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Reality Check 2

Sleep Apnea and the DOT

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I have done DOT exams for over 20 years in 2 states for both occupational med clinics and through family practice.

 

I chose to get certified when the whole change went down. 

 

Now, it is becoming the bane of my existence and sleep apnea is probably the biggest issue.

 

I have read the regs, studied Natalie Hartenbaum's book and trolled websites looking for some clarity.

 

Bottom Line - lots of folks have sleep apnea or are high risk based on obesity, neck circumference, comorbid diseases and, some, you just look at clinically and KNOW they have sleep apnea.

 

The pushback and frank rudeness of drivers is overwhelming. I have been yelled at, cried at, threatened and blasted with all kinds of govt control/conspiracy BS and "ruining my career" and "none of your business" and everything inbetween with profanity.

 

The local doc in a box is running about a 75% rate of giving out 3 month cards and DEMANDING sleep apnea tests. The drivers then find out I am certified at their Family Practice clinic (that they never come to anyway) and come in expecting me to just sign them off based on "knowing them" and "understanding" that they can't afford the test and don't have time and the "government has no right to interfere in this"...........

 

Best line ever - "well, have you EVER seen a negative sleep study? It's all about the money - they say everyone has it."

 

Well, in all honesty, I would have suspected sleep apnea whether you came in for a physical, med check, illness or your DOT. Risk factors don't change based on why you are in my office.

 

So, I am struggling ----- the 52 yr guy with a BMI of 41, a neck of 19", narrow pharynx, semi-controlled HTN and refusal to treat lipids or address metabolic syndrome yells at me because the doc in a box gave him a 3 month card after paying full price and wants him to have a sleep study that all his coworkers had to have as well and their insurance sucks and they have a $3000 copay.

 

Sorry, that is not my fault, my doing or really my true medical concern. It sucks and insurance sucks but I am bound by Federal Regs and cannot ignore the quite literal 900 lb elephant in the room. 

 

Wanted to shove this out there and ask what others have experienced? Any resources of any validity?

 

I am resigning myself to the idea that a lot of folks are going to hate me and a lot of folks have Sleep Apnea whether they want to deal with it or not.

 

And I seriously doubt I will renew my DOT examiner certification. Not worth the time, effort, money or hatred.

 

I want safe drivers. I would like my sanity and my safety as well.

 

Deep Sigh

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For people on CPAP, we require records.  I've mostly been getting skinny drivers lately, but the overweight ones I've been telling they will likely have to get sleep studies before their next card, and urge them to work through their regular provider so it's not a crisis when it comes to that.  We'll see if anything comes of it.

 

Oh, and I HAVE seen a negative sleep study, but since we use a pretty thorough pre-screener, that's a rare occurrence, since the sleep studies are done only to confirm suspected sleep apnea.

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Mine are all "new finds" - where they went to the Doc in a Box for the first time in 1-2 years to get their DOT and - voila - they get a surprise 3 month card and told the obvious - they need a sleep study.

 

They feel threatened, vulnerable, old and replaceable. They feel like they have been ambushed when the problem has been there all along - no one dealt with it and DOT didn't enforce or recommend anything.

 

They are also stubborn and become hateful and mean when forced to deal with this.

 

The one chain of clinics is seriously at about a 75% rate of giving out 3 month cards - BMI alone, BMI and neck circumference or neck circ alone.

 

A lot of DOT particularly guys don't have a PCP.

 

The DOT needs a POLICY on this - not recommendations.

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Guest UVAPAC

I started administering the STOP BANG questionnaire to all of my patients with the standard DOT paperwork.  I was planning on mandating a sleep study for all patients scoring 5/8 or higher.  When my attending physicians found out I was doing this I got reamed out, and told "I do not make policy" and they will determine what is and is not necessary.  Again I think OSA is a huge issue, and a lot of drivers are slipping through the cracks with no real screening.  

 

I do ask and document from each patient "Do you have difficulty sleeping at night"  "Do you have daytime sleepiness"  That way I have at least some ground to stand on as to why I don't mandate sleep studies on every patient with a BMI greater than 35 or neck circumference greater than 17 inches.  

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The federal regs can't be usurped by your docs or admins.

That is one really big struggle when seeing these folks in the Family Practice setting.

 

You want happy patients but there is no way to circumvent the facts to keep a patient "happy" instead of safe.

 

I have had several threaten to "find someone else". My rapid fire response is "good luck". I am at least nice about the regs and will treat you as a whole patient instead of just a dude in the queue needing a DOT.

