Diabetes in Remote Settings

If you have diabetes, you understand the seriousness of keeping your glucose levels under control.  Hopefully you have it well managed at home.

In the Wilderness, Scouts and Adult will face new challenges that drastically affect glucose control, testing and administration of medications.

Safe glycemic control threatened by:

• Dietary changes

• Food type & availability

• Exercise

• Exertion exceeding baseline

• Other Physiological Stress

Wilderness travel may:

• Increase insulin sensitivity for those with type 2 diabetes

• Require an additional 2000 calories per day

• Decrease insulin requirements by 50%

Not accounting for these can lead to a diabetic emergency. 

Diabetes-related conditions and complications include:

• Increased risk of dehydration (hyperglycemic osmotic diuresis)

• Increased risk for heat injury (heat exhaustion and heat stroke)

• Increased risk for cold injury (hypothermia and frostbite)

• Increased risk for infection

• Diabetic emergencies – which can be lethal

Insulin and Gear 

• Insulin is at risk of freezing in the cold 

• Insulin is at risk of overheating

• Insulin is sensitive to UV light

• Bottles can brake if dropped

• Risk of loss or running out of supplies

• Many environmental concerns related to testing

There are MANY other Wilderness and Equipment issues that need to be considered and we are happy to talk to you about these concerns.

Unplanned Evacuation

Evacuations in the Wilderness have many challenges that most people are unaware of. 

• Can be delayed by hours or days

• We may not be able to communicate with rescuers due to communication challenges in remote settings

• Many locations are inaccessible by ambulance or any type of vehicle

• Evacuations affect the entire team and can place everyone at risk

Not properly planning for how Wilderness Travel will affect glycemic control will place people with diabetes and great risk of a serious event.  Consequences of a serious event are compounded by delays in evacuation to a medical facility which can easily take over a day, depending on where we are at, what we are doing, and current weather and terrain conditions. 

Troop 60 Policy

Diabetes is a serious medical condition and improper planning, preparation and inadequate maturity can result in a life threatening event.  It is vital that scouts are able to manage their diabetes before heading out into the Wilderness where advanced medical care is hours or days away.  

Management and risk reduction are possible but requires:

• Significant planning and leadership

• Education to person with diabetes and those helping him/her

• Development of a robust wilderness medical plan which must be done in partnership with a medical provider.  This will likely require some trial and error during pre-trip conditioning/experimentation.

• Flexibility and maturity – you may not be ready in time for your trip if we don't have things dialed in

Medical Stability

Wilderness travels places stresses on the body that most are unaware of and will challenge glucose control for very mature and experienced travelers with diabetes.  If you are visiting the ER for hypoglycemic or hypoglycemic while in an urban environment, you are at GREAT risk of a diabetic emergency on any outing.  And in remote settings, we won't have the luxury of easy access to higher medical care.  Emergencies that can be managed in an urban setting can be lethal in the Wilderness. 

If it is not medically safe for you to travel in the Wilderness, we will need to delay participation in these types of events until it is safe for you to do so.  This if for the safety of the Scout or Adult with Diabetes and the entire team who will also be affected by an emergency in the Wilderness.

Redundant Medications and Gear

Scouts and Adults with Diabetes need to have 2 complete sets of testing equipment and medications.  These will be split up and stored in two different places (such as two different backpacks or two different canoes).  If one set is lost or damaged, we have a backup set.  All medications and prescriptions need to be current. 

Diabetes Buddy

Any Scout or Adult with Diabetes will need a trained Buddy.  The Buddy will need to know what to look for, how to take a glucose and ketone measurement and how and when to administer medications.  The Buddy  is ideally an adult and parents are invited to join us on outings since they are experienced at "reading" their youth and generally make for great Buddies.  The Buddy's main job on any outing is to be their for the Scout or Adult with Diabetes and should have not have any distracting duties.  The Buddy can NOT be the trip leader who is primarily responsible for the Safety of the entire team as having both duties will prevent the leader from doing either optimally.  We will NOT compromise on safety. 

Robust Wilderness Plan

Our Medical Staff and Leadership will partner with you to develop a Robust Wilderness Plan.  This will take months to develop as we dial in how to manage glucose in different environments.  This plan will continually evolve as a Scout grows.  

A Robust Wilderness Plan will include:

• Learning what and how much to eat on treks

  • A Wilderness Diet is likely very different than your Home Diet

  • Different foods

  • Different amounts

• Learning how to adjust insulin and glucose dosing based on

  • Activities

  • Environmental factors

  • This may be a COMPLETELY different system than what you do at home

• How and when to test glucose levels in the Wilderness

  • This includes breaks that need to be incorporated into the group plan

  • This includes training other members of your team

• Learn how to deal with hypoglycemic and hyperglycemia events

  • They are going to happen

  • Person with diabetes needs self awareness

  • Team needs to know how to handle these situations

• Gear plan

  • We need to develop a gear plan

  • How much and what type of medications do we need?

  • What is your favorite Wilderness Glucose and how much do we need?

  • Must have a redundant set of gear

  • How is it all packed?

  • What do we pack - may be different than what you use at home

  • Other members in the team need to be familiar with gear and setup

• Buddy 

  • Diabetes Buddy need to fully trained in using gear and medications in the Wilderness

  • Needs to learn how to "read" person with Diabetes

• Basically figuring out how it make it safe on outings

Come talk to us so that we can share safe adventures together. 

BSA Policy

High Risk Scouts should NOT participate in the strenuous activities

• Newly diagnosed diabetes <6 months

• A change in delivery system (e.g., insulin pump) <6 months

• Hospitalizations for diabetic ketoacidosis within the past year

• Problems with hypoglycemia within the past year

A Scout with Diabetes AND one other person in the group:

• Must be able to monitor personal blood glucose 

• Know how to adjust insulin doses based on risk factors 

• Recognize indications and treatment of excessively high and low blood sugar

• Both should carry insulin on treks (in case of accident)  

Supplies 

• For ANY type of overnight experience, bring enough supplies:

  • Enough medication plus extra

  • Testing supplies

  • Equipment

    • Batteries for pumps  (without provisions for recharging)

    • Pack out all supplies (remember Leave No Trace guidelines)

Insulin on Treks

• A diabetic scout AND one other individual should carry insulin
  on treks (in case of accident) and a third vial should be kept at the Health Lodge for backup (Philmont). 

• Insulin can be carried in a small thermos, which can be resupplied with ice or cold water at most staffed camps.

• Does insulin attract bears? 

  • Internet hoax vs paranoia vs real threat?

  • Bear proof container with food and toothpaste?

  • Store glucose outside of tent with pull cord?

Resources:

• Wilderness Medical Society Clinical Practice Guidelines for Diabetes Management
  VanBaak, Karin D. et al. Wilderness & Environmental Medicine, Volume 30, Issue 4, S121 - S140

• UIAA Medical Commission Recommendations for Mountaineers, Hillwalkers, Trekkers, and Rock and Ice Climbers with Diabetes
  Hillebrandt D, et al. High Alt Med Biol. 2018 Nov 3

• mountainmad.org.uk