=======================================================================

                            Tips for Pumpers

-----------------------------------------------------------------------
I.   Introduction
II.  Disetronic Tricks
     A. Batteries
     B. Filling the Cartridge without Injecting Air into the Insulin 
        Vial
     C. Changing the Cartridge But Not the Infusion Set
     D. "Stupid Pump Trick" - Using the Air Bubble
     E. Clearing 07 Alarms
     F. "Autopriming" (priming with little or no battery use)
III. MiniMed Tricks
     A. The "No Delivery" Error
     B. SofSet Insertion (and MiniMed QR Sets)
     C. If You Run Out of Insulin
     D. Slow-bolusing with a Temporary Basal Rate
IV.  General Tricks
     A. Dealing with Skin Irritation (look here for tape tricks)
     B. Wearing Your Pump  
     C. Tips for Better Absorption  
     D. Sleeping with Your Pump
     E. Showering with Your Pump
     F. Before You Stock Up on Tape and Infusion Sets
     G. Inserting a Teflon Cannula
     H. Removing Adhesive
     I. Reusing Leftover Insulin
-----------------------------------------------------------------------

I. Introduction
---------------
This is a collection of tips, tricks, and suggestions that I wish I'd 
had when I started pumping. I've included tips for both Disetronic and
MiniMed pumps as well as general tips that apply to both brands. I hope
this collection will continue to grow. I'll be looking for additions, 
and I hope pumpers will send me their ideas. Updates will be announced
on the type_one list. I am not posting this "document" anywhere. Please
feel free to pass it along to other pumpers, but please do not post it
or add it to a list of FAQs without my permission. Thanks to these 
people for contributing: Aileen, Betsy, Polly, Sarah, Maryle Ashley, 
Chris A. Bates, Gloria Breen, James Canning, Tere Griffin, Karen 
Gundy-Burlet, Ed Hanley, Peter McCracken, Larry Murphy, Brian J. 
Rodriguez, Jim Sandberg, Laurie Schatzberg, Ed Stanford, Ayaz Usman, 
Douglas Walter. 

Please send additions, suggestions, corrections to:  sasjcs@unx.sas.com

Last modified 07Aug96: Added information to IV.B., Wearing Your Pump
                       Added information to II.A, Batteries
                       Added information to II.F, Autopriming (priming
                          with little or no battery use)
                       Added information to IV.A, Dealing with Skin
                          Irritation 
                       Added information to IV.E, Showering with Your 
                          Pump

Copyright 1996 by Joan Stout. Re-use beyond the fair use provisions
of copyright law and convention requires the author's permission.
-----------------------------------------------------------------------     


II. Disetronic Tricks            
=====================

A. Batteries
------------
After you get batteries for your new Disetronic pump, DON'T BUY ANY 
MORE. The special Disetronic batteries are just over-priced holders for 
generic batteries. When the batteries are dead, you can use a small 
screwdriver or utility knife to pull the plastic top off the metal ring
and eventually extricate the batteries. Replace them with generics 
purchased from the local Costco, and put the unit back together.  

You can tell which ones have been used and which ones have not by 
looking for a small circle in the bottom of the lower battery, which is 
inscribed into the battery when it's screwed into the pump.

Another pumper's version:

If the battery package is disassembled, you can push out the plastic 
insulator at the top. There are about 6 raised "plastic locking 
pieces" that you can cut off. Once this is done, put the metal cage 
back together with the base. It is now possible to push the insulator 
and batteries back into the assembly without taking it apart. When 
screwed back into the pump, the batteries and insulator will be held in 
place. (Battery type is #357 - amazing, same battery MM uses... For me, 
Duracell works better than other brands. )

B. Filling the Cartridge without Injecting Air into the Insulin Vial
--------------------------------------------------------------------
I fill 3 cartridges at a time. I fill as many cartridges as the vial 
will fill, so I only handle the vial at one "setting." A vial can fill 
3 cartridges plus a little bit of another. I use only one cartridge-
filling needle at each setting and save the unopened ones for "change-
cartridge-but-not-infusion-set" days. I re-cap and then store each of 
the FILLED cartridges in an empty One Touch 2 vial of test strips. I 
tear out the dessicant from the strips' cap, so the capped cartridge 
fits in there quite nicely. The partly-filled cartridge I cap and store 
the same way, but I mark the cap on that one "partly filled." Next time 
I need to fill cartridges, I top off that cartridge first and use it 
first. (I labelled on of the strips lids with the #1 on it to help me 
know which is which). I store all the filled/part-filled cartridges in 
their little vial homes (not to be confused with vile little homes) in 
the fridge.  

