Farm Industry News Blog

Gladys Kravitz rides shotgun with me now

Team FIN farmer Jeff Ryan has had diabetes since the age of three. He's since developed some funny ideas he thinks medical device manufacturers should implement into insulin pumps.

"You and your fancy pancreas!"

That's one of my favorite phrases to toss out to people who aren't diabetic. Sure, they don't have to think much at all when they eat something. Dig in, chow down and let the auto-pilot function of your body take over from there. Must be nice.

I've been an insulin-dependent diabetic since the fall of 1971 when I was three years old. The first specialist I saw for my diagnosis was a guy I didn't particularly care for, based on his personality. I could tell my mother wasn't a fan of his either. He kind of set the wheels in motion for my somewhat unconventional diabetes management system in the years following. That management system did not include the assistance of a doctor. I saw that guy for a little less than ten years. All he ever did was nag about everything I couldn't do, couldn't eat, and couldn't enjoy. He also made regular references to everything bad that was going to happen to me as a result of my condition. All in all, he was not a positive experience.

Without the ongoing nagging of a medical professional, I did quite well on my own for about twenty years. Then the reporter who was in the operating room with me for brain surgery (and is a diabetic herself) mentioned an upcoming meeting dealing with insulin pumps. I decided to go and see what there was to learn. The whole thing looked appealing enough that I decided to jump on board and get an insulin pump. That was in 2001.

My choice for a brand of pump was swayed by a company rep at that meeting. I had shown him the giant magnet that controls the bionics I have in my brain to deal with Essential Tremor and asked if it would cause problems with the pump. He saw the company name on the magnet (Medtronic) and asked me to step behind his booth for a more in-depth discussion. Turns out that Medtronic owned a chunk of his company at the time. (They have since bought the remainder of it.) That's what made me decide to go with his particular brand of insulin pump.

Here is how an insulin pump works. You fill a syringe-like reservoir with insulin and it is connected to some tubing. The tubing connects to an infusion set that is stuck into your body. The infusion set has a small cannula that goes a few millimeters below the skin and injects insulin into the tissue. You can typically leave the infusion set in place for three to five days before you need to switch to a different site. The pump puts a measured amount of insulin into the tissue throughout each hour of the day, because your body is always breaking down glucose even if you don't eat anything. When you do eat something with carbohydrates in it, you take a larger dose of insulin (a bolus) to counteract the carbs. 

The trick is to decide how much insulin to take for the given amount of carbs you have eaten and the level of activity (or inactivity) you will be having as the day goes on. The bigger trick is to balance those quantities and levels to stay as close to the rest of the population with their fancy pancreas that's on autopilot all the time. If you guess wrong and your blood sugar level stays high, you can eventually cause damage to your organs and also make yourself sick from high glucose levels. If you guess wrong and your glucose gets too low, you can also run the risk of doing damage to yourself by not being aware of what you're doing.

Let's say, hypothetically, you run large equipment, or maybe even drive a semi, or work with livestock regularly. Those are all bad situations to be in with blood glucose levels at extreme levels. One radio station had a story years ago about a traffic incident caused by a driver who "had a diabetic attack."

That line was clearly written by someone with a fancy pancreas. Even so, if I walk by a plate of cookies and grab one, I look at whichever skeptic is nearby and ask, "Hey, you don't want to see me have a diabetic attack and make headlines, do you?" 

In 2009, I got another addition to my medical arsenal. It is a Continuous Glucose Monitoring System (CGMS.) That is a small sensor stuck into the skin that measures blood glucose levels every five minutes. That data is sent electronically to the insulin pump where it can be graphed to show the user what trends are taking place with his/her blood glucose levels. The previous option for tracking that kind of thing was constant finger sticks with a needle to get a blood sample to measure.

Any researcher will tell you that more data is a good thing. Any diabetic will tell you that more finger sticks is a very, very bad thing when it happens that frequently. An electronic check every five minutes beats the heck out of that many jabs to the finger throughout the day. One check is a snapshot. Multiple readings will show you trends. The trend is where the real knowledge is.  

Sounds good so far, doesn't it? Now let's add practicality to the equation. All of that data and all of that compilation work does no good if you don't make use of it. Looking at the pump to see the data is good, but what if you reach a level where you may not be totally aware of what's going on with your person? That's where electronic subtlety comes into the picture.

