Diabetes

Mysteries of Laura: Giving Insulin

/ Jordyn Redwood / Leave a comment

The NBC detective show Mysteries of Laura might need a new medical consultant. In one of the first episodes of this season we have a boy that’s been kidnapped and of course– he’s a diabetic in need of insulin or he’ll die in short order.

Cut to scenes of distraught parents wringing their hands wondering if the police will get there in time to administer the life-saving medication.

Of course, when they find the young boy, he is unresponsive. One quick insulin shot into his leg and within mere seconds– he’s awake and crying.

This doesn’t happen in real life.

The first thing to understand about why the medical approach to this scenario is bad is to understand why a diabetic who doesn’t have their insulin gets sick. In a Type I diabetic, their body doesn’t produce insulin. Insulin is what moves sugar from your bloodstream to the inner part of your cells for energy so they can function. When there is a lack of insulin, the sugar can’t move from the outside to the inside of the cells and that’s not a good set-up for sustaining life.

As a rescue measure, the body begins to metabolize fat and muscle for energy. The byproduct of this type of metabolism leads to a build up of acids in the blood called ketones. You can also get a build up of ketones in the blood from not eating carbs as well. When you do this, even though you may produce insulin, your body still perceives a starvation state and will enter into the same process.

In the case of the diabetic, the sugar is “stuck” in the bloodstream which is why they have high blood glucose levels. However, the reason a diabetic is so sick is not really from the high blood sugar– it is really from the build up of acid in the blood from the break down of fat and muscle. This is also known as diabetic ketoacidosis or DKA. The more acidic a diabetic’s blood is when they seek medical treatment– the more emergent the condition.

So, in this episode we can assume that the diabetic is in DKA. The question is how long does it take to reverse this process?

In a nutshell– hours– not minutes. If a diabetic comes in unconscious then it will take them some time to regain consciousness after treatment is instituted to lower the acid levels in the blood and of course, by also lowering blood glucose levels.

What would have been a realistic medical scenario for this episode would be for the boy to have trouble with hypoglycemia or low blood sugar. Or, to have it be that the criminals were giving insulin but giving too much of it.

When a patient’s blood sugar is too low, we give glucose IV. In this instance, an unconscious patient WILL wake up very quickly because glucose (sugar) given IV becomes immediately available to the cells for processing and a patient can and will wake up very quickly.

You can still be dramatic using an accurate medical scenario.

Author Question: Juvenile Diabetes

/ Jordyn Redwood / Leave a comment
Carol Asks:

I have a 5y/o girl who was recently diagnosed with diabetes.

Is it possible to need insulin sometimes but not others if she’s eaten “correctly”? Does stress play a role? What is she has lunch at noon and doesn’t get another real meal for at least 24 hours? Maybe some crackers, granola/protein bar, peppermints,etc but she’s trapped in a post-Katrina-esque situation from about 1700 until the next afternoon/early evening.

She has a pediatrician with her. How often would he need to check her blood sugar during that time? How often would she need insulin?

Jordyn Says:

A diabetic always needs insulin. They cannot live without it (Type I or juvenile diabetes). Basically, their body is not producing insulin anymore. Insulin carries sugar from your blood to the inside of the cell where it is used for cellular energy. In the absence of glucose, the body will begin to burn fat and muscle for energy. This leads to a build up of acid in the blood and evidence of this is ketones spilling over into her urine.

Diabetics typically check their blood sugar before each meal and before bed time. Some diabetics check their blood sugar up to eight times a day. Usually, they look at what they’re going to eat and decide how much insulin they need to “cover” themselves. Even if they don’t have insulin and are not eating– their blood sugars will still go up. Typically, diabetics are using insulin pumps that will give them a small but continous dose of insulin all the time but it really depends on the age of the patient and parental involvement to decide if an insulin pump would be a good idea. Also, when diabetics are newly diagnosed, it is hard to get them regulated.

