Transcript The medico-legal aspect of emergency medicine

Our role as health advocates and our legal
responsibilities
Farooq Khan MDCM
PGY2 FRCP-EM
McGill University
July 19 2010
Objectives
To review common conditions that may
impair driving
 To employ a simple approach towards
evaluating fitness to drive in the ED
 To understand the health advocate role
and legal obligations of the EP within the
Quebec healthcare system with regards
to driving fitness
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Common concern..?
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21 year old male presents with delayed
seizures post-TBI
58 year female with lupus presents with with
CRAO
47 year old male with new onset Parkinson’s
disease
68 year old female presenting with a
mechanical fall who is found to have early
dementia
29 year old female with pseudotumor cerebri
who undergoes dilatation for fundoscopy
Should these patients be driving?
What is our role as physicians in
determining fitness to drive?
 How do we go about doing it?
 What, if any, are our legal obligations?
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Why do we care?
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Medically unfit drivers contribute to 100 motor vehicle
related fatalities every day in North America
Worldwide 5000 pedestrians per year are killed by
medically unfit drivers
Doctors have a responsibility to protect the public and
serve as health advocates
These drivers and their victims end up in our EDs
An epidemiological study at Sunnybrook trauma center in
2008 found
 37% of drivers admitted for MVC had reportable conditions
 Fewer than 3% were actually reported
 85% of those patients had visited a doctor in the past year
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In most of Canada and the US, reporting medical
conditions that impair driving is mandated by law
How?
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Think of whether or not the patient can
fulfill all the required functions of driving
 Can they operate the various controls?
(pedals, steering wheel, indicators, mirrors,
etc)
○ Motor skills, coordination, balance
 Is their sensory perception adequate?
○ Audition, vision, touch/proprioception
 Do they possess the mental faculties?
○ Memory, judgment, vigilance
Observe your patients as they enter
the examining room
General appearance: hygiene, grooming,
hemiplegia, glasses, involuntary
movements
 Mobility: gait, speed, posture, balance,
need for assistance, transfers
 Handshake: grip strength, upper extremity
ROM
 Conversation: audition, confusion,
coherence, mental status, dysarthria, EOM,
social appropriateness
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Historical elements of concern
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PMH:
 CVA, DM, CAD, arrythmias pacer/ICD,
aneurysms (all types), dementia, epilepsy,
neurodegenerative disorders, glaucoma,
cataracts, macular degeneration, sleep
apnea, substance abuse
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Medications:
 psychotropics (benzos), antiarrhythmics,
anticonvulsants, narcotics, muscle relaxants,
EtOH and illicit drugs, mydriatics,
cycloplegics
Historical elements of concern
Prior visual/auditory problems
 Unexplained LOC
 Evidence of memory loss (especially in
elderly, obtain collateral history)
 Decrease in ADLs, IADLs
 Pain, limited neck movements
 Vertigo/dizziness
 Palpitations
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Driving history
How the patient arrived
 Type of vehicle (truck, motorcycle, etc.)
 Previous accidents, infractions
 Change in driving habits
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 Voluntarily imposed limits (avoiding rush
hour, or driving at night)
 Long distance driving
 Races
Presence of alternate driver
 Professional driver (bus, taxi, etc)
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Physical exam
VS: arrythmias, bradycardia, hypotension
Visual acuity and gross visual fields
Neck mobility (particularly rotation)
CVS: aortic stenosis murmur
Abdo: AAA
Extremities: sensory/motor deficits, limited
ROM, amputation
 Gait: assisted, antalgic, paretic, loss of
balance
 Mental status: low MMSE, psychomotor
retardation, attention deficit, apraxia, lack
of judgment or planning
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So now recap
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Is there a medical condition (intrinsic to the patient
or acquired through therapy) that decreases the
patients aptitude to drive or renders it unsafe?
What kind of conversation should you be having
with your patient?
 How long should they avoid driving?
 Should they be giving up driving altogether?
 What kind of modifications will allow them to retain their
licenses?
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What resources can help you and your patients?
 Occupational therapy, neuropsychiatric evaluation,
specialized evaluating MDs.
 Public transit, Transport adapté, community services
Ethical and legal considerations
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Ethical principles at odds
 Patient privacy, confidentiality and autonomy
 Public health, protecting other citizens from
dangerous drivers
Physicians in Québec do not revoke
licenses. The SAAQ makes that decision.
