Excerpted from my website. If you are a Type 1 and need some additional guidance, please PM me.
-------------A Supplement to the Burning Man Survival Guide for Type 1 DiabeticsIntroduction
This supplement to the Burning Man Survival Guide is intended to offer adult Type 1 (“insulin dependent”) diabetics the information they need to prepare, survive, thrive, and fully participate in the Burning Man experience. This supplement is intended only for adult Type 1’s. Please note that infants, children, Type 1.5’s, Type 2’s, LADAs, and those with gestational diabetes have entirely different management needs that are incompatible with the discussion herein. Although I may appear to refer to “diabetics” generally herein, this term should be construed to include only those adults with Type 1 diabetes (diabetes mellitus).Disclaimer
Within this supplement I will attempt to present issues and suggestions for dealing with the unique needs of adult Type 1 ‘Burners. Because I have encountered these issues in my own life I feel I am qualified as a lay commentator. However, it must be clearly understood by the reader that I am not your doctor, and I am not a medical professional who specializes in, or treats in any manner, diabetes mellitus. The information presented here is based solely upon my experience as a T1. As such it is offered freely and without warranty. It is my gift to you and you are free to accept it, or reject it, as you see fit. It is my fervent desire that you have a good Burning Man experience, but you are ultimately responsible for your success or failure. I would suggest that radical self-reliance would properly begin with printing this supplement out and taking it with you to your next doctor’s visit so you can discuss my suggestions and opinions with your diabetes care team. If your doctor approves of my suggestions and opinions, use them. If he has any contrary thoughts, then you should listen to him and adjust your Burn strategy accordingly. Preamble
Burning Man is a hostile environment. I think everyone with a brain gets that message, but Type 1 diabetics have some unique and additional challenges that need addressing.
Part of the Burner creed is to encourage radical self-reliance. As Type 1’s we already have lots of experience in self-reliance. To wit: we keep ourselves alive every day. We test, correct, count, calculate and control. We have taken an autonomic function (glucose management) and have mastered manual control over it. This is certainly “radical self-reliance” of a very high order. We have done this since the day we were diagnosed, and we will continue to do so until our path meets the clearing at the end of the rainbow. Sooo… GO US!!!
We know from experience that surviving as a diabetic anywhere comes down to good glucose management. Control the glucose, and you control diabetes. But on the Playa this becomes a greater challenge because there are some sneaky new factors waiting to bite you. But if we are armed with a little extra knowledge and a positive mental attitude, a Type 1 diabetic can overcome all of these hurdles and integrate fully into the Playa Dream. But first we must “Learn How To Burn”.Learn How To Burn
You have heard this part before, but now you must listen carefully and understand the reasons behind the mantra. As a Type 1 diabetic, you need to HYDRATE. Really hydrate. “Drink until you piss clear” is the mantra expressed everywhere on the Playa, but we must take this axiom even a little further. “Drink until you piss clear, and then drink some more” is our rule. Hydration is at the root of diabetes management on the Playa. The rest of the Playa can cheat on fluids and perhaps get away with it, but we can not.
How do you know if you are hydrated? Simple. If you are not constantly sipping water and visiting the Johnny Can at least every 4 to 5 hours, then you are behind the fluid curve and may become a contender for a Darwin Award.
That being said, some of us seem to have inherited a “camel gene” and can “hold it in” nearly forever. For this crowd let me give you some quantitative numbers for when the dam finally bursts:
• Adult males should piss not less than 2500 cc’s per 24 hour period. Graphically, this means you must fill-up 2/3rds of a 1 gallon container as a minimum.
• Adult women should piss not less than 2000 cc’s per 24 hour period. Graphically, this means you must fill-up a little more than half of a 1 gallon container as a minimum.
Note the above values are the minimum standards for a healthy person who is moderately active on the Playa. But these standards yield to common sense: if you are not “pissing clear” then you need to push more fluids, the amounts listed above notwithstanding. Certainly if you are sick, acutely stressed, or running a high blood glucose (“BGs”) level or are having ketone issues, then your fluid intake must be adjusted upwards accordingly.
What is not generally appreciated by diabetics is that hydration is the single biggest factor they can directly control short of accurately counting carbs and getting the right amount of insulin. Proper hydration is the backbone of accurate BG testing. Since this testing data drives all insulin dosing and just about everything else having to do with diabetes management, staying hydrated means staying in control.
Why is hydration so darned important for us? For starters, a dehydrated diabetic may not get an accurate blood-glucose test result. In other words, your trusty BG meter may be lying to you.
