#334 Dexcom's Tomas Walker is Back
Scott Benner
Companion show to episode 327
Dexcom's Director of Clinical Projects, Tomas Walker is back to talk about how Dexcom is being used in hospitals during the Covid-19 crisis. Companion show to episode 327.
App is free & already on your iPhone ⤴
You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Pandora - Spotify - Amazon Alexa - Google Podcasts - iHeart Radio - Radio Public or their favorite podcast app.
Check out diabetesprotip.com
+ Click for EPISODE TRANSCRIPT
DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.
Scott Benner 0:00
This is a recent review of the Juicebox Podcast. I am a dietitian working towards taking the diabetes educator exam hopefully at the end of this year. I don't have much experience with type one patients since I work with gestational diabetes, and type two patients most of the time, it has been great for me to hear real life experiences from people living with type one. I love hearing you and Jenny working together on the pro tip series. You guys are doing a great service. Thank you for your work. This episode of The Juicebox Podcast is sponsored by those pro tip episodes. You can find them at diabetes pro tip.com. And they are also available right here in the feed to your podcast. Just search diabetes pro tip. The pro tip episodes as well as the entire podcast are as always 100% free for you to enjoy and listen to
Hello, everyone and welcome to Episode 334 of the Juicebox Podcast. This is a good standalone or this episode can serve as a sidecar to Episode 327 where Dr. disalvo came on, and talked a little bit about how Dexcom is being used during the covid 19 crisis to limit the exposure of healthcare workers to people with type one diabetes, who are also dealing with COVID-19. While I was having that conversation with Dr. disalvo, I started having more nuts and bolts questions about how that was happening. And so Guess who's back? Tomas Walker, dex comms Director of Clinical projects. And he's here to talk a little more in depth about how the CGM is being used in the hospital environment to limit exposure. I thought it was a great little conversation about a half an hour, right? Just fill your mind a little info. And right back on your way. This is another one of the bonus episodes that I'm putting out over the weekend that are ad free. That's right, baby. You ain't gotta hear no ads. Not today. Wait, are you thinking what bonus episodes there was one yesterday with IndyCar driver Charlie Kimball. Please don't forget that nothing you hear on the Juicebox Podcast
should be considered advice, medical or otherwise, please always consult a physician before making changes to your healthcare plan, or becoming bold with insulin. Again, today, there are no advertisers. Why? Because I'm going to take a moment to tell you about diabetes pro tip.com. That's my website. It's absolutely free for anyone to use that calls together, every one of the diabetes pro tip episodes from the Juicebox Podcast all in one place. Now you can of course listen to the show in your podcast player, you can do that forever. But if you really want to get a feeling for how many episodes there are in the pro tip series, or if you'd like to share it with a friend, or countrymen and neighbor, or just some guy who you heard to say like I can't get my a one seater come down, man. And I'd like to have toast with breakfast. Send them to diabetes pro tip calm. Thank you very much. And now Tomas Walker. Honestly, we should just start calling them by one name like Madonna. Or what are some other one named people adult? Why don't keep thinking a women? Kanye? I don't know. Kanye West. Anyway, Tomas.
