By Buck Tilton
Wilderness Medicine Institute of NOLS
Reprinted from The Leader, Winter 2000, Vol. 16, No. 2
July in the Wind River Mountains. A young woman vomits again. Typically upbeat and energetic, she complains of extreme fatigue-in an irritated tone of voice-and you know she has been lagging behind for days. She doesn't think she can finish the course. Her skin is flushed and warm. History reveals frequent thirst, an unusual amount of fluid intake, and, as you might expect, frequent urination. She also reports unusual hunger, but, for the past 24 hours, she has been vomiting almost everything she eats. She appears to have lost weight, much more than you would expect, even though you can attest to the fact that her appetite has been good for most of the past three weeks.
What are you going to do? Setting camp early, she rests, drinks a liter of water, then eats lunch. She vomits everything up. You decide to evacuate the young woman.
You decide wisely. The hospital discovers a blood sugar level of more than 1,000. Normal runs between 70 and 125. She is diagnosed with insulin-dependent diabetes.
Your body runs on sugar-glucose to be more precise. You manufacture glucose from the foods you eat. Some body parts (muscles, fat, liver) store glucose in case of future needs. Other parts, especially your brain, cannot store a significant amount of glucose. To meet the critical demands of the brain, you carry sugar in your blood at all times.
Glucose passes freely across the blood-brain barrier. The rest of your body's cells cannot accept sugar without the presence of insulin, a hormone produced in the islet cells of your pancreas. But, if you have diabetes mellitus, your pancreas forms an insufficient amount of insulin. An insulin-dependent diabetic may suffer from hypoglycemia (low sugar in the blood) when she or he exercises too much, eats too little, or takes too much insulin.
Due to the brain's critical dependence on blood sugar, an altered level of consciousness, confusion, irritability, permanent brain damage, even death may result in a brief period of time. Other signs include a rapid pulse and pale, sweaty skin. Symptoms include headache, hunger and weakness. Signs and symptoms almost always appear rapidly, within minutes. Hyperglycemia (high sugar in the blood) can result when a diabetic gets too little exercise, eats too much, or takes too little insulin.
There is no immediate danger since the brain has an adequate supply of glucose, but, untreated, serious problems, even death, may occur. Signs include warm, dry, flushed skin and deep respirations with a "fruity" odor. Irritability and confusion are common. Symptoms include headache, thirst, nausea and the need to urinate frequently. Onset is typically slow, over hours to days. Your patient in the Winds has hyperglycemia, the only diabetic possibility since she has never been diagnosed with diabetes and has never injected insulin.
Hypoglycemia must be field treated immediately with sugared drinks or sweet foods, or glucose tablets or jellies. If the patient is not able to take foods or drinks, glucose or sugary substances can be rubbed into their gums. If you're unsure whether your patient is hypoglycemic or hyperglycemic, treat for hypoglycemia-it saves the hypoglycemic patient and does not harm the hyperglycemic patient. DO NOT give insulin-NOT EVER. Evacuation of a diabetic patient depends on whether or not the patient returns to a normal condition, and whether or not the patient wishes to remain in the field.
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