Reporting is discretionary not mandatory
 The Code de sécurité routière authorizes
physicians to break confidentiality and
inform the SAAQ when patients are judged
to be inapt at driving
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Ethical and legal considerations
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Our ethical and professional obligation is to inform our
patients of their condition and the risk if they continue
to drive
Recommend that they discontinue driving until an
exhaustive evaluation can be carried out
If it is felt that the patient will not respect the
recommendation and continues to be a danger to
others, then the physician is duty bound to inform the
SAAQ
Inform patients of your decision to report and document
carefully!
Seizure disorders, EtOH and drug abuse, and
psychiatric disorders are high risk diagnoses for
litigation
Physicians have been found liable for failure to report
Take home messages
Keep fitness to drive in the back of your
mind
 When a condition of concern presents
itself, take a couple of extra minutes to
assess the situation
 Advise your patients of the risk involved,
and take action if the patient’s behaviour
is a danger to self or others
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Contact the SAAQ
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SAAQ: Service de l'évaluation médicale - QUÉBEC
Postal address :
Société de l'assurance automobile du Québec
Service de l'évaluation médicale
C. P. 19500
QUÉBEC (Québec)
G1K 8J5
Telephone: 418 643-5506 or 1 800 561-2858
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Highway Safety Code: Regulation respecting access to driving a
road vehicle in connection with the health of drivers, R.S.Q., c. C24.2, r.0.1.0001
http://www2.publicationsduquebec.gouv.qc.ca/dynamicSearch/telecharge.php?type=3&
file=/C_24_2/C24_2R0_1_0001_A.HTM
References
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Collège des médecins du Québec, L’évaluation médicale de l’aptitude à conduire un véhicule automobile, Guide
d’exercice, Montreal, Collège des médecins du Québec, mars 2007 [En Ligne]
http://www.cmq.org/fr/MedecinsMembres/Ateliers/~/media/9DADF56514BB48D2B0C70568F96FB8FF.ashx?410
16
American Medical Association National Highway Traffic Safety Administration. Physician’s Guide to Assessing
and Counseling Older Drivers, [Chicago (Illinois), American Medical Association, September 2003]. [Online]
http://www.nhtsa.dot.gov/people/injury/olddrive/physician_guide/PhysiciansGuide.pdf.
Canadian Medical Association. Determining Medical Fitness to Operate Motor Vehicles, CMA Driver's Guide 7th
edition., Ottawa, Canadian Medical Association, 2006. [Online]
http://www.cma.ca/index.php/ci_id/18223/la_id/1.htm
Canadian Cardiovascular Society Consensus Conference 2003. Assessment of the Cardiac Patient for Fitness to
Drive and Fly: Final Report, [Ottawa, Canadian Cardiovascular Society], 2003. [Online]
http://www.ccs.ca/download/consensus_conference/consensus_conference_archives/2003_Fitness.pdf
Collège des médecins du Québec. Aspects légaux, déontologiques, et organisationnels de la pratique médicale
au Québec: ALDO-Québec, Montréal, Collège des médecins du Québec, mai 2006. [En ligne]
http://www.cmq.org/aldofrancais.aspx
Société de l’assurance automobile du Québec. Guide de l’évaluation médicale et optométrique des conducteurs
au Québec, 1re éd. rév., Québec, Société de l’assurance automobile du Québec, 1999. [En ligne]
http://www.saaq.gouv.qc.ca/documents/documents_pdf/permis/guidemed.html
Redelmeier, D., Venkatesh, V., Stanbrook, M.. Mandatory Reporting by Physicians of Patients Potentially Unfit to
Drive. Open Medicine, North America, 2, Feb. 2008. [Online] http://www.openmedicine.ca/article/view/141
European Commission. Transport, Road Safety
 Diabetes and Driving in Europe: A Report of the Second European Working Group on Diabetes and Driving,
[Brussels,European Commission, July 2006]. [Online]
http://ec.europa.eu/transport/roadsafety/behavior/doc/diabetes_and_driving_in_europe_final_1.pdf.
 Epilepsy and Driving in Europe: A Report of the Second European Working Group on Epilepsy and Driving,
[Brussels, European Commission], April 3rd 2005. [Online]
http://ec.europa.eu/transport/roadsafety/behavior/doc/epilepsy_and_driving_in_europe_
final_report_v2_en.pdf.
 New Standards for the Visual Functions of Drivers: Report of the Eyesight Working Group, [Brussels,
European Commission], May 2005. [Online]
http://ec.europa.eu/transport/roadsafety/behavior/doc/new_standards_final_version_en.pdf