Tomas Walker 3:29
Thomas, it's nice to speak with you again. Thanks for coming back. I appreciate it. That's good to talk to you again, Scott, I always enjoy talking to you and you're on your podcast. Well, if you don't mean that, I still appreciate you saying and if you do mean, I thank you very much. That's very This is the third or fourth one I've done with you. If I didn't enjoy it, I wouldn't be here. Well, that sort of takes my feeling of of the power I have away you're like, Oh, I wouldn't do it. If it doesn't mean that much to us. Just so you know. Really, I know it takes time out of your day. I really appreciate it. So what happened was I was speaking recently with Dr. disalvo, about how decks coms were being used to help save PP during the COVID-19 problem. And I started having questions that I think were better asked of us. So I got you on the show. I'm glad to be here. Thank you. Happy, happy to help if I can. So I'm interested in I guess the first thing is who approach to about this? How did this begin? Okay, so by it You mean how did we get to the point where hospitals began requesting to use continuous glucose monitoring and an effort to better manage patients, reduce PP, and hopefully reduce this the burden on the health care staff at this time? Is that what we're talking about? Yeah, yeah, yeah, really like who's the person who had the bright idea and reached out? Oh, Dexcom had been in contact with the FDA. We had also been encouraged by some We'll have the healthcare companies we'd work with to make some contact and see if we could open this up. Going into the hospital has always been a long term goal, I think for everyone making continuous glucose monitoring, because there's such a clear need. You know, if a patient ends up on an insulin drip, you're trying to do a finger stick and manage their glucose every 30 to 60 minutes while you're titrating, the insulin drip following some sort of an algorithm. And what really, I think brought it to light was there was a small paper published out of China, I'm sorry, the author's first name, or the author's name eludes me. But it demonstrated that patients with diabetes had a four to 600% increase in mortality associated with COVID. And as we saw the COVID pandemic begin to get a foothold in the US. And back in your neck of the woods. We saw this incredible increase in the amount of people with DK people coming in with hypoglycemic states with no history of diabetes, we have new onset type ones, hyperosmolar crises, truly in numbers we'd never seen before. And I think that was a push on both sides, both us as a company and the FDA, and even on the side of the the frontline health care providers to say, we need to see what we can do to improve the options we have available to care for these patients. Well, it's it's a minute seems simple, right? It seems like such an easy fix. You don't want to go into the room with somebody and this helps not but how do you? How do you fix the problem of using the share and follow if What if the person who's in crisis doesn't have a phone? What How did you guys handle that? Yeah, so that actually, that actually took us a little bit to think about and what we ended up doing, and I think we've come up with a good solution that's helped a lot of people is we worked with a medical device company whose specialty was provisioning phones, for medical devices, which you know, the, the smartphone was not part of our life at all 10 years ago, and now you can't do anything without it. And it has been adapted and adopted into many clinical trial settings. So there are a few small companies whose entire program is built around creating phones as medical devices. So what Dexcom did was reach out to one of these companies, and request the provisioning of several thousand Android phones, which are preloaded with dexcom apps, including share and follow in Gen six, they already have Wi Fi on them. They're preloaded with a data plan. And we made those phones available to the self health systems that wanted to use them, to give them a data pathway to you share and follow to offer some remote access. And we're doing this for free. We're donating these phones on request to the hospital. It's lovely. How many hospitals is happening in Do you know, or how many patients? Right?
Unknown Speaker 7:55
Yeah, it's well over 100 hospitals right now. And the number of patients is in the dozens of patients not counting providing the hundreds of patients yet, but it's being adopted rapidly. And we're seeing hospitals using both the the Android phone devices, as well as the dexcom dedicated receivers to manage the data remotely. Because remember, that transmitter has got a Bluetooth radio, we've got a range of about six meters, about 20 feet there, where we can receive the data from a ways away. So can actually put the receiver outside the room or against the window of the room and be able to monitor that patient's glucose without having to have close contact with them. That's brilliant. How do you find out about new patients is, is there a red? Like, I don't know how that would happen. Like, how does the hospital even know that I have someone with type one I should contact ex con or vice versa? Yeah, yeah. So there, it's really helped if there's a champion inside the hospital. And as we've seen this rolled out, one of the things that I've really been able to see make a difference is when one of the intensivists, or one of the endocrinologist on staff says, You know what, we can use this technology, we can use it to help manage care. And we can make the difference with it. But it does take a champion. And what one of the hospitals has actually done is they've actually created a CGM referral service inside their COVID management team. So they're, they're actually putting their COVID patients with diabetes on separate units. And then they're creating this referral where they they send in the nurse practitioner, or the physician's assistant or the diabetes educator to start to CGM to get the