Sixteen years old, just round the corner from these clowns a month ago. I shivered when the name of the district came up on my screen – working alone in a Rapid Response Unit I’m supposed to think a little harder before storming into less desirable areas. No mate behind you to watch your back or second set of six senses letting you know that things have turned south.
I park up at a six-in-a-block, this corner of the estate small and clear enough for my back-up crew to see the vehicle from the passing road, no need to leave the roof lights and red strobes to guide them in. From the boot I swing the response bag over my shoulders, hopping in place as I tighten the straps to suck the weight into the small of my back. The defib comes next, lifted from its housing on the left hand side.
Working alone on the RRU you get the luxury of carrying lightweight O2 cylinders. Carbon-fibre over old steel, half the weight, same capacity and tiny. Small enough to snuggle into the bag itself, leaving a crucial one hand free for your approach to the scene.
You can tell a lot by the state of peoples’ front doors and these are clean, new (but not the-polis-raided-last-week new) and in good order. The stair’s shitty, but on a weekend, so’s mine.
A woman in her 40s answers the door and leads me into a sitting room.
“He’s in the toilet just now…”
Perfect. Unless things have gone horribly wrong in the past 30 seconds while he’s in there, I can at least log the patient as “Alert and ambulatory”.
He’s at my back before I’m in the living room, grey cotton trackie bottoms, the hems slack on the floor behind his feet, a football shirt, not this season’s (I assume, like I’d know) if its soft, frayed edges are anything to go by. No shoes and an asymmetric curtain of hair under a woolen beanie. He is, in short, the ultimate image of kid-from-a-bad-estate.
Except for his body language. There is no stuck out chin, no sneering eyes and mouth, his left hand lacks a bottle of cheap cider, his right shows no signs of being lodged permanently down the front of his pants.
Instead his shoulders are up, his head down, his hands curled in front of his chest in a like a foetal boxer, covering up. Shivering manically, when he looks up in answer to my greeting his eyes are red rimmed and exhausted. Pale and gaunt, cracked lips, his shoulders banging up and down as he pants like a well-run mutt.
“Appears unwell” is often recorded on medical records, but I’ve got a better phrase for him.
He looks like cold shit.
He tells me he’s felt unwell since the morning, but tonight he started throwing up and now he can’t keep anything down, not even sips of water. When I ask him if he’s sore he drops his hands, crushed , to either side of him.
“I hurt everywhere. My head, my chest, my belly, my arms, my legs. Everywhere. My head’s the worst. I go to pee and I can’t, but I have to. I’ve had nothing to eat all day…but my sugar’s high, it’s weird.”
“Let me check on my machine? Not that I don’t trust yours, but…”
I jag him, drop blood onto a plastic strip and we wait dutifully while the monitor counts down from 20.
It reads 27.8 and underneath warns me “Ketones?”
I sniff his breath, a dusty carpet of stale vomit and dehydration, cut through with just a shard of nail varnish remover.
Here comes the science bit…
I want you to imagine that insulin is a stern school teacher, keeping everything on an even keel in your body. It ensures that your liver, pancreas and blood all toe the line, playing together nicely.
Diabetics have either insufficient, or no insulin in their systems. With insufficient insulin managing his body, a number of things have started to happen.
The hormone glucagon has a vital role in your body, it bullies your liver into converting a chemical called glycogen (which it jealously hordes) into glucose and pours it out into the blood stream.
Think of glucagon as a meanie who torments the fat kid into sharing his sweeties.
Given the chance, glucagon would bully the liver all day long, producing an unending stream of humbugs, but it’s kept in check by insulin, the stern teacher, who moderates the number of sweets the liver has to give up, making sure that glucagon doesn’t spoil dinner by stuffing itself.
In a diabetic with insufficient insulin, however, glucagon can go hog-wild, beating shit out of that chocolate hording little hepatic pansy. And so it does, the liver having no choice but to empty its pockets of every precious ju-jube and eclair into the blood stream.
You know how rough you feel when you have too many sweeties?
Your metabolism feels the same way.
