In the United States, approximately 30 million people (or 9.4% of the population) have diabetes. However, 23.8% of those individuals have never received an official diagnosis. Furthermore, researchers estimate that 132,000 children under the age of 18 have diabetes [1].
Diabetes is a lifelong disease, which can be managed by a variety of treatment options. At its core, diabetes represents a dysfunction in the way the body processes sugar. The body either does not make enough of the hormone insulin, or it cannot effectively utilize insulin to move sugar from the bloodstream into the cells.
1. Type 1 diabetes
Type 1 diabetes was once referred to as insulin-dependent diabetes or juvenile diabetes. However, type I diabetes can present at any age. Symptoms occur when the pancreas either makes an insufficient amount of insulin or makes no insulin at all.
The actual cause of type 1 diabetes is an autoimmune response. During this response, the body attacks the beta cells in the pancreas, which are responsible for producing insulin. Heredity clearly plays a role in predisposing patients to develop type 1 diabetes, but parents with type 1 diabetes do not pass it onto their children. The CDC estimates that approximately 5% of diabetes cases are type 1 [1].
Type 1 diabetes is treated by supplementing the insulin produced by the patient’s body. Insulin is generally delivered through an injection or a wearable insulin pump. While lifestyle habits are not the cause of type 1 diabetes, they do play a role in managing the disease.
2. Type 2 diabetes
Type 2 diabetes is also known as insulin-resistant diabetes. While the pancreas of a patient with type 2 diabetes produces insulin, the cells in the body do not respond normally; they don’t properly use or store glucose. In an attempt to maintain homeostasis, the sugar remaining in the bloodstream causes the pancreas to create more insulin.
Over time, the cells become accustomed to the increased levels of insulin, so they won’t respond if there’s only a normal level present. The cycle continues until the pancreas is no longer able to produce enough insulin to keep blood sugar levels at a normal level. From that point on, blood sugar remains chronically high.
Type 2 diabetes may have a genetic component as well, but being overweight or inactive drastically raises the risks of developing the disease. In fact, the number of people with type 2 diabetes has increased, which mirrors the way obesity is related to diabetes. In fact, 87.5% of diabetics are overweight or obese [1].
Type 2 diabetes is treated in one of these ways:
- Supplementing the insulin in the body, in order to take some of the strain off the pancreas.
- Taking oral medications, which reduces the production of glucose that the liver produces.
3. Glucometer 101
A glucometer has been a common piece of equipment on ALS EMS vehicles for some time and can increasingly be found on BLS equipment lists as well. The glucometer measures the concentration of glucose in a drop of blood. Most EMS systems consider a normal blood glucose reading to be between 80 and 120 mg/dL.
The process of using a glucometer seems straightforward:
- Get blood.
- Put it on a test strip.
- Get a reading.
However, it is still important to review the manual that your agency provides with the glucometer. Some glucometers are only calibrated to be used with capillary blood, and only from certain locations on the body. When starting an IV, some EMS providers may use the blood collected in the flash chamber in order to save the patient from a second poke. However, that blood may not be accurately tested, due to the type of glucometer being used.
It’s also important to follow the manufacturer’s recommended process for testing the accuracy of the glucometer and calibrating the device. Since the glucometer is often used to rule out diabetes in cases that involve stroke or overdose as a possible diagnosis, it’s important to obtain an accurate reading. If you have questions about the device your service uses, contact your supervisor or medical director.
4. Common diabetes medications
While lifestyle and diet changes can be effective at managing diabetes, many patients also need pharmaceutical treatment. Medications are generally divided into categories, such as the route and the mechanism of action.
Patients with both types of diabetes may need to take supplemental insulin, in order to assist the body and move glucose from the bloodstream into the cells. Insulin can be short-acting, intermediate or long-acting. Some patients may take a combination of types.
EMS providers responding to a diabetic patient should determine which type of insulin the patient takes, and try to confirm that the patient took the correct kind. For instance, a patient who normally takes a larger dose of long-acting insulin may mistakenly take a dose of short-acting insulin, then experience an abrupt drop in blood sugar. The most commonly seen injectable insulins are short-acting, and NPH, which is intermediate.
Oral diabetic medications vary in underlying action in the body. The most common first-line oral medication is metformin, which reduces the speed at which the liver produces glucose. By decreasing glucose production, metformin decreases blood sugar. Other oral diabetic medications speed up the release of insulin from the beta cells in the pancreas, increase the use of glucose by the cells, and inhibit the action of hormones that raise blood glucose.
The best option for EMS providers treating diabetic patients is to keep a good medication list handy. Then they can review the mechanisms of action for specific medications in the moment.
5. Conditions affecting blood sugar
A variety of conditions can alter a patient’s response to insulin, as well as their blood sugar levels. These conditions can cause the body to behave in an unexpected fashion and may leave a diabetic patient with either high or low blood glucose.
Common causes of abrupt hypoglycemia in patients are:
- taking too much insulin or
- not eating within proximity of taking an insulin injection.
In either case, patients will present with low blood sugar. Then they should be treated with an oral intake of sugar (if appropriate and allowed by protocol) or by ALS treatment, like glucagon injection or administration of IV dextrose.
Exercise or other forms of exertion can create a drop in blood sugar levels. Similarly, stress, increased carbohydrate intake and illness can all change the way that the body responds to insulin, and they may all result in high blood sugar.
When responding to a diabetic patient who has high blood sugar, work with the patient and bystanders to determine if there have been other recent health changes that may have affected the body’s response to insulin.
Case resolution
Upon further assessment, you find that Christina’s blood glucose is 54 mg/dL. Since she is alert and able to maintain an airway, you elect to give her oral glucose, which she is able to self-administer.
Her symptoms quickly improve, and you continue obtaining her history. Christina states that she took her insulin before her game that day, but she did not have time to eat before the game began.
You recheck Christina’s blood sugar and obtain a reading of 98 mg/dL. Knowing that the oral glucose will quickly metabolize, you recommend eating something more substantial, in order to prevent her blood glucose from dropping again.
Christina’s mother arrives, and you contact your base hospital to complete a Treat and Release. You clear the scene shortly after Christina and her mother go home.
ABOUT THE AUTHOR
An EMS practitioner for nearly 15 years, Patrick Lickiss is currently located in Grand Rapids, MI. He is interested in education and research and hopes to further the expansion of evidence-based practice in EMS. He is also an avid homebrewer and runner.
REFERENCES
1. National Center for Disease Control Prevention and Health Promotion. National Diabetes Statistics Report, 2017 - Estimates of Diabetes and Its Burden in the United States. Available at: https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf