I'VE GOTTEN ATTACHED TO MY INSULIN PUMP

by Veronica Elsea

Photo:� portrait.� Caption:� Veronica Elsea

FROM THE EDITOR:� Veronica Elsea is a professional musician with her own studio, and a member of the Diabetes Action Network of the National Federation of the Blind.� Here she provides, based on her own experience, a detailed explanation of how blind diabetics can independently use insulin pumps.

With the recent awareness of the benefits of tight glycemic control, many of you may be considering the use of an insulin pump.� Yet along with the curiosity, excitement, and optimism come some challenges for blind persons.� We must often start by convincing our health care professionals that yes, we can make use of this new technology; a tricky proposition if we've never actually seen or used the device ourselves!� I hope that by describing how I manage my pump, this challenge will be more quickly and easily met.

I am totally blind, a type 1 diabetic, and I have been using the Disetronic (H-Tron V) insulin pump since September of 1991.� The learning process was quick.� I had the entire kit:� pump, supplies and manuals, sent to me ahead of time.� I did not then own an optical scanner, so my husband read the manual to me, and I had the time to privately explore the pump.� This process took one evening, and I found it very helpful.

The pump is small, about the same size and shape as a little travel pack of facial tissues.� It has only three buttons, two on top and one on the front.� There are no complex menus or screens to learn.� In fact, for a totally blind person, the training is usually very quick, as most "training time" is spent learning the print symbols for cartridge, battery, etc.

Everything you do is confirmed by beeps.� Press once on either top button, and three short beeps tell you your pump is running; one long beep will tell you your pump is stopped.� (When in stop mode, the pump also beeps every minute to remind you of this.� So if I'm removing my pump and don't wish to wake my husband while I shower, I temporarily turn off the beeps.)

Batteries:

The pump uses two batteries, which are very easy to install and remove.� There is a low battery alarm which I'll cover later.

Filling the Cartridge:

The pump uses a glass cartridge, holding 315 units of regular insulin.� Filling it is a very blind‑friendly process.� I simply place the cartridge in its holder, attach a needle to one end, and its plunger to the other.� After removing the cap from the needle, I insert the needle into an insulin vial, upright on my table.� I then turn the whole works upside down, and grasp the holder in my left hand.� I can then push the plunger all the way up, and begin pulling it out, slowly and steadily, filling the cartridge with insulin.� The holder prevents the plunger from being pulled out too far.

The question most sighted people ask is about preventing air bubbles.� I find it's easy to get air bubbles because it's hard to pull the plunger out evenly.� So, after I fill the cartridge, I slowly push the plunger back in again, and surprise; the air bubbles are very audible!� I usually do this a few times, pushing and withdrawing the plunger, sometimes tapping randomly on the holder.� When I push in and hear nothing, I stop, pull it back out, and that's it!� I then pull the insulin vial off, cap the needle, unscrew the plunger and the needle, put a little cap on the cartridge, and lift it out of the holder.� Sometimes just to be safe, I fill the cartridge in the evening, and let it stand overnight, before placing it in my pump the next morning.� This allows the air bubbles to dissipate. Disetronic is now recommending this procedure for sighted pumpers as well.

Priming the Pump:

Near the battery compartment there is a hole into which the cartridge fits. �I insert what's called the "piston rod" into the cartridge, where the plunger had been.� This piston rod is what moves, forcing the insulin out of the cartridge. Once the cartridge is in the pump, I pull off its cap and put on what's called the "gray adapter."� It forms an airtight seal and has an opening in the top where the tubing is attached.

By pushing a few buttons, I tell the pump it has a new cartridge, and it sets its display accordingly.� The pump beeps when the process is complete.