Now to the point of the story... Fill each cartridge as you've been 
instructed EXCEPT be sure to skip the step that says "inject air" into 
the vial of insulin. Really. Skip it. You'll need stronger hands to fill 
the cartridge while drawing a bit of a vacuum, but it works just fine
and results in much less air being introduced into the cartridge. 

C. Changing the Cartridge But Not the Infusion Set
--------------------------------------------------
To change a Disetronic pump cartridge without changing the bent-needle 
infusion set:

Finish drinking your coffee and wash hands. The stuff you'll need close 
at hand: filled cartridge, screw cap for end of infusion set, plastic
clamp thing, cartridge-filling needle (one of the ones you use to fill 
a cartridge from the insulin vial).

Turn pump off. Fasten that little plastic clamp thing to the end of the
infusion set, as close as you can to the screw top. Disconnect the 
infusion set from the pump and screw on the little screw cap to the 
exposed end of the infusion set. Now you're connected to a plugged-up 
infusion set, and the pump is separate from you.

Remove the empty cartridge and insert a fresh cartridge as usual. Now
you're ready to top-off the infusion set and reconnect.

Attach the cartridge-filling needle to the pump and begin to prime.
Unscrew the cap from the end of the infusion set. As drops of insulin 
begin to appear at the tip of the needle, allow those drops to drip into 
the now-exposed end of the infusion set to fill up any air gap that was 
created when you disconnected it. The needle is useful to pop any air
bubbles that are in that spot, too. When the air gap is filled, unscrew 
the cartridge-filling needle from the pump and re-attach the infusion 
set to the pump as usual. 

Remove the little plastic clamp thing from the end of the infusion set.

Turn your pump back on.

Bring coffee cup back to the kitchen and place in sink (if it's SO's 
turn to clean up after YOU!) or in the dishwasher (if that day hasn't 
arrived). Continue with normal life routines.

D. "Stupid Pump Trick" - Using the Air Bubble
---------------------------------------------
So far, I get a little air bubble in my pump every time I fill the
cartridge. Because I have a clear pump ( I think it is pretty cool
actually, being clear and all), I can see the air bubble move when I 
turn the pump. So I now can use my pump as a tool to check for 
"levelness" with the ground. Sorry I can't really explain this too 
clearly, but essentially my pump replicates those tools that carpenters 
use - a level.

E. Clearing 07 Alarms
---------------------
Try switching the motor and electronics batteries.

F. "Auto Priming" (priming with little or no battery use)
---------------------------------------------------------
I find that if I fill the cartridge by pulling the plunger all the way
back, until it hits the stop on the filling aid, when I replace the 
cartridge, there is enough positive pressure to fill the infusion set.

1) Fill the cartridge as usual.
2) Reattach the infusion set before placing the cartridge in the pump.
3) Clamp the infusion set right where it is attached to the cartridge.
4) Turn the star washer on the plunger rod so it is at the top (at the 
   "hat"), then turn it back 1/4 turn, as per the instructions.
5) Install the plunger rod.
6) Insert the cartridge and tighten the gray adapter cap.
7) Make *sure* the infusion set is not attached to you.
8) Unclamp the line and watch for insulin at the end of the needle.
9) Attach the infusion set to you as usual.

Another version:

1. Load the insulin cartridge and insert the piston rod as normally 
   done.
2. Remove protective cap from cartridge.
3. Drop cartridge and piston rod into cartridge compartment. (Attempt 
   to position flat sides of piston rod to align with flat edges of 
   recess at bottom of cartridge compartment.)
4. Attach infusion set luer lock to adapter. (It need not be completely 
   tight, though it should be most of the way in.)
5. Position adapter over cartridge and screw into pump.
6. Make sure both adapter and luer lock are tight.
7. Use batteries to finish priming.

