August 22, 2019 Stay safe while driving with type 1 diabetes

[00:00:10] Welcome everyone to Diabetes Canada's 2019 Type 1 webinar series. My name is Grace Leeder and I will be your host today. We are delighted that you are able to join us today for the webinar entitled "How to stay safe while driving with type 1 diabetes".

[00:00:24] I would like to welcome our first speaker Dr. Anne Kenshole and thank you for joining us today.

[00:00:29] Dr. Anne Kenshole trained in the United Kingdom and initially planned to come to Canada for just three weeks and yet 50 years later she's still here. Dr. Kenshole has a special interest in type 1 diabetes and continues to be impressed by the way people live with it so well. So without further ado I present to you Dr. Anne Kenshole.

[00:00:46] Good day. It's a pleasure to be here. This slide shows approximately 300 gravestones. That represents about the number of people who die in road accidents in Canada each month.

[00:01:05] Now 10 percent of people in Canada have diabetes. What do we know? Are people with diabetes as safe as other drivers? Conceivably safer.

[00:01:16] By a company forward can can. The answer is yes. At least 95 percent of people with diabetes are just as good on the roads as anybody else. However a small percentage, perhaps around about 5 percent, specifically of people with Type 1 are at identifiable risk of having accidents and episodes on the road. And there is a common cause for this. When somebody has frequent blood sugars below 4, which is the usually taken definition of hypoglycemia. If they go low often often often, they no longer are able to feel the typical symptoms of hypoglycemia. Another way of putting that is asymptomatic hypoglycemia. It's also called neuroglycopenia, which means the brain is affected by inadequate glucose at that time and people who experience this may have lots of sugars in the 3s and in the 2s, even in the case I'm familiar with, the patient had a blood sugar of 1.9 mmol/L when he was in the lab and the ambulance was not called. He appeared to be acting speaking and so on normally. I do not know if he drove away from the lab, but people's thermostat if you like for perceiving hypoglycemia can be set progressively lower and lower, if they have frequent hypoglycemia. Now why is this? In the normal response to hypoglycemia is the first responder of course is adrenaline. Everybody with type 1 knows what adrenaline feels like. One feels sweaty, one's pulse goes up, you can feel shaky. Some people feel hungry, some people don't. And this is the body is very finely tuned to sensing and reacting to hypoglycemia. Why does the body, perceives hypoglycemia as dangerous? Very particularly, the brain has to have adequate sugar to form to function.  Other organs in the body concerns fats, for example the brain can't. So a constant availability of sugar is vital for brain function but with repeated hypoglycemia the body sort of assumes that this must be the new norm, in that having blood sugars in the 3s or even the 2s it is okay. So it no longer responds by pouring out the adrenaline or indeed the whole cascade of other hormones which are secreted when somebody does have hypoglycemia.

[00:04:36] So why can this happen. Why can the thermostat as I call it be reset.

[00:04:44] Well that's the cause a bigger problem. Sorry. Moving onto the next slide. I just want to take you very quickly through three Ontario tragedies, which have resulted in five deaths, 2 honeymoon couple, a honeymoon couple as they left the church and one team has been permanently disabled. And I think it's very important to categorize the drivers, because they were upstanding citizens. Three middle aged professional men, responsible car drivers, excellent driving records, meticulous in their self-management of their longstanding type 1, 20, 30 years or more of type 1. Two of the patients who were on pumps and using CGM. I don't have details of the third case. What is important in the two cases I'm familiar with, both of the drivers were noticed to be either exhibiting odd behavior, speaking unusually fast or not making particularly good sense, in one case, or noted to be ar- driving erratically within a few minutes before the fatal crash. So what is the science behind neuroglycopenia. And there's a lot now in the medical literature the diabetes literature about what happens when sugar levels are too low. And I'm going to put one study which is really a seminal study in my view. This was done down in Virginia a few years ago. Thirty seven people with Type 1 diabetes in what I- read take part in this study and they were in the lab their blood sugar was kept within six to seven range steadily for an hour or two to establish equilibrium. This was done by having IV's running with glucose in another I.V. with tiny bits of insulin. So literally the blood sugar could be kept within a steady range. And then having done that, the blood sugar was lowered from- lowered from 4 to 3.4 and kept steadily again at 3.4. And at that time each of the drivers was asked how do you feel. Do you think you are hypoglycemic. Are you safe to drive. Here you are, this juice if you want it. And though some patients, some drivers felt that they were hypoglycemic at 3.4. None of them wanted juice already their brains were not functioning absolutely normally. Their judgment was off. They continued the experiment. They brought the sugar down from 3.4 to 2.8. Let it equilibriate. Again the same questions actually the clients that are diabetic patients were asked the same questions every five minutes through this study. Again how do you feel. Do you think you are hypoglycemic. You think you're safe to drive. Do you want to juice. Now, all of the 37 patients felt that they were low at 2.8. But still some of them those with really neuroglycopenia, they knew it was slightly off, but their judgment was really impaired and quite a few of them again refused to take juice though, they knew they were low.