To understand why, recall your blood glucose number (BG) is expressed in milligrams of glucose per deciliter of blood (aka “mg/dL”). Under the normal Default World circumstances, the fluid volume in your body remains fairly constant, but on the Playa, this basic assumption can get blown all to hell. As you dehydrate the fluid volume in your body is reduced. First the interstitial fluids become more scarce, and then your blood starts to get thicker. As your blood thickens, the red blood cells themselves actually dehydrate and become less flexible too. As you lose fluids, the glucose in your body becomes more concentrated. Thus your BG meter may tend to read progressively higher even though the same absolute amount of glucose is present.
(To clarify this concept let us use salt water as an analogy. The water is “blood” and the salt is “glucose”. Dissolve a teaspoon of salt in a gallon of water. You can faintly taste the salt. Now boil-off half of the water. Now you can very clearly taste the salt. The measured concentration of salt vs water has changed due to the evaporation of the water, but the absolute amount of salt in the water remains the same).
This “concentration” problem isn’t the only thing that can confuse your trusty BG meter. Your meter uses a chemical reaction between a set of electrodes to generate a voltage that is proportional to the amount of glucose in the blood sample. That voltage is electronically measured by the meter and it forms the basis of your BG reading. However this chemical reaction is only designed to be accurate within a narrow viscosity band. If your blood is thicker or thinner than the reference design parameters, the results displayed can be off. Depending on the meter and the technology used therein, these testing results can be pretty close… or off by quite a bit.
As further food for thought, consider that your meter uses the electrolytes present in your blood (sodium, potassium etc.) to act as an electron transport mechanism between the sample under test and the electrodes on the test strip. Any major swings in your blood electrolyte levels will serve to compound the other types of meter errors.
So we have three possible sources of error: concentration by dehydration, viscosity error, and electrolyte imbalance. All of these error-producing factors are likely to be present at the same time because all of them are cause by… you guessed it… a failure to hydrate.
Realizing that your cherished meter is potentially suspect is only part of the Playa Madness. We also must talk about temporarily reforming your deeply trained responses to “high” and “low” blood glucose levels.
You have been trained by your physicians to “add insulin when you are high, and add glucose when you are low”. In the Default World, this is indeed excellent advice, but you need to double-think this a little further when you are on the Playa.
Picture this: It is Thursday afternoon and you have not been keeping up with your hydration like you should. But because you are a faithful Type 1, you do a finger-stick just to see where your BG number is at. Your trusty meter says you are cruising around 200 mg/dL and it has been 4 hours or so since your last meal. Ouchies. That’s a fairly high BG. But no worries because you have done this many times before. You have been trained to think “I just need to add more insulin”. So you do the math, compute your correction bolus, and you inject (or pump) the mathematically “correct” dose.
Except the “correct” dose is potentially wrong.
By any measure, a BG of 200 mg/dL is a fairly high reading, but is it really that high? Remember: you are dehydrated. So perhaps you should view the test results more like guidelines and not as absolute data. Guidelines tell you which direction you are off but only approximately how far off.
When you are on the Playa, your immediate response to mild highs should really be modified to “add water, wait a little bit, and then re-test”. How long should you wait? Call it 30 minutes. Your BG number may change considerably during that period due solely to your hydration status. “Adding water” when you are dehydrated will drive the measured BG number down. Think of it as “dilution”, because that’s essentially what it is.
A Quick Story: I once watched a BG go from 205 mg/dL to 150 mg/dL in 45 minutes. That would not be unusual, except this change was due solely to my rehydration efforts. No insulin was added, and there was no IOB running, and the CGM before and after plots showed both of these to be stable numbers. That 55 mg/dL drop was all due to added fluids. Had I pulled the trigger with a full-sized and “mathematically correct” correction bolus based on that initial 205 mg/dL reading, there is no question I would have gone low. But by waiting until I was better hydrated before I bolused, I avoided an unnecessary low.
Important Note: All of the above needs to be taken with a dose of reality. If you are cruising at a very high BG, (call it 300 mg/dL) then you need to both “add water” and “add insulin” at the same time. After all, the possibility of not needing *some* insulin at a 300 mg/dL level is absolutely zilch, so it certainly would be prudent to get some insulin running even if you are dehydrated. But consider reducing your initial bolus a little bit “just in case” your meter is being confused by your hydration status. What would be a good initial bolus reduction? I would suggest you start your dosing at 70% of what your BG numbers suggest and then work your way backwards or forwards from there. Please understand that everyone is different, so there are no hard and fast rules. Just remember you can always tweak-in a little more insulin later if you need it. I would also remind you that running a little high for a couple of hours due to an overly conservative correction bolus won’t kill you, but crashing low due to an over-bolus will ruin your whole day.
