Taking EMS Into Tomorrow: Part 2

Some people call it "paramagic." He is unconscious, unresponsive, pale, cool, drenched in sweat, snoring respirations, with his spouse hovering over him, wringing her hands and warning us he's diabetic. While murmuring words of comfort to the family, we gracefully slip a catheter into an elusive vein. We gently squeeze the syringe full of syrupy sugar water, watching carefully for infiltration. As the plunger on the amp of D50 reaches the halfway point, his breathing starts to normalize, and his pasty cheeks fill with color. Gradually he wakes--a little confused at first. Soon he says something like, "Guess I forgot to eat lunch today."

This process is one of the coolest things we get to do in EMS, and we get to do it a lot. Waking up someone who looks near death from hypoglycemia is paramagic at its finest. But it's rare that an EMS provider looks much beyond the emergency to see the big picture of diabetes for their patient.

According to the Centers for Disease Control and Prevention, there are 14.6 million people in America who have been diagnosed with diabetes. It's estimated that 6.2 million have diabetes that has yet to be diagnosed, and more than 41 million have pre-diabetes. That means nearly one in five Americans is suffering from, or is at risk for suffering from, the complications of diabetes.

The list of complications from this disease is long and daunting. The short-term complications, hypo- and hyperglycemia, are the ones with which EMS providers are most familiar. It's also important that we become aware of the devastating long-term complications. Diabetes is the leading cause of kidney failure, accounting for 44% of new cases in 2002. Diabetic retinopathy is the leading cause of new blindness in adults 20-74. People with diabetes account for more than 60% of lower-limb amputations (over 82,000 in 2002), and 73% of people with diabetes have high blood pressure, which leads to myocardial infarction and stroke. In one state surveyed, 26% of people with diabetes reported having had a myocardial infarction or stroke, compared with 6% of the nondiabetic population.

Diabetes is not an equal-opportunity disease. According to the CDC, Native Americans and African Americans are more than twice as likely to have diabetes as whites. The rate among Latinos and Asian Americans/Pacific Islanders is also higher than among whites. Diabetes is more common in people without high school educations, with household incomes less than $15,000 a year, and without telephone service. More than 20% of people over 65 have it.

Mortality rates associated with diabetes are also rising. Rates from 1999-2001 were 61% higher than from 1989-91. "Diabetes has reached epidemic proportions in the U.S.," says Dr. Michael Alderman, professor of epidemiology and population health at Yeshiva University's Albert Einstein College of Medicine. And according to Paul Zimmet, director of the International Diabetes Institute, it's estimated that more than 330 million people worldwide will be affected with diabetes within the next 20 years. The epidemic is happening faster in Asia than in any other region. One researcher predicts that if current trends continue, by 2020 all the insulin presently manufactured in the world will not be enough for China alone.

Insurance companies are not helping reverse these trends. Diabetic self-management education programs receive meager reimbursement from insurance companies, while treatment for severe complications is paid for. A January 2006 New York Times article described how over the last seven years, three of the four hospital-based diabetes programs in New York City closed their doors due to lack of funding, while the number of people with type II diabetes doubled. The article said, "Insurers, for example, will often refuse to pay $150 for a diabetic to see a podiatrist, who can help prevent foot ailments associated with the disease. Nearly all of them, though, cover amputations, which typically cost more than $30,000."