DOT Case Discussion Type II DM on Insulin

[Guest UVAPAC]

Hi,

I am looking for your opinion on this case.  

Female in 30's looking to get a public service license.  

 

First encounter with patient late 2017:  1000+ mg/dL glycosuria.  Admits she is a Type II Diabetic -  Not on any treatment.  Decided she felt normal without medication so discontinued insulin/orals.  HA1C obtained ( >14.5%).  Patient disqualified.  

Second encounter 4 months later:  Patient returns to our office for another DOT examination.  She has a recent HA1C of 6.8%.  She states after leaving our office she had 2 episodes of DKA, had a "come to moment," established care with Endocrinology, and is now compliant with her Lantus and sliding scale Novolog.  She has a letter from her endocrinologist stating she believes it is safe for her to operate a vehicle, and while she does get symptomatic hypoglycemia - has prodromal symptoms, carries food with her, etc.  I issued a 6 month card INTRASTATE ONLY (with state granted waiver), rationale - improved glycemic control, compliant with meds/diet, letter from Endocrinologist.  

 

Today:  Patient returns for re-certification.  Upon review of hospital records, she has had TWO admissions for DKA in the last 30 days.  ED reports document poor dietary compliance, poor insulin compliance.  Her HA1C is back to 10.0%.  I disqualified with the rationale of non-controlled Type II diabetes.  

I spoke to the patient's Endocrinologist:  They seemed quite annoyed with my call.  They asked "on what basis are you disqualifying them" and when I explained my concern with the recent hospitalizations (abdominal pain, nausea/vomiting, etc), large fluctuations in HA1C, poor compliance with insulin (concern for both hyper/hypoglycemia)...

Them:  "You do understand a HA1C of 7.0 puts them at higher risk for sudden incapacitation don't you."  

Me:  "Yes I do"

Them:  "Um OK, goodbye."  

Am I missing something?  Does Endocrinology really believe someone with 4 hospitalizations in the last 9 months, 2 in the last month, with wild fluctuations in blood sugar should be driving a school bus?  DKA/HHS can cause neuro symptoms and incapacitation, same as hypoglycemia?

[Cideous]

Disqualified.  Period.  End of story.  No if's, ands or buts...

[jmj11]

My only thoughts are, in neurology, we disqualify people from driving if they have had a sudden onset of change in cognition for any reason (usually seizure or TIA). I know that professional drivers have a different standard. Maybe the way that the endocrinologist is seeing it, is that hypoglycemia is not probable with that patient, while long term organ damage is but not relevant to their driving today.

[GetMeOuttaThisMess]

Did FMCSA guideline change requiring a waiver (which no one ever gave) for an IDDM pt.?

[Guest UVAPAC]

9 minutes ago, GetMeOuttaThisMess said:

Did FMCSA guideline change requiring a waiver (which no one ever gave) for an IDDM pt.?

There are 2 waivers for IDDM.

1)  Federal Waiver

2)  State Waiver

The way the state waiver works in our state is you complete the examination, and check "accompanied by a insulin waiver" regardless of if they have the waiver or not.  The DMV then verifies if they have been granted a waiver or not.  If they have not been granted a waiver, they mail them the paperwork to be complete by their managing provider (it does not have to be an Endocrinologist).  The paperwork is then submitted to the DMV and the waiver is approved or denied.  In this case her Endocrinologist completed the necessary paperwork, and a waiver was granted 6 months ago.  

[GetMeOuttaThisMess]

Hmm. Okie dokie. I second above. No way, Jose.

[Guest UVAPAC]

Thanks for the responses.  I just wanted to make sure I am not crazy.

It was very clear that this "specialist" was irked I denied a card, and essentially tried to tell me that hyperglycemia in no way/shape/form can cause sudden incapacitation and therefore I am an idiot for disqualifying the patient.  

[Cideous]

18 hours ago, UVAPAC said:

Thanks for the responses.  I just wanted to make sure I am not crazy.

It was very clear that this "specialist" was irked I denied a card, and essentially tried to tell me that hyperglycemia in no way/shape/form can cause sudden incapacitation and therefore I am an idiot for disqualifying the patient.  

1.)  DOT drivers drive looooong distances and do it all in a stretch.  She might not go out suddenly without warning, but the way these guys/gals push themselves to get the load delivered, I could absolutely see her going into DKA on a trip and loosing their ability to focus 100% on the road.

2.)  She had her chance and blew it.  It's on her, not you.

3.)  Is the Endo's name going to be on her card?  No, but yours will be and that is the first thing they will pull when they are scraping up kids from the bus she just ran over.   Worth it?  Only you can decide that, but as I said above, no way in hell or earth I would sign that card.