Jamie on Diabetic Ketoacidosis

We lost our dear and gentle Jamie in 2009 to cancer and diabetes. Jamie and her cat Boots were long-time friends on the Feline Diabetes Message Board. Jamie will live forever in our hearts. I am copying here what she wrote about her own DKA episode. Thank you, Jamie, for one of your many legacies.

What does DKA Feel Like? WARNING: Reading this story may be upsetting.

The physical manifestations (and, to a lesser extent, the mental manifestations) of Diabetic Ketoacidosis, or DKA, as I have experienced and thus described, can be summed up very simply: suffering. Reading this story is reading about suffering. It's not all graphic; the bad bit begins and ends at the asterisks (***).

You may want to just skip over this if you're not in a good place at the moment. "Not in a good place" might include: your kitty is newly diagnosed with feline diabetes and you are feeling overwhelmed; you have a kitty who is currently experiencing ketosis or DKA; you have lost a kitty to DKA, especially if you've lost your kitty recently; your kitty's diabetes is not under good control, and you're stressing.

Please understand that in posting this story, I am not trying to cause or exacerbate pain, grief, or guilt on anyone's part. I only want people to be aware of the exceptional seriousness and danger of DKA, and how careful monitoring of our diabetic cats can help prevent suffering on their part. If, after reading this story, you find you need to talk, email me or send me a private message through the board. You may also want to visit the FDMB forums for Health, Community, and Grief where you can talk to others. Remember that everyone here understands the stress and worry that comes with having a beloved feline companion with diabetes. I tend to worry more about Boots' diabetes than I do my own.

Background: I am a diabetic human. I was diagnosed with type-I diabetes mellitus (also known as "insulin dependent" or "juvenile" diabetes) in June of 1999. I had just graduated from high school. Since my diagnosis, I have developed diabetic ketoacidosis, or DKA, on two occasions, one of which was mild, the other moderate. The following was written after the moderate episode. If you have a diabetic cat, I have written this to help you understand what DKA feels like, at least for a human, both physically and mentally. I hope that after reading this, you will appreciate the importance of insulin therapy and blood glucose monitoring. It is also my sincere hope that you will remember to test for blood or urine ketones whenever your kitty develops any symptoms of ketosis or is known to be at increased risk of developing DKA. Please see Further Reading at the end of this section to find links to more information about this potentially deadly complication of diabetes.

I woke up at 11:00 a.m., and I was weak. I had trouble standing when I got out of bed; I had to crawl to get up the stairs from my bedroom in the basement. My eyes itched and burned. Where the sides of my fingers rubbed one another, the skin felt like sandpaper. My lips and sinuses were so dry that they had cracked and bled while I slept. Thirsty, god, I was so thirsty. I crawled to the kitchen, where I drank a giant glass of water and then fought waves of nausea until I threw up. Still, I was thirsty. So much so that I drank more water immediately after I vomited. It too came back up.

I was peeing gallons. I felt like there was no fluid in me at all; like every single cell in my body was crying out for water!, but I was still peeing like crazy. It's hard to really comprehend how much fluid is in the human body until you try to pee it all out; it's a lot I checked my urine for ketones: positive for moderate to large amounts. I checked my blood sugar: 565. I gave myself 10 units of insulin. I drank a glass of water and threw up. I fell asleep on the couch at noon.

I meant to call Mom and tell her to come home and take me to the hospital, but I was so tired. My hearing aids were in my room. I knew if I went down the stairs, I’d be lucky if I could get back up them. I didn’t really mean to fall asleep, but I was too tired to stay awake. I'd only been up for an hour. I hadn't called Mom.

*** The fatigue of DKA is not something that many people in first-world countries will ever know first-hand. Be thankful. The fatigue of DKA lies beyond tired, or sluggish, or worn out; it's a state of severe dehydration combined with an inability to move muscles starved for energy. Everything happens in slow motion, and every movement is accompanied by an awful sort of soreness, as if you've spent the last few weeks doing hard physical labor without sufficient rest, without sufficient food, without sufficient water.

I must be covered in purple-black bruises; there is no good analogy for this sort of aching. You can almost feel how every movement you make inflicts hundreds of tiny injuries inside each muscle, making each subsequent motion more difficult and more painful. Every time you move your head, there is a nasty little whoomph!, similar to having a very bad hangover, but more intense. The inside of your mouth is not wet or even damp; it's tacky. You can't swallow. You are confronted with the dual problem of being terribly thirsty and terribly nauseated. The thirst wins, you drink; the nausea wins, you throw it all up, only now it's acidic and leaves a foul taste in your mouth. You need more water to rinse the taste out, then you're driven to drink again, and again your body rejects it in favor of eliminating a little more acid from your system.