NOTE: When the adapter is put into place, any insulin will be forced 
into the infusion set tubing. In most cases, enough insulin will be 
forced out to completely fill a 42" infusion set. (When you first 
attempt this process, it may seem a little awkward - causing some loss 
of insulin. With practice, you can reduce battery priming to 4 units or 
less. As little as 0 is possible.)

************************************************************************



III. MiniMed Tricks
===================

A. The "No Delivery" Error
--------------------------
When the "No Delivery" error results from clogging, open the back cover 
and push on the lead screw follower - just until you notice the syringe 
plunger move. This will actual give you a bolus, but it's very small and
doesn't cause me problems. Your mileage may vary.

B. SofSet Insertion (and MiniMed QR Sets)
-----------------------------------------
I'm thin, about 6' tall and 135 pounds, and I've had problems with the
SofSet introducer needle hitting the muscle wall during insertion. This
is quite painful. My technique is to pinch up the skin, insert the set
all the way, and pull up the introducer needle about 1/8 of an inch. 
This makes the needle just about flush with the cannula. Then release
the pinch, continue pressing the set flat, and tape it down. After
taping it down, I remove the needle, I remove the needle entirely. If I
don't pull the needle, it hits the muscle when I release the pinch and 
try to tape it down.

C. If You Run Out of Insulin
----------------------------
When you run out of insulin, and you're caught with an empty syringe 
(in my case usually at work, before lunch), you can still use the 20 
some odd units of insulin remaining in the infusion set tubing. Take 
the syringe out of the pump, detach the infusion set from the syringe, 
pull back on the plunger to fill the syringe with 25 or so units of air, 
reattach the infusion set to the syringe, put the syringe back in the 
pump, and presto, you've got enough insulin to last (in my case) the 
rest of the day.

This isn't something I would do all the time, but in a pinch...

D. Slow-bolusing with a Temporary Basal Rate
--------------------------------------------
I use this method when I want more lead time for a meal but don't want 
the entire bolus to hit all at once. It is useful when you know you'll 
be eating a large meal, but you're not sure exactly when it will be 
served. A banquet would be a good example. I also tend to be very 
insulin-resistant in the morning (as many people are) and use this 
method to safely give more lead time before I eat breakfast.

It's very simple. Instead of programming in your bolus as a bolus, you 
set a temporary basal rate that includes your bolus and your basal. 

With the MiniMed, you have to work with 30 minute increments for a
temporary basal. I never "slow bolus" for a period longer than an hour. 
If you use an hour period, you simply add your bolus to your basal, and 
program it in as a one-hour temporary basal. If you want to do it over 
a 30-minute period, you have to program in DOUBLE your bolus plus your 
standard basal to make it come out right. This is because all basal 
rates are in units per HOUR. So, for example, to get 10 units over 30 
minutes as a temporary basal, the rate would have to be set to 20 units 
and the time period to 30 minutes. You'll probably have to go into your 
setup menu and change your maximum basal to 20 units (the maximum 
permitted) to make this work.

My endo actually suggested this method as a way of dealing with my 
morning insulin resistance. Her approach was to give the bolus in 
several small increments starting an hour before eating, but the 
temporary basal rate method is much easier. Just be very careful to 
double-check your programming, especially the amount of time for the 
temporary basal.


IV. General Tricks
==================

A. Dealing with Skin Irritation (look here for tape tricks)
----------------------------------------------------------
I used to get a little sore at the spot on my skin that came in contact 
with the spot on the bent needle set where the needle is plastick-ed 
into the butterfly. That little plastic blob always seemed to give me a 
little red blob that often took longer to heal than the place the needle 
penetrated. Solution: Finish coffee and wash hands (it's a good idea to 
wash hands even if you're not drinking Finnish coffee). Cut a very small 
length of Hypafix tape and place it over the general area on your abdomen 
where you wanna insert the bent needle. Insert and fasten as usual, but 
insert the needle THROUGH the tape.

