by Ed Bryant
From the Editor: Ed Bryant is President of the Diabetes Action Network and editor of its quarterly publication, Voice of the Diabetic.
The following article first appeared in Voice of the Diabetic, Volume 14, No. 2, Spring, 1999, and was updated in July, 1999, and January, 2000. Because diabetes management is an important topic to all those interested in increasing the independence of blind people, we reprint it here. This is what Ed Bryant says:
As editor of the Voice of the Diabetic, I am often asked about the relative strengths and weaknesses of the various voice-enunciation-equipped home blood glucose monitors available today. Although individuals have their preferences, there is no best talking glucose meter; no one monitoring system is ideal for everyone. Features, prices, convenience, and clarity of instructions vary, and new equipment periodically appears.
Although many companies make blood glucose monitors and some of these display their results in large print, only four currently available meters allow voice enunciation, in which the device's voice synthesizer actually speaks the meter's instructions and test results.
My personal favorite is the Accu-Chek Voicemate. This talking meter, which incorporates the proven Accu-Chek Advantage into a system designed and built by Roche Diagnostics, is the most advanced on the market today and the easiest for a blind person to use. Its new Comfort Curve test strip allows quick and reliable nonsighted placement of the blood sample. No more hanging drop of blood--just smear or dab it on; the strip sticks well out of the meter, and you just find the tactile cutout on the side. Even if you have fairly severe neuropathy in your hands, this feature should make it easy to find the blood placement spot. And blood never drips onto the meter--so there is far less need to clean it. Its voice is clear and understandable. The Voicemate includes two completely new features: 1) code-key system for calibrating the meter to a new set of strips (no more numbers to punch in), making this the only talking meter a blind person can calibrate without any sighted aid at all; and 2) an insulin-vial identifier. If you use Eli Lilly insulins new enough to be bar-coded (1/2001 expiration date or later), insert them into the special opening, follow the spoken directions, and the machine will identify the type of Humulin insulin you are testing. (If your insulins are not bar-coded or not from Eli Lilly, the Voicemate's other features will still function properly.
Past Boehringer-Mannheim meters (Roche has purchased B-M) were available only through company representatives. The new Voicemate can be ordered through any pharmacist. Have your pharmacist contact Roche Diagnostics, telephone (800) 428-5076, and ask for catalog #2030802.
The LifeScan One Touch meters--the Profile, and the now-discontinued One Touch II--are often adapted to voice synthesis. These two meters use the same procedures and test strips and feature the same detachable test-strip holder. Both require a hanging drop of blood. Both meters are accurate, but their operating drill makes them difficult for some users. Both accept talk boxes, but voice synthesizers designed for the One Touch II will not operate with the Profile and vice versa.
The voice boxes, speech synthesizer modules that plug into the meter's data port and provide its voice, are not made by LifeScan, but by several competing firms, described below. These manufacturers have been producing voice units for the old One Touch II and updated versions for use with the Profile. If you already have a LifeScan One Touch II or Profile, no modifications are needed to allow use of one of the speech synthesizers. If you do not yet own a LifeScan monitor, shop around, because some pharmacies and major discount stores sell glucose monitors substantially below list price.
Talking Glucose Monitors and Voice Boxes
1) The Accu-Chek Voicemate talking glucose monitor: Roche Diagnostics Corporation, 9115 Hague Road, Indianapolis, Indiana 46250-0100, telephone (800) 428-5076.
The Accu-Chek Voicemate, developed in cooperation with Eli Lilly and Company, incorporates the Accu-Chek Advantage glucose monitor. The Voicemate is small, portable, and weighs only twelve-and-a-half ounces. It contains a bar-code reader to describe insulin type (Lilly insulins only). First offered for sale in 1998, the Voicemate is supplied with a new test strip, the Comfort Curve, which vastly simplifies the problem of blood-sample placement. Very good audiocassette and large-print instructions are supplied (in English). Suggested retail $495-$525, available through your pharmacist. Spanish-language customer service is available. Purchase price includes a carrying bag with adjustable strap.
Note: The National Federation of the Blind Materials Center now sells the Accu-Chek Voicemate for $475, the lowest price on record. Contact Materials Center, National Center for the Blind, 1800 Johnson Street, Baltimore, Maryland 21230, telephone (410) 659-9314.
