As you may recall, I recently experienced a trip to the hospital. It wasn't the most pleasant experience I've had in my life to this point. The bills for my lodging and care have begun arriving in the mail in the last week or so. I'm quite happy that I have a reasonably decent insurance policy through my place of employment. I doubt that I could afford the treatment I received without it, at least not without sacrificing a few of the many luxuries that I enjoy.
The thing is, I realize now that the entire episode could have been avoided altogether. Laying in a hospital bed tethered to an IV bag and pump gives you lots of time for reflection and prayer. Not knowing what put you there in the first place is scary. Working it out from the things the doctors say to you and the numbers the nurses and assistants pull when they check your vital signs gives you even more pause to reflect.
What put me in the hospital was ketoacidosis. Often ketoacidosis leads to a diagnosis of type-1 diabetes, because it is the first symptom of diabetes leading people to see a doctor, so it's not that uncommon among type-1 diabetics. Ketoacidosis rarely occurs in type-2 diabetics like me, and it is usually triggered by a severe illness. I know that for about four days before finding myself in the hospital I was suffering from nausea and unable to eat, after having vomited several times one night for the first time in over 25 years.
Since nausea and vomiting are one of the symptoms of ketoacidosis, I'm not entirely certain what the trigger was in my case. I may have gotten the flu or some other illness which could have caused the nausea and vomiting leading to the ketoacidosis, or I might have developed the condition gradually with the first major symptoms being nausea and vomiting. Since I had had a flu shot about a month before all of this, I think that in my case it may well be the latter.
I was diagnosed with diabetes several years ago, I don't recall exactly when, but it was some time before I started drag racing, which puts it in the 1990s. At the time I had no clue that there was anything wrong with me. My health seemed pretty much as it always had. My appetite was normal, at least for me — I've always had a large appetite, eating two to three times as much as most people around me. One of my friends and coworkers noticed that I was drinking large amounts of fluids, and getting up from board games and card games frequently to use the bathroom. I didn't think much of it, but he recognized the symptoms of diabetes and suggested I see a doctor.
My wife is a nurse. When I told her about what my friend had said, she obtained a used blood glucose meter and brought it home. We checked my blood sugar that night and it was somewhere around 360 mm/dl. That was enough to convince her, but I questioned it, having just eaten a fairly large meal on the way home. So she told me what the “normal” range should be and tested her own blood sugar level. I made an appointment to see a doctor, and he confirmed the diagnosis with some lab work. I was devastated. I went through denial, depression, and anger when I found out I had diabetes.
My doctor prescribed an oral medication called glyburide. Oral diabetes medications are generally only useful for type-2 diabetics. This is because type-2 diabetics generally still produce insulin in their body. Oral medications like glyburide can stimulate the pancreas to produce more insulin as well as lowering insulin resistance in the body's cells. Insulin dependent diabetics don't produce insulin, so oral medications aren't effective for them.
Lucky me, I didn't need to give myself shots every day. With regular testing of my blood sugar and the prescription for glyburide, I managed to keep my blood sugar levels under control for quite a while. Gradually though I needed more glyburide to do this, and so my dosage was increased. Soon enough though, other factors came into play.
One of these “other factors” is simply my own personal failings. I'm lazy, and I also like to eat more than I should. I don't know that these problems quite rise to the level of “sloth” and “gluttony” (you know, two of the seven deadly sins), but they're still problems. They're also not the only weaknesses that I am plagued with. I also liked to indulge in recreational pharmaceutical products and intoxicating botanicals. And, as we all generally know, one of the “side effects” of substance abuse is “paranoia.”
I call paranoia a side effect of substance abuse, but I don't think that what I'm referring to was actually paranoia, nor was it caused by substance abuse. Rather, I think it was simply the rather healthy fear of getting caught having used illegal drugs. After all, there are consequences to such behavior — from incarceration to unemployment or other lesser problems. I didn't want my drug abuse showing up in laboratory tests, and so I stopped seeing doctors.
When my prescription for glyburide ran out, I had also stopped checking my blood sugar on a regular basis. I fooled myself into thinking that there was no problem, that “diet and exercise” had mitigated my need for treatment. Because of my denial I went untreated for a while. I knew this wasn't good, and I tried to quit my drug habit. For some time I managed to do just that. After a few months, I returned to the doctor and ended up back on glyburide, and on a new (to me) diabetes medication, metformin. Once again my blood sugars were under control.
It didn't take too long though before I returned to my bad habits (yes, all of them). I again stopped the careful monitoring of my blood sugar. Why would I quit testing my blood sugar levels? Well, I can't really claim ignorance, but I made excuses to myself all the time. Testing your blood sugar involves puncturing your skin and drawing blood. The most reliable site for doing this is your fingertips. Pricking your finger once doesn't hurt so much. Doing it several times a day leaves your fingers rather tender though. You have to choose a different finger pretty much every time or your testing will leave your fingertips raw.
That minor pain isn't really a good reason not to check your blood sugar though, and newer meters have made it even easier. My current meter lets me test my blood sugar on my forearm. There's a very minor instant of pain involved with that, but compared to pricking your fingers it might as well be painless.
At some point, I went back to see the doctor, and ended up taking insulin and metformin. Sometime after that, I finally managed to kick my drug habit permanently. I've been clean and sober for many years now. I still enjoy an occasional glass of a fine single malt scotch or a beer but never enough to even become “tipsy.” In the process of cleaning up, I ended up suffering a clinical depression.
Lots of things went along with that depression, including an apathetic attitude toward my health. At the same time I ultimately ended up quitting my job, looking for a change. There were a lot of other reasons involved with leaving that job that I won't go into here, but one of the side effects was that my medical insurance lapsed. I could have applied for C.O.B.R.A. continuation health coverage when I left my job and continued to receive diabetes care and treatment. Remember though, one of my failings is laziness, so I didn't bother.
By the time I started looking for work after quitting my job (I had enough money set aside that I didn't need to work for quite some time) I was in an uncomfortable position. Not enough time had lapsed that I could obtain treatment for diabetes through my new health insurance, thanks to the fact that it was a “pre-existing condition” and that I no longer had coverage to transfer. That meant that I had to go without treatment for a while after that.
Most insulins are available by prescription only. “Happily” (or not) as it turns out, 70/30 human insulin is actually available without a prescription. Of course it costs more without one since insurance won't pay for it unless its prescribed. The cost runs about $60.00 to $80.00 per 10 ml bottle depending on where you buy it. Metformin on the other hand is available by prescription only. So I ended up continuing to take insulin while ignoring and letting the metformin prescription lapse. I was taking the same amount of insulin that my doctor had prescribed, but not taking the metformin. I also wasn't checking my blood sugar regularly.
When I finally had coverage for diabetes again, I saw a doctor, had lab tests done and received a new prescription for metformin to go with the insulin I was still taking. Again I resumed checking my blood sugar regularly and got it back under some control, although it wasn't nearly the tight level of control that I once had, and had abandoned on multiple occasions. This didn't last. Once again, I stopped regular blood sugar tests, and stopped seeing my doctor. Again I let the prescription for metformin lapse.
This was the state of my health care for a couple of years, and ultimately I think it's what put me into the hospital. Since I wasn't checking my blood sugar, I couldn't be certain that the insulin I was taking was keeping it under control. When I finally got sick and couldn't eat, I stopped taking insulin altogether. I did this out of the mistaken belief that since I wasn't eating anything, I couldn't have high blood sugar. It doesn't work that way though. Your liver continues to release sugar into your bloodstream even when you're not eating.
When I went into the hospital, they performed lots of tests on me, including a hemoglobin A1C test. The results of the test indicated that my blood sugar had been very high for at least two or three months prior to my ending up in the hospital. High blood sugar levels above 240 mg/dl can cause the body to start consuming fat and muscle in order to meet its energy demands. This results in an increased level of ketones in the bloodstream and, in my case, ketoacidosis. Whether I was sick with the flu and thereby developed ketoacidosis or whether it was the result of long term high blood sugar is of interest. I can delude myself, if I wish, into thinking that it was the flu that caused my problems, but I think we all know better. It was the lack of blood sugar control that put me into the hospital.
Ketoacidosis is scary. It can be life threatening. Laying there in a hospital bed and finally knowing that that was the problem made me realize how near things could have been. I might never have survived it if it hadn't been for the grace of God and the care I received in the hospital. I put myself there, but it took a while to understand that. Once I did, the importance of changing my life was hammered home.
When I left the hospital, the doctor gave me a prescription for an insulin only treatment regimen. That regimen included a long acting insulin called LANTUS® that I was to take before bed each night and a sliding scale for regular insulin that I was to take four times a day. The long acting insulin is intended to deal with the continual release of sugar into the blood accomplished by my liver. The sliding scale was meant to deal with post meal peaks. Under this regimen I had to check my blood sugar four times per day.
