I'd love some input - I have opportunity to give some feedback to first aid instructors, who teach the general public about emergency diabetes care - currently the curriculum emphasizes hypo care, very little about hyperglycemia. So, got me to wondering: 1. which do you find harder to deal with - hypo (lows) or hyperglycemia (highs)
2. which is more common to require emergency care (i.e. a trip to the hospital)?
3. are you likely to need help with care in case of DKA?
Thanks!! (and if you have any ideas of things first aid instructors might be missing out on in their teaching about diabetes related emergencies ... feels free to let me know, i'll pass along what I can)
Excellent plan for education! I don't have any stats about emergency care needs of hypos vs hypers, though if someone takes the trouble to look up that information I'd be interested in hearing it too! My guess from anecdotal reports is that hypos are more common. Some people on here have reported having multiple occasions where they needed emergency care for hypos (though I still think it's the minority in diabetics, especially since advances in testing, cgm's etc). Most people report having DKA just on diagnosis (and not all of us had that experience) Again there are exceptions with people that had DKA more than once in their diabetic lives but most of the time again we can catch it and treat highs before they get that dangerous. So bottom line my guess is that hypos are still more commonly emergency situations.
Having said that, I think it's important to educate people about the difference. I think the public just thinks "diabetic coma, give them sugar". Couple problems with that: 1. You don't try and force sugar down the throat of an unconscious person, many people have died from choking. 2. if they're in DKA that is the last thing they need. I think the reverse is true as well: "diabetic coma, give them insulin" - again the last thing a person in a severe hypo needs! So education is important.
On the third question: My take on it (again looking at anecdotal evidence only) is that once you are in DKA you always need medical care. It is often possible to correct highs and get them down with diligent attention and effort before it gets that far. But my understanding is that DKA is always a medical emergency.
If someone does come up with some stats to answer your question, my follow up question would be what countries those stats are taken from? I would think in developing countries where good diabetes care is unavailable or financially out of reach of most of the population, the picture would be much graver. With lack of regular and reliable insulin, lack of testing equipment let alone Cgm's and pumps, I think DKA would be, unfortunately much more common.
thanks so much Zoe! I've got the same feeling that ER visits are more common for hypo - I can't seem to find stats for this anywhere but it does go against my personal experience - i've only been hospitalized for DKA (once, not at Dx, and when I was very young), never for Hypo (always have been able to treat - though never used glucagon, it was there if needed and no further care would have been needed). DKA worries me... symptoms are easy to attribute to other factors if you aren't paying attention - vomiting, disorientation, lethargy, and it's easy enough to ignore them until things go really bad (unconciousness) - OK as well informed diabetics we are not likely to ignore those symptoms but, if you were say, on a canoe trip... those symptoms might be just as likely to from being tired and dehydrated, and you might "push through" and keep going, missing D care, until things are pretty serious.
It's too bad that the training can't include putting the students, or even better the instructors!, through actual hypos and DKA :-). Getting lectured by docs who have never had a hypo or DKA gets pretty boring after a while. The good docs know enough to not even try.
"Hypos" can be incredibly common but a more useful distinction for what you are talking about, might be what the DCCT classified as an "extreme hypo", one requiring medical intervention or the help of another person.
Statistics from DCCT indicate rate of ambulance call/ER trip for severe hypos to be on average one every few years, with the rate increasing as therapy gets more intensive. Another graph about "severe hypo" rates from the DCCT (but only a fraction - unspecified - of severe hypos required a ER trip):
Anecdotally DKA events are much less common although maybe more common for the very young, and maybe more common for those on a pump. DKA can very definitely need extreme help (I was hospitalized for two weeks at diagnosis!!) but will be less common among those who are correctly diagnosed and treated. My overall impression is that while DKA is a bad thing (obviously) that the time crticalness of a hypo is much much more serious.
I think I also have to distinguish DKA crisis from "spilling some ketones". Obviously there is an overlap. Real DKA (i.e. actual acidosis) requires hospitalization but just spilling ketones, if promptly and appropriately reacted to, is not such a big deal (insulin + rehydration),
When I worked as a nurse hypoglycemic emergencies were more common, probably because they can come on alot faster than a DKA emergency. They can both have a fatal outcome. For myself, lows are easier and faster to treat but feel very bad. It can take hours to bring a high back down.
