Fancy New Toys: Minimed 640G insulin pump

For once in my life, I found out about a new piece of diabetes technology before the rest of my family-full-of-doctors. When I went to my quarterly date with my diabetes nurse over here (2x a year is the endocrinologist, 2x is the diabetes nurse. I'm not such a fan of this endo thing; it requires way too much of my time), I was asked what insulin pump I was using. I proudly showed her my Paradigm 530G Revel, with its fancy threshold suspend and active insulin indicator, and was shocked when she went 'Oh, you're using the old pump.'

What? You must be mistaken. This is the top of the line, super fancy pump. There isn't anything newer.

Apparently there is. Available in select European countries as of May 2015 (and the Netherlands as of August), the Minimed 640G is the new kid on the block and it wants to kick ass and take names.

So naturally, I went about getting my hands on it ASAP. Cuz I like to play with fancy new toys that I can't get in the States and are covered by my Dutch insurance. Oh, the excitement! Since according to my Dutch insurance I'm a new pump user, Medtronic sent someone over to my house to train me. I didn't question it, since from putzing around with the 640G I realized I was going to need a lesson or two. Preferably in English.

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The first thing you notice about the 640G is it looks nothing like the previous Minimed insulin pumps. Minimed has had the same pager-like layout and interface since before I started using them in 2001, with some updates to the interface as different features including bolus types (regular, square-wave, and duel-wave), CGMs, and Bolus Wizard were introduced. The basics, though, remained unchanged, and navigating/programming the newest iteration of pump required minimal training (except for using the sensors). Like most technology, the pumps have gotten slightly smaller with each model... until the 640G.

The evolution of my insulin pumps, 2009 - present (left to right): MiniMed Paradigm 522 , Paradigm 530G Revel, 640G 

The second thing you notice is it's bigger. And heavy. I'll get to that in a minute.

In my mind, the biggest selling point of the 640G is the predictive suspend ('Smart Guard') feature. You can program a target blood glucose level (BGL), and the pump will automatically suspend when you drop below the target range and trend towards a low BGL. When your BGL starts trending up and re-enters the target zone +2.2 mmol/L, it will turn itself back on. This is an improvement on the threshold suspend introduced with the 530G, which will suspend for 2 hours when you reach a set BGL. This feature is nice, but is reactive rather than preventative, as it is responding to an already-low blood glucose, while the predictive suspend is designed to prevent the low. This is a huge step closer to a closed-loop system.

The next awesome thing is that the 640G interfaces with the Bayer Contour Next Link 2.4 glucose meter, which automatically transmits glucose readings to the pump and suggests a correction if needed. The meter prompts you to select the type of reading (fasting, pre-meal, post-meal, other) and you can enter notes. Both the pump and meter will prompt you to take a correction if your blood sugar is high. Have I mentioned the meter is a remote for the pump? That is so freaking cool! My only gripe with the Next Link is that it is larger than other meters on the market (pretty much the same size as the OneTouch Ultra) and the case it comes with has an awkward layout. This is easily fixed by not using the case and/or finding a different one.

I took this opportunity to see if my FreeStyle Libre was holding calibration. It is. I'm still madly in love with it, even though it isn't 'smart'.

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To go along with the facelift, the 640G has a totally new interface. For long-time pump users like me (14 years and counting), this takes some getting used to. On the other hand, the 640G looks a lot less like a pager, so maybe I won't get asked why the hell I'm using something from the 1990's anymore. The menus have many more options (this goes along with the additional features, so I'll forgive it) but aren't always as intuitive as the old interface.

The Easy Bolus feature is managed with only one button (rather than 2) and can only be used while the pump is 'asleep', which worried me a bit since it's how I program (at least) 80% of my boluses. I have been doing it by feel for years, and was not excited at the prospect of having to look at the pump every time I want to take insulin. While the buttons are still textured, there are 7 of them (compared to 5 on previous models), which are different shapes and arranged in a way so it's easy to press the wrong one. More annoyingly, it's really easy to accidentally wake up the pump so Easy Bolus can't be used. It took me a couple days to get used to the new interface, but the transition wasn't as bad as I thought it might be. I still have to look at the screen, but I suspect with time I'll end up closer to the 'program the pump without looking' level.