I'm sure it was an improvement over my pre-hospital control, but my blood sugar levels were still all over the map. In the first couple of weeks the were below 70 mg/dl twice (hypoglycemia), but more often they were well over 240 mg/dl and sometimes over 350 mg/dl (hyperglycemia)! Since complications from high blood sugar was what put me in the hospital in the first place, that was clearly not acceptable. The nurse working with my doctor taught me how to adjust the LANTUS dose, and asked me to check my blood sugar two hours after meals as well as the other four times a day I was already checking it (Oh thank God for a meter that lets me test in my forearm. Testing seven times a day on my fingers would have been a real pain).
For another two weeks, that's how things went. The nurse had me writing down the blood sugar readings, how much insulin I was taking, and comments about the food I ate. At my last appointment, my blood sugar levels were still out of whack, but they were starting to get better. But now the nurse had enough data to make some changes to my plan. She took me off of the sliding scale for regular insulin, and instead placed me on mealtime insulin using a rapid onset insulin called NovaLog®.
On a quick side note, for the past couple of years, I've listened to people talk about their friends and relatives with diabetes. One thing that struck me as odd is the attitude that some people have (and that I also held, remember, I was in denial) that diabetes isn't really that serious of a condition. Another was the notion that a person that adjusted their insulin dosage based on what they were eating was somehow “gaming the system,” or otherwise not handling their treatment correctly or taking it seriously enough. Part of this is, I suppose based on the warnings that diabetics are given not to make changes in their insulin regimens without a doctor's supervision, and part of it on the attitude that diabetics can only eat certain “diabetic” foods.
Well, I certainly found out that diabetes is a very serious disease with some alarming consequences. I'd known about potential complications like neuropathy, retinopathy, kidney disease, and heart disease, but always had that “it won't happen to me” attitude. Now I know better, in fact I'm taking lisinopril for high blood pressure (diagnosed while I was in the hospital) and simvastatin to keep my cholesterol low (it's actually normal, but my doctor is concerned because I'm a diabetic and my family has a history of heart problems).
The mealtime insulin plan my doctor prescribed for me is another eye opener for me, and it seems to be working although I don't have more than two days of data yet. I still have to check my blood sugar at least seven times a day for a while. I have to check it before every meal, and I have to determine how much carbohydrate my meal will contain. Then, I have to calculate the NovaLog dosage to take based on both values. I am supposed to take one unit of NovaLog for every 25 mg/dl my blood sugar is over 120 mg/dl, and one unit of NovaLog for every 10 grams of carbohydrates in the meal. Then I have to start eating within 10 minutes. That's right, I have to adjust my insulin dosage based on what I'm eating, and it's not “gaming the system,” it's the only way to get the correct dosage.
Two hours after every meal I'm supposed to check my blood sugar again, to make sure that the insulin dosage isn't bringing my blood sugar down too far. At night, I'm on the sliding scale still, but it's still NovaLog I'm taking — one unit for every 50 mg/dl my blood sugar is over 120 mg/dl. I go back to get my dosages/regimen adjusted again in two weeks, so this may end up changing and I may only have to test my blood sugar four times a day.
So far, this seems to be working. My blood sugars have been very close to the “acceptable” target range given to me by my doctor. They're still a little bit high, but they're very much closer than they had been.
Counting carbohydrates is a lot of work though. To do it, I have to read labels, and estimate portion sizes. If I go out for meals, I have to go armed with information about the food I'm about to eat, or ask for nutritional information pamphlets. It's all so much more involved than it used to be when I was able to take oral medications alone and control my blood sugar.
The doctor in the hospital told me that insulin therapy was the most natural way to control blood sugar for diabetics. After all, it's what your body does naturally when it's working right. It's also the only way to control blood sugar for type-1 diabetics. The interesting thing there is, most type-1 diabetics are diagnosed as children. They have to take check their blood sugar and take insulin their entire lives, starting at a very young age.
I'm forty nine years old. I'm alive. I've got nothing to complain about. My trip to the hospital really scared me. Like I said, it was an opportunity to reflect on a lot of things. I've decided that living beats the alternative. Although I do believe that the Lord is my salvation and that there's a better place for me in the end, I don't think I need to go before my time.