There is nothing on there that tells you a total of how much it’s delivered? Like on many (most?) pumps, you can look at a particular day and see how much bolus you took and how much basal you took. Nothing like that? Is there a total insulin amount displayed anywhere?
This is fascinating to me.
Actually, it clarified what you were saying considerably. I agree that if the low overnight sensor reading is causing your delivery to undershoot your basal needs irrespective of DP, then it is going to make your BG rise, again irrespective of DP. I don’t even see that as particularly controversial: same thing would happen if the same sensor problem were occurring in the afternoon–or whenever. In that sense it’s really just a semantic wrangle.
The only thing I’d question is this:
The thing is, the ICR lets you set different ratios for different times of day–practically the only thing you can do in auto that feels like you have some actual control over it–so if you do one for, say, 3am-5am or whatever, it shouldn’t affect your wizard setting for eating breakfast at 6:30 or other meals later in the day.
That’s what I was experimenting with, setting a different, super-aggressive ratio in the wee hours, and I thought I was seeing some progress, but then one morning it started to go the other way, and I sat there looking at another higher-than-I-want fasting BG, scratching my head. The problem was that I couldn’t tell what to conclude from the result. Maybe the official word I got was correct, that it wouldn’t make any difference, and I’d been seeing some improvement for other reasons. Or maybe it did work, but there’s that whole business of new settings not getting integrated into the algorithm for 6 days or whatever it is, so maybe it hasn’t integrated yet and it’s not doing anything yet. Or my infusion site was losing absorption… or the sensor was registering lower than before… or… or… or… And I finally said to myself, Ya know what? I wasn’t having this problem on manual. What exactly is the benefit I’m getting in return for all this struggle? Heck with ICR ratio, what about AVB–Aggravation Versus Benefit–ratio? That’s when I switched the thing off.
I think the chief problem that we’re all running into is that Mdt is so closed-mouthed about how the algorithm actually works that we’re left at the mercy of user-community lore, some of which may be fact based, some not, and nobody actually knows except by empirical fiddling. Experimentation, in a word. There’s nothing hidden about how a manual pump works, but with auto mode you’re continually reduced to trying to deduce what’s in that blackbox.
As I’ve said in other posts, technologies embed ideologies, and this one veers uncomfortably toward one in which patients are supposed to shut up and do what the Dr says. The upside is supposed to be that it takes all the fuss and bother out of dealing with this dangerous drug, insulin, that we have to dose ourselves with–something unique to this disease that the medical profession has never been particularly comfortable with. But that easily shades over into the old “We’re the medical professionals, you don’t know enough to have an opinion” attitude toward D-care that I thought we had long since moved away from.
for everything you said. 
@Nickyghaleb, props to you for your spirit and your endurance and sharing your tinkering!
I can’t imagine that any of the first several iterations of “closed-loop” anything are going to work with my body’s version of diabetes. All of my dosing parameters are fully elastic…meaning that on work days my bolus is 30-50% higher than on weekends. During ovulation days, I need +40% basal at work but just +30% basal at home. My breakfast bolus’ change depending on their proximity to my last weekend day as my activity decreases through the work week.
Any system that can pivot to my body’s needs will be amazing. Women have a different bag of tricks to work with (against), too.
Kudos to you and I’ll continue reading with great interest!!
No, there is, but you’re still thinking like there’s any rhyme or reason in the delivery. You can go back and see totals, but if your BG has reached a 270, commonplace with this mode, there are no fixed rates to consider. In fact, every hour is a snowflake… you’re walking around and your pump is deciding on these rates based on, well, a whole bunch of things, but also your sensor glucose value (which is often delayed) and your trend. So you hit 270, and you have to go through all the regular questions… did you forget to bolus? Is there something wrong? I won’t bore you… MORE than I have. But NOW you also have to ask yourself how much insulin you got… and the only way to see this is on your graph screen where you get…pink dots. Or none. Each pink dot is a micro bolus, but even their presence isn’t enough to determine if you’ve gotten enough insulin because each dot can be anything from a .025 unit of insulin to, from what I hear, a .9. They all look the same. So you scroll across your screen adding up your micros to see if that’s what’s causing your high, and in MANY cases, it is. But you only do this if you know to, and most people have no idea. They just look at their SG until it all of a sudden shows high, check with a finger stick, see something even higher, and then they blame their carb counting. But all of this is my experience and might not be true for everyone. Some people can eat a little ice cream and not be affected… I can’t even enjoy it WITH insulin and not spike. We’re all different. But there are so many people out there talking about these things that I highly doubt my experience is unique…
You know so very much about your disease… that is really respectable. And cool. 
