Is a Driver Healthy
Enough to Drive?
What You and Your Insured Companies
Need To Know & Do
To Reduce Your Risk Exposure
(and prevent a human tragedy)
March 22, 2012 | Janet E. Ploss, MD
Outline of Presentation
The Causes of Bus Crashes, especially driver-related causes
Sleep Apnea
The FMCSA’s Rules and Guidelines
CDME
Other Rules
What is on the horizon?
A National Registry of Certified Medical Examiners
What You Can Do to Decrease Your Risk of a Driver Health Problem
Causing a Bus Crash
What Causes Bus Crashes?
In a 2009 Study of 40 Buses involved in crashes with fatalities
* In 19 the critical reason was assigned to the bus
* In 15 of these, the critical reason was the driver-related
inadequate surveillance
6
inattention
4
following too close
2
other
3
Health Problems Among the 40 Drivers
* Prescription drug use
8
* Driver had vision problems
6
* Inattention/distraction
5
* Hearing Problems
2
What About Sleepiness & Fatigue?
• Risk Factors for Sleepiness & Fatigue Causing Crashes:
• Youth
• Shift work
• Alcohol & Drug Use
• Over-the Counter and Prescription Medications
Characteristics of Sleep-Related
Crashes
•Often associated with morbidity and mortality
•Tend to occur after midnight and in the midafternoon
•Typically involve a single vehicle leaving the roadway
•Occur more often on high-speed roads
•Sleepy drivers are like likely to take evasive action to prevent a crash
•Sleepy drivers are us
Reducing Sleep-Related Crashes
1. Carriers & Drivers following Hours of Services Regulations
2. Using Medical Providers for the CDME who understand and follow
the Guidelines on Sleep Apnea & Prescription Drug Use
Obstructive Sleep Apnea
Normal Nasal & Oral Pharynx
Obstructive Sleep Apnea
Risk Factors for Sleep Apnea
Male gender
Being overweight
Being over the age of forty
Having a large neck size (17 inches or greater in men and 16
inches or greater in women)
Having large tonsils, a large tongue, or a small jaw bone
Having a family history of sleep apnea
Gastroesophageal reflux, or GERD
Nasal obstruction due to a deviated septum, allergies, or sinus
problems
BMI Chart for Men
Epworth Sleepiness Scale
The Epworth Sleepiness Scale is used to determine the level of
daytime sleepiness.
Use the following scale to choose the most appropriate number
for each situation:
0 = would never doze or sleep.
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping
Situation Chance of Dozing or Sleeping:
Sitting and reading ____
Watching TV ____
Sitting inactive in a public place ____
Being a passenger in a motor vehicle for an hour or more ____
Lying down in the afternoon ____
Sitting and talking to someone ____
Sitting quietly after lunch (no alcohol) ____
Stopped for a few minutes in traffic
While driving ____
Total score (add the scores up)
(This is your Epworth score) ____
Epworth Sleep Scale
Scoring
≥ 10: Sleepy, should be evaluated
for possible sleep disorder
≥ 18: Very Sleepy, definitely should
be evaluated by a sleep specialist
Drivers Who Can Be Given a 3 month
Certification Pending Further Study
1. History is Suggestive (snoring, excessive day-time sleepiness,
witnessed episodes of stopping breathing)
2. Two or more of the following:
a.
BMI greater than or equal to 35
b.
Neck circumference greater than 17” in men and 16” in women
c.
Hypertension (new, uncontrolled, or requiring 2 or more meds)
3. Epworth Sleep Score greater than 10
4. Previously Diagnosed Sleep Disorder
5. AHI 5 to 30, without any other factors
Drivers Who Should Be Taken Out of
Service Immediately
1. Observed or Confessed Unexplained Excessive Day-time
Sleepiness
2. MVA likely related to sleep disturbance, unless evaluated for sleep
disorder in the interim
3. Epworth Sleep Score greater than 16
4. Previously Diagnosed Sleep Disorder and
a. Non-compliant
b. No recent follow-up
c. Surgery without follow-up
5. AHI greater than 30
Consequences of Untreated Sleep
Apnea
High blood pressure
Stroke
Heart failure, irregular heart beats, and heart attacks
Diabetes
Depression
Worsening of ADHD
Motor Vehicle Crashes
Federal Motor Carrier Safety
Administration (FMCSA)
&
Commercial Driver Medical Exam (CDME)
The Federal Motor Carrier Safety
Administration (FMCSA)
• Established within the Department of Transportation on January 1,
2000, pursuant to the Motor Carrier Safety Improvement Act of 1999
(49 U.S.C. 113). Formerly a part of the Federal Highway
Administration, the Federal Motor Carrier Safety Administration's
primary mission is to prevent commercial motor vehicle-related fatalities
and injuries.
The mission of the FMCSA’s Office of Medical Programs is to promote
the safety of America's roadways through the promulgation and
implementation of medical regulations, guidelines and policies that
ensure commercial motor vehicle drivers engaged in interstate
commerce are physically qualified to do so.
Vision Statement - All bus and truck drivers are healthy, safe and
medically fit to drive. Everyone - drivers, medical examiners, bus and
truck companies and the public - understands and values the
importance of driver health and wellness, and our safety regulations,
policies and programs.
The Commercial Driver Medical
Evaluation (CDME)
• Long before the FMCSA, there was in 1939 the first criteria for
commercial drivers:
• “Good physical and mental health; good eyesight; adequate
hearing; no addiction to narcotic drugs; and no excessive use
of alcoholic beverages or liquors”
• 1992 Amendment allowed providers other than physicians to perform
CDMEs, including physicians assistants, ARNPs and some
chiropractors
• Medical Examiners Use a standard form in use since 2003
• 2005 Legislation mandated the establishment of a National Registry of
Certified Medical Examiners (its implementation is imminent and we will
be teaching a course required for those who wish to be certified)
Who has to have a CDME?
