When Things Get Ugly

It saddens and upsets me to have to write this. But I have to write this. Despite our community’s outrage over the Doug Burns’ hypoglycemia case, there are times when the lines between “medical condition” and wrongdoing are not so clear…

Two local diabetic drivers here in the San Francisco Bay Area were recently involved in separate car accidents in which people were killed. Both drivers were experiencing insulin shock at the time.

Car_crash

Both drivers were charged with “vehicular manslaughter,” but the charges against one were later dropped “because prosecutors said they didn’t think they could get a conviction.” Santa Clara County prosecutors are still proceeding against the second driver, believing they “have a solid case” against the 52-year-old man, who killed a 20-year-old couple in a fiery crash.

The newspaper pontificates:
The cases highlight a complex and emotional debate: To grieving families who believe diabetes can be managed, drivers must be held accountable. But the diabetic community says it’s not that simple, because insulin use is hardly an exact science.

You’re damn right this is a hard one. We all know how easy it is to take too much insulin. Are these two men guilty of negligence in managing their disease? Doubtful… more likely they each just had one extremely bad day.

My point in supporting Doug Burns was that people experiencing severe hypoglycemia are in no way acting purposefully nor are they cognizant of their actions. Even though they may be mobile — and verbal — they are actually incapacitated during a severe low, in the same way as someone experiencing a seizure or a blackout. Thus they cannot be treated as criminals for events that may occur while in this state.

But what about when people die? What then?

I don’t pretend to have the answer.

The prosecutor in the Santa Clara County case claims the diabetic man charged was an unsafe driver because he took too much insulin. “Too much of any drug, even if it’s a prescribed drug, can cause a person to be under the influence,” he says.

The victims’ families have little sympathy for “diabetic episodes” either. And I can’t blame them. If it were my child who’d died, you bet I’d be demanding some punishment.

“When a loved one is killed, everybody wants to have somebody held accountable,” says Redwood City DA Steve Wagstaffe (yes, the very same official we lobbied).

I can’t imagine the pain of losing a loved one in this way. But as a Type 1 diabetic myself, I can imagine that the pain of having done such a thing during a hypoglycemic episode cuts almost as deep.

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30 Responses

  1. M
    M June 4, 2007 at 5:52 pm | | Reply

    You touched on a topic close to my heart here Amy – Something I’ve been worrying about for a while.

    On one hand, it almost makes sense for diabetics to be banned from driving. I wouldn’t want that, and I doubt the rest of you would either!

    99% of the time I’m fine to drive. I almost always test first, and I do my best to keep my numbers in check all the time anyway. (Of course, as you quoted, insulin use is NOT an exact science, and I’m far from perfect!)

    Just the other day I popped out to the dairy, got home and tested at just under 4 – I shouldn’t have been driving. I can make all sorts of excuses – it was only round the corner, I was careful, I felt fine… but in reality, I still shouldn’t have been driving. I’m not sure why I didn’t test before I left, but I guess it’s an example of how our brains are the first to go when we’re getting low, and sometimes dammit we just want to be spontaneous and life a normal life!

    It scared me! I wasn’t really hypo, just low enough to be on the edge of the safe range, but two lessons were learnt in that moment:
    1: ALWAYS test before getting in the car. ALWAYS!!!
    2: Regardless of how hard we try, we wont always get it right.

    But that’s a scary thing – we may like to think that accidents like that only happen to people who don’t have their D under control, who don’t test regularly, or who are on the wrong insulins… but in reality, it could be any of us on a bad day. Even on a good day if we’re not careful.

  2. Manny Hernandez
    Manny Hernandez June 4, 2007 at 6:16 pm | | Reply

    My words, M:
    ALWAYS test before getting in the car. ALWAYS!!!

  3. greta
    greta June 4, 2007 at 6:53 pm | | Reply

    Perhaps they could issue conditional licenses. Your license would be valid as long as you documented that you tested before getting into the car and every X amount of time on long drives. This might nudge people to do the testing.
    This is also a situation in which the CGMs would be very useful. Insurance companies would also have to support the additional testing.

  4. Jenn
    Jenn June 4, 2007 at 7:03 pm | | Reply

    I agree that you should alway’s check before driving, but sometimes lows hit so fast and hard…what is the answer?

    Should we not drive unless we are 99% sure that there is no fasting insulin in our systems?

    This is tragic and terrifying, and especially frustrating that our daily struggles are belittled by those who don’t understand.

