FOLLOW DR. KO: Staying up late…Worrying…

PICFB.tmpIt is now midnight, hours after the end of my shift, and I just texted the night resident from home to ask for an update about my patient who went into diabetic ketoacidosis (DKA) this afternoon.

DKA is a potentially life-threatening complication from uncontrolled diabetes and is more prevalent in those with Type I Diabetes, otherwise known as Juvenile Diabetes, than in people who suffer from Type II Diabetes wherein insulin resistance is acquired later in life.

In DKA, the body does not have enough circulating insulin, a crucial hormone in carbohydrate or glucose metabolism. When insulin is not around to allow glucose to enter cells and be “burned” for energy, the body resorts to burning fat, which then results in the formation of “ketone bodies” such as beta-hydroxybutyric acid which render the blood acidic. The human body is amazingly adept at buffering any changes in the pH (a measure of acidity or alkalinity) of the blood in order to maintain homeostasis, which explains why “alkaline” or “acidic diets” advertised to change the pH of the blood and hence mitigate diseases have no scientific validity.

However, in the case of severe insulin deficiency, the system does eventually get overpowered. A cascade of complications ensues, some of them catastrophic: dehydration, abdominal pain, vomiting, electrolyte disturbances, and labored breathing called “Kussmaul respiration”, the body’s last attempt at ridding the excess acid by exhalation. Stupor, coma and death may ensue.

Before the advent of insulin therapy in 1922, DKA was virtually always fatal. Today, the death rate has dropped to less than 2% thanks to scientific advancement. Nevertheless, DKA remains a medical emergency and is often managed in the Intensive Care Unit, hence my concern about this patient whom I shall name Paul.

Paul is a young man in his early 30s who has not been lucky. Born deaf and mute, diabetic since childhood, he looks frail and thin. He relies heavily on his mother to communicate with the outside world, which makes him appear child-like, and yet he exhibits maturity and patience when it comes to his illness. Day or night, whenever I go to see Paul, his mother is at his bedside without fail. Also without fail, Paul always greets me with a nod, and never protests against the myriad of tests and blood draws that he has to endure.

On admission, Paul’s chief complaint was abdominal pain and shortness of breath. His blood glucose was abnormally low, probably secondary to taking his usual dose of insulin despite decreased appetite and food intake. His was given extra glucose to correct his hypoglycemia, meanwhile his chest x-ray revealed an ugly picture of severe pneumonia obscuring almost half of his lungs. Intravenous antibiotics were immediately started. Probably through the hustle and bustle of shift changes, somehow Paul’s blood sugar level was overcorrected and he went into DKA which was subsequently successfully treated.

To my dismay, Paul’s blood sugar crept up again and he again developed DKA. I made sure he was being properly hydrated intravenously, started him on a continuous insulin drip, and checked his labs periodically. I felt bad for drawing this poor young man’s blood so many times, poking him left and right. I also had a pang of guilt for perhaps not having supervised my interns more tightly to minimize the chance for error.

I am quickly learning that being a senior resident comes with a whole different level of responsibility, a weight that I carry with relish but also with a tad of apprehension and caution. With no senior above me to verify what I do, except for the attending physician, I double and triple check my work, my orders, afraid that I might have missed or forgotten something. But I also stay later because I care more and enjoy my job more.

Finding a healthy balance is always a challenge in medicine, and now more than ever. After a few hours, I had to put my trust in my colleagues and sign over to the night team to continue the management of my patient. Probably still hypervigilant from being a new senior, I texted my co-resident from the night team to make sure that Paul is ok. She might call me obsessive-compulsive instead of vigilant, and she would be right.

I trust that Paul is in good hands and accept that I cannot single-handedly do everything. Instead, I will now rest my mind and body in slumber to refuel for another day.

Melody Ko

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