Complex Pediatric ECHO: Diabetes Technology (CGM, pumps, etc.) – 1/5/18

Complex Pediatric ECHO: Diabetes Technology (CGM, pumps, etc.) – 1/5/18


Hi to everybody out there on our big screen sitting in front of me. I’m Yolanda I’m a registered dietician certified diabetes educator and we’re going to talk today about pumps and glucose meters and CGMs continuous glucose monitors on pediatric, I work with pediatric endocrinology with Dr. Eckert at Renown as a dietitian, also the diabetes educator and then we’re just going to go around and introduce ourselves and it would be helpful if you all introduced yourselves as well. So go ahead. I’m Kathy Eckert I’m a pediatric endocrinologist I’m Steve Graybar I’m a clinical psychologist and work here at the Medical School in the department of psychiatry. And then let’s go to Skyler.. My name’s Skyler I’m an RN with the Elko County School District Great thanks for joining us I’ll take you off mute just a sec Go ahead hi I’m Bobby Shanks I’m the school nurse coordinator with Elko County School District. Great thanks for joining us and Dr. Stage Hi I’m Danielle Stage Im’ a pediatrician in Reno at Community Health Alliance Alright think we’re ready Cool so it sounds like we have a couple school nurses on which is awesome in case you have any specific questions, I think for all of us the more conversation we have the better it is for us and we want to address whatever interests you have and so I’m sort of surrounding pumps and CGMs and meters to use you’re certainly welcome to ask us any specific questions that you have as we go along. Sound good? Does anyone have anything specific that they wanted to ask? So I can head in that direction.. Or any cases that we can do at the end as well if diabetes or otherwise. Feel free to let us know. Yeah. So if you have anything let us know so we don’t go over time we want to make sure we give enough time for that stuff too. Alright so here we go. So meters and pumps and CGMs, Oh my which is my funny way of referencing The Wizard of Oz. This is kind of like a little trip to Oz Alright so we’ll talk about blood glucose meters certainly one of the most important parts right of monitoring blood sugar aside from making sure you’re taking your insulin we also want to know what your blood sugar is. There’s currently 88 meters on the market and that was as of a couple months ago so that’s probably higher than that now, think there’s a million meters out there certainly sort of big business because someone needs to be checking their blood sugar’s in pediatric endocrinology so typically lots of type 1’s we’re checking their blood sugars a minimum of four times a day and so they can go through tons of meters. It’s typically the meter that someone’s put on is insurance driven so whatever their insurance is going to cover is what we want to give them. The meters themselves aren’t expensive we typically have meters that we can give out it’s the strips that are so expensive. Things to consider when you’re handing out meters just ease of use of the next one of the slides I’ll show you sort of blood sample size. In the 20 years that I have done this the sample sizes are so much smaller you can get away with using so much less blood which is a big huge deal for someone who’s poking their fingers you know upwards of five or six times a day. Some of them have illuminated screens all of them store results and they can store as much as four or five-hundred results which is a little bit excessive but it’s nice if we can get at least two two weeks worth of readings saved. Some of them you’ll hear about alternative test sighting so people always come in and ask so can I check on my arm or on some other part of their body. We say no, that you always want to use your finger because you’re going to get a more accurate reading. The requirements for blood glucose meters of FDA is that they must be within 20% of the lab value, if it’s over 75 and within 15 points of a lab value if it’s less than 75. So of course for more accuracy for a lower blood sugar 20% is a pretty big is a pretty big significant amount so if you’re talking about the difference between a hundred and eighty it’s pretty big. So people are always saying that their meter they check on one finger and then checked another finger that they’ve got two different readings so we’re looking for about 20% between the two. So blood drop size just to give you an idea most of the meters use 0.3 so it’s a really small small amount of blood that goes on that strip. It’s pretty amazing it seems like a little bit more than that but most of the news we use in the office are about 0.3. Tips for checking blood sugars you always want to make sure that your patients or students are washing their hands it’s best to wash with warm water that seems to help the blood get to the fingertips a little bit better super important that they’re drying their hands we have a lot of kids who won’t dry their hands completely and on purpose so the sort of dilutes the blood. Kids come up with all kinds of cool things to make your blood sugar look better than it actually is and so watching that they’re drying their hands is a big one. I’ve also had kids spit into, this is awesome, spit into their lancet device like there’s almost like a little in that yeah you know it’s like sort of like a well yeah and so they’ll literally like turn their back to us in the appointment spit into it so that when the lancet comes out it’s possibly not as high a blood sugar. So I would watch for spitters and for some wet hands. Of course we always want to avoid the center of the fingers important I think too if you’re at a school with the kid that’s checking almost any time I watch a kid check their check their blood sugar I find something that they could do maybe a little bit better. So one is making sure that they’re poking on the side of their finger it hurts a lot less and then also really dialing down the lancet device people tend to really crank up the depth that that’s going to poke you with and they really don’t need to you need such a small amount of blood that I would dial that all the way down I almost always get blood out a kid on the lowest on the lowest setting kids have really soft fingers. So and that can save them because if it hurts to poke your finger a million times a day then they’re not going to do it, so those are really small things I think that can make a huge giant difference just in their everyday life. Changing out the needle technically