    Wishing all of us with type 1 safe travels

    Jenn

  5. AJ
    AJ June 4, 2007 at 7:04 pm | | Reply

    What a tough one.

    Of course, there may be more to the story than we know, but I am sad to say I would be tempted to view the diabetics as guilty.

    I am a Type 1, but only for the past 10 months. My BG has not gone below 45 so far. I still have strong low symptoms. So for me, if I get the slightest “odd” feeling, I check my BG. I take my test kit with me everywhere, and my vehicle is stocked with a pure form of sugar at all times.

    Consider this comparison, since it fits quite well:

    Drink driving inhibits your mental reactions and reflexes, etc. Same as a low.

    We are ALL held accountable to monitor our alcohol intake before getting behind the wheel. We can all even buy breathalizers to be sure we are legally “sober”. If you get behind the wheel drunk, you can’t claim medical disability because you weren’t aware you were drunk.

    The fact is: when we get behind the wheel, we are ALL accountable for our actions. Whether you are drunk, stoned, getting a blowjob or a bloodglugose low, it is YOUR responsibility, and it is MY responsibility to pull over and do the right thing.

  6. Bernard Farrell
    Bernard Farrell June 4, 2007 at 8:11 pm | | Reply

    Wow, this is a complex problem.

    About 3 years ago I took part in a study that was around educating people with diabetes about driving. I believe the people involved are trying to develop some simple criteria for people to use before driving.

    This is one case where having a continuous glucose monitor is a clear winner. There’s almost no effort in looking at it before driving (there is if the numbers are dropping or already low).

    It also helps because if I’m driving for 2 hours, my numbers could change a lot in that time.

    As many others said before, the critical thing is to know where your levels are before starting.

    But I’d also add the importance of having glucose tabs, some fast acting carbs on hand in the car at all times.

    And remember to stop at least every 45 minutes and test to see where your numbers are at now.

    Maybe in time they’ll develop systems where the car is disabled until it gets a reading indicating your levels are good. But I’m not holding my breath on that one. Heck they can’t even make meters that talk with one another!

  7. Felix Kasza
    Felix Kasza June 4, 2007 at 8:43 pm | | Reply

    Hi Amy,

    you compare the incapacitation due to insulin shock to having a seizure (blackout is a symptom of something else, so I don’t count it). Frankly, if an epileptic gets into his car and causes an accident, I would hold him responsible; “unforeseeable” applies only before the diagnosis is made — that is the difference between a heart attack and a hypo, in my view.

    Cheers,
    Felix.

  8. Anne
    Anne June 4, 2007 at 8:45 pm | | Reply

    I agree that we all must drive responsibly, and not put ourselves and others at risk by driving when impaired, whether that is from a hypo or from lack of sleep.

    But the attitude of the prosecutor in one of the cases concerns me. Quoting from the San Jose Mercury story Amy linked to: “‘He was an unsafe driver because he took too much insulin,’ said prosecutor Peter Waite. ‘Too much of any drug, even if it’s a prescribed drug, can cause a person to be under the influence.’”

    I hope that people can gain some understanding through all of this. My heart goes out to the families who have so tragically lost a loved-one, and to the 2 diabetics who carry this sad and heavy burden. I hope that the families can find the strength to forgive.

  9. Michael Park
    Michael Park June 4, 2007 at 8:46 pm | | Reply

    This is certainly a powerful and emotional issue. I’ve often played the devil’s advocate on issues like whether diabetics should fly planes or not. It always comes down to the aim for tight tight control. The lower we aim our sugars to be, the more damage a simple miscalculation can cause.

  10. Living With Diabetes
    Living With Diabetes June 4, 2007 at 9:04 pm | | Reply

    Diabetes Mine: When Things Get Ugly

    Amy sent me a comment today, and I do have somestrong feelings about this. Diabetes Mine: When Things Get Ugly First, the Doug Burns is pretty cut and dried to me — he went to the lobby for help, they…

  11. Anne
    Anne June 4, 2007 at 10:50 pm | | Reply

    I think we should consider another point made in the Mercury News, which is that this seems to be an extremely rare occurrence.
    From the article: “Cases like Mayfield’s and Nebel’s, in which fatalities occur, are considered unusual. The Santa Clara County District Attorney’s Office said it couldn’t remember another such case. Neither could Wagstaffe.”

    Of course, even one fatal accident is one too many. There are thousands of fatal automobile accidents each year (4,329 in the California in 2005 according to http://www-fars.nhtsa.dot.gov/). I wonder how many are caused by type 1′s with low BG’s.

