• Place supplies in convenient locations around your house and workplace. • Showothers whereyour supplies are kept. • Keep glucose tablets in your car,pocket, or purse. • When traveling, keep a full set of supplies in your hand luggage and also in your checked luggage , just in case a piece of lug gageis lost or stolen. • It may be wise to replace glucagon on or before the expiration date on the vial.
In an emergency, however, it isn't necessary for your savior to worry about the expiration date.
In the United States, glucagon isusually soldwith veryshort dating.Manypeo ple are sold costiy emergency kits markedwith expiration dates
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YOUR HYPOGLYCEMIA TOOL KIT
To make sureyouare not caught unprepared bylow bloodsug ars, you should always keep the following supplies on hand at both your home and yourworkplace:
If You Take OHAs or Even ISAs • 1-3 bottles (100 tablets each) Dextrotabs or other glu cose tablets; always carryglucose tablets with you
If You Take Insulin and Do Not Live Alone, You Also Need • One package of three tubes Glutose 15 • Glucagon EmergencyKit • 4-ounce bottle metoclopramidesyrup
only a few months later.
Don't worry.
Glucagon is sold as a freeze-dried powder that will probably remain effective for five years after the "expiration"date, unless of course it has been ex posed to moisture or extreme heat (as in a closed car in the sum mertime).
It retains its longevity especially if it is refrigerated.
Once diluted, however, it is good for only 24 hours. • Always replace supplies when some have been used.
Never allow your stock to become depleted.
Keep plenty of extra glucose tablets and blood sugar test strips on hand.
Emergency Identification Tags If you useinsulinor OHAs, youshouldwear an identification tag that displays a recognizable medical emblem, such as a red serpent encir clinga red staff. The tag,which maybe worn as a braceletor necklace, shouldbe engraved with a message that relates to the treatment of hy poglycemia. Myown bracelet is engraved with the following message: DIABETIC. IF CONSCIOUS , GIVE CANDY OR SWEET DRINK. IF UNCON
SCIOUS , to hospital. Since bracelets are more likely to be spotted by emergency personnel, I prefer them to the necklaces. Most pharmacies and jewelers sell medical ID tags. Prices begin at
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$5 for stainlesssteeland go into hundreds of dollars for solid gold.The MedicAlertFoundation, Turlock, CA95381, will keep a record of your medical historyand will sendyou a stainless steelID bracelet or neck lace,with their emblem,for $45.Sterling silver or gold-plated IDs cost slightly more.
Beautiful 14-carat goldIDsare available at considerably higher cost.Theywillalsoengrave the tag diabetic for the same cost.
Alltags are stamped with your special ID number and with their "call collect" 24-hour telephone number.
Byphoning this number, a hospi tal can secure your name and address, contact information for your next of kin and physician, a list of allyour medicalconditions, and the doses of medications that you take.
You can obtain an application form by writing to the above address or by phoning (800) id-alert.
Diabetics who do not take medications that can cause hypo glycemia would also be wise to wear a MedicAlert bracelet, if only to discourage the automatic use of intravenous glucose infusions , a common practice of emergency personnel on victims of motor vehi cle accidents, heart attacks, and so on.
Emergency Alarm Service If you live alone, you may want to consider using an emergency alarm system.These can automaticallyphone a friend, relative, or emergency squad when you push a button on a necklace.The system can also be activated if you do not "checkin" at predetermined time intervals.The least expensive system that I have encountered is supplied by the MedicAlertFoundation. Their "failureto check in" alert unfortunately can only be activated at 24-hour intervals,so you can be unconscious for 24 hours before someone is notified.
The Continuous Glucose Monitor Most of us have jobsthat bringus into contactwith other peopleduring the dayand family withwhomwehave contact afterwork.
These contacts offer considerable protection from severe hypoglycemia, as colleagues and relatives willintervene ifyoustart walking into walls or talkingsilly.
A sleeping partner can frequendy pick up on the labored breathing and cold, clammyskin or damp nightclothes that accompany hypoglycemia and then awaken you and askyou to checkyour blood sugar.
If you liveor sleep alone, or if your sleepingpartner is an extremely
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deep sleeper, however, you don't have this protection at night.* A new backup is now available.
Several companies are now marketing continuous blood glucose monitors.1 A continuous blood glucose monitor works via a tiny sen sorimplantedbeneaththe skin,usingatechnique similar to that used for insulin pump tubing.The sensor constantly measures glucose con centration in the tissue fluid present at its subcutaneous location.
A combinedpower supplyandradio transmitter attaches to your skin or clothing.
The transmitter sends up to several hundred glucose read ings daily to a small portable receiver that you can keep in a pocket.
The number displayed is approximately equal to the blood sugar about 20 minutes prior to the reading.