Your pediatrician is going to have to stay on top of things– particularly if they are stuck in a situation where the child doesn’t have insulin– she’s going to get sick and it could happen pretty fast.  

Check out some previous posts I did concerning diabetes.

Diabetes Primer Part I and Part II.

Diabetic Emergency by Dianna Benson


Author Question: What is a Good Condition for my Character?

/ Jordyn Redwood / Leave a comment





Teena asks:

I want my main character to have a medical condition his girlfriend is unaware of. It needs to incapacitate him and put him in a bit more jeopardy when he doesn’t get his meds. I also want him to have a concussion so he black outs once or twice while he’s with the bad guy. But he also needs to escape.

A little earlier in the book I want him to exhibit some symptoms to his girlfriend but without revealing his condition…maybe watching what he eats, and in another scene exhibiting dizziness and weakness to a friend but claiming he’s just out of shape. Then, a little later, while he is by himself working on his novel, maybe some shaking where he takes pills and readers don’t know why. They may just think he’s an addict.

He is not obese and is in his early thirties. Which is counter to the profile for most type 2 diabetics I think.

Any suggestions?

Jordyn Says:

Thanks for sending me your question.

I don’t think Type II diabetes is a good option considering his age and good health status.

Here are a few posts I did specifically on diabetes:

1. http://jordynredwood.blogspot.com/2011/07/diabetes-part-12.html
2. http://jordynredwood.blogspot.com/2011/07/diabetes-part-22.html

Off the top of my head– I might consider some type of cardiomyopathy. Where he needed digoxin and lasix as maintenance meds. If he came off those– he could definitely be symptomatic. A lot of the criteria you want would fit this type of condition.

1. What is cardiomyopathy: http://www.nhlbi.nih.gov/health/health-topics/topics/cm/

2. Cardiomyopathy: http://www.nlm.nih.gov/medlineplus/ency/article/001105.htm

3. Cardiomyopathy: Treatment and Drugs (and lots of other info): http://www.mayoclinic.com/health/cardiomyopathy/DS00519/DSECTION=treatments-and-drugs

Read through these resources and see if they strike a chord.

Teena Says:

Thanks so much for the suggestions. I think maybe the hypertrophic
cardiomyopathy is the way to go!

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Teena Stewart is a published author, artist, and ministry leader. She is currently working on a sequel to her first completed romantic suspense novel. Recent published books include Mothers andDaughters: Mending a Strained Relationship and The Treasure Seeker: Finding Love and Value in the Arms of Your Loving Heavenly Father. For more info visit www.teenastewart.com and
http://nearly-brilliant.blogspot.com/

Diabetic Emergency: Dianna Benson

/ Jordyn Redwood / Leave a comment

Dianna’s back for her monthly guest blog. Today, she covers EMS care for a diabetic emergency.

