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What is the mission of FMCSA? FMCSA is focused on reducing crashes, injuries, and fatalities involving large trucks and buses. Who and what does the FMCSA regulate? Interstate commercial operation, including the driver, vehicle, motor carrier, and the transport of hazardous materials. Examples of CMV driver stress factors Interruption of normal sleep, exercising, eating pattern, and access to social support networks resulting in fatigue, obesity, and or/alienation of affection. Environment that may have excessive vibration, noise, and extremes in temperature and or/adverse road or traffic conditions that can interfere with driver ability to recognize a driving hazard, cause temporary or permanent physical damage to sensory perception or affect driver behavior. Increased potential for injury and fatalities should there be a crash when driver is responsible for passenger safety or hazardous cargo. What are the differences between the medical standards and medical guidelines? Regulations are law and are mandatory. The ME must use standards to determine interstate CMV driver medical fitness for duty. Medical guidelines are not regulatory and the ME may choose not to follow the medical guidance. In which regulations are the driver physical qualification standards and Medical Examiners cited? Driver physical qualification standards are found in 49 CFR 391.41. ME responsibilities are found in 49 CFR 391.43 What objective tests and measurements are required as part of the driver physical examination? Height & weight Vision Hearing BP & pulse Urinalysis (spec gravity, protein, blood, glucose) What are the possible outcomes of the driver physical examination? Certification Disqualification Determination pending What date is used to determine medical examiners certificate expiration? The date of the exam is used as the basis for certificate expiration, except when determination pending is chosen. When determination pending is chosen, if the driver returns with the necessary information prior to the expiration of the driver's current certificate and the driver is qualified based on that information provided, the date used for the basis of the certification timeframe is the date the driver returned with the necessary information. What is the ME certificate expiration date for the following drivers? A - Exam 4/16/2011, meets standards in 49 CFR 391.41, qualifies for 2 year certificate. B - Exam 4/16/2011, meets standards, but periodic monitoring required due to HTN, qualifies for 1 year certificate. C - Exam 4/16/2011, determination pending due to not having results of post-CABG stress test, pt returns and provides that info on 4/25/2011, driver is qualified for 1 year. D - Exam 4/16/2011, disqualified due to benign position vertigo on 3/15/2011, returned to ME for certification examination on 5/20/11. He has been asymptomatic since 3/11/2011. Qualified for two years. A: 4/16/2013 B: 4/16/2012 C: 4/25/2012 D: 5/20/2013 Patient example: Karen, recertification exam 42 y/o female No health history, no medications. Vision acuity: right 20/20, left 20/30. Both 20/20. Horizontal field of vision Rt 80 degrees, Lt 80 degrees. Not corrected vision. No monocular vision. No hearing aids, Whisper test 5' bilaterally. N/A audiometric testing UA: spec grav 1.020, protein 1+, blood 4+, glucose neg. Hgb 12.4 BP 134/88, P 80, regular. PE: on 4th day of menses with heavy bleeding. Advised to consult PCP or GYN for eval of excessive bleeding that could lead to anemia, leading to fatigue that would affect her driving. Two year certification - no disqualifying health history or PE abnormalities. Ask about medication use, including OTC medications. ME obtained hemoglobin testing based on PE findings. (not required) The ME should correctly note the body system in which there was an abnormal finding. The note reflects inquiry as to the affect on driving ability and is also supported by Hgb test results. ME also documented medical follow up advice. Who can perform the vision portion of the interstate CMV driver physical examination? The certified ME, optometrist, or an opthalmologist. If the specialist provider performs the exam, they should complete and sign the provider's information on the report form and provide the results. To pass the interstate CMV driver vision exam, a visual acuity of ___/___corrected or uncorrected is required. 