The ER nurses had a hard time getting the needle in. My normally plump veins are so empty that they’ve retreated into my chalky flesh, dehydration camouflaging their true locations. Still, the IV fluids are finally running now, although I can’t say that I’m feeling any better. Not that I’m feeling any pain. Or nausea. Or much of anything. I’m feeling… well, I’m not sure what I’m feeling. Confused mostly. Cloudy headed. Tired. Dizzy even though I’m lying flat in a hospital bed.

Behind and above me, the heart monitor sounds an alarm again. Blood pressure low, heart rate high.

My mouth is parched, tongue as dry as if I’d crawled across the sands of the Sahara for days following a plane crash in the arid, barren waste. I try to reach for one of the popsicle-like sponge-on-a-sticks on the nearby countertop, but I might as well be in a straitjacket. Tubes and cables entangle me like a Borg octopus, limiting my movement.

My diabetes “sister” Lisa hands me one of the sponges while she listens to my wife rant about the wait time on a Monday afternoon at the ER. “Why didn’t you just tell them your husband’s a type 1 diabetic who’s been throwing up?” Lisa asks, “That’s what I always do. Gets me right to the front of the line.”

I’m appalled. “No,” I croak though parched lips, “I’m not playing the DKA card just to get accelerated service.” The mere notion is… wrong… offensive. Like using diabetes as some sort of excuse. A crutch.

At that very moment the harried ER doc enters the treatment room and without pausing for breath says, “Well, you’re in DKA.”

“No way,” I say, stunned, and not just by the timing. I’ve written about DKA. (More than once.) I’ve taught people about DKA. I’d know if I were in DKA.

The doc, literally, rolls her eyes.

“I’m sorry,” I stammer in apology, “of course there’s no mistaking something like that, but it never once crossed my mind that I was in DKA.”

The doc gives me one of those withering looks the medical types reserve for people who should know better, and goes on: “Your white cell count is through the roof, you’re severely dehydrated, your electrolytes are way off, and you’re starting to having some issues with your kidneys. I’m admitting you. You’ll be here at least two days, maybe more, while we sort this all out.”

DKA? Me? How is that possible? I’d know if I was in DKA… wouldn’t I? 

 

Diabetic Ketoacidosis: The 411

People with type 1 diabetes live life on a tightrope. To one side, low blood sugar—called hypoglycemia—can kill you. On the other side, high blood sugar can trigger something called Diabetic Ketoacidosis, or DKA. It can also kill you.

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Here’s how DKA works: When insulin is low, the cells in your body can’t metabolize sugar. Even if there’s a ton of sugar to be had. Sans insulin, no matter how much glucose the cells are swimming in, they can’t get a sip of it. Starving in a sea of plenty, the cells turn on each other, the lean and mean ones attacking the fat and lazy ones. Instead of sugar, the cells start metabolizing fat for fuel. Yep. It’s cannibalism in the best tradition of the B&W Tarzan movies of the mid 1930s. All across the jungle of your body, as distant war drums throb, big iron pots are dragged out of thatched roof huts and oily cooking fires are lit. The smoke from those oily, fat-cooking cannibal fires rises above the jungle canopy, blocking out the sun… 

In the literal case of your body, these sooty smokes that are the byproduct of metabolic fat burning are called ketones, and their presence in high enough volume shifts the entire bloodstream to a more acidic point, hence the acidosis in the name of this most dangerous of diabetes complications.

And that can cause some bad shit to happen. Including death.

The main symptoms of DKA that we’re told to watch for—other than those associated with high blood sugar in the first place, like crazy thirst and peeing like a race horse—are nausea or vomiting, abdominal pain, fruity-smelling breath, rapid breathing, and confusion.

Of course, you can’t smell your own breath. If you are confused you probably don’t know it. And most people aren’t aware of their respiration rate. So the main warning sign of impending DKA that all type 1s are taught to be alert for is the union of nausea and abdominal pain in the presence of high blood sugar. 

And I never had any. Nausea or pain, but clearly as my doctor noted, I was experiencing DKA.

