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Inexplicable Bolus #2166

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marionbarker opened this issue May 5, 2024 · 2 comments
Open

Inexplicable Bolus #2166

marionbarker opened this issue May 5, 2024 · 2 comments

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@marionbarker
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Describe the bug
Loop automatically bolused an amount that is not understood.
This may be related to Issue #2156

I hope @ps2 can look at these 2 issues.

Facebook Link:

Summary:

  • The user noticed the sound of the pod clicking and wasn't expecting a bolus.
  • They cancelled the bolus and reported on Facebook
  • They emailed me a Loop Report and Critical Logs Export, attached below.

Comments:

  • The 6 U was for sure an automatic bolus that was sent by Loop.
    • The time stamp is 2024-05-05 06:39:19 UTC, which is 09:39 am local time for the user.
    • The user canceled but 3.4 U were delivered
  • The Dosing.json has an 8 hour discontinuity
    • from 2024-05-04T22:15 to 2024-05-05T06:41
    • Possible theory: Loop thought all basal was "missing" from those hours?
  • The user posted a graphic of the Event History and there is a similar gap in events shown on the screen shot
  • The Glucose.json does not has a gap and shows stable values.

Graphics from FB:

images-from-fb-post

Details:

These are the 2 adjacent records from Doses.json that show the gap.

{"automatic":true,"createdAt":"2024-05-04T22:15:42.865Z","date":"2024-05-04T21:59:18.957Z","deliveredUnits":0,"doseType":"tempBasal","duration":983.8817870616913,"insulinType":3,"modificationCounter":17012996,"mutable":false,"raw":"dGVtcEJhc2FsIDAuMCAyMDI0LTA1LTA0VDIxOjU5OjE4Wg==","title":"Temp Basal","type":"TempBasal","unit":"U/hour","uploaded":false,"value":0,"wasProgrammedByPumpUI":false},
{"automatic":true,"createdAt":"2024-05-05T06:41:39.449Z","date":"2024-05-05T06:39:19.998Z","deliveredUnits":3.4,"doseType":"bolus","duration":139.42656993865967,"insulinType":3,"modificationCounter":17013786,"mutable":false,"raw":"Ym9sdXMgNi4wIDIwMjQtMDUtMDVUMDY6Mzk6MTla","title":"Bolus","type":"Bolus","unit":"U","uploaded":false,"value":6,"wasProgrammedByPumpUI":false},

Build Details - Mac build

  • appNameAndVersion: Loop v3.2.3 (57)
  • gitRevision: c6b058b
  • gitBranch: N/A
  • workspaceGitRevision: 279e6c5
  • workspaceGitBranch: main

hardware:

  • G6 CGM
  • Omnipod DASH

uploaded files:

Export-20240505T133939Z.zip

Loop Report 2024-05-05 16_38_35+03_00.md

@bedtime4bonzos
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bedtime4bonzos commented May 11, 2024

I looked at this a bit and I think this is probably a legitimate bug.

The logs show that the user was in open loop all night.  The insulin effects on the prediction eventually run out, at which point the RC terms keep the prediction extended out about an hour.  So far, the  the automaticDoseRecommendation is well behaved (less than 1U and consistent with ISF to bring prediction into range).

Next, the RC prediction drops out and the prediction becomes only 15 minutes long with Momentum as the only contributor.  At this time, the automaticDoseRecommendation jumps to 6U (40% of max bolus of 15U).  The predictions and ISF don't support this dose at all. It's significant that the prediction is well-behaved, but the recommendation makes no sense.

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The erroneous recommendations continue for almost 2 hours until the user goes back to closed loop and the 6U dose is actually delivered (and luckily interrupted by the user).  After that, the recommendations go back to making sense.

settings.json shows the open and closed loop timing as described above. However, the user does not recall closing the loop in the morning and doesn't remember going open loop for the night, but did recall having gone open loop for a while during the previous day (see FB discussion). I'm inclined to believe settings.json here, but mention this for completeness.

I attempted to reproduce this result on my backup phone a few times by entering insulin in the past and running open loop until the insulin and RC effects dropped out. I achieved the shortened forecasts that match the issue report, but didn't trigger an erroneous bolus in this very limited testing.

@bedtime4bonzos
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There is a somewhat similar report on Zulip here.
https://loop.zulipchat.com/#narrow/stream/148543-Loop/topic/Inexplicable.20Bolus.2E

In this account, user HEDRG got a large bolus after being away from his RileyLink all night.  The logs aren't as useful because there aren't any predictions during the outage so we don't get to see if the automaticDoseRecommendation goes bad at exactly the time that the prediction becomes Momentum-only, but there are some strong similarities: 

  1. No automated dosing for long enough that insulin and RC effects dropped out.
  2. A large automatic bolus that didn't agree with prediction/ISF.
  3. Momentum-only prediction at the time of the erroneous bolus
  4. automaticDoseRecommendation is maxed out (based on maximum bolus setting and application factor)

It's worth mentioning that this user had extensive code customizations including shortening insulin duration significantly.

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