system's going to keep the staff familiar with the data and to take advantage of that share and follow and be able to aggressively manage this patients without direct contact. Do you think this experience will serve as a pilot for the idea of getting the Dexcom into hospitals so that every time a person with Type One Diabetes is brought in for any reason that this can happen for them? I think it's probably too early. To say that because we're still, you know, we're still learning. And, you know, one of the guys who trained me a long time ago, like around 40 pounds ago, told me that there's a couple things you need to know in life, you need to really care about what you do, and you need to know what you don't know. And we don't know yet. I think that the initial impressions are really good that this is being well appreciated by clinicians and nursing staff. And CGM really can make a difference, you know, the kind of the parallel I like to drive when I was still in practice. And a few years ago, when CGM was much more novel to patients. And you first put a patient on a CGM, and they could see their glucose value, and they could see the trend. And they can see what the insulin they took did, and how much that bowl of mac and cheese really raised their sugar. And it was like, This light turned on. And we're seeing that exact same scenario with hospitalist, and intensivist. Realizing that it's not just about the glucose now, it's about how I got here and where I'm going. And once you cross that bridge, you know you're across the Rubicon there. But you don't want to go back, you see the value with Britain's I don't think it can be under valued, to be honest with you just for people in that situation. Because I've known people who have gone to the hospital with Type One Diabetes, my daughter's one of them. I've had close friends, and they get into a situation where, you know, they start worrying in the, you know, the hospitals keeping their blood sugar too high, they're worried about them getting a low, you know, they're not treating for meals until, you know, significantly after they've eaten. I've seen it slow people's recoveries down as a matter of fact, and I just I'm excited that they can see it all the sudden it seems like the beginning of something to me, at least. You know, and I think it's opened the door to a lot of discussions because there were a lot of hospitals that didn't have policies about patients showing up with their own CGM. You know, they probably had a hospital policy about an insulin pump, you know, if I show up with my pump, can I keep my pump looks like Well, yes, here's the policy. And now they're looking at this going, gosh, if the patient's coming in with this technology, if we're using this technology, we really need to think farther down the road. It's not just about now where's about where we're going? As we look at managing the COVID, the COVID issues and the hyperglycemia. And we know we'd all love to see this thing go away. But the reality is we're going to be dealing with it for many more months.
Scott Benner 12:29
Yeah, there's upticks, right now in places like think like Nebraska, and you know, just where you wouldn't expect, I think there's, you know, these places that were more rural more off the coasts. And now, there's, I was hearing about this one town that, you know, a large, I think 10% of the population of the town works inside of this one place. And now all of a sudden, 700 of the thousand people that work there are positive, that those people are going to go home to their families, and it's going to, it's going to start there, you know, these little wildfires are gonna are gonna keep popping up until, you know, and we don't know until when right like, is it? Are you looking for a vaccine? Are you hoping we're gonna get some sort of herd immunity? Eventually, you don't know what it's going to be? Exactly. So this, I guess, could go on for a while.
Unknown Speaker 13:15
Again, it's a list of things we don't know. And the answer is now or to try to provide the best options we can, and the best care available for patients that we can today, because we know their clients see their glycemic management in hospitals isn't always great. You pointed that out yourself. And if we can put one more tool on the table there to improve the outcome, to save a bad day and ICU to get that patient out the door alive and faster. We should do it. It's a big deal. It really is. So
Scott Benner 13:44
here's my question. Now, I come into the hospital, I have type one, I've got COVID-19. The hospital says, Well, you're in luck, because we're gonna put a glucose monitor on you. Now all the sudden, for the first time in my life, I see the impact of my food and how my insulin works. And then, you know, good luck comes my way. And five days, 10 days later, I'm leaving the hospital and I'm completely healthy. COVID is gone. But my Dexcom stays behind. Right. How does that happen? That That seems like those people would want to take that with them. Does that an issue?
Unknown Speaker 14:19
So it hasn't been an issue that's been discussed by patients that I've heard. But I've had discussions with clinicians who are looking at actively implementing these programs, because one of the things we have seen his, you know, new onset Type One Diabetes associated with COVID. And there have been a couple of small studies that have looked at this that we should start CGM at the time of diagnosis. And, you know, I would imagine looking looking at your own family. It's like, Can you imagine getting diagnosed today and not asking for a CGM. So I think we're going to see this driving an uptake in the outpatient world also, as more people become aware of this technology, still kind of shocking to me sometimes that when you Look across the large data sets. Looking at the population, like the Type One Diabetes exchange, the uptake of CGM is still somewhere in the 30 to 40% range.
Unknown Speaker 15:11
What do you think? What do you think the reasoning is behind that?
