The subconscious as a travel agent

Well before my mother passed away after her battle with Alzheimer’s, while she still was aware of who I was and having more clarity about what was happening, we made sure to capture her living will and advance directive for medical decisions. While this is a difficult conversation to have with your loved one, it’s one you will be thankful for when you are faced with the very difficult decisions you might need to make concerning their health and treatment as they approach the end of their life. This allowed her to state her wishes: things like not wanting to be intubated or resurrected in the face of such a situation (she didn’t want to become a burden for an indefinite time), to wanting to be cremated, not buried, and rest close to my dad in Miami.

In a subsequent post, I will share more about the experience of my mother’s cremation: a tough episode, but one I’d love to share with anyone who could learn and benefit from it. Today, just over a year after she passed and was shortly after cremated, I find myself still having her ashes in the small box they put them in for me to take. A year ago, I told myself I’d be bringing the ashes to Miami “very soon”, yet here they still are… In connection with this, I found a recent experience fascinating and felt you’d appreciate the irony and the power of the subconscious.

Last year, I was invited to attend the North American HR Executive Summit in Orlando. Having registered for it back in August 2018, I forgot about it until early this year. Someone helped me get my hotel booked for it, so in January I sat to book my travel, and here’s where the interesting part begins… I convinced myself that the conference was going to be in Miami (a 4-hour drive and a 1-hour flight from Orlando), so I decisively proceeded to get all my travel set, including a stop in Denver on the way back home, to spend a day with the folks at myStrength, the company that Livongo acquired this year.

It wasn’t an easy task, I must say, because I try to fly Alaska whenever I can, and Miami is not one of the airports they fly to, so I had to go out of my way to find best fares to and from Miami. Ultimately, I aggregated all flight information and lodging information within TripIt, which has been a great tool to make sense of travel plans for many years now. I pull up the upcoming “Miami, Denver” trip, and that’s when it hit me: I didn’t need to go to Miami!! At least not for the HR Summit! Why did I do this?

Enter the subconscious… it is my belief that on the surface, I have been postponing bringing her ashes to their final resting place, as I am still working through some of the things that were left unsaid and undone. But my unconscious seems to have a different opinion: it seems to be saying “JUST DO IT! Be done with it, so you can move on.” If only it had done the full booking, and saved me a room in Miami, it would have probably tricked me into going there, with her ashes in hand.

I ended up changing all the tickets to/from the correct destination (although you could argue that I could have still stopped in Miami to drop off her ashes). I have now planned to make a dedicated trip to Miami for this, in March. And as the trip approaches, I feel some of the pain from her loss resurface, but it’s pain that I need to go through.

Review: @TandemDiabetes t:slim X2 Insulin Pump with Dexcom G5 integration

Manny Hernandez with X2+G5

Last year, when I the Tandem X2 pump that supports software updates via USB (the only pump to do so) was approved by FDA, and they announced that their first update would support integration with the Dexcom G5 CGM sensor, I signed up for it. I left my clunky Animas Ping behind and became a Tandem pump user.

Recently, FDA granted Tandem approval for the Dexcom G5 update. And today, I am happy to report I am sporting my Dexcom G5 data on my Tandem X2 pump, as you can see above. This post summarizes my experience and feedback during the update process and over the course of the first few days of using the integrated product.

The Update
Upon receiving the instructions with my Update ID (you need one to proceed with the update), I downloaded the Tandem Device Updater:
Tandem Device Updater
After I had the software installed and running, the update literally it took under 15 minutes. This even included completing the recommended safety steps.
Update successful
In (silly) defiance to the recommendation to do the update in connection with a site change, I found myself needing to load the pump as you would have to with a site change. So, while you technically can still continue to use your current infusion site, you will need to go through the process of loading the pump. And since you need to prime by letting a minimum of 10 units flow through the tube, if you do not have at least 50 units of insulin in your cartridges, I recommend you follow their recommendation, unlike what I did… :/

At this point, my pump looked pretty much like it used to before the update… because my Dexcom receiver had not yet arrived, and it took about a week to get here…

The CGM integration
Once my Dexcom transmitters arrived, I was able to continue with the process, and get down to the really exciting stuff.

Entering the transmitter ID is a bit more “fun” than the way you enter it on the Dexcom receiver, where there’s no keyboard. The advantage of a touch screen is that the screen can be turned into a keyboard, only not a full keyboard but more like a phone pad keyboard:
Dexcom keyboard
You are prompted to verify the Transmitter ID (enter it twice), which is different from the Dexcom-only experience too. Not too sure what this does for the process, but not a big deal either.

