Transcript No Slide Title

Medical Fitness to
Drive
Updated by
Nadine Abdullah, MD, M.Ed, FRCPC
March 2007
Outline
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General objectives
CMA guidelines
Ontario regulations
Medical Condition Report
Cases
References
General objectives
• To review Ontario regulations for the reporting
of patients who are assessed to be unsafe to
drive
• To review specific medical conditions that are
commonly encountered in practice
• To review the process of reporting to the
Ministry of Transportation
CMA Guidelines
• Individual assessment needed and can be facilitated by referring
to the CMA guidelines
• If a physician deems a patient unsafe to drive they must notify
the patient and inform the ministry in writing (see new online
medical condition report)
• Responsibility for issuing/taking away license rests with licensing
authority
• Where interest of individual driver and safety of public conflict,
latter has priority
• Some cases require temporary cessation of driving (eg. post
anaesthetic, new time-limited prescription for sedating drug
post- injury); patient must be advised, but does not necessitate
notification of the ministry
Ontario Regulations
• Liability in Ontario
– mandatory reporting of unfit drivers (even if they do not
have a license or own a vehicle)
– physicians protected from liability if they report unfit drivers
– physicians liable to negligence suits for failing to report unfit
drivers
• Patients appeal directly to licensing authority
– may have input from applicant’s physician
• Restricted license (eg daylight, not highways) not
available in Ontario
http://www.mto.gov.on.ca/english/dandv/driver/medreport/medreport.pdf
Case 1
You are assessing a 43 year old female for follow-up of
her epilepsy. Although compliant with her medications,
she reports 3 seizures in the last 2 months. You:
a) advise her not to drive
b) advise her not to drive on highways or during rush hour
c) advise her not to drive and report this to the Ministry of
Transport
d) take away her driver’s license
Learning Objectives
• Understand principles behind determining
patient’s ability to drive
• Understand medical legal issues
• Provide guidelines for driving for patients with
seizure disorders
Seizures - First Seizure
• No driving for at least 3 months until complete
evaluation (EEG, CT or MRI)
• If alcohol withdrawl seizure, can drive if remains
alcohol free and seizure free for 6 months, and
completes a rehabilitation program for substance
dependence
• If no cause or no epileptiform activity
– private driver can drive if seizure free for 3 months
– professional driver can drive if seizure free for 12 months
Seizure - After Epilepsy Dx
• If patient has diagnosis of epilepsy and compliant with
anti-epileptic medications
– can have private license if seizure free on medications for 6
months
– wait 12 months if simple partial seizures
– can have commercial license if seizure free for 5 years
• After medication withdrawal or change
– for private license wait 3 months
– commercial license wait 6 months
Back to Case 1
You are assessing a 43 year old female for follow-up of
her epilepsy. Although compliant with her medications,
she reports 3 seizures in the last 2 months. You
a) advise her not to drive
b) advise her not to drive on highways or during rush hour
c) advise her not to drive and report this to the Ministry of
Transport
d) take away her driver’s license
Case 2
You are assessing a 45 year old TTC subway car driver who is 3
weeks post anterior MI. He has Gr IV systolic LV function and no
reversible defects on Thallium GXT. He is medically managed and
has NYHA III symptoms. He asks when he can return to driving
his train. You recommend:
a) 1 month from his MI
b) 3 months from his MI
c) 6 months from his MI
d) never
Learning Objectives
• Review driving guidelines for patients with:
– coronary artery disease
– arrhythmias
– congestive heart failure
Coronary Artery Disease
Private
Professional
Stable Angina
No restrictions
No restrictions
Acute MI/UA
Wait 1 month
after discharge
Wait 48 hrs
Wait 3 months
after discharge
7 days
Wait 1 month
after discharge
Wait 3 months
after discharge
PTCA/stents
CABG
Cardiac Arrhythmias
• Consider
– frequency,
– risk of malignant ventricular arrhythmias
– presence of other cardiac disorders
• VT/VF controlled on medications or ICD
– private - wait 6 months
– commercial - disqualified
• Atrial arrhythmias and non-sustained VT
– in general, can drive unless associated symptoms
Cardiac Arrhythmias
• AV block
– disqualified for all classes if Mobitz type II, trifascicular
block or acquired 3rd degree
• Pacemaker
– can drive if asymptomatic 1 week after implantation for
private, 1 month for professional driver
• ICD
– All commercial driving disqualified
– For private, primary prophylaxis classes I-III wait 4weeks
after implant
– Secondary prophylaxis without symptoms, wait 1 week
– Secondary prophylaxis with symptoms, wait 6 months after
event
CHF, LV Dysfunction
• Private - can’t drive if
– NYHA IV symptoms
• Professional - can’t drive if
– NYHA III symptoms or worse
– EF < 35%
Back to Case 2
You are assessing a 45 year old TTC subway car driver who is 3
weeks post anterior MI. He has Gr IV systolic LV function and no
reversible defects on Thallium GXT. He is medically managed and
has NYHA III symptoms. He asks when he can return to driving
his train. You recommend:
a) 1 month from his MI
b) 3 months from his MI
c) 6 months from his MI
d) never (unless LV function and symptoms
improve on therapy)
Case 3
You are scheduled to see the following patients in
clinic today. Assuming investigations have not been
completed, who would you consider safe to drive?
