DOT exams

[jwelter05]

For those of you that perform DOT exams I have a few questions (new to this).... 

 

Patient on oral medications for diabetes with glycosuria ...do you get a finger stick or do A1C ? The patient usually has to pay for this service and I have had a few refuse... Would you just give them a 3 month card then ?? 

 

Also, for sleep apnea ... If patient has high BMI and neck circumference > 17 do you automatically send for sleep study (as my company suggests) or do you consider co morbidities and th en  issue 3 month card or have you extended it to 6 months? 

 

I work with a very angry, disgruntled population and they don't take too kindly to a young "lady" telling them they need to make these scheduled follow ups. 

 

Also with CAD - and previous stent or bypass surgery - if they don't provide annual ETT or echo results do you put their physicals on hold or give them 3 months to get this stuff??  

 

I feel like there is such a grey area and every provider in my group does things a little differently (all NPs by the way). 

 

thanks in advance... 

[rev ronin]

You need to reorient yourself. Your client is not the person standing in front of you, your client is society.

 

I don't see a whole lot of really sick people, but when I do, they DO NOT GET ANY CARD OF ANY SORT WHATSOEVER unless they do everything required of them. Make sure you collect the fees up front, so that if they walk away, your clinic isn't out any money for their intransigence: You are being paid to evaluate them against a specific set of standards, not being paid for their medical card.

 

For everything else, stick to the letter of the regulations.  Do you have a copy of the FMCSA handbook?  If not, PM me your email address and I'll send you my 3-2014 copy.  The ever-so-helpful DOT website apparently doesn't have a copy at the moment because they're "revising" it, but absent better guidance, that's still what I would use:

 

* Glucosuria: If they're on Farxiga or another SGLT2, no biggie, but in any other circumstance a BMP and an A1c are in order.

* Sleep Apnea: Yes, they get a home sleep test if they have clinical symptoms suggesting it.

* CAD/CABG.  If they have a cardiologist, I ask the cardiologist for a written opinion on whether they should be driving commercial truck.  Remember, it's YOUR call, but you're entirely allowed to rely on specialists' judgment.

 

I have never issue 3 month cards for anything other than BP not at goal but within the Stage 1 range.  I don't recall this practice--where is it coming from?

[GetMeOuttaThisMess]

Agree with RR, these examinations are not being done for the direct benefit of the individual but for the purpose of protecting the general public FROM them!  There is ambiguity built into the system to allow for personal allowances, but to also protect the consulting providers who establish the recommendations from liability.  Some areas are quite strict such as when PCI/CABG and MI individuals can resume driving.  With regard to your specific situation, you order what you deem necessary, regardless of what the individual says.  I know it can be difficult.  I performed these up until the time that registration was taking place for courses and before the exam was offered for examiners.  My employer and the employer for the drivers were one and the same, thus creating some potentially difficult situations since no DOT card meant no job.  I also agree with RR that if the person has a specific question regarding their ability to not only be able to drive but they also have to be in such a condition to be able to get under a trailer to inspect, as well as to unload a trailer if required, regardless of THEIR specific job description, then submit the appropriate guideline section from the FMCSA website along with a referral note and have the specialist comment in writing and keep with the driver record.  If vision or hearing are outside the allowed parameters we don't think twice about referring so why should DM or CVD be any different.  If something were to happen guess who the investigators are talking to first?  YOU!  I know this from a local fatal accident involving a commercial driver who was at fault and they went right to the examiner who signed off on the DOT medical card (not myself).

 

Here's another perspective, what if you were the employer who was referring these drivers to yourself and your associates and one was cleared incorrectly and it resulted in a liability for the company?  Not only do the investigators knock at your door but the employer will find other examiners as well.

[Guest UVAPAC]

I have a question for others performing these examinations:

 

Recently we have had a lot of patients coming for DOT Examinations on Narcotics, generally for "chronic back pain"

 

I explain to all patients this is an absolute contraindication to having a CDL License, unless they are able to get a letter from the prescribing physician stating the diagnosis, medication/dose/frequency, any side effects of the medications, and if they feel it is safe for their patient to operate CDL vehicles while using this medication.

