DOT National Registry Exam
Drug Abuse & Alcoholism Documentation documentation of successful completion of a drug rehabilitation program, what should be documented? 2 items
* SAP documentation of successful completion of a drug rehabilitation program, as well as - a negative drug test result,
• If this is the first time driver has been diagnosed with Stage 1 BP and driver is not on hypertensive medication, ME may certify the driver for how long and advise what?
- 1 year. • ME should advise driver that driver should follow-up with her/his primary care physician for consideration of hypertension treatment. - should advise driver about the nature of hypertension, the importance of hypertension as a risk factor for CVD. - advise driver that if hypertension is not controlled by the next certification examination that the driver's certification status may be limited or the driver may not be able to be certified.
What are three Neuro "cannot be qualified" conditions?
- 1) Epilepsy, 2) Meniere's disease, 3) AVM not surgically treated. ( arteriovenous malformation is an abnormal tangle of blood vessels connecting arteries and veins, which disrupts normal blood flow)
MI YES TO CERTIFY
- 2 months post MI - Cleared by cardiologist - No angina - EF >= 40% - Medication tolerance
What is the Maximum certification ETOH recovery?
- 2 years
Stage 1 HTN - If the driver has been previously diagnosed with Stage 1 hypertension or is already on medication treatment for hypertension, the ME may certify for how long and advise what ?
- 3 month certification and advise the driver that the driver should follow-up with PCP to obtain treatment that controls blood pressure to less than 140 over 90. - and advise the driver that if this is not done within the 3 month timeframe the driver will not be certified until the driver's BP is within the certification guidelines of 140 over 90.
Stage 2 HTN requirements at f/u review and indication for certification .........
- A BP in this range is an absolute indication for anti-hypertensive drug therapy. Provided treatment is well tolerated and the driver demonstrates a BP value of 140/90 or less, he or she may be certified for one year from date of the initial exam. The driver is certified annually thereafter.
• History of alcoholism, not to certify if the driver has: 4 items
- A current clinical diagnosis of alcoholism. - Signs of a current alcoholic illness and/or non-compliance with DOT alcohol conduct guidelines. - An alcohol-related unstable physical condition, regardless of the time element. - Not met return-to-duty requirements.
Certification/Recertification - Stage 2 Hypertension Recommend not to certify if the driver has ....... 2 items
- A one-time, 3-month certificate for stage 2 hypertension and BP greater hypertension greater than, equal to 140 over 90, - BP greater than or equal to 180/110, regardless of any other considerations.
Who must be tested for ETOH/drugs?
- All drivers, including part-time, holding a commercial driver's license (CDL) and operating CMVs (greater than 26,000 combined gross vehicle weight rating, or transporting more than 16 passengers, or placarded hazardous materials) on the public roadways must be U.S. Department of Transportation (DOT) drug and alcohol tested. - This means any driver required to possess a CDL, including drivers employed by Federal, State, and local government agencies and owner operators. - Equivalently licensed drivers from foreign countries. NOTE: Drivers who only operate CMVs on private property not open to the public do not require testing.
Stage 1 hypertension corresponds to a BP of ........
- Between 140 and 159 and/or a diastolic BP of between 90 and 99. - The driver with a BP in this range is at low risk for hypertension related acute incapacitation
• The ME should obtain additional evaluation by appropriate mental health professionals, which may include: 4 items
- Breath alcohol technician (BAT). - Designated employer representative (DER). - Medical review officer (MRO). - Substance Abuse Professional (SAP). Do not to certify a driver who uses -2 items* - Methadone - Schedule I drugs include marijuana and are disqualifying, including "medical marijuana" or marijuana for "medicinal use." and are not considered safe, even under medical supervision.
Pacemaker post placement waiting period to certify, parameters and how often to certify
- Certify 3 months post placement - documents of correct function - no symptoms - ANNUAL RECERTIFICATION
Examine driverʼs mental status and note signs, symptoms, or other findings which may require follow-up with a mental health professional:
- Comprehension and interaction; - Cognitive impairment, for example: • Orientation • Intellect • Memory • Obsessions • Circumstantial/tangential speech • Signs of depression • Paranoia • Antagonism Aggressiveness
Cardio Vascular Disease not to certify diagnoses, 5
- Hypertophic cardiomyopathy. - Restrictive cardiomyopathy. - Pulmonary hypertension, regardless of the underlying cause • Other cardiac diseases: - e.g., myocardial infarction, CHF, coronary insufficiency, cardiac arrhythmias - Uncontrolled hypertension.
