Transcript No Slide Title

MEDICAL FITNESS TO DRIVE
Prepared by
M. Bacchus and K. Locke
MSH AIMGP Seminar Series
2003 - 2004
OBJECTIVES
• Understand the rationale and evidence for
restricting driving privileges
• Understand physicians’ legal obligations in
Ontario
• Understand the mechanism for driver reporting
• Understand the impact of specific medical
conditions on the ability to drive
REFERENCE
• Canadian Medical Association, 2000.
Determining Medical Fitness to Drive: A
Guide For Physicians, 6th ed.
(Sections are posted on Website)
• CMA members may also access at:
http://www.cma.ca/cma/common/displayPage.do?pageId=/staticContent/H
TML/N0/l2/publications/catalog/driversguide/index.htm
(sign into www.cma.ca first then paste the above)
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
• understand mechanism of reporting
• provide guidelines for driving for patients
with seizure disorders
CMA Guidelines
• no hard and fast rules
– individual assessments needed
– “evidence” is mostly consensus opinion
• responsibility for issuing/taking away license
rests with licensing authority, we only report
• where interest of individual driver and safety
of public conflict, latter has priority
Medical Legal Aspects
• Liability in Ontario
– mandatory reporting of unfit drivers
– physicians protected from lawsuits if they report
unfit drivers
– physicians liable to negligence suits for failing to
report unfit drivers, may have to pay damages
• Patients appeal directly to licensing authority
– may have input from you as their physician
• Restricted license (eg daylight, not highways)
not available in Ontario
Mechanism of Reporting
• A. See patient, examine for clinical
condition
• B. If certain that patient should not drive,
inform patient and make a report to the
MOT
• C. If uncertain, obtain consultation, inform
patient, and send report and consultation to
MOT
Seizures - First Seizure
• no driving for at least 3 months until
complete evaluation (EEG, CT)
• if no cause or no epileptiform activity
– can drive class 5 (private vehicle) or 6
(motorcycle)
• if professional driver (class 1-4 license)
– seizure free for 12 months
Seizure - After Epilepsy Dx
• if patient has diagnosis of epilepsy and
compliant with anti-epileptic medications
– can have class 5 or 6 license if seizure free on
medications for 12 months
– any class license if seizure free for 10 years on
medications or 5 years off medications
– Change meds: must wait 3 months
– D/C meds: must wait 5 years
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 bus driver who is
3 weeks post anterior MI. He has a Gr III/IV systolic
LV function and no reversible defects on Thallium
GXT. He is medically managed and has NYHA II
symptoms. He asks when he can return to driving his
bus. 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 guidelines for driving for patients
with
– coronary artery disease
– arrhythmias
– congestive heart failure
Coronary Artery Disease
• Stable AP - no restrictions/waiting period
• acute MI/UAP - after all initial management completed
- private drivers - wait 1 month once stable
- professional - wait 3 months once stable
• PTCA/Stents
- private drivers - wait 48 hours
- professional - wait 7 days and also reassess
at 6 months with exercise stress test
• CABG - private drivers - wait 1 month
- professional - wait 3 months
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
CHF, LV Dysfunction
• Private - can’t drive if NYHA IV symptoms
• Professional - can’t drive if
– NYHA II symptoms or worse
– EF < 35%
– > 3 beats of VT on Holter, or > 10 PVCs/hour
Back to Case 2
You are assessing a 45 year old TTC bus driver who is
3 weeks post anterior MI. He has a Gr III/IV systolic
LV function and no reversible defects on Thallium
GXT. He is medically managed and has NYHA II
symptoms. He asks when he can return to driving his
bus. 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, functional class
improve on therapy)
Case 3
You are scheduled to see the following patients in
your clinic today. Assuming no other medical
problems, who would you consider safe to drive:
a) 62 year old with TIA 2 days ago
b) 85 year old with pneumonia
c) 50 year old truck driver with diabetes mellitus, starting on
insulin
d) 65 year old with syncope 1 week ago
e) 55 year old taxi driver with dyspnea at rest from COPD
Learning Objectives
• review driving assessments for patients with
–
–
–
–
–
cerebrovascular disease
peripheral vascular disease
diabetes mellitus
syncope
lung disease
• 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
– if cause not clear: single - can drive; recurrent - can’t drive
• Completed Stroke
– wait 1 month if minimal loss of functional ability and
underlying cause addressed
– if residual loss of function - road test (OT assessment)
• Aortic Aneurysm
– if > 5 cm, treat surgically before allowing to drive
Age and Driving
• old age not a contraindication to driving
• driving may be critical to maintaining
independence for isolated seniors
• increased prevalence of chronic diseases
which may impair driving means increased
frequency of medical exam for fitness to
drive needed in older age (eg. yearly after
age 80)
Diabetes Mellitus - Insulin Treated
• Private driver - OK if
– no severe hypoglycemia within last 6 months
• Professional driver - OK if
– no severe hypoglycemia 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 and no cardiac/neuro cause
found (if found - correct!)
– private - wait 1 mo; professional - 3 months
• 2 or more in 12 months
– private - wait 3 mo; professional - 12 months
• Recurrent events during waiting periods “reset the
clock”
• Isolated clear vasovagal episode - no restrictions
(may drive immediately)
Lung Disease
• COPD
– private - OK unless on supplemental oxygen
– professional - only if mild impairment (e.g. dyspnea
uphill or walking quickly on level ground)
• portable oxygen
– private - can’t drive unless pass road test with apparatus
– professional - should not drive
• Obstructive sleep apnea (verified by sleep study)
– OK if compliant with CPAP or successful surgery
– History of somnolence (any cause): can’t drive
Case 3
You are scheduled to see the following patients in
your clinic today. Assuming no other medical
problems, who would you consider safe to drive
a) 62 year old with TIA 2 days ago
b) 85 year old with pneumonia (if resolved, stable)
c) 50 year old truck driver with diabetes mellitus, starting on
insulin
d) 65 year old with syncope 1 week ago
e) 55 year old taxi driver with dyspnea at rest from COPD
Odds and Ends - Vision
• Visual acuity (both eyes open, examine together)
– private - 20/50
– taxi - 20/40
– rest - 20/30
• Colour vision
– class 5 and taxis - no restrictions
– others - discriminate red, green and yellow
• hemianopsias - no for all classes
• uncorrected diplopia within the central 40 of primary
gaze - no for all classes
BOTTOM LINE
• If you aren’t sure, advise the patient not to
drive and inform the ministry of
transportation
• Interest of public has priority over that of
individual driver (although take both into
account)