Update:  Blind Diabetics Can Draw Insulin Without Difficulty

by Ed Bryant


    (This article appeared in VOICE OF THE DIABETIC, Volume 11, No. 1,
Winter 1996, published by the Diabetics Division of the National
Federation of the Blind.)


    A major aim of the Diabetics Division 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 techniques. 

    I became blind from diabetic retinopathy about 17 years ago.  When I
first lost sight, I didn't use insulin gauges to help draw my insulin, as
I had never heard of such devices!  Fourteen years ago, I designed my own
insulin gauge, and I used it for approximately three years, with no
difficulties.  I do not advocate the use of nonstandard 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 I
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
Jordan Medical Enterprises, wins the blue ribbon.  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 Becton Dickinson
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.  Diabetics
Division Second Vice-President Janet Lee has 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 10 cc (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:  Though it 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. 


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 Dept. 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, Director of the Independent Management for Blind Diabetics
Program at BLIND, Inc., Minneapolis, Minnesota, states:  "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." 

    Ann Reardon, RN, MSN, CDE, with the Georgia Dept. of Human
Resources/Medical College of Georgia, 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, Diabetes Program Coordinator, Cleveland
Sight Center, and her colleague Marylin Teasley, RN, CDE, state:  "In the
last eight years we have 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

    Our Diabetics Division publishes the Resource Guide to Aids and
Appliances, a compilation of equipment and information for diabetics,
especially blind diabetics.  Categories include:  General and
Miscellaneous, Automatic Insulin Injection Systems, Blood Glucose
Monitoring Systems, Insulin Pumps, and Large Distributors of Insulin
Equipment and/or Supplies.  Available in large print, Braille, or
cassette, copies cost $2 each, and can be ordered from:  Materials Center,
National Federation of the Blind, 1800 Johnson Street, Baltimore, MD
21230; telephone:  (410) 659-9314.