One more thing to consider: Dehydration can cause the release of stress hormones (glucagon, cortisol, catechol) that trigger both a release of glucose from the liver, and an increase in your resistance to insulin. This is another reason why “adding water” is an excellent idea when you are high. If you already have insulin running and it doesn’t seem to be doing the job, then simply “adding water” may calm the inner metabolic monsters and allow that insulin to work better. Basal Rates
The next thing we need to talk about is basal rates. Burning Man can play hell with basal rate and I have heard it said that anyone not chasing their basal rates all over the map are ‘burning rather lightly on the Playa.
Generally speaking, you will need less, and perhaps a lot less, basal insulin during, and immediately after, Burning Man. This is a function of your increased level of activity and exertion. Increased activity generally means your resistance to insulin drops and your body becomes more effective at scavenging glucose.
You will know when it is time to make a basal change if you go low before your regular mealtimes and after your IOB (Insulin On-Board) has reached zero. If this happens, start backing off the basal rate. Veteran burners who have some experience with the Playa will have a feel for what is coming and will start a basal reduction when they turn-off the main highway to BRC. By the time they get past Gate and the Greeters, have made a few dust angels and set up their camp, the reduced basal rate will be in full swing and the party can continue without having a Killer Low. If you are on a pump (aka a “pumper”), cutting-back your basal programming is as simple as pushing a few buttons. If you are on multiple daily injections (a “shooter”), then you will need to compute the basal reduction manually and start it at least 24 hours ahead of the burn. Plan ahead.
Reminder: If you are significantly tweaking your basal rates (i.e., making more than a 20% change), you should carefully watch your I:CHO (“insulin-to-carb ratio”) and CFs (“correction factor”) as all of these will tend to track each. Individual results will vary but usually: Less basal = less bolus = smaller correction factor = less insulin. And the converse is true too: More basal = more bolus = larger correction factor = more insulin. Insulin Active Time (aka IOB time)
If you are a pumper, another factor you may have to monkey with is your pumps “IOB Timer”. This is the amount of time the pump thinks insulin stays active in your body after being injected. Generally speaking, IOB values for Novolog/Novolin are about 4 hours. For Humalog/Humalin about 6 hours. Everyone is a bit different, but you get the idea.
The first factor to consider when tweaking your IOB times on the Playa is… wait for it… hydration! If you are well-hydrated, your IOB time should stay about the same as it was in the Default World, or perhaps drop a bit. If it drops on the Playa this is likely because you are more active than usual. Why is this? Read on.
Recall that what makes a bolus of rapid-acting insulin work over time is the buffering effect of the fat layers under the skin. Insulin injected directly into the bloodstream would last only a few minutes (and could kill you due to the rapid exhaustion of glucose), but this fat layer acts like a sponge and slows absorption way down. Because the fat layer is near the surface, the insulin absorption rate is somewhat dependent on, and affected by, the ambient temperature, capillary dilation, and (you guessed it!), your general hydration status. Absorption will tend to increase as the tiny blood vessels in the fat layer dilate… like when you are hot or the muscles nearby are active. Conversely absorption will tend to decrease at night when it gets cold, or when you are powered-down for a nap.
The absorption situation changes for the worse if you become dehydrated. With increasing dehydration, perfusion times into the bloodstream will increase across the board. Your blood will be somewhat thicker, slower, and more laden with other “stuff”. The interstitial fluids will be less abundant. As you become dangerously dehydrated, the signals your body sends to dilate the near-surface blood vessels may be over-ridden as your body attempts to keep these precious fluids away from the surface and more within the body core.
The IOB Timer issue becomes a Real World problem when you’re nibbling and drinking your way across the playa and trying to bolus for each snack. Under these conditions you may find you are “stacking” these boluses. When this happens you will wind-up far from your target number due to the serial miscalculations induced by your faulty IOB number.Insulin Sensitivity
There are no hard-and-fast rules when it comes to insulin sensitivity on the playa. Everyone responds differently. Some people find that all the stimulation, broken sleep patterns, and general party atmosphere provokes a stress-type of physiological response and more bolus insulin will be needed to cover a given number of carbs. For others, the constant movement and exertion combined with a sharply reduced caloric intake will cause insulin sensitivity to increase. The only way to find-out how you will react is to track your BG carefully until you see what your body does.
