I recently wrote some on diabetes mellitus. One of our readers, Strych9, posted an extremely information-rich comment in response. Strych9 (who I’ll refer to as ‘he’ for lack of further information and need for a pronoun) is a Type I diabetic who has learned a lot about the practicalities of managing the condition and insulin therapy. Frankly, I thought the information was way too good to sit only in a comments section where few would see it.
Some of what Strych9 talks about was known to me; and all of that was spot-on accurate. That gave me enough confidence that the things he added that were new to me were also good info that I wanted to pass it on.
This post is mostly Strych9’s comment. I’ve done some editing for clarity. Anything that is not Strych9’s I’ll put in italics. Neither Strych9 nor I am a physician, and neither of us are giving medical advice. This is offered as information.
Strych9’s opening comments:
First, well done. This is actually better than most articles written strictly about
diabetics and for diabetics. Kudos on that!
On to the quibbles!
NOTE: What follows is mostly MY OPINION. THIS IS NOT MEDICAL ADVICE. I’m just a diabetic, not a doctor or endocrinologist.
On stockpiling insulin:
First, the expiration on refrigerated and unopened insulin is 2-3 years. You won’t get that far leaving it at room temperature but unopened it will last awhile and after you open it it will last a bit over a month. The numbers on this stuff are rather conservative and for good reason.
Cold or not you’re not going to be able to stockpile insulin because of the price and the way it’s Rxed. A good diabetes doc will give you a few extra months supply but they can’t go much farther than that without drawing regulatory suspicion that they’re involved in insulin doping (enhancing athletic performance via insulin and sugar mixes to extend the duration of exercise, a practice uncovered at the Olympics back in the 1990’s).
Further, insulin is something that an insurance company WILL NOT pay for you to stockpile ANY amount of. Anything past what’s on the MONTHLY Rx is up to you in cash, up front. I am quite sensitive to insulin and therefore take quite little of it in comparison to other folks, a months supply in cash is $550 for vials (with a discount card) or $800 for pens (with a discount card). You’re not going to stock up on this stuff like it’s SPAM or beans. Walmart might cut your prices a bit but it’s still hundreds of bucks a month up front in cash and you can get yourself in trouble buying it without an Rx or even with one if someone thinks you’re involved in a doping program.
On who to talk to for advice:
Second, you cannot trust a GP doc about this. If you want straight dope on insulin and diabetes talk to an endocrinologist. My, now former, GP very nearly killed me repeatedly with misdiagnoses and improper information on the use of insulin once it was made clear to them I needed it when I nearly died. Even the docs in the ICU and ER didn’t really know what they were doing.
On monitoring to determine insulin need
One other thing: test strips. Sorry, but you want battery power in this case. Rechargeable if possible. Test strips of the urine testing variety require no batteries but also make managing diabetes nearly impossible because they don’t give you real time data. A finger-stick or a CGM [continuous glucose monitor] tell you your current glucose numbers with a 10% MOE [margin of error]. A urine strip has a larger MOE and is going to tell you what was happening 1-4 hours ago and your blood sugar can change by 2-4mg/dl per minute if you eat or take insulin meaning whatever that number you saw on the strip was could be +/- 120-960mg/dl. If the strip says 200mg/dl you could already have someone in insulin shock or running very high. You won’t know.
Strych9 finds continuous glucose monitors far better than test strips. Might stock up on battery recharge solutions.
If you make a mistake by even 40mg/dl you can put someone into insulin shock. a minimum MOE or 120-240 is just not workable especially since without an insulin pump your best ability to measure a dose is 0.5u which in an insulin resistant person might do next to nothing while in an insulin sensitive person might drop them 150mg/dl.
On emergency response to insulin shock
First off, sugar under the tongue for someone in a hypoglycemic coma isn’t going to be very effective. [Yeah, I’d heard that recommended for the ‘groggy but able to swallow’ state] Gross as it is, if you can’t inject them with sugar or a special kit, chew up a sugar tab or hard candy, or take gulp of soda into your mouth and spit it into the unconscious person’s mouth and assist them in “swallowing it”. 15g of sugar should do this. Wait 15 minutes. If they don’t wake up, rinse and repeat 15g sugar every 15 minutes until they wake up.
Avoid candy bars, the fat in them means the sugar adsorption will be slowed.This is a race against their cells pulling out enough sugar from the blood to kill them. You gotta win that race. Speed, in this case, saves. Liquid SUGAR is the fastest way to bring them back up. Anything else is slower.
A Glucacon kit is nice for this situation. It will impede the action of the insulin they have on board and give them a dose of sugar. If you don’t have one, the advice above is about as good as you can do.
On responding to diabetic ketoacidosis (DKA)
Secondly, DKA. This won’t be brought on by stress in 99% of circumstances. It’s a lack of insulin, infection or injury.
