Every doctor has a few cases that become memorable. In my fourth year of medical school, I was working in a Brooklyn hospital as part of an endocrinology team. During that month I treated many people with diabetes – but one case stood out. The patient taught me valuable lessons in nutrition, orange juice consumption, calories in an orange, and the use of the HbA1c test for the management and treatment of diabetes.
My team was called up to the ICU one morning to consult on a patient that had been admitted to the hospital through the Emergency Room the night before. He came in in pretty bad shape, but the doctors in the ER were able to stabilize him and get him comfortable until the long-term care doctors could take over.
The patient was in his mid-40’s. He had a long history of pretty severe type II diabetes, mild hypertension, and more than his share of nutritional challenges. In short, he didn’t eat well, and it showed. One day, his delicate health balance snapped and he found himself in the ER. It was the job of my team to find out what went wrong and make a plan to fix it.
One of the many tests that were run on this patient is called the HbA1c. It is a test that allows a doctor to tell what the average blood sugar has been over the last 90 days. The scientific basis of the test involves glucose “sticking” to the red blood cells. The more glucose you have in your system, the more red blood cells that become “glycosylated”. Using this test, a doctor can determine what a person’s average blood sugar has been. You can’t lie about your sugar consumption.
Normal HbA1c is less than 6%. This patient was 17.9%. For those that aren’t trained in medicine, this is an absolutely insane number. By all rights, the patient should have been dead. He was only alive (barely) because that level rose slowly, allowing his system to at least partially acclimate to the insanely high amounts of sugar in his blood.
In order to help the patient, we desperately needed to find out what he was eating to cause this high level of sugar in his blood. We spend a long time talking to him about his diet. He claims to have been working with a diabetic nutritionist – making a great effort to improve his old “pizza and beer” diet that he lived on for many years.
After about an hour, we hit the jackpot. One of the things his nutritionist had told him he needed to eat more of was fruit. She’d even given him a list – things like oranges, mangos, strawberries, and such. It turns out he likes oranges. Great!, said his nutritionist.
So he began to consume oranges in a way that he liked, and seemed to him to be healthy – he drank them. He reported drinking about two gallons of orange juice every day. He thought he was doing the right thing. But he didn’t know that orange juice is very high in sugar. Very high. It almost killed him.
In the end, my team managed to stabilize him. We got him back to the nutritionist, with specific instructions to get a more detailed menu of acceptable foods. There is a lesson in this case – you can’t assume a person is going to understand all the nuances of instructions that are given to them. Even the best of intentions can go horribly wrong if the details are left out. It’s a testament to the resiliency of the human body that this patient was able to survive a dangerously high HbA1c.