Diabetes First Aid
Managing the Hyperglycemic Casualty - Cadair Idris, May 2026
Climbing the Cyfrwy Arete with my T1 diabetic son ...
I have called mountain rescue twice in my life, and each time it has been for a diabetic casualty.
Having scrambled up two pitches of easy climbing, my son and I arrived at the proper start of the Cyfrwy Arête on Cadair Idris, in Wales. I’d built an anchor and the pair of us were tied in, with me ready to climb. I’d stepped up, and as I was placing my first piece of gear I heard three rising tones emit from Patrick’s insulin pump.
“What’s that mean Patrick?” Patrick looked down, and pulled his pump out from beneath his shirt. “My pump’s out of insulin Dad.”
Diabetes – a recap: what is it?
When someone has diabetes, they lack the ability to control their blood sugar levels. Normally when we eat food we consume sugar: pasta, fruit and jam for example all provide sugar in one form or another.
Our bodies are generally dead clever at working out how much sugar we need at any one time. And so as we consume food and our blood-sugar levels rise our body tempers the blood-sugar levels by producing insulin. The insulin then facilitates the transfer of glucose (sugar/energy) to our body’s organs, which in turn lowers the blood sugar levels. Someone with type 1 diabetes however isn’t able to produce any/enough insulin and a type 2 diabetic produces insulin but their body is resistant to it.
Someone with type 1 diabetes constantly monitors their blood sugars through the day using a finger prick test or more commonly now, a constant glucose monitor (usually found on their upper arm). They will see their doctor (maybe 1 – 4 times a year) who helps them to work out how much insulin they may need to inject themselves with, based on their average activity levels and individual metabolism.
A diabetic can become hypo (rhymes with low – hypoglycaemic/low blood sugars) or be hyperglycaemic (high blood sugars).
“How to Save a Life With a Slice of Flapjack” – managing a hypoglycaemic casualty – learn more here.
Hypo, hypo, hypo – some context …
This past year, Patrick and I have spent a lot of time running together in the Peak District. Despite our best efforts, it’s been really hard to cover a 10Km route without him having a hypo. The body is far more sensitive to insulin when we’re exercising and so it’s easy to become hypoglycaemic. The continuous glucose monitor (CGM) on his arm is about 10 minutes behind his actual glucose levels, and so often, when he’s exercising, he will know he’s having a hypo before the CGM has even registered it. In turn we’ve been learning to be really proactive in managing his diabetes so he doesn’t become hypo when exercising.
It’s so common for him to become hypoglycaemic whilst out in the hills, that I totally forgot that hyperglycaemia (high blood sugars) at the other end of the spectrum are also a form of diabetic emergency to be prepared for …
Back to the Cyfrwy Arête (and reality)
I asked him what his sugars were at? The safe range for our blood sugars is somewhere between 4 and 7mmol/l and he now told me his were 18 going up.
As I romped up this easy pitch, my first thought was – oh he’ll be fine! His sugars are a bit high, so what? We’ll just exercise that off… A few meters higher and I knew this wasn’t true. I knew it was never so simple as that. I knew it was a beautiful day, I was climbing with my son, we were on a super 3 star classic and all I wanted to do was climb and that for that moment, I was in complete denial.
If his blood sugars had been high and he had insulin to give himself, then yes he could have simply ‘burned’ the high sugars off. But he was out of insulin, and we didn’t have our backup on us. Those sugars wouldn’t be going down any time soon and from experience, I knew this was something I had to take seriously. I knew we would have to escape from the route.
I built my stance and he climbed up to me. We were on the ‘Table Top’ now, and so an easy scramble allowed us to downclimb to the notch, situated between the arete we’d just ascended and the face above us. I had a 60m rope, easily long enough for an abseil, and two climbers were close behind (who could, if need be, toss down my rope after us). It was a no-brainer to abseil off.
Patrick, with his chiming pump, was now tied to the rope and ready to be lowered off. First though, I wanted an idea of where his sugars were at now: 20 and rising. As he reached the ground I noticed he then took a pee: another key sign of a hyperglycaemic casualty. It was a hot day, and I knew he’d need all my water, in addition to his own. When a diabetic casualty is hyper, they will urinate far more than is normal.
Mountain Rescue
Thankfully, abseiling off was straightforward and easy. I knew the right thing to do now, would be to call 999 and to alert mountain rescue. Calling mountain rescue before an emergency is a really good idea. I didn’t think they’d be needed, but I knew they would want to know what was going on should matters get worse. But also, as I was hatching a plan, I wanted to have a second opinion from someone who would have a wealth of training and experience, and who would have a calm and rational thought process.
Before calling mountain rescue though, I wanted some information, and so I handed Patrick my casualty card to start filling in, whilst I coiled the rope. As I finished stashing away various kit, I handed him my water bottle and told him to drink. On the reverse side of the casualty card I noted the time he’d just had a pee. All this could be relevant and helpful information, further down the line.
