Sunday, January 24, 2010

Driving While Diabetic

One of the scariest situations Diabetics can face is being behind the wheel with a low blood sugar, particularly one that's dropping even lower.

Recent new stories have told some horror stories of this happening across the country: here in Ohio, and a tragic story here in Orange County, California. Regardless of the particular facts of each situation and whether that person involved did or didn't do what they should have as far as Testing Before Driving, some reader comments question why these and all diabetics aren't prevented from driving completely. An Outright Ban. Those stories come on the heels of a study showing tight-control leads to even more crashes and driving incidents of diabetics.

Of course, in writing this blog initially, I'd forgotten about an outstanding blog post in November 2009 by Shannon over at LADAdeeda, touching on this very topic that's so very dear to her. She was more harsh and on point, but we relay the same point of personal responsibility - especially when it involves situations like those found in the news articles above. So, here's a revision with a shout out and accompanying revisions that came to mind after re-reading her post.

I've faced this scenario myself. Sadly, more than once. Generally, I test before I am going to drive. MY policy is to not get behind the wheel if my blood sugar is 60 mg/dL or less. If it is Low like that, then Eat and Wait. Test Again Before Driving, just to make sure. Seriously, the test itself takes less than a minute - even on the older monitor models. We're not talking routine-changing time here. But the pre-driving testing doesn't always do the trick to stop the practice. For a Key Reason.

I have, on occasion, faced dropping blood sugar levels that have caused me to lose awareness and get behind the wheel. Without Being Fully Aware of It. Now, it wasn't as if I'd made the decision to started driving, knowing I'm low. It just kina happened. (Not an Excuse. Just saying.)

Once it happened during lunchtime when I was en route for food. At a safe level prior to driving, I managed to quickly drop and create confusion about what I wanted to eat, therefore continuing the Food Search Drive and creating even lower sugars. That time, police pulled me over and called paramedics who IVd me back to normal levels. Luckily, no one was injured.

Early last year, I dropped quickly about the time I was leaving work. Walking outside and during the block-length walk to my parking garage, my levels dropped incredibly low. Luckily, I managed to not get behind the wheel in this state - actually, I got confused and found myself riding up and down the parking garage elevator for 30 minutes. Phoned Suzi, and she was on her way to me when I eventually had enough sense to eat Glucose Tabs and sit in waiting, in my car, but not turning on the ignition to drive. Luckily.

Scariest Driving While Low incident happened in August 2009. Did a test and was in the 90s before getting ready for an interview mid-afternoon. Turns out, though, I was dropping even lower and somehow decided to leave the office for my interview, even though it was a phone-based interview that required me only to be sitting at my desk. But I left the office. Wandered to my car. Drove home (a 20 minute drive mid-day, without traffic). I recall thinking that I was going to interview my dog because I missed her, something that just doesn't make sense in a Normal State of Mind but in a Low Reaction State, is not out of the ordinary. Apparently made it most of the way, but missed my expressway exit and had to drive another 5 miles south, getting off and then getting lost in this Low State as I manuevered the back cornfield roads on my way back to my subdivision - still dropping. I recall seeing the road, and not realizing why the drivers were on the wrong side of the road. Ended up driving into a ditch directly in front of my subdivision entrance. Learned later that someone called 911, reporting that I was driving erratically. Police responded, and I decided to put it in reverse to get away from the officer who was trying to steal my keys. Before I could, he reached in and grabbed the keys from the ignition.

Paramedics arrived, and strapped me into the ambulance where they began pumping me full of sugar and bring up my levels. They took me to the hospital, and after this incident I'm still paying off about $1,200 post-insurance coverage resulting from this incident. Learned later that I'd also taken out a speed-limit sign on the grassy side of the road, which I'd apparently driven up onto at some point in aimlessly driving the area. It caused damage to my red Ford Escape, as can be seen here.

This could have been so incredibly worse. Luckily, someone above was protecting me and other drivers nearby that day. I'm blessed, and eternally grateful for that.

