Rule 172: Any juvenile diabetic with recurrent admissions for ketoacidosis is omitting insulin until proven otherwise.
Confrontation of this is rarely ever helpful. Knowing this, however, can be very helpful.
This rule comes from Dr. Clifton Meador’s A Little Book of Doctors’ Rules, a book I received early in med school. What follows is a deep dive of Dr. Meador’s 172nd rule: Any juvenile diabetic with recurrent admissions for ketoacidosis is omitting insulin until proven otherwise. Confrontation of this is rarely ever helpful. Knowing this, however, can be very helpful.
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During my first rotation I met a young man who was well-known to the medical service for this very reason. Like all patients referenced here, we will call him “Mr. Smith.” He was a teenager, slim build, a fan of the Marvel movies, and a type 1 diabetic on insulin.
Diabetes and ketoacidosis…
Before we dive into this rule, let’s briefly talk about type 1 diabetes and diabetic ketoacidosis, or DKA for short. Type 1 diabetes is an autoimmune condition where your body’s own immune system attacks the insulin-producing cells of your pancreas. As a result, your body loses its ability to produce and secrete insulin. This is significant because insulin is needed to transfer glucose (your main fuel source) from your bloodstream to your cells. If you can’t do that, you can’t use glucose to power your body.
Without insulin, glucose builds up in your bloodstream and your body turns to other fuel sources – free fatty acids. Oxidation of these free fatty acids leads to “ketone bodies.” As ketone bodies build up, the pH of your blood decreases, or becomes acidic. This causes problems. That’s the ketoacidosis part – which isn’t good.
Another aspect of DKA is dehydration. Because your blood is overloaded with glucose (AKA sugar) your kidney eventually reaches a point where it gets overloaded and sugar “spills” into your urine. Wherever glucose goes, water will follow, and you’ll lose even more fluid because glucose pulls additional water into your urine. This results in significant dehydration - which also isn’t good.
With all this in mind, some classic signs and symptoms of DKA are nausea, vomiting, abdominal pain, dehydration, fruity breath, fatigue, and “Kussmaul” breathing.
Side note: Kussmaul breathing is a type of breathing pattern with emphasized exhaling. This is because carbon dioxide is acidic, and since exhaling releases carbon dioxide, this is your body’s way of trying to regulate its pH by releasing something acidic.
The classic triad of labs of DKA will be hyperglycemia (high blood sugar), ketonemia (ketones in the blood), and acidemia (low blood pH). Regarding ketonemia, your doc may get a urine ketone instead or in addition to the blood ketones because it’s quicker. DKA is treatable with IV insulin and fluids.
So yeah… DKA isn’t a good time.
Courage and hope…
After reading about DKA, this begs the question: why would someone omit insulin? There may be a few reasons. The fact that he’s a juvenile patient may point to a lack of maturity, or maybe a desire to escape responsibility. Maybe there’s not a complete understanding of insulin, glucose, the diagnosis, and/or how to take their medicine – something I’ve touched on in Rule 17.
However, I want to go in a different direction and talk about acceptance as a concept underlying this rule: on the sides of both patient and provider. Let’s talk from the patient’s point-of-view first.
To participate in a treatment, a patient must first accept that there’s something to treat. This can be a difficult process for some people, especially young people who yearn to just fit in with their peers and aren’t anticipating medical challenges. It can be doubly difficult when the diagnosis is chronic like type 1 diabetes – meaning it is treatable, but not curable. At that moment, your life is changed. And I’m not sure about you, but I don’t know anyone who is excited or thrilled to be diagnosed with a chronic disease.
Going back to Mr. Smith, this was a young man who felt it was easier to simply live his life like he wasn’t diabetic rather than accept treatment. His desire to not have diabetes was so great, that it outweighed his desire to accept reality, take his insulin, and live a healthier life. This is more common than you might think, and applicable to many different patient populations and people other than those with diabetes. In other words, people commonly make choices based on what they want reality to be, rather than what reality is.
From a provider point-of-view, knowing this is helpful, because we must accept our patients’ behavior for what it is and something we can influence, but ultimately cannot control. For example, from our perspective taking insulin is obviously the better choice compared to not taking it. There are many people with type 1 diabetes who life healthy, productive, and meaningful lives. Confronting our patient about omitting insulin isn’t helpful, because they haven’t fully accepted the fact that they have type 1 diabetes. So why would they be receptive to discussion? This was also true in the case of Mr. Smith.
Understanding this as a doc, and accepting your patient’s behavior for what it is, allows you to be of greater service to your patient. How? Well, I cannot cure diabetes, but I can give you the courage requisite for accepting your diagnosis. I can give you hope that things will get better. If I can understand the actual reasons behind your behavior and accept it, I then put myself in a better position to provide these things.
In times of change, which are common in the medical field, people need courage and hope. Courage to accept what “is” and hope for a brighter “will be.” This is the challenge for the doctor: acceptance, hope, and courage are imperative to providing service, and values for which we should always strive.
I learned a lot about medicine and life from Mr. Smith. It was a privilege to care for him and work on his medical team. He improved with treatment and ultimately returned to home.
As always, thanks to Dr. Meador for this great rule.
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- Tyler
Excellent article! As someone with a family member who has diabetes, this was very informative.