 

I am worried that despite this letter, there is still a huge amount of liability when certifying these drivers.  If they are involved in any kind of serious accident, and are using these medications, I assume that a narcotic would draw huge red flags regardless of if it actually played a role or not in the crash.

 

 

Does anyone certify people using narcotics regularly?  Should we be disqualifying all of these individuals, or looking at it case to case?

[Reality Check 2]

Natalie Hartenbaum, MD MPH is THE guru of occ med DOT.

Her book is The DOT Medical Examination - a Guide to Commercial Drivers' Medical Certification

ISBN 978-1-883595-53-1

 

The book translates the DOT rhetoric into plain terms with charts and timetables, etc.

 

Some stuff is simply not negotiable and YOU are responsible.

YES, MI patients HAVE to have ETT and echos and such every few years whether the cardiologist prescribes it or not.

I photocopy the page from her book and fax it to the cardiologist with the request and it gets done 99.9% of the time with no questions asked.

 

Narcotics are a problem. WHY do they take them and is this condition disabling or contraindicating to driving is the main question.

 

Her book is an excellent resource and she is part of a listserv for Occ Med providers where folks can post anonymous cases and ask for feedback and share knowledge and experiences about DOT issues. It is ultimately helpful. I don't have the address on me at the moment but you can google her and find it. You have to ask to join and be invited by secure email. 

 

The 3 month card is a BAD OUT for anything except the blood pressure algorithm. Do NOT feel pressured by drivers. 

 

My kids could be on the road next to them when they become incapacitated and I couldn't forgive someone for certifying a medically unqualified driver due to a feeling of pressure.

 

I have been yelled at and threatened by angry drivers and read the riot act about government interference and privacy. Boo Hoo - if you drive a commercial vehicle on public roadways - it is MY business to make sure you are safe. Deal with it.

 

If the driver doesn't have a PCP - they need to get one to make sure they stay healthy enough to drive.

 

Good Luck and Keep Asking Questions - forever.

[Febrifuge]

I wouldn't feel comfortable certifying anyone who takes narcotics on a regular basis, full stop. Opioids are poor treatment for chronic back pain, but beyond that the meds are (or can be) incapacitating. If they're trying to tell me that NOT taking the meds means an incapacitating level of pain, then we have another problem, because what happens if you accidentally drop your last 10 pills in a truck stop toilet halfway across the country?

 

I'm kind of surprised that opioid use isn't an automatic disqualification, but whatever wiggle room might exist, it seems like the kind of thing I might actually make use of once every 5-10 years at most.

[Guest UVAPAC]

I wouldn't feel comfortable certifying anyone who takes narcotics on a regular basis, full stop. Opioids are poor treatment for chronic back pain, but beyond that the meds are (or can be) incapacitating. If they're trying to tell me that NOT taking the meds means an incapacitating level of pain, then we have another problem, because what happens if you accidentally drop your last 10 pills in a truck stop toilet halfway across the country?

 

I'm kind of surprised that opioid use isn't an automatic disqualification, but whatever wiggle room might exist, it seems like the kind of thing I might actually make use of once every 5-10 years at most.

I am pretty sure it is an "automatic disqualification" unless they have a letter from the prescribing physician stating the rationale, dosage, side effects, etc. and then it is up to the certified medical examiner to make a decision.

 

I know recently I have qualified several drivers on long term vicodin and percocet with these notes.  After reading this board, and further consideration... I am just going to start disqualifying drivers on these medications.  

[Reality Check 2]

More confusion --

 

25 yr old male on Insulin, Invokana and Metformin comes in for DOT for INTRASTATE only in the State of Washington - local driver.

 

SOMEONE has been signing cards for several years despite his insulin and he says he has a state waiver.

 

I have taken the wa.gov website apart and cannot find a single set of qualifications for the waiver.

 

I went back to the federal waiver program - all 25 pages of the application.

 

This kid is NOT compliant with ANY of the requirements on the federal program - no endocrinologist every 3 months, no glucose logs, no driving logs. No Ophthalmology records.

