Photo by Mark Tanner

Issue: Autumn 2005

The Boy in Room 2

Taking Emergency Action

By Francine R. Kaufman

Gordon – the teenager who told me, “Diabetes sucks” – was diagnosed in the emergency room of Childrens Hospital Los Angeles. He arrived by ambulance, unconscious, and was rushed into Room 2, the ER room for our most desperately ill or severely injured patients. No one knew why Gordon was unconscious. Doctors were called over their beepers in anticipation of his arrival. Specialists streamed into Room 2 and waited to see if they were needed. A neurosurgeon and a general surgeon arrived just in case.

The senior emergency room physician ordered a host of blood tests immediately, trying to determine what was wrong. Anyone who arrives unconscious received a blood glucose test in the ER, since the cause might be extremely high or low blood sugar. Within one minute the answer was known: Gordon’s blood sugar was above 600 mg/dl, the highest level the emergency room glucose meter could register. I was paged. I raced to the ER from my clinic, nearly crashing into one of the surgeons as she left.

Gordon lay on the gurney in Room 2. One glance told me that he was obese. That meant he probably had type 2 diabetes. His condition was just as life-threatening as the diabetic coma of someone with type 1. When the report came back from the laboratory, we learned that Gordon’s blood sugar was 984 mg/dl. Quickly I reviewed his medical records. The boy was 13 years old. Though his mother realized in retrospect that he’d been urinating excessively for about four months, he had been noticeably sick for only the past week, with flu-like symptoms that included abdominal pain and three days of vomiting. Now he was unconscious.

I began my least favorite balancing act: racing to bring a child back to normalcy without killing him in the process. I needed to get his blood sugar level down by giving him more intravenous fluid, but I couldn’t give too much at once for fear of causing brain swelling. Gordon’s mother, Denita, stood in the corner of Room 2, tears pooled in her eyes. Once the insulin and fluid drips were established, I approached her and introduced myself. “I will tell you everything as we go along,” I promised. “He’s really sick now, but most of the children do okay in the long run.”

“Do okay with what?” she asked. Apparently no one had explained why her son was unconscious.

“He has diabetes,” I said. Denita gasped, covered her face, and began to sob. A social worker appeared. She wrapped her arms around Denita and led her out of Room 2. I returned to Gordon’s side to examine him. Although his blood sugar was extremely high, that didn’t explain why he had become so gravely ill so quickly. Usually a teenager with type 2 diabetes would not reach such a point until after months of severe symptoms that only a negligent parent would fail to notice – for example, an unexplained 40-pound weight loss. But Denita was clearly a devoted mother.

Was anything complicating Gordon’s diabetes, I wondered. I put my stethoscope over his chest and listened. An extra heart sound would indicate heart failure; crackling sounds as he breathed would suggest a lung infection. I moved the stethoscope to his abdomen. If he had a ruptured appendix, bacteria in his blood might account for his condition. In that case, I’d be unable to hear the sounds that his bowels would normally make as food and fluids coursed through them. But I could hear faint rushing bowel sounds, so a ruptured appendix was unlikely.

I lifted Gordon’s eyelids and looked into his eyes with the ophthalmoscope. If the optic discs at the backs of his eyes were blurry, that would suggest swelling of his brain or a possible infection in his spinal fluid. But the edges of his discs were sharp. I touched his skin and pressed the tips of his fingers to determine how well his vessels were circulating his blood. When you press on the skin, you force all the blood out of the capillaries and the skin turns white. Then you let go. If circulation is normal, the capillary blood comes back instantly and skin color returns. But if blood return is sluggish, the skin stays white for several seconds. Poor circulation is one sign of dehydration. Gordon’s circulation was sluggish, indicating he was dehydrated, but even dehydration didn’t explain why he was so profoundly ill.

I tapped his knees and ankles to check his reflexes. If there had been a difference in the responses of his left and right foot, that could have meant he’d had a stroke. But Gordon’s reflexes, though slow, were not abnormal. I palpated his abdomen with my fingers. His belly rose like a mountain and seemed very tender, especially around the middle and upper sections. Gordon hadn’t responded to other stimuli – the bright light of the ophthalmoscope, the sound of his mother calling his name, my touch on his legs, chest, and face. But when I probed his belly, he involuntarily winced. This type of abdominal sensitivity suggested the possibility of pancreatitis, an inflammation of the pancreas. It could explain why he was so sick. Pancreatitis is uncommon in children but not unheard of with type 2 diabetes.

Gordon was wheeled from the ER to the intensive care unit. Denita joined us, clinging to his limp hand. Every drop that went into his body was measured, as was every drop that came out. I calculated and manipulated, continuing to adjust his IV drip. Four hours later Gordon stirred. “Gordon!” I called, trying to penetrate his hazy consciousness. He opened his eyes for the first time. I felt relieved and exhausted. Denita wept.

Tests confirmed my hunch that Gordon had pancreatitis and type 2 diabetes. One of the causes of pancreatitis is a high level of triglyceride – fat – in the blood. Normally the blood triglyceride level is less than 125 mg/dl. But Gordon’s was 845 mg/dl. This elevation is caused by his genes, plus obesity, terrible eating habits, and uncontrolled diabetes. I told Denita that we would teach them all they needed to know for Gordon to stay healthy and well. Much later, Denita told me that she’d made a promise to God in Room 2: if He would bring Gordon back, she would do whatever she could to make sure he never got sick again. She has kept that promise.

Excerpted from Diabesity: The Obesity-Diabetes Epidemic That Threatens America – And What We Must Do to Stop It, by Francine R. Kaufman M.D. © 2005 by Francine Ratner Kaufman. Used by permission of Bantam Books, a division of Random House Inc.