Snorkeling and Insulin Pumps

Diabetes Technology Insulin Pumps
1

Hey Pump users!

I have been using a Medtronic Paradigm pump and I have decided to get into snorkeling and scuba diving. I've tried not wearing my pump during snorkeling but I find my sugar just sky rockets even if I plan for it. I would like to be able keep my pump on but of course want to keep it dry. I would also like to get into scuba diving since my husband does it. He is a tech diver and I don't plan on going that deep. I know pressure and the pump can be a concern. I have heard of the aquapac but I here that the seal can actually squeeze the insulin line too much and stop insulin flow. Are there any experts on wearing a pump and diving out there with suggestions?

2

We have a scuba diving group here, please join it and ask them, sounds like fun!

http://www.tudiabetes.org/group/scubadiving

3

Thanks so much!

4

The scuba group tends to be very quiet and not necessarily very helpful; somewhat cliquey.

I've snorkeled as well as dived and I've never had any problems snorkeling with the Omnipod, however it *is* rated to depths beyond the depth I can comfortably free-dive to; 25ft, the depth of swimming pool dive ponds. I can only manage about 12ft while snorkeling.

The waterproof pumps all have depth ratings:

1) Minimed Paradigm: 3ft (absolute max; it only has an IPX7 rating.)
2) Animas Ping: 12ft (you can use the controller to that depth too.)
3) Insulet Omnipod: 25ft (not the controller - I put it in a Dry-Pak when on a boat.)

So snorkeling with Medtronics is out, and, indeed, their web site says this: "You should temporarily disconnect the pump while bathing or swimming."

AquaPac, or any of the other iPod cases, should work just fine within their depth limits. They work by allowing the pressure to equalize, so the 'pac' is squashed until the air pressure inside equals the water pressure outside. This is why they have such a limited depth capability; there has to be enough air in the pac at the surface to ensure that, when compressed, the water pressure does not bear on the device. iDive make similar containers that have their own air (CO2) supply and are rated to much greater depths, but they don't allow for earbuds like the iPod cases.

The pressure at any depth (including tec depths) isn't enough to compress insulin, but the case itself collapses so I guess it could kink the tube.

Bottom line is that with the Paradigm you probably want to disconnect it and (therefore) not snorkel for more than an hour.

John Bowler

5

I keep beating this dead horse on this website and I guess I must be doing something wrong, because there is no pump currently on the market that can be used at depths a scuba diver would see. OK, I am a Type 2, but I am an experienced hard hat diver and scuba instructor. Do not wear a pump with scuba gear. Period.

The suggestion to use Lantus and Novolog is probably a good one, but I am not an endocrinologist, I am a diver. Go see your endo and ask him.

What I am trying to do is open up the wonderful sport to diabetics of all ages. It wasn't that long ago that diabetics were prohibited from diving as it was felt that a low glucose event underwater could be fatal. Hogwash. Read through some of my threads about sucking glucose goop out of a tube underwater. It is an acquired skill. Wearing a snug fitting wetsuit over an insulin catheter is a no-no.

The biggest safety factor is your buddy. Do what I do, dive with a tough, badass, highly capable diver that knows what to do, how to do it and when to do it. Develop your own hand signals.

Most of all, relax and enjoy the sport and the wonderful world of underwater exploration. Search for buried treasure, gold dubloons, emeralds and rubies! And have fun.

Rock

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6

The 2005 workshop, which, so far as I am aware, is the latest consensus on diabetes and diving:

http://www.diversalertnetwork.org/files/UHMS_DAN_Diabetes_Diving_2005_Workshop_Proceedings.pdf

It has little to say about pumps. At the time the participants were not aware of any pumps that function under water. The consensus summary has nothing to say about pumps:

https://www.diversalertnetwork.org/files/DiabetesSummaryGuidelines.pdf

This is probably because only the YMCA participants had protocols for pump use, and pump use was identified as part of the future initiatives (page 55.)

Despite that, as I understand the YMCA protocol, the intention is to just detach the pump before diving, not to remove the cannula/catheter. I can't see why there would be a problem wearing a wetsuit over the cannula.

When this was discussed before the general recommendation was to protect the cannula during the dive with some sort of tape or cover. Tegaderm is effective for this, although it is necessary to use some non-adhesive cover under that to prevent the cannula being pulled out when the Tegaderm patch is removed.

This applies just the same when snorkeling or swimming; there are no issues caused by the increase depth when diving because the pressure on each end of the cannula remains the same. (That applies even with Tegaderm, because it is flexible so compressed around the cannula while diving.)

I stand by what I said before, which is to do the same thing with the cannula (whatever it is) for swimming, snorkeling and diving.

John Bowler

7

I used to dive when I was on MDI but have not done so since starting pumping 6 years ago. I have thought about diving again.

One strategy used by pumpers is to go onto a "semi-tethered" regime. This involves taking a modest daily dose of Lantus - enough to cover a proportion of basal requirements. This will provide a safety level of background insulin whilst detached for the dive (you could do the same for snorkeling). You would have to adjust your basal programs to reduce your basals during the period you were taking the Lantus.

I used to dive with my wife, I assume your husband could act as your buddy. There is actually a hand signal for Low BG (flat hand with thumb out to make letter L). I also had a little waterproof divers pack containing glucose tabs that I clipped to my BCD and a second one for my buddy. There are apparently gels you can consume whilst under water, but I never dived deep enough to require a long equilibration stop on the return to the surface.

Good luck

Joel

8

I'm a certified SCUBA Instructor. This issue comes up from time to time.

At present, the only workable solution is covering basal with a long-acting for the days diving, and pump only for boluses. Management gets a bit more complicated, with more frequent monitoring and active control with glucose and corrections. As Jim mentions, the strategy is to short the long-acting just a bit for a safety margin, preferring running a bit high (<200) over risking hypos under water. Finally, if you're going to do this, practice, practice, practice above water. Be sure you know and have done this modified routine so much before you go under water that it's nothing novel when you put it to real use. Understand well how you're BG is going to react to the physical effort, etc. under this regime.

Finally, a CGM is just short of mandatory. Leave the receiver topside during the dive. The Dexcom G4 sensor/transmitter assembly can go very deep, as it is constructed of solid resin (no internal air spaces).

Omnipod users are, paradoxically, in worse shape than tubed pump users for depths that exceed about 30 feet (most SCUBA dives). For pod users, they pretty much just have to switch completely to MDI on a dive trip, unless they want to waste a lot of pods.

9

I can only agree with everything said so far. Scuba opens up a beautiful world that everyone should get to experience.

I think you will have to come up with what works for you, and from your description of snorkeling, it sounds like using a long-acting insulin might be beneficial.

In my case, even though I can snorkel with my pump, I choose not to because it was just easier to disconnect and correct when back to above water life.

For Scuba, I simply disconnected before diving, made sure my blood sugar wasn't diving and above 120, went for the dive for an hour, reconnected when back on the boat between dives and repeated. Frequently, I would dive with both food and insulin in my system. I always dove with two gel tubes (like cake frosting, only glucose), but I never needed them. I rarely finished a dive above 200; of course, all highs would be corrected as needed.

Scuba is truly wonderful and a discipline where practice is the key to relieving any anxieties that might prevent you from enjoying the underwater world. For me, I practiced taking in glucose from the tube while doing my certification dive (of course, I had to correct later!).

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10

Medtronic make (or maybe used to make) the "minimed sportguard"; currently about $80 on amazon.com

The case is claimed to be "waterproof". I couldn't find what that meant, but while searching I did discover that Medtronic have pretty much denied that the Paradigm pump is waterproof in any meaningful; they apparently say it shouldn't be used when swimming or taking a shower!

The sportguard case itself can't be found on Medtronic's own online store, so quite probably it is no more waterproof than their previous attempts.

There's a lot of information here:

http://www.insulinpumpforums.com/lofiversion/index.php?t65.html

That discusses the AquaPac 158 case; this is the one they explicitly sell as an insulin pump case:

http://store.aquapac.net/insulin-pump-case-158a-29.html

It's using a clamp style closure on the tube, which means you don't have to detach the tube to get the pump inside, however the case is less waterproof than the original (now denied) Medtronic claim for the Paradigm. (It can only last for 5 seconds if under 3ft of water pressure, so the clamp has no pressure resistance.)