I’m the most dangerous kind of diabetic… I’m learning all of this stuff about the technology and the physiology behind it and this rule and that theory, and then I see a ho ho… and convince myself I can pull it off. (I can’t, by the way, without running 4 miles… which kills the joy of it).
I’m 41 years old. I developed diabetes at 27… i’m certainly old enough and have had the disease long enough to have determined any effect all of my female stuff would have, but I haven’t got a clue. You have yours broken down by like time of day, weather pattern, wind speed, moon phase, and your cycle… My game plan is “today I’m going to do insulin, tomorrow i’m going to do insulin and then the next day… insulin.”
Which actually puts me lightyears ahead of auto mode as i do know that insulin, and enough of it, are definitely going to have to be part of the plan.
I’ll stop…with the auto jokes. I really better be at least partially right about this stuff, or i’m going to look like a FOOL with all of these jokes…
I’m just going to use all of your words for the next video… and pretend like they’re mine. Try to get some of that respect back. 
Seriously, I’m going to go back and reread this a couple of times. There are some real gems in there, and I think it will, in turn, help clarify things for me.
And that’s how you do it… This is much clearer than my telling people I don’t believe in dawn phenomenon because micro bolus elves are what’s really delivering high blood sugars… which is what it sounded like I was claiming. I was kidding about stealing it though, with your permission, I will try the better interpretation out on my facebook room. Only with permission, of course.
You’d be surprised with this crowd…
This is a real conversation and a valid point. It’s all so refreshing I had to sit down. I’ve been making the point about having to live with those day-long ICR change results because it was my fear, but you are absolutely right that they’re not all day at all. I still don’t think I’d be happy with the results anyway because needs in auto mode vary morning to morning, but it certainly lightens the weight of the concern. Point taken.
This is the FUN part of auto… the not knowing what you’ve gotten. Again, it’s possible I am entirely wrong, but I only got a “light” night of insulin approximately 80% of the time (complete roundabout figure). I have identified, in my own carelink reports, two general patterns over night… They’re roughly segmented into a 12 am-3 am block and 3 am-6 am block. I get up around 6 so that’s where it stops for me. Generally speaking, more than 2/3 of my nights I received a good deal of insulin between 12-3 before auto hit the breaks going into that second block. On those nights, I would have collected, over the last 3 or 4 hours prior to waking, a significantly reduced amount of insulin than what I would receive in manual. Sometimes almost 2 hours of it would have nothing, and the other 1 or 2 would have just 35%. I’m giving examples, but these are very accurate to the numbers I saw. When I averaged the 4 hours going in, it would come out to 22%… even 62% would be a problem… Usually, just about 20 minutes before I would rise, I’d see those micros really jump. They’d start putting in work to cover my rise… the rise that was caused by auto… but they were very limited. I’d see .1, .15, and .175s, with the vast majority between .1 and .15. So auto would try to fight it, but as you said earlier… i won’t butcher it. You said it better. (Again, would an ICR have anything to do with those micros?? Medtronic will take that secret to its death)… But what about the rest of the nights? They were quite different. It would be a smaller, more conservative delivery during the first block that would TRIGGER those nice, plump and juicy micros during the second block of 3-6. Lots of insulin. Rolling in it. I’d get up in the morning, and I had no idea WHY, but I’d just trend downward. Same coffee routine, same everything, but it would feel more like a regular morning chasing kids, trying to get them ready for school. So I got into the habit of waking up in the morning and sitting over my coffee, adding up pink dots to try to determine whether or not I needed to chug my coffee or average one sip an hour. Trying to determine what kind of morning I might be headed for. The vast majority were headed toward a high, but there were enough of those to keep it… fun. 
