How Can You Help!
“I’ve got to get home! I’ve got to get home!”
All Steven Lee could think about was driving home as quickly as possible to save himself from the hypoglycemia he knew was quickly drawing him toward unconsciousness.
He passed right by a 7-Eleven store, where he could have bought the food his body so badly needed. But in his confused state, Steven could think of only one thing—home.
Finally, unable to drive farther, he pulled his car off to the side of the narrow street and shouted for help.
In just a matter of moments, people had rushed from houses on both sides of the street. By then, Steven was hitting his head on the steering wheel. His hands and arms seemed to be flying all over the car. His body was totally out of his control. Yet somehow Steven knew enough about what was happening to plead for some juice to drink.
Two men quickly lifted Steven from the car and laid him on the sidewalk while others ran to their kitchens to see what sweet drink they could find. The first returned with some orange juice. Another brought some fruit drink. Meanwhile, someone telephoned for an ambulance.
By the time the ambulance arrived, however, the juice was already beginning to raise Steven’s blood sugar level. By then, he was thinking more clearly than the nervous young ambulance trainee, who got his questions all mixed up.
After they had checked Steven over carefully and he had correctly answered every question, the ambulance attendants took him to buy some food at the nearby mini-market. They phoned the hospital to say that Steven was okay, and he drove away—going home at last, after the slight delay!
Steven later remembered the whole episode as “scary—I was so out of control. I was rolling around and hitting my head on the concrete!” At the same time, with the different drinks that people brought, Steven “was having a real picnic!” A slightly embarrassing picnic, however, as he remembered, “The poor guy who gave me orange juice—I threw it in his face. He left real soon after that!”
Strange behavior that was for a person usually so quiet and gentle as Steven Lee! Yet, when the brain does not get enough fuel for proper function, things start to go wrong. And for the diabetic who regularly takes insulin or some other type of medicine for diabetes, things can go really wrong.
Too little sugar in the blood results in the potentially deadly condition known as hypoglycemia. Or insulin shock, insulin reaction, or simply low blood sugar—they are all names for the same condition.
Have you ever been so hungry that you started to feel weak and dizzy? Probably it was because your blood sugar level was too low, and your body could no longer function quite right. For most of us, it is nothing to worry about—all we need to do is eat something pretty soon, and we’ll be all right.
However, for the diabetic who is dependent on insulin or oral medications for blood sugar control, that dizziness or weakness—or any of several other symptoms—may signal real danger. (Those type II diabetics who control their diabetes only by diet and exercise are in little danger of having a hypoglycemic reaction.)
As I have taught the students in my first aid classes, hypoglycemia can kill! When the body and the brain run out of “fuel”, they can no longer function. Within a short time, the person may go from the earliest symptoms to a state of confusion and on to total loss of consciousness. Without help, he would die.
Fortunately, however, there are usually some recognizable signs and symptoms of hypoglycemia. If the diabetic is alert to his own body’s early warning signals, he can take action quickly and remedy the situation before he loses consciousness.
It is very important that those people nearest to the diabetic also know the warning signs and what to do about them. Then, if he fails to take action himself, they can step in and handle the emergency. Indeed, hypoglycemia is a medical emergency
The Signs of Hypoglycemic Reaction
Just as there are rarely two people who look exactly alike, there are also rarely two diabetics whose bodies react alike even in the same situation.
Some diabetics may have several of the usual symptoms. Other diabetics may have only one or two of the common signals. Occasionally there are diabetics who have unusual feelings not experienced by others, but that they have learned to recognize as warnings.
A few diabetics feel no warning signals at all. Others, who experienced the warning signs when they were younger, find that as they grow older those signs become fewer and less obvious. Diabetes-caused damage to the nerves may interfere with warning signs. If the diabetic has trouble knowing when a hypoglycemic reaction is coming on, he should talk with his doctor about how to avoid problems.
In hypoglycemia, the diabetic may at first simply feel hungry. Most of us can just ignore that hungry feeling if we are too busy at the moment or if the clock says it is still an hour until the mealtime. But the diabetic who takes insulin or oral medicines for his diabetes must never tell his stomach to wait for a more convenient time to eat. By then, it may be too late!