  12. Lauren
    Lauren June 4, 2007 at 10:55 pm | | Reply

    Fatigue-related accidents, caused by “drowsy driving,” are similarly tragic, in my opinion. In both cases, an error in judgment occurs, whether it’s misjudging the degree of sleepiness, or the relative risk of hypoglycemia.

    I’ll be honest about my own less-than-perfect strategy for dealing with this fear: when I drove alone from San Francisco to L.A., I purposely ran high. I stopped to get coffee along the way and felt the caffeine kick in: I noticed a quickened heartbeat and slight shakiness. Terrified that this was the beginning of a low, I pulled over on the side of the I-5 and tested my sugar, which was over 150. I didn’t correct it, and I kept a regular soda in the cupholder for the entire trip. I felt safer above 120.

    When I eat a meal and know I’ll be driving shortly afterward, I give myself less insulin than I would if I were staying home for a few hours.

    I strive for tight control, largely due to terror of complications, and it’s hard for me to see high numbers on my meter. However, there are times when a short-term high is infinitely preferable to a low, at least in my rookie opinion. This entire issue poses many tough questions. How can we retain our independence and assure our safety, as well as the safety of others?

    Although the drivers’ degree of responsibility is open to debate, I do resent the prosecutor comparing insulin shock to overuse of a prescription drug — unlike many drugs that alter consciousness, insulin can’t be “abused.” Is insulin, being a hormone, classified as a drug? That doesn’t seem right to me.

  13. Jolene
    Jolene June 5, 2007 at 3:30 am | | Reply

    Problem with banning all diabetics from driving is that the people in this country without diabetes don’t know the difference between the 2 versions, and because of a few, the majority of us will be punished. If they took my license from me because I’m a diabetic, I would leave this country. Too much “nanny” state crap for me. The people in Amy’s story should be prosecuted -and their “condition” at the time taken into consideration at sentencing.

  14. Kevin D.
    Kevin D. June 5, 2007 at 4:11 am | | Reply

    This is exactly why I think Doug B. was guilty as well. In the case of Doug, would it be any different if he fought the officer and broke the officer’s arm or grabbed his gun and shot him? I betcha thousands it would have.

    I think in this case both drivers are guilty. Remember, driving is a privelege, not a right. Therefore we have to earn that privelege. Yes, this is a case where it’s unfortunate for us, but what would you want done if you or a family member were a victim in a case like this?

    Diabetics need to be held accountable 100% of the time for their actions.

    Greta, you said something about a conditional license. Well, guess what. In every state that I can recall there is a stipulation that you MUST tell the BMV that you are a diabetic at which point they will issue you a special medical license that in most states has to be renewed every 1-2 years and you must have doctor’s notes stating you are in superb control. However, I know alot in the diabetic community think a) it’s no right for the BMV to know your medical situation and b) they don’t want to go through that hassle all the time so they just don’t tell and they get a standard license.

    I work for a police department and we had a driver drive his vehicle into some woods once on a neighborhood street. We responded and he outright admitted to being a diabetic. But what would the case have been if someone was walking on that street? Or if instead of swerving right he went left and hit an oncoming car? How about if he drove into the living room of a house?

    People seem to be clouded and think diabetic deserve special treatment UNTIL someone is killed or seriously injured at fault by the diabetic. Why do we deserve ANY special treatment in these cases? Personally, we don’t.

  15. Thomas
    Thomas June 5, 2007 at 4:35 am | | Reply

    Hi Amy,

    In the UK most diabetics have to renew their driving licences every three years and part of that process deals with hypoglycemic warning signs.

    I heartily agree with the comments here about testing before we turn the key in the ignition (and every two hours on a long journey), but I firmly believe that if we aren’t getting clear hypo warning signs we should seriously consider hanging up our car keys.

    PS, I really do think we ought to club together to send Steve Wagstaffe on a diabetes awareness course.

  16. Scott
    Scott June 5, 2007 at 5:22 am | | Reply

    I think this is one instance why insurance companies must be forced to pay for continuous glucose monitors for everyone with T1DM (T2DM, which generally have far less glycemic variability, is another story). At the moment, the manufacturers are taking the lazy way out, leaving virtually all of the lobbying to JDRF. Why should we have to jump through hoops to get these things approved? How many more people need to die as a result? The other issue is with pre-existing condition exclusions which all but make it impossible for people with diabetes to buy insurance plans as individuals. Fortunately, the 2008 Presidential Candidates are discussing the issue, but why did it take them over a decade to do so?

