Diabetic Coma

The Malaysian cuisine is delicious and is easily available just about everywhere one walks. Malaysians generally eat well, are well-fed and eat three main meals a day. There is so much food and many food choices today as compared to the 1950s and 1960s. The cuisines today are varied and exquisite, from spicy to bland, from slow-cook to fast food, from pounded to blended, from sauteed to deep fry. The culinary magic is among Malaysia's strong points that supports its tourism industry and hospitality industry. People are eating all the time and everywhere. All these are possible because Malaysia is a hot pot of many ethnicity from the globe. There may not be Vikings and Inuits in Malaysia, but there are Malays, Chinese, Indians, Mongols, Thais, Filipinos, Indonesians, Nepalese, Uyghurs, Japanese, Koreans, etc in Malaysia. They have contributed much to Malaysia's unique international cuisine. Malaysians are mostly obese. Diabetes is common in Malaysia.

Diabetes is Malaysia's biggest health problem, apart from overweight and obesity. Malaysians are not scared of diabetes. They just dislike it and let it take its course. They toy around trying to find a traditional cure for their diabetes. No amount of doctors' advice will ever change them (hard core). They trust and prefer the methods of their ancestors when dealing with diabetes. They do not like Western medicine and do not heed the dangers of diabetes. They will come to hospital at the last minute, but still, they will not comply with medical advice. Nothing will change them. Thus, we see a number of diabetic complications.

Up in the male surgical ward, there were men with amputated limbs. There was a man whose rotten leg stump was placed in a bamboo; it was stinking badly. Over in the ladies ward at another hospital, there was a woman who had undergone wound debridement; she was moaning in pain and wanted to go home, but she died in hospital. In a few homes, family members with severe neuropathy were playing with their own poop and had to be chained. There are many horror stories of Malaysian diabetics.

There is a group of diabetic patients who have made the hospital their second home. They suffer from pre-diabetic coma. Diabetes is reversible, and so is diabetic coma. Diabetic coma is a medical emergency and patients need to be brought to hospital immediately. Semi-conscious patients are brought to hospital Accident & Emergency (A&E) Department by their caregivers, family members, relatives or friends.

Often, the national identity card (MyKad) and hospital registration card (HUSM RN) are the two documents used to identify local patients. If the patient is registered at the hospital where he/she is currently being admitted, doctors have access to the patient's file, medical history and medical status of the last hospital visit to the Diabetes Clinic. Weight and blood pressure (BP) readings should be in the patient's folder. Obesity and hypertension can be made out.

Unconscious or comatose patients can't speak for themselves; doctors will need to work on their medical status and underlying causes. For diabetics, there are four possible causes of coma or unconsciousness:

(1) Hypoglycaemia causes altered consciousness - inability to focus, giddiness, dizziness, etc. This could be due to inappropriate injection of insulin (insulin overdose).
(2) Hyperglycaemia - dangerously high glucose levels in blood. This could be due to skipping insulin doses or skipping insulin altogether, and preferring to try traditional herbal medicine instead (which usually don't work in diabetes).
(3) Dehydration - not consuming sufficient fluids or loss of fluids - vomiting, diarrhoea, drugs, medications, herbal prep etc.
(4) Alcohol consumption worsens pre-existing dehydration in diabetics.


There will be biochemical and pathological changes in the body in diabetic coma:

(1) Acid-base imbalance: Metabolic acidosis; diabetic ketoacidosis (DKA)
(2) Fluid imbalances: Hypovolaemia; edema
(3) Electrolyte imbalances: Hyperkalaemia
(4) Kidney problems: Anuria/oliguria; ketonuria; kidneys cannot filter blood properly
(5) Respiratory system: Acetone breath
(6) Blood: Ketonemia; hyperglycaemia;
(7) Blood lipids: Lipaemia; hypercholesterolaemia; hypertriglyceridaemia; increased fatty acids
(8) Liver: Fatty liver (30%-40% of liver is fatty)


There are Standard Operating Procedures (SOP) for Diabetic Coma under Intensive Care Medicine. Treatment of diabetic coma will depend on the status of the patient:

(1) Hyperglycaemia: infuse insulin
(2) Hypoglycaemia: infuse glucagon
(3) Acidosis: infuse alkali
(4) Hypovolaemia: infuse saline
(5) Lipaemia: apheresis
(6) Fatigue:
(7) Pain:
(8) Fever/infection(s):
(9) Neurology:
(10) Heart:
(11) Blood: dialysis


There will be medical and ethical issues to deal with once the patient pulls through after dialysis, before he/she exits the Intensive Care Unit (ICU) to the open ward. Some patients die soon after dialysis due to cardiogenic shock. This is often stated as "badan reject dialisis" among family members present outside the ICU.

Families can expect patients to pull through by two weeks hospitalisation at ICU and the open ward. Patients are able to sit up in bed and eat hospital food. But families often prefer to supply home food to newly recovered patients (as a gesture of caring). Salty food and certain fruits will set off the biochemical imbalances again. Care has to be accorded to observe that families comply with doctors' strict orders for proper patient care and rapid recovery while still in hospital. But families tend to think that they know better than doctors and choose to disobey.


External links:
http://diabeticsupplies.sgu.ca/2016/12/20/diabetic-coma-in-diabetes-type-2-fact-or-fiction/
https://en.wikipedia.org/wiki/Diabetic_coma
https://shop.lww.com/Irwin-and-Rippe-s-Intensive-Care-Medicine/p/9781608311835
https://psitnotes.com/wp-content/uploads/2016/12/Irwin-Rippes-Intensive-Care-Medicine-7th-Edition.pdf