Here are some of the common signals of a hypoglycemic reaction:
Warning Signs of Hypoglycemia
- sudden hunger or “butterflies in the stomach”
- tingling sensation in the forehead or around the mouth
- inappropriate laughing or crying
- sudden moodiness or behavior changes
- loss of coordination
- clumsy or jerky movements
- darting eye movements or crossed eyes
- slurred or stuttering speech
- pale skin color
- difficulty paying attention or concentrating
- nightmares or a lot of dreams
- loss of consciousness
A diabetic may sometimes behave very strangely as his blood glucose level drops too low and he loses control of his actions. “It’s really weird, knowing what’s happening but not being able to control your body,” says Steven. These hypoglycemic reactions don’t happen to him often, though his brother Roger has them rather frequently.
Like the time Roger walked into the 7-Eleven store with his friend, George, whom he had been helping all day with a landscaping job. Roger had not eaten enough to compensate for all the heavy labor, and he knew he needed food.
About the time they started looking around in the store, however, the reaction hit. Roger’s arms started waving around wildly, sending packages of potato chips and corn chips flying in every direction.
While the astonished store clerks looked on, George reassured them. “Don’t worry. It’s okay. It’s okay. ”It’s okay.” And with every muscle in his 72-kg body, George pushed his 100-kg soccer-playing friend up against a wall and started trying to pour orange juice into his mouth.
What to Do for a Hypoglycemic Reaction
If any of these warning signs occur, the diabetic should check his blood sugar level immediately if possible. (Urine testing is useless in hypoglycemia—urine tests only show if the blood sugar level is too high, and a normal healthy person should have no sugar in the urine.)
If the blood test shows that the blood glucose is low, or if it is not possible for the diabetic or a family member to test his blood right then, he should immediately take some form of quick-energy food to raise his blood glucose level.
Even if the diabetic is only suspicious that he is going into a hypoglycemic reaction, he must act immediately.
The blood sugar level may be raised quickly by taking some fruit juice or other high-sugar drink. (Use regular drinks, not diet or diabetic drinks, to treat hypoglycemia.) Other quick energy sources include some sugar cubes, very sweet hard candies, a candy bar, or even ordinary sugar or honey. A handful of raisins is another good source of concentrated energy.
Each diabetic may find that there is a certain type of food which works best for him. For one person it may be orange juice; for another it may be milk. The diabetic should decide with his doctor and with experience how much juice, candy or other sugar to take in case of hypoglycemic reaction.
Anyone who takes diabetes medications should always keep some quick source of energy handy. Many diabetics carry hard candy in their pockets; others prefer to carry glucose tablets.
In school, teachers and physical education supervisors should know if a student has diabetes. They should know how to treat a diabetic emergency, and should keep some form of sugar readily available.
When a person has had to take juice or sweets for a hypoglycemic reaction, he should check his blood sugar level again within 10 to 15 minutes. If the glucose level is still low, or if he still feels the symptoms of hypoglycemia, he should either take another snack or eat a regular meal. He should also telephone his doctor before taking his next dose of insulin or other diabetes medicines.
Sometimes a diabetic fails to recognize the early warning signs. When that happens, he may become too confused to realize his need for sugar.
Roger Lee is like that. After a soccer game, he is tired. His body aches from the game. All he wants to do is relax. Sometime he plays his stereo; other times he just sits down in front of the TV. Often he forgets that his body needs more food. When the tingling starts in his forehead, warning of hypoglycemia, Roger is too tired to notice. Within only a few minutes, Roger’s blood sugar level is dangerously low. In his mind he knows what is happening, but it is as if he’s a trance. Though Kathleen turns Roger’s head to face her, he still stares blankly into space. Sometimes she can get to take a drink of orange juice. On such occasions, within five or ten minutes Roger is usually alert enough to say, “Wow, I just had one horrible reaction! Thank you.”
In the classes that Robert conducts for other diabetics, he always emphasizes that every reaction-prone diabetic must have a mind set. He must train himself through constant reminders that “No matter what I think or feel, if I’m offered juice, I’d better take it. I must cooperate.” Even when life is going along in good control, Robert prepares for an emergency by telling himself, “Even though I know they’re wrong, I’ll take what they give me.”
Sometimes, however, a diabetic becomes unconscious before anyone can give him food or drink. What should you do if you find a diabetic unconscious from hypoglycemia?