Am I an unsafe driver because of the above incidents, and because I still drive? Should I voluntarily surrender my license? Should there be a law aimed at preventing my ability to legally drive, absent of or based upon my history Driving While Diabetic History?

I don't think so, but it does concern me.

I'm in relatively good control, and have what I consider to be a responsible practice of testing before driving. My practice is also to have quick-acting sugar on hand, just in case. Like Shannon and others in the D-O-C, I keep a full-sleeve of Glucose Tabs in my driver's side door and also (in the winter) have one in my coat pocket, as well as other candy placed in the center console. But when I push for Tight Control, my sugar levels sometimes drop to scary-levels and that can happen despite the best Before and During Preparation. Sometimes, you don't always have the ability to recognize these dangerous situations. At night when sleeping, and unfortunately when driving is going to happen. This has motivated me in the past to avoid tight control, and instead keep my sugars higher to avoid this from happening.

I've pondered: Is it better to stay higher, risking possible future complications that may never materialize, to be safe now and not endanger myself, those I love, and strangers? OR do I push for tight control, and do all I can to prevent these situations but face the reality that they could happen no matter what I do? It's an ongoing mental and emotional struggle.

Practically, I can't afford to not drive. We just don't have adequate public transportation here in Indy that I can take advantage of. So, with this, I'm eager and motivated to fight for a CGM - a device that can catch and alert me to those dangers of both Night-time Lows At Home but also Driving While Low incidents. Recently, I've trial-tested two CGMs (Navigator and Dexcom) and these have both caught some Driving While Low episodes. I've tested beforehand, but then managed to dip lower while driving. The alarms notified me, and allowed me to inhale some glucose tabs to curb the drop. Otherwise, I may not have felt them coming on before it was too late. (Note: We won't debate that it wasn't the smartest decision to make in Driving While Low, Snapping a Photo for D365 While In Motion.... Agreed it's bad, but I feel I had it under control. Just sayin.)

We can easily sit back and read of these above stories, shaking our heads and wondering why the Diabetic didn't test or take better care of themselves, or as an extreme just stop driving if they realize this could happen. What should be a big fear for any PWD is how these above situations, and those highliy-publicized tragedies, will stand out to lawmakers and create a justification for law changes. Despite all of those who test before driving, who've stopped voluntarily, or who use a CGM for the prime reason of keeping this in check. They stand out and could provide a foundation for those arguing that Diabetics shouldn't be able to drive, no matter what. I fear we could someday have a misdemeanor or felony, Driving While Diabetic (DWD).

In the UK, a Diabetic must inform the licensing agency of their diagnosis or health condition, as it may impact driving. Apparently California has this rule, according to an article found here. Courts have addressed this in some fashion already: The Supreme Court of the United States ruled in the 1971 case of Bell v. Burson that driving is an "important interest" that can't just be taken away from a licensed driver without a government agency's providing procedural due process. In 1983, the California Supreme Court found in Berlinghieri v. DMV that the revocation or suspension of a license "can and often does constitute a severe personal and economic hardship, and a lower California appellate court found in the 1993 case of People v. Superior Court that a person with insulin-dependent diabetes is not automatically subject to license forfeiture or nonrenewal, and an agency may do so only if the diabetes affects the driver's safe operation of a motor vehicle.

Maybe all of us diabetics should have a CGM, if we're going to drive. But requiring this could create any number of legal and practical issues, among them the one that spawns a whole other debate about health insurance coverage of these CGM systems, and that inevitable fight many of us face about getting coverage for these in order to prevent the above driving disasters or night-time lows. This isn't the time to blog about that, for fears of digressing...

Reflecting on this, I think the overall point is that Diabetics must be even more aware that meticulous care is necessary before and during our drives. We must always be keen to where our sugars are, even if the numbers just before appaer to be fine. That's not enough. A CGM can offer peace of mind, but until we get to the point where it's 100% accurate AND more people have them, we must take on the task ourselves. Or give up driving voluntarily. We must prove that just because we're diabetics, we aren't destined to create crashes or erratic driving. Though it's possible, we can be just as prepared as anyone who gets behind the wheel.

