Megan Asks:

I’m so glad I found your website. I would love it if you would answer this on your blog. Thanks for reading and I look forward to your answer.

My YA manuscript has scenes with two sixteen-year-old teenage boys on a  twelve hour adventure race in the mountains. One of the boys has Type 1 diabetes. He consistently tests his glucose and knows what to eat/drink and he has an insulin pump. All is going well until his insulin pump malfunctions and he realizes he has left his back-up insulin in a cave they had sheltered in earlier in the story.

My specific medical question: What would happen to him if he has to wait approx. one to two hours for the other boy to retrieve his insulin and return to him? What symptoms would he show? And, after taking the insulin (1 – 2 hours past his regular schedule), would he be able to function well enough to walk to the finish line area without further medical assistance?

Jordyn Says:

Hi Megan!

Thanks for sending me your question.

I don’t think your character would be affected dramatically by a one to two hour delay in getting his insulin.

Insulin works to transport sugar from the outside of your cells to the inside. In the absence of insulin, his blood sugar will start to rise but how fast it rises depends on a lot of factors. For instance, what is he eating and drinking? How vigorous is he exercising? Considering he is stopping to rest and wait for his friend will help.

The rise in blood sugar is problematic, but is actually not the most concerning issue. What usually causes the emergency is a build up of acids in the blood due to the body’s inability to use the sugar inside the cells. Because the body still needs energy to run, it begins to break down fat for energy leading to a rise in ketones in the blood— hence the name diabetic ketoacidosis (or DKA).

If he were to continue to exert himself, I could see a situation where this process could be hastened, but though he might not feel awesome— I don’t think he would be incapacitated. Also, if he’s not eating or drinking, his blood sugar could also get too low depending on what type of insulin his pump was delivering.

I found this article that gives some tips on what the patient might be feeling. In my experience, I haven’t seen anyone using the blood based ketone testing— just urine test strips.

Some sites say DKA can develop in one to two hours. That might be true, but I would be doubtful a patient would be incapacitated in that time frame. They may not be feeling great, but can function. How severe DKA is really depends on how acidic the blood is when they seek treatment. Some people have ketones in their urine, would be considered in DKA, but their blood is not that acidic. People like this can usually be rehydrated with fluids in the ER, an insulin correction given, and sent home.

The more acidic the blood— that determines the course for a pediatric DKA patient. We measure this by the pH of the blood via a blood gas. Diabetics who have very acidic blood generally end up in the ICU for many reasons I won’t outline here.

Hope this helps.