*Never try to force any liquid or food into the mouth of an unconscious person. It could easily cause him to choke or drown. Telephone for an ambulance or rush the person to the nearest hospital. (The ambulance attendants will likely begin treatment immediately. They may either start an IV drip with glucose in it or inject a special hormone called glucagon, which helps to raise the blood glucose level quickly.)
*Do not give insulin. That is the exact opposite of what the diabetic needs when he has hypoglycemia. And it may kill him.
*Give glucagon if possible. Glucagon is a hormone which raises the blood sugar, and it can be given by injection in an emergency. Any diabetic who is likely to have a hypoglycemic reaction should have a doctor’s prescription for it and keep some at home. His family members should learn how to inject the glucagon in case of an emergency. When a child with insulin-dependent diabetes attends school, it may also be wise for a teacher or school nurse to keep glucagon available.
*When in doubt as to whether a diabetic patient is in hyperglycemic (very high blood sugar) coma or hypoglycemic shock, it is always safe to give glucose by mouth if he is conscious, or give a glucagon injection if he is not conscious. Insulin must never be given until it is certain that the problem is hyper—high—glycemia.
What Causes Hypoglycemia?
There are three main reasons why hypoglycemia may occur.
*Eating too little food, skipping meals or eating off-schedule while still taking diabetic medicines.
The insulin is busy doing its work of removing sugar from the bloodstream, but if the person hasn’t provided enough sugar through his meal, the insulin keeps working anyway, dropping the blood sugar level lower and lower.
*Getting extra exercise or doing more physical work without taking extra food.
With the additional exercise, the body may use up its supply of “fuel”. To prevent this from happening, the person should eat more food before, during, and after the additional or prolonged exercise, as mentioned in the previous chapter.
Exercise actually makes the body use its glucose supply more efficiently and effectively, thereby reducing the need for insulin.
*Taking too much insulin.
If a person is careful about his diet and exercise, but his blood sugar level often drops too low, he should see his doctor. It may be necessary for the doctor to reduce the amount of insulin or to change the insulin-taking schedule.
Previously, it was easy for a diabetic to draw up the wrong amount of insulin in the syringe. Nowadays, however, with better insulin syringes, it is not as easy to make a mistake if a person uses the right type of syringe for the kind of insulin he is using. In trying to save money by using cheaper syringes intended for a different kind of medicine, a person may put himself in real danger of overdosing.
Some syringes are especially made easy-to-read for people with poor eyesight. However, if a person has very bad eyesight because of old age, diabetic retinopathy or any other reason, another family member should be responsible for giving the insulin.
There are several other less-frequent causes of hypoglycemia.
A person may be a “brittle” diabetic, often going out of control in spite of taking the usual precautions.
Illness is another. When a person has vomiting or diarrhea, his digestion and absorption of sugars is thrown out of balance, possibly resulting in hypoglycemia. Drinking carbonated sodas may help keep the blood sugar level up during diarrhea or vomiting. Hospitalization may be necessary early on to prevent severe hypoglycemic reaction.
A person may lose his appetite when he is sick. It is important, however, that he not stop taking nourishment, even if it is only in the form of fruit juices.
Although it may seem logical for a person to take less diabetes medication—or none at all--during illness when he is not eating properly, he must keep taking the medicines. Sickness actually increases the body’s need for insulin. He should monitor his blood sugar level more closely and he should contact his doctor for advice.
If the weather is very hot or very cold, the body has to work harder to keep the body temperature at the normal level. Any extra work, even regulating the body temperature, requires extra fuel. Many diabetics find that extra-hot weather is harder to cope with. If a diabetic travels to a place with a different climate from what he is accustomed to, he should be extra alert to the possibility of hypoglycemia.
Drinking alcohol on an empty stomach may cause hypoglycemia.
For women, there are two other conditions which may cause more reactions and poorer diabetes control. Menstruation and pregnancy both place extra stress on the body and require closer attention to blood glucose levels.
Prevention isn’t always quite as easy as 1-2-3. Yet there are some guidelines which can help the diabetic avoid most problems.
*Eat meals and snacks at the scheduled times. If a meal is delayed, drink some juice or take some other snack at the normal mealtime.
