by Ed Bryant
From the Editor: Anyone who answers an NFB telephone knows that one of the most prevalent questions asked about managing diabetes as a blind person is, can someone who can’t reliably see what she is doing safely draw up insulin and administer it? I am not diabetic, so I cannot answer from firsthand experience, but I intend to send people the following article. I also intend to see that such callers get a copy of our new book, Bridging the Gap: Living with Blindness and Diabetes. This article first appeared in the Voice of the Diabetic, Volume 21, Number 3, the Summer 2006 edition, published by the Diabetes Action Network of the National Federation of the Blind. It was updated in October of 2009.
Diabetes self-management (the only way to cope with the condition) requires a number of precise measurements and manipulations. It’s a lot of work. To preserve health and independence, diabetics learn the skills of blood glucose measurement and insulin administration. Many diabetics are blind or losing vision. Poorly managed diabetes can cause sight loss, and folks already blind can develop diabetes. So how is a blind diabetic supposed to draw up and administer insulin without help from a sighted person?
Some folks still insist blind diabetics cannot independently self-manage without sighted aid. They’re wrong. We’ve been doing it for decades. Veteran blind diabetics have often had far more experience with adaptive insulin preparation devices than have most sighted health professionals. Here are a few examples. Individual experiences vary because some of us use the insulin pump, and others use insulin pens, but many of us have found adaptive ways to use the syringe.
Most insulin is drawn up into syringes. Traditionally, you read the marks on the syringe, like filling a measuring cup. But there are ways to accomplish this without looking. The simplest way, the old way, was with insulin gauges. These were usually flat cards with notches appropriate for a given syringe, a given insulin type, and a given dose. You held the gage against the plunger as you drew insulin. They worked; I made my own insulin gauge and used it for approximately three years, but there are better, safer, more reliable ways to draw up insulin without sight. I do not advocate the use of nonstandard or homemade insulin measuring gear, unless all components have been checked for reliability by someone knowledgeable about insulin preparation.
Although several devices are available to allow you to draw up a measured insulin dose, one is so far above the rest that it takes the blue ribbon. This is the Prodigy Count-A-Dose, manufactured by Diagnostic Devices, Inc., available soon from the National Federation of the Blind Independence Market, in Baltimore, Maryland. To order, contact (410) 659-9314, ext. 2216, or <www.nfb.org>. The device will be on the market as soon as final approval (now pending) is received from the FDA. The price will be $40.
How does it work? The Prodigy Count-A-Dose measures insulin in one-unit increments and is calibrated for the BD LoDose 50-unit insulin syringe. The device holds two insulin vials and directs the syringe needle into the vials’ rubber stoppers. The thumb-wheel adjuster clicks for each unit drawn (clicks can be both heard and felt), so the blind diabetic can reliably draw and mix his or her own insulin. Any technology for the blind needs instructions in formats accessible to the blind. The Prodigy Count-A-Dose is shipped with audiocassette instructions.
Lots of diabetics, both blind and sighted, use insulin pens, which combine insulin-drawing and -dosing functions. Most pens nowadays are preloaded at the factory. The cost per shot is a bit higher than with syringes, but the pens enjoy wide acceptance. Despite the resounding evidence that blind people can use insulin pens safely and effectively, most pen manufacturers include language on their insulin pen packages warning blind people not to use these products without sighted assistance: “This pen is not recommended for use by blind or visually impaired diabetics without the assistance of persons trained in the proper use of the product” – but the pens incorporate tactile and audio cues and are rugged and reliable, and a great many blind diabetics use them successfully without sighted aid.
In the past the big emphasis was on reloadable pens marketed by Novo Nordisk, Eli Lilly, and Owen Mumford, but increasingly manufacturers are packaging their insulin in their own disposable pen products. They are different but all pretty well made and reliable. Talk to your doctor and your pharmacist about the insulin pens you could use today.
The third choice is the insulin pump. The pump is a little box, about the size of a pager or a cell phone, often worn at the waist, attached to the body by catheter, that does away with the need for regular injection-dosing of insulin by continuously injecting microscopic amounts of insulin. In addition, the user must program the pump to give added insulin with each meal. These pumps are complex and expensive, but blind diabetics successfully use them.
So you do have options. There are choices, ways to keep your independence, alternatives to becoming dependent on somebody’s help. I’ve been around this issue for many years, several times actively involved in testing and evaluation of insulin-measuring devices, and I can assure you that with a little work you can take care of yourself and manage your diabetes without sight.
People may raise specific concerns about blind diabetics drawing up their own insulin. Here are some of the ones I have heard and why they are not significant.
Air bubbles in an insulin syringe
Here’s the technique I use. I mix insulins in a syringe without sight, and, to make sure I’m injecting insulin and not an air bubble, I first draw two or three units of regular insulin into the syringe and then inject it back into the vial. I then repeat this operation twice more. The fourth time I draw the full amount of insulin needed from this first vial. Then, when I draw insulin from the second vial, I draw the exact amount needed. I have tested this technique countless times, and no air bubbles were present. Others performing the same test have duplicated my result.
What about tapping the syringe to remove air bubbles? The sighted use this procedure, but, if you follow the technique I just described, tapping is unnecessary. The one to two units of air in the hub of the needle (where needle meets syringe) are expelled in the process I described above. I’ve demonstrated this technique to nurses, who are delighted to see that air bubbles are not present at its completion and that the insulin measurement is accurate. Of course long-term insulin users will be familiar with the need to inject (pressurize) as much air into the insulin vial as insulin they have withdrawn, to facilitate getting the insulin into the syringe.