(UPDATE: I'm still having trouble with the easy bolus. Part of this is that the tones are different than the old pump (and there are more of them, which I'm still trying to get used to), but it's also hard to tell if it actually accepted the bolus without looking at the screen (bah), and it's too easy to accidentally 'wake up' the pump and bypass the easy bolus.)

The 640G is only available in 3.0mL right now. You can use the 1.8mL reservoirs, so that's not a problem, but it does result in a larger pump, which I would rather not have given the already-increased size.

Another thing worth mentioning is the 640G takes a AA battery rather than the AAA that previous Medtronic pumps use. This likely accounts for some of the additional size and weight, as well whatever extra stuff they had to do in order to make the pump waterproof.

A side-by-side comparison of the 530G and the 640G
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My initial impressions are as follows:

Pros:

- The Smart Guard predictive suspend is an exciting step forward for diabetes management. Reviews have been largely positive, and I'm in the process of trying to get my hand on the Guardian 2 transmitter so I can try it out (the US and European sensors transmit on different frequencies, and the Guardian 2 is a new transmitter).

- The preset bolus and basel rate feature is awesome, easy to use, and time saving. I can simply chose a temporary basel of 0.2 units/hr for 2 hours (or whatever I've programmed in) without having to manually set it each time I go out for a run. Similarly, I can quickly select pre-programmed bolus amounts. This feature makes perfect sense and is easy to access through the home screen.

- The introduction of an unlock button helps prevent accidental anything. However, you have to look at the pump to unlock it, since the button changes. In fact, I have to actually look at the pump to do pretty much anything. I know this is an improvement, but I'm set in my ways and this adds yet another step to every process.

- It is now pretty much impossible to accidentally deliver insulin. A bolus requires 5 steps (actually, this is annoying and yet another reason I use easy bolus most of the time):

The bolus stages (from top left): home screen (select 'Bolus'), unlock, bolus menu, select bolus type and amount, deliver bolus, bolus delivery screen

- The interface with the Next Link meter is pretty darn slick and will automatically calibrate your sensor as needed. The fact that it's also a remote makes discreetly taking insulin easier and eliminates rummaging around in your bra or reaching up your skirt when in public.

- It's waterproof! Finally, Medtronic has addressed the only significant difference from the Animas by making a waterproof insulin pump. While I have no intention of swimming with it, this is great news, as I have murdered a couple pumps with sweat (they're not a huge fan of being stuck in a sweaty sports bra for 4-plus hours) and incidental snow from playing outdoors. That said, I've also had quick dunks that left the old pump no worse for wear, so the waterproof thing isn't that big of a deal for me. Plus, the customer service and warranty of Medtronic is bloody amazing (they have a no-confidence exchange policy, which is exactly what it sounds like), which takes away most of the stress when your pump starts acting weird.

Mildly Annoying:

- For pretty much everything except using easy bolus, I have to remove the pump to use it, otherwise I'm twisting my neck and giving myself a headache trying to read the text upside down. The backlight feature has been eliminated and the new screen is blank when the pump is asleep, so I can't use it as a time piece anymore. I suppose this means it's time to invest in a watch. Medtronic has done a decent job of making the screen readable in direct sun/with glare, but it's not perfect. More importantly, the text size on the 640G is noticeably smaller. I have good eyesight but have a hard time reading some of the menus without taking the pump out. This is one of the only aspects where I think the 640G falls short of previous models.

- The reservoir change interface is even more time-consuming than the 'improved' one of the 530G. The older pump models (through the 522) had only 3 steps in the reservoir change process: rewind, prime reservoir, fill cannula. The 530G added some steps and requires confirmation before moving on to the next: disconnect set from body, automatically prime reservoir, manually prime until you see drops at the end of the cannula, insert set, fill cannula.

The 640G has added even more steps and literally walks you through the set-change process in itty-bitty baby steps. At some point, the prompts are too simple and serve only to make my set change take longer (I can change my set start-to-finish with the 530G in under 3 minutes. The 640G set change took me almost 5). Personally, I feel that the 530G has a good balance between efficiency and idiot-proofing, although my change-resistant ass still prefers the super-basic setup of the 522. We'll see how much the extra-special-stupid-kid reservoir interface prompts piss me off.