you should change them out every time the biggest thing is the needle is just going to get dull right every time you poke and so that’s gonna also obviously cause more pain. We also have kids try out lots of different lancet devices people feel really close to their lancet device which ever one it is that they pick and so it doesn’t have, they don’t have to use the lancet that device it comes with the meters so we’ll mix and match those a lot too. So if there’s kind of a simple thing too if the kids just not checking their blood sugar a lot it’s possibly using a different lancet device dialing that number down, showing them where to poke, all of those things are going to help with their compliance. Can you think of anything else? no Make sure they’re not checking their cat or dog’s blood sugar. Yeah yeah I think that’s on another slide too, yeah. Stuff to watch when you’re reviewing meters so as a practitioner is looking at the meters make sure that time and date is accurate sounds really silly but so much of the time restarts analyzed low sugars and they’re at the wrong time so are you really checking at 3:00 in the morning? Sometimes we have them checking at 3:00 in the morning but that was actually at 3 p.m. after school or it could just be two or three hours off which is just a pain. So making sure that the date and time is accurate on the meter just makes things go so much more smoothly there’s the patient washing their hands yesterday I had a kid that got up between 5:00 and 8:00 in the morning and ate a quart, a type1, ate a quart of ice cream without anybody knowing. Next morning mom gets up pokes his finger and he was over 600. She gave him a correction and an hour later he was 180 it was dropped really fast blood sugar dropped really fast but one of my concerns was, did they wash his hands before he was poked because if this kid was just like going in and like voraciously eating this quart of ice cream was he gonna have just sugar all over his fingers and we were now correcting, you’re correcting for an accurate number anyway because you just had that ice cream coming into his system. But that was one of the first things I thought was there was their ice creams all over his hands. So watch their them washing their hands and then drying their hands. Do all the readings belong to the patient because parents and families and kids will poke each other and so sometimes I had readings that are making me feel like they’re too low but it’s because it’s someone else in the family, so just ask them they’ll forget to tell you so just ask them those things. And then are all the readings blood sugar because we have had families will put wine into the strips just to test wine they’ll test orange juice, they’ll just put various liquids in there and so they forget to tell you that they’re doing that. Meter downloads they try to just take a quick shot of sort of what a download looks like. If you have the capacities or capabilities to download any of the meters that you’re looking at it’s really helpful to see on the cover screen on the cover page we usually have how many readings per day they’re doing. This is actually a teenage boy who’s a type 1 but he’s checking about 1.2 readings per day, so much less than he should be and then it’ll give you a high and low. I think on that for that the thing I’m looking at most is how many sort of the average of how many times they’re checking in a day. And using that more as a way of showing parents that they’re not checking because you’ll have days where they’re checking all the time then days when they’re not checking it also average. And then you can look just sort of day by day we usually look at about two weeks at a time to analyze the trends what’s going on you can see on this one the most recent, he was in the office on 1116 so if you checked once that morning a day before we checked one time looks like he had a 92 on Saturday probably ate then and then was checking a couple hours later because he was freaking out about it. But in general this is somebody that tends to go most of the day without checking and then sometimes he’ll have more checks just later in the day this is a good example of that but he’ll check more. So sort of what a download looks like you can see a high on this meter is over 500 on some meters high if it’s over 600. I think last time you guys looked at some. Yes The only other thing I would comment on and with regard to this is maybe you’ll touch on it too but it’s always a big surprise to the parents when we show them these downloads and because they think Johnny’s checking you know eight times a day or something and my point is they have the capability fairly easily to upload these to go and other other means of either printing it out or you know even just looking at the meter and most of the time our families just don’t. Maybe you can help us understand that. Yeah I think I think most of the time what happens is parents are saying did you check your blood sugar from the other room and then the kid says yeah. What was it and they say you know 221 or 120 it’s always 120 and that the parents don’t ever actually go back to look I think probably one of the most discouraging things for me is we have so much more technology. Been a dietitian for 20 years now and I can do so much more technology and so much more means to watch and to help us and it’s used very rarely parents usually don’t download the kids blood Sugar’s at all they have no idea other than calling from the other room, did you check and they say yes and they’re completely surprised at appointments that they haven’t checked. Can you say anything to