Across the other side of the playground, your fatty tissues are freaking out. They’re the obedient, but dumb kids in class, never doing anything too interesting but sitting still and trying to win gold stars by not falling over their own feet too many times in a single day.
But now there’s no-one to impress, no-one to put your hand up to, insulin is gone and nothing else will keep them under control.
The fatty tissues can’t handle this; sycophantic, but ultimately stupid, they’re likely to eat the glue sticks and piss themselves. And so they do, peeing out acids that the liver quickly turns into ketones.
See, your body’s not useless. It knows something’s horribly, horribly wrong and that you can’t maintain this insulin-less condition for too long. So it makes ketones. Your brain can run on them for a good wee while, they’re sort of like cerebral iron-rations. When times are tough, your brain can survive on acid.
Didn’t know that, did you?
Ok, ok. Now that we’re all congratulating ourselves on being X-Men who can run on acid…back to the point.
While ketones are terribly clever and amazing emergency brain fuel and all that business, they’re acidic and make your blood acidic too.
Your body runs brilliantly at pH 7.3/7.4, slightly alkaline. At that point the electricity that runs your nervous system works just great. You shuttle chemicals in and out of your cells at top efficiency. Everything inside you stays, pretty much as it’s meant to.
Step beyond normal blood pH, though and you’re fucked. Your nervous system gets thrown out of whack, your ability to absorb oxygen decreases, ultimately your organs fail in a big soupy mess. It’s really not very nice.
Your body’s good at dealing with acidosis, though. One of the ways it can fix it is by increasing your respiratory rate and gulping down extra oxygen.
But this adds to your problems further. Breathing excretes moisture from your body; not a huge amount but enough to worsen the situation if, say, you were massively dehydrated.
Did I mention the dehydration?
See, when your blood gets jam-packed with glucose, it reaches a point of exceeding saturation and the glucose molecules start to spill over into your urine. This would be fine, since it’s the excess glucose we’re trying to get rid of in this situation, but like a drowning man, glucose pulls extra bits and pieces into the urine with it. Bits and pieces like water, sodium and potassium. All the important things that make your metabolism, you know, work. Ketones do the same thing, being excreted in the urine but dragging water molecules down with them as they go.
I suffered a sodium/potassium drop in Abu-Dhabi last Autumn, I wrote about it here. I felt *hideous* and only had the slightest of slight cases.
I dread to think how grim our patient feels.
Anyway, science lesson over. Back to the story.
“So, Luke…here’s the plan…”
He barely raises his eyes and head at me.
“…we’re going to take you into the hospital and get this dealt with, in the meantime we’re going to give you some fluid to sort out your dehydration. Deal?”
You can tell a lot by how someone reacts to getting an IV, some people complain and squirm, jerking their hand away when they feel the point of the needle against their skin. The average teenager is a fucking nightmare to cannulate.
This guy, though, is cool. He stretches his arm out straight when I ask and, though he grimaces and complains when I stick him, keeps it where I need it until the wide-bore cannula is in place.
The crew arrive to back him up, two technicians, so one of them takes my car while I stay with the patient on the way to hospital. We pass a standby to hospital and run lights and sirens to resus while I stand by the trolley squeezing litres of fluid into his veins.
We’re on the bypass when his Mum asks me a baffling question.
“What do you think’s wrong?”
“What do you mean?”
“What’s wrong with him? Why’s he ill?”
“Well…he’s in DKA.”
“His blood sugar…?”
“Is he having a hypo?”
“No, he’s…how long has he been diabetic for?”
“About a month.”
That explains a lot. I take some time to bring her up to speed on what’s going on and, after our short chat, I look back at the patient.
He’s curled in a loose ball on his side, the blanket pulled around his chin. The shakes have gone, his face is pink and relaxed.
He opens his eyes.
“How you doing?”
“Feeling a bit better?”
Another nod, this one more emphatic.
It’s nothing major, nothing special or Hollywood, no babies born or hearts shocked.
But there’s a massive thrill to be had from just making someone better.