Cons:

- The 640G is heavier and larger than the 530G. Much heavier. It's also big enough that it no longer fits easily into my hand. It sticks out about the same, but the belt clip is sub-par and the pump is bulky enough it doesn't fit well into a pocket. 

- The belt clip. I was going to put this under the 'mildly annoying' section, but it just keeps disappointing me. The clip feels flimsy (turns out, it actually is flimsy. It's now been repaired twice) and the spring is much weaker than the older models, allowing the pump to shift around on your jeans and fall off easily when bumped. You can no longer clip the pump upside down to the bottom of your shirt - it falls off immediately. This isn't a big con, but I often do this when I'm changing for convenience. I suspect the pump would hit me in the face if I did a handstand. Hold on. I need to go test this.

Yup, the clip fails the 'stay on my pants under gravity load' test. Bummer (and now my cheek hurts a little. I suppose I deserved that).

(26/12/15: After 2 months of continuous use, the belt clip has pissed me off enough that I am seriously considering switching back to the 530G until (unless) I can get my insurance to cover the CGMs. It really is that bad.)

- After a low battery alarm, you only have a couple hours to change it out. This is very different from the older models, which can last over 24 hours with a low battery (obviously, you're not supposed to do that, but I never claimed to do everything the way I'm supposed to). (Note: the battery lasted 3 weeks before it died on me, and I'm not using any of the fancy features. So that's... really crappy. Also, you only get 4 hours of (basic usage, no fancy features) life before it totally dies. This is really not a redeeming quality.)

- The Bayer Next Link 2.4 meter and test strips aren't covered by most insurances in the US (and the meter itself isn't covered by my insurance over here, but the strips are. Go figure).

- The CGM sensors aren't covered by insurance over here since I'm not an actual child (maturity doesn't count, apparently), have long-term good control, and am not trying to get pregnant. This is the first case where I've found a major improvement in US insurances, since my sisters and I have been able to get CGMs covered in the States.

- Only available in Europe (seriously, US FDA, get your shit together).

(NOTE: as of August 2016, the Minimed 630G is available in the USA. This really is the same pump as the 640G, with all the same features, interface, etc. I've been told the belt clip is better, but haven't tested it)

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A couple other things I've noticed after a few days of use:

The 640G feels much bigger than the Paradigm. I know the size difference isn't really that much, but between the weight and larger dimensions, it just seems clunky. I noticed this immediately when I first put it on, and it became even more noticeable when I clipped it to my sports bra when I went bouldering. While the pump didn't bounce around more than than I'm used to, there was no ignoring its presence.

That said, the belt clip is recessed into the pump, which makes it sit flatter. The chafing due to the increased size is a little irritating, and may be more of an issue for those with bigger boobs. The lower profile clip means that the big 'ol box clipped under my shirt is less noticeable, which is definitely a plus, especially since it means that the pump is less visible under my shirt when clipped to a regular bra, thus (mostly) eliminating the third boob effect.

(Top: Minimed 640G, Bottom: Paradigm 530G)

I clip my pump to the back of my shorts when I go for a run (it rubs too much if I put it in my bra), which has potential for annoying bouncing and being super irritating. Given my reservations regarding the belt clip, I was curious to see how the bigger, heavier 640G would handle a run. I was pleasantly surprised to find that it didn't bounce around much more than the 530G, probably once again due to the lower profile of the clip, but the extra weight did pull my shorts down a bit.

UPDATE: I was wrong. The pump bounces around like crazy if there's any sort of slack in your pants and falls out of a sports bra if you bend over. The longer I use it, the more irritating it becomes, to the point where the pump is approaching unusable. I'm going to have to rig something to make it work, because this is very not ok.

