Several prominent dBloggers have posted this week about issues related to Driving While Low (DWL) and premature death. The subjects of these posts were people with Type 1 diabetes, which is the group with which we normally associate rapid-onset dissociative hypoglycemia. While this sort of hypoglycemia is certainly most common in Type 1 diabetes, it is occasionally seen in insulin-dependent Type 2. Most of the time, these lows would seem to be related to insulin activity peaking early or late -- or at least not in synch with one's food and drink.

Unfortunately, insulin is not always the culprit.

"EJ" was one of my mother's closest friends; they met when her daughter and I were in Girl Scouts. She was diagnosed with diabetes (Type 2 assumed) some time in the mid 1980's, and as far as I know, she was on oral medications to control her blood glucose levels. Some time before her diagnosis, EJ's husband became physically disabled and wheelchair-bound. His health issues eventually progressed to the point where she had to leave her job to become her husband's full-time caregiver.

We normally think of the hypoglycemia associated with certain classes of Type 2 oral medication as being slow-onset, of relatively small magnitude when compared with that seen in insulin-dependent diabetics (particularly those with Type 1), and not as dangerous. EJ died in 1987, before home blood glucose monitoring for Type 2 was common, and before super-fast-acting insulins like Novolog and Apidra were readily available.

We learned of EJ's death through a story in the local newspaper. The address and the family description sounded much like hers, and a call to the family to make sure everything was OK only confirmed the tragic news. Without a sophisticated forensics team, this is what we were able to piece together from her husband's account and the evidence:

EJ's routine was to take her morning medications, then to almost immediately have breakfast, which as I recall included a slice or two of bread. On the morning of her death, something happening with her husband distracted her between her medications and her breakfast. By the time she got her husband settled, we understand she began to feel dizzy and went outside on the 5th floor balcony to clear her head. Without food, the dizziness and disorientation worsened, eventually causing her to fall over the railing, to her death. I don't remember if her husband had heard her fall, or if he got frustrated when she did not come back in from the balcony after a reasonable period of time.

EJ's friends understood that she may have been clinically depressed, but to my knowledge, they did not observe any potentially-suicidal behavior; furthermore, our knowledge of EJ's character was that she would not have wanted to leave her daughter -- who lived out of state -- to deal with the quagmire of legal and logistical issues surrounding her father's care. While we did not have the forensic evidence to categorically rule out suicide, our personal understandings are that the likelihood of a planned jump was extremely slim.

Thus leaving us with the belief that it is possible for Type 2s who are not on insulin to go dangerously low, relatively quickly.

The moral of the story, if there is but one, is not to ignore anybody's self-sense of hypoglycemia, but to test, treat if required by that person's medical plan, observe that person until s/he "returns to normal" if treatment is not indicated -- or if that person is not "recovering", get him or her to a medical professional. If there is a second moral, it is not to ignore -- ever -- indications of depression, whether or not they include signs of potentially suicidal tendencies. Diabetes has its own tricky way of getting at us while we're on level ground -- no need to give it a chance to push us off the roof.