Reminder: If you suddenly observe your insulin sensitivity drop, you are likely dehydrated. Dehydration is a physiologic stressor which can reduce your sensitivity to insulin. Hydrate, hydrate, hydrate!Pumping & Burning
My own experience leads me to conclude that pumpers have an easier time of diabetes management on the Playa than our brothers using multiple daily injections (MDI). The reasons are: flexibility, convenience, and response times. Pumpers can reduce their basal rate just before a dance-a-thon and then ramp it back up a few hours later. Pumpers can power their way through a gifted fruit drink with a few button presses. Pumpers are never out of reach of their insulin supply, and they do not need to worry about sharps disposal. Pumps adapt very well to Playa life as long as the human has been properly trained.
Shooters have a few unique challenges. That gifted fruit drink means you will need to dig-out your insulin, fill a syringe, sterilize a new injection site and inject. (This of course happening on the Playa, in the dust, while everyone is watching you. You and I certainly do not care about the social issues, but it can understandably freak-out a needle-shy bystander or get the undivided attention of a cop who may think it’s heroin instead of insulin). Shooters will also find temporary basal adjustments are more difficult to accomplish because long-acting insulins (like Lantus) takes 18 to 24 hours before any dose adjustment will become physiologically evident. And of course, shooters will need to pocket their used syringes until they get back to camp for proper sharps disposal.
The message here is “if you have a pump, use it”. Burning Man is not a good time to go on a “pump holiday”. If you have a pump but don’t like to use it, perhaps consider giving it another chance at having a relationship (but start the second honeymoon weeks ahead of the Burn so any lingering relationship issues won’t leave you stranded on the Playa). If you do not have a pump, then by all means “run whatcha brung”. Do not freak-out and think you can’t do a Burn as a shooter. That is absolutely not the case. You just have to understand what you are up against and bring a positive attitude, lots of syringes, and commit to frequent testing and tweaking. Ketones
A smart diabetic will check himself for blood (not urine) ketones every day. Ketones are the body’s signal that it is burning fat instead of glucose. Fat burning is an abnormal state of metabolic starvation where stored energy reserves are being consumed to keep the party going. Why do we check blood-based and not urine-based ketones? Because blood-based ketone testing is far more accurate and it shows what is happening right now. In contrast urine-based testing is considerably less accurate and is not a prompt indicator when something is amiss. By the time urine-based ketone tests say there is a problem, the horse is out of the barn.
To a healthy non-diabetic, having some ketones in the blood isn’t a big problem. In fact this is how many diets (especially “Atkins” types and their ilk) work. But we diabetics need to go on full alert when we detect more than trace ketones because this could mean we are not getting enough insulin. To a diabetic, this condition is dangerous on a good day, and potentially a disaster on the Playa.
The way to tell the difference between harmless ketones that are produced by “I’ve been partying too hard” verses ketones that are saying “I am about to need a hospital visit” is to check both your ketones and your BG at the same time. Here is the breakdown:
• If you are near-normal (or low) on the BG and high on the ketones, then it’s likely you are burning fat because your body ran-out of carbohydrate fuel. This would be the case if you had been partying hard and not eating right. Ketones are a natural physiological response to balls-out exertion and insufficient carbohydrates. To fix this you should rehydrate, add insulin AND CARBS (a good, well-balanced meal would be ideal, if there was such a thing on the Playa), and then get a little rest. Retest in a few hours and you should see the ketones have radically reduced or disappeared entirely. This condition is called uncomplicated ketosis, which in a healthy diabetic is a fairly low-risk and rapidly reversible condition. You don’t want to be in ketosis at Burning Man if you can avoid it, but it isn’t the end of the world if treated quickly. BTW: Gatorade with an insulin chaser often makes for a very fine killer of uncomplicated ketosis.
• If you are high on the BG (over 250 mg/dL) and you have raging ketones (greater than 2 mg/dL), then you are in diabetic ketosis (bad!) and rapidly moving toward diabetic keto-acidosis (disaster!). In this scenario you are not getting enough insulin and your body has turned to burning fat stores instead of glucose. Your blood is loaded with glucose, but lacking insulin to allow you to “burn” it, your body is still starving for energy. Because you are burning fat, your blood will become rapidly more acidic and this whole trainwreck will become serious business in a short period of time. In this case you need to immediately hydrate (as in massively hydrate with just plain water) and at the same time start adding insulin with mandated rest. Avoid ingesting any carbs until you see the BG and ketone numbers drop substantially. A few hours of high ketones and raging BGs will leave you feeling pretty icky, but it’s not immediately life-threatening if you are otherwise healthy. However, if the ketones and BG numbers are not dropping like a rock after hydration, 4-6 hours of rest and a couple of correction boluses, then you need to get yourself over to Medical Services pronto and get some professional help. Raging BGs and ketones even after a correction bolus or two means you are STILL NOT GETTING INSULIN. If you are on a pump, assume (at least temporarily) that the pump has failed and fallback to manual injections ASAP. If you are on MDI therapy, assume (at least temporarily) that your insulin is bad and open a new vial.
