 unit syringe and for the first time in over 3 years stuck the needle into my gut to manually give myself insulin.  The day was kind of saved and we wouldn't have to leave the party early.

For the next 5 hours I kept a close watch on my blood sugar levels but knew there was no way I could be as precise with a 50 unit syringe as I could be with either a novolog pen or especially my pump.  For dinner I ate as carb light as I could passing over the meatballs, pasta, steak and fried chicken for quinoa, salad and green beans.  Even with a super careful eye for carbohydrates my blood sugar was just not stable, the difference between giving myself 3 and 5 units of novolog is huge from a blood sugar perspective, but on the syringe each looks about the same.  So for the next 2.5 hours I battled a bunch of lows, but had an ample supply of clif mojo bars and Erin Bakers brownie bites to stave off the glucose deficit.

Once home I happily put in my infusion site and once again had my tail attached to me.  Sleep Saturday night/ Sunday morning was a mess however.  The combination of my attempts to work out last week at a lower blood sugar target and my non-precise insulin calculations during the day had me wake up four times with blood sugars in the 40s!  After some extra eating on Sunday including a flat bread pizza, ice cream and a delicious avocado and potato salad my blood sugars have stabilized and I'm back to normal. But my day of MacGyvering out blood sugar management was an interesting one.

Tweaking Nutrition

Any change to a type 1 diabetic's exercise nutrition plan takes a ton of practice and bit of patience.  I'm awesome with the practice part; patience, not so much! For the past few weeks I have been attempting to start my work outs with a blood sugar around 160, rather than the 220 I had been aiming for the past couple years.  The new target is for both performance and health.  It's probably not healthy for me to intentionally spike my blood sugars into the 200s once a day to get in a workout. Also, spikes that high in blood sugar can really degrade performance. So in addition to trying to get my weight down to 175 this off season Coach E and I set a lower pre-workout blood sugar target as priority A.

My first big experiment with the new target is to take in insulin with my pre-workout food.  Historically I had eaten a Clif Bar 30 to 45 minutes prior to exercising to spike my blood sugar for the start. If I was just munching on a Clif Bar as a snack I would take in 3 to 3.5 units of insulin (a carb ratio ranging between 1:11 and 1:15).  Now I'm experimenting with taking in 1 to 2 units of insulin for the deliciousness that is a White Chocolate Macadamia Nut Clif Bar.  I'm then taking in some liquid nutrition right before the start of my workout so that my blood sugars don't plummet during the first 15 minutes of output.  So far, so good.

The results have been pretty good thus far.  I haven't yet tried any workouts longer than an hour with the new plan.  The big workouts I've been doing over the past few weeks are a 5 mile trail run in the Ward's Pound Ridge Reserve (awesome park if you're in the Westchester area) and a 1,500 to 2,000 yard swim set.  For the past 2 weeks I have been consistently starting my workouts with a blood sugar between 140 and 170 and ending with a blood sugar right around 90.  I've noticed that this has helped my speed towards the end of my run but has really hurt my effort during the swim.  I'm not convinced that my blood sugars will hold up during exercise of longer than an hour yet but this will be an iterative process with alot of trial and error.

Also, a huge shout out to Triabetes Captain Annie who broke 6 hours in her first Half Iron this past weekend!