Recommend to certify if the driver with a history of alcoholism has: 3 items
- No residual disqualifying physical impairment. - Successfully completed counseling and/or treatment. - No current disqualifying alcohol - related disorders.
Alcoholism: Except where absolute criteria exist (i.e., a current clinical diagnosis of alcoholism), who makes the final determination as to whether the driver meets the Federal Motor Carrier Safety Administration (FMCSA) medical standards for driver certification.
- The ME, you - Use whatever tools or additional assessments you feel are necessary. If the driver shows signs of alcoholism, have the driver consult a specialist for further evaluation.
Regulations: The ME Must Evaluate On examination, does the medication the driver is taking have: 2 items
- The desired effect on the underlying disease (e.g., blood pressure is lowered)? - Side effects that interfere with safe driving (e.g., uncontrollable tremor or orthostatic hypotension)?
Alcoholism - What is the waiting period for Certification/Recertification and what must be completed?-
- Waiting period: No recommended time frame. - Do not certify the driver until the driver has successfully completed counseling and/or treatment.
HTN History, PE, Additional Info, Disqualifying Diagnoses History - Current over-the-counter (OTC) and prescription medications and supplements, .........
- potential side effects, which may be potentially disqualifying. - Cardiovascular diseases (e.g., hypertension, congestive heart failure, myocardial infarction, coronary insufficiency, or thrombosis).
MI DON'T CERTIFY parameters
- recurrent symptoms - EF <40% - Abnormal ETT - ischemic changes - Poor tolerance meds
Cardiac Symptoms
- syncope, dyspnea, chest pain, palpitations
The driver who is disqualified for high BP/uncontrolled hypertension should not be considered for recertification .........
- until BP is stabilized at ≤ 140/90. - Treatment should be well tolerated before considering certifying a driver with a history of stage 3 hypertension.
Requirements for previous Stage 3 HTN certification and for how long ?
140/90 or less and treatment is well tolerated. - driver may be certified for 6 months and biannually (every 6 months) thereafter if at recheck BP is 140/90 or less. • Annual recertification is recommended if ME does not know hypertension severity prior to exam. - An elevated BP finding should be confirmed by at least 2 later measurements on different days.
Waiting period - post MI
2 month post MI
HOW LONG POST MI TO CERTIFY?
2 months
The driver disqualified for stage 3 hypertension may be recertified for how long and what parameters?
6 months if BP is less than, equal to 140 over 90, and medications are well tolerated.
Drug and ETOH Health Counseling
Counseling: advise a driver regarding side effects and interactions of medications and supplements (e.g., narcotics, anticoagulants, psychotropics), including over-the-counter (OTC) medications (e.g., antihistamines, cold and cough medications), which could negatively affect his/her driving. Inform the driver of the rationale for delaying or potentially disqualifying certification, which may include health dysfunctions (e.g., depression, bipolar).
Syncope do y don't certify; max time of certification
DON'T certify w/ symptoms, high risk, Max 1 year certification Cleared from specialist Annual evaluation by specialist Annual medical examination Certify - No exact waiting time; not till stable, can refer to pacemaker guidelines
Drug and ETOH CMV Driving Demands 3 items
Demands of CMV driving may complicate adherence to prescribed dosing intervals and precautions. • Irregular meal timing, periods of sleep deprivation or poor sleep quality, and irregular or extended work hours can alter the effects of medicine and contribute to missed or irregular dosing. Physical demands may increase pain and the need for medication.
Parameters that may be used in determining certification:
Diagnosis of - MI, angina, murmurs, arrhythmias Risk of sudden death - progressive angina, 2nd y 3rd degree heart block, a. Fib, SVT and V tach
What are ME requirements for drivers with alcoholism who have completed counseling and treatment to the point of full recovery and drivers with a history of prohibited drug use - who showe vidence he/she is now free from such use.
Document results of Substance Abuse Professional (SAP) evaluations for alcohol and drug use and/or abuse by drivers with alcoholism - who have completed counseling and treatment to the point of full recovery and drivers with a history of prohibited drug use - who show evidence he/she is now free from such use.