Unknown Speaker 15:16
You know, medicine is is a very slow beast to turn. And it, it is still some adoption on the part of clinicians. It's still some adoption on the part of patients. I don't think sometimes people realize all the benefits they can get from CGM. And it all boils down to what I was saying earlier, that aha moment when you can look at your glucose but understand that this is not a static system. Yeah. This is a system that is constantly changing.
Scott Benner 15:43
No, I, I think about it always pops into my head, because I've had a DVR for so long. If you try to explain to somebody years ago, there's this thing that will record television for you. They say, Yeah, I have it. You know, it's, it's, it's called a VCR. And you're like, No, no, no, trust me, that's not that it's this thing. And you can't explain to somebody in a minute why they need it. But once they have it, my goodness, they know forever, right? They know why. And they're and they don't want to give it back. And so it just it is one of those things, like once you have it, there's no way you would want to give it back again. I don't know I feel good that people are seeing it. I want them to be able to keep them afterwards. Because you start really feeling like I mean, you know, we've been making some little adjustments with Arden's insulin over the past three or four days. And I have to pull it up for you because it's it's there are adjustments that could not have been made without the dexcom data. last three days ardens estimated a one c five or standard deviation 25 or average blood sugar 97. wakes up at 102 goes to bed at 72 has been in range for the past 14 and a half hours. And for clarity amazing margins range is 70 to 120. So you know and and I'm telling you I've I've managed diabetes without a CGM, and I'm not that good at it.
Unknown Speaker 17:11
But with
Unknown Speaker 17:12
with one I am it's too hard to do it with just snapshots. I mean, when you get the full when you get the full High Definition movie, it changes the entire experience. Yeah. And we're see we're seeing that, with the anecdotal reports coming in from the hospital experience. people calling and saying just we never would have been able to do this without this. Yeah, there was one particularly great story I heard from a hospitalist in New York City, who had gotten a call on a woman who came in and DK with a history of type one diabetes. And they had not been on CGM, they got on CGM, and they were able to aggressively manage or DK and avoided having to intubate her, which, you know, in the hospital environment today, intubation is a necessity. And it's also a known risk. There's no there's no, no certainty you're going to get that to about again, ever.
Unknown Speaker 18:07
Sadly, true. Yeah.
Unknown Speaker 18:08
You said something earlier, I want to make sure I heard you correctly. There's people are being diagnosed with type one, as they have COVID. Yeah, this has been kind of one of the strange things we've seen. And there's a few people looking at this, that there seems to be a slight increase in new diagnosis of diabetes associated with covid. We've seen type people come in with no previous history of type two diabetes with horrible hyperglycemia people come in with no history of type one diabetes, clearly in decay. It's been kind of an interesting experience. And it wasn't really reported. And a lot of the Chinese data that's been reported on the early experience with COVID. So there's a lot of people looking at this right now, there have been a couple of small papers published on this already. And I expect we'll see quite a few more in the near term.
Scott Benner 18:58
Yeah, I mean, it. Listen, my daughter had, I forget her hand foot mouth, right before she was diagnosed. And I say that out loud. 100 people are going to come back and tell me, oh, my kid had that right before their diagnosis as well. And I think everyone knows that, you know, some sort of stressors on the body can take a person who's already got the markers and sort of push them over the edge a little bit. This would clearly qualify as, you know, a stressful on the body. So it didn't it didn't surprise me. I just was interested that people are looking at it already. So there, I guess that's another thing. It's in its infancy.
Tomas Walker 19:33
Yeah, there's been some interesting reports on this coming. All anecdotal still, but people are starting to try to gather the data and see if there's a pattern. You know, you're correct that that's the stressor of the illness on the body can unmask this? But the question is, is this virus specifically doing something that is causing this or is it just such an aggressive virus, that the overspeed stress simply becomes overwhelming?
