Halloween is over, but that doesn’t mean we’re done with scary for the year. For a real fright, check out the interesting bits of last Friday’s swim session. I condensed about a half hour into 2:19 . . . including bloopers! (And I don’t just mean my really bad swimming form. Boom!)
I initially thought that I could just mix some Total Immersion drills into my normal routine and I would get better. That might still be possible—theoretically—but I think I need more focused work on my form. So tomorrow morning I’m just going to do drills. *sigh* It’s for the best.
The next boat to Awesomeville leaves tomorrow morning at 5:45AM.
I’m not sure what they’re saying, but I think the Italian dialogue could probably be translated as “Holy shit! People are going to ride their bicycles down that at over 40 miles per hour!”
Today’s Diabetes Blog Week topic, diabetes bloopers, should make for some good reading. Here is my “man hit in groin by football” contribution. (BTW, this post contains videos that might not show up in your RSS reader. You might want to visit the page directly.)
I make a bunch of diabetes mistakes. (I know, I know. No stop; it’s true.) Mostly they’re miscalculations based on too little information or because I’m too busy/distracted/asleep to put the effort into getting things “just right.” Sometimes this causes me to have hypoglycemia and say ridiculous things, but mostly my life is pretty boring. (And that’s not always a bad thing.)
Occasionally, I make a big mistake or one of my devices malfunctions. Those are the real bloopers. Usually, they’re pretty tame and good for a “you’ll never guess what happened to me” story, but every so often one turns into a slow-motion, should’ve-seen-it-coming disaster.
This is one of those tales.
Those of us intimately familiar with the Medtronic Minimed Paradigm insulin pump know that it has an insulin-filled reservoir with a plunger at one end and tubing at the other. The tubing connects to our body, and the plunger is pushed by a very finely tuned stepper motor that pushes (usually) small amounts of insulin into our bodies.* Every few days, the pump has pushed all of the insulin into the body, and it’s time to change the “consumables.” That process goes something like this: disconnect the pump tubing from the body, rewind the motor, put in a freshly filled reservoir, start a “manual prime” to fill the tubing with insulin, insert a new infusion set into the body, attach the new tubing to the new infusion set, and give a very small “fixed prime” to finish the process.
As you can see, there are a few steps. If you do this enough times — about 100-150 times per year — you get pretty proficient. You can do it quickly in a variety of settings: at home, at the office, in the passenger seat of a car driving down the Kansas Turnpike, in a terminal of the Oakland airport, etc. In fact, it gets so routine you might be tempted to not think about it too much or to cut some corners. Which is usually fine.
A year or so after I got my first Minimed Paradigm pump, it started to have a problem. As noted above, there are two priming steps: “manual prime” and “fixed prime.” The manual one starts the motor moving rapidly toward the plunger and then continues more slowly after a sensor detects the initial contact. A typical manual prime moves about 20 units of insulin to fill the tubing. None of that prime goes into me initially. The fixed prime fills the space left by the starter needle and is only 0.3 units, which goes straight into the part that’s attached to me. It does this so that the next the motor steps, the insulin actually gets delivered and I can get it’s blood sugar-lowering goodness.
The problem with my pump is that the motor wasn’t detecting that it had made contact with the plunger. Can you see where I’m going?
On that day years ago, while changing my insulin and infusion set at the office, I started the manual prime like normal — that is to say, with the pump completely disconnected from my body. After seeing insulin drip (or rather spray) out of the end of the tubing I attached the tubing to my body and (by habit) pressed the button that should have delivered 0.3 units of fixed prime.
Instead, I heard a whirring of the motor as it delivered a whole bunch more insulin. I looked at my pump and saw that it still said “Manual Prime.” After disconnecting, I estimaged that I had given myself somewhere between 15-20 units of insulin, enough for about 150-200 grams of carbs, or about 1/3 to 1/2 of my daily dose at the time.
The good news is that I was ultimately unharmed by this adverse incident, and I had a new pump the next morning. But at the time, as I was drinking glass after glass of orange juice at my kitchen table with my meter next to me — having quickly driven home to be near new pump supplies, my refrigerator, and Lisa, not to mention a fire station full of first-responders just down the street — I made myself a promise that I’ve kept to this day: “I will never again attach the tubing to the infusion set before I see the flashing words ‘Fixed Prime 0.3u.’”
* — The pump bone connected to the reservoir bone. The reservoir bone connected to the tube bone. The tube bone connected to the infusion set bone. The infusion set bone connected to the skin bone. The skin bone connected to the fat bone. The fat bone connected to the blood sugar bone. . . .
I’m going to start right off by saying that I love my CGM.
Once I made a few calibratrion-related changes and after I decided that it was never going to give me very good information during the first half-hour (or more) of exercise, I’ve started to feel more comfortable with its accuracy.
