March 23, 2009

When You Need to Go to The Emergency Room with High Blood Sugars

My uncle, like all his family, was a bit of a cheapskate. He hated to spend money unless it was absolutely necessary. He was thin and active, having only recently given up a career as a singer and dancer performing weekly on a nationally televised variety show. So when he felt unwell one weekend night, he turned down his wife's suggestion that she drive him to the emergency room and told her he'd wait til Monday when he could see his family doctor. Why waste all that money on an ER visit that was probably unnecessary?

As it turned out, he didn't need to see his doctor on Monday. He died that night. He was a few years younger than I am now and the fatal heart attack he experienced was the first symptom he had of our family's odd form of inherited diabetes.

But this is why, even though I've inherited the family "cheap" gene, if there's any possibility something dangerous is going on, I head for the ER.

Usually it is a waste of money. I was in a small car accident a few weeks ago that left me with nerve pain running up and down my arms and legs. I sat for four hours at our local ER, saw the doctor for five minutes, and was sent home. The diagnosis, whiplash. The treatment, wait and see if it gets worse. The bill? Over $900.

I went to the ER because I'd called my family doctor's office and they told me to. Whiplash usually resolves on its own, but occasionally it can cause swelling in your neck that can kill you. I'm not equipped to judge what kind I had, and unlike my uncle, I wasn't about to gamble.

So with this in mind, you can understand my reaction when a stranger contacted me recently, after reading my web page, and told me that his blood sugar, which had been normal until very recently, was testing in the 500s on his meter except when his meter wasn't able to give him a number. Cutting the carbs out of his diet was not lowering his blood sugar, either. He'd been told to go to the ER, but didn't have insurance. This is an ugly situation, but being alive without insurance is a whole lot better than leaving a tidy estate. I told him to go to the ER too.

A blood sugar over 500 mg/dl is an emergency. Especially if you aren't already diagnosed with diabetes or under a doctor's care. It's an emergency not because those very high blood sugars will lead to complications. They will, but it takes more than a few days of exposure to high blood sugars to cause complications. It's an emergency because the are two different disorders that can occur when your blood sugar is very high that can kill you within hours.

One is diabetic ketoacidosis (DKA). This is a condition that usually occurs in people who are not making any insulin at all. Usually this means someone with a diagnosis of Type 1 diabetes. But it is also diagnosed in people with Type 2, probably because many people who develop diabetes late in life are misdiagnosed with Type 2 when they really have some form of autoimmune diabetes that is killing off their beta cells.

DKA occurs when people have no insulin in their bodies to counteract their rising blood sugars. Unable to burn glucose without insulin, their cells begin to starve even as their blood sugar rises extremely high. The body survives by burning stored fat which produces ketones. If high levels of ketones build up in their bloodstream, which is already filled with unprocessed glucose, the acidity of the blood rises to a point where, if not treated, it damages tissues irreversibly and causes death.

The symptoms of DKA are high blood sugars (300 mg/dl or higher ) and: excessive thirst, frequent urination, nausea and vomiting, Abdominal pain, loss of appetite, Weakness or fatigue, shortness of breath, fruity-scented breath, and confusion.

The occurrence of DKA is often what triggers a Type 1 diagnosis. Estimates of its fatality range from 1% to 10% but if you get to a hospital when you develop DKA you can be rescued with intravenous insulin and fluids.

The other dangerous condition associated with very high blood sugars is the hyperosmolar hyperglycemic State.(HHS) Untreated this condition leads to coma and death.

It happens when people with Type 2 diabetes become severely dehydrated at the same time that they are experiencing very high blood sugars. This can happen when they have a serious diarrhea and vomiting syndrome like that caused by norovirus or e coli, or in elderly people who are prone to dehydration. With HHS, the patient will not be spilling ketones. But if it occurs it is more likely to be fatal than DKA. Estimates of its fatality range from 10-20%.

HHS may develop over a course of days or weeks, unlike DKA which develops suddenly. Symptoms include very high blood sugar (over 600 mg/dl) and: drowsiness and lethargy, delirium, coma, seizures, visual changes or disturbances, hemiparesis (one sided paralysis), and sensory deficits. Patients with HHS do not typically report abdominal pain, which is often seen in DKA.

What these conditions have in common is that if you develop them, you can go from fine to dead very quickly though they can be treated successfully with intravenous insulin and fluids at the ER.

Not everyone whose blood sugar goes over 500 mg/dl develops either condition. And if you have been diagnosed with diabetes of either type and see an occasional reading over 300 mg/dl, which most people will, it isn't likely to kill you. Nor does one very high reading mean you have to head for the emergency room if you have tools at hand that you have used in the past that you know will lower your blood sugar.

If your high blood occurred because you forgot to take your insulin, because your insulin spoiled due to exposure to high temperatures, or because your needle or cannula got blocked and the insulin you used didn't get into your body, all you may need is another dose of insulin, possibly one from a new vial or a new cannula for your pump.

