Hypoglycaemia in Clinical Diabetes

326 LIVING WITH HYPOGLYCAEMIAwith glycaemic control, although this usually causes deterioration in control rather thanhypoglycaemia (Poole et al., 1992). Measures to avoid and/or treat hypoglycaemia at workare no different from any other time or circumstance, although in some jobs, blood glucosemonitoring may not be feasible while at work and break times for snacks and meals maybe variable. It is essential that workmates or colleagues are familiar with the emergencytreatment of diabetes and that a supply of quick-acting carbohydrate is available in the workplace. It is advisable that the individual’s employer is aware that he or she has insulintreateddiabetes, although some people conceal this fact, fearing dismissal or discrimination.Legislation to avoid this is in place in many Western countries, but widespread ignoranceremains about the nature of diabetes, its treatment and the possible side-effects, and this hasto be confronted by those with specialist expertise.Similar arrangements for emergency treatment should be in place in schools (see Chapter 9),colleges and other venues of tertiary education, including university accommodation. In separatecases in Edinburgh (Strachan et al., 2000), two young male students with type 1 diabetesdied tragically after developing severe hypoglycaemia while living in university halls of residence.One of the students was left lying unconscious for two days on the floor of his room,despite being observed by a member of the domestic staff who thought he was asleep or drunk.Although the warden had known that the student had diabetes, other members of staff were notaware. At the subsequent fatal accident enquiry, the Sheriff discussed the dichotomy betweenmaintaining the privacy and confidentiality of the individual, and the duty of care owed to youngpeople living in university accommodation. As a result of his report and recommendations,the facilities and practical handling of students with type 1 diabetes in residencies were modifiedin Scottish universities. However, these cases highlight the importance of disclosure ofdiabetes, and its potential metabolic problems (especially hypoglycaemia), to the appropriateauthorities and those who may potentially be required to render emergency assistance.Specialist Medical ReportsPhysicians who specialise in diabetes are often required to provide medical reports foremployers, either related to the suitability of specific types of work for a person with type1 diabetes or to their capability of performing the job. It is often necessary to advocate onthe behalf of patients when a problem at work is specifically related to some aspect of theirdiabetic management, such as hypoglycaemia. The introduction of insulin therapy sometimeshas to be delayed because of the impact that this will have on the individual’s employment.By strict dietary measures, an oil tanker driver (with a LGV licence) attending my clinic,who had longstanding type 2 diabetes, managed to maintain adequate glycaemic control onthe maximum dose of combined oral antidiabetic therapy for nearly two years, delayingconversion to insulin. He was anxious to protect his pension rights until his retirement, atwhich point insulin was commenced. However, procrastination with starting insulin therapyis usually inadvisable in type 2 diabetes, and is not possible in those presenting with newlydiagnosedtype 1 diabetes. Sympathetic medical counselling may be necessary to recommendan alternative occupation. This is often necessary in people who hold vocational drivinglicences, such as bus drivers or lorry drivers.School and Academic ExaminationsIt is recognised that school pupils and students with type 1 diabetes may be disadvantagedduring school or college examinations by unpredictable fluctuations in blood glucose