The tests Imperial performed (reported on the forum page and on the AquaPac page) also included the 550. That case showed a better result (92% flow) and I think the clasp is identical to the smaller case, so you would probably be able to get the pump in without disconnecting. The case rating, however, still doesn't allow for any water pressure so you can't use it while snorkeling and even swimming is a little risky (don't get the case more than 3ft deep!) AquaPac have this to say:

"Waterproofness Warning!: This case features our 'TC' Aquaclip which makes the case waterproof to IPX7. Temporary immersion is fine, but not continuous immersion."

Notice that in both cases the Imperial tests showed no flow reduction for high flow rates; the reduction was only detectable over 2 units. My assumption is that this is a feature of the pump they used (a Roche), however the reduction over an hour (1.16U worst case) is more than enough to block my own basal over that time (0.5U).

The issue with pumps is that the ones designed to work with substantial pressure increases - 40% for the Ping, 80% for the Omnipod - need to have no substantial air pockets in front of the plunger. That's because an air pocket will be compressed, to 1/1.8 (55%) of its volume in the Omnipod case, and that compression will replace the basal insulin flow. So my basal will be stopped for a whole hour if I take my Omnipod to 25ft and it has a 0.9U volume bubble of air in front of the plunger.

(Incidentally, if you do the PADI open water course you get taught all the pressure stuff, and there's a question on it in the written exam. I thought that one was a give-away, but that's just me.)

Anyway, a bubble of that volume (0.009ml) has a diameter of 1.3mm (that's not part of the OW course :-). That's a pretty big bubble; visual examination of the bubbles in my Omnipod reservoirs suggest that they don't exceed 0.5mm, which is about 0.0005ml/0.05U and way below the amount necessary to make a significant change to my basal.

Any pump that doesn't have to deal with water pressure, however, has far looser constraints. Pretty much the only issue is that the pump has to deal with the pressure change in pressurized aircraft; this corresponds to at most 8,000ft of elevation, pressure reduction to 75% of sea level, and happens over a period of maybe 30 minutes. Atmospheric changes due to weather are much slower and don't typically exceed this anyway.

My suspicion is that the Roche pump which showed 42% flow rate just happened to have a larger air bubble as a result of less careful priming.

If you believe me then simply releasing the clamp on the case will release the insulin; the case doesn't actually cancel your basal, it just delays it.

All the same, what I don't like about either of those cases is that they really aren't pressure proof and that they compress the tube linearly. Inserting the tube through a grommet would work far better, and this is the technique used on (hard) camera cases to allow moving components to penetrate the case so the camera buttons can be operated.

I can't see any problem feeding the tube through a case with a grommet. Unfortunately I also can't find any cases that use this arrangement. I had thought iPod/MP3 cases did this, but the ones I've been finding have built-in, sealed, headphone jacks (the AquaPac 518 for example) not grommets that accommodate a moveable cylinder like the hard camera cases.

None of this is very helpful, unless you were considering changing to a different pump manufacturer, but I think that things will get better in the future as pump manufacturers compete over the very large market amongst active diabetics for waterproof pumps.

John Bowler

11

Yep, "untethered regimen". Half the basal is covered by slow acting insulin, and then since you are doing physical activity, the increase in BG is probably going to be slow. Seems like it should be pretty manageable.

12

John, given the comparatively small market that SCUBA represents in the general population, and the even tinier market that consists of T1 divers, combined with the substantial expense of making something truly pressure capable at depth, I'm as close to 100% positive as I can be that there will never be a SCUBA-capable pump -- ever.

Sorry to be so glum about it, but the economics just don't work. Also, I think you're very mistaken that the T1 watersport market is "very large" -- rather, I'd say it's very tiny, and will forever be so. Tens of thousands of people are insignificant in a US market of 300+ million people (or 6 billion worldwide).

13

I'm going to rant once then go back to my standard analytical approach.

I disagree. All the evidence is that technology improvements in other areas will bleed into diabetes technology just as they are currently bleeding into the antiquated technology of the dive world.