A CDME is required if a driver is driving a commercial motor vehicle
over 10,001 lbs or is carrying 16 or more people (driver plus 15 or
more passengers).
Rules vs. Guidelines
• Rules or non-discretionary standards exist for certain conditions
• Waiver programs exist defining the requirements for making exceptions
to certain rules
• For many conditions panels of experts have weighed in and made
recommendations upon with guidelines are based
• Both the rules and the guidelines are included in the bible for
examiners: The DOT Medical Examination, Fifth Edition
• The author, Natalie Hartenbaum, MD, MPH is the acknowledged
leading expert in the field and is the past president of the American
College of Occupational and Environmental Medicine
Absolute Disqualifying Conditions
1. Vision: Worse than 20/40 with or without correction in each eye;
Peripheral vision less than 70 degrees in horizontal field; Inability
to distinguish red, green and yellow; monocular vision (exception:
state waiver provided)
2. Hearing: Forced whisper test less than five feet with or without a
hearing aid
3. Diabetes: requiring insulin (exception: patient has state waiver)
4. Epilepsy: Established history or clinical diagnosis; and taking antiseizure medication
5. Hypertension: BP at or above 180/110
6. Opioids: methadone
Relative Disqualifying Conditions
1. Hypertension: At or above 160/100; 3 month card, send back to
PCP to get BP 140/90 or better; certify annually
2. Cardiovascular Disease: Various cardiac conditions. Cardiac
bypass surgery and pacemakers are not disqualifying, but they
must have a normal EKG and pass a stress test, not be on meds
that would interfere with driving and be cleared by a cardiologist;
certify annually. An implanted defibrillator is disqualifying.
3. Limb impairment: loss of a foot, leg, hand or arm is disqualifying
unless the driver provides a Skill Performance Certificate to the
examiner; certify biannually
4. Any musculoskeletal condition which could interfere with the ability
to control and safely operate a motor vehicle; certify annually
Relative Disqualifying Conditions
5. Mental Disorders likely to interfere with the safe operation of a
commercial motor vehicle. Most psychoses are disqualifying. If
stable on medications and cleared by a mental health
professional, certify annually
6. Automatic disqualification for certain neurological disorders.
Seizure disorder disqualifying, but if only one seizure, must be
clear for five years. If history of seizure disorder, must be off meds
without any seizure for 10 years.
7. Newly diagnosed diabetes not on insulin: 6 month card and
monitored by PCP, then certify annually; must have evidence of
being under control and understanding their disease
Relative Disqualifying Conditions
8. Substance Abuse Disorders
a.
Any use of Schedule 1 drugs (drugs that have no purposeful
medical use) is prohibited when driving a commercial motor
vehicle. A present this includes marijuana, medical marijuana
laws notwithstanding.
b.
Use of opioids, amphetamines, benzodiazepines, or any other
habit-forming drug requires that the medication is prescribed by a
physician who knows the patient and his or her job duties and who
provides a written statement that the prescribed drug will not
interfere with the driver’s ability to safely operate a motor vehicle.
c.
A current diagnosis of alcoholism is disqualifying. If cleared by a
specialist, certify annually
8. Respiratory Dysfunction: Any respiratory disease that would be
detrimental to safe driving. If a driver has such a disease, he or she
must undergo lung function testing, be cleared by a pulmonary
specialist and certified annually. Supplemental oxygen is disqualifying.
Other Rules You Should Know About
• As January 30, 2012, drivers have to go to the state agency which
issues their CDL and self-certify that they are either an intrastate or an
interstate driver. This has to be done by January 2014. Then interstate
drivers will have to have their medical certification scanned into the
CDL system, but intrastate drivers will not.
What you can do to lessen the risk of
driver-related bus crashes
1. Pick Occupational Health providers who are familiar with the rules
and guidelines
2. Pay the cost of the CDME for those drivers who go to qualified
medical providers
3. Have the driver sign a release of medical information so that the
provider can let you know whether the driver passed, for what
period of time and with what conditions
4. Have the medical provider notify you whenever a time-limited card
is issued or a waiver is required
5. If the drivers have union representation, let the union know the
negative consequences of having primary care providers do the
CDME
Key Resources for the CDME
Federal Motor Carrier Safety Administration
(http://www.fmcsa.dot.gov/)
Medical examiner handbook
(http://nrcme.fmcsa.dot.gov/MEhandbook.htm)
Medical expert panel reports
(http://www.mrb.fmcsa.dot.gov/reports.htm)
Medical frequently asked questions
(http://www.fmcsa.dot.gov/rulesregulations/topics/medical/faq.asp)
Medical programs (http://www.fmcsa.dot.gov/rulesregulations/topics/medical/medical.htm)
Key Resources for the CDME
Medical reports (http://www.fmcsa.dot.gov/factsresearch/research-technology/publications/medreports.htm)
Medical review board (http://www.mrb.fmcsa.dot.gov/)
National Registry of Certified Medical Examiners
(http://www.nrcme.fmcsa.dot.gov./index.aspx)
Rules and regulations (http://www.fmcsa.dot.gov/rulesregulations/rules-regulations.htm)
Hartenbaum NP, ed. The DOT Medical Examination: A Guide to
Commercial Drivers' Medical Certification. 4th ed. Beverly Farms,
Mass.: OEM Press; 2008.
We at Group Health
Occupational Health are here
to help you and your bus
companies with the CDME and
related health issues.