But if your blood sugar does not come down swiftly in response to your usual techniques, or if your blood sugar is over 300 mg/dl and you are vomiting and cannot keep down liquids, or having a lot of diarrhea, you do need to head to the ER.

And if you are new to diabetes and your meter is reading "HI" or in the 500s and you don't feel well, you most certainly need to head to the ER.

It's possible you'll end up being told your high blood sugar isn't a crisis and leave, as I did, with a huge bill. This is what eventually happened to the gentleman who contacted me. The ER confirmed that his blood sugar was very high, gave him an emergency shot of insulin, told him he had Type 2 diabetes, prescribed metformin, and referred him to a doctor. I don't know what labs were done, but I would hope assume his urine was checked for ketones.

He may be thinking that his trip to the ER was a mistake, but it wasn't. He was feeling unwell and until a doctor determined he wasn't going into DKA or HHS, with the high blood sugars he was experiencing there was a significant risk he might.

You don't want to end up like my uncle. Much better to guess wrong and end up with an ER bill than to guess wrong and end up dead.

14 comments:

Rad Warrier said...

I sat for four hours at our local ER, saw the doctor for five minutes, and was sent home. The diagnosis, whiplash. The treatment, wait and see if it gets worse. The bill? Over $900.

Here in Canada ER visits are free. You pay for ambulance if you called one (typically $50). Fortunately, I didn't have to visit the ER yet.

Regards,
Rad

Anonymous said...

Rad, even in Canada, ER visits aren't free. You, the patient, are merely well-insulated from any direct perception of the cost.

Anonymous said...

I went to the ER with a BS reading of over 500 when initally diagnosed. I was admitted and spent three days. Lucky I have good insurance. I needed the rest and I left with my BS in a good range and was well taken care of.

hazelmay said...

Rad is right. It's free. Anyone can go. We like sharing the burden here. We prefer that to people dying for the lack of money to go.

srp said...

My precious daughter who had type 1 since she was little got sick. She was 30 and her roommates did not know that it could get so serious, and she also maybe was too sick to call 911. Her roommates left for the weekend, and she died in her bed. Her blood sugar level was 1320. Call 911. And get help. The lack of money should never cost you your life.

Jenny said...

Srp,

My heartfelt condolences for the tragic loss of your precious daughter.

Kathy Erb said...

My heartfelt condolences as well to you and your family. I work with a co-worker who refuses to take his type 2 diabetes seriously and has a sarcastic look to life. He has been told many many times by staff and co-workers to eat better and he will for a wk or two but then goes back to old habits. We know we cant do much but we are all very worried about him and his health. We work for the public as well. He could collapse in front of us serving the public. Why wont he take his illness seriously?

ConcernedSon said...

This was the most helpful explanation of BS levels and there consequences I have found yet. My Dad dropped off urine samples at his doctors this morning because he had extreme thirst frequent urination and blurry vision. He left and went to work where there was no cell service. His first sample was 500 and his second, from 2 hours later was 1000. The doctor couldn't get ahold of him and my mom had to go find him and bring him to the ER. I realize now how fortunate he is to be alive with that high of BS levels.

susan runco said...

im 67/eat bad/am a type 2 diabetic/my bs reading 2 days ago was 586/im a little concerned now/HELP!!!

Jenny said...

Susan,

The system did not notify me of your post, hence the late response. I hope you called your doctor to find out if you needed an emergency room visit and that you are okay now.

That is a very high reading. If you aren't on insulin yet, ask your doctor to get you started. With readings that high insulin is the only safe approach.

claire ashley said...

Hello don't know if u can help me but been having high bs reading I'm a type 2 dieabetic on tablets but the past couple of weeks suger has been very high I took a bs this morning before I had breakfast and it read 22.2 n also said ketone what dose this mean n when do u know the right time to visit the er

Jenny said...

Claire,

Usually when the meter says "Ketones" it is telling you to check for ketones which people do with either special meters or urine strips. High ketones and a blood sugar that high show that you might be at risk for diabetic ketoacidosis, a very dangerous condition. It is most common with Type 1s, not Type 2s.

However, with a fasting blood sugar that high it is possible that your diagnosis was wrong and you are Type 1. I would get to a doctor as soon as possible. Can you call your family doctor's practice for advice here?

Better a wasted ER visit than a serious crisis.

BigTimeMike said...

I have type 2 diabetes and get a reading on my Bayer Contour Meter of over 500 ~ HI in which it can't read the highest number and I have been like this for 2 1/2 years now and take all the right meds I get from my Dr. I feel this may lead me down a road I don't to go down and I have know one to turn to, it's getting worse by the days and fear I might die soon because of this,

Jenny said...

Mike, You need a better doctor. Can you see an endocrinologist who could give you an effective insulin regime?. It is not necessary to have such high numbers.

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