[00:08:54] And while this experiment was going on the drivers were in the driving simulator. Here's an example of one. And I don't know if you've ever been in one, but it's remarkably like life like, you see traffic coming towards you. there are people on the sidewalk, a dog runs out into the road at some stage. The traffic lights you're required to take or do left turn- left turns right turns, whatever it's just like driving.

[00:09:26] And at the same time they were wearing a head, just like this. This isn't a portable EEG, a brain wave test. So their brainwaves would be recorded throughout this progression of hypoglycemia.

[00:09:47] And what were the outcomes. Well I touched on them before. Some felt low 3.4 but felt safe and refused juice. However their driving performance was already deteriorating. They were braking or accelerating not very smoothly. When a dog ran into the road, they took quite a long, a longer time than usual to jump on the brake.

[00:10:15] In fact is- that in other words their reflexes were slowed, and by the time they were down to 2.8, many still feeling I'm fine. I'm a good driver refusing juice. They were all over the road, weaving over the central line making left turns when they were told by a voice command to take a right turn and so on. I mean just for people you don't want to have on the 401 or anywhere, under those circumstances. And, here are the brain waves on the left, which are showing a fairly normal pattern from one individual. Well a normal pattern at the beginning. And you can see the second half of the tracing it is just again chaotic. There's massive alteration in the brain waves throughout the entire head, but particularly focused in a couple of areas, those responsible for judgment. So it's important because here is a biological underpinning of what happens when people go low and aren't able to recognize it appropriately, and what is very important after their blood sugars went back to normal, it took 45 minutes on average, for the blood- the brain waves to return to normal. And that's where in the Canadian Diabetes- Diabetes Canada guidelines it says you know treat yourself and wait 45 minutes before you turn the key in the ignition. It says that in the American guidelines, it says it in the UK guidelines. It's universal, because this information came from scientific studies that the brain does not naturally normalize for its function for 45 minutes after an significant low. There we are. So very importantly, can neuroglycopenia be reversed? And the answer is in most people. And I emphasize most people by total avoidance of hypoglycemia for anywhere from one to six months. The average length of time is about three months. And yes it means that the individual's A1C will rise, usually 1 percent or slightly less, but if that's the price you have to pay at least temporarily, to be able to drive safely for your own sake, for the sake of your family, and for the sake of other road users, it's worth the candle. So that is the most important thing to do. And because the body is now no longer being hammered by hypoglycemia it allows the normal hormonal response to start to improve, so that if everything goes well one should be able to see hypoglycemia in the way one did when one first got type 1 diabetes. The other important message I would suggest I want to offer, is consider if anybody does experiences are you over insulinized? And that is where a little bit of biology comes in. The normal pancreas and all beta cells in the lean adult i.e. not overweight, seceretes 30 to 35 units of insulin a day. That's all. So if somebody is taking 45, 50, 55 units and they are not obese, because we know that overweight and certainly obesity results in an element to the insulin resistance, including in people with type 1. But the normal weight individual, if they're taking more insulin than seems physiologically appropriate, what is that insulin doing? Well it may well be if you like stacking up in the bloodstream and one of the significant causes of quote brittle diabetes and people having lows for reasons they can't understand and I expect people listening and watching, many of you are truly very insulin sensitive. So just a difference of 2 or 3 units in a 24 hour period, to make a huge difference and report to because again I expect many people are on pumps. I hope they are. And when you started on the pump, your total daily dose was automatically cut down, because so many people are actually over insulinized and labile control, this is often due to over insulinization. And then a quick word about the A1C. The literature suggests that most events on the road including in people with diabetes, well specifically people in diabetes, is not- it does not correlate well with their A1C.