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I started administering the STOP BANG questionnaire to all of my patients with the standard DOT paperwork.  I was planning on mandating a sleep study for all patients scoring 5/8 or higher.  When my attending physicians found out I was doing this I got reamed out, and told "I do not make policy" and they will determine what is and is not necessary.

You aren't working for them.  You're working for society.  Their name isn't on the medical examiner's certificate--yours is.  If they want to have a say in what they're comfortable with, they are perfectly entitled to see those DOT patients themselves.

 

Or maybe I should take a step back: No doc who is NOT credentialed as an FMCSA examiner should have any input into the process whatsoever.  If that's happening, then I have a real problem with that.

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You aren't working for them.  You're working for society.  Their name isn't on the medical examiner's certificate--yours is.  If they want to have a say in what they're comfortable with, they are perfectly entitled to see those DOT patients themselves.

 

Or maybe I should take a step back: No doc who is NOT credentialed as an FMCSA examiner should have any input into the process whatsoever.  If that's happening, then I have a real problem with that.

 

 

Could not have said better myself.

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Spent 14 years as a sleep tech before heading back to PA school, I know your pain. The DOT guys are usually very frustrated with the whole process and many of them showed up at the lab with a chip already on their shoulder. 2/3's of the patients either demanded that they be put on CPAP regardless of results or demanded that I not put them on CPAP because it was all just a scam. The other 1/3 were guys who knew the regulations, were compliant with their CPAP and felt like they were better at their job because of their machine. I half joked with our medical director that we needed to make a list of those guys and pay them to come in and talk shop with the doubters to get them on board.

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Got my first NEGATIVE sleep study today.

 

Guy has a BMI of 44 with basically no neck and barrel chest but had an AHI of 3 on testing.

 

The patient will either be pleasantly surprised or angry that he had to have the test.

 

Either way, I have documented proof for the DOT and his employer.

 

We will see how he reacts.....................

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Guest UVAPAC

I am just curious if you guys have any updates on this subject:

 

I am having a lot of difficulty deciding when I should and should not send people for sleep studies.

 

Yes I understand the risk factors of BMI, neck circumference, mallampati score, gender (male), Age etc...

 

I have had a lot of people come in with a BMI between 40-50, with Mallampati score of III... who adamantly deny daytime sleepiness, difficulty sleeping, loud snoring.

I will generally give all of them the Epworth Sleepiness Scale Test (Yes I know it is easy to lie on these tests) and most of the time will get scores ranging from 3-7 (low risk to average risk of OSA). 

Many of these drivers have been on the road 10+ years with not a single accident to their name. 

 

Is it enough to document that the patient denies these issues, and has an appropriate Epworth Score... or do you just say... listen you are overweight, have a narrow airway.... deal with it and go pay for a sleep study?

 

 

 

Like the initial poster mentioned this can be a very emotional topic:  People without the money to pay for it, people who depend on their card to feed families, etc...

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Now that I WORK in sleep medicine ~2 days a week, BMI 35 as a hard "must have a negative sleep test or CPAP compliance numbers" is just that much more sustainable.  Seriously.

 

As a FMCSA examiner, your job is NOT to play nice with the patient and trust them: Your client is society, not the patient. Your client is the poor person in the Subaru who will or will not be killed or maimed by the sleepy driver.

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Guest UVAPAC

Now that I WORK in sleep medicine ~2 days a week, BMI 35 as a hard "must have a negative sleep test or CPAP compliance numbers" is just that much more sustainable.  Seriously.

 

As a FMCSA examiner, your job is NOT to play nice with the patient and trust them: Your client is society, not the patient. Your client is the poor person in the Subaru who will or will not be killed or maimed by the sleepy driver.

 

Rev-

 

Do you foresee FMCSA ever mandating sleep studies at a certain BMI?  Or at least certain criteria in which it is non-negotiable to have a sleep study. 

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I certified and am SO glad I don't have to do them any more at my new job. I feel your pain. I have been yelled at so many times it isn't funny like I made them obese or deaf or blind. I tell them all the same thing... my job is to keep you from killing a bunch of people when you are dragging 60k pounds down the highway. I work for the goverment and the people you share the road with not you. If you are that worried about your career take some responsibility for your health.

I had one guy come in for an initial physical for his CDL and he was wearing an insulin pump.... criminy

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Do you foresee FMCSA ever mandating sleep studies at a certain BMI?  Or at least certain criteria in which it is non-negotiable to have a sleep study. 

I sure hope so!