a) 62 yo with TIA 2 days ago
b) 50 yo truck driver with diabetes mellitus,
starting on insulin
c) 65 yo with syncope 1 week ago
d) 55 yo taxi driver with dyspnea at rest from COPD
e) 80 yo with visual impairment
Learning Objectives
• Review driving assessments for patients with
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Vascular disease
Diabetes mellitus
Syncope
Lung disease
Visual impairment
• Review driving issues related to aging
Vascular Disease
• Single or recurrent TIAs
– cannot drive until assessed and investigated
– can drive if no loss of function and cause addressed
• Completed stroke
– wait 1 month if minimal loss of functional ability and underlying
cause addressed
– if residual loss of function - road test
• Aortic aneurysm
– if > 5.5 cm for men or > 5 cm for women, treat surgically before
allowing to drive
Diabetes Mellitus - Insulin Treated
• Private driver - OK if
– no severe hypoglycemia within last 6 months
• Professional driver - OK if
– no severe hypoglycemia or hypoglycemia unawareness within last
6 months
– no instability of insulin regimen (e.g. starting insulin or changing
dose, need 1 month wait)
– no peripheral neuropathy (with loss of function), cardiac reasons,
visual impairment
– self monitors
Syncope
• Single episode of typical vasovagal syncope
– no restriction
• Diagnosed and treated cause (eg. PPM for bradycardia)
– private wait 1 week; commercial wait 1 month
• Situational (eg. micturition)
– wait 1 week
• Single episode and unexplained
– private wait 1 week; commercial wait 12 months
• 2 or more episodes in 12 months
– private wait 3 months; commercial wait 12 months
Lung Disease
• Chronic respiratory disease
– no restriction if none to moderate impairment
– road test required if moderate to severe impairment or
supplemental oxygen required at rest
– must use supplemental oxygen if required and equipment
must be safely secured in the vehicle
• Obstructive sleep apnea (verified by sleep study)
– OK if compliant with CPAP or successful surgery
Visual impairment
• Visual acuity (both eyes open, examine together)
– private – not less than 20/50
– commercial – not less than 20/30
• Colour vision
– no restrictions but need to be aware of problem to compensate
• Hemianopsias - no for all classes
• Uncorrected diplopia - no for all classes
Age and Driving
• Older age not a contraindication to driving
• Driving may be critical to maintaining
independence
• Due to increased prevalence of chronic diseases
which may impair driving, increase frequency of
medical exam for fitness to drive needed as
patient ages (eg. yearly after age 80)
Back to Case 3
You are scheduled to see the following patients in
clinic today. Assuming investigations have not been
completed, who would you consider safe to drive?
a) 62 yo with TIA 2 days ago
b) 80 yo with visual impairment
c) 50 yo truck driver with diabetes mellitus,
starting on insulin
d) 65 yo with syncope 1 week ago
e) 55 yo taxi driver with dyspnea at rest from COPD
Bottom line
• If you aren’t sure, advise the patient not to drive
and inform the ministry of transportation
• Public safety has priority over individual driver
References
• Determining Medical Fitness to Operate Motor
Vehicles: CMA Driver’s Guide 7th edition, 2006
• CCS consensus conference 2003: Assessment of
the Cardiac Patient for Fitness to Drive and Fly
– executive summary
• Ontario Ministry of Transportation “Medical
Condition Report”
http://www.mto.gov.on.ca/english/dandv/drive
r/medreport/medreport.pdf