THEN I learned how to set my alarm and get out of auto at 4:30 in the morning so I could guarantee I’d get all that insulin, and that really worked well… until I just got…SICK… of waking up at 4:30.
Love it. I’m sorry, really sorry, to make you relive it.
Thank you thank you thank you and thank you. Sometimes we need a little validation. I try not to depend on it. I try not to elicit it. But you put so well into words what I believe to be true. It feels wrong, this experience. It’s not empowering, and I’m not sure it’s more beneficial than potentially harmful. That’s a big statement, and I’m not even comfortable with that, but there sure are a whole lot of 300s floating around and volumes of justification from Medtronic to let them remain. It seems they should be spending some of that time helping people to get their blood sugar under control or fully disclosing the risk.
You are HILARIOUS! Especially since I’m a grounded commercial pilot due to T1D, the “wind speed” part was hysterical to me!
I also have to change my I:C ratio when I’m solo parenting vs when my husband is in town. It’s amazing how many more steps I get in the house taking care of two boys when it’s just me doing it. Otherwise I will go low in a hurry!
Good luck with the technology tinkering. Props all around to you!
That’s it in a nutshell. I’ve been on four major regimens since dx’d in 1983, from R/N to basal-bolus MDI, to a pump, and most recently a hybrid-loop pump, the 670g. Until now, each time I’ve felt like more tools were being put into my hands that gave me more ability to fit my medication to my life, instead of the other way around. R/N was so constricting I called it the Eat Now Or DIE! regimen. Lantus-Novolg was so liberating I literally closed my office door and cried the day I tried deferring lunch until mid-afternoon and discovered I could do it without even feeling low, let alone losing consciousness, which was a constant fear with R/N. My first pump was a more incremental improvement, and it took 6 months to get it really dialed in, but it was still a progression in the same direction. I looked forward to this pump as hopefully being the same–that it would help me iron out some of the dosing quandaries that have defeated me for years due to my own peculiar metabolism. Instead, it really felt like a step backward: everything locked up, only a couple of parameters I could adjust myself, and the core functionality girt round with secrecy.
Two things I’d add: one is that a lot of people are ecstatic about the thing and it’s working splendidly for them. YDMV is obviously the rule here. Or as Duke Ellington put it, “If it sounds good, it IS good.” The other is that I don’t think this model for hybrid looping is the only one. The DYI open source looping systems people are using offer much more user control over their functionality and ultimately I think/hope that’s the model that’s going to prevail.
Obviously I’ve spent a lot of time thinking about all this and trying to pin it down in words. If any of mine have been helpful to you, you’re welcome to them.
I am very happy that LOOP is completely transparent and adjustable, the philosophical opposite of the Medtronic black box approach. But I’m going to argue against your hope that extensive user control will ultimately prevail. What I hope for is a knob-free black box that does the right thing, always. …l don’t think we can get there until we have dual-hormone pumps and really good sensors and algorithms.
To me, extensive user control mostly is a mitigation that enables us to compensate for the limitations of current closed-loop systems. I drive a manual-transmission car because I like the extra control it gives me, but I really don’t think I want paddle shifters on my insulin pump. I’d prefer that it be fully automatic because controlling my BG is not an enjoyable pastime. Really, will anyone want to have a sugar-surfing hobby if a fully-auto AP system is working well?
Dual-hormone pumps… those words have never occurred together in my mind before this last couple of conversations, and now I feel like it’s what I’ve been waiting for all my life. It’s very logical. And having experienced, in dramatic fashion, the painful shortcomings of the automated insulin pump, I am hoping this idea is eating away at the minds of pump manufacturers and designers as well, and conceiving it, even at the earliest possible stage, is underway. The problem with your list of prerequisites to a SUCCESSFUL fully automated insulin delivery device is in the need of good sensors and algorithms. Those would be tough to achieve.