  17. carol
    carol June 5, 2007 at 5:23 am | | Reply

    Yes, definitely a difficult issue. After the initial emotion of hearing of such horrible tragedies subsided, two things popped into my head (1) We should not have to fight our insurance cos. to get enough strips to test as needed (including before driving), yet we do. (2) The recent article about how hypos do not have a lasting impact — I think the families of all involved in these tragedies would disagree.

  18. Ed
    Ed June 5, 2007 at 6:12 am | | Reply

    The onus really falls on the diabetic. Vehicular man slaughter cases are completly different than the Doug Burns case and really can’t be compared. I always make sure that I have glucose tabs or power gels in my center console and test regurally. Really this compares to drunk driving – both insulin and alchohol are legal drugs and the responsibility falls on the individual to use it responsibly when behind the wheel of a motor vehicle.

  19. mollyjade
    mollyjade June 5, 2007 at 8:03 am | | Reply

    I’ve had drivers licenses in two different states. I remember checking off that I had diabetes on both forms, but I never had a note from my doctor. I even remember asking if I needed to do anything special when I got my first license at 16, and the DMV told me not unless I had been unconscious in the last six months. I just looked it up, and I’m required to have such a note. It seems like these laws aren’t enforced.

  20. Mary
    Mary June 5, 2007 at 8:10 am | | Reply

    Scenarios like these – both the accidents and the Doug Burns case, should be a big wake up call to people who insist Type I diabetics can do anything from flying airplanes to being policemen to running marathons. IF you add achieving a wonderfully low HA1C to doing anything and everything, you have created a recipe for disaster.

    Whether or not the drivers are criminally responsibe for the accidents, I really don’t know what to think. Did they routinely suffer from unexpected lows? Did they routinely lose touch with reality during lows? Then, I’d think they were responsible. Was their care haphazard, or were thy striving for extra tight control? Both extremes increase personal responsibility for the lows.

  21. Ed
    Ed June 5, 2007 at 9:18 am | | Reply

    Mary, Type 1s can do anything that a person without Type 1 can as long as they plan for it and act responsibly. It’s not as if we’re a bunch of people with chronic illnesses who turn into zombies without a warning sign. Precautions and planning allow us to live the same life as anyone else.

  22. Pteryxx
    Pteryxx June 5, 2007 at 9:59 am | | Reply

    I object to the comparison of diabetic lows with drunk driving. The last I heard, nobody developed life-threatening medical complications from NOT drinking. Diabetics have no choice but to be on an often complicated and unpredictable regimen. Besides, plenty of accidents are caused by the stupidity of people that don’t have a convenient red-flag label as a blame target. Quotes:

    “Distracted drivers were involved in nearly eight out of 10 collisions or near-crashes . . . . Data from police reports had estimated that driver inattention was a factor in about 25 percent of crashes.”

    “Drowsy driving increased the driver’s risk of a crash or near-crash by four times to six times, the study said. But the study’s authors said drowsy driving is frequently underreported in police investigations.”

    (Quotes reported in 2006 NHTSA study.)

    The lawsuit-based logic would lead us to ban diabetics from driving, whether or not they have a history of excellent control. But it is discriminatory to hold one class of people to a higher standard of behaviour – not performance, but behaviour – because of a medical condition.

  23. Titos
    Titos June 5, 2007 at 10:59 am | | Reply

    Studies in the UK, Sweden and I believe also in the US have documented that the accident rate of diabetics while driving vehicles is actually lower than non-diabetics. This obviously does not help in this tragic incident, however the discussion should be put in perspective: The vast majority of diabetics, even young people, is very careful when they drive as a low can be life threatening – also to themselves. Obviously insulin dosing is not an exact science yet – and in this case technology needs to help. Using a CGMS while driving seems to me to be a perfect application for the technology given the built in alarms. Perhaps here liability insurance could play a role by obliging diabetics to wear CGMS while driving, which then health insurance / Medicare would be obliged to pay. This should be mentioned to the manufacturers.

  24. Anne
    Anne June 5, 2007 at 1:23 pm | | Reply

    nicely put, Titos.

  25. Titos
    Titos June 5, 2007 at 3:31 pm | | Reply

    Thanks Anne, I think it all comes down to responsibility and discipline – and I guess diabetics learn this the hard way. Another interesting statistic is the following: Finland has the highest incidence of Type 1 diabetes in the world and is one of the few (if not the only) countries that accepts diabetics into the military. A significantly higher percentage of diabetics than non-diabetics then go on to become officers. It is the same effect.