A lot of the engineers who design these devices must think we all lead active, outgoing, involved lives. We're all apparently on a whitewater raft most of the day, or in the middle of an intense game of racquetball. We're sure not in the library, because then we could get by with a low-key notice of our impending blood glucose doom. Maybe a hushed whisper, or a gentle tone like a harp.

Nope. You're moments from death in the midst of audio chaos. We'd better go one step below a car alarm to get your attention!

Sure, you can change the notification somewhat and use a vibration, but it won't vibrate all the time. It will still toss out the wail to keep you from going unnoticed, because, really, you're almost dead. Why keep that to yourself? Everyone else in your meeting / church / restaurant section / line at the grocery store needs to know you're about to go off like a bomb any second now.

The folks at TSA love it if your pump goes off while you're in line. Tends to create a bit of a buffer zone around you in line, that's for sure.  

There has now been yet another technological upgrade to the insulin pump from Medtronic. They have a pump with a feature called Threshold Suspend. You can program in a selected glucose level ahead of time for your notification. If and when your blood glucose gets to that level, it will alert you and shut off your pump. That will stop the ongoing basal rate of insulin you don't dose by hand and get your glucose level rising again. If your body's steam engine is going full-blast downhill on the way to certain death, the solution is to take away the shovel so no more coal goes to the engine. It's not so much an emergency brake as a fuel shut-off valve.

Once again, the process happens with what could best be called "minimal subtlety." The chirping starts and the pump vibrates. Your attention will be acquired.

Quite frankly, I have a reasonably wide level of functionality at various blood glucose levels. Your blood glucose (with your fancy pancreas and all) probably never goes below 70 and rarely goes much higher than 140. I have no problem dipping into the 30's and 40's and still being able to walk and talk. Some diabetics are more or less out of it at 65. The high side isn't so much of an issue. The low side is where the real fun is.

Sherill can usually tell how low my blood glucose is by the way I sound. If it gets to 60 or so, I start having a hard time remembering words and completing sentences. If it gets to 40, I become a bit difficult to handle. She always asks me to say a complete sentence to see how low I am without doing a finger prick. If you ask how I am, I'll always tell you I'm fine. Two words, tops. Making me come up with a complete sentence of five or more words is a bit more challenging for me at low levels.

The new Threshold Suspend feature adds another feature that I discovered recently while working in the feedlot one night. Winter had drug on forever this year, so I was still in coveralls and a heavy coat. My pump had started to vibrate at me as I was cleaning out a cattle pen. I felt fine, so I kept working. The pump kept vibrating, but the only way to get it to stop was to stop the skid loader, raise the safety bar in the cab, unzip my coat, unzip my coveralls, reach down to my side to unzip my pump case and then pull the pump out to hit the series of buttons to see what my alert was and then acknowledge it to get the alerts to stop.

It's a whole lot easier to keep working. Besides, no one was there to ask me for a complete sentence. I recited one to myself as sort of a self-check. It may have been directed at my pump, which was in the role of inquisitor-on-duty at that moment. It may not have been suitable for younger viewers.

I got my task finished and shut the gates to finish for the day. On my way to the house to eat supper, I looked at my pump and saw the message it was giving me. In reality, it wasn't for me. It was for whomever found my lifeless body slumped over in a heap, half a gingersnap from certain death.

"I have diabetes, call for emergency assistance. To clear ESC then ACT."

Huh. My pump is now a tattle-tail! As if the nagging wasn't bad enough, now it's Glady Kravitz and will be telling all of my personal history to anyone who shows the slightest interest in having a look-see for themselves! 

Obviously, Medtronic did not ask for my input when working on this latest pump. If they let me design my own pump, I'd customize it a bit on the Threshold Suspend alerts.

At 85: "Ya know, some pie might be good right now."

At 60: "Add some ice cream and Magic Shell to the pie."

Anything from 55 on down: "Hey! Get me some weapons-grade eclairs, STAT!"

 I just need to find the right engineer.

Guy No. 2

Jeff Ryan is Guy No. 2 in the operation of Two Guys Farming, Inc., near Cresco, IA.

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The Farm Industry News Blog features commentary from Willie Vogt, Jodie Wehrspann, Kathy Huting, Lynn Grooms, Daryl Bridenbaugh and Jeff Ryan.

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