Guest UVAPAC Posted June 18, 2016 The following is a case of a current patient I am seeing for DOT Certification. Any input/advice would be appreciated! Patient is a 73 year old male who has been a long time driver for a local bus company which primarily transports elderly population to medical appointments, grocery stores, etc. (Requires class B Endorsement). Patient has a long history of aortic stenosis, and has no other remarkable past medical history. We obtained an echocardiogram in 2014 which showed "moderate aortic stenosis" and patient was asymptomatic and following up with cardiology regularly. He was given a clearance letter from his cardiologist stating no contraindication to his driving. He presented last week for re-certification. Again he had clear murmur consistent with AS radiating to carotids. Per the recommendations, I had patient go for echocardiogram. This was interpreted as "severe aortic stenosis, with rapid progression from previous study obtained in 2014." "No Left Ventricular Hypertrophy is noted" His Cardiologist essentially wrote him a note stating because he his asymptomatic, and does not have LVH, his risk of sudden cardiac death is slim. He believes watchful waiting is the best approach, and surgical intervention is not warranted at this time. He scheduled a 6 month follow up and repeat echo, at which time if it continues to progress, he will replace the aortic valve. The FMSCA guidelines which have been pulled down from their website, previously recommended not certifying anyone with severe AS regardless of if they are asymptomatic. Natalie Hartebbaum (regarded as the guru of DOT Physicals) recommends not certifying anyone with severe AS regardless of if they are asymptomatic. I discussed this case with my attending physicians, who along with me did research in regards to severe AS and incidence of sudden cardiac death. Essentially there is an annual incidence of 1-5% (which in my mind is high). I believe because of the previous guideline, the patient should be automatically disqualified. My attending physicians believe a stress test should be ordered, and if it returns as negative, consideration of a 6 month card should be given. Anyone have thoughts on this case/situation. If I were responsible for a bus of people crashing, I don't know how I could sleep at night knowing what the previous guideline had recommended. (Meanwhile the patient calls our office 2-3x daily asking when my decision will be made, and reminding me I have taken away his job and he is unable to work until he is cleared)
logos Posted June 18, 2016 I agree with you. I would not certify. Let your attending know you are not comfortable clearing him. I did these for a number of years and remember some vey upset patients that did not pass. If your attending recommends signing ask him if you can put the patient on his schedule for him to complete the paperwork. Not ideal, but a reasonable option.
Moderator ventana Posted June 18, 2016 Moderator stress for AS? why - no anginal s/s what he needs is a CATH to determine his actual valve area, so you can get the right data.... US is not that great on valve area - - also if he is less then 0.7cm he likely needs surgery anyways unless he has a short life expectancy..... which is sounds like he does not.... as for Certification - if US (was it transthoracic or TEE?) Could start with a TEE to get better pictures...------ but if you have a current US saying SEVERE AS and the guidelines say this is a disqualifying finding, answer is clear...
GetMeOuttaThisMess Posted June 18, 2016 stress for AS? why - no anginal s/s what he needs is a CATH to determine his actual valve area, so you can get the right data.... US is not that great on valve area - - also if he is less then 0.7cm he likely needs surgery anyways unless he has a short life expectancy..... which is sounds like he does not.... as for Certification - if US (was it transthoracic or TEE?) Could start with a TEE to get better pictures...------ but if you have a current US saying SEVERE AS and the guidelines say this is a disqualifying finding, answer is clear... If you have FMCSA documentation that states this individual should not be cleared then I would not clear (concur with above quote). Remember, it isn't about the individual, it is about protecting the rest of us FROM the individual. Personally, no way in Hades that I clear this patient. Too many other options/examiners that the driver can partake of that might allow him to be passed. If YOUR name is on the certificate then YOU'RE the first stop for the FMCSA folks at the time of the fatality investigation. All that being said, you DO have the letter from the specialist who gives you authorization to clear but what I always did in the past was provide a highlighted copy of the FMCSA guideline in the referral letter to the specialist for that particular concern and attach a copy of same to the letter from the specialist clearing the individual. Just because the pt. hasn't had any of the classic triad of symptoms for AS there WILL be a first time at some point. You just hope it isn't while he's behind the wheel.
Administrator rev ronin Posted June 18, 2016 Administrator I concur with the above. The cardiologist can make a recommendation, but the examiner has the final say. In this case as presented, I would not pass this gentleman either. "Rapid progression from previous study" seals the deal for me.
Reality Check 2 Posted June 19, 2016 Do you have Natalie Hartenbaum's book on DOT? If not, get one. I photocopy the pages from it all the time and give to the patients. I print out from the DOT websites so the patients know I am not pulling this out of my shorts. It is so hard to have folks understand that there is nothing punitive about this. It is safety 100%. If this guy is a bus driver - do you really want him with a bus full of kids? I always stress to the patient that I am bound by federal law to ensure these rules are followed. I don't make them but I sure have to follow them. It sucks if someone says you "ended" their career but better to end that than to see them on the news in a bus crash. Bus drivers where I live face mountain roads, rural routes, ice on roads in May sometimes and we have had one turn on its side and skid down a gulley. The driver had to pull each kid out of the roof hatch before the bus went down the hill. Could your guy do this? Doubtful Stick to the rules, know you didn't make them but know you are doing the right thing for public safety.
Administrator rev ronin Posted June 19, 2016 Administrator I openly mock the rules to build community with the drivers. "Yeah, we're only doing the hernia check because DOT says I have to. When was the last time you heard a driver go 'Ow! My Hernia!'?" (said while pantomiming turning a steering wheel to the left) Often gets a chuckle out of them.
CAAdmission Posted June 20, 2016 Your docs want to stress test a guy that has a US report stating "severe" AS? They have a lot higher sphincter tone than I do. What could possibly go wrong?
Reality Check 2 Posted June 20, 2016 In the old days, I "stress tested" truck drivers by putting a pulse ox on them and having them go around their own truck 5 times while inspecting the tires and hookups. My old clinic had their rigs in the parking lot. We could do a lot of interesting things back then. They would be out of breath, pulse ox often dropped (tons of smokers) and their pulse would be in the 130-140s. Their final sputtering cough and hawking a loogy as it were - that polished off that visit. One company would actually measure their guys and make them demonstrate ability to fit through the cab door without adjusting the steering wheel. Tell tale sign on walking into the clinic - overalls with the side buttons unhitched and nowhere in the same zip code to one another.....
CAAdmission Posted June 20, 2016 One company would actually measure their guys and make them demonstrate ability to fit through the cab door without adjusting the steering wheel. Tell tale sign on walking into the clinic - overalls with the side buttons unhitched and nowhere in the same zip code to one another..... As a society we are approaching the point where weight and BMI will soon be meaningless. We are going to have to start measuring a patient's gravitational field.
Reality Check 2 Posted June 20, 2016 I watched the movie Wall-E for the first time recently - yeah, I am way behind and my kids are too old. The folks in there lived on a spaceship and were so fat they couldn't walk - so the robots did everything for them. Are we there yet????? Pretty close.
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