Hypoglycaemia in Clinical Diabetes

328 LIVING WITH HYPOGLYCAEMIAalcohol can promote hypoglycaemia in people treated with insulin, and may be a contributoryfactor to inducing the low blood glucose, so causing further difficulty with identificationof the underlying metabolic problem. This emphasises the importance of an individual withinsulin-treated diabetes carrying some form of identification to indicate that they are takinginsulin and may be at risk of developing hypoglycaemia-induced coma. In addition to therisk of being arrested during an episode of hypoglycaemia because of aggressive or abnormalbehaviour, low blood glucose may develop while in custody. The police may have limitedcomprehension of the needs of a person with diabetes and the risks of hypoglycaemia. Theyoung male patient with undiagnosed Addison’s disease, described earlier, who was arrestedon a driving charge, was profoundly neuroglycopenic when taken into custody. He wasdetained without treatment for two hours. When his father arrived at the police station, herecognised immediately that his son was severely hypoglycaemic and needed emergencytreatment with dextrose. This type of situation is clearly alarming, and potentially could havea fatal outcome. An initiative in Edinburgh has liaised successfully with the local policeforce to improve the way in which people with insulin-treated diabetes are handled while incustody (Barclay et al., 2007).Management of Diabetes in PrisonThe general problems of managing diabetes in prison have been examined in two Britishstudies (Gill and MacFarlane, 1989; MacFarlane et al., 1992) and recommendations havebeen made to improve the care of diabetes in prison, by the American Diabetes Association(Eichold, 1989) and by Diabetes UK (Gill et al., 1992).Imprisonment causes particular problems for the management of diabetes, which areconducive to the development of hypoglycaemia. These include the following:• an inadequate or inappropriate prison diet;• long ‘lock-up’ periods necessitated by prison routine;• solitary confinement for individual prisoners;• restrictions in the time and place of insulin administration;• the use of some insulin regimens (e.g. basal-bolus and/or injection of bedtime isophaneinsulin) are precluded by prison routine;• a long time interval between the evening meal and breakfast the following morning(sometimes over 12 hours);• no blood glucose monitoring facilities being allowed in cells;• lack of medical knowledge among most prison officers with few personnel having anymedical training.Many of these problems predispose to a risk of nocturnal hypoglycaemia, and activelydiscourage any attempt at achieving strict glycaemic control. Various measures can besuggested to try and prevent hypoglycaemia in prisoners with insulin-treated diabetes: