Case study 11: Three cases

Hypoglycaemia

• Diabetes mellitus,
• Weight loss,
• Lump in neck,
• Weight gain.

The problem is presented as descriptions of 4 cases to direct students’ thoughts to a number of major issues concerned with different presentations of diabetes in children, adults and in pregnancy and the problems of different presentations of hypoglycaemia.

• Case 1 is a pregnant 18 year old girl with diabetes whose baby has poor intra-uterine growth. Following delivery the baby develops neonatal hypoglycaemia that necessitates his transfer to a special care baby unit.
• Case 2 is a 28 year old Muslim man who has recently developed insulin-dependent diabetes. He develops hypoglycaemia whilst driving his lorry.
• Case 3 is a 62 year old man who has longstanding insulin dependent diabetes and has occasions of diabetes. He develops sudden hypoglycaemia without any warning.

Staying in work and expanding the opportunities for work are major current preoccupations for the highly vociferous and influential diabetic associations in many countries and particularly in the UK.

This may be because diabetes can be a condition present throughout many people's working lives. Maturity onset diabetes impinges on the careers of many in later life and its onset is coming earlier and earlier for future populations.

It is a matter of opinion and of some fierce debate how realistic some of the aspirations being projected onto diabetics actually are. Visit the Diabetes UK website to get a feel for the work-related campaigns they are running at the moment.

An 18-year old diabetic girl who has had a sick baby

Just now, the last thing she is thinking about is work. She may be on benefits or on maternity leave but sooner or later she will be likely to engage with the workplace. If she does go back to work, what problems does she face that are particular to a diabetic?

• Difficulties associated with maintaining breastfeeding,
• Pressures of balancing work, home, child rearing,
• Controlling her diabetes, including the pressures of the previous two points.

Do you know what duties her employer has to her in law? Do you know what limitations apply to those laws?

• The Equality Act applies (but only applies if she remains available to work),
• The Health and Safety at Work Act applies (actually the Health and Safety at Work Regulations part),
• The Equality Act requires an employer to make reasonable adjustment to work to accommodate the disability (working hours, duties, etc),
• Her work may have to be specially assessed for risks in relation to breastfeeding (e.g. chemical exposures).

If she does not attend work regularly due to her health or the employer cannot make suitable adjustments which are "reasonable", she can still lose her job. A lot of people think this is wrong. What do you think?

A 28-year old Muslim man with recent IDDM who gets hypoglycaemia

He drives a lorry for a living and this medical situation puts his job at risk. Things may be further complicated by the observance of his faith, e.g. fasting during Ramadan.

The vehicle licensing authorities (DVLA) take a constructive view in terms of helping people to go on earning their living through driving but they have to balance public risk against private disbenefit. Write down what you feel that the issues for this man should be in relation to the following questions:

• Should the rules be more stringent for a professional driver (i.e. someone who drives all day in his working time) than for someone who uses a van as "part of the job"?
• Should there be more stringent rules for a heavy goods vehicle driver (40+ tons) than for a light van driver (1-2 tons)?
• Should awareness of the illness and compliance with treatment be factors taken into account when decisions are made about returning a driving licence?
• Should he conceal his condition and just carry on driving?

Many doctors advise their patients to conceal medical conditions so that they can get or keep jobs. When things go wrong, patients sometimes blame their doctor. So far no doctor has been sued about this but it is only a matter of time. Where do you stand on this? Check your views against what the DVLA actually does and consider whether you feel the balance is right.

• Whatever vehicle you drive, you have to tell DVLA if you get IDDM and if you get hypoglycaemic attacks (hypos).
• For Large Goods Vehicles (LGV), the fitness requirements are very stringent and IDDM is a bar to driving such vehicles.
• For smaller good vehicles, the gentleman would have to demonstrate that he is able to recognise warning signs of a hypo-attack. He will be sent for assessment for his fitness to drive by the DVLA and issued with a time-limited licence (1-3 years), subject to review. Visit the DVLA website and look at the section on medical aspects of fitness to drive.

Quite often people like this man move to "alternative" duties such as vehicle shunting and loading, but many have to change their jobs altogether.

Sudden onset of "hypo" attack in long-standing IDDM

Much of what has been said in Case 2 would apply if this man worked as a driver but there are possible ramifications from this change in medical state for a range of other jobs. What sort of jobs would you think of?

This is one of those situations which, if you were managing the case as a doctor, you would have to flag up the occupational risks to your patient. Which of these jobs could be affected by the sudden onset of a "hypo" attack with risk to your patient or to others?

• Train signal operator?
• Scaffolder?
• Bricklayer?
• Lavatory attendant?
• Orthopaedic surgeon?
• Machine operator?

The answer of course is all of them. So get used to asking that key question "what job do you do" and just as important, if not more, "how does the medical situation or its treatment affect my patient's capacity to work?"

If your advice is too cautious your patient may lose his job unnecessarily; if too permissive, your patient may injure himself or others. It's often a matter of careful judgement. So don't be afraid to ask!