For years divers had to purchase extremely expensive accessories for cameras to allow underwater use. Two weeks ago I was doing dives to 84ft in Cozumel with a Canon Powershot D30; an off the shell point'n'shot camera depth rated to 82ft. Canon didn't do that because of the dive market; after all the Nikonos went out of production years ago. They did it because manufacturers are competing on depth and Canon could take what I believe is an unmodified D20 and repackage it with a higher depth rating.

What is more divers, like everyone else, will use technology beyond its specified range as needs require. Check out the IPX8 rating (depth+time) of the Dexcom G4 on page 67 of the Dexcom G4 platinum user manual, and this comment:

"The Dexcom G4 sensor/transmitter assembly can go very deep,"

just like the Omnipod, which has been observed to work by two separate divers at 65ft or more.

We need to teach people how to read, find and understand manufacturer IPX ratings and how to apply them to watersports, certainly not just diving.

This thread, which, remember, is about snorkeling, not diving, illustrates how important that is. Specifically the Aquapac case (IPX7) is not rated for snorkeling, regardless of any insulin flow issues. That's implicit in the IPX7 rating.

We need to relate experiences of people who exceed the limit of those devices and discuss how to mitigate possible failures. I'm absolutely sure some people with Medtronic pumps snorkel with them (follow the links I posted), so what do they do, stuff an AquaPac with tissues? How about using desiccants instead?

I started diving in 1972, when I was still British. I sincerely believe that none of us should repeat the mistake the British Scuba Society made a year or so later when they banned all people being treated for diabetes from diving because a "diabetic" diver with an undiagnosed heart defect died while diving. As has been said for disabilities in general, we are not diabetics, we are people with diabetes.

So the BSC said "diabetics can't dive" and divers who were diabetics responded either by stopping diving (me, I was only 15) or lying (others).

Therefore we need to educate people and that means explaining, accurately, where risks exist (diving or snorkeling with a CGM is outside the specs of any known CGM) and where they don't (diving to 25ft with an Omnipod is within the manufacturers specs so long as you don't dive for longer than 60 minutes at a time.)

We also need to communicate how to mitigate these factors. For example Animas Ping users can swim for the whole day and night and remain within the spec, as can Dexcom G4 users, however an Omnipod user should get out of the pool once an hour. In practice, however, many Omnipod users have swum (floated, in my case) more than an hour continuously in the pool and we can reasonably say that Omnipod was a 1 hour limit because that is what Insulet tested. Likewise I'm sure there are a lot of people who snorkel with the Ping and don't worry about the 12ft limit.

Then we have to acknowledge that some people will dive, or swim, or snorkel, or hot-tub, or sauna, beyond the manufacturer limits. With regard to hot-tubs, saunas and swimming there have been rationale discussions on tudiabetes about the experience of people who have done it. These discussions seem to be sadly lacking in the tudiabetes dive community.

End of Rant.

14

My understanding is that you need to switch over to Lantus injections to have coverage in the water. None of the pumps are truly waterproof, least of all the Minimed. Mine shut down one day when I was doing yard work and just some sweat got into it!

15

Several waterproof pumps are available these days and there are many happy water-loving users of those pumps. The different pump forums on tudiabetes are a great way to find out what works and what doesn't.

This is particularly important for parents of young people with diabetes; children often love water and pumps are frequently strongly recommended for younger people. We need to look for a pump with an "IPX8" rating then check the manufacturer description of the waterproof capability (they are required to give one by the IP standard.)

Animas Ping and Omnipod are both known to work well for people who regularly engage in water sports, including swimming and snorkelling, they have been available for a long time so there's a lot of information about them. Other pumps which claim IPX8 ratings are emerging from other manufacturers, but the details need to be checked (e.g. the Accu-Check combo isn't waterproof when it is in use!)

All these same issues apply to CGMs; another device that is very important and frequently used by younger people. The Dexcom G4 probably has the most user knowledge amongst waterproof CGMs, but the Animas Vibe has a better rating and an integrated pump.

It's a rapidly changing field; for example I just discovered the Medtrum product which I hadn't even heard about before! (Tubeless IPX8 insulin pump with integrated CGM..) So the options are limited at present but I'm sure they will expand over the next couple of years.