 

His A1c today is 8.2......................... Oops - and a year ago is was 7.9.

 

He thinks he is a type II diabetic but has been on insulin since age 17. Seriously doubt this kid is type II - sounds like type I to me. I think the Invokana and metformin are overkill and probably worthless. The Lantus is what is helping him.

 

Anyway - I show him the federal waiver app and he says he has FIVE of them at home. Yet, not one to show me and nothing within 12 months. He hasn't been seeing an endo and hasn't been seen every 3 months and has no glucose or driving logs.

 

I called 4 phone numbers for Washington DOT and not one has anyone qualified to talk to me or provide guidance. So, again, I am relegated to using the federal requirements which he is not following.

 

So, I am 1000000% confident in NOT providing him a card of any sort. I no charged him and sent him on his way. We are his PCP office - I KNOW HE isn't going to get a waiver - why waste everyone's time. 

 

I am frustrated in how freaking difficult this is and how little clear cut info and resources are available.

 

If I had Natalie Hartenbaum's direct phone number --- I would have called it in a heartbeat.

 

Just venting my frustration - anyone else had any success in dealing with any of this garbage???

 

Man, I am old - and getting crankier......................

[rev ronin]

On insulin is a no-go, and if the driver wants to show me a state waiver process on something like that, they have to find it for me.

 

I'm concerned that you guys are his PCP and don't have any records from any endocrinologist to say whether he's II or I.  Sounds like he may have been dodging the issue...

[GetMeOuttaThisMess]

At last check, no one has ever been granted a waiver for insulin therapy, though the process does exist. The other point here is that the employer has the ability to mandate guidelines above/greater than FMCSA, just not lesser than.

[Reality Check 2]

He has played hopscotch and shopped to get what he wants.

He has seen an IM NP who does diabetes but she is not a board certified endocrinologist. Never sent us any records either.

 

He splits his care to keep the picture hazy.

 

He is pissed that he is diabetic and pissed that this affects his job.

Completely dodging the issue that he has a lifelong process.

 

I just inherited him from retiring doc - records sketchy at best.

 

I KNOW he is a type I just by history and looking at his few exams and body weight, etc.

 

He doesn't want to hear anything except that he can work.

I get that but - again, the DOT is not for him - it is for public safety.

 

I am following federal guidelines since there are no viable state guidelines readily available.

When in doubt, default to federal - can't go wrong.

 

Another deep sigh....................

[spflynn4]

More confusion --

 

25 yr old male on Insulin, Invokana and Metformin comes in for DOT for INTRASTATE only in the State of Washington - local driver.

 

SOMEONE has been signing cards for several years despite his insulin and he says he has a state waiver.

 

I have taken the wa.gov website apart and cannot find a single set of qualifications for the waiver.

 

I went back to the federal waiver program - all 25 pages of the application.

 

This kid is NOT compliant with ANY of the requirements on the federal program - no endocrinologist every 3 months, no glucose logs, no driving logs. No Ophthalmology records.

 

His A1c today is 8.2......................... Oops - and a year ago is was 7.9.

 

He thinks he is a type II diabetic but has been on insulin since age 17. Seriously doubt this kid is type II - sounds like type I to me. I think the Invokana and metformin are overkill and probably worthless. The Lantus is what is helping him.

 

Anyway - I show him the federal waiver app and he says he has FIVE of them at home. Yet, not one to show me and nothing within 12 months. He hasn't been seeing an endo and hasn't been seen every 3 months and has no glucose or driving logs.

 

I called 4 phone numbers for Washington DOT and not one has anyone qualified to talk to me or provide guidance. So, again, I am relegated to using the federal requirements which he is not following.

 

So, I am 1000000% confident in NOT providing him a card of any sort. I no charged him and sent him on his way. We are his PCP office - I KNOW HE isn't going to get a waiver - why waste everyone's time. 

 

I am frustrated in how freaking difficult this is and how little clear cut info and resources are available.

 

If I had Natalie Hartenbaum's direct phone number --- I would have called it in a heartbeat.

 

Just venting my frustration - anyone else had any success in dealing with any of this garbage???

 

Man, I am old - and getting crankier......................