But that’s small potatoes.
Much more important is that I’ve started to look beyond the actual numbers, as recommended in Beyond Fingersticks, to see meaning in the swoops, peaks, dips, plateaus, and flat lines in my CGM data plots. A rise with a plateau? Probably not enough bolus insulin. A slow, steady climb or fall? Probably an incorrect basal rate or the hangover from exercise (also a basal rate issue). A big spike that comes right back down — after a couple hours, that is? Maybe I should bolus earlier for food or add something to the meal to slow down the hit.
This knowledge is especially empowering. For the first time in a long while I have hope that I can improve how I manually do what my pancreas should be doing. I’m starting to draw better inferences about the relationship between the actions I take and the effects they have on my blood glucose. And because the CGM has low and high alarms that act as a safety net and early warning system, I feel more confident in giving some of the larger insulin boluses that I’ve been too chickenshit in the past to take. Back in the pre-CGM days, I didn’t have the level of trust in those recommendations that I really needed in order to “do the right thing.” Now . . . well, I’m getting there.
All this was already on my mind before I saw the TedMed talk by Wired‘s Thomas Goetz. It’s a must see for people trying to improve their own health behaviors or those in their patients. (It even singles out a very bad ad campaign by the American Diabetes Association. sigh)
Goetz’s argument that we need personalized data to improve health outcomes has three main parts. (1) When it comes to behavior modification, fear is less important to patients/people than a sense of our own efficacy. (2) There’s a powerful and positive feedback loop when we have an emotional connection to data that’s by and about us. And (3) most medical data isn’t presented in a way that helps us create those strong emotional bonds.
The feedback cycle starts with personalized data, which leads to a sense of personal relevance that informs which health options are best and helps us take action. When done right we should be able to see the results of those actions in a new batch of personalized medical information. For those times when we do create new health data, we should be asking ourselves these questions:
Can I have my results?
What does this mean?
What are my options?
What’s next? How do I integrate this information into the rest of my life?
This is the amazing power of CGM that I’m beginning to harness: I see the results of my eating, dosing, and exercise decisions in a tight loop. I’m still learning how to understand how these three factors (and others) appear visually on my little CGM screen, but the fact that I can see them in anything approaching realtime is just so powerful.
Goetz concludes by noting that “compliance is not the same as engagement,” which is having the opportunity to act as one’s own agent.
I feel like I have a whole new model for engagement with my diabetes.
This evening I started reading T.R. Reid’s The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (2010). It’s a more detailed version of the PBS Frontline show he wrote and narrated a couple years ago.
Reid’s journey around the world in search of ideas that the United States can borrow in order to make substantive improvements in healthcare is shaping up to be a good read, and I will post some ideas from it. I’ll get the ball rolling by noting the four axes he’s using to gauge other countries’ health systems:
Coverage — How many people does the system cover? Who makes access-to-treatment decisions? Everyone else’s systems seem fairer than the US model.
Quality — How can the United State match health outcomes of other countries? People in most other rich nations have better health than we do.
Cost — How much do those other systems cost? How do other nations spend less per capita than the US?
Choice — What are the options and trade-offs for seeing the doctors you want at the hospital you want in a timely manner?
I may ask you, my dear readers, about some of these issues. Stay tuned!
I finally uploaded the video that I made from our trip to Australia. Lisa and I hope you enjoy it. (Be sure to set the playback resolution to at least 480p.)
File formats come, and file formats go. Strike that last part. File formats never really go away. People just stop storing data in them, and vendors stop supporting the formats in their products. Eventually the data is just a bunch of bits that nobody really cares about. (At least that’s how I feel about most of the papers that I wrote in college.)
While formats never really retire*, there’s a steady stream of rookies. Sometimes a format totally destroys the competition: PDF, JPEG, GIF, etc. (Being first helps, as does being in the right place at the right time.) Other times a new file format results from an actual deficiency for one community in an existing family of widely-used formats. Those formats — such as DNG, JPEG 2000, etc. — have rather more difficulty overcoming the inertia of the majority of data users’ workflows despite their superior qualities.
For example, DNG never really took off the way I had hoped. My Nikon D300′s RAW file is still NEF. As are all Nikon RAW files. And I’m not convinced that there are enough applications that support DNG in my workflow (beyond the obvious Adobe applications) for me to consider converting my .nef files to DNG on import. It’s a funny chicken and egg problem.
Add to this menagerie two new video file formats.
I don’t have a lot of video experience. Still photography was always more accessible and interesting to me, though I have to confess that I’ve been greatly enjoying editing the video from our trip to Australia. iMovie is surprisingly good at what it does, and the video coming out of my point-and-shoot camera is acceptable for reminiscing. I still like the story that a still photograph can tell, but video fits that niche that I always used to fill with babbling during my slide shows.