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Overall Impression:

The Minimed 640G has some major improvements over previous models. The new interface takes some getting used to for existing pump users, but all the features are still there, although most of them require some additional steps to access. The pump looks slick but bounces around more than older models. The predictive suspend alone is a reason to upgrade as soon as possible if you have access to the Enlite CGMs. From a safety standpoint, this is a feature too long coming and should absolutely be taken advantage of. As a stand-alone pump, you can't use many of the new features, so if you can't get your hands on the Next Link meter or the sensors, it's probably not worth the upgrade if insurance doesn't cover 100% of it.

My main gripe with the 640G is its increased weight and really shitty belt clip. The pump feels bulky and heavy, and the annoyance factor doesn't seem to be diminishing over time. Especially given the weight, the belt clip is inadequate and flimsy. Hopefully Medtronic picks up on this and updates the clip (they did this a few years back for the Paradigm models, so it's not unprecedented).

In short, for a new pump user I think the 640G is an excellent choice. It walks you through absolutely every step for pretty much everything you would ever do and suggests when to take a correction for low or high blood sugars. If you use the Bolus Wizard feature, it will even tell you how much to take. In conjunction with the CGM, this is an incredibly powerful tool. For existing pump users, the new features provide valuable insight and can help fine-tune your control. There's a bit of a learning curve, but it's not too bad. As an athlete, there isn't a big difference between the pumps outside of the increased weight, although storing it in a bra is potentially abrasive for people with actual boobs.

(updated 15 November 2015)

(updated (again) 26 November 2015)

I'm boring and lazy

So I (obviously) haven't written anything in, like, almost 3 weeks. Sorry about that. My life is quite unexciting. It pretty much consists of:

Wake up

Go for a run (3x a week, or at least that's the goal. I've been doing surprisingly good as far as getting out at least twice in the mornings...)

Try to be productive for a couple hours but possibly end up watching Netflix

Go to class

Be productive

Go to class again

Realize I probably forgot to bring enough food

Go bouldering (~2x a week - it took me a year, but I've managed to establish a group of people who go bouldering with me on Fridays! And sometimes I can get someone to go out during the week)

Bike home, usually in the rain or with a lovely headwind

Try to decide if I want to cook dinner, eat cereal, or order food.

Decide to eat cereal (I've been cooking large amounts twice a week or so, but that ends up being lunch)

If I'm lucky, talk to Ev

Watch Netflix until way too late

Go to bed

As I said, super exciting stuff.

I promise I'll write something... interesting. Eventually. I managed to get my hands on the brand new Minimed insulin pump (not available in the US yet), so there'll be a review of that soon. Good times.

Oh, and it's almost exams again.

Seriously, the quarter system is evil.

But Paige sent me a package. I now have crunchy peanut butter, the lack of which is a serious shortcoming of Europe.

Extra crunchy, in fact. It's so damn amazing.

Hanous Climbs and How All my Friends are Crazy

I've been trying to decide what to write about this week, and coming up short. There are several topics I plan to blog about, but not for a few more months (at least) so as to avoid being/sounding ignorant. So, because apparently my running post was popular, it's time for Stuff Amy Loves: Episode 2: Hanous Climbs and How All my Friends are Crazy. Because who doesn't want to hear me wax philosophical about fun things.

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The relationship between climbing partners is fairly unique. Every time you rope up with someone you are literally putting your life in their hands. You have to trust their belaying technique, their attentiveness to you during the climb, and be able to communicate. You establish routines that become habits: safety checks (hold out the rope to show the knot, squeeze the carabiner on the belay device to show it's locked, eye contact, nod to confirm you're on belay, and climb), awareness of each person's technique (especially clipping) and the speed they're comfortable being lowered off a route at (Nick and Jesse will lower you super-freaking-fast if you let them, and it may scare the pants off you).

You have to know that your partner will catch you on a lead fall. Because the alternative can be quite unpleasant.

This deep trust is why finding new climbing partners absolutely sucks. At some point, you have to take the plunge and let someone new belay you. There are ways of taking some of the worry out of the equation; Ev will keep a close eye on the new belayer until we've decided they're not going to drop me (this goes both ways). But at the end of the day, you have to put your trust and your life in somebody else's hands and hope to hell it all works out.