So if you had taken a reading with your conventional method 20minutes ago, this would be roughly the same asthe reading from the sensor right now.
Also displayed is an up or down arrow to indicate whether blood sugar is increasing or decreasing.
What's most valuable is an audible alarm that can be set to sound at any selected blood sugar value and also to signal rapid drops in blood sugar.
There aresome potential problems associated with these devices,so they're not for everyone,and certainly not for me. • The sensor remains under the skin for 3 days.
During this time, there is always a possibility for inflammation or infection (prob ably a low risk). • Fibrosis, or scartissue, can potentiallybuild up at the sensor site over time (although how long this would take is as yet unclear) and eventually make measurements less accurate. • Measurements are inherently less accurate than ordinary blood sugar monitoring, so the devices need to be calibrated against finger-stick blood sugars about twice daily.
For now, at least, I would recommend that any blood sugar correction be made based on finger-stick measurements. • Both the equipment and the disposable sensors with associated supplies are quite costly and may not be coveredby many insur ance policies.
Many insulin users will awaken automatically when blood sugar gets too low during sleep,so these people have built-in protection. *Search the Webfor "continuous glucose sensor"to compare different models.
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• Advertising for these products may falsely imply (but does not state outright) that a sensor-insulin pump combinationwillau tomatically monitor and inject insulin to keep blood sugars on target around the clock. • The sensor is typically implanted in the abdomen, and has a bulky exterior. • The sensor will typically work for only 3 days, because the en zymeused is then depleted. • The setup requires training to use.
While the sensors have at best limited usefulness at the moment, it isentirely feasible, just froman engineering perspective, thatthey willvastlyimproveovertime.That said,I'm not holding mybreath , this technology has been around for decades, and manufacturers have made plenty of money by employing it shoddily. One can still hope, however, that some brilliant entrepreneur will develop a highly accu rate and timelysensor that can provideconstant, accurateblood sugar readings. But we're not there yet.Soto sum it up, if I werelivingalone,I'd use the sensor to protect from nighttime hypoglycemic episodes and for get about using an insulin pump.
"HYPOGLYCEMIA UNAWARENESS"
Some diabetics have absent or diminished ability to experience the warning signs of hypoglycemia. This occurs under five circumstances that have been documented in the scientific literature:
• Severe autonomic neuropathy (injury, by chronicallyhigh blood sugars, to the nerves that control involuntary bodily functions). • Adrenal medullary fibrosis (destruction, by chronically high blood sugars, of the cells in the adrenal glandsthat produce epi nephrine).
This is especially common in long-standing poorly controlled diabetes. • Bloodsugarsthat are chronically too low. • The use of beta-blocking medication for treatment of hyperten sion or cardiac chest pain. • The use of large(nonphysiologic) dosesof insulin, as is common for individuals on high-carbohydrate diets.
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All ofthese situations result inlowered production of, or sensitivity to, epinephrine, the hormone that produces tremor, pallor, rapid pulse, and other signs that we identify withhypoglycemia.
It is ironic that epinephrine production or sensitivity is most commonly dimin ished in those whose blood sugars have been chronically either very high or very low.
Injury to the autonomic nervous system by elevated blood sugar has beendiscussed on pages 61-62.
Individuals whose heart rate vari ation on the R-R interval study is severely diminished may be espe cially susceptible to this problem.
People who have frequent episodes of hypoglycemia or chronically low blood sugar tendto adapt to this condition.
They appear to beless sensitive to theeffects ofepinephrine, which, when repeatedly released in large amounts, down-regulates its own receptors.
This condition cannotbe predicted byR-R studies.
It is, however, readily detectable if you measure your own blood sugar frequentiy.
If caused by chroni cally low blood sugar, this condition can be reversed by taking mea sures to ensure that blood sugaris maintained at normal levels.
Hypoglycemia unawareness can deprive one of potentially lifesav- ing warning signals.
To compensate for this disability, blood sugar should bechecked more frequently.
For some rare insulin users, it may be necessary, for example, to measure blood sugar every hour for 5 hours after meals, instead of onlyonce or twice after each meal.
For tunately, we have the tools to circumvent this problem; we need only to use them diligendy.
I frequently encounter patients who do not take glucose tablets for low blood sugar measurements because they "feel fine." These arejust the people who are most likely to lose consciousness or find them selves in an automobile accident.
Whether or not you have hypoglycemia, it is essential that you check your blood sugar before driving a car and , after finding a place where you can safely stop your vehicle , every hour while driving.
POSTURAL HYPOTENSION , THE GREAT DECEIVER
Syncope, or fainting, is fairly common as people get older. It is espe cially common among diabetics. Even more common isnear-syncope.
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