2) The Voice-Touch speech synthesizers, for the LifeScan One Touch II or LifeScan Profile: Myna Corporation, 239 Western Avenue, Essex, Massachusetts 01929, telephone (978) 768-9000.
Myna makes a pair of light, compact, convenient, and reliable glucose meter speech modules. The two models are not interchangeable. The Voice-Touch modules attach firmly to the meter, adding little bulk and forming a single, reliable unit. There are no separate switches to remember; the modules operate off the controls of the LifeScan monitor. The user may choose male or female voice. A Spanish-speaking Voice-Touch is now available.
The Myna Corporation offers the Voice-Touch speech synthesizers for $225 for One Touch II or Profile, the LifeScan meters alone for $135 (One Touch II) or $109 (Profile). An optional AC adapter is offered, as is a carrying case, $15 each. Myna's instructional cassettes and large-print instructions clearly explain the speech modules but do not describe operation of the LifeScan glucose monitors.
The LifeScan One Touch meters and Voice-Touch speech synthesizers are also offered by the National Federation of the Blind, Materials Center, 1800 Johnson Street, Baltimore, Maryland 21230, telephone (410) 659-9314.
Note: The Materials Center is open 8:00 a.m. to 5:00 p.m., weekdays, Eastern Time. The NFB offers the combination (One Touch II meter plus voice module) for $309, the lowest price for a talking glucose monitor in the U.S.; the voice module alone for $189 (specify whether for One Touch II or Profile), or the glucose meter alone for $120 (one Touch II) or $135 (Profile). An optional AC adapter costs $12.
3) The Digi-Voice modules: Science Products, Box 888, Southeastern, Pennsylvania 19399, telephone (800) 888-7400.
Science Products makes several versions of its robust and reliable Digi-Voice speech module: The Digi-Voice Deluxe, and the smaller Mini Digi-Voice. Voice boxes designed for the One Touch II will not operate with the Profile and vice versa. The Digi-Voice modules connect to the meter by a twenty-two-inch patch cord, providing audio output for its readings. Controls are simple; on the Deluxe a volume control knob and a toggle switch run the voice synthesizer, separate from the monitor's controls. The Mini's single button both turns on the voice box and adjusts the volume control, again, separate from the meter's controls. Readings are announced in a clear, somewhat military, male voice. Thorough cassette instructions explain the voice box and briefly cover the Profile meter (Science Products' instructional cassettes do not cover operation of the One Touch II glucose monitor). No large-print instructions are supplied. Science Products sells the Digi-Voice Deluxe module alone for $275 and the Mini Digi-Voice modules alone for $199 (9-volt battery) or $219 (with AC adapter). They offer the LifeScan Profile glucose monitor for $120. The One Touch II meter is no longer available.
Science Products also now offers Digi-Voice modules for the later version of the LifeScan SureStep blood glucose monitor. The later version features a data-port for downloading to a home computer. The Digi-Voice talk boxes access to the same port. The Digi-Voice module for the SureStep is not interchangeable with the similarly-named modules for the One Touch meters. Be sure to specify which.
4) The LHS7 Module, a voice box for the LifeScan Profile: LS&S Group, P.O. Box 673, Northbrook, Illinois 60065, telephone (800) 468-4789.
The small and light LHS7 attaches to the bottom of the Profile glucose meter by means of a Velcro patch and operates through the meter's controls. Two-position volume control (loud and soft); AC adapter included in purchase price. English-language voice only; no audiocassette or large-print instructions are provided. Cost $199, or $313 with a new Profile meter.
5) Connecting Cables for Adaptive Computers: Blazie Engineering, 105 E. Jarrettsville Road, Forest Hill, Maryland 21050, telephone: (410) 893-9333
Users of Blazie's adaptive computers can connect these machines to the LifeScan One Touch II or Profile by plugging into the meter's data port with the appropriate adaptive cable (such as the Blazie BNS-6). With the appropriate software (available free from Blazie; One Touch II users need no software), their notetakers will speak the LifeScan meter's commands and results.
6) The Diascan Partner talking glucose monitor: Formerly made by Home Diagnostics, Inc., it is out of production and unavailable.
Medicare recognizes home blood glucose monitors as Durable Medical Equipment, and coverage is provided for diabetics under Medicare Part B. Glucose meters without audio output have one specification on the Fee Schedule (EO607), and glucose meters with voice synthesis or add-on voice boxes for home blood glucose monitors have another (EO609) available to diabetics who are at least legally blind. Be sure to follow all guidelines for reimbursement.
An Invitation to Manufacturers
Currently available talk boxes (speech synthesizers) make use of the same data port installed in the meter to allow interfacing with and downloading to a computer. For many monitors the hardware is already in place, and adding speech compatibility should be a simple process. The National Federation of the Blind urges manufacturers to go the rest of the distance and make talking versions of their monitors available to those diabetics who need and want them. NFB Resolution 97-12 (adopted at the 1997 annual convention in New Orleans, Louisiana) calls on monitor manufacturers to make their meters speech-compatible.
Hints and Tips
A. If an insufficient amount of blood is placed on the test strip, most meters will indicate "not enough blood." You may even have to prick your finger again. There are several possible explanations for this frustrating occurrence.
The initial drop of blood may have been too small; some folks don't bleed enough. They can get more blood by holding hands below waist level for about fifteen seconds, shaking them, or soaking them in warm water for a few minutes before the test. Warm water stimulates the flow of blood to the fingers. A slightly longer lancet with deeper penetration may help some. Milking the finger (squeezing it gently) can also help, as can wrapping a doubled rubber band between the first and second joints of the finger to be lanced. This will help cause the finger to become engorged with blood. Hold the rubber band down with the thumb while lancing. Remove the band as soon as you lance.
Doctors and diabetes educators who treat heart patients have noted that prophylactic aspirin therapy, an enteric-coated aspirin a day to thin the blood and reduce risk of a heart attack, makes it easier for their diabetic patients to obtain a blood sample. If you are a difficult bleeder, the same therapy with enteric-coated aspirin might help you too. Be sure to talk to your primary-care doctor about aspirin and to your eye doctor as well because blood thinners like enteric aspirin can increase the risk of retinopathy.
B. There may have been enough blood, but it was placed on the wrong part of the test strip: Some folks bleed fast and may lose the blood drop from the finger before they are ready. By the time they get the finger to the test strip, the blood has fallen in the wrong place. A fast bleeder needs to work closer to the test strip and perhaps to employ one of the blood placement aids discussed in this article. Users of the Diascan Partner should try bending up the tail of the test strip as an aid to location and placement. If you are new to your meter, I suggest you test in front of your diabetes educator or someone else familiar with your meter--perhaps there is some part of the drill you could do better.
C. Some enthusiastic people press down too hard when placing the blood on the strip and push the blood out of its correct position, shoving it onto the wrong part of the strip. If you use the LifeScan One Touch II or Profile, it is best to deposit a hanging drop of blood onto the test strip very gently. Marla Bernbaum, Maryland, writing in The ADEVIP Monitor, offered the following suggestion pertinent to diabetics with severe neuropathy (who wouldn't feel the otherwise painful fingertip stick she discusses here):
I have discovered another way to apply blood to the LifeScan test strip, which has been useful for several of our patients. This method allows them to stick the tip rather than the side of the finger. We use the same platform modification [described below], with a dot of Hi-Marks or T-shirt paint on each side of the strip guide near the depression where the blood is to be applied. For this approach the meter should be turned sideways. The patient can then place the pad of the finger on the raised dot perpendicular to the length of the strip and rock the finger forward so that the tip of the finger lines up with the depression on the strip and deposits the blood droplet in the appropriate place. This method increases the portion of the fingertip that can be used and is preferable for some patients, particularly for those who bleed slowly and therefore must place the blood drop in precisely the right location.