I am incredibly lucky to have not just one, but 6 people I trust with my life and consider some of my closest friends. There are many inside jokes (there's a reason we call Nick's place The Nunnery), creative language (apparently I'm good at that), movie nights, bang bangs, and too many Janssen's to count. And, because they're each a bit, uh, special, I'm going to introduce them. Because they told me I could and I have nothing better to do with my Sunday then talk about the people who have heard me say things that should never, NEVER be repeated.

Like all groups of people who are probably too close, there are roles that must be filled. So, without further ado, I give you... The Guys. In alphabetical order, because I don't know how else to rank them. Deal with it.

The legendary day when Nick took up aid climbing and we clipped every piece of gear we brought to him. Literally, every piece. He didn't notice until we started clipping backpacks to him. Actually, I'm pretty sure he's still pissed about that.

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Adam (The Wild Card)

Every group has a wild card. Adam is ours. And dear lord, he deserves that title. Adam is a special, special man-child who, I shit you not, is basically a walking Snickers commercial. He'll get cranky and not want to climb, but you give him a Snickers and he'll pep right up and go back to his normal bubbly self. I've experimented. It has to be a Snickers. Cookies, granola bars, or other candy bars don't have the same effect. I have no idea why, but Ev and I now carry an extra 'Adam Snickers Bar' when going out with him.

Famous for forgetting his helmet, he catches a lot of crap for not being attached to his brain cells. You never know what he's going to say next, which keeps you on your toes. I have an established policy of never clicking a link Adam sends me until someone else has confirmed that it is not, in fact, something that will scar you for life. 

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Angela (Grown-Up Amy)

When I grow up, I want to be Angie. As the other girl in our group, Angie is about as mature as I am, which is to say, she might be a 15 year old boy. She's also a fierce ice climber and a bit of a badass on rock. While she doesn't come out to the crags with us that much, she joins the early morning gym climbs. 

Angie is famous for bailing on our grand adventures, but when she does join a grand time is had by all. It's also possible she has a drinking problem to go along with her excellent life advice (no, seriously, she gives really solid advice). She's not as much of a wild card as Adam, but she definitely has her moments, complete with the eternal optimism.

It should be noted that Angie does not take a bad picture. I'm not sure how she does it, but it's a bit ridiculous. 

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Dakota (The Muscle)

Dakoty is a baby. Although you would never know by looking at him. We were all surprised a few years ago when we realized he wasn't old enough to order a beer (he can now, but that was as of this spring). Everyone kind of assumed he was our age, although that's deceptive since we range from mid-20's to mid-30's. When I was going through his Facebook pictures to find something appropriate for this blog, I stumbled across his prom pictures. From 2012. Holy crap that makes me feel old. He also has the dubious honor of being the only non-engineer in the group (Angie doesn't count, she basically does engineer stuff). He's a geologist. Psh.

Anyway, Dakota is a man of many faces. Most of them silly. He catches a lot of crap for being the token sport climber in the group. Although to be fair, Ev and I have turned into sport climbers since moving to Europe. 

Dakota is credited with creation of the word 'hanous', a hilarious misspelling of heinous that now has its own definition, t-shirts, and has been incorporated into every-day jargon:

hanous (noun):

1. Difficult or strenuous but not that bad.

2. Something that was a no-good, very-bad time but wasn't actually as much of a sufferfest as Dakota claims it was. Think the crappy end of Type 2 fun.

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Everet (The Looks)

Ok, fine. Talking about Ev is kind of unnecessary. Ev is my partner in life. It's because of him I climb, run marathons, do triathlons, and remain sane. I talk about him all the time. We have adventures, Janssen or otherwise, and challenge each other to keep improving. We are damn efficient when we start climbing, moving between routes on a wall in a matter of minutes. Splitting up gear is a well established routine, as are the safety checks (primarily non-verbal at this point, but always present) and the established history of not letting each other die. The dying bit is from first-hand experience - he got my broken ass off Fox Creek when I unscrewed my ankle attempting to take up ice climbing.