Getting Insulin Where It's Needed:

The insulin is delivered through a needle or cannula, which is placed anywhere you'd give an injection with a syringe.� I only use my abdomen; I find it easier and more reliable.� I use a Teflon cannula called "Tenders," made by Disetronic.� I find them easy to insert and very forgiving.� In fact, if you have any neuropathy in your hands, you may actually find these cannulas and cartridges quite a blessing, as they're fatter and larger than regular syringes.� The "Tenders" are inserted at an angle, anything up to 45 degrees or so.� I just hold it at a slant, push it in and don't worry about it!� As you might expect, once you insert the cannula and remove its insertion needle, it is held in place with tape.� With the new "Tenders" the tape is part of the cannula, so I no longer find myself holding something in place while searching for a piece of tape somewhere on a table!� It's designed for one‑handed operation by a sighted person, which means we can do it easily and comfortably with two.

Tubing:�

The cannula is connected to the pump through special tubing.� One end of the tubing is pushed into the end of the cannula, and the other screws into the gray adapter, as mentioned above. Before I connect the tubing, it must be primed (filled with insulin).� This is very simple:� Press all three buttons at once.� When priming, I hold the end of the tubing in my left hand, and extend one finger until it rests directly under the spot where the insulin will come out.� When that finger is damp, I know my tubing is completely primed.� I stop the insulin flow by pushing one button with my right hand.� I then attach the tubing to the cannula.� Priming is treated as a separate function because the pump keeps track of your daily insulin usage, so the amount of insulin used in this process is not added on to your total.

Insulin Delivery:

With a pump, you receive insulin in two different ways, the basal and the bolus.� When your pump is running, you will automatically receive insulin every few minutes. �You program (set) an hourly rate.� For instance, my basal rate for this current hour is .4 units.� The pump then portions that amount over the hour.� I can set a different rate for each hour, or make many of them the same, depending on my needs.� (I keep a list of my rates in a file in my Braille Lite.)

The process of setting basal rates is one of counting beeps.� With the pump stopped, I push one button to move from one hour to the next.� The remaining two buttons allow me to go either up or down, .1 unit at a time.� There are special shortcuts (button combinations) for some tasks, such as setting all rates alike, or repeating the same setting for the next hour, etc.� And yes, if you really get lost, you can just go back to "0" and start over.

When you eat, or if you need to take extra insulin because you're high (elevated sugars), you give yourself a "bolus."� When the pump is running, a press of either button on top will deliver .5 units of insulin.� So if you wanted three units, you'd press the button six times.� The pump will beep as you press the button, and then will repeat the beeps back to you, before actually delivering the insulin.� By the way, these buttons are designed to be felt through clothing, so you need not stop and fish out the pump.� I have often given myself a bolus while standing in the buffet line, making my food selection.� In the same manner, you can temporarily reduce your basal rate in cases such as extra exercise.

Carbohydrate Counting:

This is a skill you will learn as part of your pump training.� In my case, I take one unit of insulin for every 12 grams of carbohydrates, except in the morning, when one unit covers 10 grams.� I worked with a dietitian to learn portion sizes, and read food packages.� There are many print books which list the carbohydrates and calories for various foods, and I'm hoping we'll shortly find this information on line.

Alarms:�

The pump has alarms for low batteries, occlusion, electronic problem, "out of insulin" and end of use of your pump.� Although the same beep sounds, the different alarms behave differently.� Disetronic has expressed willingness to make these alarms easier to understand by having the beep match the "error number."� For instance, error 3 means a low motor battery.� In the future, the alarm for this might be a repeating pattern of 3 beeps (it doesn't yet).� But for now, we just have to learn what the beeps mean.� An alarm will beep constantly until you silence it.� If you do nothing else, you'll get beeped at again in one hour.� This process can go on for as long as 12 hours.

I have learned that I usually get about two months' use on one battery set.� So if I'm planning a trip, I usually just change them when I think it's about time, not waiting for the alarm.� Incidentally, the pump does not forget your basal settings when you change batteries.� The occlusion alarm, on the other hand, will emit the same constant beep until you silence it.� But you'll hear it again every time the pump tries to deliver insulin, every few minutes.� It also puts the pump in stop mode.

