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MANY BLIND DIABETICS SUCCESSFULLY
USE INSULIN PUMPS
by Ed Bryant
(This article appeared in Voice of the Diabetic, Volume 15, Number 2,
Spring 2000 Edition, published by the Diabetes Action Network of the National
Federation of the Blind. Updated January 2005.)
Insulin pumps, which deliver continuous doses of insulin, are being used
by more and more diabetics, blind and sighted, to achieve better diabetes
control. Unfortunately, there are health professionals who assume it isn't
possible for a blind patient, or one with severe vision loss, to operate an
insulin pump. These individuals, and some blind people, have the
misconception that blindness is synonymous with inability. They're wrong.
Most people with type 1 diabetes, sighted, blind, or visually impaired,
can successfully use an insulin pump if they desire. With the pump, they can
come closer to "nomal," non-diabetic blood glucose than with any other
means short of a pancreas transplant.
Today's pump is the size of a deck of cards, or smaller, and is highly
computerized. Insulin runs from the pump, through a tube (catheter or
cannula), usually attached to the abdomen or thigh. Insulin is delivered under
the skin, through the tiny, flexible tube. The user programs the pump for
basal (continuous) delivery, small amounts of short-acting insulin 24 hours
a day. He/she also programs the insulin pump for bolus insulin delivery, to
receive extra insulin just before eating. Insulin pumps have several different
controls and alarms, and your doctor may want you to spend a few days in the
hospital for training.
Current insulin pumps are easier to use than their predecessors; they
simplify dose computation -- but they do not set themselves. Insulin pump
users need to check their blood glucose often, at least four times a day.
Since only short-acting insulin is used, no mix of long- and short-acting
insulins, it is important the user check blood sugars regularly to avoid really
high or low blood glucose. Warning: If the needle, or catheter, comes out
from under the skin, there may be no warning alarm to alert the user;
dangerous ketones can start building up in about one hour. With little or no
insulin in the body, ketoacidosis can develop in just a few hours. Note: Pump
users say the needle or cannula rarely, if ever, comes out; and if it does, they
can feel what happened. Additionally, if the needle has detached from the
skin, then insulin will flow onto the clothing which will after a while become
wet. Most users should also be cognizant of leaking insulin, as it smells very
bad. To reiterate, it is important that you closely monitor your blood sugars.
An insulin pump might be what you need if you are having major
problems controlling your blood glucose with insulin shots. You might
consider a pump if insulin injections do not keep your blood glucose near a
normal level, or if you have big glucose swings. Nighttime can be difficult for
some, because they have episodes of hypoglycemia, or get up in the morning
with high blood sugars before breakfast. The pump can be programmed, so
it can deliver less insulin at night and more insulin before dawn, minimizing
nighttime lows and before breakfast glucose highs. We should all be
monitoring our blood glucose, working toward tight control. We should all be
working with our health care team to reach euglycemia, normal blood glucose.
You may be able to wear your insulin pump while bathing or swimming.
Some pumps are waterproof, and some come with a water protective case.
Insurance
Some insurance companies will help with the cost of pumps and
supplies. They realize better diabetes control means less diabetes
complications, less time in the hospital, and a bottom line of less expense for
the insurance provider. Your doctor should be able to help show insurance
companies the value of covering the cost of pumps and supplies.
As of April 1, 2000, Medicare began helping type 1 diabetics with the
cost of pumps and related supplies. For information, telephone:
1-800-633-4227, and ask for "Durable Medical Equipment."
Pump Manufacturers and Costs
Change has become quite rapid; new models and new manufacturers
are announced almost every month. Do some research -- much of the
"published information" is already incomplete and outdated, and few sources
mention all your options. The internet is a great place to start.
Animas (the R1000 and R1200 pumps)
Frazer, PA
1-877-767-7373 or 1-877-937-7867
Dana Diabecare (the Diabecare II)
New Orleans, LA
1-866-342-2322 (in USA)
Korean-designed, built and sold all over the world
Deltec/Smith's Medical (the Cozmo and Cozmonitor)
St. Paul, MN
1-800-826-9703 (in USA)
www.delteccozmo.com or www.smiths-medical.com
UK-based, the Cozmo includes a coupled meter (the Cozmonitor) and
Cozmanager computer software.