[00:15:49] Most events are kind of one offs. A meal is delayed or somebody was extra busy and therefore sugars were running lower than usual. And so on. In hindsight, and these are the things we try and analyze at the Department of Transport, when people who've had an event, when they fill in the diabetes questionnaire, we try to determine what it likely to be a one off or is this situation with this driver is really at risk of having further adverse things happen on the road.

[00:16:24] Anyhow, there's only one study so far, are looking very specifically at the A1C's and diabetic drivers. And this was in Ontario. Using Ontario data between 2003 and 2005, and that actually did show a correlation.  Here you can see people who have had an A1C equal to or less than 6.9 had a three fold likelihood of having a crash, a road event, compared with somebody with an A1C of 8 to 8.9. Now I'm not suggesting that one should be aiming for an A1C in the 8, not at all but the risk was threefold higher and twice as high, where- if the A1C was 7 to 7.9. So this is the best of my knowledge, is the only scientific data on this subject. So I'm going to leave it there and turn it back to our moderator.

[00:17:38] Thank you so much Dr. Kenshole, that was really informative, really interesting, and really good information for our participants. So now I'd like to welcome our second speaker Sergeant Murray Campbell and thank him for joining us today. And before turning it over to Murray I'd like to give you a brief introduction. So Sergeant Murray Campbell is the supervisor of traffic services for the Toronto Police. He manages a platoon of traffic investigators, accident reconstructionist drug recognition experts and breath- breathalyzer technicians to check people for impaired driving. Sergeant Campbell is the lead investigator on all serious life threatening- life threatening collisions involving death. Sergeant Campbell has been living with type 1 diabetes for 32 years. He was on a regimen of multiple daily injections for 20 years and for the last 10 years has been on an insulin pump. So without further ado I present to you Sergeant Murray Cam.

[00:18:28] Thank you very much Grace.

[00:18:30] Hello everybody. I'm going to introduce myself first of all not as Sergeant Murray Campbell but as Murray Campbell. I've been diabetic for over 32 years and driving for almost 30 of those years. Initially starting out as a type 1 diabetic, I probably went into what Dr. Kenshole described as neuroglycopenia.

[00:18:55] I was a loose control, started out as a type 1, and driving at the same time, and suffered multiple events where I would be driving and suffering from low blood sugar. Since then from going onto pump and subsequent to that, to the CGM, my control has become greatly increased. When you get a little bit older, you realize the consequences of your actions. You start to take in a little more notice of the world around you and your effect that you have on them.

[00:19:29] Additionally to being a Type 1 diabetic, I am a sergeant with Toronto police traffic services. I have a platoon like I said earlier of traffic investigators. We go out to all the collisions across the City of Toronto and to the more serious ones that involve life threatening injuries or death, I am come-. I come out and I am the supervisor in charge of the scene of those investigations. Part of what we use to conduct those investigations, like said earlier was a technical collision reconstructionists, technical collision photographers, to gather evidence of what happened. Drug recognition experts and by experts I mean that these people have been qualified in the courts as an expert to give opinion evidence for people that are impaired by drugs both legal and not legal drugs and- operating a motor vehicle. Enough a lot of other calls that we get are for impaired drivers. And now an impaired driver, by definition in the code, which I'll go over a little bit later, is somebody who's consuming drugs or alcohol to the extent that it effects their ability to operate a motor vehicle. A lot of these calls that we get are from people on the roads for their calling in to suspected impaired drivers. In some instances, it is found out later on that they're in fact not impaired drivers, not impaired by drugs or alcohol, and I mean by an illegal drug, but they are such hypoglycemic drivers. These drivers are exhibiting the same symptoms, or show exactly the same effects as an impaired driver. They become combative, argumentative. They are slurred speech, glassy eyed and people believe them to be impaired. And that's why we get calls. These people are not only impaired drivers, hypoglycemic drivers are involved in collisions. Some of them serious. Some of them fatal. And I'm going to talk about one fatal collision that happened, this was not a collision that I was involved in. This is not a collision that I investigated in many ways. But it is a collision that happened in Ontario that changed the way that we deal with people who are licensed drivers and are diabetics, both type 1 and Type 2.