On exam, what does the ME evaluate the driver for ? 4 items
Does the driver: - have signs of alcoholism, problem drinking, or drug abuse, including: Tremor? Enlarged liver? • Who uses alcohol have a consumption pattern that indicates evaluation may be needed based on quantity per occasion or per day/week? • Pass standardized screening questions (e.g., Alcohol Use Disorders Identification Test (AUDIT), CAGE, and T-ACE)? • Have a history of driver and/or family alcohol-related medical and/or behavioral problems?
Is Drug and/or Alcohol Testing Required Pre-employment:?
Drug testing is required; however, a driver may be exempted from testing if the driver was in a testing program within the last 30 days and tested within the last 6 months or in a program for the previous 12 months.
EF DISQUALIFYING
EF <40%
Neuro - Physical Examination and Evaluation
Examine the driver's neurologic status and note: • Impaired equilibrium, coordination, or speech pattern(e.g., Romberg, finger-to-nose test). • Gait disorders, sensory, or positional abnormalities. Tremor, radicular signs, reflexes(e.g.,asymmetric deep- tendon, normal/abnormal patellar, and Babinski).
If the ME believes immediate testing for alcohol is warranted, contact
FMCSA or contact the employer of the driver directly
Stage 2 HTN - What is the range, certification length and advice?
Greater than equal to, 160 over 100, and less than 180 over 110 certified for 3 months. - and should be advised to - obtain treatment that controls the driver's blood pressure comfortably in the range that allows certification. less than, equal to 140 over 90. - If this is not done within the 3 month timeframe the driver will not be certified until the driver's BP is within the certification guidelines
When an interstate driver tests positive for alcohol or controlled substances under Part 382, the driver (is or is not) required to be medically reexamined or to obtain a new ME's certificate?
IS NOT provided the driver is seen by a SAP who evaluates the driver and does not make a clinical diagnosis of alcoholism. The SAP provides the driver with documentation allowing the driver to return to work.
Identification & History
Identify, query, and note issues in a driver's medical record and/or health history as available, which may include: Neurologic disorders (e.g.,loss of consciousness, seizures, stroke/transient ischemic attack (TIA), headaches/migraines, numbness/weakness).
Pre-employment alcohol testing (is or is not) required;
Is not ... however, the employer may require alcohol testing before the driver can
When in remission, alcoholism (is or is not) disabling
Is not unless transient or permanent neurological changes have occurred.
when maximum doses of multiple antihypertensive medications are used without achieving BP at or less than 140/90, ......
It is prudent that a more aggressive treatment plan should be monitored for effectiveness, interactions, and tolerance prior to driver certification. Follow-up: The driver should have a medical examination at least every 6 months.
MI max certification; Consider what 3 other conditions
Max certification 1 year; ,look at CHF, coronary insufficiency, thrombosis
Neuro - Refer a driver who exhibits evidence of any of the following disorders for follow-up care and evaluation by an appropriate specialist or primary care provider
Musculoskeletal(e.g.,arthritis, neuromuscular disease). • Neurologic(e.g.,seizures). Neurological examination parameters include: • Function, Range of motion, Strength, Sensation. • Referral to a neurological specialist for specialized conditions. Disqualification for any condition that poses unacceptable driving risk.
ETOH - Is ongoing voluntary attendance at self-help groups (e.g., 12-step programs) for maintenance of recovery disqualifying?
No it is not.
Who determines that recommended treatment for drug abuse has been completed, and the recommendations for return to work and follow-up testing.
The SAP
Stage 1 hypertension may be medically certified to drive for how long and how often certification examinations with what BP parameters?
_a one-year period. _Certification examinations should be done annually thereafter and should be < 140/90.
An elevated BP must be confirmed by ........
a second measurement later in the examination. All measurements taken should be recorded.
FMCSA considers how many and when BP findings that confirm high BP and require that FMCSA BP protocols be followed .........
any two consecutive BP readings - at the same examination, or any combination of examination, follow-up examination, and/or recertification examination,
If there are significant discrepancies between two readings, .........
at least a 3rd reading should be taken.
How often for ETT if hx of MI?
biennial; every other year
If previous stage one HTN is less than 160/100, at one year certification .......
certification may be extended one time for 3 months and should be < 140/90 at 3 month check up
• If driver fails to lower BP by the expiration date of the one-time, 3-month certificate, the driver will be .......
disqualified until BP is ≤ 140/90 at exam.
Side effects of medications that might interfere with safe driving include ........
dizziness, fatigue, interactions with other medications.
