Survival and the Diabetic

[I requested this of my friend William Michael Kemp. I know of no one who knows as much about diabetes as Mr. Kemp. If this condition touches your life or the life of a loved one or friend, pay attention!]

SURVIVAL AND THE DIABETIC

This will be directed largely at the type one (juvenile) diabetic, and
the very insulin-dependent type two. I was diagnosed diabetic in 1963.
I am a severe, extremely brittle, type one diabetic. If I go 24 hours
without insulin, I am greatly debilitated. If I go 48 hours, I am not
very functional at all. If I go 72 hours, I am at death's door. Any
more, and no matter what happens, I will likely not survive,
regardless.

One half of all type one diabetics die within 20 years of their
diagnosis. One half of the remainder die within the next 20 years. It
only gets worse from there. If anything, type 2 diabetics, and
particularly severe type 2 diabetics, exhibit worse statistics. I am
within a few of months of being 45 years a diabetic. I am 20/20 or
better in both eyes, which have never seen a laser used for 'treating'
diabetic retinopathy. My kidneys are fully functional. My blood
pressure is normal and untreated. I have both feet, minus a little
surgical whittling on two toes. Forgive my boasting, but for an old
diabetic, that not only 'ain't bad', it is in fact exceedingly rare.
And my path has not been smooth. I have been incarcerated several
times, and survived less than stellar care. In fact, in three of those
instances, I lived through periods of 48 to 72 hours with no care at
all. An old jailbird, eh? Yeah. But do note that I am still legally
entitled, even in these days of the war on gun ownership, to own
firearms. I trust that those reading this understand from this that
while I may be an old jailbird, I am NOT a 'criminal'.

I was taught, within a few months of my diagnosis, by an old doctor
who was not only a diabetic specialist, but was in fact a severe type
one diabetic himself. He was literally saved in his youth by the
discovery of insulin by Drs. Banting and Best. He KNEW diabetes, and
was world-renowned in his field.

For a tidbit of information, he
discovered, at the summer camp for diabetic children which he ran, the
fact that if you shine a bright flashlight in the eyes of a sleeping
diabetic child, he will squint a bit, if his blood sugar is in the
safe range. If the blood sugar is not above, let's pick a number--
70-- he will not squint. Thus you wake the child and feed him.
This camp for diabetic children typically had 100 children attending
every summer. And every two hours during the night, it was necessary
for competent staff to circulate among them all, checking each for
signs of sweating or other overt signs of distress, usually awakening
them to verify their safe condition. This became a real chore as the
number of children increased. This response to a light in the eyes is
referred to as 'The Smelo Response', after Doctor Leon Smelo, the man
who taught me and whom I must here thank for teaching me to live. I
have done my utmost to 'pay this gift forward', first by going back to
the camp for diabetic kids as a counselor as soon as I got 'a real
job' after taking a Bachelor's in chemistry from Tulane, and thus had
vacation, and subsequently by preaching Dr. Smelo's gospel to all
diabetics who will listen. And this is more of the same effort.

Dr. Smelo taught me that I am my best physician. He taught me that
only the diabetic is a truly competent judge of his condition and his
needs. He taught me that no doctor can guide me through my life. If
life were such that you could get up at the same time after precisely
the same amount of sleep, eat precisely the same breakfast, engage in
precisely the same activities, eat precisely the same lunch, the same
supper, every day precisely the same as the day before and the day
after, it STILL would not be sufficient to follow a
physician-prescribed regimen. The diabetic's body and condition simply
is not stable.

EVERY day brings new challenges, even if you approach
the ideal of exactitude in all fundamentals. It simply doesn't behave
that way. That said, I further state that routine and habitual
behavior is the ONLY friend a diabetic has. It provides the basis to
judge variations, in activity, in composition of meals, in disruptions
caused by the activity of the liver in acquiring and shedding glucose,
in disruptions caused by periodic illnesses. Let me repeat this--
routine is the diabetic's ONLY friend and ally. The more you vary from
routine, the more difficult the task becomes. You are required to be
technically competent with the minutae of diabetes.

So he taught me that I must depend on myself, on my knowledge and my
studied and considered best opinion. I have not been under a
physician's care since I was old enough to smile and agree with
whatever physician I was afflicted with, then go do what I thought
best and necessary. Not only have I suffered maltreatment at the hands
of jailers, I have lived an active and athletic life, with
construction work, field work, and varying and unpredictable
conditions throughout.