Disetronic Medical Systems, Inc. (former manufacturer of the D-tron and H-Tron)
Fishers, IN 46038
1-800-280-7801
Disetronic is now part of Roche Diagnostics. Their new pump, currently
"in the pipleine," will be marketed as the "AccuChek Spirit." Roche will sell it;
Disetronic will support it, as they do their D-Tron and H-Tron models. It's not
available yet; we'll tell you more when it's available.
Medtronic/MiniMed (the Paradigm 515 and 715)
1-800-933-3322
Sylmar, CA 91342
Minimed's Paradigm series pumps link (by wireless RF) with a dedicated
B-D blood glucose monitor, to ease computation of basal and bolus dose.
Nipro
1-888-651-7867 (in USA)
Miramar, FL 33025
Osaka, Japan,-based Nipro, a newcomer to the U.S. market, offers the
Amigo II pump.
On The Way:
The AccuChek Spirit (Roche Diagnostics). Successor to the
Disetronic pumps, in development, no technical details available.
Under the Aegis of LifeScan, Inverness Medical and Swiss R&D firm
Debiotech have been developing a tiny pump that attaches directly to the
skin, eliminating the long cannula. Researchers report they plan "to make
their pump the size of a credit card." The new mini-pump will require a
concentrated insulin not yet perfected. No name has been put forth for the
mini-pump.
Although many blind people successfully use insulin pumps, no pump
manufacturer to date has embraced the need to create a tactile or talking
insulin pump designed to ease independent nonsighted use. The technology
exists; all that has been lacking is manufacturer interest. We hope this will
change.
The insulin pump is an amazing device. If you have type 1 diabetes,
and need to use insulin, the pump best approximates the function of a
healthy, non-diabetic pancreas. Can a blind diabetic use it, fill it, program it,
attach it, independently, without sighted aid? Absolutely.
As I said, there are still people who believe otherwise, and some who
just don't know. Who are the "experts" in this case? The blind pumpers who
are doing it for themselves. Here's what they had to say about their pumps:
Why should a blind diabetic consider the insulin pump?
Susan Stewart, a blind pump user from Medina, Ohio, says: "I've
always wanted to be on the pump; it was a convenience thing. The pump
gives me more flexibility. If you're considering an insulin pump, definitely
really look into it, because it has given me independence and freedom..."
Tammy Rupp, a blind pumper from Carrolton, Georgia, says: "The good
thing about the pump is that you can be real flexible. You don't have to be on
a schedule. You can be, but you don't have to be."
Sally York, a blind pumper from Castro Valley, California, and Board
Member of our National Federation of the Blind Diabetes Action Network,
says: "My MiniMed insulin pump has given me back my independence. I
can't imagine going back to life on multiple injections. I can honestly declare
my pump has given my life a positive boost."
What specialized techniques do you use to manipulate the pump
without sight?
"With respect to filling the syringe," says Tom Tobin, a blind pumper
from Cleveland, Ohio, "I have developed a system that works well without any
sighted assistance. First, when filling the syringe, I pull down on the plunger
until the bottom of the syringe barrel and the plunger are about the distance
from the tip of my index finger to my first knuckle; so as a measuring device,
you always have your knuckle.
"Then, as with a regular syringe, I tap the sides of the syringe barrel and
then push the insulin back into the vial. I repeat this step until I cannot hear
any "bubbles" escaping when pushing the insulin back into the vial; there
should be a "smooth" sound.
"Next, since air may trap at the top of the syringe itself, I pull a little air
into the syringe and push up on the plunger ever so slightly until insulin comes
out the tip of the needle; just a little push. That completes filling the syringe.
"Next, while holding the syringe in my left hand, I take the infusion
tubing and remove the cover at the end of the tubing that goes over the neck
of the syringe, where the needle once was. Make sure that there is a snug
fit as you tighten down the collar of the infusion set over the neck of the
syringe. (I sometimes use my teeth to make sure it is really tight.) Then I put
the plunger of the syringe on a flat surface, usually a table top, and begin
pushing down on the barrel of the syringe, thus filling the infusion set. I want
to stress, that this should be done very, very slowly to avoid any pocketing of
air in the tubing. If it is done right, there should be no air bubbles at all in the
tubing. Letting a drop fall on the back of your hand is fine, although I put the
needle guard at the other end of the infusion set between my teeth, and use
my tongue to feel when the drop falls. Whatever works for you."