 

Fact is, CPAP therapy is cheaper and better every year. My sleep team is able to get 90-95% of people who trial a CPAP mask to tolerate it, and some of the others are intentionally failing because they want oral appliance therapy but their insurance mandates CPAP trial.

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Wife says I need it but I just can't imagine tolerating an apparatus though others obviously do. No claustrophobia. Her school has a new program for techs and wants me to volunteer at no cost. Seems like it would be a no-brainer.

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I have had very poor response to dental therapy for CPAP. We have a very enthusiastic dentist in town who loves this stuff.

 

But, she says it can take months to get the right appliance and then I make them get a sleep study with the appliance in to show their AHI has dropped below 5 with it in. They really don't like this. They all want a one year card while fitting the device and I say no.

 

Trying to get the drivers to understand THEY are responsible for bringing me the compliance reports has gone over like the proverbial turd in the punchbowl. Somehow, this is punishment and they think our office is supposed to get all this data as part of our job.

 

I will be leaving the DOT realm soon at the VA and am actually quite thankful. I am exhausted by the fighting and anger that the drivers and employers are spouting. 

 

Sleep Apnea needs to be more concrete with DOT with solid regs and not these nebulous recommendations, just like insulin.

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Guest UVAPAC

So we have just basically come to an agreement in our practice (after I pushed the MD's for years) so we could have some uniformity...   (I hate the idea that a patient could qualify with one of us, and not with another.  Yes I know these are somewhat subjective examinations, but we should all be on the same page).

 

Basically anyone with a BMI > 40 with 2+ risk factors (Mallampati score > 2, DM II, HTN, Neck Circumference, Age, etc) will be mandated to go for a sleep study.  Non-negotiable, unless they have had a recent one showing no evidence of OSA.

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Guest UVAPAC

So I just want to see if others have an opinion on this case.  50 year old female:  

 

BMI 53.5

Type II DM -  Controlled HA1C 7.6

HTN-  Controlled with lisinopril 5mg

Mallampati score III

Neck circumference > 17.5cm

Given Epworth Sleepiness Scale -  Score 2

Issued a 3 month card and required to go for a sleep study.

 

Patient became extremely irate, basically called me incompetent, said she can't afford a sleep study and I am costing her her position of many years driving students on a bus.  I don't see any way around my determination?

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On 2/28/2018 at 4:20 PM, UVAPAC said:

So I just want to see if others have an opinion on this case.  50 year old female:  

 

BMI 53.5

Type II DM -  Controlled HA1C 7.6

HTN-  Controlled with lisinopril 5mg

Mallampati score III

Neck circumference > 17.5cm

Given Epworth Sleepiness Scale -  Score 2

Issued a 3 month card and required to go for a sleep study.

 

Patient became extremely irate, basically called me incompetent, said she can't afford a sleep study and I am costing her her position of many years driving students on a bus.  I don't see any way around my determination?

The last I looked up DQ standards for Sleep Apnea, absent a sleep study and clearance following the study/Rx the pt could not be granted a medical certificate for a CDL.

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Guest UVAPAC
8 hours ago, CAdamsPAC said:

The last I looked up DQ standards for Sleep Apnea, absent a sleep study and clearance following the study/Rx the pt could not be granted a medical certificate for a CDL.

If they had previously held a CDL and are "asymptomatic" which almost everyone claims, they recommend issuing a 3 month card and ordering a sleep study.

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11 hours ago, UVAPAC said:

If they had previously held a CDL and are "asymptomatic" which almost everyone claims, they recommend issuing a 3 month card and ordering a sleep study.

The "asymptomatic" must be documented by the Sleep Study physician or I don't sign the form........

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On 2/28/2018 at 1:20 PM, UVAPAC said:

So I just want to see if others have an opinion on this case.  50 year old female:  

 

BMI 53.5

Type II DM -  Controlled HA1C 7.6

HTN-  Controlled with lisinopril 5mg

Mallampati score III

Neck circumference > 17.5cm

Given Epworth Sleepiness Scale -  Score 2

Issued a 3 month card and required to go for a sleep study.

 

Patient became extremely irate, basically called me incompetent, said she can't afford a sleep study and I am costing her her position of many years driving students on a bus.  I don't see any way around my determination?

STOP BANG of 4: BMI, neck, HTN, age.  Considering all the other criteria are subjective or falsifiable (snoring, tiredness, observed apneas), or inapplicable (she's not male) I would likely not even issue her a 3 month card.

ESS is for PATIENTS only.  CDL medical certificate examinees are not patients and cannot be relied upon to answer questions truthfully against their own economic self interests.

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