An article in the LA Times reports on the death of Lawrence M. 
Moore, City Manager of  Compton, Calif., who died at age 54 from 
diabetes.  The article quotes a policeman: 

   "He wasn't feeling well and was told he had allergies," said Lt.
Danny Sneed. "He died in a diabetic coma. He never knew he had 
diabetes." 

   Mr. Moore died shortly after he was found unconscious at his
place of residence.

   It is not impossible to understand how the symptoms of diabetes 
could be misinterpreted as allergies, since fatigue and dry mouth 
are common to both -- and nearly 6 million Type 2 diabetics in the 
U.S. are slogging along with no idea at all that they have diabetes,
chalking up their symptoms to everything but diabetes. 

   While it is not clear whether Mr. Moore had Type 1 or Type 2 
diabetes, the odds, of course, are strong that it was Type 2 diabetes 
and that his diabetes could have been diagnosed for quite a while,
had he been carefully checked for it.  In memory of Mr. Moore, I'd 
like to say a few things about diabetic comas.    

   Diabetic coma refers to the crisis that occurs when blood sugar 
levels are quite high.  While a diabetic can also become unresponsive,
unconscious or pass out from low blood sugar or excessive insulin, 
this is not what is usually meant by the term "diabetic coma."  
It is not necessary for a person in diabetic coma to actually be
unconscious or unresponsive, which is what we usually associate with
the word "coma."  

   While any diabetic can experience Diabetic Ketoacidosis (DKA) 
and many Type 2 diabetics do experience DKA, it is more common 
among Type 1 diabetics and occurs when insulin levels are inadequate.
The diabetic becomes increasingly dehydrated and the body begins
breaking down fats, releasing free fatty acids (FFA), which are 
Oxidized in the liver, producing waste products called ketones.  
Excessive levels of glucagon accelerate the process and the ketones
can begin to excessively accumulate in the blood and urine.  If 
dehydration reduces the urinary excretion of ketones, body chemistry
may become increasingly acidic and systemic metabolic ketoacidosis 
may ensue. 

   Among the common symptoms of DKA are thirst, loss of appetite, 
nausea or vomiting, stomach pain, increased urination, dehydration, 
deep and rapid breathing, a fruity or acetone (nail polish remover) 
smell on the breath, and changes in awareness, ability to think, or 
consciousness.    Many studies suggest that the most common cause of
DKA in diagnosed Type 1 diabetics is failing to take any or enough 
insulin.

   While DKA is a serious emergency that requires expert care, about
95% of diabetics with severe DKA can be expected to recover fully.  
One of the important issues in treating DKA is to make sure that the 
blood sugar level is not brought down too rapidly.  It's also important
that the dehydration be repaired with care.  When DKA treatment does 
not go well, it is usually due to trying to bring down the BG level 
too quickly, replacing the lost fluid too quickly, or not timing 
potassium replacement correctly. 

   Type 2 diabetics are prone to a type of diabetic coma called 
Hyperglycemic Hyperosmolar Non-Ketotic Coma (HHNKC), also known as 
Hyperosmolar Hyperglycemic Diabetic Coma (HHDC).  It is most common
among elderly Type 2 diabetics and those who are acutely ill from 
another cause, such as infection, pneumonia, stroke, surgery, 
anesthesia, thyroid condition, renal or cardiovascular disease,
pancreatitis, heat stroke, or the use of some medications (diuretics,
dilantin, propanolol, and steriods).   The diabetic has excessively
high BG levels and is severely dehydrated.  

   Because they have not experienced the early excessive ketone 
accumulation that causes the symptoms usually found in DKA (the 
nausea,  stomach pain, breath smell, breathing problems, etc.), 
Type 2 diabetics with HHDC are often in severe crisis by the time 
they receive care -- and less than 50% can be expected to survive 
the crisis.    

   Symptoms of this type of coma are frequently missed until they 
are very serious, with high BG levels (often over 600 mg/dl), severe 
dehydration (osmalality often over 350 mOsm/kg), and nervous system 
dysfunctions ranging from difficulty thinking, disorientation and 
decreased mental awareness to loss of consciousness.   They may have
low blood pressure, rapid heart beat, and be so dehydrated that they
are not able to urinate.    

   As with DKA, it is important to bring down the BG levels and 
repair the dehydration very carefully.  The primary focus is usually 
to restore the sodium level,  circulation, and urine flow.  Potassium
levels usually need to be carefully restored earlier than in diabetics
with DKA.   Everything needs to be carefully monitored and timed, 
With great care taken to avoid causing cerebral edema, and monitoring 
should be rigorous and continuous.  It is also important to look for 
any underlying illness that may have precipitated the situation, 
including infection, stroke, and renal function.   Diabetics using
Glucophage (metformin) may be more likely to also have lactic acidosis, 
requiring additional considerations.   Expert treatment is essential 
and may still not be enough to save the diabetic's life.  

   Again, this is part of why some of us stress so much the importance 
of never letting ourselves get dehydrated.   I know I talk about it a
lot, but it's a terribly important thing for us because we can often 
slog along with very high BG levels for quite a while if we're getting
enough water -- but if we get dehydrated, we can get into some terribly 
serious crises very swiftly and Type 2 diabetics might particularly not 
notice how bad things are getting until it's too late.    

   When in doubt, it is always better to get some immediate medical 
attention as soon as possible.  As always, we should have someone else 
take us to the hospital and not attempt to drive ourselves. 

                - Paula