[00:22:04] I have been involved in investigating a few of those crashes and I specifically do not want to talk about those ones because some of them are still going on in the courts today.

[00:22:16] So. So impaired drivers. But should diabetics be allowed to drive?

[00:22:24] Should we be allowed to drive in Ontario because we know that we pose an increased risk to everybody that's out there. Our potential for crashing and getting involved in collisions is much, much higher than everybody else. So the answer to that is yes, we should be allowed to drive we are human beings with a disease and maybe a disability. But we need to be able to drive with certain conditions, and those conditions are put on there to- for the greater good of everybody. Okay? So like this I said before, diabetes is a disease and it's been classified as a disability within Canada. We have certain rights in Canada that are guaranteed under the Charter of Human Rights. The Canadian Human Rights Act, and specifically in Ontario which should also govern driver's licenses, it is the Human Rights Code. So in summary it states that most people should be free from discrimination with a disability. When you think about that if we are considered to have a disability why are we governed differently than the rest of the people that are on the roads. Well we must understand that driving is a privilege and not a right. All right. We all across North America, Type 1 diabetics are allowed to drive with certain conditions and those certain conditions are placed upon us because of the greater good- the need for a greater good for the greater population. All right. The risks that we face is both hypoglycemia like was described earlier but also hyperglycemia, that also affects things like your eyesight and nerve endings and things like that which has change in your body's ability to- able to operate a motor vehicle correctly. Like the Charter of Rights has survived many challenges by people saying that is unjust and unfair that diabetics, other people with disabilities be treated differently. And it has been found by the courts that this is a reasonable, change for diabetics to be treated differently for this greater good.

[00:24:48] All right. So what is impaired driving? So are hypoglycemic drivers impaired drivers?

[00:24:57] So for repeat definition coming out of the criminal code is impaired driving use operating or having care and control of a conveyance while your ability to do so has been impaired by in any degree, by consuming drugs, alcohol, or combination of the two.

[00:25:14] Now can insulin be that drug? Can insulin be the cause of your impairment?

[00:25:21] Well yes, it can cause you to be impaired and be an impaired driver. But I want to put forth the caviar before I continue on there is that, being Type 1 diabetic for 32 years not once have I ever wanted to have a low blood sugar. Not once have I ever wanted to get into a car and drive with a low blood sugar. I don't enjoy being hypoglycemic and as you can well imagine that everyone else with type 1 when they're treating a low blood sugar, they overcompensate for it because they do not want to be continuing in that state. For all of the impaired drivers that I have pulled over and charged, I've done- I charge many of them. Every one of them has made a decision at some point to drink alcohol, consume a drug, and made the conscious decision to put their keys in their hand, get into their car, and operate that car.

[00:26:22] So going forward. Are impaired drivers the same as insulin impaired drivers? No. Everyone that I pulled over shows signs of glassy eyed, swaying, falling down, reduced cognitive ability, decision making ability is impaired. They're sweating. The they have slurred speech. They're anxious. They want to fight, all the same traits that are displayed, when even myself, as a hypoglycemic attack.

[00:26:53] All right.

[00:26:54] So can impaired drivers be classified the same as a drug impaired driver that is using insulin. Well the change there is the intent. Two parts to prove a charge within the courts in Canada. And one [00:27:13]is the actor swears [0.7s] which is the act of- the action of doing something that is wrong. [00:27:19]The menswear [0.1s] having the mental ability to commit the crime. For most Type 1 diabetics that I'm aware of and hypoglycemia don't ever have that mental ability that they want to get in the car and drive. So how does that affect us. Well there are some consequences of driving while our blood sugar is low. All right. There are over 30- 7300 insulin dependent diabetics reported in Ontario. And that's stats from a few years ago. So what risks do they have when they're driving a car?

[00:27:56] All right.

[00:27:58] I want you to look into one case, in specific. That case has caused an awful lot of changes in the way that insulin dependent diabetics and also Type 2 diabetics, are reported and managed within the province of Ontario. This- this is a case that shows the- how the bureaucratic nightmare of our government broke down and allowed something to happen and to continue to happen even after the event. For the case that I'm going to talk about, constant inquiries we launched in [00:28:36]2014 invited an investment [2.0s] for Ontario, Andre Martin, and he produced a study and called "Better safe than sorry".

[00:28:48] This is Andre Martin here, and this is him presenting this case "Better safe than sorry". So this case involves the 2009 Hamilton High School teacher named Allen Mackey. He was tried and convicted of three counts of dangerous driving causing death because of an event that occurred.

[00:29:09] He was charged also with three counts of criminal negligence causing death, but was not convicted of that.

[00:29:19] And the reason I have an opinion [00:29:22]on the reason he was such a victim [1.0s] of the criminal negligence but I would disagree that both these two charges kind of fit into what happened on the day.

[00:29:31] So this is the background that happened in 2009.

[00:29:39] Three people were killed that day. An 81 year old cyclist, named Tong Vi Duong, a 27 year old newlywed, Hannah Gordon-Roche, a 29 year old newlywed, her husband Jeffrey Roche. All right. The- it all started on the last day of school for high school teacher, Alan Mackey, who is a 40 year old type 1 diabetic. And he was treating his diabetes with multiple daily injections of insulin. He was cleaning up this classroom for his last day, he was very excited to leave, had an awful lot on his mind wanted to get started in the summer vacation and tested before he left the school and found that he was low. He didn't say that he was overly low, but low enough that he had a snack to treat his- his low blood sugar, which he had done many times. He unfortunately didn't wait and retest, like Dr. Kenshole has described is a must that we do. But instead he packed up his car and headed out. He made his way towards the bank, and Hamilton Police at that time had received phone calls about the suspected impaired driver and was driving erratically on the roads.

[00:31:01] That driver was Alan Mackey at the time.

[00:31:04] So after- during his banking and talking with some of the bank tellers at the bank, it was noted that he was acting weird, he was not himself. He was- he was a little bit lethargic. His answers to questions were not what would be normally expected of him, but he continued on not knowing that his blood sugar was low.

[00:31:27] At some point through his driving, he came across a cyclist that was cycling down the road and that was 81 year old Tong Vi Duong. He actually struck Mr. Vi Duong and killed him, instantly at the side of the road there. Mr. Mackey didn't remain, did not stop his car, but continued on driving from there, and became involved in a second collision, where he ran into the back of a very small car that contained both Mr. and Mrs. Roche. That collision caused their car to spin out and come in contact with a fast moving oncoming pickup truck. As a result, both the occupants of the car were killed. At that point because this car was no longer able to be operated, Mr. Mackey stopped driving.

[00:32:20] As you can imagine, the scene must have been quite chaotic. Two separate scenes, with three dead people and injured person in the pick-up truck as well, and possibly an injured Mr. Mackey. Happy arrival of ambulance and fire and police. Obviously the most serious injured were treated first. And Mr. Mackey was subsequently treated a short time later.