Still, it comes down to personal responsibility. Realizing that even with the best preparation, sometimes you can't stop the Lows While Driving and that may mean sacrificing what you love to do. It comes down to you. I personally believe that, and would hate it even more if laws changed because of those unprepared diabetics who allow this bad driving to happen because of poor control. It's our job as Diabetics not only to prevent this kind of stuff from happening in our own driving worlds, but also to make sure those bad examples don't dictate driving laws for all of us.

16 comments:

Elizabeth Joy said...

Really good post...And I have to admit that I've driven several times while low. I'm very hypo unaware, and because of that I'm pretty capable in the 50's, and even the high 40's. I'm a novelist, and I've written some not-too-bad stuff while low, so my brain still works pretty well. But I might very well be less aware of what's going on around me, and past the mid-40's, I'm sure my driving would be as bad as someone driving DUI.

The scariest incident for me was a few years ago...I was near a stop sign and saw a schoolbus approaching at the cross street, and even though I did stop, my reaction time was so slow that I stopped what must've been about 3 feet past the intersection, close enough that I came within inches of hitting the bus. I got home and tested and was 34(!!!) And the memory that sticks in my mind is of two little boys who must've been 7 or 8, staring out the bus window at me.

After that, I started testing before I got in the car, and on longer drives I pull over every hour to test. If I know there's a chance I might be dropping fast (I've done a recent correction or it's near mealtime), then I'll make sure I'm reasonably high (above 110) before I get in the car. That's worked really well for me, and I haven't had any more episodes since the near miss with the bus.

I have to say that IMO, where there are repeated incidents where a diabetic has gotten in accidents or been found driving erratically, their license probably should be suspended until they figure out how to make sure it doesn't happen again. It's definitely a huge hardship to have to take public transportation, but I just don't think we can justify putting other people's lives at risk.

Shannon said...

You had to expect me to comment ;-)

I have some very strong feelings about this topic, both as a diabetic and as someone who was nearly killed by the negligence of another driver.

As a diabetic, I consider it my absolute responsibility to test before driving each and every time. I keep a supply of fast acting glucose in my car at all times, and I wear a Dexcom (I've actually gotten to the point where I feel naked without it).

That said, I, too, have dropped unexpectedly while driving. There was a specific incident (pre-Dexcom) when I was returning to the office after running errands. I was waiting at a red light when I started to sweat. Since I have pretty severe hypo unawareness, sweating is often the only symptom I get. So, even though I was only a few blocks from my office, I pulled into a parking lot and tested; I was 37 mg/dl (despite being 85 mg/dl 20 minutes prior). I drank a juice box, cranked the A/C and waited for my BG to rise before I drove again.

We all have those unexplained incidents, but overall, I'm a very responsible diabetic. I LOVE to drive (especially in my new car), and I'd be devastated if the behavior of a few non-compliant diabetics ruined this privilege for the rest of us.

A few months ago, I wrote a blog about this very topic. As always with me, I took a harsher point of view (http://ladadeeda.com/2009/11/dwd-driving-while-diabetic/), but our overall message is the same.

Getting a CGM will be a great start for you!

Judi said...

And always remember that driving is a privilege, not a God-given right. When I got my first driver's license in 1969, I had to bring a note from my doctor saying that my diabetes was in good control and I was not a danger on the road. I didn't have a home blood testing meter at that time, so there was no way to tell if I was a danger on the road except by how I felt. Things are so much better now in being able to watch yourself.

Casey said...

Many states have forms that physicians must fill out and you can get your license taken away if you have an incident. I remember being afraid that I might not be able to get my license when I was diagnosed. I agree with you and all the comments. Test, test again! and always keep glucose close. We can't predict when lows will occur. Just like we can't predict when a stroke/heart attack/death might occur in someone driving. We do know we are at risk and we have tools that can help us prevent at least some episodes.

We are responsible for our safety and others around us when we are driving, no matter if we have diabetes or not.

Oscar the Great said...

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JT said...

Michael,

It's good to see the candor. Brave of you. (Beware your insurance company reading it and using it against you, but...)

One technology that may be coming our way soon that could help is an air/breath meter. The U of FL has that going on, and if a test strip company doesn't buy and bury it, that's going to make life easier on us all.

What about a pump? I'm Type 2, so I freely admit that I don't know enough about them to say, but it seems that a system that is constantly measuring and administering according to need would be superior.

I'm also guessing when I wonder if your lows aren't coming from the type of insulin you use. In other words, if there's too much long-acting and it ends up being compounded, when it all gathers and kicks in, might that be causing you to go lower than anticipated?

I tend to agree with the courts that the diagnosis (especially generalized D, not specifying type,) isn't cause enough to preclude driving. But if it happens repeatedly, then we should police ourselves and not drive until we resolve the problem.

Finally, you stated that you don't think you're dangerous on the road. All due respect, your article has plenty of proof in it that you ARE. Your perception that everyone was driving on the wrong side of the road, while you took out a sign and ended up driving in a ditch, for example. That could easily have been a pedestrian that you didn't see or remember. It could have been head-on into traffic. You ARE dangerous on the road, sir, and need to get the problem under control.

Malama pono!

JT

Michael Hoskins said...

Thanks for the comments everyone. Appreciate them, as always.

In respect to your comments, JT, let me address them.

With a pump, you don't have long-acting. It's not like injections. You have a continuous stream (basals) plus whatever extra (boluses) needed once you eat or correct for a higher sugar. The insulin sensitivity may very, but it's nothing that is of concern for me as far as type of insulin.

You misread my point about being a danger on the road. Being a Type 1 for 25 years and every year since I've been able to drive, the situations have been few and far between. They happen, but I do everything in my power to make sure they don't. Following each, I do evaluate incredibly carefully the events and get under control to prevent this from happening in that way again. The point is well-taken as far as it could be a person, vehicle, or brick wall rather than a sign post. Believe me, that's something that goes through the mind and always will, no matter what. The "problem" was under control within a day (and for the record I didn't drive by myself for several), with analysis from everyone including my endo.

The point is whether, in full, do I present a danger on the road given that I have a practice of testing before, and during, and always have sugar handy inside the vehicle no matter what? Am I more of a risk than those who don't test at all before driving, or don't keep anything on hand in case of a Low? In that, I would say no.

I am a risk, and I've lost the fight on occasion, but it's one that is closely monitored. I would equate it to having a heart condition - I've done everything possible to prep, but in the end I might have a heart attack while driving because that's just the way it is.

This is different from, let's say a Type 1 or 2 that simply doesn't test and just assumes they're fine. Are they more safe than I, simply because they've guessed correctly and not had a driving incident despite their lack of care? I do what I can, and believe me, I do everything humanly possible in my responsible D-Care to prevent this from happening. I hope all diabetics do, but it's clear from the news stories that it isn't happening.

JT said...

Michael, I'd rather equate it to someone who is texting while driving, talking on the cell phone while driving, has screaming kids or undisciplined pets in the vehicle, is tired, etc. They are all potential distractions, things that could spring up at a moment's notice, and have nothing to do with Diabetes.

The thing for EVERYONE (Diabetic or not) to realize is that it's not just you you're making choices for when you decide you're safe to drive. You're deciding for the others on the road, the pedestrians, your loved ones and theirs.

I don't agree that driving is a "privilege." I have the right to travel, I have the right to own a car, therefore I have the right to USE that property while traveling. None of that says I have the right to do so irresponsibly, whether on foot and tromping through someone's garden, or in a car and distracted, under the influence, etc. In that sense, I believe presumption of innocence must have the higher priority.

The question, Michael, was whether we think you're dangerous on the road. Was it a rhetorical question?

A while back, something was affecting me, causing me to nod off. Not quite narcoleptic... maybe even an earlier symptom of problems with my BG levels, for all I know. I redoubled my efforts, made a point of keeping cold air coming in through the windows, not driving when I felt fatigued, etc. I lived a long ways from town and had little choice but to drive, so I took a calculated risk and tried to mitigate that risk as best I could. But I never denied to myself that I was risking others' well being when I decided to get behind the wheel while that was going on.