*Never skip meals.
*Eat extra food before prolonged, heavy work or exercise.
*Take diabetes medicines as the doctor has prescribed.
*Know your own body’s warning signals and pay attention to them.
*Always carry some form of sugar wherever you go, to take at the first sign of hypoglycemia. Wherever you are—at home, at work or at school—keep it in your pocket, purse, briefcase or car.
Larry carries some raisins in his pocket; Robert keeps some hard candies in his shirt pocket. Grandmother Lee always keeps some orange juice by her bedside. Even when she travels, whether she stays with family or in a hotel, she never goes anywhere without her orange juice. It doesn’t matter what they choose, as long as the quick energy food is nearby and as long as it works well.
*Anyone who has frequent hypoglycemic reactions should have a blood glucose meter and should test his blood regularly. He should also write down when he has had hypoglycemia, and the times and amounts of both food and exercise. By keeping such a record, he and his doctor may be able to see why the hypoglycemia is occurring and make the necessary changes.
Another medical emergency caused by diabetes out of control is hyperglycemia, which is caused by too high a blood sugar level. In fact, the word hyperglycemia simply means too much glucose in the blood.
Hyperglycemia may occur for a variety of reasons:
*When a person forgets to take his diabetes pills or insulin or if he takes too little of the medicine.
*If a person eats too much food, so his normal amount of insulin is not enough.
*When a person is sick or has an infection—remember, during illness the body needs more insulin.
*When a person is under extra stress—the body also needs more insulin to cope with additional stress.
There are several common signs of high blood sugar. The diabetic and his family should learn to recognize them.
Signs of Hyperglycemia
- sugar appearing in urine tests
- high sugar level in blood tests
- frequent urination
- dry mouth and dry skin
- loss of appetite (sometimes followed later by extreme hunger)
- nausea and possibly vomiting
Hyperglycemia is probably responsible for most of the complications of diabetes which we will talk about in the next two chapters.
A diabetic who usually takes oral medicines for his diabetes control may have to take insulin temporarily if he develops hyperglycemia.
If the urine shows both ketones and a high level of sugar, the diabetic or his family should contact the doctor immediately. Ketones in the urine show that the insulin and blood glucose are not in proper balance, and the person may develop the life-threatening condition known as ketoacidosis.
Ketoacidosis, which usually affects only people with insulin dependent (type I), diabetes, occurs when the blood glucose level stays too high 450-700 mg/dl (25-40 mmol/l) when a normal level is from 60 to 120 mg/dl (3.1 to 6.6 mmol/l). The cause, however, is not actually the high blood sugar level but rather a lack of insulin.
The diabetic may have forgotten to take his insulin, or perhaps gave himself too small a dose, so the sugar is unable to get into the cells. Without insulin, the sugar cannot enter the body cells to give the energy they need in order to do their normal work.
Or, the diabetic may not have eaten enough food to provide the body with energy, forcing the body to burn fats. A third possible cause of ketoacidosis is that the person may have had hypoglycemia—low blood sugar—while he was asleep, again forcing the body to burn fats to get the energy to keep going.
Any time that energy from stored sugar is not available to the cells, those cells turn to the body’s stored fats for an alternative source of energy. As the fats are broken down for fuel, they also produce acid substances called ketones. Too high a level of these ketone acids can be deadly. So, when ketones are present in the bloodstream, the kidneys work hard to get rid of them. That is why a diabetic should test his urine for ketones also.
Neglected diabetes care is one of the most common causes of ketoacidosis. Undiagnosed diabetes is another rather common cause. In addition, however, illness, extra stress—anything that increases the body’s need for insulin—may also cause it.
If the diabetic or someone who knows of his diabetes fails to recognize the warning signals, the ketoacidosis may progress to a state of unconsciousness, or coma.
Knowing the early warning signs may help to prevent serious problems.
Signs of Ketoacidosis
Early warning signs:
- dryness of the mouth
- frequent urination
- high blood sugar levels
- high levels of ketones in the urine
Later warning signals:
- constant tiredness
- dry and reddish colored skin
- more difficult breathing (short, deep breaths)
- fruity-smelling breath (or like acetone—fingernail polish remover) because of the ketones
- sometimes vomiting or pain in the abdomen
- confusion or difficulty with concentrating
If the diabetic or someone who knows of his diabetes fails to recognize these warning signals, the ketoacidosis may progress to a state of unconsciousness, or coma.