I have had quite a time finding the right combination of infusion set 
type, site, and additional tape when necessary. I've found that I'm very 
sensitive to just plain alcohol, so I use baby oil to remove adhesive 
and even swab it over a stubborn piece of tape before peeling it off. If 
redness is particularly bad, I also use some over the counter 
hydrocortisone cream, avoiding the actual insertion site that I've just 
finished using. Perhaps you would benefit from something to protect your
skin. I use Skin Prep, which comes in a box of 50 swabs for about $11.00 
US. Lots of other skin barriers like this are available. This stuff is 
swabbed on the new insertion site area and allowed to dry for a minute 
or so before doing anything to the skin at all. I use it all the time,
no matter what type of infusion set I'm using - or tape, for that 
matter. It makes tape easier to remove and seems to make my skin less 
sensitive, too. 

I notice that the more hair under the tape, the more the adhesive sticks 
when I try to remove it. I shave the areas about one a week so whenever 
I'm gonna move to a new site, it's relative hairless (for me!). I've 
used alcohol and cotton to get stubborn adhesive off -- but NEVER the 
same day I remove the old set. Baby oil is also good for removing the
adhesive. I do the best I can with GENTLE techniques (I leave each set 
in for a week or so) -- use a bit of Hibiclens on the old site, and wait 
a day or so to work on any stubborn adhesive. Another possible remedy is
a little vitamin E oil on the old site. Just puncture one of the vitamin 
capsules and GENTLY (always) apply some to the skin. I do this for a day 
or so after I remove an infusion set and find that the little red dots 
heal rather quickly.     

I use soap and water, then alcohol, then Hibiclens to prep my infusion 
sites. It may be a little bit of overkill, but I haven't become 
allergic to any of it, and I'd rather be safe than sorry. I use the 
Diestronic bent needle sets with the little cotton pads on the back of 
them. At first, I put a sheet of Tegaderm over the set, and for the 
first couple of months I was on my pump, that worked fine. Then I 
started having awful problmes with the Tegaderm peeling off if I got it 
wet (even sweaty). I swim or ride an exercise bike nearly every day, so 
this was bad. Someone else on the list recommended Hypafix and sent me 
a sample. It's wonderful stuff. One roll of it costs about $12 at my 
local pharmacy instead of $88 for a box of Tegaderm. And I think the 
roll of Hypafix lasts longer, but I don't know because I haven't 
finished it yet. The only slight drawback, which just took a little 
getting used to for me, is that you can't really see through the 
Hypafix. I still prefer it over Tegaderm, though, because it actually 
stays on and doesn't let moisture under it like T did for me.


B. Wearing Your Pump
--------------------
Cut slits in dress pockets from the INSIDE and then hem the slit. You 
can then place the pump in the pocket from the inside, with no exposed
tubing.

No convenient place to put the pump? Try a baby sock. Drop the pump into
the sock and pin the sock somewhere underneath your clothes. If you're
wearing a jumper and a shirt, pin it to the shirt so it doesn't pull on
your outer layer of clothing. If you don't want to carry a purse, you 
can also add a few rolls of emergency Smarties to that pump sock.  

I bought an elastic belt with a pouch from Sugar Happy (1-800-347-4848).
It was advertised in a recent issue of _Diabetes Forecast_. The pouch 
is made of a soft velour material in black. The belt is fastened by 
velcro. You can wear the belt around your leg - with adjustments if 
you're thin - or around your waist. I wear this at night since I sleep
without clothes, and I am not comfortable with putting my pump under my 
pillow or by my bed. It works for me. And when I wear a dress that just 
doesn't allow the pump to go anywhere, I use the belt to hold my pump 
on my leg. Of course, if it is a slim skirt, the pump would show so I 
don't wear it for that type. I also clip my pump in front in between 
the breasts on the bra if I have a dress on that is full enough to 
hide it.

When I wear dresses, I sometimes use the belt clip to attach the pump 
to the side of my bra under my left arm. Since I'm right-handed, if I 
do lift my arm to write on the board, nobody can see the pump. The clip 
I'm talking about is not the one that came with the pump. It is a 
little plastic hook on a vinyl case that the pump is slipped into. It 
does make it a challenge to bolus in public, but I don't wear dresses 
on days when I won't have some privacy at that time. [Editor's note:
you can order this clip/case from Unique Pump Accessories. See below.]