Examples of ME inquiry about medications used to control hypertension include requests to identify medications used including .........
dose, frequency, side effects, whether treatment has stabilized.
Stage 2 Follow-up - The driver must follow-up on or before the one-time, 3-month certificate expiration date and how can be rectified and how long?
driver has BP ≤ 140/90, the driver may be certified for 1 year.
Examples of other historical information that would assist the ME in assessing driver medical fitness for duty include ........
driver history of traffic, accidents, traffic tickets, episodes of weakness, fatigue, or syncope.
The driver disqualified for stage 1 hypertension may be recertified ......
for 1 year if BP is lowered to less than or equal to 140/90.
Heart examination Need for additional testing or referral,
ie murmurs, extra sounds, enlarged heart, pacemaker
OTC y prescription medications side effects;
ie weakness, dizziness, fatigue ie Beta blockers
Document for conditions
if necessary rate of progression, degree of control likelihood of gradual or sudden incapacitation
Episodic abuse of substances by commercial drivers that occurs outside of driving periods may still cause ......
impairment during withdrawal.
If the SAP determines that alcoholism exists, the driver .......
is not qualified to drive a commercial motor vehicle in interstate commerce. The ultimate responsibility rests with the __?__ to ensure the driver is medically qualified and to determine whether a new medical examination should be completed. *motor carrier
HTN: the driver should remain under the supervision of a treating physician in order to ........
monitor not only blood pressure but the effects of blood pressure medication, possible side effects of medication, and to monitor other risk factors for CVD.
INR monitoring records how often
monthly
Exercise tolerance test parameters
no ischemia tolerate exercise >6 MET
Once the driver with Stage 3 HTN has a documented BP of ≤ 140/90, the driver may be certified for ........
no more than 6 months, and future certifications of the driver should be for no more than 6 months. _- Driver should have no excess sedation or orthostatic change in BP. • If on confirmation of blood pressure less than or equal to 140/90 and a full examination was not performed, the expiration date should be ......... * one year from the date of the original examination.
If the SAP determines that alcoholism exists, the driver is
not qualified to drive a commercial motor vehicle in interstate commerce.
DVT - advise driver
of risk w/ inactivity while driving
Alcohol and other drug dependencies and abuse are profound risk factors associated with .....
personality disorders that may interfere with safe driving.
REMEMBER - Goal is to
qualify for safety for driving, not diagnose y treat
• Return-to-duty and follow-up testing is conducted when an individual who has violated the prohibited drug and/or alcohol conduct standards .....
returns to performing safety-sensitive duties.
- The ultimate responsibility rests with the —-?—- to ensure the driver is medically qualified and to determine whether a new medical examination should be completed.
the motor carrier
Certification/Recertification - Stage 3 Hypertension • At semi-annual examinations, if BP is stage 1 or stage 2 hypertension, consider .........
the one-time, 3-month certificate in accordance with stage 1 or stage 2 hypertension guidelines.
FMCSA considers ................ as readings that confirm an elevated BP.
two elevated BP readings at consecutive examination, whether follow up or recertification.
Even in absence of abuse, the CMV driver should be informed of effects on driving from interactions of drugs with
with prescription or nonprescription drugs and alcohol (e.g., alcohol enhances hypoglycemic effects of sulfonylureas).
Stage 1 Hypertension - Recommend to certify one time for 3 months if the driver has:
• A 1-year certificate for untreated stage 1 hypertension and is not on medication to control blood pressure. • Advise the driver that failure to lower BP to less than or equal to 140 over 90 will render the driver medically unqualified for continued certification
ETOH - A driver should not be certified if the driver has: 4 items
• A current clinical diagnosis of alcoholism. • Signs of a current alcoholic illness and/or non-compliance with DOT alcohol conduct guidelines. • An alcohol-related unstable physical condition, regardless of the time element. Not met return-to-duty requirements.
Drug and ETOH Risk Assessment Consider such general health and wellness factors as:
• Adverse health effects associated with rotating work schedules and irregular sleep patterns. • Long-term effects of fatigue associated with extended work hours without breaks. • Risk factors associated with common dietary choices available to drivers. • Stressors likely associated with extended time away from driver social support system.
Document Discussion of medication used
• Any affirmative history, including: - Onset date, diagnosis. - Medication (s), dose, and frequency. - Any current limitation(s). • Potential negative effects of medication use, including OTC medications, while driving. • Any abnormal finding (s), noting effect on driver ability to operate a CMV safely. • Necessary steps to correct the condition if appropriate, or reasons for disqualification. Any additional tests and evaluation.