Everything is a risk, and anything we do in public (and some things we do in private) will pose risks to others. Those others on the road know that as well, and agree to take those risks themselves by being there on the road. The risks, though, are taken under the expectation that the fellow drivers are sober, capable and not unduly distracted. (Those are the rules of the road, per se.) What happens when someone blows off those rules and decides to text while driving, for example? Hundreds of times, that person may get away with it. Then the one time happens and they plow into the back of someone's car, causing death and destruction. How does one take that back? How does one undo the choice made to drive while texting that day?

This is a decision every person must make. I don't presume to know where the line is at. We are ALL dangerous on the road, some more than others at one time or another. I just hope we make responsible choices, aware of that we're choosing for others as well. So long as we can honestly say that we're safe, that's fine. Can you bet someone's life on your choice?

JT

Michael Hoskins said...

Ok. I'll make one more comment, then leave it.

Personally, I take offense to classifying DWD to Texting While Driving - one you make an active choice to NOT do. Diabetes isn't a choice. You can't just choose to not be distracted by it at your own beck and call as you can with cell phones, gadgets, etc. Yes, driving is a choice that is bigger than ourselves and must be personally handled with responsibility. You can't take back a tragedy; you can only work to prevent one as best you can and leave the rest to a Higher Power. That's what I do, to the best of my ability, but it makes my blood boil when those who have the ability to do this choose not to. That gives a bad name to those of us who take this seriously, and weigh it with every single thing we do.

I make the responsible choices and do what I can to be safe, and ALWAYS evaluate the decision to drive before starting my car and when evaluating the state of my health. Despite the history, I can honestly tell myself I am doing everything I can and working to prevent disaster.

Whether that's good enough for some isn't my concern, and frankly it's that train of thought that will take away driving privileges from anyone with diabetes, since they are a potential risk more than the everyday healthy driver. This ability to drive isn't stated in our constitution, so therefore it can be taken away if we misuse it. If I do negligently drive, either by not taking care of my health, or being under the influence of drugs or alcohol, then it should be taken away because I wasn't responsible.

Bob Fenton said...

Thanks for covering what several other bloggers are covering. While I cannot say that I agree with you, you have some good points.

Everyday we see people fixing their hair, putting on makeup, texting, talking on cell phones, trying to keep unruly pets or children in their seats or quiet, looking at themselves in the mirror, and the list is endless.

Even worse, are the people with untreated sleep apnea who drive. Many of them cause more accidents, but I can't prove this as no definitive data on this is kept to my knowledge.

Do I agree that this is dangerous?
Yes, and something does need to be done about it. What? I'm not totally sure.

I am sure that anyone that has certain diseases needs to be evaluated on a regular basis to keep their drivers license. I would even agree to a maximum of two years between renewals.

Depending on violations or disease progression, licenses should be suspended, revoked for a determined period, or permanently taken away. When it comes to safety on the roads, it can be done and is being done. Drivers of commercial vehicles (CDL) have their licenses taken away when they are on insulin.

I will equate texting to a person with diabetes. Anything that causes a distraction or accident can be equated. And I am a PwD, a T2 on insulin.

The issue of irresponsible driving will continue as long as there are accidents. Lastly, having a drivers license in most states is defined as a privelige and not a rignt. A right means that the state can not revoke and we know this will never happen.

Bob

Cherise said...

Mike-

You've been through a lot. Hugs! You wrote this-Realizing that even with the best preparation, sometimes you can't stop the Lows While Driving and that may mean sacrificing what you love to do. It comes down to you-I totally agree.

I don't think there is really a right our wrong answer in responding to Ms. Diaz or any other PWD. It's a learning experience for us all but I don't think PWD's should have to go an extra step to get their drivers lisc.

JT said...
This comment has been removed by the author.
the poor diabetic said...

That is scary Michael, I for one have never been low in my 12 year diabetic life but I have been high once in a while and behind the wheel and the dizziness alone almost had me in a ditch. So I can somewhat relate.

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John said...

That's a very interesting article. You have to be extra careful if you're driving while diabetic. You wouldn't know when the pain in your feet comes.

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