30. 4. 2014

Ski touring in Silvretta from T1DM + CGM point of view

List of abbreviations:
T1DM - Type 1 Diabetes Mellitus
CGM - Continuous Glucose Monitoring

When I come home from a ski tour, my parents always ask - how was the trip? My usual answer is - good, we have survived.
This time we have survived the ski touring in Switzerland. As for me, I really mean survived. Lukas has already published nice and simple travel article on his blog - Ski touring in Silvretta. Therefore I do not want to write much about the tour itself. I would like to focus more on my blood sugar monitoring during our physical activity in the Alps.

Preparations of the sensor and insulin pump

I am using Medtronic Paradigm insulin pump with Apidra insulin analogue. After I shaved and cleaned the skin, I placed the sensor little bit over my right hip to avoid the a proximate contact with my ski pants (left image). The sensor fortunately paired with the pump and from that moment on I got 6 days of continuous blood sugar monitoring.

Day 1 - 27.3.2014: Tour to Chamonna Tuoi hut (2250 m)

Before entering Switzerland, we slept in Austrian village Pfunds. I got hypoglycemia early in the morning, after which my blood sugar escaladed to 15 mmol/l and stayed there for the rest of the night. The whole tour to the Chamonna was fine. For 2 hours I stopped the pump because I was feeling a little low. 
But as we arrived there, the sugar started to rise up to 20 mmol/l. I expected actually just the opposite because the demand for blood sugar remains higher for some time after the physical activity. However around the dinner and some avalanche rescue training I got back to normal. But I was high again at night.

Day 2 - 28.3.2014: Tour to Hintere Jamspitze (3156 m)

I managed to lower my glycemia towards the morning. The spike in the morning represents the breakfast. After the breakfast I set my basal insulin to cca 15% with duration about 6,5 hours. The tour was fine. I was eating some sweets along, but not much - just to maintain the sugar in the reasonable range: 7 - 10 mmol/l.
But again as we arrived to Chamonna, the sugar rose up to 15 mmol/l. I thought there has to be something wrong in the system so I replaced the cannula. I felt the sugar is more constant later. So probably that was the problem (or the adipose tissue, hm).

Day 3 - 29.3.2014: Tour to Silvrettahorn (3244 m)

We left our hut early (6:00) and the tour started with some steep ascent. Without any surprise I was feeling low somewhere in the middle. The sensor told me 6 mmol/l, but because of the 20 minutes delay between the actual blood sugar and interstitial fluid values, from where the sensor gets the information about the sugar, I thought I was having the hypoglycemia. I needed to make a break. And I stopped the pump.

There was some big ski tour ahead of us, so with my not-pumping pump we crossed glaciers and climbed up Silvrettahorn. During the descent of Silvrettahorn I was feeling a little weird. I started to be more tired and breath more rapidly. Of course it could be because of the air at the higher altitude and a lot of physical activity. The blood sugar was still around 10 mmol/l so I though everything was just fine. Before the last downhill to the hut we made a small break. After 10 minutes of resting on the sun I was still breathing rapidly. Till that time, the pump hadn't pumped for about 7 hours. Then I turned the pump on again.


When we arrived back, all I wanted was just to go to bed and sleep. I dug into the quilt and blanket and tried to sleep. I needed to make some heat because I was feeling cold. But I couldn't sleep and I was still breathing rapidly. I was just lying there covered with everything around that could make me warmer and Lukas was reading something on his smartphone next to me. After 1 hour I got some idea. I asked Lukas to google Kussmaul breathing. When he finished reading the wiki out loud to me, I took my Diaphan urine test stripes and went straight to the toilet. The result: the ketones and glucose markers totally black. That means a lot of glucose and ketones in the urine. Not good. (Actually some level of ketones during the sport is normal, because you are burning the fat tissue)

I did what I remembered from the hospital. I asked for a cup of tea and sugar. I put a lof of sugar (cca 50 g, maybe even more) in the tea and I drank it slowly. And I injected 5 IU fast bolus. Then I just waited. Basically I just told my body: I have a lot of insulin, do not make glucose from fat. To turn the glucose metabolism around. After one hour I felt much better, the rapid breathing was gone and during the dinner I was already OK. Actually I had a super-great time because the whole time we were coming back to the hut I was afraid of the worst scenario - diabetic ketoacidosis (DKA) and transport to hospital. 

The experience

This experience was priceless, but I wish this happens to no one. Especially in the high mountains without medical personnel around. It was my mistake and this was the lesson I do not want to forget.
The CGM did a great job. Unfortunately due to a higher price I cannot wear it always, but at least I tried to extract as much informations as I could from these blood glucose measurements. For every person with diabetes climbing up a mountain is always the double win. Doing it again and safe is perhaps more than double the effort. But ski touring is worth that effort.

Photos from Silvretta - Lukas' Google+

A right leg of a diabetic person with our 2 pairs of ski together and Piz Buin in the background:

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