How Well Do You Control Your Diabetes?

October 21, 2017

It was day eight in the emergency department, and just like always, I started my shift with vigor, zeal and the willingness to become a better provider. Treating people wasn’t a chore here. It’s not that I have to do it. It’s I get to do it. And I love it. Even after an exhausting 12-hour shift, it is so uplifting when a patient looks at me in a certain way- the way that tells me that I have exceeded their expectations. I have never doubted that I chose the right profession, until that one day…


There wasn’t much going on in the emergency department that late afternoon. I tried to pick up as many patient charts as I possibly could to see who needed my attention the most, but the majority of patients were just complaining of headaches or sore throats. As I returned to my desk to review their charts, EMS radioed in with what sounded like non-emergent traffic, yet on a day like this, it was definitely something more serious than anything I was treating.  


The man brought in on a stretcher was young, probably right around the age of 45. The paramedics looking for a provider to pass the patient off to, found the doctor I was currently rotating with. As the patient was being rolled down the hallway over to the acute side, the paramedics reviewed the patient’s history with the doctor. The large man on the stretcher looked tired, he was moaning and turning his head back and forth as if he was lost or confused. The paramedic stated that he’d been acting this way since they picked him up from his family’s house. The patient was experiencing neurological side effects from his uncontrolled diabetes. The paramedic stated that apparently the patient had been refusing to use his insulin for the past 2 weeks. I looked over at the patient right before we entered the room and he appeared to be agitated and unaware of what was going on. 


As he got settled in, we called the nurse to place his 5 lead for cardiac monitoring and start an IV for blood work and medication initiation. After the finger stick confirmed a blood sugar of 800, insulin and saline were ordered. We didn’t hear much from that patient until the nurse let us know that he was tearing off his IV’s and unconsciously removing the cardiac leads. The nurse tried to get everything under control but the patient became combative. The physician knew that if his blood sugar didn’t get under control soon we would be facing many bigger issues. So the patient was sedated and put to sleep. 


I stood by the doctor as he called all his orders, I was content just being by his side observing, just observing. But then things changed... I don’t think I will ever forget that moment when the doctor called my name and told me to intubate the patient. I felt my heart stop. What? Me? Intubate a patient, like right now? My heart started racing and my palms started sweating, I reminded myself of that one time I intubated a dummy. It wasn’t so bad, right? As I stumbled over to the bedside, I looked at the patient and quickly snapped backed into reality, this wasn’t a dummy. This was a person, someone’s son, someone’s brother, and maybe even a father. If I was going to intubate him, I had to do it with confidence and couldn’t mess up. But then I started thinking of all the things that could go wrong, what if I crack his teeth, rip his vocal cords, or can’t get the tube in fast enough and he becomes hypoxic. I think I psyched myself out. I stepped back and looked at the doctor and asked: “is it okay if you do this one and allow me to observe?” He nodded at me and said, “alright but the next one is all yours.”


With so much confidence the doctor tilted the patient’s head and lifted his chin. After two squeezes with the Ambu bag over his nose and mouth, he advanced the curved blade in preparation to begin the intubation process. It looked liked things were coming along until the doctor’s voice changed and he asked his nurse for suction. There was a greenish/brown fluid coming up and out of the esophagus. I couldn’t tell you what it was and I knew it wasn’t the time to ask questions so I figured it just had something to do with the high levels of glucose and the body being in an acidic state. The doctor's voice was even more serious this time, he continued, “suction, suction, more suction!” The oxygen saturation was dropping, the doctor continued to maneuver the curved blade until he could visualize the vocal cords. With the oxygen level dropping significantly, the doctor removed the curved blade to allow for better suction. After a few more squeezes with the Ambu bag, the doctor tried again. This time he was able to successfully advance the curved blade far enough to send down the endotracheal tube. There was a collective sigh of relief from everyone in the room once the intubation process was over with.