As well as the outs, I wanted to know the ins. He’d had a sandwich just 40 minutes ago or so … I reckoned on 40g carbs in that … I was doing some rough sums in my head … 40g of carbs would bring his sugars up 8mmol/s. It wasn’t important: his sugars were rising and I need to get him off! I was making a note of all of it nevertheless, trying my best to write legibly in case anyone would need this record later on. His vital signs were then checked, and they were all good.
We called the police and requested mountain rescue, and then we began our hike off the mountain.
You want me to get back up that hill?
We were making good progress descending down through the scree. It then occurred to me that he might still have some ‘insulin on board’. When diabetics inject themselves with insulin the body takes time to absorb this and the pump he had would be able to estimate how much insulin was still on board.
He had 0.91 units on board – I figured that might normally bring his sugars down 2 mmol/l but with exercise having a ‘multiplier’ effect, then maybe more? While I was checking out a safe passage down through some steep ground, I told him to head back up the hill. He didn’t look too pleased. I explained my theory, and without another word, off he trotted! (To this day I have no idea if that was a good idea or not).
It was 18 minutes since our first call to the police before we received a text message from mountain rescue with a SARLOC link – a means for them to track our location. Another 8 minutes later they called me, 26 minutes since my initial contact with the emergency services. A lot of people don’t realise that when you call for the mountain rescue, that that call has to be relayed through various centres before it gets to the team that will be helping you. It’s never instant, or if it is, you’re very lucky!
I told Dave the call handler my plan. He sounded reasonably calm and was happy with my thought-process. We pressed on.
The signs and symptoms of a hyperglycaemic diabetic casualty …
Maybe ten minutes later, he called me back, no longer sounding so calm. I think he may have talked to a team medic. He was now going through a list of questions … Was Patrick nauseas or feeling sick at all? Did he have stomach pain? No and no. Did he have fruit-scented breath (like pear drops) – yes maybe; did he have any shortness of breath, confusion, dizziness, or altered mental status? No, no, no & no.
But he had just peed again. His sugars were now at 23mmols/l.
Why are high blood sugars a big deal anyway?
(And what are Ketones all about?)
The one thing that Patrick needed, right now, more than anything, was insulin. And this was in an ice-box, in our car. (And it is with some shame, I write these words – since that was my responsibility).
My reckoning was coming later
I was thinking ahead. At home, if Patrick goes this high we have ‘sick-day rules’ we follow. This is in essence an aide-memoire how to manage a hyperglycaemic casualty’s sugars and condition. It gives you clear step by step instructions of what to do. I didn’t have them with me, but I knew my wife would. At this point, I reluctantly called my wife to let her know what was happening, and to ask her to send me a picture of the sick day rules. We both knew my reckoning was coming later.
Dave called me back again to check in on us. Patrick heard him say an air rescue unit had now been put on standby. Oblivious to the enormity of the situation, Patrick joked maybe if he had a granola bar now he’d get to ride in a helicopter! We wouldn’t need rescuing, we were nearing the car park now.
What’s the treatment for hyperglycaemia?
If someone is hyperglycaemic they need insulin. This is not something a first-aider can ever administer since every diabetic has different ratios to the next. Fortunately Patrick’s levels of consciousness were still good. He reached for his insulin kit, and first took an accurate reading of his sugars using a finger-prick. Unlike the CGM this gives a real-time reading of his sugars.
He then calculated how much insulin he’d need. The key thing here is to under-dose slightly. We’ve found in the past if he takes too much insulin in one dose he then feels nauseas. He noted how much insulin he took and made a note to review his sugars an hour later. Additionally, now was a time to check his ketone levels. Fortunately they were zero and so we knew he was safe.
What’s the first aid for a hyperglycaemic casualty?
There are myriad of reasons for someone having high blood sugars: maybe their pump hasn’t fitted properly to their tummy, maybe the insulin has denatured in the heat, maybe they didn’t take enough for a meal … The list of causes is endless.
That day my training kicked in and I knew that even though Patrick looked ok it could very easily get worse. So if you’re a first aider managing a hyperglycaemic diabetic casualty, in the mountains, just stop.
If the casualty has insulin, allow them to correct their sugars as necessary. If there is no insulin available, call 999 and organise a rescue. Keep your casualty as hydrated as possible and continually monitor their sugars and their vital signs, keeping a record using your casualty card. If you have the means to check their ketones this will also be really good information to have to inform the emergency services how serious this casualty is.
When to call 999 for diabetic (hyperglycaemic) casualty
Diabetics’ sugars swing from high to low and back all the time. Just because someone hits 20mmol/l doesn’t mean they need to be rushed off to hospital, so long as those sugars are on the way back down again. You need to call 999 when:
- The casualty’s sugars are high and they have no insulin to correct them
- The sugars are high and treatment with the insulin they have is not taking any affect
- The casualty shows signs and symptoms of going into KTA – breath smells of pear drops/fermented fruit, nausea, shortness of breath, confusion, dizziness, or altered levels of consciousness
- You measure the ketones and they are 2 or higher
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