November is national diabetes month, and as such today we bring you a story included in a new book about the difficulty of living with the disease, Published by Vanderbilt University Press. The excerpt — from A Life of Control: Stories of Living With Diabetes, by Alan L. Graber MD, Anne W. Brown RN and Kathleen Wolff RN — tells the story of a now-retired truck driver who, in order to keep his job (with an impeccable safety record), for years was forced to devise methods to falsify his medical certification to meet the blanket ban on insulin-treated diabetics from truck driving. It’s a short, though incisive, portrait of the difficulties the FMCSA’s ban put on haulers living with the disease.
FROM CHAPTER 22 of “A Life of Control”:
Jack had driven an eighteen-wheeler since he was eighteen. He had made a good living, supporting his family by working as a commercial truck driver. He had driven to forty-nine states, including Alaska. He’d never had an accident.
Somewhere along the way, he had developed diabetes. He couldn’t remember precisely when—possibly during his twenties or thirties. He had gotten sick and gone to an emergency room, where the doctor had told him he’d have to take insulin for the rest of his life. He did what the doctor told him and had always felt fine.
Jack had had an occasional hypoglycemic reaction, but never while driving. When he drove, he had cut back on his insulin dose and let his blood sugar run a little high. He had always carried candy bars in his glove compartment, just in case, but he had never needed one. He didn’t smoke or drink. He had taken good care of himself. He had heard tales of guys acting crazy or losing consciousness and going into a coma because of low blood sugar, but it had never happened to him. The idea of an eighteen-wheeler going down the road without a fully aware and competent driver at the wheel was repugnant to him.
During his career as a truck driver, the U.S. Department of Transportation (DOT) required a physical examination and medical certification every two years. One of the questions was “Do you have diabetes?” He always answered no. He knew that if his employer found out that he had diabetes and took insulin, he would lose his job. He feared the urinalysis: sugar would appear in the urine if the blood glucose level had exceeded 170 mg/dl at any time since the previous emptying of the bladder.
Jack’s scheme for avoiding glucose in the urine, according to my recollection, went something like this. He scheduled the examination as early in the morning as possible. On the morning of the exam, he took his usual dose of insulin plus a few extra units, then skipped breakfast. Immediately before entering the exam, he emptied his bladder to be certain it didn’t contain any urine from an earlier time when his blood sugar might have been higher. Then he drank some water so that when he was given the container for the urine specimen, he could produce an adequate amount for the test. Since he hadn’t eaten breakfast, he knew there was a definite risk of low blood sugar during the exam, especially if the doctor was late or the exam took longer than usual. Low blood sugar sometimes produced sweating or nervousness, but somehow Jack always managed to get by. As soon as the exam was completed, he ate a candy bar. He never flunked the exam or was disqualified from his job.
Several years after Jack retired, the Federal Motor Carrier Safety Administration (FMCSA) at the DOT replaced the blanket ban that had prohibited anyone with diabetes who used insulin from driving commercial vehicles in interstate commerce. The FMCSA provided a protocol for case-by-case review to issue exemptions to certain insulin-using diabetic drivers. Congress passed a new transportation bill in 2005, requiring that individuals with insulin-treated diabetes demonstrate stable control of diabetes while taking insulin and fulfill fifty-seven other criteria listed in the September 3, 2003 Federal Register Notice (with two revisions in the November 8, 2005 Federal Register Notice). These requirements included: an annual examination by both a medical examiner and an endocrinologist; written confirmation from the endocrinologist on a quarterly basis regarding the details of glucose monitoring correlated with daily records of actual driving times; the driver’s compliance with stringent guidelines to monitor his blood sugar every two to four hours while driving and taking appropriate action to maintain it in the range of 100 mg/dl to 400 mg/dl; and the driver’s freedom from severe hypoglycemia within the past five years.
Freedom from severe hypoglycemic reactions in this context means no recurrent (two or more) hypoglycemic reactions within the past five years resulting in loss of consciousness or seizure, requiring the assistance of another person, or resulting in impaired cognitive function that occurred without warning symptoms. For each of these, a period of one year of demonstrated stability was required following the first episode of hypoglycemia.
Reprinted with permission from the new book A Life of Control: Stories of Living With Diabetes, by Alan L. Graber MD, Anne W. Brown RN, and Kathleen Wolff RN, published November 2010 by Vanderbilt University Press. For more information: https://www.vanderbilt.edu/university-press/