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Your Camp and Country Survival Guide

There is something about the sultry, heady summer air that makes us wish our responsibilities and obligations would melt right into the heat and curl up in a lazy haze of smoke. Two unhampered months wink with the promises of amusement parks, sticky ices, and pure, no-strings-attached relaxation. We yearn to sit back, unwind, and watch the world slide slowly by.

Somehow, diabetes and summer don't always seem to click; at least not at the beginning. But these tips should help make it less overwhelming.

For now there's no vacation from diabetes. But careful vigilance and preparation CAN insure that all of us make the most of the slower-paced, glorious summer days. This year, gain more than two months of vacation. Utilize the opportunity to get a taste of true freedom; freedom from wide blood sugar swings, freedom from excess worrying and last-minute calamities due to poor planning. You can't extend your summer vacation, but you can master the habits and gain the information that will afford you a real freedom throughout the entire year!

Adjusting for Increased Activity:
IMPORTANT: The following points are only guidelines. Make sure to discuss them thoroughly with your doctor before you decide to implement any of them. 
It is also important to remember that the affect of exercise on blood sugars will vary greatly from person to person. The same person might even respond differently to identical activities done on separate days. Sometimes your muscles are hungrier for sugar, and sometimes they demand less. There are many factors involved. You will have to check BGs before, at frequent intervals during, and after the activity.

Summer might cause a change in insulin requirements. It is important to discuss with your doctor your change in routine, and if an initial reduction in basal rate or long-acting insulin might be necessary.

·         Before embarking on any strenuous exercise, for example, an extended walk or a long swim, eat a long lasting carbohydrate. Or, if you are eating a meal prior to the activity, you can administer less insulin than would be necessary to cover the food. Discuss all insulin and food adjustments with your doctor. (Many people would cut insulin dosing by 50% if they will be doing strenuous activity following a meal.)

·         Extensive exercise might also require an adjustment in basal rate or long-acting insulin. Your basal rate should generally be decreased one hour before the exercise begins, and it should only be returned to normal one hour following the activity. But practice makes perfect. The better you keep your records, the quicker you will be able to find a pattern.

·         If you have been unusually active during the day, eat an extra snack before bedtime. In addition, your overnight basal may need to be lowered.

·         It is extremely important to drink liquids often in the summer to prevent dehydration. This is especially important for diabetics, and specifically while doing exercise.

·         No matter what type of exercise you are doing, always make sure to have plenty of Winkies (or another source of quick-acting sugar) at hand. Remember that one roll of Winkies contains 6.7 grams of carb. Whatever you use to treat low BGs will have to be tested; it varies with each individual.

Safety Tips for Camp:
Remember that every time we mention camp, we are referring equally to any dorm or sleep away situation e.g. Yeshiva, seminary, etc.

Compile a clear list of instructions for recognizing and treating a low blood sugar. (See our tips in this issue.) Make several copies, and laminate each one. Make sure you have one copy of this list in your dorm or bunkroom, and one in the nurse's office. In addition, some or all of the people mentioned in the following list should have a copy.

·         It is important that all of these people should be aware that you have diabetes:

o    Nurse

o    Camp Director

o    Head Lifeguard

o    Head Counselor

o    Bunk Counselor

o    Cook (if necessary)

·         Keep your extra insulin and Glucagon kit in the nurse's refrigerator.

Tips for treating Low BGs:

Since many people find themselves away from home during the summer, this is a good time to review these vital points.

If awake and alert, treat with Winkies (dextrose tab with kosher certification). Each roll contains 6.7 gr. of carbs and will raise BG's 18-25g. Try not to over treat; that is what causes high BG's later.

With children or those on large amounts of long acting insulin, it is sometimes recommended to follow with a snack. With the pump, keep in mind that if the low is due to a basal rate that is slightly off, do not over treat because the basal may be off by only 1 or 2/10 of a unit. If you treat too much without additional coverage it will raise BG's too high.

If no Winkies are available, milk is a very good source to raise BG. In almost every shul, school, or office there is milk available.

If awake but not too alert, glucose gel, or cake icing in a tube can be rubbed on the gums, inner cheek, or upper palate

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If G-D forbid one is not conscious, use either Glucagon or powdered dextrose, which can be mixed with water and administered as an enema. Everyone should have one of these in the house and know what to do with it! Again, don't wait for an emergency to learn a lesson.

Remember: in the summer, when your body is working hard to keep inner temperatures stable due to extreme heat, blood sugars might fall rapidly and drastically. With precaution, enough checking BG's, and enough Winkies, lows can be avoided.

Tips for Treating Highs:
It is never advisable to go around with high blood sugars for an extended period of time. This is especially important when doing exercise, as exercising without enough insulin on board can cause serious highs. Discuss with your doctor how much insulin to take to lower a high. (Just as carb-to-insulin ratios are very individual, the same is true for amounts of funny pictures insulin needed to lower blood sugars. It must be discussed with your health professional.) Never take additional insulin as a patch-up for lowering high BGs without first calculating how much insulin might still be working in your system from a previous injection. (We have discussed the unused insulin rule in our September holiday magazine. See the helpful chart in this issue for calculating the unused insulin rule for a square wave bolus.)

It is known that muscles burn up the most carbohydrates (blood sugars), so one of the fastest ways to bring down blood sugars is to inject intramuscularly, and then to exercise that particular muscle. One must use extreme caution not to take too much insulin because; using this method, less insulin will work more efficiently.