John Bowler

16

Well, I'll just say that I disagree with your market and business theory here, based on my direct professional experience. I'll leave it at that.

However, I do object strongly to what I see as misleading information regarding the technical matters regarding liquid ingress in devices under pressure, due to incomplete information in your posting. It wouldn't be any big deal discussing a camera, which only threatens lost property value. In the case of an insulin delivery system, a person's life could be threatened -- exceedingly unlikely, but a risk nonetheless. Far more possible is a bad diabetes health experience, including a hospital visit for DKA, if things go really bad.

I speak in particlar regarding the definitions of the various IPX liquid ingress ratings. While IPX8 means waterproof to a minimum pressure of 2 atm, the actual rated depth is up to the manufacturer. So do not assume reliability deeper than that. For the omnipod, it's 33 feet.

Finally, in my opinion what you're advocating here is rather dangerous: Basically what you're calling for with pumps is the equivalent to the PC gamer overclocking model -- push the tech as far as you can, share via community, and develop parameters assisting others for how far they can push things.

Again, comparatively inconsequential for a computer CPU being overclocked, then overheating, and burning out. Which happens to overclockers all the time, following the "successful" advice of the OC community.

Hugely consequential for a diabetic (which goes without saying, but it seems to need to be said).

The problem here is variation in manufacturing that don't show up until you push the device to its limits. You may wind up with one batch of pods that work like a champ at 60 feet depth, then another batch that are flaky, or all fail at that depth. You won't know until something bad physically happens to you at depth, or when you get back on the boat, test your BG, and find that you're either way high or way low.

One nightmare scenario to consider: Pump leaks, electronics are compromised in just such a way that the pump gets stuck "on" pumping. You go major hypo at depth, pass out, and drown.

My advice to everyone reading is to stick to the parameters published by the manufacturer, and not exceed them. Period. You're life and health are not worth experimenting on.

17

I'm on the Omnipod and I just returned from a 10 day cruise to the Caribbean where I swam daily and snorkeled a few times with no issues.

18

Based on your short description, I'm guessing you didn't exceed 10m (33ft) depth.

Given this is Insulet's stated and supported water "proofness", I'd be surprised if you did have any problems.

There's little argument that the Omnipod is a superior solution for most people engaging in surface watersports. SCUBA is a very, very different animal.

19

Errata:

IPX8 means waterproof to a minimum pressure of 2 atm
This is incorrect -- IPX8 requires only water ingress protection up to 1m depth at MSL, which works out to about 1.1 atm pressure, or just over 16 psi.

Insulet guarantees pods are waterproof up to 30ft depth, just short of 10m and 2 atm (~30psi).

20

The Xcaret Mayan theme park in Playa del Carmen has an underground river ride which involves floating down the river between the cenotes. You can leave your non-waterproof belongings in lockers at the start but it takes 30-40 minutes then you have to walk back to get your stuff.

Anyway, I did that a couple of years ago with the Omnipod, but I left the controller and my test equipment in the locker. They were ok with the pump, I told them I had one; they have a medical disclaimer at the start, but it was a warning not a commandment. The ride worked pretty well for me, doing it with a pump that has to be disconnected would be more challenging but not, I think, a showstopper.

If I did it again I'd pack the controller and test strips in a DryPak. I've got a DP-46W that floats fine with the controller in it, I use that on boats. DryPak doesn't give a waterproof rating but says "[f]or beach, pool, boating, snorkeling and more"; I wouldn't deliberately submerge the case even though they say, on the DP-46W packaging I have, "[a]lthough DRY PAKs have proven to be 100% waterproof at various depths, we do not recommend using them at depths greater than 30ft."

On the other hand Xplor, which is in the same place, had a blanket ban on people with diabetes when I checked.

There's a lot of stuff on tudiabetes about theme parks - Disney in particular - but there don't seem to be any issues.

Of course the main thing in all these cases is not the water, it's the possibility that the pump will be forcibly disconnected, and there's a lot of pump-specific advice on tudiabetes about avoiding that using stuff like tegaderm.

John Bowler