One nice thing about ketones is if you are otherwise healthy and have had them for less than 24 hours, they should clear quickly once you get some insulin running. Once you have cured the underlying cause, (usually a pump error, an infusion set issue, an empty reservoir, kinked line, or a really goofed-up or missing meal bolus), it is routine to see the ketones drop from a high value (e.g >4 mg/dL) to nearly undetectable… sometimes in only 2 hours or less. So once you have administered a correction bolus, recheck yourself in a couple of hours and look for the drop. Once it happens, you’ll likely have a hell of a headache and a ravenous appetite so plan accordingly. Continue a very high degree of hydration for the next couple of days while your body sorts-out the metabolic wreckage. Check BGs frequently (every 4 hours) to make sure you are not relapsing. And remember that the sun, wind, high ketones and raging BGs all cause a rapid depletion of fluids and electrolytes.Ketosis/Keto-Acidosis Danger Signs:
You know you are in deep trouble with ketones when any of the following are present: “Fruity” or “acetone-like” breath (mine smells like Beechnut Gum, YMMV), a panting-type of breathing (called “Kussmaul’s Sign”), a compulsive thirst coupled with frequent urination, and any degree of nausea, vomiting, headache or befuddlement/apathy/disorientation. These are all clear danger signs of diabetic keto-acidosis. This constitutes a genuine emergency. DO NOT DELAY GETTING MEDICAL HELP. Once keto-acidosis sets-in, you will NOT be able to self-treat successfully. Emergency medical intervention WILL BE REQUIRED. You will need IV fluids with dextrose and insulin, potassium and other electrolyte replacements, blood tests, and close medical supervision to prevent swelling of your brain, seizures, etc. If you believe you can treat this on your own, you are wrong. Without medical treatment there is a high likelihood you will get worse and die. However, given early detection and prompt medical treatment, you could be out of the hospital in 24 hours or less. Other ConsiderationsSterility On The Playa
I spoke with a medic once who told me the dust on the playa is largely sterile due to the high alkalinity and summer temperatures. If true, this is likely the only good thing I will ever say about Playa dust. True or not, best practices say you need to carefully clean and disinfect any sample, injection, infusion or CGM sensor site. No exceptions. Bolus injections, if you are fastidious about cleaning your skin, generally cause few issues. But consider doing any infusion site changes and CGM sensor insertions inside a car/truck/RV/tent where you can take your time, clean your skin twice, and use a proper antiseptic prep/scrub. Note that while the Playa dust might be sterile, your skin most certainly is NOT after wandering around the playa for a week. The old school nurses all say “when in doubt, scrub it out”, and this is sound advice. Peroxide and rubbing alcohol are your new best friends. And don’t forget to rub a little lotion on old injection/infusion/CGM sites. Sterile protocol is hard on natural skin oils, and the Playa is one place you should not skimp on anything that will protect or promote healing. Infection
Each time you puncture your skin you are setting yourself up for a possible infection. Diabetics are constantly puncturing themselves so we are always in the “at-risk” category. When you are on the Playa, you should carefully inspect yourself at least once a day. (Or, for more fun, have a friend look you over too. Maybe show him/her that “secret” tattoo?) Your body will generally warn you in advance of a real infection crisis, but you must look for the hints. Bleeding, oozing, “feels hot”, or “smells funny” or “what are those dark streaks?” or “Dude, that just doesn’t look right” are all an invitation to introduce yourself to one of BM’s fine medical staffers. CGMs
If you have a Constant Glucose Monitor (CGM) talk to the manufacturer about the dust and weather conditions found on the playa. Most are not sealed against this type of environment and you may not be able to use them successfully during the waking hours. But it will make for a much easier (and safer) sleep-time, and for this reason alone it is worth bringing it. Remember you can leave the sensor attached to you even if the receiver gets left behind during your away-from-camp adventures. Put the receiver in a baggie on top of the food in an ice chest when not in use. Cool is OK, but freezing is bad. At night take it out and synch it up so you can sleep knowing it is watching your back. Consider setting the alarms a bit more aggressively (i.e., wakes you earlier for lows and highs). The object here is to give you more time to respond to an out-of-bounds condition when you are tired and vulnerable to Killer Lows. Due to the abundant ambient noise issues, I like to put the CGM receiver (still in its protective baggie) under the pillowcase cover and pin it securely to the pillow so it stays on-top and right next to my ear. Tell your camp-mates what you are doing, why you are doing it, and then demonstrate the alarm for them. Ask them to wake you, forcefully if necessary, if they ever hear it go off. Remember to calibrate the receiver with at least two blood samples (or per the manufacturers recommendations) before bed.Planning For Murphy
There will be failures on the Playa. Count on it. So in the spirit of radical self-reliance, bring spares for everything needed to keep you alive and partying. Spare infusion sets, reservoir cartridges, disinfectant wipes, lancets, test strips, glucose tablets, and insulin are good places to start. A smart Burner would also bring contact information for his endocrinologist as well as a prescription for more insulin. (Most doctors will happily do a scribble-scribble-rip rather than risk being called-in for an emergency telephone consult during the Labor Day weekend!). Note that Murphy-Proofing your Burn also means keeping spare batteries for your meter, pump, CGM, etc. Finally, if you have access to a “vacation loaner pump”, seriously consider taking one with you. Both Animas and Medtronic have FREE “vacation loaner pump” programs for their customers. (Call them at least 3 weeks in advance. During peak season, spare pumps can get scarce).