I say this to encourage you to trust my words. I DO know of which I speak.
The first thing required is this: you must make a conscious decision
to survive, no matter what.

The next thing required is, you must act on this decision. You must
consciously take specific actions in order to live through whatever
may come, or at least to live as long as is physically possible, for
once you are dead, you are dead. And until you are dead, you are
alive. I wish to stay that way. Not only do I 'wish', I have acted and
do act and intend to continue to act to maximize the likelihood of
that happening.

I will pass by the obvious, that you will need to eat, at least a
couple or three times a week, minimum. Since your food supply is
likely to be haphazard, and not necessarily of your choosing, you will
need a GOOD supply of a GOOD multivitamin. Further, you will need
water. You would be astounded at what you can safely drink, if you put
a little chlorine bleach in it. You may immediately think of gallons
of Clorox, but granulated swimming pool chlorine is far cheaper than
clorox, much more concentrated, and if kept tightly sealed in the
original container, will last a very long time. Portable filters are
good, but that can be expensive and commonly requires replacement
filters. A 20oz soft drink bottle, thoroughly cleaned and absolutely
dry, makes a convenient container for a goodly supply of granulated
chlorine bleach to throw into a 'git kit'. Do not get anything that is
not pure chlorine bleach. It will add unwanted taste and may be less
than good for you.

Diabetics particularly need to keep their hands and feet as dry and as
warm as possible. Deal with it.

It would be really nice to have a blood sugar meter, some extra
batteries, and a supply of reagent sticks. More is better.
Moving along, now we come to the 'diabetic specialty' stuff. You will
need insulin. You will need syringes. This is not as simple as you may
think, and there are ways and means of extending what you have.
It is preached that you should 'dispose' of used syringes. As I have
stated, I have survived conditions less than ideal. There have been
times, more than I care to recall, when had I not retained my used
syringes, I would have had no syringes at all. Yes, I know the proper
and approved method of disposing of used 'sharps'. Sorry, but you may
not always have a handy pharmacy to insure this supply.

So, rule one, be very careful with the needles. This violates all
principles, but hear me. Very carefully recap your syringes, being
most particular to leave the needle uncontaminated by contact anything
other than your clean skin-- as clean as you can manage. Alcohol
swabbing cleans the skin, it does not 'disinfect it'. But it helps.
Soap and water is just as good as an alcohol swab, perhaps better. Do
not allow the needle to touch anything after you give an injection. Do
not blunt the needle by carelessly recapping it, hitting the cap while
recapping. Take an empty gallon milk jug, or the equivalent, label it
'ONCE USED', and drop it in. When it is full, store it and get
another. If you damage or contaminate the needle in the recapping
operation, discard it-- safely discard it. Consider it your store of
'cleanest dirty shirts'. If pressed into a survival situation, use
another container labeled 'twice used', and place those reused
syringes into that container.

So we come to insulin. I am going to use rough numbers and
descriptions, do please apply my teachings and modify your behavior to
your conditions.

If pressed into a survival situation, where food supply becomes
chancy, realize that your body requires a 'base load' of insulin even
in the absence of food. I have on two occasions fasted for a week at a
time, for my own enlightenment. My insulin demand, by blood sugar
monitoring every three hours, declined from a nominal 50 units per day
to perhaps 12 units per day, administered in 2 unit increments of R
insulin every 3 to 4 hours. I was not immobile nor non-functional
during these periods of fasting. With an intermittent supply of food
in varying amounts, your bodily demand will reach perhaps one third to
one half the normal 24 hour requirements. You will lose weight. You
probably eat too much anyway (a little humor there-- lighten up). A
little extra body mass may even help you live through a limited period
of a survival situation. In the absence for several days of any food,
it will likely drop to one fourth or less of your normal insulin
demand.

But you must be prepared to adapt to the here and gone food supply.
You must know how to use the insulin that you have, and know how all
the types act.