that? Well I mean it’s understandable people want I think it’s hard for people to really conceptualize what chronic disease needs and what its implications are and we’re used to taking medications and being done and moving on. This is not that way having all this technology you still need to be willing to use it so we try and encourage parents one parent in a very non-judgmental non public excitable way to go through one evening a week to go through a week and to see what’s been happening and if you this would never happen if you did that once a week. The kid would test 1-2 times a day on average but it’s hard and it’s hard to it’s hard for kids it’s hard for families to wrap their heads around the relentless grind of type one diabetes in childhood. So I get it I mean I absolutely get what they’re struggling with and yet it’s also sort of mind-blowing given how incredible the technology is as little as fifteen years ago. (inaudible) I had a patient yesterday he’s in his second admission for DK he’s 12 years old he’s very smart very capable but not checking he had an admission maybe three months ago where we identified that dad was asking are you checking your blood sugars he has a dexcom but the child wasn’t his continuous glucose monitor but nobody’s checking to make sure that he’s calibrating it which we’ll talk about in a little while, I was really sort of stunned because I thought after that last DK that that would change but it’s only been I think three months and sort of the same patterns have happened again so he had the psychologists go in to the room and sort oou the things that the dad was saying and in the child were saying dad said that the kid gets super defensive anytime anybody asks him about his diabetes the child was saying clearly the child was struggling way more than anybody just sort of I think recognized. He’s like a really smart kid and pretty resilient and sort of plays his cards close to the vest so I think he’s probably a lot more sort of emotional turmoil and we thought he was. So hopefully that will be addressed but I was surprised I was against it he gets really angry if we ask him what his blood sugar’s were child said that he’s sort of on this group text to household he’s on the group text with new step mom, dad, mom and they’re all texting him asking him his blood sugar’s so they were they really need to identify sort of a better way to do that because it wasn’t working for him. Yes well typically like excuse me, a better person one individual person that can tolerate the swings and ups and downs. Yeah he doesn’t feel so defensive too because I think there was usually a parent right even with my own kids like one of my kids that I might trigger more than the other so like identifying the person that isn’t in a threatening way checking in. Okay so continuous glucose monitor so that’s briefly about meters continuous glucose monitors really the one that everybody uses is the Dexcom and it’s the g5 and if perhaps you can sort of see there’s three parts to the Dexcom it reads blood sugars every five minutes so the awesome thing about this is if you are checking a blood sugar you check a blood sugar it’s150 obviously you know what the blood sugars at that moment in time and it’s going to be different in ten seconds. The continuous glucose monitor you wear for seven days and it’ll allow you to see which direction the blood sugars moving so 120 is great but is it what 120 staying steady at 120 going straight up or of course worst case scenario 120 dropping like a brick. So it’s gonna read blood sugar every five minutes, allows the user to see which direction it’s moving and the rate at which blood sugars moving, there’s three parts there’s the sensor the sensor has changed out every seven days the sensors. I think that Troy’s going to help me… The sensors, sort of the purple part if you look under back here there’s like a really thin wire it’s almost like a hair and that sits under the skin so that is what’s changed out every seven days. So that goes under the skin a transmitter is snapped into the sensor and the transmitter is usually good for about two to three months and then it’s sent the information is sent to a receiver which can be the receiver that it comes with or it can be your phone which is cool. The latest model of the Dexcom you can actually see the blood sugars on your phone. So I’m going to try to pull up the app see if you can see a little bit of what it looks like. So the best part of this especially for kids is that parents the info is uploaded to the cloud from the child’s own that’s reading him blood sugar and then people can follow the blood sugar So it looks sort of like this but you’ll have a bottom line and a high line and then the blood sugars go up and down in between there. Sensors changed every seven days transmitter lasts three months your receiver can be a cell phone which is best in Pediatrics because then somebody else can follow to see where the child is. Private insurance we usually pay for the system and the monthly supplies hopefully unfortunately we don’t seem to get it covered if somebody’s on Medicaid or Medicare. But parents, spouses and caregivers can follow blood sugars biggest thing that we’re seeing lately with this is I talked about it with that other child is the kids aren’t calibrating. You still need to do finger pokes every 12 hours so that you can calibrate and make sure that you’re getting a really nice correlation between a finger poke and the what the Dexcom reading is and people just start to trust those numbers and we’ve had Dexcoms that are even the 200s and kids who come in and DKA in the five and six hundred. Then we are able to download the data and there it says a physician’s office you can download the data off of the receiver the parents can do that also so I spend a fair amount of time showing parents how they can access the data they don’t need to wait three months to find out that the kids not calibrating. So just some pictures to sort of show you you can see how sort of thin the wire is I don’t it’s it is kind of like a wire but it’s not stiff like a wire is I’ve worn it many times and it’s pretty darn comfortable the adhesive is probably the trickiest part we have sort of tips for keeping the adhesive on but if you’re wearing it for seven days it starts to get, it can start to kind of raise we have sort of things we can do for that. Off to the right is the inserter so you can sort of see how that works a needle goes into the skin comes back out it leaves behind the sensor and then that big the big arm just sort of comes off transmitter is snapped into the sensor and then you can see the receivers off to the side. It used to be that you had to have the person who’s wearing it had to have an iPhone on them but now there’s some Android phones that will act as the receiver but the kid does have to have a phone on them in order for parents to follow so that’s kind of the big thing there. And then they have to have Wi-Fi connection at all times. Could you speak to the studies that have been done that show differences in control again studies are going to be different than what our population is and then also the costs associated with it, if it’s not covered by insurance. So I believe the system itself is between three and five thousand dollars, that sound right to you?