You will always need medical care with DKA it is very serious and will be fatal without treatment.
You may need medical care with hypo, depending on how low you are and how functional you/your family are at treating it.
The most important thing I have noticed missing from education about Diabetes: Diabetes causes hyperglycemia not hypoglycemia. Hypoglycemia can happen when your medication doesn't match up with your fuel intake, or you burn off fuel through exercise.
Most important: if you can't wake somebody up it doesn't really matter why. Just call 911.
Wonderful Tim, thanks for the stats and link, i've had so much trouble tracking these down.
I soooooooooo wish it was possible to let a non-PWD experience hypo or hypoglycemia, so impossible to simulate these events.
The first aid these folks teach is pretty advanced, and not standard urban first aid - they teach to people working in remote environments, where medical care can be days away - so quick treatment of hypo is important, but it's fairly successful to treat in the field.... hyperglycemia, over time, can go from bad to really bad if not well managed. Make sense?
(and totally unrelated to my questions but that graph scares the #!%$Q out of me... i'm working on more intensively management my care and bringing down my A1C - an extreme hypo is what I fear most in this world!)
I would think that with persistent testing and response to prolonged highs that those symptoms wouldn't catch one unawares. Maybe I'm naive about how quickly it can happen, but I know that whenever I see a high in the 200s I'm quick about correcting and then follow up testing and changing my set/using injection if it isn't coming down. If it's 300 then I'm in emergency mode, changing my set automatically and then monitoring carefully.
Thanks Kathyann... I should have clarified earlier... these folks teach first aid to people basically working where calling 911 isn't going to get you quick help, where medical help can be days away - so yes, call for help, but they also teach what to do to keep someone stable until help gets there. Some of the courses that they teach are even for medical professionals.
I love the point that "Diabetes causes hyperglycemia not hypo...." that is a GREAT point to make.
I kind of have a different reaction to that graph. It's the one that numerous doctors have used to tell us that an A1C in the 5's is only achieved at the risk (and the actuality) of numerous hypos. That can, of course be true in that A1C is an average. Ironically my last two A1C's were both 5.7, but the first one was achieved through working really hard and having really well managed blood sugars. The second one was taken during a period when I had way too many highs and lows and they averaged out. However, the first 5.7 is one that many people achieve through good management (and the luck of the draw). Many people with A1C's in the 5's have good control, both of highs and lows. But doctors have used the DCCT stats as scare tactics to say that the only "safe" A1C is one over 6.5, or at least 6.0
1. I don't find it that hard to deal with either, although I prefer treating hypos (by eating...) to hypers.
2. Hypos I think but I haven't ever gone to the hospital for hypers, except when I was dx'ed in 1984.
3. I don't know about that either. I don't own ketone strips and don't let my BG run up for more than an hour or two before I'll notice it and fix it.
Re the DCCT graph, the thing about "intensive therapy" being "risky" isn't entirely correct since you can generally avoid most of those type of incidents by increasing the frequency at which you test up to and including a CGM, testing a couple of hundred times/ day. Yes the accuracy can be a bit off but, once I had one for a while, it seemed like I could sort of interpret the "offness" accurately enough to make it a very useful tool.
I've only been to the ER twice with hypos in 30 years and I think I'm pretty "intensively" managed (A1C's in the 5's or 6's almost all the time). I suspect there's other here who do better than me.
You might think an extreme hypo resulting in a 911 call and ambulance ride to the ER would be the scariest thing in the world... but really it isn't. In fact the ambulance guys and the ER's do it day in and day out and while it was far from an enjoyable experience it is not the worst thing in the world. I saw "Steel Magnolias" when it was out and it freaked me out but believe me in the real world... it's all with much less histrionics!!!
Thanks Tim, it's not the "after" part of calling 911 that scares me, it's just the worry about not being able to call 911 in time if I needed help (I live and work alone most of the time). The impact of Diabetes on my life would increase dramatically if I had to rely on someone to keep an eye on me. I need to look at statistics with a more critical eye... just because the incidence of severe hypo increases with lower AIC, doesn't mean it will happen more with me :) - an interesting topic nevertheless!
