Tuesday, June 26, 2012

Hanging out with insulin pumper extraordinaire, Dr. John Walsh...

(And by 'hanging out with' I mean 'in the audience of a presentation by'.)

So, yay! John Walsh was in Toronto last week doing a few presentations. I packed my bags and travelled for a whole hour out to a convention centre around Pearson Airport for his last session... at 9am on a Saturday morning. Despite the early rise, however, the room was pretty packed and I had trouble finding a spot to sit.

The early presentation began in pretty much the same fashion that every person with diabetes starts their day: numbers. The first topic for discussion was the Actual Pump Practices study, whereby the data of 396 pumps with meter results input were analyzed. The data was divided into three categories depending on the average blood meter glucose results: 
  • Low Third- 144 mg/dl (8.0 mmol/L), 
  • Mid Third - 181 mg/dl (10.0 mmol/L),
  • High Third- 227 mg/dl (12.5 mmol/L.
The results were kind of interesting (even without caffeine), because in terms of behaviour all three groups were similar. 92.7% used the bolus calculator to cover meals and 96.5% were using the calculator to correct high readings. People in the lowest blood glucose group were testing their blood an average of 4.73 times per day; while, similarly, those in the high group were testing 4.01. The only noteworthy differences between the lowest and highest groups were that the latter tended to be using greater amounts of insulin, and infusion set failures/occlusion errors appeared to significantly raise blood glucose averages. From this there was a conclusion that high blood glucose results were not necessarily a matter of people not trying to manage, but rather those people needing more insulin, or losing insulin from set malfunctions.

The next topic my new BFF Dr. John Walsh discussed was how to go about fine tuning your pump settings in order to gain the best control you can of your diabetes. On paper, this looks like:
  1. Stop lows first
  2. Find an iTDD (improved total daily dose- using chart from the new Pumping Insulin)
  3. Set and test basals
  4. Set and test Carb Factors
  5. Lower post-meal blood glucose
  6. Set and test Correction Factors
However, in real life my new BFF Dr. Walsh likened all the data needed to analyze and manage diabetes to a Jackson Pollack painting. It was funny...

The rest of the presentation was essentially about steps 1-6... But here are the points that struck me the most:
  • small carb factor changes make a big difference- ex., a person 73kg (160 lbs) has a TDD of 40 U (<--- I don't actually know what weight has to do with anything, but I wrote it down, so I feel like it was important somewhere?) Said person changes from 1U per 10g CHO to 1U per 9g CHO. On avergage people from the APP study ate 190 grams of carbohydrate a day. Assuming this average, changing that carb factor puts another 21 units 2 units (forgot subtraction!) on the person's TDD.
  • try not to eat if your blood glucose is over 8 mmol/L (144 mg/dl)
  • half of the protein you eat turns into carbohydrates
  • some fats seem to provoke insulin resistance (I heard something about cheeses and then I tuned out, because I can't eat dairy. Sorry)
  • setting the duration of insulin action on your pump is important, because setting too short a time is a recipe for later lows 
And this one made the whole room gasp: A woman asked how she could avoid so many bad infusion sites. New BFF Dr. Walsh asked if she used a set with an auto-inserter. She said yes. He said stop using those... because they way that they are cocked means that they are difficult to get to go in straight and without kinking. (And from my experience those suckers tend to bleed into the canula more times than not.)

With respect to infusion sites, there were also these recommendations:
  • Sure-T/Contact Detach, Sof-Set, and Silhouette are more reliable infusion sets
  • always anchor the line with 1 inch tape to reduce irritation and tugging that can cause insulin small leaks at the site
  • suggested tapes were: durapore, transpore, hypafix
  • when you have a site failure and your blood glucose shoots up (to the sky) don't forget that you were not getting basal along with whatever you carbs you might have bolused for... you, therefore, will likely need more insulin to get your blood glucose down to target.
So, that was that. In a nutshell (<--- no carbs!) My favourite part was during break when a woman went up to ask about her up-and-down blood glucose readings that she'd been trying to get under control with the help of her CDE. He asked her a few questions and then asked if he could look at her pump settings. Occassionally he would look up and say, "Do you have x, y, z happen?" and she would respond, "Yes, that's exactly what happens." And he'd change a setting and explain. I like to think her blood glucose is a constant 5.5 mmol/L now and forever. She should probably never wash her pump again.

They gave away a few copies of the new 5th edition of Pumping Insulin at the end of the morning. I didn't get one. I kind of imagined that after the draw someone would stand up and pull an Oprah, yelling for everyone to look under their chair to find a copy of the book... "AND YOU GET A BOOK! AND YOU GET A BOOK! AND YOU GET A BOOK!" And we'd all lose our shit, just like on the show... But that didn't happen either. 

In the end, though, I was just really happy I got to hear from what could maybe be define as the rock star of pumping insulin (too much?) He was pretty engaging and generous with his knowledge. Even during break he didn't stop to get anything to eat or drink, but instead made sure he got to everyone's questions. I hadn't realized that he also has diabetes and has been on what seems like every pump imaginable over the years. Because of that he would make the occassional reference to diabetese, like the Pollack-type BG graph joke or talking about type 3's (aka 5.5ers or support people without diabetes.) So, despite the early start time and the rather obscure location and the no free book under my chair issue, I found it was really good times and learning.


Dylan Kelly said...

Cool Virtue, I actually signed up for that but then bailed last minute because of the early saturday morning obscure location factor... That's interesting 1/2 of protein get's converted to carbs, I was trying to find a number for that. The part about the carb factors is true.. a small change can make a large difference, although the math is like this: 190g of carb for 1:9=21 units, 190g of carb for 1:10=19 units, a 2 unit change, not 21.


Virtue said...

oh, crap. i'm bad at math as is, but my blood sugar was wonky! don't write and test/bolus! imma correct. thanks Dylan :)

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