Yeah it’s really expensive and then the monthly supply’s so in theory each sensor you’re gonna wear for about seven days so it box of supplies is four sensors and those can cost several hundred dollars. But the provider buys the monitor and everything, buys the unit and then they just give it out to the patient’s.. So they, the families own it so they have to apply I go through their insurance and their durable medical person has to get approved and then they receive the receiver, hopefully two transmitters every three months and then three boxes of sensors. Oh okay so it’s the families, got it. Yeah they have to do all of that and we help them Is Medicaid covered? Hm-mm, no we’re working in that direction it seems like it’s going in that direction but I feel like I’ve been told that for like two years now anyday now we’re going to be able to get medicaid patients ever. But I mean we have Medicaid patients with kids with type one who are less than two years old and it’s incredibly hard to predict how much a two-year-old is going to eat right and how active they’re going to be and how much insulin they need or can in fractions per unit, you’re writing really high numbers a lot of the time out of safety and so to me it’s not an extravagance it should be just standard and everybody have one. It’s kind of frustrating and a new one it’s been approved I think now the Libre I saw yesterday I think the sensor’s $75 much less expensive and then supplies $150 for a months worth. So much more affordable to buy out of pocket than the Dexcom is. So we’ll see how that all pans out but we have I think one patient that I know possibly two who are on a Libre that they got in Europe and have brought back but I just don’t have that much experience with them. If you’re looking at Dexcom reports or things that you want to look at first you want to make sure that the patient is actually calibrating, less than two calibrations for 24 hour period isn’t good and more calibrations it’s not better so sometimes you have read the patients are constantly calibrating and that’s not a good thing either. Patients need to be told and reminded that they should calibrate when blood sugar is stable and these are really good things for those who are working in the schools to know to just kind of reminding kids because I say this all the time and they still forget. You want to always try to calibrate when the blood sugar’s stable when the arrows going straight across otherwise we’re constantly trying to hit a moving target so if the blood sugar’s rising and falling you’re not going to get a good correlation. The FDA as of last February I think it was I should say January because my kids say I say February really weird, as of last January the FDA says it’s okay to use a Dexcom reading to calculate doses. So rather than a kid having to, at school for example at lunch poke their finger and check their blood sugar to calculate their doses they can go ahead and use the Dexcom reading. Here in Washoe County we will sometimes not let the kids do that if they haven’t been calibrating regularly sometimes we have parents who still want their kids to poke their finger. I think I’d probably still get a finger poke if it was up to me. You can use the Dexcom to your advantage to sort of watch those rises and falls but I would still want a number to calibrate or to calculate a dose. You want to advise the patient to confirm with a finger stick if the blood Sugar’s over 350ish or 80ish so if you have if they have a high or a low on the Dexcom go ahead and try to correlate try to check the finger stick also because those are you know numbers you’re treating. We also want to check the blood sugar or the finger stick if the symptoms don’t match the Dexcom readings if the kid is feeling weird and the Dexcom says they’re at 200 which feels as normal for them they still want to check. One of the things that you have the families that don’t check and don’t calibrate and aren’t getting close correlations and then you have the families who are excessively calibrating and poking and freaking out about postprandial excursions. So it’s interesting when you wear a Dexcom, I’ve done this too, so you where you wear it and then you go drink a Bloody Mary and eat two waffles um to see what happens to your blood sugar it’s pretty startling how high your blood sugar goes so now your I have a pancreas it in theory works pretty well. So parents will see that a kid starts out even if they’re starting out at 200 they might go up to 400 in the next hour and that freaks them out and they want to give corrections they want to do something about those numbers and so a lot of times you just have to remind them like to sit tight. You want that blood sugar to come back to you on this in the next four hours or so, insulin is still active in their body just need to caution them about them trying to correct those really high numbers. Dexcom reports they look like sort of shows average glucose um standard deviations, you’ll see the calibrations on the right hand corner it says average calibrations 2.1 per day so it’s pretty good on this particular person. I just grabbed yeah I actually grabbed someone that’s pretty good. So you can see that the calibrations are pretty steady at like 9 in the morning and 9 at night mm-hmm. This is on Monday that’s just a loss of connection I think that’s when they came in for their appointment and disconnected it, but those actually is actually really pretty good control the bottom line is looks like I’ve set it at 80 and the top line it’s set at 150 that’s really close. Usually