Most modern insulin will store for a week or two at room temperature, or 2-3 days at body temperature. But none of the present formulations will last more than a few hours at Playa Temperature. Ideally, insulin should be kept at 40F to 45F. Therefore the best place for insulin is in a waterproof box in the top of a cooler. The big no-no’s are freezing (this kills the potency almost immediately and causes insulin to become cloudy) and overheating (same symptoms). NEVER keep insulin in a hot vehicle or in a cooler containing dry ice. NEVER expose a naked vial of insulin to the bacterial brew sloshing around inside an ice chest. (Put it in a waterproof container to prevent contamination). Insulin in a pump reservoir undergoing active administration is generally good for up to three days, but don’t be afraid to change it out with fresh insulin if you have any questions about potency. And remember, cloudy insulin always goes into the trash, never in your body.Sharps Disposal
This should go without saying, but here it is anyways. Bring a bona fide sharps container with you. These are 8 bucks at WallyMartus and are worth every penny. You should never discard sharps of any kind on the Playa, in regular garbage bags, or in a burn(ing) pile. Why? Consider the poor Schmuck who is deMOOPing who gets your syringe stuck in his hand. He will be wondering if the original owner of this syringe was a diabetic or a hard-core druggie. What was in this syringe? Was the owner clean or did he have AIDS? Hepatitis? What a nightmarish way to finish your week at Burning Man! Alcohol
Some diabetics tolerate alcohol well, while others get into near-death experiences after just a couple of brewskis. How your body handles alcohol can only be determined by trial and error. But do not make Burning Man your gutter-crawling tolerance test-bed. Find out where your limits are before you hit the Playa. And once you find your limits, stick by them. Learn to say “No Thank You” and to smile, and how to mean it. Remember that alcohol will dehydrate you quickly, so compensate proactively.Alternate Sites
If you are pumping insulin, you may want to experiment with alternate infusion site locations. (After all, how are you going to pull-off your bare-breasted version of “I Dream Of Jeanie” with an infusion set camped next to your oh-so-cute navel?). Alternate sites can save the day. Good possibilities are on the buttocks, thighs, lower/outer back, upper/inner arms, etc. You likely know about these, even if you haven’t ever used them. The problem lies not so much in finding another site – it is knowing how that site will change your absorption, dosing, and basal programming. Each site has slightly different characteristics and a smart Burner will find-out what those characteristics are before they hit the Playa. It Takes A Village To Raise A Type 1 Burner
Consider letting everyone in your camp know that you are a diabetic. Explain briefly your known behaviors when you are low, and what you need them to do if you start crashing. (“When in doubt, feed me Gatorade first and get me to EMS second. If I’m not conscious or I am unable to swallow, then empty this syringe of glucagon into my buttcheek … then get me to EMS fast while I try not to puke on you”). If your buddies know you are at-risk, they can help if something bad happens.High Is Better Than Low
Many diabetics survive for decades at 200+ mg/dL, but nobody survives for long under 40 mg/dL. So given a choice, and with your doctors consent, you may choose to aim a little higher than is technically “optimal” for the week. This management ethic gives you some room to fall and precious time to get back to camp before a Killer Low ruins your day. Gatorade and Glucose Tabs. Don’t Leave Camp Without Them!