 

I recently went through the federal waiver process as a T1, and I can tell you that it's intensive from the patient's prospective. It's tough to get communication from the federal program, and questions are rarely answered in a timely basis. The requirements are very black and white, so it sounds like he wasn't doing his part. It's frusturating as a diabetic to have people like your patient disrespecting the process and making it tougher to get anything done. 

 

At last check, no one has ever been granted a waiver for insulin therapy, though the process does exist. The other point here is that the employer has the ability to mandate guidelines above/greater than FMCSA, just not lesser than.

 

I obtained a waiver for insulin therapy last year. Its doable but not easy by any stretch. It's a long process, but it's nice in that it pushes a strict A1C guideline and follow-up schedule with both Endo and Ophthalmology (which is a good schedule for all diabetics to follow). 

[Guest UVAPAC]

At last check, no one has ever been granted a waiver for insulin therapy, though the process does exist. The other point here is that the employer has the ability to mandate guidelines above/greater than FMCSA, just not lesser than.

I have several patients in Connecticut who have been granted waivers for insulin therapy.

[Guest UVAPAC]

Had a firefighter come in last week who only checked off "Hypertension" as a medical problem treated with Lisinopril.  

 

Upon further questioning he disclosed he takes "Vicodin 5x daily for chronic pain."  I explained to him that he would require a letter form the prescribing physician at bare minimum listing medication, dosage, and stability of the dose, with any documented side effects.

 

I get a letter from the PCP stating he takes Percocet and MS Contin for pain.  He is stable on his medications, with no reason he should not be able to continue his CDL duties.  No dosages were given.  

 

I look the patient up in the state PMP, and come to find out they are on

 

1.  Percocet 10/325 10 tablets daily  

2.  MS Contin ER 30mg twice daily

 

These have been prescribed several years for fibromyalgia.  

 

 

I told the patient there is no way I can certify him on 160 morphine equivalent daily despite a letter.  He is very upset and now states he will "just stop taking the medications all together."

[Reality Check 2]

UVAPAC - awesome job of investigation.

 

NO WAY to certify this person on that much narcs.

 

The underlying reason for the narcs should have been delineated by the PCP or prescriber.

 

The underlying diagnosis is the root of the problem - chronic back pain with radiculopathy and loss of sensation in a leg or a frozen shoulder or something unfixable means they cannot perform the basic jobs of truck driving including linking trailers, pulling tarps and hoses and getting themselves up in the cab or crawling under the trailer to check connections. 

 

As we all know - long term narcotic use doesn't preclude someone from a sudden change in consciousness due to illness, dehydration, mixing of drugs, alcohol or just the unknown of a way too high dose of pain meds. 

 

I would also ding the driver for LYING on a federal DOT form by not answering the questions properly about medications and medical conditions.......

[GetMeOuttaThisMess]

I have several patients in Connecticut who have been granted waivers for insulin therapy.

Something has changed then since I got out from performing these exams right before the required exam passage. I attended a Concentra Occ Med conference in Dallas ~2011-2012 and at that point NO one had ever been waived due to the agency fearing hypoglycemic episodes on the med. I'd love to know what's caused this change in heart unless the regulation itself was re-written.

[Reality Check 2]

I am counting the days until I do not have to do another DOT exam.

 

Every single exam I have done recently has been returned by the employer who has no idea what they are doing - they say I checked the wrong box or signed the wrong area or didn't sign this area or that.

 

SICK OF IT. 

 

If I sign the area that says INTRAstate only then the driver can't cross state lines. If I sign the federal portion too then we have a conundrum - you can't be restricted to state lines AND federally ok too - to cross state lines.

 

If folks who employee DOT drivers cannot figure this out - then they shouldn't be doing it.

 

A cranky butt Monday with some less than stellar folks telling me my form is wrong - again - same form as last time - same boxes checked and the DOL and the DOT don't have a problem with it but some uneducated secretary filing forms does.

 

Throw in all the arguments about sleep apnea, documenting compliance, vision that won't pass, high A1cs and all the other garbage - I AM DONE.

 

Looking forward to not doing these anymore.