by Ed Bryant
This article appeared in Voice of the Diabetic, Volume 16, Number 2, Spring 2001, published by the Diabetes Action Network of the National Federation of the Blind.
A major aim of the Diabetes Action Network of the National Federation of the Blind is to provide support and information for blind diabetics, so they might better maintain or regain independence and productivity. Our national support and information network allows communication across a wide area, something important for blind or visually impaired diabetics and their families. With the trauma of sight loss, sometimes the newly blinded do not realize that most blind men and women with diabetes CAN self-manage safely and accurately, by use of alternative/adaptive techniques.
I became blind from diabetic retinopathy about 25 years ago. When I first lost my sight, I didn't use insulin gauges to help draw my insulin, as I had never heard of such devices! Twenty-three years ago, I designed my own insulin gauge, and I used it for approximately three years, with no difficulties. However, I do not advocate the use of non-standard or homemade insulin-measuring devices, unless they have been checked out by someone knowledgeable in insulin-measuring techniques.
Members of the health care community sometimes forget that although a diabetic may be newly blinded, he or she has often been successfully self-managing the disease for 15 years or more. Most long-term type 1 diabetics have had years of experience drawing their own insulin. Veteran blind diabetics often have more experience with adaptive insulin preparation devices than do many sighted health professionals. The following observations are only a small sample.
Because of my experience with diabetes and blindness and my editorship of Voice of the Diabetic, I am often asked to evaluate insulin-measuring gauges designed for the blind or visually impaired. I have tested numerous measuring devices, and in my opinion the Count-A-Dose, from Medicool, wins the blue ribbon. (Note: The Count-A-Dose is available from the National Federation of the Blind Materials Center: (410) 659-9314.) I hasten to add that no one instrument is ideal for everyone; however, the Count-A-Dose provides a very easy method of insulin dispensing. Designed for the B-D LoDose syringe, the Count-A-Dose holds two insulin vials and directs the syringe needle into the vials' rubber stoppers. Using the thumb-wheel, which clicks for each unit measured (clicks can be both heard and felt), the blind diabetic can reliably draw and mix his or her own insulin.
How to Get Air Bubbles Out of an Insulin Syringe
There are techniques by which a blind diabetic may draw and mix insulin without drawing air into the syringe. Like many others, I have used them successfully for years. I first draw four or five units of regular insulin into the syringe and then inject all of it back into the vial. I then repeat the operation two more times. The fourth time, I draw the full amount of insulin needed from the first vial. Then, when I draw insulin from the second vial, I draw the exact amount needed. I have put this to the test; 100 repetitions without air bubbles. Diabetes Action Network former First Vice President Janet Lee twice performed the same test. In both cases the complete absence of air in the syringe was independently verified.
"Tapping the syringe to remove air bubbles," a common technique used by the sighted, becomes unnecessary. The one to two units of air in the hub of the needle (where needle meets syringe) are expelled during the procedure used with the first vial of insulin. I demonstrate this technique to nurses, who are delighted to see that air bubbles are not present and the insulin measurement is accurate. Of course, long-term insulin users will be familiar with the need to inject as much air into the vial as the amount of insulin they withdraw, to facilitate getting the insulin into the syringe. For further information, consult your health care team.
How to Know When an Insulin Vial is Getting Low
Each vial of insulin contains 10cc, 1000 units. The maximum number of units used per day, divided into the vial's 10cc (1000 units) capacity, gives the maximum number of days the bottle can be used. When I open a new vial of Regular insulin, I divide its 1000 units by 20 units, the maximum I use daily, so one supply should last me 50 days, but as a safeguard, I assume that the new bottle contains only 940 units (9.4cc), which should last a maximum 47 days instead of 50. I measure my NPH insulin in a similar manner. As long as at least 60 units of insulin remain in the vial, the needle will remain submerged while filling, and there is no danger of drawing air. In drawing out the insulin, I keep the syringe vertical, needle straight up in the vial, so as not to inadvertently draw out air. Many blind consumers (and diabetes educators) are unaware of this point's importance—that the natural tendency is to tilt or slant while drawing, which can lead to inaccurate filling and air in the syringe.
Many methods exist to determine how long a supply will last. One way to keep track of the amount of insulin in the container is to set aside the number of syringes that will be needed for 940 units of insulin. Another might be to employ Braille, large print, tape recorders, or personal computers, to record how much insulin has been used each day. Many blind consumers, like myself, realize the importance of keeping their blood glucose under tight control, and follow regimes of insulin mixing and multiple injections, both of which increase the need for precision. I have found the more precise the record of insulin drawn, the easier to safely predict when it is time for a new supply. NOTE: Although not as precise, before drawing insulin you can gently shake the vial and, with practice, easily determine whether it is full, half-full, or nearly empty.
