Monthly Archives: August 2015

Diabetes ketoacidosis ABC

Diabetes ketoacidosis ABC.


Diabetes ketoacidosis ABC

I have blogged about DKA before. 

DKA – diabetes keto acidosis. Starving in the sea of plenty. Too much sugar – way too much in the blood stream and not enough insulin to get it – the glucose into the cell. Did you ever do those experiments at school about osmosis, where water moves through a membrane to where it is being drawn? In this case the cells, so to speak, dehydrate and start to die and the vascular system is “loaded” with glucose. The cells are dry dry dry and have no way of doing what they need to do – metabolism – without which the human whose cells they are die.

A process begins and catapults quickly and rapidly into a serious life threatening environment which is hostile in the nth degree. Acidosis – pH below 7.4 is very unkind and unfriendly to human life.

The by-products of this deranged metabolism – which is by the way the bodies way of desperately trying to stay alive – are called ketones – these one can measure. 

NOW, a 100 years ago we did not know about ketones, about 50 years ago we discovered a way to measure them in the URINE – major breakthrough. About 20!! years ago we learnt how to measure them in the BLOOD – this is FAR more accurate – far far more accurate, in terms of being related to the timing of what is actually happening in the body as well as giving an accurate quantitative measure of the ketones. In other words one can more accurately monitor and wash them out if you are checking the blood ketones.

Generally speaking if a doctor uses urine ketones to monitor and treat you it will take up to 10 days to get rid of the ketones. IF the doctor uses blood ketones you can see that they disappear (if of course you are doing the fluids correctly and the insulin infusion) within 12-24 hours at the most 48. Not you tell me, patient, medical aid and family which would YOU prefer? Ahospital stay of 2 days or 10 days, one in ICU or one in a well run ward?

Is there a good reason to use urine ketones over blood ketones? No I really don’t think so, it is like using a horse drawn cart to drive to work.

Sorry but I just can not take it any more. Surely it is indelibly printed on your inside if you are a doctor that you wish to do NO harm and wish to HELP your patient to the best of your ability? The best of our ability at this point in time when it comes to DKA is using blood ketones (not urine ketones and yes the occasional blood gas does help but it is a painful investigation and one can very easily and safely manage with new techology).

blood ketones vs urine ketones

blood ketones vs urine ketones

The ethics of refusal of treatment in an emergency

I have not yet become calm inside myself yet. Perhaps I should not be writing a blog still in the state of turmoil of emotions. How on earth do you study a degree in the health profession and when presented with an acute LIFE threatening emergency in a CHILD whose vitals are not great on the not great scale the to point of extremely close to decompensation and not a great outcome i.e. fatality, you send them back to the place they came from – an hour away?

I would like to know in this scenario – IF a fatality had occurred – who would be responsible?

I am deeply horrified and traumatized, not to mention the patient and the family.

Basic human rights, dating back to the day of the story of the good samaritan mean that as a human beings you would do this – help – even if you were not trained?

How does one blandly cop out with excuses like “she is over the age of 12”, the unit here will only see “known” patients – IN AN EMERGENCY??

Yes I acknowledge that we should not have gone the route we did – seeking out the best care for this patient who is on an insulin pump and has previously been traumatised and treated very very badly in the local state institution. We should have just argued as I did with the local institution until we got her into a unit that could take care of this emergency. It was partly trying to respect the patients rights and dignity and wishes. Next time the only thing I will consider is her LIFE and getting the emergency treatment (albeit having to argue for more than an hour and a half on my own cell phone) to get it.

There is something VERY very wrong with the way things work when a child’s life hangs in the balance and bureaucratic CRAP stands in the way of rescuing that life.cathair

That baby fat – getting rid of “so how many months are you? grr”

Any lady who has been pregnant (well except those freaks of nature who only gain a few kgs and shed them immediately as you shed a jersey), will know that if you gain an excessive amount of weight during pregnancy it can be an incredibly hard task to shed them.

In my case it took me a long long time. It was around a year ago that I finally grew weary of the endless comments – “so how far along are you?” “when is your 3 rd baby due?”. Well I was not and my 2nd baby was already one, so yes why did I still look like a pregnant fairy?

I made up my mind that it was going – all of it and set some rigorous goals. And for me more than anything else it was that mindset and determination. Yes I cut out sugar and refined carbs. No I did not strictly “Bant” so to speak but I do believe I combined the best elements of “banting and Noakes ideas” with healthy eating and added in exercise where I could – although anyone with 2 children will know this is quite hard.

Slowly the kgs came off and most delightedly my waist line shrunk away.

Now the comments are along the lines of ” you are wasting away” – I can live with that. 🙂

beatiful bump -no this is not me

beatiful bump -no this is not me

A combo that combines the best of pump with the best of continuous monitoring

I am so glad and so grateful for the partnership between Roche accu-chek combo and Dexcom (ethitech) for bringing together effective algorythyms for delivery of insulin with really accurate continous glucose monitoring. It is making the biggest difference in stable sugars since I have started helping diabetic type 1 patients a good many years ago.

For the first time in their lives my 5 patients on dexcom/accu-check combo pump have a tool that helps minute to minute but essentially prevents hypos and high excursion in blood sugar. The result more stable moods, more energy, I guess in short better quality of life due to not “recovering” from a high or a low. Better adjustments on the pump because of quality information that actaully makes a difference.

Life as a type 1 for both patient and all the family and friends of that patient is tricky. This is making it far less tricky and changing quality of life as well as long-term health translating into less complications downstream. (Note to funders : this will cost you less in the long run – less heart attacks, amputations, dialysis, etc)

combo pump

combo pump

dexcom difference

So I have 5 patients on Dexcom – continuous monitoring for diabetes. They are all type 1 patients (but type 2s could use this device too). It has made the hugest difference in terms of almost NO hypos ! Why? Because you see it dropping and you react !

Seems obvious but if you are diabetic you know how @@$$%% awful a low is. And being able to prevent is like a magic trick.

Also a lot less high excursions – you see the trend of it going up and you can exercise, run a temp basal or if really high like >15 do a correction bolus (aiming for not too aggressive otherwise you induce a see-saw pattern we are trying to avoid).

Delighted I am for them as well as all the other patients in the future that is it going to help.

The technology is simply one that works – an amazing little filament with embedded sensor that detects change that is fed into an algoryhtm. It is accurate, hard working, simply a wonderful armentarium in the diabetes tools.dexcom

Can I ask anyone out there to give feedback on their dexcom tips?