BGs can fall rapidly under Playa conditions. How fast? I’ve seen 4 mg/dL/minute on several occasions. That’s fast. This means if you are more than a couple of hundred yards from camp and you don’t feel a low until you are in the 50’s mg/dL range, you may not have enough time to get back before the lights go out. So always carry two things: Gatorade and glucose tablets. This in addition to your usual water supply. How many carbs should you carry? I carry 50 at all times, evenly distributed between liquid and solid forms. A first-time Burner or a newly-diagnosed diabetic should also consider taking their glucagon emergency syringe when away from camp.Tag Yourself, Or The Playa Might
You should wear your diabetic ID at all times. If you are worried your dogtag might clash with your 1960’s love-vest, pink afro and heartie-glasses, then its up to you to figure-out another way to let first responders know you are a Type 1. One trick is to thread your shoelaces through the hole in your dogtag. Walla! You are officially tagged but in a place that casual on-lookers won’t ever notice. (But the EMS boys are trained to look there, especially on kids. They actually make a medical tag designed to be worn threaded through the shoelaces now). In a pinch, get someone to scribble “Type 1 Diabetic” somewhere on your body with a waterproof Sharpie. However you do it, make sure you are immediately identifiable as a diabetic to first responders.Never Burn Alone
Don’t camp or wander the Playa alone. Take a buddy. (It’s more fun anyway!) Make sure Buddy has some back-up carbs and fluids too. If Buddy is also a diabetic, so much the better. The Buddy system is good advice for anyone, anywhere, but for Type 1’s in a hostile environment, it is doubly important.Be A Universal Buddy
On that note, make it a point to be a Buddy to everyone else, too. In other words, if you see someone who is “drunk”, but the whole scene just doesn’t look right to you, stop and inquire. That “drunk” may be a fellow Type 1 Burner who is having a Killer Low. The signs are so similar (incoherent thoughts, emotions, disorientation, belligerence, etc) that EMT’s are taught “When in doubt, carb ‘em up”. Adding carbs to someone like this is a no-harm move. If they are just flat, pissing drunk, there is no harm done. But if they are a diabetic fighting a Killer Low, then you may have just saved their evening (or life). If you ever encounter a confirmed diabetic that isn’t responsive, that can not swallow, or is having a seizure, you absolutely owe it to them to give-up your glucagon. Minutes count when you have an unconscious or seizing diabetic, so administer glucagon first and then get someone rolling to find a Ranger or LEO fast. Make It A Party
Diabetes is not a long, sad slog to the grave. On the contrary. It is a celebration of you taking-over a formerly autonomic function! You are EMPOWERED. You are SUPERIOR! You are the MASTER AND COMMANDER of your body! So find a friend and celebrate your power. Maybe you can cajole each other to drink and have a pissing contest (literally!), or play poker with your BG numbers. Whatever. But make it fun and maybe invent a little drama over it. (I once saw a lad of about 15 years old jump up on a cooler, mash his lancet against his finger and scream “Nobody moves or the pinky finger gets it! I swear to God I’ll do it! I’m a diabetic on the edge!!!!” It was nothing more than a routine finger stick, but the way he played it out absolutely slayed his entire camp). Another thought: If you are having issues coping with your diabetes and feel like you are being left-out or just overwhelmed, take an hour or two and wander over to The Temple. The Temple is a neat place to leave emotional baggage like this. And there are lots of eyes there, many of which are trained to spot “issues”. It’s hard to get into too much physiological, or emotional, trouble there.Dump The Modesty Crap
This part always leaves me scratching my head. John Q. Diabetic has just (un)dressed into a pink tutu, fuzzy bunny slippers and is wandering around with a significant percentage of his sex organs showing. Everything about him screams “look at me!”… but he is still shy about telling his camp mates he is a *diabetic*? Seriously? Have you lost your mind? HELLO? Or in the case of Diabetic Jill: That group of 12 guys in the front row could almost see your tonsils as you slid-down that stripper pole mostly naked, but somehow you are just TOO MODEST to spill the diabetic beans to your campmates? Both of you guys need to get over it and make the call. Confess it and be done with it. “I am a diabetic”. Say it with me loudly. Call it “bonding” or something, but know this simple act may allow your campmates to save your life. Modesty SUCKS.