Tactile Insulin Pens
Many blind diabetics make use of the easy adjustability of insulin pens. Pens combine the insulin drawing and dosing functions, and, though all still bear the legal disclaimer: “Not for use by blind or visually-impaired individuals without sighted aid,” most incorporate tactile and audible cues for each unit drawn, and many blind diabetics successfully use them—without sighted aid. Some even come “pre-filled,” and are meant to be discarded when empty. Though pens have their drawbacks (no mixing, higher price), they work, and one from Novo Nordisk, Eli Lilly, Owen Mumford, or Disetronic might be appropriate for you. Talk to your doctor and your pharmacist.
The Possibility of Inserting a Needle into a Blood Vessel
Since injection sites are in fleshy areas, and insulin needles are short, chances of inserting a needle into a blood vessel are minimal. The worst that can be done is to hit a small capillary, which would result in a small area becoming infused with blood—a hematoma. Again, it is unlikely the needle will be inserted into a small blood vessel. The amount of insulin entering the bloodstream via a capillary would be insignificant, and would cause no harm.
Something to Think About
I periodically have my insulin gauge checked for accuracy; it has always measured
precisely. If the diabetic is careful, difficulty in measuring insulin will
not occur. I have found that inaccuracy is often the result of haste or carelessness.
It is reported that insulin gauges are more accurate than sight. When the plunger is pushed firmly to the gauge, the same amount of insulin will be obtained every time. Sometimes my sighted friends make errors in drawing insulin. Perhaps they would be more accurate if they used insulin gauges! Note: Syringes are mass-produced. Although there is quality control, some errors are made in syringe markings. If a gauge is used, the measurement will be accurate no matter what the syringe shows.
At first hearing, all this may sound like a lot to remember, but it is not difficult. Marla Bernbaum, MD, CDE, Assistant Professor at St. Louis University Medical School Department of Endocrinology, states: "In our experience here, most blind and visually impaired diabetic patients have been capable of drawing their own insulin with complete accuracy."
Janet Lee, former Director of the Independent Management for Blind Diabetics Program at BLIND, Inc., Minneapolis, Minnesota, stated: "In my ten years of working with blind diabetics, hundreds of them, there have maybe been two, who, because of a combination of disabilities, could not measure their own insulin."
Ruth Ann Petzinger, RN, MS, CDE, Diabetes Care Manager/Educator at St. Peters Medical Center, New Brunswick, New Jersey, states: "During the time I have been working with persons with diabetes and visual impairment, I've never had a patient who truly wanted to be independent with insulin administration or blood glucose monitoring who was not able to achieve these goals."
Anne Whittington, RN, MSN, MBA, CDE, with the U.S. Navy Medical Center, San Diego, California, states: "In my experience, with proper training almost all diabetics are able to prepare and administer their own insulin safely, regardless of visual impairment."
Ann Williams, MSN, RN, CDE, formerly Diabetes Program Coordinator, Cleveland Sight Center (now completing her Ph.D.), states: "In the last eight years I worked at CCS, we taught about 800 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. I control it through the use of alternative techniques, some of which are described here. Many members of our organization, the National Federation of the Blind, use them daily to live active lives. With alternative techniques, blind diabetics can be as productive as when they were sighted.
Come to us and 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.
Resources
The Eye-Dea Shop: Cleveland Sight Center, 1909 E. 101st Street, Cleveland, OH 44106-8696; phone: (216) 791-8118 ext. 278
The Syringe Support Insulin Measuring Device: Uses only the B-D 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 one half-turn draws a single unit. Although the dial lacks definite tactile or audio indicators, in most cases any error would be fractional. Still, the Syringe Support performs best for those who must draw doses greater than 10 units. Instructions (standard print only) are bilingual (English and French). Cost: $26
National Federation of the Blind, Materials Center: 1800 Johnson Street, Baltimore, MD 21230; phone: (410) 659-9314; fax: (410) 685-5653; Hours are 8:00 a.m. to 5:00 p.m. EST, weekdays; Web site: http://www.nfb.org
Count-A-Dose Insulin Measuring Device: Gauge calibrated for use with vials and B-D 1/2cc (low dose) syringes only. By turning a thumb-wheel, clicks are heard and felt for each one-unit increment measured; holds 1 or 2 vials of insulin for mixing; needle penetrates vial stopper automatically. Print and audiocassette instructions provided. Price: $40.00
Palco Labs, Inc.: 8030 Soquel Ave., Santa Cruz, CA 95062; phone: 1-800-346-4488; fax: (831) 476-1114
Load-Matic: Tactile insulin measuring device, accepts B-D 100-unit syringes; aligns needle with vial stopper; two separate controls (one for single-unit and the other for ten-unit increments); tactile prompt to confirm dose setting. Audiocassette instructions included. Individuals with neuropathy may have difficulty with the one-unit scale, and it is possible to unintentionally "short-stroke" the ten-unit loading lever and draw an incomplete dose. Cost: $47.99