Diabetes Camp: Insulin and Blood Sugars
I just returned from our second year of Diabetes Camp Take Charge sponsored by Brainy Camps and Children's National Medical Center. After 4 days and 3 nights sharing time with 30 campers aged 12 to 16 years in Harrisonburg, Va., I would like to share our experiences in managing blood glucose and insulin. Last year, I discussed the power of the peer group in working and playing together. At diabetes camp everyone is in the same boat. Everyone is required to check blood sugars, count carbohydrates at meals, and inject insulin (or take oral medications). There is no need for explanations to peers without diabetes and no need to feel different. Our campers become empowered to take charge and learn to manage their diabetes.
As a result of our experience last year, we adhered to a similar insulin and blood sugar protocol. As with all diabetes camps, we had three main goals:
1. To have fun with activities such as swimming, games, ropes, zipline, arts and crafts, campfires, dancing, etc.
2. To empower our campers in the management of diabetes
3. To keep our campers safe by avoiding extreme highs and lows
The latter goal was the one that kept me awake at nights and on high alert during the days. I finally realized that the reason I could not fall asleep until after 3 am was because I was waiting to have everyone's blood sugars checked, and, if low, treated with carbohydrate; and if high, corrected!
Upon arrival to camp, all campers/caregivers were required to detail their diabetes regimens carefully in writing. Our medical staff from Children's National included the camp medical director (me), two pediatric residents and two RN/CDEs. The medical staff then recorded the diabetes, as well as other medications, in a notebook. We used the insulin/blood sugar records that are employed in our patients using multiple daily injections and insulin pump therapy. These grids may be generalized for all types of insulin regimens including conventional split mixed insulin: 2 or 3 shots/day and even for oral medication (glyburide and Metformin with teens diagnosed with MODY and Type 2 diabetes). We then divided the campers into three groups where one staff member (pediatric residents assisted) managed 10 campers. Notebooks with grids were kept for the campers. All activity counselors met with one of our diabetes nurse educators in the morning prior to the arrival of our campers and were taught blood glucose monitoring and the signs and symptoms of hyper/hypoglycemia. Throughout the camp duration, these counselors were very attentive to our campers and ensured their safety.
The children arrived at camp early afternoon and we immediately decreased all basal insulins by 20 percent. In children using multiple daily injections with Lantus or Levemir, we applied a 20 percent reduction in the evening dose. For example, if a child was taking 20 units of Lantus at night, we decreased the Lantus by 4 units to 16. Likewise, if a camper was receiving 15 units of Levemir in the am and 15 units in the evening, we decreased both doses to 12 units in the evening and 12 units in the morning to start. We did NOT initially change insulin to carbohydrate ratios or correction factors. For pumpers, we added a new basal rate pattern (to be able to return to their pre-camp basal pattern after camp) and reduced each of the basal rates by 20 percent (to start). Once, again, we did not initially change insulin/carb ratios or correction factors. For campers taking NPH/rapid acting/regular regimens twice or 3 times/day, we initially decreased the basal insulin (NPH) by 20 percent, as well, for the morning and evening NPH.
We provided the carbohydrate counts/portions for all components of the meal. A measuring cup was available to scoop out the appropriate amount of food. We then asked the campers to write down all the carbs they planned on eating at the meal, check their blood sugars, and determine the amount of rapid acting insulin they wished to bolus based on the carbs, and the amount of correction bolus to either add or subtract to the food bolus. Each of the campers met one of the staff in the cafeteria, discussed their plan, and proceeded with insulin dosing based on the information. They then enjoyed the meal after they injected the insulin. Campers on conventional split mixed dose insulin received their insulin as per usual.
Blood sugars were then minimally checked at breakfast, lunch, dinner, bedtime, and 3 am by the counselors and reported to the medical team. Of course, if the camper felt low/high throughout the day, the activity counselors checked blood sugars immediately. If blood sugars were very high, blood ketones were checked and the appropriate treatment provided.
Carbohydrates were available at all times and included smarties, juice, cheese sticks, etc.
There were, indeed, many lows due to the increased amount of activities. These lows were treated and documented so that the next day, insulin doses could be adjusted downward including both basal and bolus insulin.
At the end of camp, we included the record of all blood sugars in the campers' medical supplies so the family could have the blood sugar information during the 4-day, 3 night stay.
All in all, camp was uneventful in terms of major blood sugar related difficulties. Most importantly, the campers had so much fun they wanted to come for 7 days and 6 nights next summer!