As the room started to settle down, the provider confirmed the orders to be started for the patient and right before we left the room the cardiac monitor indicated an irregular rhythm. Just when we thought things were calming down, one of the nurse technicians yelled, he has no pulse (the heart was no longer beating). The code team was called and a wave of people came rushing in. Everyone grabbed a pair of gloves and got in line to perform CPR. The doctor looked over at me and asked if I had ever seen a patient go into cardiac arrest, I shook my head and he responded, “well get in line."


When it was my turn to start chest compressions, a million thoughts went through my head. Is this patient really about to die? Am I really about to witness my first death? Is it all because of his uncontrolled diabetes? My eyes started to water, there was no way he was going to die, I mean it was just diabetes. As I powered through my weak arms slowly started to burn, I thought to myself, but my dad has diabetes, and this could be someone’s dad. As a single tear rolled down my left eye and on to the patients chest, I felt embarrassed that I was so affected by what was happening when everyone else in the room was going about their job like it was another day in the office. I stepped to the side and let the nurse technician take my place. I took my gloves off and wiped my face as I watched 5 different nurses, technicians and providers all perform chest compressions for over 15 minutes.


The hand held radio attached to the head nurse kept going off, the receptionist from the lobby upstairs was asking if the patient could have visitors because the family had followed the ambulance to the hospital. In that very moment, I questioned everything about the career path that I had chosen for myself. Why did I want to do this, to watch people die? This was breaking my heart; I couldn’t handle it. There was a team of medical professionals fighting to save this man’s life while the family members upstairs had no idea what was going on. After multiple pulse checks, the doctor kept asking the team to push just 5 more minutes. We were easily about 30 minutes in now, and my chest felt heavy. Forty-five, he was only 45.


How many of you have a family member or know someone with diabetes? It’s actually a lot more common than you might expect, about 25.8 million people in the United States are living with it, while only 18.8 million of those people are aware they have it. Diabetes Mellitus is the 7th leading cause of death in the US and that night, it took its next victim.


Patients often find themselves in a state of hyperglycemia (increased blood sugar) because they haven’t been taking their diabetes medications as directed by their doctor. They feel fine, so they simply ignore the medication. This leads to a quick rise in blood sugar that may eventually alter your mental status if not corrected. Uncontrolled diabetes can also lead to long term conditions like microvascular and macrovascular complications. Microvascular complications include damage to the kidneys, eyes, and nerves while macrovascular includes complications that affect the heart and brain.


First, it attacks your kidneys; this is called diabetic nephropathy. If left untreated your kidneys will completely fail and you will have to start dialysis or get your name on a kidney transplant list. Next, it damages your nerves; this is called diabetic neuropathy. Patients with this condition suffer from loss of sensation in their peripheries. These are the patients that develop ulcers on the soles of their feet without feeling them. Finally, the disease progresses to take your vision; this is called diabetic retinopathy. You might notice the beginning stages of diabetic retinopathy with blurred vision and difficulty perceiving color. Mild cases can be treated with lifestyle modifications such as healthier eating and exercise, but advanced retinopathy only gets better with more invasive procedures like surgery or laser treatment. Now these conditions don't necessarily always show up in this order, but this is the most common progression I've seen. And unfortunately those are just the microvascular complications; the more serious conditions associated with increased sugar in the blood are side effects like hardening and narrowing of the arteries.


When the arteries that supply the heart and brain struggle to provide fresh blood, you literally deprive those organs of oxygen. This ultimately leads to heart attack and stroke. Adults with diabetes are 2-4 times more likely to have a heart attack or a stroke compared to those who are not diabetic. When your condition gets to this point, there is nothing and no one that can save you, trust me, that 8th night in the emergency department we did everything we could but the heart of our 45 year old patient just gave out on us. So please, save yourself from a situation like this. 


Remember, normal blood sugars usually run from 70-100 before meals and may go up to 140-150 after meals. Your blood glucose level should never go higher than 200. 


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