Dulce

Diabetes Mellitus comes in two forms. Type 1 diabetes usually begins in children or young adults. It is a failure of insulin production by islet cells in the pancreas. Type 1 diabetics require insulin to survive. At this time there is excellent treatment but no cure for type 1 diabetes. Type 2 diabetes was in the past referred to as adult onset diabetes. Obesity, advanced age and lack of exercise are risk factors. As obesity has become an "epidemic" in the USA, the incidence of type 2 diabetes has increased, even among children. Type 2 diabetics produce insulin but the amount produced is inadequate for the body needs. Target tissue, such as muscles, and fat become resistant to the effects of insulin in type 2 diabetics.

As an ER doc I have seen children who present with what seems to be viral gastroenteritis. Persistent vomiting, and clear signs of dehydration are evident. The child has an abnormally high respiratory rate. The lab tests tell the tale. The child has an elevated glucose, low bicarb and elevated serum acetone. This is the typical picture of a child with new type 1 DM. The child and his or her family will never be the same. This is a life long condition.

My friend Ken developed DM when we were 8 years old. The monitoring of glucose levels, at that time, was by urine testing. I was given a basic understanding of the signs of high and low glucose levels. Hypoglycemia, low blood sugar can be obvious or subtle. Ken and I were playing a board game at my house (it was the early sixties, no electronic games). He started acting odd. He played poorly and then turned over the board. I asked him to leave. As he tried to ride his bike up the street, it hit me that he was having an insulin reaction. I chased after him, dragging him back to my house and force fed him OJ with sugars added. He rapidly returned to his usual affable self.

In the past months I had three patients who demonstrate the complexities and potentially devastating effects of DM and it's treatment. Frequent monitoring (blood testing), multiple injections and or pills, and constant attention to diet and exercise is daunting. Long term complications of DM are manifested by kidney failure, vascular disease, visual problems, and nerve damage. Diabetes is the leading cause of both kidney failure and blindness in the USA.
Vascular disease increases the diabetic's risk for heart attack, stroke and peripheral vascular disease.

The first patient in my diabetic trio was a 70 year woman who's presenting complaint was weakness. Her symptoms had progressed over 2-3 days. She was somewhat confused. Her attentive family gave her medical history and described her rather sudden change in health. They also brought all her medications. The nurses had done a capillary blood sugar immediately and it was 460. Her physical exam was remarkable for generalized weakness, clear lungs with a respiratory rate of 28 and disorientation to date and recent events. She took oral medication for her type 2 DM. I noticed that the amount of metformin she was taking was above the usual recommended amount. An arterial blood sample revealed a pH of 6.67. Normal pH is 7.4 and as this is a logarithmic scale, her pH showed a profound acidosis. Her lactic acid level was 15 (normal is 2 or less). As I began treating her with insulin, IV fluids and Bicarb, I admitted her to the ICU and called the intensivist. I gave him her history, physical and labs. His comment was that with a pH of 6.67 she should be dead. Luckily she recovered completely. Her life threatening lactic acidosis was most likely caused by the metformin she took for her DM.

Patient 2 and 3 came to the ER the same night. Patient 2 was a type 1 diabetic who worked construction. This has been an especially hot and humid summer and he was working outdoors doing heavy labor. Low blood pressure, dry skin and mucous membranes, and tachycardia, prompted rapid infusions of IV fluids. Even after 3 liters of IV fluid, the patient had not produced any urine. A catheter was placed in his bladder and only a trickle of urine was obtained. The lab tests showed a critically elevated BUN and creatinine. My patient had kidney failure. This gentleman was an undocumented immigrant. He was an honest and hard worker. He supported his family. He obtained insulin by occasionally seeing a doctor in a local clinic. His lack of insurance precluded him from getting the close supervision and support that might have prevented this complication of DM. The heat and hard labor had sealed his kidneys' fate.

My third diabetic patient in this tale, was a type 1 diabetic who had insurance, a good job, a supportive family and access to good health care. This gentleman was in mild ketoacidosis and was very hypertensive. He had not felt well for a few days. He had little appetite, nausea and some vomiting. His response to these symptoms was to stop taking his insulin and blood pressure medications. This is an all-to-common reaction by diabetics. No eating=no need for insulin. The treatment was not difficult. Insulin, IV fluids, blood pressure control and admission to the hospital. The difficult aspect of his care was convincing him that he needed in-patient treatment. "Can't I just go home?" His wife and I were able to get him to agree to being admitted. He thanked me and assured me that in the future, he would do better at managing his diabetes.

The incidence of diabetes in patient who go to ER's, is much higher than the rate in the overall population. Poor compliance with treatment is rife. As a person with obsessive-compulsive tendencies, I would like to think that the frequent finger sticks, strick diet, and need to keep one's weight stable would be easy. The reality is that managing DM is very time consuming. Diabetics want to be just like their non-diabetic friends. They want to have fun, eat junk food, have an alcoholic beverage (or two), and be one of the guys.

No lessons will be offered in this blog. Diabetes, with all varying forms, and both short and long term complications, does not lend itself to simple fixes. I would encourage everyone with diabetes to see their physician regularly, take their medications as prescribed, and seek help early with any changes in their health.