EMS 4 diabetic emergency at 123 Fox Street, at 123 Fox Street on TACH Channel 12

I stuff the rest of my sandwich into my mouth and gulp down some water as I rush out of the fast food joint to hop into my ambulance. As my partner signals RESCOM (dispatch) we’re en route to the above (sample) call, I speed our ambulance down the road, lights and sirens.
I won’t discuss the full assessment and treatment we’d perform on a diabetic patient, but if you want clarification or further explanation for your fictional writing needs, please ask me.
On scene we find first responders assisting an unconscious male sitting slumped over in a Target bathroom.
“His blood sugar is 12,” one of the firefighters tells me. “He works here and his co-workers say he takes insulin daily.”
“Sir?” I say to the patient. “Can you hear me?”
No response. His eyes are half open. His pupils are dilated and sluggish.
My partner and I insert a line (IV), and push one 25g AMP (ampule) of D50 (dextrose 50% in water). I attach him to our cardiac monitor via a 12-lead (ECG patches), and assess his heart rhythm and all his vital signs. He’s in normal sinus rhythm and all his vits are within normal range; however he’s slightly tachycardic (heart rate too high), but an elevated HR is the body’s defense to survive a hypoglycemic episode (low blood sugar).   
“Sir?” I place my hand on his shoulder. “Hey, buddy, talk to us.”
The patient remains unresponsive, so my partner and I push another 25g AMP of D50.
Via a glucometer, we test his BGL (blood glucose level). It’s now 43. We’re headed in the right direction, but the patient is still unresponsive. We administer 1mg of glucagon IM (intramuscular injection).
“Sir?” I squeeze his hand. “I need you to talk to me. Okay?”
He stirs, his eyes attempt to focus. We load him onto our stretcher and wheel him inside our ambulance. Within a few minutes, he stares at me. “Where am I?”
“You’re in an ambulance, sir. I’m EMT Benson.” I finish retaking his BGL again. It’s now 98 (within normal limits). “Do you know what happened?”
He nods. “Yeah. It happened again. Twice this week. Stupid blood sugar.”
Can you tell me your name?” I ask, even though I know his personal information via his co-workers. I start this line of questioning to assess the patient’s mental status.
“Bob.”
“Okay. Bob, what’s your birthday?”
“Ah…February 3, 1972.”
“Uh-huh. Gosh, Bob, my math is horrible. How old does that make you?”
“Thirty-nine, but don’t tell my girlfriend. She thinks I’m thirty-one.”
I laugh. “I won’t say a thing, but you may want to tell her yourself soon, what do you think?”
“You’re probably right.” 
“You take insulin, I hear. Did you take any today?”
“45 units, early this morning.”
“45, huh? Have you eaten anything today?” I note the time is twenty minutes past noon.
“Two graham crackers.”
“You need to eat more than that, you know? Especially after 45 units. Breakfast is the most important meal of the day. Promise me you’ll eat breakfast everyday.”
He nods as he smiles at me. 
I radio the hospital. “Wake Med, EMS 4 en route with pt (patient) initial BGL 12, then 43, now 98. We’ve given 2 AMPS of 25g D50, and 1 mg of glucagon. Initially pt was unresponsive, now A&O times 4 (alert and orientated times 4). Vitals within normal limits. ETA 2 minutes.”
“ED room on arrival. Wake Med out.”
“EMS 4 out.”
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After majoring in communications and enjoying a successful career as a travel agent, Dianna Torscher Benson left the travel industry to write novels and earn her EMS degree. An EMT and Haz-Mat Operative in Wake County, NC, Dianna loves the adrenaline rush of responding to medical emergencies and helping people in need, often in their darkest time in life. Her suspense novels about characters who are ordinary people thrown into tremendous circumstances, provide readers with a similar kind of rush. Married to her best friend, Leo, she met her husband when they walked down the aisle as a bridesmaid and groomsmen at a wedding when she was eleven and he was thirteen. They live in North Carolina with their three children. Visit her website at http://www.diannatbenson.com 

Guest Blogger: Lillian Duncan

/ Jordyn Redwood / Leave a comment
I’m pleased to have Lillian Duncan guest blogging here at Redwood’s Medical Edge today. She’s discussing her research into diabetes and how she managed this character’s disease in her novel Pursued.

Welcome, Lillian!

According to statistics, diabetes affects 25.8 million Americans of all ages which is 8.3% of the U.S. population. It only makes sense that sooner or later one of my character’s was going to end up with the disease.

The character’s name is Reggie Meyers and you can find her in my new book, Pursued.  In spite of Reggie being chased by an unknown killer, she manages to keep her sugar level on an even keel while her blood pressure spikes through murder attempt after murder attempt. The woman is seriously committed to eating right and taking care of herself!
In real life, diabetes is not a laughing matter, and I certainly don’t treat it lightly in my book or in my life. I don’t have diabetes; however, my father died from complications of it along with my paternal grandparents, aunts, uncles, and cousins on both sides of my family.