I’m thinking about school too I’ve had parents who put the high alert on 200 and then Dexcoms beeping all the time we know that kid’s gonna rise you know even a couple of hundred points after they eat and so you don’t want to unnecessarily stress everybody out by having beeping going on. So I’ll usually set the high at possibly about 300. Alright so insulin pumps so I was was asked why does a patient want a pump, and their first answer is I don’t have to carry so much stuff. Which isn’t true you actually have to carry more when you’re on an insulin pump than you do on multiple daily injections, cause we ask you to carry everything you would normally carry on MDI plus all of the stuff that you need to do a site change in case your site goes bad. It’ll be less work people think it’s going to be a lot easier they’re going to have a lot better control and then with kids it’s because so-and-so had it at camp like everybody has this pump at camp or if they’re at their meetings. You usually try to like vet out like who’s gonna do best, I really strong feelings that the people that do best on pumps are the ones that have spent time figuring out how to get really great control on multiple daily injections. I feel like those that have really great grasp on that are the ones that do best on pump. I feel that it’s not a good idea to start a pump too quickly or when somebody’s in their honeymoon phase because they get away with quite a bit more in the honeymoon phase and I’ve had starting a pump coincide with the honeymoon phase ending and it just sets up for a bad relationship with the pump thinking that the pump everything changed when they went on the pump. So we usually try to be careful about that. You think of any other big things? Just dispelling the rumors that it’s going to be a piece of cake because a lot of people do you think that they don’t have to watch anything anymore, this is parent I mean and children are just not able to do all of this by themselves. Yeah I think it’s almost easier for parents to not be as involved when kids on the pump because kids are pushing all the buttons and doing everything it’s probably easier to be unaware of what’s going on. Scary but I think in our practice all the practitioners feel that a pump’s a privilege and not a right. You know and certainly other practices to it differently where they start on pumps right away. I think in Pediatrics student especially the teenagers pumps can be like a pretty good carrots to dangle in front of somebody, is that a good technique? Well I just above pumps so much are about fantasies what pumps can do and we’ve had and often times I remember we had parents, one parent would be pushing a pump fanatically and it was usually the uninvolved parent didn’t understand what that meant and okay it was usually the dad who wanted the pump and it was buying the whole different venue of problems with the pumps. They’re just hoping that the pump actually it’s sort of misnamed pumps, it sounds like it’s gonna be an artificial pancreas and it’s just not. Yeah. So then there’s a big let down and another failure for the kid and for the family and it’s really too bad actually. I think you guys do it, the way you guys have always done it has been great. To not give in to that kind of pressure and there was always a lot. Yeah sometimes it’s good too cause you cn say here are the things, here are the three things that we want you to do in order to get a pump. And then we start kind of chipping away of what those things are. Yeah I guess I have a patients to that’ve sort of pulled their stuff together so that they can get the pump and then it goes sideways pretty quickly after, so you have that happen too. And I have lots of kids who do find on the pump that just don’t like it they go off with it in the summer or I have one girl yesterday who I thought was perfect pump candidate for years and she was completely not interested at all in doing it, and she’s now been on for about six months and she said it was life-changing and her mom said and here you were resistant for all those years and I was like wait, wait, wait.. Wisely so. Yeah it works because it was the right time for them so I think that’s why it’s been such a good experience she’s doing awesome. And to that point you know like Steve was saying there are a lot of parents who want the pump and the child is not into it at all and it won’t work we can pretty much guarantee it will not work. And once we’re talking about a toddler or a preschool child you know older kids after age five or so, if they’re not into it it’s just not gonna work at all. So we don’t recommend that you do it. Yeah I have like another family that the high school son has had diabetes for a while and has no interest in a pump, little brother was diagnosed and wanted to be on a pump within six months and the little brother’s probably sixth grade and the older brothers is like a junior in high school and I thought it might turn the older brother around. Not at all no interest whatsoever and it’s just not for everybody. You take pumps away too. So if people aren’t doing what they need to be doing if we feel that they’re not safe then taking pumps away happens too and it’s not fun. We tend to see three different pumps in our office give you a little overview of each the Medtronic the Omnipod, and the Tandem tslim. So a little bit of information about about them the Medtronic the 670G system is what is, it’s a system because it has a CGM that comes with it but this is what you’ll hear about most on the news and articles is being called an