Little Random ThingsEverybody:
Tie a glowstick to your meter case or to the zipper thereon. This makes it easy to find it in the dark.Everybody:
Put a non-diet soft drink (carbs!) into your empty shoe and store it within easy reach when you sleep. If you go low you can let your fingers do the walking and not have to traipse outside your tent to find some fast-acting carbs. (FWIW I put my meter and glasses in the other shoe to achieve some weird kind of cosmic symmetry).Shooters:
If you use Lantus and a rapid-acting insulin like Novolog/Novolin, you may be able to safely combine them in one syringe. This would definitely cut-down the number of syringes you have to pack-in and pack-out. To find out if this is right for you, show this peer-reviewed paper to your doctor. FWIW I used this method extensively before I went on the pump and it works well. Kaplan, W.; et al. (2004). "Effects of Mixing Glargine and Short-Acting Insulin Analogs on Glucose Control". Diabetes Care 27 (11): 2739–2740. doi:10.2337/diacare.27.11.2739. PMID [//www.ncbi.nlm.nih.gov/pubmed/15505016 15505016]. The full article text is contained here: http://care.diabetesjournals.org/conten ... /2739.fullPumpers:
Score a half-dozen samples of Torbot’s Skin-Tack Adhesive Wipes. These make infusion sets and CGM sensors stick rather tenaciously to your skin, sweat and movement be damned. Google “Torbot Labs Skin Tack Adhesive” for retail sources. About $15 for a box of 50. If you need really insane adhesion, Ferndale makes a product called “Mastisol” with a FEROCIOUS adhesive that actually requires a solvent to get it off. Google “Ferndale Mastisol Liquid”. About $25 for a small bottle. Pumpers:
Use a prep wipe containing at least 2% of chlorhexidine gluconate on your infusion set areas before insertion of your site. This wipe is very effective at killing germs and it leaves behind a thin film that continues to kill the nasties long after it has dried. Using this as an infusion site prep (after using an alcohol wipe) can prevent infections and it is gentle on the skin. Google “chlorhexidine gluconate 2% wipes”. About $15 for a box of 24. Various makers.Pumpers:
Make sure to take a spare pump reservoir nut and battery cap with you. Your pump will not work if either of these are lost or broken. About 15 bucks for the both of them. Replace both of them with new ones once you are back in Defaultia.Pumpers:
Take a minute to dust-off your pump casing before you go to bed. Your pump is likely to be water and dust proof, but that Playa dust is very abrasive. Sleeping with a dirty pump is just like rubbing it with sandpaper all night long. Abrasion damage may only be cosmetic, but it is permanent and it is not covered under warranty. Pump “skins” help too. A damp cloth works wonders.Pumpers:
Take a can of Dust-Off (designed to blow the dust out of computers and stereo gear) with you to blow-off the area around the reservoir nut and battery cap. You should do this before changing either your battery or the insulin reservoir. You must keep the Playa dust out of your pump at all costs. The micro-mechanical systems in insulin pumps absolutely hate Playa dust!Everybody:
MediCool makes a nifty thermo-electric micro-cooler just big enough to fit 9 bottles of insulin or 3 insulin pens (or any combination there) that is powered by 12VDC. Perfect for traveling, it costs about $50. Note: If you use any thermo-electric cooler like this while on the Playa, be sure to keep it in a cool place. Thermo-electrics can cool down to 30 degrees under the ambient temperature and not much more. While traveling, such a cooler can be helpful, but on the Playa this design feature can bite you. Consider that if you put this in a hot are where it gets to 150F during the day, the “cold” space inside the cooler will be 120F… far higher than insulin will tolerate. Conversely, if it gets cold at night, you might want to unplug your cooler so you don’t freeze your insulin. When all is said and done, the best place for your insulin may be in an electric cooler while traveling to Burning Man. When you arrive on the Playa transfer your meds to the top of your ice chest. Parting Comments
You did not come to Burning Man to spend all day managing your diabetes. Before you hit the Playa, have everything you need (spares!) packed and ready for fast access. Once the party starts, keep your management goals firmly in mind, but also cut yourself some slack. It may be technically possible for someone to keep himself perfectly tuned at 100 mg/dL for 7 days in 100F degree heat, 40 mph winds, with the nights dipping into the 30s while eating and drinking all manner of random stuff, but that person isn’t reading this. You and I are going to have some fun, and this will cause some hiccups in your numbers. The best way to deal with this is to talk with your doctor about SLACK… as in cutting yourself some, and understanding what you can expect. Maybe you can work-out a deal with your Doc to aim for 140 to 175 mg/dL as your temporary “target” range during your Burn. Dunno. Everyone is different, but I think most doctors would look at Burning Man as a constructive attempt to have some fun and learn some new management skills with an eye on becoming a little more independent.The End (almost) “Nothing in this document should be construed to be medical advice. This document should be considered a work of fiction. No diabetic (or any human being for that matter) should ever be exposed to the harsh Playa conditions. Burning may be hazardous to your health. You have been warned.”