I chose to give my heroine diabetes to bring more awareness of the disease to my readers. I also wanted to show that with a combination of diet, exercise, and other lifestyle choices, a person can live a full and healthy life in spite of having it.

It was easy in my book to keep Reggie making the right food choices and following good medical advice. Unfortunately, it’s a lot harder in real life. People struggle every day with making the right lifestyle choices or suffering from the consequences of not making the right choices.
As I wrote Pursed, I had to walk a fine line between keeping it in the readers’ minds that Reggie was diabetic without belaboring the point. If I wrote about it too much, it would bore the reader. If I didn’t include enough details—especially physical details— it wouldn’t feel real.
An example of this is during a scene where all the characters are drinking a soda. Without mentioning her diabetes, Reggie’s friend simply hands her a sugar-free soft drink. No big deal. Another time, Reggie is given two choices for breakfast—sweet rolls or multi-grain cereal. She is sorely tempted but in the end she made the right choice.
Research was an important component when I decided Reggie had Type 1 Diabetes. In spite of family members having the disease, I wanted to make sure I had the right information, which isn’t always easy in spite of the glut of information on the Internet. I only included a small amount of what I learned, but it was there in the back of my mind as I wrote each scene.
Reggie’s diabetes definitely added to the challenge of writing Pursued, but I’m glad I included it. I wanted to show a character who had a serious health issue, but didn’t use it as an excuse to not accomplish her goals and dreams. In Pursued, Reggie makes the choice to be as healthy as she can be in spite of being a diabetic.
Everyone has challenges in this life. The question becomes are we going to let the challenges stop us from being the best we can be? And the answer comes in the form of the choices we make every day.
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Lillian lives in a small town in the middle of Ohio Amish country with her husband, four parrots, one Jack Russell, and a Cavalier King Charles Spaniel. Whether as a speech-language pathologist, an educator, or as a writer, she believes in the power of words to change lives, especially God’s Word. She also enjoys a variety of activities, including traveling, camping, and bowling. She is active in her church where she serves as a sign language interpreter and teaches sign language classes. Lillian believes books can be entertaining without being trashy. She writes the types of books she loves to read, suspense with a touch of romance. Along with writing novels, she writes devotions for ChristianDevotions.us. Previous novels include Shattered and In a Corner of Her Heart. To learn more about Lillian and her books visit: www.lillianduncan.net

Diabetes: Part 2/2

/ Jordyn Redwood / Leave a comment
Diabetic emergencies are not uncommon in the emergency room. In simple terms, there are two types of diabetic emergencies: the blood sugar is too low or the blood sugar is too high.
Hypoglycemia: This is a term used when the blood sugar is too low. Often times, in a person with diabetes, it is the result of taking too much of their medication causing sugar levels to drop. This is not the only thing that can cause a blood sugar to be too low.

Unrelated to diabetes, in the pediatric population, particularly among infants, there can be several causes of low blood sugar. Some of the top reasons are sepsis (blood or urinary tract infection), stress, and hypothermia (low body temperature).