Ev is the person who gave me the most amazing catch when I came off a route in Mallorca. I slipped off while mantling on the crux of a 6b, which just so happened to be right off the bloody ground. I had the first bolt clipped, but was far enough above it that when I came off I just knew I was going to deck and prepared myself for impact. Which never came. Instead, Ev jumped back and sat down, and I swung into the cave, my butt inches above the ground (luckily I'd pulled my feet up when I came off). 

In other words, Ev is awesome. But you already knew that.

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Jesse (The Captain)

Jesse is hard to describe. For starters, he is freaking immune to mosquitos. More times than I can count I've looked over at him and seen his legs covered with those evil little bloodsuckers, which seems to bother me more than it bothers him. Sometimes I brush them off. Or spray them with bug repellent. Jesse laughs at me when I do that. 

Then there are the man-thighs. 

Jesse wears pants for climbing so rarely that it's actually weird to see him in them. He has many pairs of brightly colored shorts, that may or may not be a wee bit too, well, short. You cannot go climbing with him and not be subjected to slightly more leg than is comfortable. It's a thing. In fact, Angie was recently subjected to the, uh, whole package when belaying Jesse and looking up at exactly the wrong moment. Apparently it was memorable. And completely unsurprising. 

But Jesse is always down for anything. Climbing, hiking, river trips... if you need a friend or a partner, 99.5% of the time, the Captain is in. Although you will be subject to the deadpan stating of the obvious. A few memorable (and recent) quotes include:

Me: Wow, it's so beautiful up here!

Jesse: Well did you expect it not to be beautiful?

Me: Dakota, how are you so young? 

Jesse: Amy, everyone isn't exactly your age.

Me: So how do we feel about proper sleep schedules?

Jesse: How do we feel about the sky being blue?

Totally deadpan. Hence, Captain Obvious, aka the Captain.

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Nick (The Brains)

Nickles is kind of a badass. Insane, but a badass. He is the original purveyor of the term 'Janssen,' which by now should be in the vocabulary of everyone ever. This is the guy who climbed Denali, ran a couple ultra marathons, does more mountaineering than is probably healthy, and scares the living crap out of me on a semi-regular basis. There was this spring's ground fall, which he told me about by starting with the oh-so-soothing words 'So I had a trip to the ER yesterday and I just want everyone to know I'm going to be ok.' Which is, obviously, an excellent way to make your friends across the pond go 'WHAT THE HELL DID YOU DO?!' There was also the incident on Mount Mathers where he and his partner managed to dodge rock fall, a small avalanche, dropping an ice tool, and running out of water. Oh, and a bear (go Alaska). Despite the mega-Janssens, Nick is the guy who is cautious, who goes to great lengths to make sure things are as safe as possible, who isn't afraid to turn around, and who knows when it's time to call it quits. 

Nick is also our photoshop guru. And we love him for that. A man of many talents, he is annoyingly good at pretty much everything he does. He plays way too many instruments, sings (our road trips turn in to sing-alongs of early 2000's rock), climbs some sick ice (and rock, obviously), runs way too freaking fast, and is apparently smart enough to be finishing up a PhD. It kind of makes you want to punch him, doesn't it?

He has also summarized one of my fundamental problems with bouldering: sit-starts. You don't start climbing a mountain sitting on your ass. Why the hell would you start a regular climb by sitting down? It's stupid.

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For me, climbing is the opposite end of the spectrum from running. It's technical. It requires complete focus, because a small mistake can have dire consequences.

It's a high stakes sport, with a delicate balance between the mental and physical components. You can't push yourself and improve if you don't have your head in the right place, and there's a mental state where you can problem solve under pressure to keep things from going south. But you also have to be physically able to finish the climb, which means you have to know your limits. Sometimes you call it a day because you're mentally drained. And sometimes it's because you can't hold on to the rock anymore.

Climbing takes you places you would never otherwise go. You get views that you earn, and stories that make you sound like a badass to the uninformed (cuz honestly, what non-climber knows the difference between a 5.7 and a 5.13? People hear 'climbing' and think Alex Honnold). And the satisfaction of finishing a long multi-pitch, of putting up a project or thrashing your way up something you really weren't sure you could do is impossible to describe. 

Like running, climbing makes you work for it. But in climbing, those feats are not for you alone. They are shared with your people: your climbing buddies.