As far as whether or not more user control could make for an overall better experience, I’ve gotta say not a day went by in auto mode that I didn’t wish it would communicate to me the actions it had decided upon and let me decide whether or not to execute. A more shared-responsibility kind of relationship. I understand why that’s not exactly what we’re all waiting for, but I still think it would be an improvement. Actually, even having this pump communicate to me what it’s already DONE would be helpful. You just gave me nothing—not one drop of insulin—for the last 2 hours? Good to know. It’s the incredibly interesting combo of not having any control or any idea that’s the real zinger.
It turns out, though I didn’t know it at the time, I was doing my own form of sugar surfing in auto. Tried it for 2 weeks. You’ve heard of “too many cooks in the kitchen”, right? I would set things up the way I wanted them—a small, controlled rise to get ready for exercise, or a drop in blood sugar because it was too high—only to find out auto was responding to my action. I’d go for a 10 minute walk to try to facilitate a drop in blood sugar, and auto would send me into minimum delivery. Very quietly. Like on the down low. Once I ruled out the possibility of being able to stay one step ahead of it, I had to sever ties. Except for when I go in for experimental purposes… I just can’t quit the habit.
Yes, i remember reading that about your being a grounded pilot… It hurt just reading the words. Can’t imagine how you dealt with it.
And thank you for the supportive words. I make YouTube videos and run a 670G facebook group. 350 people… Sometimes I post something about my theory on minimum delivery and get a solitary thumbs up. Anyway, the supportive words are always helpful. It helps to balance 349 missing responses… Though some might suggest I check my math on that.
And taking care of two boys alone, by the way, is no joke. I have 3 of my own, and I’ve thought on many, MANY occasions how difficult it would be to do it alone… so props all around to you, too.
That’s FUNNY. Probably not funny living it, but a great name.
That part made me feel bad for laughing at the last part. You should warn people that your name for it is way funnier than the reasons you called it that. That sounds like it was really HARD.
That’s an interesting summary… Do you think there really are a lot of people who are? It’s not how it feels. My facebook group is at about 350 people, a pretty thin sample, sure, and they are reporting from everywhere THEY’VE been this kind of overall unhappiness. Bitterness even. Now I respect everything statistics and am forever interested in how easily they can be manipulated in order to support our own side, but outside of the pictures of “unicorns” and the victorious outbursts at that initial drop in a1c, evidence of long term approval is lacking. I’m not hoping for its failure, and I hope I don’t come across that way, I”m just not willing to buy into its success without real proof.
Duke Ellington’s stuff IS good. It was easy for him to throw that around with such confidence and ease.
YDMV… YDMV… I probably shouldn’t admit this, but… ??
Your Diabetes May Vary. It’s a play on “your mileage may vary,” which the auto manufacturers used to explain away the difference between their advertised mileage and what normal drivers would actually get. YDMV just acknowledges that we all have our differences layered over the commonalities, so what works for one person may not be suitable for another.
Oh, okay… makes sense. That’s my favorite part, it’s uniqueness. My other favorite part is when what works one day fails miserably the next. 
You’re not alone. Everybody loves that part.
The worst is when you tweak your strategy, and it works really well, and you get excited that maybe I have found “The Answer”, then reality slaps you in the forehead when you realize it was only the right answer for a week…
Sorry to derail the topic… but @drbbennett’s “EAT NOW or DIE!” is just so good.
I was at a wedding a few weeks ago and as usual food comes at some random time usually an hour later than it was promised. I mentioned to my wife (we have a son with diabetes so we actually talk diabetes - I know weird…) that when I was on R/NPH - EAT NOW or DIE, I would have to bring dinner with me and eaten it at like 5pm. Then at 7pm when wedding dinner came, I would just eat salad or maybe a small bit of protien while everyone else was enjoying the food.
MDI was soooooo liberating.
“right” is always a moving Target in our house.