artificial pancreas which I don’t consider it to be and I think you probably don’t either I mean that gives like Steve was saying that gives a sense that it does everything on its own. What the 670G does is it can make really small changes to the basal rate based on what the sensor says. So Medtronic has their own sensor they don’t use a Dexcom they have their own sensor and then it can it’s supposed to sort of get to know your body and then make small changes if you’re rising or falling it can make changes. None of that is approved using using that micro bolus thing in the adjustment for patients for kids under 14 and so we don’t really have anyone right now using those features. One thing that I would say too is you’re only if it’s making changes based on what the sensor says I would want to trust the sensor a lot right and so if we were saying that even with Dexcoms that people don’t necessarily use their sensors appropriately it makes me a little bit nervous about us making decisions based on a sensor that may not be used correctly yeah. There’s an auto the auto mode you can read says that it automatically adjusts the basal insulin levels every five minutes. That being said I’ve talked to adults who are super happy because its amazing so that’s, that’s all really good. Definitely exciting stuff for changing. Omnipod, brought a PDM but forgot the pod, so all of the pumps are going to deliver insulin and they’re going to deliver insulin in hundredths of a unit really small small increments so in theory that can give us much better control because rather than waiting to give 2 units or 3 units we can give 1.25 two units so that can give us better control. So they all basically do the same thing but I’ll sort of highlight the differences between them so the omni pod is the only one that is tubeless. The other pumps are going to be through a tube that goes from the device into your skin. So with the omnipod you wear a little pod on your arm or on your legs or on your abdomen it houses the insulin inside of it so then you have a PDM um that you use to tell the pod your blood sugar and for it to send to give you insulin. You, so it’s the only one that’s tubeless you have a PDM to bolus it holds 200 units of insulin the omnipod’s great because it is tubeless the kids, the little kids can go swimming with it on and not worry about it stopping it’s still going to give the basal rate while they’re doing all of those activities. One of the things that I’d make sure people consider it that it hold 200 units of insulin, the other pumps hold 300 or 450 units of insulin everything has to be changed out at least every three days. So sometimes someone will pick a pump that hold 300 units because they can go three days without changing it. The girl I was talking about yesterday she has to change it every two days um but is super happy does not want to have wires. So it’s just until, I was telling Troy before it’s kinda like picking between a Mac and a PC, an iPhone and an Android I don’t have any sort of guess as to what people are gonna pick so I try to just highlight the things that are different. The PDM uses 2 triple-a battery so that can be a consideration that you are, have to have batteries on you all the time which speaks to carrying more stuff with you. You have to use at least 85 units in it so I think this model is attractive for really little guys because parents can hold the PDM and have control bolus their kid while he’s within five feet across the room. But the pod itself is kind of big so it can be hard to find a good spot to put it on the catheter and the needle are inside the pods, the catheter gets inserted and so that’s one option. We also have kids who don’t use more than maybe two or three units in a day and so there’s a fair amount of insulin waste. Though the PBM is also a meter too so that can be you can cut carrying out one extra thing there. And then the last one is the tandem, the t:slim it’s the only pump that has a touchscreen. It’s the only one that’s rechargeable so that could be I mean that’s something I’d point out to people that you can recharge vs. securing batteries that’s a make it or break it for some people. Holding three hundred units or four, it has a model that holds 450 units can be a deal breaker vs. two hundred on the omnipod. The tandem pairs with the Dexcom so you’re using Dexcom technology to see your blood Sugar’s on the on the pump itself. And then one of the cool things with this too is that the latest model the software updates can happen from phones, so traditionally you had to get a whole new pump if there was a new a new model the t:slim is actually you can plug it in at home and update the software so that you get the new features after you’ve had your pump. Sort of what that looks like. So that’s a t:slim with the g5 that you can look at your blood sugars on your tslim or on the phone most people are still going to opt to look at it on the phone so that parents and families can come follow the blood sugars. That’s it.. questions? I guess I’m curious too for those that are at schools, what you see in terms of any of them, uses with meters or issues you come into contact with the meters or CGMs or pumps. This is Bobby in Elko, can you hear me okay? Yeah. Over Christmas break I think we have three students come back with the tslim and the dexcom G5.. Merry Christmas I know, we didn’t know they were coming either so it was kind of a surprise but yeah we have some parents are struggling with those postprandial highs. How soon do you, how long would you like them to wait before they