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Guest UVAPAC

DOT Case (Pretty Scary Stuff)

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Guest UVAPAC

I would like to share a DOT case presentation to get thoughts/opinions on:

 

A patient (in their 70's) M patient who has been a long time bus driver (Class B License) and coming to our clinic for many years for DOT physicals.  It has been well documented for years that the patient has a grade III/IV murmur RUSB radiating to carotids.  We obtained Echo's and Cardiology clearance letters over the years documenting/confirming moderate AS.  Per guideline, if asymptomatic, with clearance from Cardiology, eligible for a 1 year card.  It was always documented patient states no CP, SOB, DOE, Palpitations, or syncope.

 

A recent echo showed "severe AS" and per the guideline automatic disqualification until surgically repaired, and 3 months post-op with cardiology clearance.  First and foremost upon disqualifying, we were contacted by an extremely irate Cardiologist telling us "the guidelines are stupid" and "don't tell me how to practice Cardiology" followed by some very choice/unprofessional language.  Anyhow we did not waiver in our decision.

 

Ultimately the patient had an aortic valve replacement.  Seeing as the patient was coming in, I decided to review their medical history in our hospital EMR (separate from our system.)  Most recent diagnosis was.... surprise... SYNCOPE 3 years ago. 

 

Turns out this patient was driving in their personal vehicle to work, had syncope going 60 MPH, totaled their vehicle, was admitted to the hospital, and ultimately discharged.  (3-4 years ago). (Obviously if this incident had occurred just 30 minutes later while driving a bus it could have been catastrophic.)

 

My question is:  Because this patient has lied/omitted information previously, would you even consider giving them a card at this point? 

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Not only would I not give the card, I would ask the grizzled old veterans of our team about under what circumstances you report a driver to the registry itself. I'm pretty sure there is a mechanism that can be used to flag people so they can't just go get a new card from the chiropractor in the strip mall, as it were.

 

Actually... the above is what I'd do if the syncope and crash happened within the last year. 3 years out, I would consider the above. I'd also have to fight the urge to ask the d!#kbag cardiologist to put their signature on a letter specifically stating that the syncope and crash from 3 years back is unlikely to happen again, and see what they say.

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If the cardiologist wants to do DOT physicals, he or she can go through the NRCME process and sit for the stupid little test and issue them him or herself.  Failing that, it's MY name on the medical examiner's certificate, and I may, but am not required to, consider input from other professionals in determining whether to issue a medical examiner's certificate.

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I had an ENT tell me he felt safe driving next to a Meniere's patient in a semi and I had no business disqualifying the guy.

 

Meniere's is permanently disqualifying condition per DOT regs.

 

The ENTs stance did not help me make my case with the patient. His wife verbally threatened me and they threw a huge fit in the office.

 

I am with Rev - I did the training and it is my name and my judgment and there are rules and regs. I am not the angel of career death - just the messenger of the rules.

 

I tell the patient I have teenagers who drive and I have a moral, ethical and legal obligation to keep EVERYONE DOT on the road held to the same standard to keep everyone safe.

 

My cert for DOT isn't up till 2024. Some days I don't want to do them anymore for fear of patient retaliation.

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DOT isn't all bad eggs.  I did one over the weekend where the guy had his A1c done, showed me his glucometer memory, and brought a current CPAP compliance log.  Happy to give him a year's cert, even if he's at 8.3.... because at least I know exactly where he stands, and he hadn't checked "no" to everything all on down the form.

 

The legit drivers who know this is their livelihood are starting to catch on and comply.  The occasional "I just need to be able to drive the dump truck to the site" guys seem to be more ignorant of the changes.

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Guest UVAPAC

Reality Check-  Agreed patient retaliation is always in the back of my mind regarding disqualifying a patient. 

 

Rev-  I agree a lot of our clinics patients are starting to "get it."  We have people bringing in HA1C's, CPAP reports, blood pressure logs, letters from PCP's/Cardiologist/Endocrinologist's/Neurologist's...

 

Unfortunately there are still a lot trickling out of primary care clinics that were wrongfully given cards for many years, and come in expecting 2 years card with no documentation.

 

 

We actually made a website stating the most common medical conditions and what you must bring for your physical with any of the above conditions-  Our front office staff gives the website to every physical booked, and documents in the computer this discussion was had... therefore there is no excuse to come unprepared. 

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I am training some to bring their stuff in and be prepared.

 

The local doc in a box that does DOTs is still giving anyone with an 18 inch neck a 3 month card and demanding a sleep study.

 

That area is still not defined - recommendations but no mandates. Hard to justify a $4000 test for someone who doesn't snore, has no witnessed apneic episodes and has a spouse or bed partner who says that nothing is going on. 

 

A couple of AHIs have come back at 5 and 7. Hard to justify CPAP at that level. Most of my true apneics have AHIs of 79 and 104, etc.

 

I try to partner with the patient and make positive moves and stress how important things are regardless of DOT - I just care about their general health.

 

My schedule today shows a 79 yr old coming in for a DOT - no history in his chart. Curious to see what this is about.

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