The medical community’s responsibility to make the highways safe is not something that automatically comes to mind, but the U.S. Depart-ment of Transportation (DOT) cites some glaring examples of medical failures that have led to major tragedies.
In May 1999, a commercial bus accident in New Orleans took the lives of 22 and injured 22. The driver was being treated for decompensating congestive heart failure and kidney failure. His physicians knew he was a bus driver, but did not make the connection between his medical condition and public safety.
In October 1999, a 79-year-old diabetic with CHF and on Coumadin was driving a school bus in New York and had an accident that led to injuries in 35 passengers. In this case, the bus driver sidestepped his primary care provider and went to a different doctor for medical certification to drive the bus. He didn’t mention his diseases or list any of the medications he was taking. The examining doctor simply assumed he was reasonably healthy, albeit elderly.
Here in Texas, an accident in Feb-ruary 2003 killed five and injured nine. The official cause of the accident was deemed weather-related, but the fact that the driver weighed more than 400 pounds was certainly mentioned in the report.
Sleep apnea is said to have been the major cause of an accident occurring in October 2003, with eight killed and six injured. The driver was on seven medications and 14 herbal supplements.
Though not exactly a medical finding--a commercial bus driver had an accident in June 2002, killing five and injuring 47. It turned out the driver had slept for only four of the preceding 48 hours. Most of his official rest time had been spent in a casino.
DOT supervises the Federal Motor Carrier Safety Administration, which determines physical qualification standards for commercial motor vehicle drivers. The FMCSA also provides standards for physicians to use in deciding certification. Commercial drivers must have a medical certificate to drive in interstate commerce if the vehicle:
• Has a gross weight >10,001 pounds
• Is a vehicle used to transport >8
passengers (including the driver)
for compensation
• Is a vehicle designed or used to transport >15 passengers (including driver) and not used for compensation
• Is used for the transport of placarded hazardous material
A certain amount of professional judgment is permitted, but physicians are expected to err on the side of safety. The standards are as follows:
• Vision must be 20/40 or better in each eye and both eyes together
• Systolic blood pressure must be <140 Diastolic BP must be <90
• When the blood pressure exceed these numbers, additional rules apply and are listed on the physical exam form
• A driver on blood pressure medication can have a medical certificate valid for only one year (the maximum for a healthy driver is two years)
• A driver may not use insulin
• Diabetes controlled with diet or
oral meds is passable but it must
be “controlled”
• Uncontrolled sleep apnea is not passable. If it was corrected with surgery, there has to be documentation that it remains effective. If the driver uses CPAP there has to be documentation of effectiveness and compliance
• History of symptomatic coronary artery disease (angina, stint placement, MI or CABG) essentially requires an exercise tolerance test at least every two years (five years after CABG and annually for ETT)
• Bruce protocol ETT is the preferred (rather than chemical stress test) be-cause METS needs to be measured and must be >6. The driver should also have an ejection fraction >40 percent
• An applicant with a history of epilepsy (two or more seizures) is permanently disqualified. A person must be seizure free for at least 10 years and on no anti-seizure medicines. A history of a single, unprovoked seizure requires at least five years off medication with no further seizure, and a provoked (brain injury related) seizure requires at least a two year, seizure-free interval — off medications
• There are many factors to consider with mental illness, including stability, medications and their side effects
In the evaluation of a commercial driver, the physician must first and always consider the public’s safety.
Additional information may be ob-tained from the Concentra Guide to Medical Certication of Commercial Drivers by Ellison Wittels MD, COHRI Press or The DOT Medical Examina-tion by Natalie Hartenbaum MD, OEM Press. |