Regularly testing the urine for ketones and recognizing the early warning signs may help to prevent ketoacidosis from becoming serious.
When a diabetic finds that he has ketones in his urine and has a high blood sugar level, he should avoid exercising. Exercise then may make his blood sugar level go even higher. The ketones indicate that the diabetes is out of control, and the diabetic should contact his doctor to remedy the problem.
HYPERGLYCEMIC HYPEROSMOLAR COMA
Type II diabetics may develop another serious kind of diabetic coma called hyperglycemic hyperosmolar coma (HHC), or hyperosmolar nonketotic coma. The blood sugar level may rise gradually to more than 600 mg/dl (more than 50 mmol/l) or even as high as 1,000 mg/dl.
The signs and symptoms are much the same as in ketoacidosis, except that the urine seldom has ketones in it—which is why it is sometimes called non-ketotic coma.
About one-third of the cases of HHC occur in people who didn’t even realize that they had diabetes. This is their first indication of trouble. In the other cases, the diabetics have just allowed their blood sugar level to continue on uncontrolled for too long a time.
Extra physical or emotional stress, an accident, a serious illness or an untreated infection may bring on an episode of HHC. Sometimes a stroke also causes this type of diabetic coma. Other causes include alcohol and large doses of such drugs as steroids, diuretics, and some tranquilizers.
Although HHC can happen at any age, it most often occurs in people over 50 who may not be able to care for themselves as well as they should. That is why it is important for family members to be alert to the symptoms:
Symptoms of Hyperglycemic Hyperosmolar Coma (HHC)
- extreme thirst
- frequent urination
- dryness of the mouth
- dry, reddish-colored skin
- blurred vision
- *upset stomach, nausea, vomiting
- high amounts of glucose in both urine and blood
- shallow breathing
If hyperglycemic coma does develop it must be treated in the hospital. It is a very serious condition, and the doctors will need to give frequently changing doses of insulin until the blood sugar level is under control again.
If you find a diabetic person acting confused or abnormal in some way, how will you know whether he has hypoglycemia or hyperglycemia—too little sugar in his blood, or too much? What should you do for him?
Give sugar, fast!
It doesn’t matter to you at that point whether the person has too much or too little sugar in his blood. If he has too little, you may save him from brain damage—you may save his life—by giving him the sugar that his body so urgently needs.
If, on the other hand, he has too much sugar in his blood, already, a little more will not do serious damage. As a young doctor friend of mine once explained it, “If you add a little more salt to the ocean, it really isn’t going to make much difference to its saltiness.” Adding a little more sugar to blood which is already too “sweet” will probably not raise the glucose level noticeably.
In either case, you will likely be sending the person to the hospital or to a doctor, where people are trained to know the difference and treat appropriately.
Always remember the simple rule for diabetic emergencies: When in doubt, give sugar.
Below is a sample wallet card which diabetics can carry. The card gives easy-to-read instruction on what to do in an emergency.
I HAVE DIABETES
If I am unconscious or acting strangely,
I may be having a reaction to insulin or
to an oral medicine taken for diabetes.
If I can swallow, give me sugar, candy,
fruit juice or sweetened drink. If I do
not recover within 15 minutes or if I
cannot swallow, call a physician or
send me to a hospital quickly.
Any diabetic who has trouble with controlling his blood glucose level should carry such an identification card with him at all times. It may be more important to him than all the charge cards or credit cards he owns! Diabetes associations in many countries have such cards available. On the back of the card is usually a place to write the diabetic’s name, phone number and address, his doctor’s name and phone number, and the types of medicine he usually takes for his diabetes.
Also useful in case of a diabetic emergency is an I.D. bracelet or necklace which says, “I have diabetes.” The symptoms of an insulin reaction—hypoglycemia—may easily be mistaken for drunkenness. So, police, ambulance personnel, hospital personnel, or ordinary members of the public may be alerted more quickly to the real problem if they see such a medical identification tag. It is vitally important to know how to react in case of a diabetic emergency. It is even more important to keep diabetes in control and prevent the emergency from ever occurring!