Thursday, July 9, 2015

Diabetes 101, or Put Down the Fucking Candy

Edit: This page seems to be getting a lot of traffic, which is unexpected, and I wish now that I'd done a better job of explaining some things about diabetes, both Type I and Type II. I certainly never expected this to be passed around as a PSA!

For those of you just visiting, this blog is a meandering mess of rants and stories about my experiences as a nurse, and the health education aspects are intended to help readers understand a little more about what I handle at work and what it means when I say my pt is "in DKA" or "doesn't take their insulin." I initially made this blog for a pretty small audience of people who were already familiar with my forum posts, and nothing here has been edited or really even thought through. I'd say half of it was written after at least one round of gin & soda.

So what you'll find here may be useful if you're trying to grasp the very basics of hyperglycemia and what it does to the body, but I strongly suggest: if you find this interesting at all, go find some other sources and do more reading. There is SO much more to this topic, and this page-long rant barely begins to scratch the surface.


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A colleague of mine related the tale of a pt, a young man with Type 1 diabetes, who went into diabetic ketoacidosis (DKA) and didn't get appropriate treatment. After a walk-in clinic failed to diagnose his impending health crisis, he went home and chugged sugar syrup-- the drink mix that's poured into soda machines, where it's diluted with carbonated water for serving-- until he lost consciousness. The next day he was delivered by ambulance to the hospital, where he died horribly.

So what the hell, you're thinking. If you know you have diabetes, why would you pound syrup like cheap beer? No, he wasn't just some stupid fuck who wanted a Darwin award. There's a genuine reason for this...

...so it’s pathophysiology time, motherfuckers. (That will be the title of my children’s network show someday.)

We kinda tend to think of insulin and sugar as polar opposites. Too much insulin and your sugar goes away and your brain tissues starve; too little insulin and your blood sugar goes up and, uh, this is bad. Somehow.

That’s really just part of the picture. Yes, the syrupy-thick blood is super bad. Sugar is corrosive to the blood vessels (just ask any nurse who’s pushed dextrose 50% into an IV and watched the vein blow) and over time even moderately high blood sugars rip and scar your arteries and veins. This is incredibly bad for things like your legs, which are the farthest from your heart and have a hard time getting blood back and forth to begin with. A few years of sticky scratchy sugar blood, and the nerves die from poor circulation, wounds stop healing because no blood is getting to them, and eventually your legs just rot off. The syrupy-sweet blood is just fudge sauce on the leg-flesh sundae that bacteria love to eat. This is why diabetics lose their legs. (The nerve damage is why diabetics go blind.)

Your kidneys, likewise, are almost entirely made of blood vessels. Too much sugar gouging out your kidneys = scarred up kidney circuits that are too damaged to let the water through. Bonus: when your blood sugar is insanely high, your kidneys can try to compensate by squeezing sugar directly out through your blood filters, which lets you piss away the dangerously gooey stuff… but rips holes in your filters, essentially. This is why diabetics have kidney failure and end up on dialysis.

On top of all that, your heart and brain blood vessels get shredded to boot, which is why diabetics have so many strokes and heart attacks. Diabetes is bad shit.

But there’s something even more dangerous than just having your blood turn into razor soup. Thick, dense blood is like a sponge, sucking water out of your tissues (read: organs and muscles). When your body enters a diabetic crisis, you become so thirsty you can’t fucking stand it. Undiagnosed diabetics are often spotted because they pack a couple gallon jugs of water to bed with them when they sleep at night. And as soon as their blood thins out a little, their kidneys dump all that new water in an attempt to flush out the sugar, further ripping themselves to shreds… which is why undiagnosed diabetics are also often spotted because they pee themselves in public or spend 2/3 of their day pissing away the gallons of water they’re chugging.

Soda-fountain guy was thirsty as fuck, and all his body’s instincts were telling him to slam a bunch of liquid. But why the fuck choose soda syrup? What the hell?

To answer that one, let’s get back to what insulin does. It doesn’t magically make sugar go away; your cells have their mouths locked shut to keep them from eating every damn thing that goes by, and insulin is the key that unlocks them. If your body doesn’t make insulin (because it destroyed all its own insulin cells), fuckin blows to be you, because your cells will starve surrounded by delicious food. If your body is fat as hell and all that fat is secreting endocrine shit to inform your body that you have enough fucking food to last you a month, your cells become insulin-resistant and it takes a lot more insulin to open those locks. (This part is the least-understood part of the whole fat ---> diabetes cascade, but while we don’t know exactly how it happens, we do know that excess fat leads almost inevitably to insulin resistance, and the ‘almost’ is generous.)

So now your cells can’t eat. Your blood is getting thicker because the onslaught of sugar isn’t slowing, but your cells are starving to death, being ripped apart by sludgy sugar sauce, and having all the water sucked out of them by your spongey thick blood. Insulin also allows your cells to eat the potassium they need to keep their internal pumps running, so now your potassium is backing up, causing your blood to become acidic, and making all your cell’s pumps run backward. In desperation, your cells start burning protein, which is a really poor energy source because it’s actually the cell’s furniture and tools. At this point, shit inside your cells is so bad that instead of putting food on the table, they’re chewing on the table legs in case the varnish is edible.

This is why that poor motherfucker was drinking sugar syrup. He was literally starving to death.

Many diabetics think they have low blood sugar right up until they realize their blood sugar is actually high—their cells just can’t eat any of it.

