John Monaco, M.D.
I know I have written on this topic before, but this disease never ceases to leave me in awe. In general, it effects young children, usually in the preteen years, who have no idea that they are genetically predisposed to acquiring diabetes.
The children go along, leading normal lives, when gradually they begin to sense changes in their bodies. Usually it begins with a lack of energy and weight loss, but the changes are subtle.
These changes may go on for a while, sometimes months. Then these kids begin to get increasingly thirsty, and notice that they are going to the bathroom all the time, and, no matter how much they drink, they can't seem to get enough water, or fluids. The thirst worsens, as does their weight loss, but soon the real trouble starts. Their bodies, trying desperately to compensate for the nearly imperceptible metabolic changes, can no longer keep up.
The acid/base balance of their blood changes, becoming more acid (acidosis). The acidosis sometimes is so profound that their survivability is threatened. And as acidosis sets in, their mental functions are affected. Early on, the changes are mainly confusion, sometimes accompanied by combativeness. Without intervention, these can worsen to the point of increasing somnolence, and eventually coma. In severe cases, death will result.
The basic metabolic defect is simple. The Islet cells of the pancreas of children with type I diabetes do not produce sufficient insulin. What this means is that glucose in the blood stream is not effectively transported into cells where it is needed for normal metabolism. Without the glucose, cells feel as if they are starving. Ironically, blood sugar is high, but there is little sugar within the cells. Since cells need energy to perform adequately, they begin to break down other nutritional sources to produce calories, namely protein and fats. It is this metabolic compensation that results in the acidosis that, left unchecked, can be potentially lethal in these children.
Recently our service cared for a 10-year-old boy who was desperately acidotic when he came to the hospital. His blood sugar was over 800 (120 is the upper limit of what's considered normal). He was sleepy and incoherent. His electrolytes and other blood chemistries were completely out of balance. Luckily, because we have cared for hundreds of these patients, his metabolic imbalance was slowly and effectively corrected, and he did very well.
But then, the day he was discharged, and he was getting final instructions on how to check his own blood sugar (finger stick) and administer his own insulin (injecting himself twice a day, for life) I was struck by the overwhelming solemnity of this disease. I know it had not yet sunk in with him and his parents. It was still too new, and they were still too thankful that they had gotten over the "worst" of it, and they still had their precious son intact.
It is true that there is lots of research in juvenile diabetes, its treatment and long term effects. But for the vast majority of kids with this disease, they are sentenced to a lifetime of twice a day injections, several blood sugar checks per day, and worse, even with good control, long term effects on their eyes, kidneys and other organs dependent on tiny blood vessels which are ravaged by years of difficult to control blood sugars.
In this political season, I could not help but be struck by the current discussion of stem cell research and potential cures of many diseases including juvenile diabetes. I know that there are deep and controversial moral issues involved. But for those of us who care for these kids, see them recover from near death experiences, only to be sentenced to a lifetime of misery, it is difficult not to wonder if we could somehow transcend these deep seated conflicts and do what needs to be done to save these kids.
Those of us who do critical care for a living have a certain degree of "adrenaline junkie" within us. The child with impending diabetic coma is one of those challenges that gets our adrenaline running and gives us the "rush" associated with saving lives. Believe me when I say, however, that if this disease could be eliminated, and I would never have to face one of these newly diagnosed diabetic kids in crisis, I would not be disappointed. Remember this as, in each progressive election, issues of economics, morality, political philosophy and healthcare become increasingly more closely entwined. The only hope for us all is to be as informed as possible before making these incredibly crucial choices.
John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida. He welcomes your comments, suggestions, and thoughts on his observations.
John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida. He welcomes your comments, suggestions, and thoughts on his observations.
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