Something very basic inside you says, "things are tearing up; I can feel them shutting down; this is how it feels to die slowly." The mental state of DKA is clouded, filmy, and viscous (think: glutinous, turbid, clotted). You can think, but it's hard to think quickly or stay focused. This is because most of your thoughts continuously come back to needs which are immediate and achingly basic: thirsty!; god, please don't let me vomit; I hurt, hurt all over; need to rest; so tired; so thirsty. You become a creature named i need.

Higher functions, problem-solving and logic, are employed for one thing: fending off the i need, because your basic state of being becomes about relieving physical suffering. The brief discomfort of things like insulin shots, BG tests, IVs, arterial sticks, and catheters are tiny flickers in your awareness. Your mind returns, relentlessly, to the same elements: thirsty, aching, hurting, lead-like body, sleep. It is my understanding that when DKA progresses to very severe metabolic dysfunction, the pain and thirst are so pressing and so bleak that loss of consciousness and diabetic coma are a blessed escape. Having experienced this "moderate" version of DKA, I do not doubt it. ***

I woke up at 2:00 p.m. and thought, have to get help. I hauled myself off the couch and clung to the wall as I made my way down the stairs. I got my hearing aids and couldn't make it back up the stairs on two feet, so I crawled part of the way. It took me 15 minutes to do what should have taken two. I checked my urine for ketones: positive for moderate to large amounts. I checked my blood sugar: 480. I gave myself 10 units of insulin. I drank a glass of water and threw up.

Call Mom. My mouth was so dry I couldn’t talk very well, and my mother knew something was wrong as soon as I tried to explain. She dropped everything at work and rushed home. She walked in the door, put her arm around me, and dragged me out to the car. More than once she threatened to call an ambulance if I couldn't make it. She took me to the ER. I drank a bottle of water on the way there. I threw up before we got there. Diagnosis: critical metabolic crisis secondary to diabetic ketoacidosis. Some relevant points: severe dehydration, hyperglycemia, electrolyte disturbance, metabolic acidosis...

In the ER, I begged for water even after the IV was running, and it was running wide-open: the pump was programmed to infuse fluid as fast as it was capable of running. I was still so thirsty. They let me drink water. I threw it all up. "We don't have any ICU beds open, we're calling other hospitals to see who can take her." The doctors weren't talking to me, because only part of me was listening. The rest of me was concerned with other matters: thirsty, aching, hurting, lead-like body, sleep.

I ended up in a helicopter, being flown to a hospital which had an ICU room open, but I don't really remember the helicopter ride or being admitted to the ICU. Mom tells me that one of the EMTs was very sweet and handsome. Yeah Mom, I need to think of finding a decent boyfriend. Thanks, but this one's first impression of me probably involves the words "frequent" and "vomiting."

In the ICU, I was given 2 IVs: fluid and insulin in one arm; fluid, electrolytes, and glucose in the other. I also got a urinary catheter and a series of nurses who poked at me every 15 minutes. No one sleeps in the ICU... except maybe coma patients. I was there for almost 18 hours, listed as "critical." However, after only 6 hours or so, I felt whole again. No more thirsty!, no more hurting, no more molasses in my head. I was moved to regular medical ward, where I stayed for another 2 days before being discharged from the hospital. I made a full recovery and sustained no lasting organ damage.

The DKA was my mostly my fault. I have an insulin pump, and I had changed the set (tubing and a little plastic cannula; it's very similar to an IV, but for insulin delivery, it is inserted into subcutaneous fat, rather than into a vein) at about 7:00 p.m. then went to bed without checking my blood sugar. Bad move. At some point that evening, the cannula became bent, which meant that I was not getting insulin all night. It also turned out that I had a very nasty infection brewing in my abdomen from recent surgery. Not getting insulin for 16 hours, bacterial infection, and the stress of surgery triggered ketogenesis, the first step toward developing DKA.

Since I slept through the stages of metabolic changes where ketosis is easily treatable, I wound up in a life-threatening situation. BG monitoring, and blood or urine ketone checks are the best methods for early detection of ketosis. The sooner ketosis is recognized and treated, the easier it is to reverse. As soon as full-blown DKA develops, you have a medical emergency.

If you see any signs of ketosis or DKA in your cat, call your vet immediately

Further Reading for DKA:
The FDMB's Ketone Page
Pet Diabetes Wiki: Ketoacidosis
Ketone Primer, from the FDMB archives
Precision Xtra meter for blood ketone testing.
Wikipedia: DKA (in humans) DKA is basically the same process in humans and cats..