Broken-down proteins and fats produce ketones. Starving cells produce lactic acid. Between those two and all the extra potassium, your blood turns to acid in your veins. Over time, your kidneys might have been able to slowly compensate for that by secreting bicarbonate, but right now they’re busy squeezing sugar and potassium out through their battered assholes. The only other way your body can try to fix the whole ‘acid blood’ problem is by blowing off as much carbon dioxide as possible, since carbon dioxide is acidic when dissolved in blood. Soon you’re sobbing for air like you’ve been running a marathon (another situation in which stressed-out and starving cells dump tons of lactic acid), your body is so dehydrated you’re losing your mind and your organs are failing, your cells are so hungry they’re literally eating themselves, and so much potassium is backed up in your blood that your heart’s muscle-pumps get overwhelmed by the back-pressure and your heart just… stops.


If you're lucky. Massive organ failure due to combined starvation and shredding is your other, slower option.


DKA is a horrible way to die.


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Addendum: Type 2 diabetics get a similar thing, hyperglycemic hyperosmolar nonketotic syndrome, which does basically the same thing as DKA, but with even higher blood sugars and a lower chance of survival.

21 comments:

  1. This one is getting copypasted and retold everywhere, and for good reason; this is one of the few articles on the Internet that accurately captures the horror of diabetes. For people who have had Type 2-related deaths happen on both sides of the family, it's absolutely fucking terrifying.

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    1. I am 100% okay with you sharing this as much as you like, as long as it helps somebody's legs not fall off!

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    2. Thanks for the addendum about the similar thing that happens in type 2. Could you explain the "nonketotic" part or is that too complicated for a blog post?

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    3. I could totally try-- I feel like this kind of post is a place to start in understanding diabetes, but there's so much more depth and so many things that are best understood initially as metaphor, and I would love to see people getting deeper into pathophysiology than I can take them with horror stories.

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    4. As the parent of a Type I IDDM child since age 9, I applaud your article. My daughter is now an adult with a small child and a home of her own. She sports an insulin pump and a continuous glucose monitor and she is only rarely lower than 70 or above 120, although she was this week, with the flu. The gross misinformation on Type I, and on Type II IDDM that is disseminated by the public is shocking and frightening. Thank you for whatever you can do to clarify for people and their families.

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  2. Can I translate this into Dutch to have some ignorant people around me read this so they can see the light?

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    1. I would be ridiculously flattered, and also glad you feel like it's an effective article!

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  3. Is there something he could have done to save himself and stave off the starvation that pushed him to the sugar syrup?

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    1. I'm curious as to what you think about this one, Elise.

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    2. Once DKA is in full swing, you genuinely need medical help to recover, and your only real shot at survival is to get to the hospital stat. DKA requires a shit-ton of insulin in measured doses over an extended period of time, close monitoring of shifting potassium and other electrolytes, and most importantly, an absolute tsunami of IV fluid.

      The best way for diabetics to avoid DKA (and the Type 2 non-ketotic version) is to monitor your blood sugars closely, drink a lot of fluids when you're sick, and stay in contact with your doctor so you can get any abnormalities looked at before they turn into something even worse.

      The best way for non-diabetics to avoid this kind of fate is to avoid becoming diabetic at all.

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    3. I don't really understand this advice - this is a story about a Type 1 person. How could he have avoided becoming diabetic?

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    4. He couldn't have, although he could have avoided DKA if he were aware of what was happening and had sought treatment. However, Type I diabetes makes up less than 10% of the diagnosed cases of diabetes in the US, and the Type II version of DKA (hyperosmolar hyperglycemic nonketotic syndrome) affects the body in a very similar way.

      Many people with Type II undergo HHNS and have no idea what's happening to them, or-- even in the absence of crises like this-- why diabetes is killing them slowly. Knowing how diabetes works at a basic level, even if it's demonstrated through a dramatic story about a different type of diabetes that presents similarly, might help other people avoid this poor man's fate. Nobody is going to get a truly deep understanding of medicine from this blog, though-- it's a crudely written mishmash of personal experiences, jargon, layman-friendly explanations, and metaphors. I strongly encourage anyone who finds their interest piqued to go read more and better works on these topics!

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  4. I just want to thank you for this. I am a 40 year old candy addict, seeing the light for the first time. I get it now.
    Thank you.
    Thank you.
    Thank you.

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  5. Very good way to describe it. I teach (or try) diabetics all the time about the disease process, which combines with hypertension and hyperlipidemia (high blood pressure and high cholesterol) and that their kidneys and blood vessels are permanently damaged from elevated blood sugar - just because they take their meds doesn't mean they can eat whatever they want to and complications of diabetes is what gets you because it damages so much of our bodies. Argh... This was very well put.

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  6. Shared this with my Type-2 coworker today. He is careful with his health but he appreciated the read all the same. Diabetes is a scary disease.

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  7. Replies
    1. You can do whatever you like with it, as long as you don't sell it! ;)

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  8. As a type 1 in the early stages of DKA when I was diagnosed, this brings back some horrid memories of the months I spent not knowing what the hell was wrong with me (It's a really hot summer, that's why I'm so thirsty! Man, I must be sleeping in some weird-ass positions to get leg cramps this bad!)

    Sending this to the people around me who might be curious about what exactly was going on at that time. Love your writing style.

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  9. Thanks from France . Need more articles like that .

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  10. As a type 1 reading this was a horror story for me. I don't like u

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  11. As a recently-diagnosed type-2, this was a thousand times more informative and evocatively-written than any official literature that I've managed to find anywhere.

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