Scott Benner 19:59
Yeah. That's it. That's a that's definitely worth looking into. I'm glad somebody is paying attention to it. I have to say that this is really cool. I think it is because I look, I'm working as hard as I can over here to tell people about what CGM is do. But I can't reach everybody and I talk all the time about, I would love it if the things that I know and the people listening to this understand about managing insulin, if that was coming from the top down, how much more quickly that that information would spread through the population of people with type one. I'm thinking about the amazing outcomes they'd have, and a lot of the struggles that they would avoid. Some of them lifelong, or, you know, feel lifelong after a few months, in a few years. So I think anything that gets the knowledge of what Dexcom does into medical people's brains, so that they can really ruminate on it and think about it. I'm sorry, this is the way it had to happen. But I am really pleased that it's happening. So it's very kind of you guys to do I know it's you said it's a few dozen people, maybe less than 100. It's still a I would think an expense.
Unknown Speaker 21:09
It's actually the number of patients who use CGM in the hospital under the under the current guidance. There's it's over 100 it's more than 100 facilities are actively involved with us. And more coming on all the time.
Unknown Speaker 21:21
Oh, I see.
Unknown Speaker 21:22
And it's growing. It's not it hasn't plateaued for you? Oh, gosh, no. Like, I know, every morning I get up, and I kind of cringe when I open my mailbox for the first time. My email
Scott Benner 21:36
is and this is a it's being used as the device no differently than if someone puts a pulse ox machine on someone. There's a company that makes that Pulse ox the cup and the hospital the body. In this scenario, you guys are donating the equipment. But it's being used like that, like you're not this isn't a study that's being done or anything like that at the moment.
Unknown Speaker 21:55
No, there are several studies that have started up, you know, under a time of challenges like this, many hospitals are in many picky academic hospitals are going to start up Institutional Review Board approved studies, to get this data to see what they can do to make an impact on the outcome. And the resource utilization, in large part knowing. So what we discussed earlier that there's going to be more waves of this coming, we are going to face this for a while and the country. And it is not been limited to just the larger institutions and just Institutional Review Board approved clinical trials. I am seeing this in 50 bed rural hospitals, they're coming to us looking to see how this technology can be used to major metropolitan medical centers on both coasts and across across the Midlands. It's growing very quickly. And people are recognizing the value. And there is a change in thinking that has to occur with this. And I mean, if you think back to your experience with Arden before CGM, and then you got introduced to this technology, with probably a small degree of apprehension at least is this really going to make it better is just going to be one more thing I have to manage every day. And then to the realization of how it can change. We're somewhere in the middle of there. And if people are still evolving their understanding of how best to use this technology, and I don't think we're gonna have that answer overnight, right? Hey, listen, I know we have a short amount of time and I wanted to be sure to ask you, when the device makes it to someone in a hospital? What's the training like for the staff? How do they How do they get brought up to speed to use the device? Yeah, so the Dexcom, we have a group of people, a group of trainers that have been stood up to assist with this process. And as they come in and request access to the systems to be used in their hospital, we make an effort to set up a training and follow up with the secondary training if needed, and then go back and touch base and make sure that they're, they're getting the results they need. Or if they have questions, we've tried to make a fairly comprehensive approach to this. So once someone comes to us, we have a pathway where we can put them into it and help them and stay in contact with them. Yeah. And I think there's too, I was wondering, is it is it a nuts and bolts training? Like this is how it goes on? This is how you, you know how it, you know, this is how you use it? Or is it how to interpret data as well? how deeply Do you go with them? Depends on the facility. If you have ability that's extremely comfortable with the CGM as, as some of them are, then it's really more about how do we deploy this and how do we get the data into the hands of the clinicians. And then you have others that are that are understand the technology but they need a little more a little more basic training and then step through the processes of of using the data. I haven't had anybody who didn't get it, it just took a little while sometimes for people to understand the the the potential of the data, right impacts the quality of care they're offering.
Scott Benner 24:58
Yeah, it's all very fascinating. You know the difference between being able to, you know, because at first glance, you know CGM to a lot of people, even consumer says, Oh, well, this thing will beep if I get low, you know, and then you start really seeing what you could be doing with the information, you think, Oh, well, there's more here I could, I could put my insulin in at a different time and really make an impact on a spike, or, you know, I could I could cut my bazel away, or maybe we could take some, you know, take some insulin away here to stop below. Like when those things start becoming apparent. It's it's very exciting. I wasn't sure if you were telling them about that idea in the beginning, or letting them sort of come to you with the ideas of Look what I'm seeing, and am I am I seeing what I think I'm saying?
