Last May, 24-year-old Charlie Kimball was in Car #35, taking Turn 3 at the Indianapolis Motor Speedway during the Firestone Freedom 100. He was in radio contact with his pit crew, who informed him that he had a headwind coming out of the turn and onto the 5/8 mile "straight." Charlie kept an eye on the car next to him, moving closer and beginning to crowd it on the inside. Having raced professionally for six years, he knew that he had to make a move, and soon.  He shifted into sixth gear and accelerated.

Charlie looked at the digital readouts on his steering wheel, which showed his speed to be 193.7 miles per hour. The water temperature and oil pressure indicators were normal. Then Charlie glanced at another screen mounted on the steering wheel, this one with an even more important digital readout:  his blood sugar level, transmitted from a DexCom continuous glucose monitor.

Charlie is the only professional racecar driver with type 1 diabetes. And car #35, with its 450 horsepower V8 engine and its paint emblazoned with the word "Levemir," is the first racing machine sponsored by an insulin manufacturer (Novo Nordisk). 

The glucose readout was 153, so Charlie was good to go. But in the event that his glucose became too low, he could sip orange juice through a straw in his helmet. "I've never gotten to the point where my vision and concentration have been affected," he says, quickly adding, "Whether I'm on the track or just driving in my personal car, this is all still new. Maybe I'm kind of paranoid, but I'm just very conscious about it."

It was only two years ago that Charlie was in Europe, having become the first American to win a F3 Euro series race. But he had been losing weight, couldn't concentrate, and was always thirsty. After he made a number of mistakes behind the wheel, both Charlie and his crew became concerned. He went for a physical, and the diagnosis was type 1 diabetes.  For the next six months, Charlie focused on dealing with the disease and figuring out how to keep racing cars. He was required to meet with race officials, along with a team of doctors, and make the case that he had control of the diabetes. In the end, though, he was given an OK.

On the same day that Charlie was driving in Indianapolis, a six-year-old boy was riding in the back seat as his father drove their pickup truck through downtown North Platte, Nebraska. Suddenly, he saw his dad slump over in the seat. Although they had just finished dinner at a restaurant, his father was having a low blood sugar.  The boy leaped onto his dad's lap and steered the truck until a local policeman was able to run alongside and stop the vehicle. The community later honored both the son and the police officer as "local heroes," while the father learned a scary lesson about checking his blood sugar before putting his truck into gear.

Most of us with diabetes aren't going to drive 190 miles an hour, and it is highly unlikely that our blood sugar levels are displayed on our dashboard. But like Charlie, we need to pay attention not only to changes in traffic, but also to changes in our glucose levels. When it comes to diabetes and driving, the single most important point is this: Test your blood sugar before turning on the ignition. A recent study in the Journal of the American Medical Association (August 2008) concluded that people with type 1 diabetes may have hypoglycemic unawareness, making them unable to realize when their blood sugar levels are low. If they don't test before driving, this inability to sense a low can create a very dangerous situation.

Driving and diabetes is an issue that has been studied, legislated, and debated for years. Every state's Department of Motor Vehicles has guidelines and directives for drivers with diabetes. (The ADA lists the rules for your state on its website, www.diabetes.org.)

Many states have a question like this on their license renewal forms: "Do you have a medical condition that may impact your ability to safely operate a motor vehicle?"  A lot of people with diabetes automatically mark "Yes." But according to the Diabetes Coalition of California (associated with the American Diabetes Association, or ADA), these people may have misinterpreted the question. According to the Coalition website, the DMV is not asking whether or not you have diabetes. Instead, it is asking if your diabetes affects your ability to drive safely. By answering, "Yes," you are indicating that your diabetes negatively affects your ability to drive. "Yes" would be appropriate, for example, if you experience severe episodes of hypoglycemia or have health issues related to diabetes, such as vision problems, that impair your ability to drive safely. By answering "No," you are simply declaring that diabetes does not impair your  ability to safely operate a motor vehicle because you take  preventive steps to avoid hypoglycemia. In other words, your diabetes is managed safely.

If the DMV receives a "Yes" answer from you, it may ask for a medical examination by your doctor, who must then report on whether you are able to safely operate a motor vehicle. However, Sandra Carter, a driver safety manager with the California DMV, says that a "Yes" answer isn't necessarily a "No" to driving. "Although a ‘Yes' answer to the medical condition question on the driver's license application often will result in an inquiry by the DMV Driver Safety Branch," she notes, "it will not necessarily result in an administrative action against the individual's driving privilege."

California takes diabetes and driving a step further. Consider this: Anyone brought into a California emergency room with "a disorder characterized by lapses of consciousness" must be immediately reported to the DMV, even if he was not operating a motor vehicle at the time of the incident. He may be required to provide medical and vision tests. If he has diabetes and the DMV concludes that he doesn't have adequate control of the disease, he may be put on medical probation. In some instances, his license may be revoked.

It was fortunate that no one was injured when the father in Nebraska lost consciousness. Unfortunately, however, there are still too many stories about fatalities and injuries caused by people with diabetes whose blood sugar dropped too low. When such drivers appear before a judge, it is common for the victim's family to suggest that diabetic drivers should be required to have a special license plate.

In fact, this variation on the Scarlet Letter is actually an option in Mississippi. The state offers a license plate with the words "Defeat Diabetes," intended to alert both police and emergency personnel to the presence of a driver with diabetes if the car is being operated erratically. Also available is a Mississippi driver's license with a blue star along the bottom, indicating that the driver has diabetes. The ADA, however, prefers to focus its efforts on training law enforcement officers to recognize diabetic emergencies and to know how to respond. The ADA also urges states to assess people with diabetes on an individual basis when it comes to driving privileges.

And Charlie Kimball?

Unfortunately, the driver who was alongside Charlie hit Charlie's right front wheel with his left rear wheel, sending both of them into a spin. Car #35 made it into the pit lane with a bent steering arm, but Charlie's day was done at Indy. Right now his crew is at work preparing the Levemir car for Firestone Freedom 100 competitions in Kentucky, Ohio, California, Illinois, and, finally, Florida in October. In every race, Charlie will have his glucose meter along for the ride.

Remember:

(1) Check your blood sugar before starting the engine, and keep your glucose meter nearby when driving, not in the trunk or the backseat.

(2) Always have a source of glucose within reach while driving, and be sure to have enough. Most endocrinologists suggest taking three glucose tablets at the onset of a low blood sugar, followed by more after twenty minutes if needed. Fruit juices work quickly too, but some, like orange juice, will spoil if kept in a warm car for weeks at a time. Non-diet soft drinks are also effective at increasing glucose levels.

(3) If you feel a low coming on, pull off the road.

(4) Wear a medic-alert bracelet or necklace or keep a card in your wallet or purse indicating that you have diabetes in the event you lose consciousness.

Charlie Kimball's Blog

Charlie Kimball on Twitter

California Diabetes Coalition

National Highway Traffic Safety Administration's "Driving When You have Diabetes" brochure