The pump lets you know as you're approaching the end of your cartridge.� You hear one beep when you have 20 units of insulin left, (I often miss this one), two for 15, three for 10, four when you have 5 units left, and an alarm when you run out.� This alarm acts like the occlusion alarm, but it has of course been preceded by all those warnings!

The Display:

I have not found any way to successfully read the display; it's too small to read with my Optacon.� This display shows the amount left in the cartridge, the total amount of insulin used since midnight, the amount and time of the last bolus, and the current basal rate.� It also shows symbols or numbers as you prime, install a cartridge, set the clock, and set basal rates.� At first, I used a calculator to keep track of my insulin usage, but now I know that under normal conditions, a cartridge lasts me about eight days.� Once in a great while, I just ask my husband to check a number, or to double check my readjustment of my basal rates.� I rarely miss this display.

The clock is also set by counting beeps.� It can get a bit tedious though, as you can only go forward; just be patient when changing back to standard time!

Wearing the Pump:

It only weighs a few ounces, has very rounded edges, and is very rugged.� Many people place the pump in a pants pocket or on a belt loop.� I prefer wearing mine tucked in my bra or in a shirt pocket.� If I'm wearing a very nice dress, I often put it around my waist (You can buy all sorts of pouches for holding the pump).� It doesn't hurt to roll over on it, bump it or anything.� I find that I only occasionally startle someone who gives me a big hug and wonders what that "thing" is!� I've gone swimming with mine, hiking, shopping, dining and more.

Until the arrival of the "Tenders," I carried the pump into the shower every day.� I would put it in a bag that I could hang on the faucet, or clip to a shower curtain, and yes, the tubing is long enough to allow plenty of room for moving around.� You can buy tubing in different lengths, although I prefer the shortest, 31 inches long.

Only once during an exuberant "good morning" did my guide dog reach up and catch her paw in the tubing.� It's a weird feeling when you catch the tubing on something, but it takes real effort to knock out the cannula.

Questions or Problems:

I have found the people at Disetronic to be very helpful when I had a problem.� They've done very well at giving blind-friendly descriptions of things over the phone, listening to my suggestions, and sending me things for trial purposes.

Advantages:

I really notice a difference in my control.� I use less insulin, have fewer highs and lows, and just plain feel better.� I also love the flexibility; I decide when it's mealtime, and can easily make adjustments if I am surprised by things like a sauce they didn't mention, or a walk that was longer because some street didn't go through!� I love the convenience of not having to carry around all those little bits and pieces.� Here's one example:� I regularly attend breakfast meetings.� I test my blood before I leave home.� Since I never know when breakfast will actually arrive, I wait until the meeting has started, then just reach up and push the button.� People don't even notice that I'm doing it; their pagers and mobile phones are much louder.

I feel very efficient and inconspicuous, just the way I like it.� If I'm out and unable to test, or don't get a valid test, I find the pump very helpful.� I take the amount of insulin which will match the upcoming carbohydrates or familiar diet pattern, and know that it's easily straightened out later, just by pushing a button.� I'm also not so worried about going out and getting in trouble from low blood sugars, since there's no long acting insulin.� If I'm low, once I eat something, I know I'll be okay.

I sincerely hope that relating my experiences with the pump will help you have a constructive discussion with your health care team about whether or not the pump is right for you, based on your diabetes, not your blindness.

Note:

Disetronic Medical Systems (H-Tron V Insulin Pump): 5201 River Road, Suite 312, Minneapolis, MN 55421-1014; telephone:� 1-800-688-4578.� Control buttons are raised, and easy to distinguish by touch.� The device has clear audio cues.

Minimed Technologies (Minimed 506 Insulin Pump):� 12744 San Fernando Road, Sylmar, CA 91342; telephone:� 1-800-933-3322.� Control buttons require modification for non-sighted use.� The device is not as accessible as the Disetronic, though some blind diabetics use it quite successfully.