JULY is a good month for us usually in the Emergency Department. The “trades” are on, the town is relatively deserted, and bar the odd catastrophe, things are generally under control.
We never use the “q” word, but we are in a brief moment of calm before the storm of wholesale staff changes and the invasion of the tourist hordes in August.
Sean should also be having a good month. He’s just finished high school, and was at one of a string of leaving parties at the weekend when he let himself go. Sean’s life is tinged with injustice. Whilst all his pals are rejoicing without inhibition, he has to hold it back, as he knows too much alcohol will unsettle the control he normally has over his diabetes. The regime of injections four times a day for the last eight years finally infuriated him enough for him to proverbially throw in the towel on Saturday night, and he went on a proper bender. Now he is paying back that debt.
Whilst most of us don’t have to worry about our bodies keeping our sugar levels within closely managed limits, Sean, does not have the ability to produce his own insulin. Without insulin (that can only currently be given by injection under the skin) the body cannot draw sugar into the cells to be used to create energy for our bodies. The sugar therefore builds up in the blood stream to a level where it starts to be pushed out through the kidneys into your urine. Diabetes mellitus literally translates as “lots of sweet urine”.
If left unchecked, the sugar levels continue to rise and cause the body to lose litres of fluid through the kidneys. The body also starts to source energy through other routes, breaking down fats and proteins to keep your systems functioning. The combination of loss of fluid and the lack of fuel accessible make the body build up an energy debt, becoming increasingly acidic and unhappy, affecting all of its systems, and making Sean feel awful.
Once at this extreme level of disequilibrium, Sean is in a condition termed Diabetic Ketoacidosis (DKA). It’s a condition you can diagnose as you walk past a patient’s cubicle. Firstly, you can smell the ketones (often from ten yards away) on a patient’s breath – a by-product of the alternative energy sourcing the body has to undertake. You can hear the breathing – fast and deep as the body tries to breathe off its excess acids by converting it to CO2, and interspersed with vomiting caused by the build up of ketones and prostaglandins in this extreme inflammatory state. Lastly, you can see the typical features – a young patient, thin, cracked lips, vacant stare, streaks of vomit around the mouth, sunken eyes, curled up, clutching their aching bellies. Now is not the time for the lecture on good diabetic control. This life-threatening condition, often with perilously high levels of acid and potassium in the blood, needs treating.
Simultaneously with a brief focused history and examination, we set about inserting two intravenous lines. Through these lines, we take some routine blood samples. One of these we can analyse in the Emergency Department within the first couple of minutes, and it allows us, with the pulse, blood pressure, and other routine observations, to estimate the level of fluid depletion and sugar and salt imbalance that Sean has developed. As soon as these samples are drawn off, we start treatment.
Perhaps surprisingly, the most important first treatment is not insulin, but fluid replacement. Restoring the circulating volume in the blood stream, diluting the high concentration of sugar, and allowing vital organs to be perfused again can require many litres of fluid replacement.
Very shortly after the fluid has been connected, we start an insulin infusion. This starts to allow the body to drag the sugar from the bloodstream into the cells where it is needed. It also reverses the breakdown of alternative energy sources within the body. This follows a standardised protocol to ensure that the sugar levels are carefully moved back towards the normal zone for the body.
As these two treatments are having their effect, we carefully monitor the levels of potassium and acid. Often, the acid levels stay about the same or can sometimes increase as the fluid replacement flushes out acidic tissues and organs of the body. The blood potassium level is often high when patients arrive in the Emergency Department, even though they may have less potassium in total in their body. This can sometimes cause the heart to go into dangerous rhythms or even cardiac arrest. One of the effects of the insulin infusion is to pull potassium with sugar into the cells, so as the sugar levels drop, so can the potassium, so much so that we may need to actually replace potassium through the drip after an hour or two.
Three hours after arriving in the ED, Sean is looking more human. He has stopped vomiting, feels less sore, and is better hydrated. He will still need a day or two in hospital to ensure he continues to recover properly – a high price to pay for a lapse in control of a condition that seems an unfair affliction.