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[IP] Clinical Decision Making: DKA on Mt. Ranier (Diabetes Spectrum)

Diabetes Spectrum
Volume 12 Number 4, 1999, Page 198
Clinical Desicion Making


DKA on Mt. Rainier: A Case Report 

Christian D. Herter, MD, CDE 


The alpine environment is an unpredictable, sometimes harsh arena that 
can test the stamina and endurance of any athlete. Those with type 1 
diabetes face added challenges, since their metabolic response to 
exertional, thermal, and barometric stressors is heavily dependent upon 
exogenous insulin. This report summarizes some of the issues that face 
mountaineers with diabetes. 

In late July 1998, a group of experienced mountaineers, including the 
author, left Seattle for Mt. Rainier, a 14,600-ft dormant stratovolcano 
southwest of the Puget Sound basin. Five members of the six-person team 
had successfully climbed the mountain before, and all had been active in 
various alpine groups for many years. 

Included in the group was A.O., a 26-year-old man who has had type 1 
diabetes for 17 years and is treated with continuous subcutaneous 
insulin infusion (CSII). The author, age 39, also has type 1 diabetes of 
13 years' duration and wears an insulin pump. The two climbers with 
diabetes self-monitored their blood glucose levels frequently and kept 
in close contact with each other to check blood glucose levels and to 
make sure there were no problems with the infusion equipment. 

The outing organizer had chosen the most popular route for the ascent, 
which would begin from a trailhead at 5,000 ft. Long climbs such as this 
are usually done over several days. The first leg of the ascent would 
involve 5 miles of hiking across a simple snow field to Camp Muir, at 
10,000 ft. Some teams rest here for a few hours before ascending; others 
take an additional day, hoping the extra time will improve their 
performance at altitude. 

Even with the burden of fully loaded packs in the hot sun, the initial 
leg of this climb was uneventful. Although the group had intended to 
stop only briefly at Camp Muir, the team leader suggested spending the 
night, since most of the climbers were sleep-deprived already (many just 
from trying to prepare for the trip on top of busy work schedules). 

The night was calm, and everyone was well-rested by morning. Since warm 
temperatures and clear skies were predicted, departure from Muir was 
postponed until sunset as a safety measure. The route would cross over 
highly crevassed glaciers and under unstable ice cliffs on the way to 
the summit. These areas would be dangerous to negotiate as temperatures 
soared under the midday sun. 

Some snow bridges along the route had already fallen away from the 
previous day's heat. In many of these areas, Forest Service rangers had 
placed narrow ladders across the crevasses. In other places, fallen snow 
bridges left fissures so vast that new routes had to be forged around 
them, which added hours to the ascent time. 

In addition, falling rock was a continuous threat. At this time of year, 
snow and ice act like cement to keep precariously perched rocks and 
boulders stable above climbers. During frosty nighttime hours, these 
missiles are locked on to their loft ledges. But with warmth from the 
sun, they rain down on climbing routes. Nighttime was clearly the right 
time for this ascent. 

After packing up camp, all the climbers roped up, checked their safety 
equipment, harnesses, and accessory climbing gear, and started across 
the Ingraham Glacier. On leaving base camp, A.O.'s blood glucose level 
was 120 mg/dl. 

During the next hour, 1,000 vertical feet were gained to Ingraham Flats, 
a level and relatively crevasse-free area high on the glacier. It was 
8:00 p.m., and the mountain was beginning to cool. This was a good place 
to have dinner and consider the rest of the route. 

The team members discussed their plans for ascending the next obstacle: 
the Disappointment Cleaver. This steep nunatak, which was completely 
visible from their present location, presented the most serious 
rock-fall danger of the route. Only a month before, a party had been 
swept off by an avalanche and falling rocks. Clearly, the challenge was 
to ascend the 1,000-ft crag with just enough of the rapidly fading 
daylight to see the route in hopes that the few hours of cooling out of 
direct sunlight was sufficient to reduce the chances of a slide. 