[00:32:47] Ambulance services at that point found that his blood sugar was extremely low at that time, and treated him for his low blood sugar. When his blood sugar came up again and two questions to Hamilton Police, Mr. Mackey have no idea what he had done. He was not aware of the collision. He can see the carnage around him, but had no idea that he was involved, other than he was slightly injured from the collision, in his car. So I ask you, whose fault was it. Was it Mr. Mackey's, who did not make the decision to have diabetes, being susceptible to hypoglycemia? Was it the other people that were on the road that day? No I think we can pretty much all come to the sense- consensus that Mr. Mackey was the person who caused all these collisions. Now remember, Mr. Mackey did not make the decision to drive when his blood sugar was low. He was not aware that he was doing it. What Mr. Mack did was not spend the time after he realized he was low to wait the time to see if his blood sugar had come up. Mr. Mackey was charged with six counts of criminal code offenses. The first one was deemed dangerous operation of a motor vehicle. So this was recycled change from what was in the criminal code last year, and then close not just a motor vehicle but it also includes a conveyance which can be anything used to move people safely including things like a canoe. So if you read the section for dangerous operation with a criminal code, it's everybody who commits an offense, operates a conveyance in a manner that having regard to all the circumstances, is dangerous to the public. Now Mr. Mackey did operate his motor vehicle. It was dangerous to the public, given the entire set of circumstances Mr. Mackey had an obligation to check his blood sugar before he started driving in the manner that he did. There are two subsections that are listed up there under the Criminal Code for the outcome of any crashes that occurred because of a dangerous operation, including causing death that he was charged with. Additionally to the charge of dangerous operation Mr. Mackey was charged with criminal negligence causing death times three. Now criminal negligence under Section 2 19 of the Criminal Code states that everybody is criminally negligent in doing anything or by omitting to do anything that is their duty to do [00:35:43]chores at once on a [1.0s] reckless disregard for the lives the safety of other persons. Now Mr. Mackey at that time did show, in my opinion, a want and reckless disregard for the safety of others because he knew that he should have been checking his blood sugar before he operator the motor vehicle. He knew that his blood sugar was low and he waited- he did not wait before he started operating his motor vehicle at the time. Now of note there, if you read Section 220 of the Criminal Code, the consequence of getting convicted of criminal negligence causing death can be up to life imprisonment, which is quite quite serious. So both of these sections fit the circumstances that Mr. Mackey was involved in but the court only convicted of the dangerous driving and I believe that's probably because of the [00:36:37]law Assembly [0.3s] that's involved with a dangerous driving causing death, as opposed to the criminal negligence causing death. So the reason the Andre Martin conducted an inquiry in this because not only was a tragic that the deaths occurred, but at that time, the Minister of Transportation had not removed his- Mr. Mackey's driver's license even after this event occurred. He continued to drive for another 18 months after this event going through the criminal process, driving to the courthouse every day by himself, which absolutely upset the general public to see that he continued to drive even after he killed three people. Now we've had reporting of medical conditions in Ontario to the- supporting the reporting by physicians since 1968. But for some reason, this one got caught up in the bureaucratic red tape and Mr. Mackey's driver's license remains in effect through this period of time. This is what caused the inquiries that happened. And as a result 18 recommendations were made for changes to the way that the Ministry of Transportation issues or suspends driver's licenses of people with Type 1 diabetes. So this is a fact sheet that was put out by the Ministry of Transportation, it shows exactly the increased scrutiny that Type 1 diabetics face. Both type 1 and Type 2 diabetics face an increased risk, but Type 1 diabetics especially the ones using insulin, are now required to self report and are required to have an assessment done by a physician or a nurse practitioner and submit that- to the Ministry of Transportation. The Ministry Transportation will conduct background checks, driving history, and collision history to determine if this person is a suitable candidate to be allowed to drive in Ontario. As you can see here on this slide, commercial drivers, people drive driving buses and big rigs that have a greater risk of harm to the public, face a higher scrutiny. The more stringent medical examinations happens more often and the reporting of it needs to continue at a higher rate than the regular class two driver's licenses. It also makes it mandatory for everybody when renewing their driver's license to make the declaration that they are insulin dependent and diabetic. If you guys have seen  recently on your driver's license that is a requirement. When I was first licensed, no one ever knew I was a diabetic, up until probably about 2014 when this requirement came into effect. The Ministry had no idea that I was a type 1 diabetic taking insulin and because of better control that I was having my doctor had no reason to report that to the Ministry. So I'm going to ask you whose obligation it is, to drive safe. Well obviously it ours, but it goes beyond that as well. Ministry of Transportation has an obligation to keep the general public safe. They need to prohibit the high risk drivers from driving on the roof. They do that already for people suffering from epilepsy or people that have hind eyesight problems that cannot meet a certain level, they prohibit them from driving because of this, this inquiry is more evident of the need to do that for drivers suffering from very bad control or lose control of the type 1 diabetes. Secondly it's physician's responsibility. They are the ones that need to identify those people that are at higher risk when driving on the roads. They have been doing this since 1968. But the obligation became theirs, where they could be charged for failing to report this to the Ministry. All right. Some of the things that they are required to report are type 1, type 2 type diabetics, people with the loss of vision, people that have a substance dependency on both drugs and alcohol. They are required to report to the Ministry of Transportation, people like I said before it was epilepsy once again they are required, by law, to report to the Ministry for an assessment to be done. But most importantly, whose obligation is it? It's yours. It really is yours. It sure is- you need to make that decision every day. You need to- when you get into the car, I make it a habit that I check my blood sugar before I drive. Every single time. All right. One way to do that is through fingerprick, and check on your blood sugar meter or by using a CGM, that would be able to tell you whether you're trending up, trending down. You need to know this information before you drive. It is recommended that you get your blood sugar for every four hours. I on the other hand, being a person who can operate a motor vehicle for 10 hours a day, at work. I also spend some time commuting back and forth to work, so my day of driving has the potential to be over twelve hours long. And because of that, I make a decision that at the minimum I'm checking my blood sugar at least every 2 hours. That's to keep them safe well and operating as a police officer but to keep me safe while I'm driving. We need to obviously report our hypoglycemic unawareness to our doctors. Like the Dr. Kenshole had to explain, this is not a prominent effect and that neuroglycopenia can be reversed and with your doctor's help, it can come back to normal, so that we are better citizens and better safer drivers. One of the biggest things you can do is keep a fasting acting carb in your car. I keep a bottle of dex tablets in my car. I usually have one in my pocket. I usually have one in my bag that I carry back and forth to work but keep it there just in case you need it. The worst time to find out you don't have anything with you to treat it, is when you're in your car and confused and away from home. This is a slide that I saw from my diabetes education centre- Charles H. Best- Charles Best Diabetes Center in Whitby. This is put up on my door as I entered into the Diabetes Center for everyone to see and it is a great use- graphic to show drivers what they should do when they're facing hypoglycemia. This it's like it was the right from the information that was provided by the Diabetes Canada 2018 Clinical Practice Guidelines, which I was honoured to actually have a part in. I was on a panel giving recommendations of what should have been given to diabetics through their physicians. As you can see the n- five and drive your green and good to go. So check your blood sugar and make sure it's above five but also make sure which way you're trending, if you're trending up and trending down, you may need to make actions before you're driving. If your blood sugar is between four to five it is recommended that you have at least 15 grams of carb and before your driving but to wait to make sure that the 15 grams of carb is going to affect you in a positive way. If Mr. Mackey had done, that he wouldn't be in the situation that he found himself in where three other people have died. It shows here to stop the red slide there, not to drive when your blood sugar is below 4. My suggestion to you is take the keys out. We all know that we make bad decision making, a bad decision making ability when a blood sugar is low and our cognitive ability to make good decisions is impaired. So take the keys out. Don't even think about putting them in. Take the 15 grams of carbs and wait at least 15 minutes to test. If it has not corrected itself, repeat it until you come above five. And as Dr. Kenshole had described before, the biggest thing is to wait afterwards. My personal opinion is after him having the 15 grams of carb my blood sugars come up, I have an additional carb including a protein a long acting protein and I wait at least 40 minutes before I start driving.