Modified LifeScan test strip guides (Left to right}: Sure Drop (on Profile
meter:, Waco-U-Finger Guide, Smart
Dot (on One Touch II meter)
If you use any of the LifeScan One-Touch series glucose meters, some blood placement problems can be solved by modification of the test strip holder (LifeScan Part #043-123: this same part fits all LifeScan One-Touch meters). The idea is simply to provide tactile locating aids for finger location and placement of the blood sample on the test strip. A raised dot on either side of the test strip will work for some, but diabetics with limited sensation in the fingertips may find a U-shaped guide more useful. Most diabetics puncture the side of a fingertip, but those with severe neuropathy, who can't feel the lancet and who prick the center of the fingertip, may be helped by the U-shaped guide. With practice and the use of such tactile cues, blind diabetics can correctly place blood samples on the test strip.
(Editor's Note: Thanks to Ann S. Williams, RN, MSN, CDE, for providing the modified LifeScan Test Strip Holders shown here.)
[PHOTO/CAPTION: Modified LifeScan test strip guides]
[PHOTO/CAPTION: (left to right): Sure Drop (on Profile meter), Waco-U-Finger Guide, Smart Dot (on One Touch II meter)]
The test strip holder is detachable, and modifications as described will in no way interfere with the operation, accuracy, or cleaning of the LifeScan meter. LifeScan's Technical Services Department (phone: (800) 227-8862) will provide a spare test strip holder upon request without charge. We recommend that the modifications be made to this spare.
The dots and U-shaped ridge were created with T-shirt paint, of the type that stands up sharply from a fabric surface. Upon application, the paint spreads a little, so apply sparingly. Best results come from tack-painting, applying a small amount, then letting it dry (minimum twelve hours), with subsequent applications to build up the height. Practice first on some other material (posterboard or paper plate), since the paint can extrude quickly. Be sure to have the test strip holder off the meter when applying the T-shirt paint. For best results insert a test strip in the holder as an aid to placement of the dots or U-shaped ridge. T-shirt paint is inexpensive and is available at most craft and fabric stores. Although a full spectrum of colors is available, bright, contrasting colors like orange may aid those with low vision. Brands and types vary; find one that gives you a hard, tactile ridge. Some paints feel too rubbery. Puff paint flakes off too easily. You may have to experiment.
Several vendors offer commercial alternatives to modifying the test strip holder. One slips over the LifeScan meter, and the other attaches directly to the test strip holder. Both devices aid in proper finger placement and serve to guide the drop of blood more precisely to the test strip. Science Products (address above, telephone (800) 888-7400), makes the Sure Drop, which slips over the body of the meter. The special Teflon-like coating on the surface of the device helps direct the blood but can be damaged by bleach or a hard brushing--clean with mild soap and warm water. A Sure Drop made for the One Touch II will not fit the Profile, and vice versa. The unit for the Profile appears well-made and easy to use. The units are priced at $24.95 each.
Smart Dot, 2655 West Central Avenue, Toledo, Ohio 43606, telephone (800) 984-1137. The Smart Dot clips directly to the test strip holder of the LifeScan One Touch II meter. This plastic platform is easy to clean and convenient to use, but there have been cases of its detaching from the meter in mid-test. Cost $19.45.
Don Kramolis and Gary Allman, Blind Rehab Specialists (Manual Skills), at Waco VA Medical Center, Blind Rehab Clinic, Bldg. 7, BRU, 4800 Memorial Drive, Waco, Texas 76711, telephone (817) 752-6581 ext. 7489, have developed the Waco-U-Finger Guide, which, like the Smart Dot, fits any LifeScan Meter. Much like the T-shirt paint described above, the Waco Guide assists with finger orientation. The guide's other features help tactile strip insertion. Its designers do not sell finished guides but offer plans and advice to interested individuals.
I have discussed the strengths and weaknesses of the blood glucose monitoring systems with voice enunciation currently manufactured. This evaluation should help blind diabetics and those losing vision, who are just as capable as the sighted of independently testing their blood sugar levels and performing all the other tasks of daily diabetes self-management. Both blind and sighted diabetics are encouraged to consult their health care teams and individuals experienced in use of glucose monitoring equipment.
Choosing the most appropriate home blood glucose monitor is an important step in diabetes self-management. As blind diabetics increase their participation in the mainstream, efficient glycemic control is needed to maintain good quality of life. The Diabetes Action Network of the National Federation of the Blind, a support and information network, welcomes your views on blood-glucose testing.