Same here, Otter; if I was able to call 911 I wouldn't need them. The only severe low I had was when I first started using insulin and it was a stupid error born of both my and my doctor's ignorance. I was unconscious but my liver brought me out of it to the point I was able to treat. The only time I actually did think of 911 was one night when I had a weird experience of my blood sugar continuing down and down despite my treating it. The lowest point hit was 28 at which point I realized I was in danger if it kept going down, but I was still thinking logically probably because it had gone down slowly so I just disconnected my pump, took a couple more glucose tablets and ate a snack too (which I never do) and it finally started to come back up. What I actually thought of doing was driving myself to the ER (6 minutes away but down a winding road) which I decided was a bad idea. (I concluded it was some kind of weird delayed absorption)
I think in general Hypos are more of an in the moment emergency and can get you quicker I think. Highs are bad too but I think you have more time, like hours to treat or get to the hospital where with hypos you have to treat within minutes. I have had both, but have only gone to the hospital for hypos, once my mom took me cause we couldn't get my sugar up and once I was home alone and called 911 and they took me. I think just teaching the symptoms, how to check someone else's blood sugar, what to do if it is low/high and when to call 911, or take the person to the hospital. Teach people how to give glucogon an when to give it. Some lows are more serious then others and knowing how to treat at each range is a good thing to know, same with highs. That is all I can really think of for now.
LOWS period! Highs can happen but the chances of needing anybody else's HELP to deal with them is almost nil..... Lows require 99.9% of any ambulance visits or hospital care.
That one hundredth of one percent accounts for all DKA episodes severe enough to ever require ambulance or hospitalization... are they medical emergencies, sure. Compared to lows they are almost non existent numerically.
so... interesting numbers I dug up today 50 million people in the US are at risk for anaphylaxis (i.e. have severe allergic reactions)
25+ million people in the US have diabetes - thus are at risk for hypo and hyperglycemia
so... I think about all the efforts that go into teaching about severe allergies (esp. food allergies - which effect about 15 million people)and use of epi pens and how little awareness there is for treating hypoglycemia, especially use of glucagon (and hypos effect 25 million people)..
I'm making a case for teaching more people about treating hypoglycemia - including BG testing and use of glucagon :)
All these stats do confirm what a great job most PWD do in self treating, even in the case of pretty severe hypo and hyperglycemia (and no, in NO way am implying that people with severe allergies don't do a good job, they most certainly do too!) There are relatively few ER visits compared with the number of hypos we all deal with every day!
A hypo is more likely to render me unable to help myself. DKA, while serious and dangerous, doesn't usually render one completely unconscious for awhile. You have time to react and do something about it. But hypos can come on fast and can leave one completely unable to self treat.
That said....hypos are generally much easier to correct. Low blood sugar generally comes up fast and you feel better within a very short period of time. High BGs/DKA can become stubborn and ultimately require IV insulin to bring down. I know even when I'm just high (not DKA, but high like 300s/400s), it takes A LOT of insulin to get me back into range.
I think the important thing to teach others is to know the difference between high and low blood sugars and what to do in each scenario. I've heard stories of people being low but having coworkers refuse to get them something with sugar because they don't think diabetics should have sugar! Eek!! I want people around me to know the basics, such as how to test my blood sugar (it's not that hard!) and what the numbers mean. Specifically:
<70, I need something sugary to eat (more specifically, I need fast-acting sugar, so nothing with a lot of fat) >250, I need insulin.
i.e. 25+ million Americans have diabetes, but may not be at risk of hypos.
I do not believe that diabetics treated with diet and exercise are at risk of a hypo. In order to be at risk of a hypo you need to be treated with insulin or be on an oral medication that lowers BG.
Hypos require immediate care and are IMHO the main reason first responders are called out for diabetics. If you teach first responders treatment for hypo and hyper care, what is the chance that they would get them backwards? That would be a big concern of mine.
This varies from person to person. If you have hypo unawareness (when you no longer have symptoms of a low), a severe low can come on without warning (because you don't realize your BG is dropping in the first place). Unless you're testing frequently, that low can turn severe without you ever realizing it. This is why testing can be so important. Also, I have generally good awareness of my lows, but there have been a few that I just didn't notice. The other day I was 50 and didn't have a single symptom. I only caught it because I happened to test before going for a walk.
Also, lows in your sleep are dangerous because you may not be woken up by the low symptoms. I usually am, but sometimes have only woken up once I was too low to help myself.
It is SO IMPORTANT to test frequently and to not let your BG drop really low on a regular basis. Keeping tight control can help ensure that you will feel those lows when they do happen.