Getting to the base of the cleaver required passing over the upper 
Ingraham Glacier, which had become extensively crevassed. The climbers 
first had to cross two Forest Service ladders, which was challenging 
while wearing climbing crampons. The apparently bottomless abyss bridged 
by these flimsy contrivances managed to raise the resting heart rate of 
even the most seasoned member of the group. 

Once at the base of the cleaver, the expedition was challenged by highly 
exposed, sometimes ice-covered rock. For the next 1,000 ft, careful 
attention to the route was the rule. In several places where the rock 
was too broken or dangerous to climb, the route detoured on to very 
steep snow slopes thought to be less risky than the unstable volcanic 
pumice. The going was slow, but strong. As the last vestiges of dusk 
gave way to a night sky filled with summer constellations, the group 
arrived at the top of the cleaver and rested. 

A.O., normally of a calm temperament, began fiercely cursing. One of the 
members of his rope team required more time than the others during the 
last pitch, and he was incensed about it. He also mentioned some nausea, 
but felt it was related to the less-than-conventional dinner he had 
consumed earlier: freeze-dried vegetarian chili and slightly wilted 
turkey and cheese bagels. 

The others were a bit surprised by his demeanor but felt that the 
exertion of the last hour could certainly have resulted in some 
hypoglycemia. We suggested monitoring blood glucose and took time for a 

It was now after 10:00 p.m., and the group was considerably ahead of 
schedule. At the current pace, the summit was only 5­6 hours away. We 
all enjoyed the extended break, taking some time to argue over the names 
of the brighter stars and taking turns searching for satellites 
streaking over our frosty perch. 

The next pitch would carry the group through the upper Ingraham ice 
fall, an area where the normally smooth constitution of this glacier was 
broken into house-sized chunks of ice and rubble. With headlamps 
lighting the way, the team roped up and set out again, planning another 
stop with the next 1,000 ft of vertical gain. 

A.O. led the second rope. Normally strong and practically inexhaustible, 
he was now having more trouble maintaining the moderate pace set by our 
leader. As the group began winding through the upper crevasse fields, 
A.O. signaled that he required a rest stop, and further, that his nausea 
was worsening by the minute. He emphatically denied any other symptoms, 
just nausea and disabling fatigue. 

As minutes passed, it became apparent that he required more attention. 
For the team to congregate in such a dangerous area, anchors needed to 
be placed and ropes managed carefully. A.O. was found lying on his back, 
somnolent, and hyperventilating. The group's two physicians made an 
assessment in the field. This could represent acute mountain sickness 
(AMS) or a metabolic abnormality resulting from A.O.'s diabetes. The 
other members of the group were anxious for a diagnosis, since they were 
beginning to chill in the cold wind of this high altitude. 

A.O. was asked about his last blood glucose reading. The initial value 
of 120 mg/dl, taken as the group left Camp Muir, was the last that had 
been done. He reported that his glucose meter would not operate at 
temperatures encountered on the mountain. He had attempted readings both 
at Ingraham Flats and at the top of the Cleaver, but the device would 
not run samples, despite A.O. warming test strips and the meter itself 
using his axillae. The strips could not be interpreted visually, so he 
had been trying to estimate his insulin needs with no confirmatory data. 

The author always carries back-up strips, which can be read visually. A 
quick sampling showed that A.O.'s current blood glucose was >600 mg/dl. 
This confirmed that he was suffering from acute insulin deficiency 
rather than AMS. 

Because the last blood glucose reading was in the normal range just 6 
hours earlier, the decision was made to administer intravenous insulin. 
Inspection of A.O.'s insulin pump infusion site showed quite a bit of 
surrounding erythema, so members of the team performed a site change. 
Since the infusion reservoir and tubing appeared unaffected, these, 
along with the insulin from the reservoir, were not changed. 

A.O. was clearly too ill to proceed. He started vomiting shortly after 
the new infusion site had been placed. The climb leader decided that it 
was unwise to continue with a member of the group in such a medically 
unstable state, and ordered the team to retreat to a lower, safer area 
to wait out the night. 