  26. Sarah
    Sarah June 6, 2007 at 1:11 pm | | Reply

    The problem is that not everyone has the same degree of control as everyone else, and not all can or will manage as well or as poor as the next diabetic.

    It does seem like this driver WAS doing the right thing by correcting his high, provided he took the “right” correction dose suggested by his diabetes educator.

    There is a risk for *anyone* with a chronic health condition to be on the road. Same goes for the elderly.

    People with Type 2 diabetes may not be prone to lows, but since many Type 2′s are overweight, have high blood pressure, high cholesterol, and/or heart disease, they are at a high risk for a heart attack/stroke behind the wheel causing an accident. I have also heard of Type 2′s who fail to test regularly or take their medication since Type 2 is not immediately fatal. These people drive around with continuous dangerously high blood sugars, which can also impair judgment.

    Visual and neurological damage from diabetes can also affect driving ability.

    Some Type 1′s also have more lows and swings in blood sugar than others, some of which are unexplained and unpredictable. A minority of those with Type 1 remain stable with few (rare)lows despite tight control. Most people fall in the middle.

    Type 1′s who drive probably should give up aim for “tight control” when behind the wheel.

    I think diabetes *in general* does increase your risk of dying or killing someone behind the wheel. I just saw a show in which a police officer pulled a man having a “diabetic emergency” out of a car, which had burst into flames.

    I don’t know what the answer is here. Perhaps my uncertainty is why I never got my license, and I don’t drive. I’m terrified I’ll go low. My fiance keeps trying to get me a car (probably so he doesn’t have to drive me everywhere :) , but frankly, I don’t know if a Type 1 like me (Old school term “brittle”) should have one.

    I already test 10x per day and wear a pump. Short of getting a CCGM (I agree they should be covered), there is nothing more I can do to stay in “control” behind the wheel. So if I still have unexplained lows and sudden swings, I assume I should not drive.

    For those Type 1′s who drive, *please* always test before you get behind the wheel, and take the time to figure out how much insulin/food you have in your system. Run yourself a little higher, and test often.

  27. Sarah
    Sarah June 6, 2007 at 1:16 pm | | Reply

    P.S. Titos, your comment is also a great potential solution.

  28. Meg Graham
    Meg Graham July 13, 2007 at 8:48 am | | Reply

    Jenn (posted 6/4/07), I’m sorry to say that I’d have to disagree with you! Us diabetics do try so hard, and when low blood sugars hit they hit you hard and fast! I test ALL THE TIME and to the point my Dr. said was unnecessary. I too was in a horrible car accident and I injured someone who, of course, sued me. I was hurt pretty bad as well. It hit me so incredibly fast I don’t even remember it happening?? Previous to this I had stopped to get something to eat, but drove along saying I’d eat while I drove. I was too late!
    The BEST THING IN THE WORLD for us diabetics is that CGMs and make the insurance companies provide for them. The first few years of being a diabetic, I had “symptoms” of low blood sugar too, but they don’t hit you hard until you’ve had it for quite a while.

  29. John Hallett
    John Hallett July 13, 2007 at 9:36 pm | | Reply

    Hi Amy I’ve had many a low in public have never been arrested but have been put in handcuffs to keep me from hurting myself or others. Have been type 1 since childhood have also had accident with low many years ago not fun. The state I live in requires if you have low regular checkups from the doctor for few years. But have found is the best way is check before you drive if below 100 don’t drive best way to do it. Agree a glucose continous monitor is good thought but they are very expense and the infusions for them are expensive too and insurance doesn’t cover them. Aloso is hard to deal with no insurance too very costly. John

  30. Sara
    Sara September 14, 2010 at 11:05 pm | | Reply

    I nearly lost my life along with my fiance and unborn child when a man plowed into us as he ran a stop light. He was going 60 mph in a 40 mph zone and as I lay on the ground after they pulled me from the car all he did was stare at me and inspect the damage on his car. Appearently he did not check his blood sugar when he left his house and did not remember even getting into the car.

    I need surgery for my injuries and I’ll be lucky i I get through this pregnancy without complications. People who are irresponsible,no matter if they are 15 or 75, need to know they will be held responsible for putting innocent lifes in danger. I will be suing this man; the same if he was to tired and knowing got into the car to fall asleep at the wheel.

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