20/40 on Snellen chart in each eye individually AND in both eyes combined. What eye conditions must the ME ask the driver about and if indicated, request specialist evaluation? Retinopathy, cataracts, aphakia, glaucoma, and macular degeneration. Pt example: Mr. Brown, 48 y/o male. No current meds, injury 5 years ago. Hunting accident 2 years ago with facial trauma and left orbital fracture. Presented a "may drive" note from eye surgeon (dated 3 months prior to examination). Uncorrected vision, right eye 20/20. left eye 20/40. Both 20/20. Horizontal field of vision Right 80 degrees, left eye is inconclusive. No monocular vision. No hearing aids. Whisper test 5' bilaterally. N/A audiometric test. UA normal. BP 122/74, p 80, regular. Exam findings: Left eye muscles do not move eye to the left, discussed disqualification pending eye exam by specialist. Explained the specialist will get precise visual field measurements. Provided driver with appropriate medical release and copy of medical exam report with vision section highlighted. Driver does not meet requirements. He is pending specialist vision exam. Diminished vision in left eye noted. Pt could be functionally monocular. What is the purpose of the interstate CMV driver physical examination? To detect the presence of physical, mental, or organic conditions of such character and extent as to affect the driver ability to operate a CMV safely. This exam is for public safety determination and is considered by FMCSA to be a "medical fitness for duty" examination. Examples of "yes" answers for hearing and ears on the health history that may require further examination before a certification decision can be made Ear disorders Loss of hearing Loss of balance Pt example: Pt has hearing of 4' in left and right ears. Do they meet the hearing standards? No, hearing minimum for whisper test is equal or greater than 5' in the better ear. This driver needs an audiometric hearing test. Pt example: Does this driver meet hearing standards for interstate CMV driver certification? Audiometric test results - [Hearing loss in decibles 500 Hz, 1,000 Hz, 2,000 Hz] Right ear: 30, 45, 40 Left ear: 45, 45, 35 Yes, the average hearing loss in the right ear is less than 40 dB. Rt ear average is 38.33 = pass Lt ear average is 41.67 = fail *only one ear has to meet requirement of less than 40 dB of hearing loss Pt example: Mr. Chin, 54 y/o male Admits loss of hearing. No medications. History of frequent ear infections in childhood, multiple TM ruptures and infections in elementary and middle school. He has "always been hard of hearing" in his left ear. Uncorrected vision acuity, right eye 20/30. left eye 20/30. Both 20/30. Horizontal field of vision 90 degrees bilaterally. No monocular vision. No hearing aids used for test. Whisper test - right ear 5', left ear 3'. UA normal BP 134/80, P 86, regular PE comments: Right ear passed forced whisper test, left ear failed. The left TM is misshapen and scarred. PND noted. Certify Mr. Chin for two years. To meet certification requirements, he only has to pass hearing test in one ear. Mr. Chin passed with his right ear. There were no other medical findings that would warrant a more frequent follow-up. If forced whisper test would have been 4', 3', he would have be referred for audiometric testing. He only has to pass one test with one ear to meet the hearing standard. What problems with the test environment exist with the forced whisper tests that do not exist with audiometric tests? Many variables that can impact the validity of the test, such as estimating the distance instead of measuring, performing the test in a room with poor acoustics or subject to outside noise or other distractions. The ME should attempt to control as many of the variables as possible, so the test is given as consistently as possible. Should the ME advise Mr. Chin to see a specialist because of future hearing problems? No, his hearing loss in the left ear is stable for years. Mr. Chin should be educated on ways to preserve the hearing in his better ear, he is at risk for noise induced hearing loss.. Can an interstate CMV driver who has had an acute MI be qualified to drive? Yes, if the AMI was at least two months prior to the date of the driver physical examination, the driver meets all recommended cardiac qualification criteria. A patient provides the ME with a copy of records from cardiologist, indicating a diagnosis of CHF and EF of 38%. Can he be certified? No, EF% must be greater than 40% to be certified. What criteria must be met in order for the FMCSA ME to qualify a driver with a known diagnosis of CHF? Pt must be asymptomatic, have no ventricular arrhythmia, have a left ventricular EF greater than 40%, be under the care of a cardiologist or appropriate medical professional. Should the following patients be certified or medically disdqualified? 1. PCI 9 months ago, no cardio follow up, no ETT 2. CABG 4 months ago, echo and 3 months showed LVEF 55%, cleared by cardiologist, no chest pain. 3. CHF with dyspnea at rest. 4. Driver with increasing angina lasting 20 minutes after tarping a load, unresponsive to Nitroglycerin. 1. Disqualified, after PCI should have cardio follow up and ETT 3-6 months post PCI. 2. Medically qualified, CABG may be qualified at 3 months post-op if asymptomatic, LVEF >40%, and meets all other recommendations (qualify with annual certification). 3. Medically disqualified, a driver with symptomatic CHF is not medically fit for duty. 4. Medically disqualified, a driver with unstable angina is not fit for duty. Driver had AAA, recent abdominal sonogram shows aneurysm size 5.3 cm in diameter. Should this pt be qualified? CONTINUED....