Tom Ley, from Baltimore, Maryland, a blind pumper and former
president of our NFB Diabetes Action Network, says: "The process of filling
my Mini Med 507 C pump with a fresh supply of insulin can be performed
successfully by a person using non-visual techniques. I will cover the subject
of inserting the cannula into the skin and securing the cannula with tape. Let
me say, at the beginning, that not once in my two years of experience has the
cannula ever crimped or otherwise unsuccessfully seated itself under the skin
when being implanted. I also find this aspect of the process very easy
non-visually.
"It is much like giving a shot in many ways. Once the needle is inserted
into the skin, a piece of special tape is used to hold the cannula in place. The
tape is designed in such a way that is extremely easy to position correctly
without yet exposing the sticky side of the tape. Once the tape is in place,
three pieces of paper that cover the sticky part of the tape must be removed.
The pieces of paper are pre- folded and shaped by the factory to make
locating and removing extremely easy.
"Then, the final step is to remove the needle from the Teflon cannula.
One simply must locate the large plastic end of the needle protruding from the
skin through a hole in the tape, twist it a quarter of a turn, and pull out to
remove. It is possible that the cannula might crimp as it is being inserted.
However, it is standard operating procedure to check your blood sugar an
hour after changing the pump set. If the sugar is abnormally high, then a set
of procedures should be followed to remedy the situation. This is no different
than what a pump user does any time blood sugars seem unusually high. As
said earlier, in two years, I have not yet experienced any problems of this
nature when changing my pump set."
"One of the first things I learned was to line up my insulin bottle with the
needle and syringe that holds the insulin in the pump," says blind pumper
Donna Blake, from Waterbury, Connecticut. "This may have not seemed like
much but at that time, I had never seen a Count-A-Dose (tactile insulin
measuring device that enables blind people to accurately measure insulin
without sight), nor had I heard about any alternative techniques for taking care
of insulin and blood sugar needs.
"After I got the syringe filled, I devised a simple way to connect the
syringe to the tubing aseptically (in a sterile manner). I placed my thumbs
together guiding the hub of the syringe into the Leur lock of the tubing. I drew
the syringe back two fingers' width and this gave me the correct amount of
insulin for three days. Next, I realized that I had bubbles that I did not know
about, so back I went to step one. I found by pushing the insulin in and out
of the bottle several times (gently), I could eliminate almost all of the
bubbles--most of the time, all of the tiny bubbles.
"In order to ensure that all of the air was out of the syringe, I would
lightly tap the syringe on the side of a table to bring the bubbles to the top.
Then I took the syringe, pulled a bit of air into it, reinserted the needle into the
bottle of insulin and shot out the air. I then tapped the needle on the side of
the table and pushed the plunger until a few drops of insulin came out (you
can really smell the insulin). I connected the tubing and the syringe. I held
the syringe and the first few inches of tubing upright and slowly depressed the
plunger so the insulin filled the initial portion of the tubing without bubbles. I
continued pushing insulin through the tubing until I felt a drop fall out and hit
the back of my hand.
"I was almost ready to insert the needle/catheter. I began this stage of
the procedure after a shower where I scrubbed the site, where the catheter
was placed, thoroughly with soap. I dried this area off with a clean towel,
separate from my other towels. Next I prepared the site with a liquid spray
called "Sween Prep," a protective skin coating that keeps me from having an
allergic reaction to the adhesive placed over the catheter site. While this stuff
dried, I placed the syringe in the pump and primed two units of insulin
through. This step ensured that the syringe inserted snugly within the pump
and I did not miss any dose of insulin.
"When my site was ready to receive the catheter, I inserted the needle
just like anyone else with diabetes does giving an injection. After I inserted
the catheter, I pulled out the small (25-gauge) needle and placed a protective
tape over the catheter and now I could go for about three to four days."
What adaptive features are there to help you?
"It has a tone-activate button," says Tammy Rupp. "You press it, and
it has a tone, and you count the tones for each unit you need, to get your
insulin bolus. Mine goes in whole units; it can go in half-units, too. And it will
automatically count it back to you so you can check it.
"There's also a select button that you use with the activate button, to
clear the pump's alarm, if it goes off. There's an alarm for "low battery," for
if something's wrong with the infusion set, or if the pump is out of insulin. It
beeps six times when you're out of insulin.
Visually-impaired pumper Anne Whittington, MBA, MSN, RN, CDE,
from Augusta, Georgia, says: "Initially I was on the MiniMed. I found the
buttons cumbersome (with my rheumatoid arthritis) and the contrast poor on
the screen. In 1993, I switched to the Disetronic pump. The audible alarms
and crisp contrast met my needs well."