 

My DKA Experience

What happened? I still don’t know. A lot of it is a blur. Something made me sick. I did throw up, but my sugar was at a normal level when it happened. But then things went south. My blood sugar level started rising and wouldn’t stop. I threw insulin at it, but it all happened so fast. So frickin’ fast. It only took a few hours, coasting just below 300 mg/dL, to send me into a full-blown metabolic crisis that left me in the hospital for three days, two of them in the ICU. 

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Days later my endo, flipping through the 59 pages of lab results from the hospital and scrutinizing my Dexcom CGM data, remarked that it looked more like a “pump DKA.” But I’m not on a pump. I’m on MDI (injection therapy), shooting up basal insulin twice a day and fast-acting several times a day in addition. But somehow the sugar got ahead of the insulin. Way ahead. Maybe I had some bad insulin. Maybe I made a mistake. But that’s not important. Not now. What’s important is that the possibility of DKA—a fundamental reality of my condition, my life—simply wasn’t in my playbook as a possibility anymore. How did that happen? 

I think it’s a bad side effect of good control.

 

Familiarity Breeds Contempt 

Back in the day, I had a complete diabetes Go-bag, equipped with everything: Glucose meter and strips. Blood ketone meter. Long-needle syringe for intermuscular injections when high. Glucagon ER kit. Spare stuff for whatever therapy I was using at the time. I was a one-man mobile diabetes treatment team, ready for anything.

But my diabetes has been in pretty OK control for a long time now, and over the years I’ve gotten lazier and lazier. Lately, I’ve been traveling light. CGM on my arm beaming sugar data to my iPhone, Flexpen in my back pocket, and a sleeve of Transcend glucose gel in each front pocket. A few spare pen needles spread across the pockets of the various jackets I favor, plus a few more in the glove box of my car.

When this disaster struck, not only did I have no clue where my ketone meter—with its dead battery and long-expired strips—was, it never even once occurred to me during this little adventure that I should test for ketones. The entire subject had plumb dropped out of my mind.

I’m closing in on two decades of diabetes with no DKA, never even close, really, and I think that lack of dancing with the Devil has lulled me into a false sense of security. Simply put: Because it has never happened to me I must have begun, subconsciously, to believe that it couldn’t.

But diabetes never rests. Neither, too, can we afford to.

 

Back to Basics

As a pilot, I’m required to undertake ongoing training to keep my license current. Many professions require something similar. It’s called Continuing Education. Even doctors must continue to learn. Part of continuing ed is to ensure that professionals keep current with changes in their professions, but it’s also a way to ensure that parts of your knowledge portfolio that you rarely use stay fresh. Like the fundamental need for people with diabetes to have a sick day plan, something I’d long forgotten about from lack of use. 

So now humbled, well-bruised and battered from my stay, telemetry alarms still echoing in my ears, I’m faced with the need to go back to the basics. To re-learn the risks, the skill sets, the tools that I was introduced to all those years ago following my diagnosis… and have forgotten since.

And I bet I’m not the only one, so I’m inviting all of you to join me on this journey Back to D-Basics, right here at DiabetesMine, starting with revisiting DKA prep today.

What am I doing to avoid a repeat performance? Other than the renewed awareness that DKA exists, can happen to any of us, can happen with stunning speed, and may not come complete with all the symptoms we’ve been taught to expect? Well, I:

  • Turned back on my CGM’s “high” alarm. Suffering alarm fatigue, I’d turned it off a while back, just leaving the low alarm in place. I made the mistake of thinking that lows are the greater threat. Now I am reminded that both highs and lows are equal threats.
  • Bought a new Precision Xtra blood ketone meter and the very expensive strips that feed it, to better assess the DKA risk when I’m running high. Any time I’m over 275 mg/dL for more than two hours, I’m breaking that puppy out. If that meter clocks anything above 1.5 mmol/L, I’m getting my ass to the ER. Even if I feel fine.
  • Dug out a ½-inch needle syringe to carry in my re-constituted Go-bag. If I have a stubborn high, injecting correction insulin into muscle, instead of fat, gets the insulin on the job faster—reducing the risk of DKA.
  • Am now carrying said Go-bag around with me again. Everywhere. No more traveling light, I’m packing everything I need to survive and thrive. I guess I’m a Born-Again Diabetic for real.

For my next refresher lesson, I'm thinking of revisiting insulin temperature control. How hot or cold can it get before losing its punch? How would you know in either case? And what tools and tricks do we have to keep it safe?