For those who are not comfortable or familiar with intramuscular shots, one can just take additional insulin, and then exercise. This will also bring your blood sugars down quicker.

For those on the pump, taking a shot of insulin will bring blood sugars down more efficiently than a bolus.

If you have taken a corrective bolus on the pump, and you still get a second high BG reading, you should change your entire pump site.

Look for patterns in your high BG readings so you can solve the problem without having to constantly correct for highs.

If there are consistent morning highs, check your basals before raising insulin doses, and check in middle of the night to make sure the high is not due to a low in middle of the night.

For those on oral medication or who are treating with diet and exercise, activity will always lower a high BG faster. Very often, one can avoid high morning BGs by eating a small amount of protein and/or a slow-acting carbohydrate at night. This will keep the liver from producing excess glucose overnight.

If one takes Regular insulin before eating and is high after the meal, it is possible that insufficient time was allowed for the insulin to start working. Don¡¯t treat the high with additional insulin, because the Regular will still kick in soon. It is advisable to take Humalog 10-15 minutes before eating the meal, and to wait 30-45 minutes after taking Regular. In camp, or any place where one does not know for certain when the food will reach one's table, do not take the insulin until the food is actually on your table. (We can also assume that some type of activity will follow the meal in camp, so the insulin will get working.)

Summer Pump Tips:
This collection of tips and suggestions will come in handy any time of year. They are especially useful over the summer, when all types of unexpected situations tend to arise!

IMPORTANT!
Affix a sticker to the pump, which says something like MEDICAL DEVICE! DO NOT remove without parental approval or medical authorization.
Many people have made the switch to the Silhouette infusion set when they found their infusion sets were not staying on, were crimping, or were just plain uncomfortable. There are now a few different infusion sets available, similar to the Silhouette that come in 6mm and 9mm needles and can also be inserted by automatic device. They both disconnect right at the site so there is no dangling tube left. (This may be more convenient for those disconnecting for swimming.) In our experience, the Silhouette can be applied in almost any direction: left to right, right to left or angled up or down. The sites we use are the arms, tummy, back, and upper butt.

THIS METHOD IS TO BE USED IN AN EMERGENCY SITUATION ONLY! (May not work with all pumps)

·         If your pump shows no delivery due to an empty syringe, and you are not near home, you can do the following: First, it is very important to disconnect at the site, or you could have a large over-bolus. Then, remove the syringe from the pump, and unscrew the tubing from the top of the syringe. Draw the syringe back to the 20-unit mark, reconnect the tubing, and re-insert it into the pump. Prime your pump until you see some insulin coming from the infusion set, (like you would when you first load your pump,) and then you are set for a little while. The air you loaded into the syringe will push the insulin through the tubing. So, you should be okay until you finish the meal, or get home. As you start to near the end of the insulin in the tubing there will probably be quite a few bubbles, so it is recommended that you fill it up again as soon as possible. This should only be done in extreme emergencies when there is absolutely no insulin or a syringe available (which should not happen!). Remember that the pump will not alarm again with the No Delivery, so one must remember to change the reservoir as soon as possible.

·         If the pump should happen to fall into muddy water, take out the batteries and reservoir, rinse it out, air dry it, and get pumping again. Call your pump company for guidance here.

·         Remember that leaving the old site in place for up to 2 hours after a site change seems to help keep the sugars stable.

·         A neat little thing to keep the pump in at bedtime is a sock. Just put it into a baby sock and pin the sock to the inside of your pajamas or nightgown.

·         Wearing it in a pants pocket without the tubing showing is easy. Just make a small hole in the upper part of the pocket lining and thread the tubing through.

·         If you wear your pump upside down, by clipping it to a belt from the bottom, it will help keep bubbles in the pump syringe and out of the tubing.

·         It is definitely advisable, especially in camp, to wear the leather case over the pump, as it is an expensive piece of equipment and should be adequately protected.

·         Use a rubber band around the pump to ensure that the hinged door doesn't open accidentally. The leather case is also recommended for this reason, especially when sleeping.

·         If you notice a large air bubble in the tubing and want to get rid of it, just keep an eye on it, and when it gets close to the Infusion set, you can disconnect and bolus it out.

·         Hit the suspend button if you have nothing on you to treat a low and you feel one coming on. Again, this should only be done in case of extreme emergency. (Shouldn't happen-­ Always carry Winkies!)

·         Hot tubs and saunas: (Some people have to avoid them due to going low, or they have another medical reason to do so.) One should wait with doing a site change after getting out of a hot tub, as the heat causes blood circulation to increase.

·         Exercise and sweat can weaken the adhesive at your pump site. On an extended walk or hike, take along at least one extra insertion set.

·         Remember to check the site occasionally to make sure it is not red or infected.

·         Remember to remove your pump before entering the water for a swim, unless you have a kit that the company specifically states is waterproof. Even in that case, it might pay to take the extra precaution of covering the pump with a plastic bag in addition to the case. Always make sure to check the site after swimming to make sure the tape hasn't come loose.

·         When going to a water park, the pump should be wrapped in two plastic bags in addition to the case. Or, if the pump is removed, one will have to test very often and bolus every two hours, or as advised by your medical team.

©Copyright Jewish Diabetes Association, updated June 2018