I do very much the same thing. I put my pump in a baby sock (so that 
it's not so slippery), close the end of the sock with a safety pin, and 
then stick it vertically (tubing end down) in the side of my bra under 
my left arm. It's hardly noticable at all (I'm *not* at all chesty, 
either. :) The last time I went to see my endo I had come straight from 
work and was wearing a dress. She had to eventually ask me where my 
pump was because she couldn't figure it out. And she knew I had it 
somewhere, unlike most people, who probably don't know or aren't 
thinking about it!

Question: My sister's wedding is August 10th. I'm in the wedding, and
my dress is fairly form-fitting. What do I do with the pump on that day?  
Answer: Some folks (shaped waaaay different from me!) put the pump in 
their bra. For slim fitting, I've done two different things, depending 
on how full the skirt part is. One is somethin' of a variation on a 
trick our Joan Stout taught me/us -- I put my pump into a knee-high 
pantihose that I pin to my slip (if there's not a pocket). I adjust the 
"length" of the pantihose by tying a knot. I've also put the pump into a 
holder that I strap around my thigh. That's less comfy for me. For my 
own wedding dress that was slim fitting to mid-thigh, kind-of, I had the 
seamstress build a pump-pocket into the fuller part o' the skirt. Worked 
great! You can sew a simple "pocket" into most any garment, too, if 
you're gettin' yer dress off the rack...  Some places even SELL pump 
pockets (see below) if yer not into sewing-for-less :-) 

Unique Pump Accessories sells several items designed to help you find
just the right place to put your pump.

Unique Pump Accessories
Penny Errek - Executive Director
11086 Lakeshore So.
Auburn, Ca 95602
1-800-831-8929 voice
916-749-0211 fax

Also available from Sugar Happy, 1-800-347-4848.

SEE ALSO: Sleeping with Your Pump (IV.D.)
          Showering with Your Pump (IV.E.)

C. Tips for Better Absorption
-----------------------------
The biggest problems with absorption come from the angle of insertion
and type of insulin, not from the type of infusion set. For the most 
part, people who have been on an insulin pump for a while are going in 
too deep and thus causing all kinds of problems. There can be erratic 
absorption and scar tissue buildup. As a side issue, the comfort level 
at the site is never very good when you are in too deep. So, what is the
correct angle of insertion? There is no one pre-determined angle 
infusion set for all people. It depends upon the site selected and body 
build. I think the best angle is about 15 degrees (most pre-bent sets 
are at 30 degrees). Look at the site you are selecting and try to 
picture where the tip of the needle is going to end up. You want the tip 
to be between the muscle and the skin. For example, under the rib cage 
you want to go at less of an angle than next to the belly button. In the 
legs you usually want close to a 10 degree angle. I use the straight 
sets because I feel I have better control over the angle and thus have 
more sites open for me to use. The new Disetronic Tender set, with a 
Teflon cannula,  also allows you more flexibility with the angle of
insertion. If you use pre-bent sets, you usually have to take out part 
of the bend before using them.

Different types of insulin will make a difference in absorption. The 
pump does not care if you are using Humulin, Buffered or Beef/Pork 
mixed. As long as it is Regular insulin, it will work. Sometimes, 
switching to another type is an effective thing to do. Check with your 
doctor.                                             

Try changing to other sites for a while. I have found that the inner 
thigh was a good place, but as I mentioned before I had to go in at 
about 10 degrees on my insertion angle. I have a friend who uses a place 
about an inch from and up and down (beside?!) the backbone. (Of course, 
he has a wife that will do that for him; mine won't). A lot of the time,
runners will use the inner arm, again going shallow on the angle. Maybe 
giving your normal site a rest would be beneficial.

D. Sleeping with Your Pump
--------------------------
Put it under the pillow.

Leave it on the bed next to you and hope for the best (I've woken up
many times tangled in pumpage).

Wear a Unique Sleep T. They are very nice, but I only have 2 and 
sometimes I'm so tired that I just can't find it. (Order Unique Pump
Accessories from Sugar Happy, 1-800-347-4848.)