When A.O. was able to walk, the group slowly retraced their tracks to 
the top of Disappointment Cleaver, at 12,400 ft. There, they dug 
trenches for protection from the wind and kept a close watch over A.O., 
checking blood glucose levels frequently. The leader had hoped that A.O. 
would be well enough by morning to down-climb the treacherous cleaver. 
If not, he would need evacuation by Search and Rescue. At 2:00 a.m., 
A.O.'s blood glucose had dropped to 50 mg/dl, and he required treatment 
for hypoglycemia, but felt considerably better. 

By morning, A.O. felt as though he had completely recovered. His waking 
blood glucose was around 180 mg/dl, the nausea had resolved, and he had 
managed to consume an additional 2 liters of water. He dosed 2 U of 
insulin through the pump to cover his hyperglycemia, then joined the 
group for the tricky descent. 

A.O. actually led for most of the route back to Camp Muir. As the team 
began packing up in preparation for the final trip back to the 
trailhead, however, he noticed recurring nausea and fatigue. He had 
taken no snack after the bolus on the Cleaver. A blood glucose check 
showed a surprising level of 345 mg/dl. 

At this point, his tubing and reservoir were replaced and filled with 
insulin from the author's emergency supply, but the infusion site was 
retained. There was rapid return to his normal level of near-euglycemia, 
and he was able to finish the hike. 

Though this medical emergency cost members of his team the summit, A.O. 
received outstanding support and medical attention from everyone. He 
hiked back to the parking area without incident, and he continued his 
involvement in back-country activities. 

Consideration of the incident suggested a causal relationship. The 
second day of this expedition was spent largely in the hot sun of Camp 
Muir. A.O. wore his insulin pump in an area exposed to direct sunlight 
most of the day. Since insulin is quite temperature-sensitive,1,2 the 
resulting heat probably diminished its potency. Evidence for this is 
suggested by his rapid recovery when emergency insulin that had been 
protected from the heat was administered by syringe. 

This theory of bad insulin seems even more likely when taking into 
consideration the relatively rapid return of hyperglycemia when, after 
switching infusion sites, A.O. connected his infusion system to the 
needle using the older insulin. When he replaced the infusion reservoir 
and filled it with the emergency insulin while retaining the previous 
infusion site, normal glycemia resulted. 

Five Extra Essentials 
All enthusiasts of the alpine environment will agree that preparedness 
is an important part of any expedition. The famous Ten Essentials is a 
list of items that should be taken along by anyone heading into the 
wilderness, regardless of the duration of stay. Extra clothing, extra 
food, flashlight, and first aid kit are among the most important items 
on the list. 

Outdoor adventurers with diabetes are at risk from more than the 
elements. They face possible metabolic consequences of too much or too 
little insulin, so monitoring and safety become life-or-death matters. 
Since even the tiniest unforeseen problem can result in disaster, an 
addendum to the famous Ten is suggested below: 
•Extra insulin. This should be packed to prevent freezing or exposure to 
the heat. •Extra supplies. More syringes and more alcohol swabs. A.O., 
who uses CSII, brought along enough equipment for several complete site 
changes. •Back-up monitoring supplies. Certain meters are more tolerant 
of temperature extremes, but even these can fail at high altitude. To be 
sure, pack an extra alternate method, such as ChemStrips bG, which can 
be interpreted visually. •Injectable glucagon. This should be kept in an 
easily accessible area of the pack, not exposed to excessive heat or 
cold, and all other members of the group should be familiar with its 
use. •Willingness to communicate. Talk to your teammates when there is a 
problem. The earlier they know, the better the chance you will all make 
the summit safely. 

If A.O. had carried along some visual strips, he might have been aware 
of the problem with his insulin before becoming ill. With that kind of 
advanced warning, this group may not have had to turn back. 


1Volkin DB, Klibanov AM: Thermal destruction processes in proteins 
involving cystine residues. J Biol Chem 262:2945-50, 1987. 

2Amaya J, Lee TC, Chichester CO: Biological inactivation of proteins by 
the Maillard reaction: effect of mild heat on the tertiary structure of 
insulin. J Agric Food Chem 24:465-67, 1976. 


Christian D. Herter, MD, CDE, is an assistant professor of family 
medicine at the University of Washington Medical Center in Seattle. 
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