Hypoglycemia is relatively easy to treat. If the patient is alert enough to swallow something, we can give them sugar by mouth (orally). It can be as simple as having them drink a small container of juice or giving them a fancy commercial preparation of sugar. If they are unable to take anything by mouth, then an IV is placed and the sugar (glucose) is given intravenously in the form of Dextrose.
Diabetic Ketoacidosis: Otherwise known as DKA. This results from a high level of sugar in the blood. As part of this, there is also a build-up of acids (ketones) in the blood as well. See last post for full explanation of this process. In order to correct this emergency, we have to bring both the blood sugar down and clear the ketones (the acidosis).
1.   Start an IV and get labs. There are several labs that need to be closely monitored in the diabetic patient. We’ll get a BMP (basic metabolic panel). This can also be known as a Chem 7 (or other number depending on how many items are measured). We’re looking specifically at the blood salts: potassium and sodium. These shift as sugar shifts. A BMP is generally monitored every 4-6 hours. Every hour, the patient will get a bedside glucose. We can only bring the sugar down so fast, typically no more than 50-100 points an hour. If the sugar falls too quickly, this can be problematic for the patient.
2.   Give IV fluids in the form of normal saline. Typically, the patient has a relative dehydration. Fluids are given very carefully as rapid fluid resuscitation can cause build up of fluid in bad places… like the brain (called cerebral edema). This is a phenomenon more common in pediatrics than the adult population. Giving fluids will also help the body clear ketones.
3.   Give insulin. Insulin is given to move the sugar from outside the cell (extracellularly) to inside the cell (intracellularly). This will bring the blood sugar level back down.
At some point, when the sugar level comes down to around 250 (remember normal level is 60-120) we will add IV fluids that contain sugar and continue to give the insulin until the ketones are cleared or the patient is no longer acidotic. We can check this by checking the urine for ketones or by testing the blood (a blood gas) to see what the pH level is.
Once both the sugar levels are normalized and the acidosis has cleared, the patient can begin to transition back to their normal diet.
Have you known someone that’s had a diabetic emergency?
Resources for you:
1.   http://www.emergencycareforyou.org/EmergencyManual/WhatToDoInMedicalEmergency/Default.aspx?id=230
2.   http://type1diabetes.about.com/od/schooldaycareandlaws/a/hypergly_emerg.htm
3.   http://diabetes.webmd.com/tc/hypoglycemia-low-blood-sugar-topic-overview

Diabetes: Part 1/2

/ Jordyn Redwood / Leave a comment
I thought it would be good to do a few posts about the more common medical conditions. Since I’ll be highlighting Lillian’s novel on Friday, I thought I’d cover the basics of diabetes and then emergency care of the diabetic patient.
There are three major forms of diabetes. Type I, Type II and gestational diabetes.
Type I: This type of diabetes is caused from an autoimmune reaction where the body turns on itself and destroys, in this case, the insulin producing cells in the pancreas. As a result, the person can no longer manufacture insulin. Its onset is usually young children.
Type II: This type of diabetes is the most common form of diabetes in our society. This is a condition where the body produces enough insulin, but the cells are resistant to it.
Gestational Diabetes: Occurs during pregnancy. Generally resolves after the infant is delivered.
When thinking about diabetes, the most important thing to understand is the role of insulin. Insulin is produced by the pancreas. It is a transport agent. It moves sugar (glucose) from outside the cell to inside the cell. Every cell in your body requires glucose to function. It is the primary energy source.
What happens when sugar is not transported inside the cell? First thing that happens is that sugar builds up in the blood stream because it has nowhere else to go. This leads to an elevated blood sugar in the blood stream. This is something we can measure. Normal blood sugar is roughly between 60-120.
When the cells are starved of sugar, the body begins to break down other sources for energy. In this case, fat and muscle. The breakdown of these tissues leads to an increase of acids in the body. The by-product of this process is ketones. You may have heard the term diabetic ketoacidosis.
Now, I need you to think back to basic biology and the process called osmosis. This is where cells try to equalize particles between barriers and they do this by moving fluid. When the sugar levels are high in the blood, the body wants to equalize that out. It does so by craving more water. This is why people with a high blood sugar have increased thirst and increased urination. Also, because the cells are starved for sugar, the patient will actually lose weight.
Your body also has a certain threshold for sugar. Once this level is surpassed, glucose begins to show up in places it wouldn’t normally be. One place we check is the urine. What will also show up in the urine are those ketones that have built up because of the body’s alternative processes for finding energy.
Have you had a character suffering from diabetes?

Next post: Emergency Treatment of Diabetes.
For further information of diabetes, check out these resources:
  1. http://diabetes.niddk.nih.gov/dm/pubs/overview/
  2. http://ndep.nih.gov/media/Youth_Tips_Diabetes.pdf
  3. http://www.diabeteswellness.net/Portals/0/files/DRWFUSdiabetes.pdf