Susan Stewart says: "My insulin pump has a screen, which I cannot
read, that shows date and time, and when the alarm goes off, it tells what the
alarm is for. It has four buttons, and one of them is the "select" button, with
which you select whatever screen you want. I use it by counting. Once I hit
the activate button, it beeps. And it has the up and down arrows. When I do
a bolus before I eat, I push the button. Say I want ten units; I'll push the
button up; it'll be 20 beeps. Then I push the activate button again, and it will
replay the number of beeps, each 1/2 unit of insulin, that I selected. Another
push on the activate button, and it will start giving me the insulin."
What about the cannula? Does it bother you? Is it safe?
Veronica Elsea, a blind pumper from Sylmar, California, says: "The
insulin is delivered through a needle or cannula, which is placed anywhere
you'd give an injection with a syringe. I only use my abdomen; I find it easier
and more reliable. I use a Teflon cannula called "Tenders," made by
Disetronic. I find them easy to insert and very forgiving. In fact, if you have
any neuropathy in your hands, you may actually find these cannulas and
cartridges quite a blessing, as they're fatter and larger than regular syringes.
The "Tenders" are inserted at an angle, anything up to 45 degrees or so. I
just hold it at a slant, push it in and don't worry about it! As you might expect,
once you insert the cannula and remove its insertion needle, it is held in place
with tape. With the "Tenders" infusion set, the tape is part of the cannula, so
I no longer find myself holding something in place while searching for a piece
of tape somewhere on a table! It's designed for one-handed operation by a
sighted person, which means we can do it easily and comfortably with two.
"Only once, during an exuberant "good morning," did my guide dog
reach up and catch her paw in the tubing. It's a weird feeling when you catch
the tubing on something, but it takes real effort to knock out the cannula."
"I'm not afraid that the catheter would fall out," says Susan Stewart. "I
use three pieces of medical tape holding it in, and never in the months I've
been using it has it come out, unless I mean to, when I'm taking it off. You
have to really tug on it sometimes to get it off--the tape is very sticky.
Although there's no alarm that would sound if it fell out, you would definitely
know--you would notice. For one, my shirt would be soaked with the insulin!
"Once you get used to wearing the cannula, and to the need to rotate
it, you can tell if something's wrong. I can tell if the tape's loose. Usually on
the third day, the tape gets a little looser than the first or second days, since
you've taken three showers since you attached it.
"I can honestly say I feel practically no discomfort at all from the cannula
that delivers my insulin," says Tom Ley. "I find its presence far more
comfortable than taking four insulin injections per day."
Do you have any advice for blind diabetics who are considering
the insulin pump?
"A lot of people say to me, 'Oh, I want the pump and I don't want to get
injections anymore," says blind pumper Tricia Kline, from Doylestown, Ohio.
They think the pump is the easy way out. And I would say, unless you have
the commitment to continue, if you think all you have to do is get a pump, and
then you can eat anything you want to, that you don't have to do this and that,
and you don't have to do blood sugar testing, unless you are committed to do
that and really work at it, you won't succeed with the pump. It's not "less
work." Sure, some people think you throw out your injecting needles and that,
but it's still a big commitment. And unless you're willing to do that, and willing
to, and have the confidence to do, your own adjustments, you won't succeed
with the pump. You have to develop, with your doctor, a sliding scale; like "if
my blood sugar is this much, then I take this much insulin, or if it's low I take
this much less." You get to know your body. But unless you're willing to gain
this much confidence in yourself to be able to make these changes on your
own, you will drive your doctor crazy."
Anne Whittington says: "Before selecting the company with the best
pump for you, consult your diabetes management team members. These
team members go beyond your doctor, and include your nurse dietitian, blind
rehabilitation specialist, and whoever else may be assisting you in learning
about the pump and its day-to-day operation. Also, please speak with
customer service representatives from the major companies before you select
a pump. Explain to them your needs as a blind person."
"With the MiniMed pump at my side," says Tom Ley, "I'm eagerly
beginning a new phase of my life with diabetes. After 25 years, I welcome
days free from insulin injections. I'm excited about the prospect of fewer high
and low blood sugar incidents, and I will enjoy my new mealtime flexibility
immensely. I'm comfortable, confident, and content."
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