correct? I think some of the parents are confused with, do I correct it says 250 at nine o’clock and then they’re correcting and then they’re dropping low. I think we see that sometimes with them getting used to the pumps and there’s CGMs. So with the pump it’ll reverse correct to so you have sort of that target range and you have the non-board right so it does that for you but we really don’t want anybody to give a correction you know under normal circumstances four hours apart sometimes we’ll have people do insulin every two hours if they have ketones and they’re higher. But I really try to have families just hang tight and watch that it’s going to come down in the next four hours or so. Okay I think to that if they start sort of overriding because you can you can override function right on the tslim like you can decide to give more or less insulin than what it’s suggesting. Families that tend to do that then we never quite get a good handle on what the actual doses should be, so I tell them I kind of try to hang tight and just do what you’re supposed to do that way we can make adjustments to the rates and that’s what’s going to give you the better control over all but when they’re constantly sort of overriding or guessing or adjusting at the beginning then we don’t get a good read. Yeah they see those highs and they freak out right. Yeah you know the other thing we do too is I think with when the press first start watching it on their phone we get the frantic phone calls you know she’s double arrow down you need to give her something, I’m like well 200 is it should we wait a little bit. Yeah What kind of guidelines do you typically give parents on those you know do you wait a little bit to see how low it’s gonna go or do you..? If they have an arrow going straight down and they’re 200 I would wait maybe wait a little while or give them some kind of protein to see if you can blunt that drop. Right okay. Obviously wouldn’t let them go long enough so that they have a low that has to be treated, but I think throwing some protein in there can be helpful. Okay And also you have to take into account the context of when that’s happening relative to insulin and food and maybe exercise because if they exercise two hours ago they may have initially gone up in their blood sugar and now they’re starting to come back down as their resistance decreases from the exercise, so it’s I mean you know when you look at the technology it seems like pretty cut-and-dry right there’s a down arrow and it’s 200 and you need to give more food but you always have to take into account so many other things to understand or try to understand why it’s happening, and that’s the tricky part. Yep, yeah that’s what we see too. Especially with the young kids because you don’t know exactly what they had for lunch and they might have told you one thing and had another and took insulin for X but ate Y you know so… Yeah I went out to recess and really hard this day but yesterday really didn’t so it’s really variable. Yeah try to make assure parents to you know we’re trying to drive between the lanes we don’t have to drive right in the center you know we just want to keep sort of the barriers on the side but you’re gonna go up and down within there. But try to help with that too they usually ask you how long has it been since they last took insulin, what they ate and you know just sit tight let sit tight for a little bit. But that tends to be when it’s really high or just high and it seems to be hanging out there I mean there’s some advanced features to so you can if there’s a food that they eat that they always just stay high for a while after which is typically pizza or sometimes like your sushi, pasta in general and you can do that extended bolus. So I’ll try to work with parents on figuring out how to use that so it gives the first unit of insulin up front and then you can decide what percentage to give up front and what percentage to give over the next two hours, the next hour and that can sometimes help when it’s really high. But again that’s a parent that’s paid pretty darn close attention those are like awesome features that they’re excited about that they never really use. And then the other thing too you mentioned the doing a finger stick between 80 and 350.. Above 350 or below 80. So yeah sorry we were doing up some research and there was an ADA statement that talked about following up with a finger stick if it’s below 70 or above 250..? Mm-hmm yeah they’re always a little bit different the numbers. In the hospital too I think they teach 75 and 300 those are my numbers I feel good about it’s 80 because I like a little bit higher. But your school orders are probably pretty specific. Well we’re developing them kind of for the G5 right now. Okay. So and if for Elko where it’s kind of different because we have patients who come toyour office we have some in Boise, Twin Falls, Salt Lake. So it’s hard to get a… Every office yeah is going to do things a little bit differently I think the Washoe County scores which is obviously what we do we see the most of say either 300 or 350 I think it’s 350 and 80. okay Yeah and if we’re going to err you know I would always err on the conservative side so, because we don’t want it to be confusing or difficult on your end to have these orders so if someone out there saying hey we like that at 70 and 250 We’re fine with that I mean it’s better to check more and be more responsive than to be less of course. So you know so we’re not gonna be stiff learners about stuff like that either. You know we have parents on both sides