How to know that the insulin vial is getting low
A vial of insulin contains 10cc, 1,000 units. The maximum number of units used per day, divided into the vial’s 10cc (1,000 units) capacity, provides the maximum number of days that the vial can be used. When I start a new vial of regular insulin, I divide its 1,000 units by 20 units (the maximum I use in a day) and determine that one vial should last me 50 days. As a safeguard against error, I assume each bottle contains not 1,000 units, but 940 units (9.4cc), and should therefore last me, not 50 days, but 47 days. I measure my NPH insulin the same way.
Why do I do this? As long as at least 60 units of insulin remain in the vial, the syringe’s needle will remain submerged while filling, drawing insulin and not air. While drawing out the insulin, I keep the syringe vertical, needle straight up into the vial, so as not to inadvertently draw out air. Many blind consumers (and diabetes educators) are unaware of this point’s importance. The natural tendency is to tilt or slant while drawing, which can lead to inaccuracy and to air in the syringe.
But how do you remember how many times you’ve drawn insulin out of a given vial? One way is to set aside the number of syringes needed to administer 940 units of insulin. Another way would be keeping records in Braille, large print, pocket recorder or PDA, or on your personal computer. I have found the more precise the record-keeping, the easier it is to predict accurately when you are due to start a new vial.
Accidentally injecting insulin into a blood vessel
Insulin is meant to be injected subcutaneously, under the skin, not IV, into a vein. Is hitting a vein a risk if you cannot see where you are aiming the needle? Not in my experience. Injection sites are in fleshy areas, and insulin needles are short. The worst that could happen would be to hit a small capillary, which could result in a small area becoming infused with blood, a hematoma. The amount of insulin entering the bloodstream from a capillary would be insignificant and would cause no harm.
Something to think about
Have someone check whatever technique you use to measure insulin periodically. Then you’ll know you’re doing everything right. If you are careful, you will not have difficulties. Inaccuracy is often the result of haste or carelessness.
At first all this may seem a lot to remember, but it is not so difficult. Robert Dyson, an administrative assistant at the Colorado Center for the Blind, says: “I am thirty-seven years old and have been a diabetic since the age of two. I lost my vision at the age of twenty from diabetic retinopathy. The Count-A-Dose gave me back my freedom. It is accurate and safe, and like any sighted person I just need to pay attention to what I am doing. I can measure my insulin amount with the device based on what my talking blood glucose monitor says my sugar is. I assist with the training of health care workers here at the Colorado Center for the Blind, and they are all surprised at how simple and easy to use this device is and always remark that they could not have imagined that it was possible for blind diabetics to do this on their own, but we know differently.”
Anne Whittington, RN, MSN, MBA, CDE, with the U.S. Navy Medical Center, San Diego, California, says: "In my experience, with proper training almost all diabetics are able to prepare and administer their own insulin safely, regardless of visual impairment, assuming there are no other disabling conditions."
Ann Williams, PhD, RN, CDE, formerly senior diabetes educator at the Cleveland Sight Center, says: "In the ten years I worked at the Cleveland Sight Center, I and another nurse taught about one thousand visually impaired and blind people to measure and administer their own insulin independently. Vision loss does not preclude safe and effective insulin self-administration."
I have no problems managing and keeping my diabetes under control through the use of alternative techniques, some of which have been described here. Many members of the National Federation of the Blind use them daily to live active lives. With alternative techniques blind diabetics can be as productive as they were when they were sighted.
Ask for assistance. We are ready, willing, and able to help. We want you to know that, no matter what your diabetes ramifications, you are not alone and do have options. We in the National Federation of the Blind know that blindness is not synonymous with inability.
Diagnostic Devices Inc. (DDI): 9300 Harris Corners Parkway, Suite 450, Charlotte, NC 28269-3790; general information: (800) 366-5901 or technical support: (800) 243-2636; email@example.com; Website: <www.ProdigyMeter.com>.
Prodigy Count-A-Dose: An insulin measurement device which measures in 1-unit increments.
National Federation of the Blind Independence Market: 200 E. Wells Street at Jernigan Place, Baltimore, MD 21230; phone (410) 659-9314, ext. 2216; fax (410) 685-5653; IndependenceMarket@nfb.org; Website: <www.nfb.org>.
Note: The National Federation of the Blind Independence Market also carries a large selection of adaptive equipment.
Independent Living Aids, LLC: P.O. Box 9022, Hicksville, NY 11802; phone (800) 537-2118; fax (516) 937-3906; Website: <www.independentliving.com>.
The Syringe Support Insulin Measuring Device: Uses only the BD 1cc/100–unit disposable syringe and measures insulin in 1– or 2–unit increments, in doses of 1 to 100 units. To mix insulins, it is necessary to remove vials from the apparatus. To draw a measured dose, the Syringe Support uses a set screw with a raised flange (its only landmark) at 12 o'clock. One full turn draws two units, and a half turn draws a single unit. Although the dial lacks definite tactile or audio indicators, in most cases any error would be fractional. Instructions (standard print only) are bilingual (English and French). Suggested retail price: $22.95.