[00:45:52] That is the end of my presentation of the [00:45:54]first cause some [1.2s] thought to be in people's minds when they're driving. There are consequences to our actions and we are the owners of our actions and we have to make the best decisions possible before we put ourselves or others at risk.

[00:46:14] Thank you very much.

[00:46:16] Thank you so much Sergeant Campbell. That was really informative really helpful and lots of great information in there. So we'll move on to- we do have a little bit of time for questions. So just know that for any questions that we're unable to answer today, please send us an email at webinars@diabetes.ca, and we'll get back to you as soon as possible. So the first question I have and it's related- that we have is I think Sergeant Campbell if you can answer. So we talked- you talked in the example about someone testing their blood sugar before they drive and their blood sugar being low, and then getting an accident. Is someone just as legally responsible if they check their blood sugar and they are above five and then say have no symp- like no symptoms and get into an accident and because their blood sugar was low but they tested above five before they started driving.

[00:47:05] So in today's- today's society we are all liable for everything and all the actions we take. And the example that I gave with- with Mr. Mackey it was nobody else's fault other than his that he operated a motor vehicle and killed three people. You will be held responsible for that both civilly and- and criminally. The best way to do it is to prevent it. I try to have the best control that I can have now when I'm operating. That doesn't mean I don't have blood sugars, but it's what actions do I take to ensure that it doesn't happen. The best way to do that is quite frankly by wearing a CGM and being aware of what is going on with your body. You know your body the best out of anybody and you have to ensure that your blood sugar remains in a safe level while you're operating a car. If you can't do that. My best suggestion to you would be do not operate it until you can make it safe.

