Every type 1 fears having a hypoglycemic event.  Because people are usually more accustomed to dealing with highs, however, a sudden low often catches them unaware. Use this fictional yet typical story to find out what might happen medically during a low and what you need to know to keep hypoglycemia in check.

Joe, our fictional person with type 1 diabetes, uses multiple daily injections of insulin. Dr. Christopher Saudek, MD, our physician, is Director of the Johns Hopkins Diabetes Center in Baltimore and president of the American Diabetes Association from 2001 to 2002. He's also a former medical consultant to the ABC News Diabetes Project. Carl Lindgren, an Arlington County, Virginia, Fire/EMS Battalion Chief, ensures that the paramedics under his command are trained to handle emergency calls to offices, residences, and heavily secured U.S. government buildings around Washington D.C. He averages at least one diabetic call every day. 

Joe is driving home from work, making the turn onto the Interstate that is going to take him home. He's had a busy day and he's tired, and he notices that sweat is showing through his shirt. No big deal, he thinks, it's to be expected. After all, it's summer in Washington, D.C. 

Dr. Saudek: Sweating is one of the symptoms that develops during a hypoglycemic event. Our body has a "fight or flight" reaction when it senses that blood glucose is low. Adrenaline increases, and the heart may beat faster. The amazing thing is each person may have his or her own first symptom. Knowing what your own first symptom is can be tremendously important. The brain needs glucose to function. The whole trick in treating hypoglycemia is to catch it before your thinking process is too confused to know what is going on. 

Just a few minutes into his drive, Joe has trouble seeing the lane markings on the road. In fact, his vision seems to be closing in; he can see only the scene directly in front of him-anything to the side, such as other cars, he can't see. The radio is on, but he's not following any of the words. He is having trouble concentrating. His shirt is drenched in sweat, so he reaches to turn the air conditioner on-but he can't find the button to do it.  

Dr. Saudek: Some people experience vision problems early on.  There's nothing wrong with their eyes, however. It's their brain's interpretative ability that's beginning to fail because it is becoming starved for glucose.

Joe hears horns honking, and he responds by yelling at the other drivers to calm down. He doesn't recognize anything familiar, and he starts to wonder if he's made a wrong turn. He thinks that the traffic is going in the wrong direction. 

Dr. Saudek: The body is starting to move from the "fight or flight" reaction to a lack of cognitive ability. The heart rate is dropping, and the adrenaline isn't as evident. In some people, speech will begin to slur. Now we are seeing a change in mental status. It is a dangerous situation. Joe may also be experiencing hypoglycemic unawareness, a condition in which one loses the usual symptoms of a low blood sugar. This often happens to people who have had diabetes for a long time, 10 to 20 years or more. Because the first symptom of being low is confusion, it is very hard to treat. Here's a trick that you can use to check your mental status: Repeat your social security number in your mind. If it doesn't come easily, immediately think that you may be low.  

Joe's driving prompts numerous cell phone calls from other drivers reporting a "drunk on the road." A nearby state trooper pulls up behind Joe with lights and siren blaring. Joe stops, but is unaware of what is occurring. The trooper sees the diabetes bracelet on Joe's wrist and calls paramedics because Joe isn't responding to simple questions. He does a breathalyzer test while waiting. It's negative.  

Carl Lindgren, EMS Battalion Chief: One of the important things I tell my crew is that while we are treating a person as a medical patient, we've also got to treat him as a human being. We follow a protocol-check that the patient can breathe by listening for clear breath sounds, then look at their vital signs. People with a low blood sugar usually have beads of sweat on their body, and they may be confused or appear intoxicated. Every time we talk to a patient, we ask a series of questions, called "the gold standard," to determine level of consciousness: what's your name, what day is it, and what's your location? Sometimes we ask a backup question of "who's the president?" for people who seem somewhat oriented but can't remember the day of the week. (In 2000, when the Supreme Court was deciding who won the election between Al Gore and George W. Bush, we asked that question and the patient said, "I don't know." We were getting ready to take him to the hospital when we realized that he was absolutely correct!) 

Dr. Saudek: Because patients with low blood sugar are often mistaken for drunk, it should be routine procedure in emergency rooms to check blood sugar levels when an "intoxicated" person is brought in. If the person is low instead of drunk, an infusion of glucose will provide an immediate cure. It's very unusual to die from hypoglycemia because it's very treatable and the cause (usually too much insulin) wears off over time. It's rare but possible that if the person is unconscious, however, an irregular heartbeat or a seizure can occur that is life-threatening. 

Carl Lindgren: Once we determine that the patient is suffering from low blood sugar, the first thing we do is try to administer some glucose gel in the mouth. If the patient is not able to swallow, we use an IV with D-50 dextrose and push 25 grams (about 50 cc's of fluid) into a vein in the arm. This works fast, and the patient usually goes from a combative "you are all jerks" to "I'm so embarrassed and I want to thank you" in a matter of two minutes. It's great stuff.

Dr. Sauter:  Glucose gel or tablets can be used only if the patient is able to swallow, and they take time to be absorbed. A simple infusion of dextrose (sugar) to treat severe hypoglycemia looks like a true medical miracle. It's given in the vein because that is a "short cut" to the brain. It is just remarkable how quickly the brain responds when glucose is administered this way. But the important thing to do, before Joe goes home, is to figure out why he had this severe hypoglycemic reaction. The chances are, it isn't Joe's first time with non-severe hypoglycemia, that is, hypoglycemia that did not require outside intervention to treat. This time, however, he wasn't able to detect the warning signs, and it developed into a very dangerous and very scary event for all concerned. In the future, both Joe and his family members should be aware of what happens when his blood sugar drops and be able to treat it quickly. 

Joe refuses to go to the hospital with the paramedics (50 percent of patients make the same decision) and signs a release form after proving to the EMT squad that he is aware of his surroundings. He turns on the radio and realizes that it's been almost 90 minutes since he left his office. He's embarrassed and angry that the situation got away from him. He looks at the eight-ounce can of Coke in the door panel that is kept there for this very situation, and he wishes that he had been able to understand what was occurring and drink the Coke. From now on, he promises himself, he'll test his blood sugar every time before he starts his car.