Anyway, I digress.
I don’t have a lot of video file format experience. Undoubtedly it’s more complicated than I know, but the sense I got was that there are a few widely used file formats — AVI, MPEG, Quicktime — with a variety of audio and video compression codecs, chroma subsampling settings, and bit depths thrown in to complicate what would otherwise be a very simple landscape.
Enter the consumer HD video revolution — partly thanks to a new generation of dSLR cameras — and it seems like we’re on the cusp of another explosion of proprietary file formats. Add in the demands of professional workflows, and you get two new file formats.
Just as it did with DNG for still cameras, Adobe is proposing CinemaDNG as an open file format for storing RAW files from digital video cameras.
Storing, retrieving, and manipulating the RAW pixels in a video frame only goes so far. Eventually those frames are edited, cut and combined with audio tracks. Those frames and audio are mixed with other assets, such as subtitles, alternate audio tracks, time codes, and other metadata. Finally all of these assets are combined with a desired output intent to create a digital or film copy for cinema projection, a television broadcast, a DVD, streaming video, etc.
The Entertainment Technology Center at the University of Southern California (ETC) has worked with industry players to develop an interoperable master format (IMF) that encapsulates audio, video, and effects assets together with metadata and output profiles into a package. Basically IMF is the file-level portion of a digital asset management (DAM) solution.
The details of this encapsulating master format are quite numerous, but the following might be of interest to people who need to contemplate support for reading and writing the imagery portions of IMF. The format is evolving, but as of version 0.82a these were true.
IMF is pretty permissive with respect to image dimensions, audio sampling frequencies, bit depths, and so on. There are a lot of “shoulds” in the spec.
“Essence files” contain the video and audio assets.
Essence files must use ISO or SMPTE standard formats. That’s good news. I hate the reinvention of the wheel.
Frame rates must be constant.
There are some required standard and nonstandard resolutions and frame rates.
Non-1:1 pixel aspect ratios are OK.
8- and 10-bit samples must be supported, and I/O drivers should support 12- and 16-bit imagery, too.
4:4:4 and 4:2:2 chroma sampling is allowed.
RGB-709, YCbCr-709, YCbCr-601, and CIE XYZ are supported color spaces.
3-D/stereoscopic imagery must be supported.
Compression is recommended, especially visually/perceptually lossless methods (but not necessarily mathematically reversible).
Compression must be industry standard and open. In fact, it probably should look a lot like JPEG-2000.
Uncompressed data will look a lot like DPX or SMPTE 384M.
Once again this is just the tip of the iceberg of the details are in the draft document. If you like these or don’t agree with them or if you have other suggestions — such as specifying a particular set of options and metadata settings as a “baseline” — do download the spec yourself and comment.
* — For an example of a moribund format, consider PICT from Apple.
First off, I went for my first ride since before we left for Australia. I know, it’s been a while. I have been running, but I think I was rather not looking forward to how slow I was going to be getting back in the saddle after a six week hiatus. It was a long enough time that I forgot a key turn on my new training route and had to take an extra penalty lap around the center of Upton. I was, as you might suspect, rather slower than before. But it wasn’t a total debacle, and my core muscles are still in pretty good shape. So yay for that! Tomorrow is another day, and the season isn’t even half over yet — well, maybe it’s about half over.
What I really want to do is to discuss today’s stage 15 of the Tour de France. Yes, it’s the one where Alberto Contador attacks Andy Schleck, the leader of the Tour, while he has mechanical issues. It was the subject of some “let’s try not to spoil the stage for Jeff, who has TiVo’d it” discussion at the office today, a spirited exchange between the Versus TV commentators, and a whole lot of 140-characters-or-fewer musings and arguments on Twitter.
I’ll give you my view, but first watch this:
Contador passes Schleck to take the yellow jersey. Schleck rides with anger and promises revenge.
The first 45 seconds show all the important events, beginning with Andy Schleck attacking and almost immediately having a bad shift that (all but certainly) jams his chain between the front derailleur and the chainring, forcing him to dismount. While he’s slowing, he’s caught by Alexei Vinoukorov, the Astana rider chasing him down for Alberto Contador, who was in second place overall at the time. (You can debate whether those two actually play that nicely and if Vino was going off on his own.) Vino knew something was up as El Pistolero passed them both and never looked back. Schleck eventually got back into the mix of it — with, I must say, some truly impressive uphill riding — but those 40 seconds he lost to the chain problem turned into an 8-second deficit in the competition.
So what do I think? Well, I hope you watched the rest of the video past the first 45 seconds, because that was some truly possessed climbing by Andy Schleck to be only 12-13 seconds behind at the top of the climb and some really daredevil descending by Contador, et al., to extend that margin to 39 seconds at the end of the day’s stage.