The most commonly used insulins for 'day long' use are NPH (N) and
Lantus. NPH is an 'old' type of insulin, in use for some decades. It
is 'insulin' physically modified by admixture of zinc crystals and
protamine, which is a protein. The body, over a nominal 12 hours,
strips the admixture away and accesses the insulin itself. An
injection lasts a nominal 12 hours, but in fact there is residual
activity beyond the 12 hour nominal. In 'normal' times it is typically
given twice a day, morning and night. If possible, I would recommend
that this be continued in a survival condition. Rather than one
'larger' shot, I would recommend two smaller shots-- likely MUCH
smaller. Your target will be to maintain a blood sugar in the nominal
range of 200, perhaps a bit lower, but to venture much lower than this
blood sugar level of a nominal 200 is to invite catastrophic drops in
blood sugar level that you may not have the means to correct-- that
is, you may not have handy some fast carbohydrate to 'rescue' you from
hypoglycemia-- 'insulin reaction'.

This is vastly higher that what is 'medically recommended', but do
understand, you are not in a normal situation. This comment is
particularly for type ones, who seem to exhibit better resistance to
higher blood sugars without immediate harm than can insulin dependent
type twos. I do not know why that is, I have simply observed it. In
type ones, it is considered that real damage is not occurred below a
blood sugar of approximately 240 or 250. I, personally, find that
level to be the point where I begin to overtly notice that my blood
sugar is too high, without a blood sugar test..

Moving on, there is Lantus insulin. This differs from NPH, 'N'
insulin, by being CHEMICALLY modified to extend the time of uptake. It
is strictly a once-per-day insulin. If Lantus has a down side, it is
in that it seems to deteriorate a bit faster after you begin to use
it. Placing air in the bottle for withdrawal exposes it to oxygen,
which is the enemy of complex organic molecules, such as insulin. I
will add that sunlight and temperature deteriorates all insulins, as
well. Protect your supply from any elevated temperatures, from
sunlight, and do not allow it to freeze.

Lantus has a drawback in that it is available by prescription only.
NPH (N) and Regular (R) insulin are available over the counter, no
prescription required, in almost all jurisdictions. This allows you to
stockpile N and R to your heart's content, so long as you have
finances.

Moving along, there is Regular (R) insulin. This is straight,
unmodified human insulin. It is also available over the counter in
almost all jurisdictions. You can purchase all you have funds for. It
has a nominal 4-6 hour activity in the body, and to use only R insulin
will require you to give at least three of four injections a day.
Divide your total daily insulin requirements as described below, and
spread that among three or four injections, equally spaced, during the
24 hour time span.

Use a rule of thumb-- add your daily insulin requirements in 'units'
of all types which you inject in 'normal' times, total it. Then divide
by two or three or four for your requirements in severe survival
conditions, and this will depend purely on the food available to you.
In the absence of food, your daily insulin requirements may be as low
as one fourth or even less of your 'normal' requirements. This is
something which must be worked out purely by experiment. Remember your
target blood sugar of 200. Realize that to err on the side of too much
insulin for available food will place you in hypoglycemia, insulin
reaction. This runs the risk of placing you in a condition of impaired
judgment, physical disability, and if severe, becoming immobile and
comatose. Without an adequate supply of 'rescue' carbohydrates, this
is a very serious condition.

The last type of insulin is Humalog (the Eli Lilly trade name-- the
'other' brand is called Novolog). This is also a prescription-only
insulin, and is specially modified to provide very fast activity after
injection, perhaps twice the rapidity of onset, and half of the
nominal time of activity of R insulin. In normal circumstances, it is
used to provide a quick bump of insulin activity to cover meals. If
you have the luxury of having either Lantus or NPH (N) AND Humalog
available to you in a survival situation, you can use Humalog as an
adjunct to the Lantus on the happy occasions of finding food. If you
use Humalog insulin normally, I would again suggest that you use no
more than one half of what you would normally use to cover a meal. NO
MORE than half, and perhaps considerably less than one half the
'normal' dose.

Humalog alone, in a purely survival circumstance, will be difficult to
meter, will require 6 or more equally spaced injections per day to
maintain some reasonable level of insulin activity and reasonable
blood sugar levels. And realize that it is sudden and drastic in its
onset and effects. This is a dangerous insulin to depend on, much like
trying to start and maintain a fire with ether. To maintain a low
steady fire, ether as an accelerant is most difficult and dangerous to
use. Therefore, I would not suggest overly stockpiling Humalog
insulin. But in a survival situation, insulin is insulin, and ANY
insulin is vastly better than NO insulin.