Unknown Speaker 25:42
No, we make sure to touch on that early on that they understand that this data can be beneficial to understand how they're managing the patient. And, you know, it's kind of Telecom, like this got in a lot of hospitals. If you're not in ICU, you're on medical surgery or telemetry, your insulin dosing might be adjusted once a day. Yeah, based on the last 24 hours of finger sticks, though they got four finger six in the last 24 hours. The hospitalist comes around, makes rounds and adjustments and walks off. And now with the ability to look at the CGM tracings, they're able to make insulin adjustments are considerations of how to manage that diabetes 234 times a day. That's an exponential improvement in the ability to manage a patient by providing that much more information. That's me, I wonder, I wonder how long it'll be before. Hospitals think, well, when we have a person with type one in here, let's put a closed system on like, let's put you know, the horizon when it comes out, let's put the control IQ on them and let the machine do a lot of the work. I mean, there are machines doing tons of work for people in hospitals. I don't know why that wouldn't be one of them in the future. Maybe that's the beginning of this really. You know, there's a lot of things being kicked around. And I I had a great conversation with a young intensive as to said that now that I've seen this, I don't know how we're ever going to go back. Yeah, because it completely changes our ability to manage a patient with poorly controlled diabetes. It's the difference between sitting through a commercial and pushing one button and jumping through it, Tomas. That's what it is.
Unknown Speaker 27:19
You are that you are the TiVo of the diabetes world.
Unknown Speaker 27:24
I'm not sure that the comp plan, I don't think it's gonna fit on a T shirt.
Unknown Speaker 27:26
That was amazing. By the way, Tomas, if you've never used it, it is it is far and away better than any of the other DVRs on the planet. In my my humble opinion. I know where I know, we have to go. I really appreciate you doing this. Is there anything I didn't touch on that I should have? No, I appreciate the chance to come on and talk to you for a minute. You know, it's a time of incredible challenges to the health care system. And Dexcom is really trying to help improve patient care, reduce the use of personal protective exposure equipment, to improve the ability of a health care provider to manage a critically ill patient. And it's really an exciting time. And it's really a challenging time for all of us. And I think we just need to keep pushing forward to learn the lessons we can and try to improve everyone's care. I appreciate that very much. I really don't listen at some point in the future. I have questions about it. He's in G seven, all kinds of stuff. You'll come back on when when the time is more appropriate. If you if you if you would I'd really I'd love to. Excellent. All right. Well, thanks so much. Get back to work. You know, I need sensors to come by going anywhere. here that pyloric isn't going away.
Unknown Speaker 28:37
Thanks, taker.
Scott Benner 28:41
Huge thanks to Tomas for coming back and explaining to me how the dexcom g six is being used in a hospital setting to help keep people safe. And I'm gonna thank myself here, right. I mean, I made diabetes protip.com. And it's sponsoring the episode technically, like not really sponsoring because I it's not like I sent myself $1 and I was like, Hey, could you put an ad for my website on your podcast? Can you imagine if I started having a conversation like that with myself? I'd be strange. What I have to pay taxes on that. If I handed myself $1 and then I took the dollar Hmm. Diabetes pro tip.com. It's where you'll find every episode from my diabetes pro tip series. In one place. It's incredibly shareable and reusable right there at diabetes pro tips calm. Check out me and Jenny Smith, CDE and T one day discussing every one of the tools and ideas around insulin management that are talked about here in the podcast,
Unknown Speaker 29:43
telephone.
Unknown Speaker 29:46
And of course, while this episode was not sponsored by anyone, there are sponsors for the show Dexcom on the pod touched by type one and the Contour Next One blood glucose meter. I stand behind all four Have those entities and there are links in your show notes or Juicebox podcast.com. If you'd like to find out more
support the sponsors
The Juicebox Podcast is a free show, but if you'd like to support the podcast directly, you can make a gift here. Recent donations were used to pay for podcast hosting fees. Thank you to all who have sent 5, 10 and 20 dollars!