If you have insulin on hand, that will treat it. Re-hydrate as necessary. Sugar free Gatorade or, preferably, an IV are best. [That’d be a saline IV, not Gatorade!] The real problem with DKA is that the cause is controllable and controllable within 48 hours. The issue is that the dehydration issue will throw their electrolyte balance off. I was diagnosed as a Type 1 at 34 years old because I was in SEVERE DKA (My first, and so far only, time in the ICU!). They actually were not sure how I was alive never mind talking. That’s not the point, the point is that my potassium levels were way, way off. Insulin gets rid of the problem that’s the root cause here but doesn’t get rid of the dehydration. If you give insulin and simply re-hydrate with water the person will die because they’re no longer in DKA and they don’t have anywhere near enough electrolytes to keep up with the water you’re pumping into them. You have to pump potassium and sodium into them at the same time. If you overdo the electrolytes the person will excrete them via urine. If you underdo the electrolytes the person will die. How you do this without lab tests and IV potassium, I’m not sure. DKA, like KA from the Keto diet, once it’s past a certain point… well you need a hospital because otherwise the chances of survival are close to none. [Yeah, I knew about this problem and couldn’t think of any ‘prepper situation’ fix, so I let that sleeping dog lie.]
Really, the best way to deal with DKA is to avoid it. Once it’s there to the point the symptoms are obvious… well, it’s a huge problem. Just avoid it. If you can’t the person is probably screwed anyway over the longer time frame. Sorry, that’s just the way it is.
On responding to high blood glucose
Something to keep in mind here, and it’s something you’ll find from an endocrinologist rather than a regular doctor: In the short term high blood sugar is not harmful. Averages are what matter here because of the way sugar causes damage (which I’m not going to get into). So, for example: If I’m at 300mg/dl right after a meal I don’t care because the insulin I took will deal with that. Also, little known is that everyone spikes in glucose levels. Eat half a chocolate cake and even non-diabetics will probably spike to 200mg/dl or more for a couple of hours. This is normal. Insulin, natural or injected, does not act instantly.
[Ok, there is a rare problem that arises from too much blood glucose, but it’s mostly seen in people with other serious health problems. We needn’t go there in this piece.]
[Strych9 adds some info on varieties of insulin. If you’re a diabetic and want to read it all, you can find it in the full comment on the article linked at the top. I omit it here because it’s less useful to the average reader.]
As for you giving them the insulin. Jeeze, I hope they gave you an outline because there are a zillion things that can affect how much of each type they need and the only reliable way to know is personal experience. Someone really sensitive to insulin… that’s hard. They could drop from 350 to 300 with a certain dose or drop to 50 with that same dose.
What if you gave them too much sugar?
If you correct low blood sugar and the person rapidly spikes higher than you thought, don’t panic. Sugar works for us like it does for you, pure sugar hits fast and wears off fast. It is likely they’ll jump from 50 to 200 and then over the next hour or so slide back down to 130 or so as their on-board fast acting insulin does it’s job. Well done. Do not give them more insulin unless they remain high for a prolonged period of time. If you do not know when they last took insulin wait at least four hours before giving more. This is not dangerous. This situation is like driving on ice. Don’t slam the brake or hit the gas, slowly release control, let the car settle and bring it to a stop. Trying to correct things too fast ensures you’ll really lose control.
On ketone test strips
Ketone test strips are stupid, don’t bother. Everyone goes into ketosis sometimes and these things will pop positive for that too. Working out puts you into ketosis, how do you think it helps you burn fat? Long story short: these things will serve no real purpose but to scare you with extra data you don’t need. If the person is in DKA, they’re probably screwed anyway if SHTF, and the answer is always insulin, electrolytes and hydration regardless. Further, they have to test positive on those strips for quite awhile before they actually go into DKA so… what’s the point? Your glucometer tells you if the sugar level is high, so act on that. On top of that if you have someone in ketosis because of hard work, but at 130mg/dl, there is no threat to them since this is normal, natural ketosis from hard work and if you give insulin, well, hypoglycemia. IMHO, you can learn nothing of value from these strips and if you get the data from them may well overreact to it creating a problem where there was none. Plus they’re an extra thing to carry/keep track of. Discard these things.
If you must err, on which side?
Finally, I would say that if you’re in a bad situation, give less insulin rather than more. A couple reasons: Someone running at 200mg/dl all day is really in no danger right now but someone unconscious at <30mg/dl is a problem we have to deal with immediately. Also, you can take care of that high glucose number with dinner/time to sleep/rest whatever. It can wait until the end of the day. Further, keep in mind that the problems associated with diabetes, of which there are many and they’re all very bad, take a long time to develop. High blood sugar numbers over time do cause everything from kidney failure to blindness to nephropathy to stroke and heart problems. This takes years, like decades of poorly managed diabetes. If you’re in a situation where the person is going to be running that high day-to-day for that long they’re screwed anyway because they’re going to die when the insulin runs out and that’s going to be long before they have any of these kind of issues. A1C is what matters here, that’s average blood sugar. This has to do with the physical crystalline nature of sugar and the way it sticks to A1C hemoglobin. If the A1C never gets real high that hemoglobin never has big layers of crystals on it and we don’t have a problem.
If you made it this far, thanks for reading, hope I imparted something useful. Thanks for reading my rant.
Thanks for taking the time and trouble, Strych9!
Old style insulin at Walmart for $25 per vial. Keep in a dark container in back of fridge for a couple of years.