As for the propriety of Contador’s actions — attacking a rider who is in mechanical distress — that’s trickier.
I can’t fault Contador for riding hard and for wanting to win the Tour. After stage 14, when Schleck countered his every move, he clearly knew that it was going to be hard to take time out of the Luxemburger. And the Spaniard was racing to catch up after his rival caught him out. It seems like Contador knew that the only way that he could win was if he got very lucky and pushed on whatever fortuitous breaks came his way. Cycling is a very difficult sport — and this is perhaps the most difficult and prestigious sporting event in the world — so I can see doing what you have to do.
But during the last few stages, Contador has looked like the weaker rider. (Still a very capable rider, perhaps even very nearly the best in the world.) And both he and Contador are equally smart racers. Contador’s Astana team does look to be stronger than Schleck’s Saxo Bank riders, though.
Now, if there’s one thing I can’t abide it’s a Tour de France won by a weaker rider who got where he did through happenstance.
As for whether Contador should have waited, just as Jan Ullrich did when Lance Armstrong fell in the mountains during the 2003 Tour, that’s open to debate. I certainly would have, had I known that he had fallen and been able to do it without sacrificing my position to challengers. (Of course my racing career only extends as far as two amateur road races in high school when I finished well off the back.)
Armstrong crashes on an attack and then has mechanical problems.
But that was 2003. Today Contador couldn’t match the attack and wasn’t able to keep up with Vino who might have pulled him up to Schleck. (That Astana team is strong, but they certainly have teamwork issues.) When the Kazakh slowed down while marking Schleck, Contador blew past them both. It’s debatable whether Vinokouraov could have told his teammate about the leader’s mechanical issues. As a domestique, maybe it wasn’t even really his place to rein in the putative leader of the team. At any rate, I can’t believe that Contador wouldn’t have sensed something was up when he sailed past the almost stationary yellow jersey. And Menchov or Sanchez surely knew and could have relayed the information to him.
Contador doesn’t seem to be the kind of rider who honors traditions or team dynamics or teammates, so I’m not surprised that he didn’t hold up. And as the defending champion he would have had the clout to keep his rivals Menchov and Sanchez from going on ahead without him and the Tour leader. Now, it all happened very quickly, but I just don’t think Contador is built that way in the sportsmanship/fair-play department.
So was it wrong to counterattack the yellow jersey during a short mechanical crisis of Schleck’s own unfortunate and unintentional making? Maybe, maybe not. But I respect those in the crowd who booed Contador at the podium ceremony when he put on the leader’s jersey — just as I respect those who cheered him. And I’m reminded of Paul Sherwen’s words in the second clip above: “You know, in the sport of professional cycling, there’s always payback time. You can never burn your bridges. Don’t ever make enemies.”
I’m hoping that Tuesday’s stage 16 has a bit of payback time in it.
Well, I finally made it work. After striking out with the PC — more like deciding I didn’t want to stay up all night on vacation searching for Windows software to make the video — I fired up iMovie HD earlier this evening and (eventually) built the video below from 83 still photos from the 19th of June.
First off, what she has done — rowing solo across the Atlantic as well as two out of three legs across the Pacific — is completely amazing. She’s currently rowing from Tarawa to Australia. You have to be a bit touched to depart from the herd like this, yet her story (and the earnestness with which she presents it) is so inspiring.
You really should watch the sixteen minute video, but here are some choice bits:
“Getting outside your comfort zone is by definition uncomfortable.”
You don’t have to look like an adventurer [or athlete or revolutionary or . . .] to be one.
“The bigger the challenge, the greater the sense of achievement.”
Things break and challenges occur; you have to improvise.
We tell ourselves stories, and our interior dialogue makes us who we are.
Tiny actions by individuals accumulate to make an enormous difference (both good and bad). What we do “spreads ripples” across the community.
We have the responsibility to make ourselves happy.
I’m going to be writing about diabetes, patient-centered healthcare, online community, and what I’d really like in a diabetes self-management solution. But that’s too big for tonight.
As a precursor, consider Eric Dishman’s TedMed talk about “moving healthcare off the ‘mainframe.’”
In a nutshell, when people do free association with “healthcare,” this is what they say:
Doctor
Hospital
Illness, sickness, disease
Dishman says this is the old “mainframe” model of health — a model based on reactive, crisis-driven, population-based treatment. Instead, he says (and I agree) that we should focus on a “personal healthcare paradigm centered on the home,” especially for our aging population. This new model would be proactive, pervasive and personalized and would be based on more than just biological lab data.
That sounds very much like what I would like to see in a diabetes solution.
I am not a doctor and do not have any medical training. Your diabetes may vary. You should always check with your health care team before making any changes to your diabetes self-management or exercise regimen.