I like to have a shirt pocket to fit it into, like a jammie top or the 
like. I run the tubing under the shirt and button over it. This way it 
is not loose to catch on things, and the pump stays in the pocket. 

Sometimes I use a soft leather belt with one of those belt cases on it 
and let the pump stay there overnight.

I find I don't notice it much unless there's more than me in the bed. 
It doesn't catch on anything, and it ends up sleeping beside me. I am 
using the 80 cm length so there's not enough to get all wrapped up in 
tubing.

I like to wear my Disetronic pump on the soft elastic belt that came 
with the pump. I've also sewn a pocket out of stretch lace on the 
insides of pajamas and stick the pump in there. I have sticky back 
velcro on my pump case, which doesn't allow the pump to slide out of the 
pocket because it adheres to the lace. This pocket would work on 
nightgowns, T-shirts, whatever your imagination leads to. You can also 
improvise a pouch out of baby socks and pin it on. Diabetic kangaroos 
would have it so easy!

SEE ALSO: Wearing Your Pump (IV.B.)

E. Showering with Your Pump
---------------------------
(This is mostly for the Disetronic pump, which is waterproof, but it will
also work for the MiniMed with the SportGuard.) 

If you wear your pump in the shower, try using a soap gripper. This is 
a disk about 2 inches in diameter with small suction cups on both sides. 
One side sticks to the wall, and the other side holds your pump. If you
position it in the middle of the wall, you can get more flexibility of
motion. You can find them in many housewares departments at hardware or
department stores and in some grocery stores. I found mine at The 
Container Store.

When I'm showering I keep my pump in a little container I made from a 
soft-soap container. My container is actually "Cussons Imperial Leather 
Shower Gel" (original formula) which I obtain in England, but I'm sure 
some American products might work as well. The thing come in two parts
-- the top part has a big red plastic hook on it, and the bottom part 
holds the soap and will latch into the top part either right side up or 
upside down (with the soap dispensing part pointing down for easy 
access). I unscrewed the soap dispensing flip-top, rinsed out the 
container, and then cut a hole in the other end, big enough for my pump 
to slide through. I cut a little 'V' on both sides (one side is 
sufficient) to leave room for the tubing to come out without being 
crimped between the two parts. For safety, I put a thick rubber band
around the two parts, and now when I take a shower my pump sits inside
this container and hangs from a nearby handle. I find it very 
effective. 

F. Before You Stock Up on Tape and Infusion Sets
------------------------------------------------
When you buy a pump, you will probably be encouraged to immediately 
order a large amount of supplies from the company or the distributor.
Think twice before you do that! Preferences for tape and infusion sets
are highly individual. One tape may make you break out in hives while
another has no effect at all. One pumper with many years of experience
reports that one brand of metal needle causes skin problems while the
other brand doesn't. The brand that works better is NOT the same brand
as her pump. So, if you can, try before you buy! All infusion sets and
tapes are interchangeable with both brands of pumps.

G. Inserting a Teflon Cannula
-----------------------------
A technique I find useful for installing teflon, which I've been 
confined to for nearly seven years, is to put a piece of Polyskin II or 
Tegaderm on the site first and install the set through this piece of 
tape. Doing so makes installation less painful, the site more 
comfortable, as well as opening up more sites for me by "toughening" 
skin that didn't like teflon before.

H. Removing Adhesive
--------------------
Several pumpers recommend baby oil for removing the adhesive that
sometimes remains after removing tape and/or an infusion set. 

SEE ALSO: Dealing with Skin Irritation (IV.A.)

I. Reusing Leftover Insulin
---------------------------
When you refill the cartridge (or syringe), you probably have leftover
insulin. This is is a method of reusing insulin without mixing the old 
and new. It should work with both pumps.

1) Remove the cartridge as usual.
2) Draw the plunger all the way back, filling the cartridge with air.
3) Point the cartridge up and mark the insulin level with a piece of
   tape.
4) Shoot all of the leftover insulin into an empty insulin bottle.
5) Draw fresh insulin but only up to the tape mark.
6) Now top it off with the old insulin that you just shot into the other 
   bottle.
7) Reattach the infusion set, prime, and replace in the pump as usual.