So we come to another consideration. How do you accumulate a supply of
insulin? With R or N insulin, you can simply go purchase whatever
makes you comfortable, but do understand, there is no such thing as
'too much'. In a survival condition, there is no resupply.
Insulin is available in nature from fetal mammals, and that was the
exclusive commercial source of insulin for nearly 50 years. Cows and
pigs were and are sent to market pregnant, to boost slaughter weight.
These fetal animals were harvested at slaughter, their pancreases
harvested, 'pureed', and the insulin extracted and purified. This is a
very complicated and difficult thing to do, particularly for the
layman in a survival situation. This is necessary because the
pancreases of animals, once born and having had even one meal of
anything, contain powerful digestive enzymes which, if released by the
mechanism of 'blending' or 'pureeing' will utterly destroy the insulin
which is present and necessary for the metabolism of the fetal animal
in the womb. So, absent the ability and knowledge to carefully
separate the insulin-producing areas of the pancreas from the
remainder of the adult or 'once-fed' juvenile pancreases, pancreases
of adult mammals are useless.

Whatever insulin you have when the flag goes up is what you have. To
maximize this, particularly for Lantus and Humalog insulins which
require prescriptions and are very expensive, I suggest the following
strategies.

When dealing with a physician, which you must to obtain Lantus or
Humalog, you have to have a prescription. So, when your physician asks
you how much Lantus or Humalog you take, arbitrarily drastically
increase it. If you take 40 units a day of Lantus, tell your physician
that you take 60 or more units. This bumps your monthly requirement
from a bit over one bottle a month to two bottles or more a month.
Store the surplus in a non-freezing refrigerator, and use the oldest
(soonest expiration date) first. Accumulate to the extent you can. If
you have some sort of insurance, this provides a surplus which someone
else helps pay for. Sorry, we're talking about survival here. Use the
same strategy for your Humalog requirements.

When obtaining syringes, and particularly if you have to have a
prescription, plead to your doctor that you are clumsy and prone to
dropping syringes and thus wasting them, so instead of one syringe a
day for your Lantus, claim that a good third of the time, you are
likely to drop or damage the syringe, and thus need considerably more
than one syringe a day.

Humalog is generally taken in much smaller doses than Lantus or N, so
tell your doctor that you eat 6 small meals per day, and thus give 6
small injections per day. This is best accomplished by using the 0.3cc
syringes rather than the 0.5 or 1.0 cc syringes usually used for
Lantus insulin. Stockpile like mad any excess. Inflate shamelessly
your actual dose per meal. And don't worry about having too many of
the 0.3 cc syringes, because your injections of Lantus will be vastly
reduced in size if you are in a survival situation, and thus most
likely the smallest volume syringes will be usable for the vastly
reduced requirements of Lantus per day.

Worried about fooling your doctor, and having a problem? Don't.
YOU meter your injections, not a physician, and the worst thing that
can happen is to find yourself in a hospital situation where IN THE
BEGINNING, they may marginally overdose you. In a hospital situation,
you should be closely monitored anyway, and such a mistake will be
(should be, but as in all things relating to diabetes, take NOTHING
for granted. If you piss off your doctor by your intransigence, well,
he'll get over it) quickly noticed and the size of the injection
reduced. Mitigate against this possibility upon admission to the
hospital by telling your doctor that your insulin requirements 'have
been grossly unstable and unpredictable RECENTLY'. And, thus, that he
should be most careful about the size of the injections until the
'immediately normal' is determined.

I proceed here to ancillary considerations. Every successful diabetic
I have ever known, excluding myself, have or have had a 'minder', a
'keeper', a 'helper' who is knowledgeable in the patient's
requirements and peculiarities. Someone to keep up with injection
times, dosages, types... someone to help maintain the blood sugar
testing regimen, someone who knows how to react to blood sugar
fluctuations, variations in food types and the daily variations in
diet and activity. This is very important. A husband, a wife, a son, a
daughter, a lover... SOMEONE to help or even to directly manage the
diabetics' requirements in the face of variations and individual
peculiarities. Someone to note when behavior becomes a bit out of
normal, often meaning low or marginally low blood sugar levels.
What this means, is, if you are 'soloing', it is greatly to your
benefit to bring someone close to you into your particular regimen, so
that in the event of your disability, can respond appropriately-- AND
PRESERVE YOUR LIFE.