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Comment by joezydeco | Hacker News Reader

I'm curious if insulin is a standard part of the medkit. I was on a transatlantic crossing once with a coworker who went into diabetic shock (that's another long story).

A nurse was onboard the flight but no insulin. We had to divert and my coworker was laid up in a Newfoundland hospital for 3 days.

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Insulin isn't something you need acutely. Insulin is used to treat _hyper_glycemia (blood sugar too high). This is a gradually developing condition, and someone couldn't go from 'normal' to 'critically ill' over the course of a flight. EDIT: reading your description below regarding the stolen meds, this seems reasonable. He likely _was_ experiencing some symptoms of hyperglycemia even as you were boarding.

The most common type of 'diabetic shock' is _hypo_glycemia (blood sugar too low). The treatment for this is simply sugar (if the patient is conscious, they can take it orally, if they're unconscious, then they need an IV with Dextrose).

I suspect most airline medkits carry dextrose (the one mentioned in the article did). I would imagine many of them carry glucagon as well (glucagon can be injected into the muscle, which is quicker and easier than establishing an IV, and it signals the liver to release its glycogen stores (by breaking it down into glucose (sugar))).

I imagine insulin is very rare. It doesn't keep for terribly long, most types need to be refrigerated, and the most common use cases are for things that don't come on 'suddenly' (generally someone experiencing severe hyperglycemia has had symptoms for hours or even days).

Don't forget the two big hyperglycemic emergencies: diabetic ketoacidosis and hyperosmolar hyperglycemic state.

Sure, but DKA and HHNK aren't generally sudden onset sorts of things. Usually there's been a few hours worth of symptoms leading up to them.

From joezydeco's follow-up comment from a few hours ago, it sounds like there was a window of concern for several hours before boarding the flight. At any rate, there was no mention of this being sudden onset. Just encouraging people on this site who don't have a medical background to understand that there are indeed emergencies due to hyperglycemia/hypoinsulinemia.

I'd still say that the most important thing there is to give fluids, not insulin. When you're seeing a new patient and don't have a medical history, it's impossible to know how sensitive they will be to insulin, and the last thing you want to do on a transatlantic flight is take them from hyperglycaemic to hypoglycaemic. Giving enough fluids will allow the kidneys to do most of the the critical fixing of blood chemistry.

(I am not a doctor, but I am a diabetic who has experienced DKA.)

Yes, I agree that one critical element of treatment is fluid resuscitation. I think that because the person who started this thread was talking about insulin, that has remained a subtext throughout the conversation. My goal in posting was to alert people to the fact that blood insulin/glucose emergencies include states on both extremes of the insulin/glucose spectrum. I didn't mean to imply anything about management.

Why would a diabetic person not travel with insulin?

Many diabetics don't KNOW that they are.

That's not at all true - at least, not for diabetics that will go into shock or experience acute symptoms.

Diabetics experience a "honeymoon" period where they will experience some symptoms - almost always enough to trigger a trip to their PCP, urgent care, ED, etc. where they will be diagnosed and put on a treatment plan.

At most they will experience one event of being "very sick" if they don't get checked out at all during the months-long honeymoon before its found.

If most diabetics didn't know they were diabetic, most diabetics would be dead.

Pretty much a collision of unfortunate events. We were at a work function until 2am in London and returned to our room to find it had been robbed. The thieves took his bag which contained his insulin kit.

So now it's 3am GMT and he can't reach his doctor in the States. We're supposed to leave at 8am for the flight home. No pharmacy is open and even if they were, they wouldn't help him. Nurses at Heathrow couldn't help him either.

So he decided to risk it and see if he could make it all the way home without having any trouble. He went into shock 4 hours into the flight.

Ouch.

Were I ever to become diabetic (and manage to figure out my fear of needles), I'm pretty sure I'd carry around spare insulin, like an epi-pen.

(Is it something that can be carried around trivially? Or does it need to be refridgerated? You know what, maybe I'll just eat healthier.)

Insulin will last around 30 days unrefrigerated. Refrigerated, it lasts until the expiration date, which is years for the insulin I have.

That said, insulin is used to treat hyperglycemia, which is usually not an acute incident. "Diabetic shock" refers to hypoglycemia, in which the individual needs sugar to raise their blood sugar to normal levels.

> Were I ever to become diabetic (and manage to figure out my fear of needles)

You get over it pretty quick when it is literally life-or-death, trust me ;-)

Actually, IIRC insulin is classified as a Pharmacy-Only medicine in the UK, rather than Prescription-Only, meaning that it can be sold by a pharmacist without requiring a prescription, to address exactly this sort of situation.

Even if they've reclassified it as a POM in the 25 years since I stopped doing that stuff for a living, if you could have found a pharmacy in the UK, then under the Emergency Sale and Supply regs the pharmacist could, on their own recognizance, dispense a sufficient supply of prescription-only meds to get the patient back home.

(Caveat: I am an ex-pharmacist. Any advice I could conceivably give you is over two decades past its sell-by date and needs checking.)

Edit Current emergency sale and supply regs are described here:

http://www.nhs.uk/chq/Pages/1011.aspx?CategoryID=73&SubC...

What is your favorite sci-fi story involving a pharmacist?

I don't think I've ever read one. And I'm not planning on writing one any time soon. (The professional life of a pharmacist is, ideally, extremely boring. If it isn't, someone's going to be very ill, if not dead.)

FYI. There's a 24-hour pharmacy in Earl's Court in London (called Zaffash I think)

Stupid diabetics exist, just like in the rest of the population (though it sounds like the diabetic in this case was just unlucky, from the grandparent's followup).

Depending when the person was travelling: some nations banned bovine insulin originating from some other nations over fears of bovine spongiform encephalopathy.

See, for example, this 2001 Australian document:

http://www.health.gov.au/internet/main/publishing.nsf/Conten...

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