Camp is in its final couple of days. Two weeks has gone by like a month to everyone working on the med staff. Everyone is very ready to return to whatever routine they had before, or better yet just a good night’s sleep. Med staff is also busy making final recommendations for “going home” insulin dose adjustments and what they’ll be saying to camper’s parents at check-out. I will address the parents from 10:30-12:30 on Saturday morning at “Parents Day”. We usually have a full house at the Rec Hall. It’s my chance to share how camp went the past week, and also provide some insight much as I have in this blog over the past couple of weeks. I also try and answer any and all questions parents have about diabetes care and technology. Basically, a diabetes update from a doctor who treats children with diabetes for a living and who has also lived with the condition for 43 years.

We must acknowledge our gracious host and sponsor, the Texas Lions League. Their vision over 40 years ago made this diabetes camp not only possible, but also unique as the first such camp that never asked for, or accepted, fees for children with diabetes to attend the camping program. Others emulate them now, but this camp was the first.

The running joke at Parents Day is that campers check out is between 12:45 and 12:46 PM! We have enjoyed caring for campers, but we are very ready to return them. Just like last week, everyone on my med staff has made the transition from novice to pro over the past week, as I assured them they would. We’ve had our challenges along the way as we always do, but we always persevere.

To a person, every volunteer on med staff has learned something about diabetes they didn’t know when they arrived here. Many have learned a great deal; and they work in the diabetes field already. I tell anyone who will read or listen, that this camp is the single greatest learning experience about type 1 (juvenile) diabetes that I have ever had. More so than any book, lecture, course or symposium I’ve ever participated in. I would hope these posts will serve to identify future med staff.

Our hosts, the Texas Lions League, hold their semi-annual board of directors meeting starting Saturday. Check out is nothing short of a circus environment, as hundreds of Lions and their families co-mingle on campus with 208 campers, 50 medical staff and 100 camp counselors and their core leadership staff. It’s amazing that any of us don’t get run over by all the cars!

In closing, I can only say that I’m fighting the good fight, I’m running the race, and I’m keeping the faith. But it’s not over for me yet, nor any of these children that we come here to serve every year. This camp will remain forever part of my life, and part of the lives of tens of thousands of children and young adults with diabetes. Besides my family, it’s one of the best things to have ever happened to me.

As a follow up to the last post, we have continued to uncover many campers with Mystery Boluses. Some are rather startling. In one case, as much as 50 units bolused through a pump, or repeated boluses totaling 50 units or more at odd times of the day, even during the middle of the night. Not surprisingly, lots of lows. When the pump history was reviewed for the past few weeks, I found several days where NO bolus was given. This camper’s pre-camp A1C was in the double digits.

The reasons for this phenomenon are undoubtedly complex. I wish there was more study behind the drivers of these behaviors, or what characteristics these folks have in common. Given the fact that more and more kids are going on insulin pumps, this will only continue to be a serious problem with potential life-threatening consequences. In my practice, I require patients considering pump therapy to go through pre-pump training that spans several visits. It’s not my intent to slow down getting a pump, but simply acknowledging the fact that these are sophisticated machines with potential for great good, or great “bad” if not started properly and educationally “maintained”.

I ask kids to sign a behavioral contract regarding their pumps. That allows me the chance to re-visit promises almost all insulin pump patients make before starting a pump. These vows are often kept as long as a New Year’s resolution by January 15th.

At camp this week, my Mystery Bolusers come from every corner of the great state of Texas. All are teens and “tweens”. I don’t typically see this behavior in the pre-teen age groups since most parents still play such active roles in their day to day pump management. I’ve contacted these camper’s diabetes doctors and shared our findings to determine the best course of action in each case.

My advice to parents of teen insulin pumpers is simple: don’t back off from your involvement in their diabetes care. Dr. Barbara Anderson has clearly defined the age of 16 years as the earliest age where greater diabetes self care independence is justified. To do otherwise invites problems like the Mystery Bolus and their cousins, the Omitted Boluses.

Just as solar eclipses happen every now and then, an unusual diabetes care event was discovered today at TLC. Sightings pretty much just happen at diabetes camp each year. It’s called the “Mystery Bolus” (MB for short). MB is only visible when someone else oversees or reviews insulin dosing in a person using an insulin pump.

Depending on your point of view, a pump is a versatile insulin delivery system used to fine tune diabetes control to near normal levels… or it’s a $6,000 weapon loaded with up to 300 units of insulin and worn on the hip of a child or teen. As a pump user myself for over a quarter century, I have some strong opinions about how pump therapy is best deployed in children. My views are reinforced each year at camp. Even more so now that pumps possess memory chips where actions and omissions can be downloaded or manually reviewed. How often do you review?

Now back to what happened today. Within a span of just 2 hours, the med staff reported three campers who’ve been Mystery Bolusing (also called hyper-bolusing) and hiding that information from the staff. Each of them had been experiencing low blood sugars at different times of the day. Several boluses were delivered during sleep, after lights out. I’m not talking about a few units, try up to 20. I always request my staff to review the bolus histories of all the pumpers in their care. This uncovered the problem (as it usually does).

The reasons for this secretive behavior are simply that: secretive. In my experience, I’ve often seen the following characteristics common to “hyper-bolusers”. These include 1) unrealistic expectations regarding blood sugar control (by child and parent, maybe even the doctor), 2) negative or even punitive responses to high blood sugars by the family (or even the child’s doctor), or 3) a desire to get a “rush” from low blood sugar, or even simply to draw more attention to themselves.

Mystery boluses are elusive and stealthy. They are the antithesis of the omitted bolus, but they can co-exist in the same person. They’re harder to detect since the extra boluses can easily be attributed to an additional meal or snack. There is no way to really refute such an argument unless access to food is controlled, as it is at camp.

One of our Mystery Bolusers did acknowledge that a 20 pound weight loss had been achieved by under-bolusing or skipping boluses over the past several months. A telltale signs of bolus omitters is the double digit A1C (often > 11%) in a pump wearer, although persons with any level of A1C control can engage in this behavior.