[00:48:05] Thank you. Dr. Kensole, we had a question about. Are there things that would impair your driving from high blood sugar. Would your judgment be impaired from high blood sugar.

[00:48:21] Well it's a good and somewhat controversial question. If it was a very small study done in the early 90s, which wouldn't meet current day's scientific rigor which showed not using the simulator, I think it was mental arithmetic that people was slowed up a bit. If they had an A1C of twelve and were running which means you're running blood sugars up in the high teens and 20s the whole time. So I'm not sure. Ideally managed patient and the this study they came to the conclusion that sustained high blood sugars are not good for the brain which may be quite true but whether one could link an occasional high which we know can happen for whatever reason people can bounce up into the teens and 20s whether that actually affects driving performance at that time it's unlikely. It's never been tested scientifically.

[00:49:29] Thank you. So Sergeant Campbell could you maybe, what are some advice you have obviously if you're having a low blood sugar your judgment is impaired. So what are some things that you yourself might do in order to make sure that you're able to make good decisions or what can someone who's maybe supporting someone living with diabetes do to help them when they might be having a low blood sugar or when their judgment might be impaired.

[00:49:58] Well my recommendation is to make it a habit that you check your blood sugar before you get into the car. I keep it- I keep a tester in my glove compartment and I use it every time before I get into the car and start driving. That is a habit that is done routinely by me. So when if my blood sugar was to be a little bit lower, it wouldn't be out of the ordinary for me to put my meter out and check myself. If I'm unaware that I'm going low, that may be the- my only ability to know that my blood sugar is going low. Like I said keeping carbohydrates in your car readily accessible and pulling over right away, stopping your driving and- and treating yourself or having others treat- treat you maybe- maybe your option. The alternative to that could be dire consequences. When you're driving for long periods of time, like sometimes I do, make it a habit, set a reminder on your watch, set a reminder on your phone. If you have to, to stop to- to know it may maybe the top of the hour, every hour that you want to check your blood sugar and make sure that you're still- in the right frame of mind and the right physical ability to operate a motor vehicle safely. Anything else that you can do to keep yourself safe while on the roadways is totally up to you. Better blood sugar control, better hypoglycemic awareness will always make you a better safer driver.

[00:51:39] That's great. Thank you so, I think we just have time for one last question and this question, it's about CGM so continuous glucose monitor so I just want to preface by saying that I know in the presentation, we talked about that CGMs are a really great tool. Unfortunately there isn't a lot of health care coverage, like public coverage for the CGM and Diabetes Canada is advocating for those- the CGM to be covered more or more availably in each province. But the question related to a CGM is because the CGM is often used a smartphone as a transmitter, are there any issues related to distracted driving and using a CGM Sergeant Campbell?

[00:52:18] So distracted driving, is anybody using or holding a handheld communication [00:52:26]device. Is the last thing in Ontario. [1.6s] There errors- there are some exceptions to it. You see drivers driving around with a thumb physical mounted to their car because it's basically continuously on. They're not allowed to actually use their phone while operating a vehicle on a roadway but the display screen can be available to them to see if you're using that as your way to see which way your blood sugar is going. That may be an option to you. Other than that, if you're operating a motor vehicle and you are using the CGM it's communicating with your smartphone. Aren't you pumped for that matter. That's rule of thumb for- to avoid distracted driving would be to pull over the side of the road, put your vehicle in park and use your phone. That's right. That is one of the exceptions in Ontario that you are allowed to use- use your handheld communication device while operating car, it has to be off the roadway and it has to be in park or not starting to be able to be put into motion. It is one of the options that I'm considering doing. Coming up is even having one of those mounted in my police car. Well if I may be able to use my cell phone to keep an eye on my- my blood sugars not only through my- my pump but through my phone as well.

[00:53:56] Thank you. That's great. So that concludes our webinar for today and I'd like to sincerely thank Dr. Kenshole and Sergeant Campbell for speaking on behalf of Diabetes Canada. It's been a wonderful learning experience.