of the vote some who are good with following up with finger sticks and some would say no we don’t have to do a finger stick except to calibrate ever again and it’s like well no, probably need to do a few. Yeah the school, or our school orders for Washoe county say we can say yes or no to using a dexcom to calculate meals doses and may change those sometimes they ask take it back and say no becuase they’re not calibrating. Okay that’s a good point. Yeah so you can have it, I mean it’s always hard because then the scores just get longer and longer and more confusing I think in some ways And I don’t want that I don’t want you know six pages of orders I want it simple but to include everything. Right! Cool thank you. Yeah thank you for sort of confirming I think what I thought probably happens is that you have some parents to just freak out and see those numbers and are calling you. There was a phone call this morning right before this. I guess they’re already back in school we still have two more weeks off I guess one more week. Yeah know we’re back in school. You know one other comment just about that particular scenario. It’s pretty unusual to have a really rapid drop in a blood sugar I mean short of significant exercise or maybe you just ate some food and then you threw it up and you take an insulin but even with that it’s not usually a rapid drop and so to Yolanda’s point you know waiting and just rechecking ten minutes later or so I think is it’s very reasonable. And the scenario that she gave earlier with the kid eating a bunch of ice cream you know we don’t really know what that number was we don’t know either of those numbers really how accurate they are and therein lies a big problem you know. So I actually spoke with that family last night about midnight because they were so concerned about his blood sugar being 130 when he went to bed and what lantis dose so they give? So you know gratefully so and then this kid is recently diagnosed as well so they’re neophytes when it comes to all this. And so you know they were just checking him every two hours or so and really really nervous again understandable but my point to them was we don’t really understand exactly what happened that morning it probably wasn’t the insulin that they gave him necessarily, it may have been differences in blood sugar readings. But also you have to take into account when someone’s in the honeymoon period they’re making a lot of insulin themselves that part just to throw another bug or two into the whole equation, that one is really really hard to tease out as well. Yeah and a child has autism and ADHD and so he, it’s hard for him to sort of tell us what he’s feeling or what happened yeah so that made it really tricky but he had dropped from 600 to like 180 in an hour and so we were really nervous that he was going to continue so he came into the office where we fed him for the next two and a half hours and checked blood sugar’s every 15 minutes. Which was probably a really good call, I think he went down to like 130 or so. It was stressful. I’m sorry that they called you last night? That’s okay, it’s my job. Can you think like and Steve would talk about this for sure but, we always say to that you throw type one into like the most stable of families that have like you know great circumstances and great support systems and it will throw them for an absolute loop. You throw any you know you throw diet type one at somebody who doesn’t have a really stable household or has any sort of other things medical conditions going on in the family or other diagnosis and it’s really really hard. I agree we see that a lot. The only other point I would just reinforce is you know with technology in so many areas and specific to diabetes we have fantastic opportunities, but as Yolanda pointed out earlier unless you’re using it not even to its fullest extent but to a small extent even it doesn’t do us any good and in fact sometimes it does more harm than good, it really does. So we have to be very very careful with who we choose to put on these different pumps and CGMs and so on. It’s not a cure-all unfortunately. Yeah I think I’ve been most bummed about the Dexcom lately we’ve had so many kids not calibrating and ending up in DKA because I feel like with the Dexcom it’s only purpose is to make life better for you. And so to somehow find a way to use it against you it’s really really frustrating for me. Are there any questions or cases that anybody wants to present today? Okay I think the other thing I wanted to ask real quick is if anything else that you would want covered in the future that you want to hear more about, it would be helpful. I think you know as there’s more technologies or new devices coming out or new ways to manage those are always really helpful to try and stay abreast of the latest stuff. Yeah That’s really helpful. There’s alot to keep up on for sure yeah. I appreciate you being on to, because I think that sometimes you don’t have quite as much communication as we could and we could and we could you know understand a little bit more about what’s happening in the office and what’s happening at school because really that’ only going to help us. Right, yeah I agree thanks. So next month we’re gonna do the fourth of the diabetes installments and that will be with the three of us but I think Steve Graybar will take a bigger role and we’re gonna discuss psychological and behavioral issues as well as some comorbidities including eating disorders associated with diabetes, so hope you can attend that one as well. Great thank you. Thank you Bye