My anxiety to be done with the rest of the process got in the way, as did my Dexcom receiver freaking out and entering into a loop where it would reboot itself over and over, as if it had sensed that it was no longer going to be with me any more (I forgot to take pictures of the Dexcom receiver acting up, and I had to do some ninja stuff to get the recurring reboot to stop, so I owe you visuals of the Dexcom screens, but I am sure you have seen them before…)

Finally, after patiently waiting for the mandatory two-hour sensor warmup period (which gave me plenty of time to finish the training and configure alarms, etc.) at 11:21, on Sep. 6, 2017, I finally saw my Dexcom G5 data on my Tandem X2 screen! 🙂

First CGM time

The Training
It will take you up to 30 min to complete the Remote Software Update – CGM Integration Tutorial. This is if you are new to the CGM or the Dexcom G5, since it covers CGM basics, how to insert the sensor, snap the transmitter, etc. I liked that it included these types of quizzes to confirm you have retained the key concepts that you’ve learned:
Tutorial
Not a huge deal, but the voiceover used in the tutorial was creepy at times. Also, I think the trainer speaking changes mid-module, which can be a tad disconcerting. Then again, not a huge deal.

Everyday use

After a few days of use, the pump battery has already shown signs of lasting less. This is not surprising, as it now has a Bluetooth radio to feed. But it’s still not necessarily the most fun extra thing to do. To be fair, it’s only one device vs. two (pump + receiver) I have to keep charging.

But the biggest downside I’ve found is that I am seeing the Out of Range icon in the place where you’d see the CGM reading more often than I would have expected, typically no less than a couple of times per day:
Out of Range 2
They indicate in the training that “Brief interruptions of up to 10 minutes [without CGM signal] are normal”. The truth is this doesn’t feel normal.

I have historically worn my pump in one pocket, on the same side of my body where I am wearing my infusion site. And I have my CGM sensor on the other side of the body (typically, both are on my abdomen). If I change my insulin pump to the opposite pocket (the one closest to the CGM transmitter/sensor), normally the Out of Range icon disappears shortly. I get that proximity matters to make sure the transmitter signal can get to the receiver in the pump, but we’re not talking 20 or even feet here, we’re literally talking inches… Although I am working on losing weight, I hope my belly is not the obstruction causing this! 😉

The verdict
I am delighted with being able to see my CGM data on my pump, period: full stop. Is it exactly the way I envision it? No. But it’s a MAJOR step for me, considering my choice of CGM at the present time (the world of CGM is changing rapidly so we will see what the future brings). In the meantime, here are two ideas (for my friends at Tandem and Dexcom) to make the integration better (which I assume they have already thought of):

  1. It would be amazing to offer the option to use a BG readings entered on the pump “side” of the device (while you are bolusing) to calibrate the CGM, or the opposite: offering the option to bolus for a BG being entered as part of your CGM calibration. Neither option is available, and they would make perfect sense. (Update, Sep. 10: Just realized that above target calibration BGs generate this prompt. Love it!) CGM calibration - correction
  2. Something that takes some getting used to is the fact that functions for loading the pump and for calibrating the CGM are respectively further out (in terms of button taps needed) than where they used to be pre-integration. I get that this comes with the territory, but I’d love to see the two companies explore ways to make the user experience a bit cleaner, specially re: calibrations which occur twice a day.

A new life after the nonprofit sector (2 years in)

In the past year, I have had a similar conversation with numerous friends who are considering other options after working in the nonprofit sector for some time. Maybe they approached me as a trusted person, who took this step over two years ago, after over eight years of running Diabetes Hands Foundation, people open up to me and see me as a potential source of advice on this topic. So I figured I’d write a blog post about it.

  1. If you have spent any amount of time in the nonprofit sector, you likely are drawn to serve people, to do things to impact the lives of people in a positive way. It may have crossed your mind that you can only accomplish this in the nonprofit sector. I used to think so too early on, and I realized I was wrong. To consider opportunities in the for profit sector, consider companies with a strong sense of social responsibility, companies that are disrupting spaces where changes in terms of access, affordability, and impact is sorely needed. To do this, look at the mission statement of the company, talk to people that work at the company and contractors/partners of the company. You may find that mission-driven companies may very well be a great next place for you to put to use the skills you developed during your time in the nonprofit sector. That is my experience I have had at Livongo, where I have been at for two years.
  2. Consider the sector you have experienced with. You likely have worn multiple hats in one or more nonprofits within the same sector, which gave you enough experience in a variety of functions. The one likely common denominator across all responsibilities you’ve had may be the sector (health, housing, etc.) you’ve worked in. That experience can be very valuable in the private sector, as you have developed a more intimate understanding of the needs of the people that your agency served. And the flexibility that you develop when you work in a nonprofit is a highly valued quality anywhere.
  3. Depending on where you are in your life journey (single/married; with children/with parent caregiving obligations), you may have different family requirements. You may have obligations that limit your ability to move. Consider which ones are flexible and which aren’t. If your biggest constraint is the potential for uprooting yourself and your immediate family, evaluate as a family your willingness to tackle it. Sometimes there may be true gems underlying what may otherwise feel like difficult choices.

These are three high-level things for you to consider if you are exploring a life beyond the nonprofit sector. I am happy to chat if you’d like to use me as a sounding board for this.