Stage 3 HTN is BP greater than and certification requirements ..........
• BP at or greater than 180/110 high risk for an acute BP-related event. The driver may not be qualified, even temporarily, until reduced to 140/90 or less and treatment is well tolerated.
Monitoring/Testing: Before driver disqualified for stage 3 hypertension can be considered for recertification (max 6 months), driver must, at exam have:
• BP at or less than 140/90. Treatment well tolerated.
Obtain additional information when indicated by:
• Blood analyses (e.g., electrolytes, toxicology, blood chemistries). Drug-level monitoring (e.g., digoxin, theophylline). Refer a driver who exhibits evidence of a mental/emotional health disorder for follow-up care and evaluation by an appropriate specialist or primary care provider (e.g., depression, schizophrenia).
Epilepsy (two or more unprovoked seizures) waiting period
• GUIDANCE: 10 year seizure free waiting period off anticonvulsant medication
Single unprovoked seizure waiting period
• GUIDANCE: 5 year seizure free waiting period off anticonvulsant medication. A possible earlier return to driving if normal neurological examination, normal electroencephalogram, and recommendation to return to driving by a specialist in epilepsy
Childhood febrile seizures. Certify or not.
• GUIDANCE: Certify if the history of seizures is limited to childhood febrile seizures. Do not to certify if: As the medical examiner, you believe that the nature and severity of the medical condition of the driver endangers the health and safety of the driver and the public.
Stage 1 Hypertension - Recommend to certify one time for 3 months if the driver has: 3 items
• Has a diagnosis of hypertension treated with medication. • Tolerates treatment with no side effects that interfere with driving. • This applies to the driver with inadequately controlled BP. Advise the driver that failure to lower BP to less than or equal to 140/90 will render the driver medically unqualified for continued certification.
Recertification of the driver disqualified for alcohol or drug abuse requires the driver to: 3 items
• Have a substance abuse evaluation. • Have a negative drug test result. • Present SAP documentation of successful completion of the SAP required rehabilitation program.
Employer responsibilities include: 4 items
• Implementing and conducting drug and alcohol testing programs. • Providing a list of substance abuse professionals (SAPs). • Ensuring that the driver who is returning to a safety-sensitive position has complied with SAP recommendations. • Conducting follow-up testing to monitor that the driver is compliant with DOT alcohol conduct guidelines and abstaining from unauthorized drug use.
Medication Use While Driving Important considerations for medication use while driving, Does the medication: 7 items
• Indicate the presence of underlying disqualifying disease or injury? • Effectively treat the disease or medical condition? • Exhibit side effects that interfere with safe driving? • Have side effects that interfere with lifestyle functions such that the driver may cease to comply with treatment (e.g., decreased libido). • Have potential for gradual or sudden incapacitation, or exacerbation of underlying medical condition, due to missed dose (e.g., seizure, psychosis)? • Require monitoring to maintain a therapeutic dose or prevent toxicity (e.g., Coumadin)? • Interact with other drugs, food, and/or alcohol, interfering with the ability to drive?
Drug and ETOH Certification Outcomes and Intervals Disqualify a driver who (3 items)
• Is currently taking methadone. • Has a current clinical diagnosis of alcoholism. • Uses a controlled substance, including a narcotic, an amphetamine, or another habit forming drug, without a prescription from the treating physician. Disqualify a driver when evidence shows a condition exists that will likely interfere with safe operation of a CMV, which may include sufficient supporting opinions and information from specialists.
Stage 1 Hypertension Recommend to certify for 1 year if: 3
• It is the first examination at which the driver has BP equivalent to stage 1 hypertension and the driver: • Has no history of hypertension Does not use antihypertensive medication to control BP
Medical Examiner Action: Stage 3 Hypertension?
• ME should not certify the driver. • ME should discuss hypertension with the driver, advise the driver that medication treatment for hypertension is indicated, and provide the driver with follow-up recommendations and requirements. • ME should document discussion with the driver, including discussion of the causes of and contributing factors to high BP, and the risk that high BP creates for gradual or sudden incapacitation. • ME should provide the driver and/or the driver's physician(s), with information regarding required follow-up and treatment, and necessary BP reduction in order to be considered for qualification.
Alcoholism: Return to Duty - A driver with a history of alcoholism can be considered for certification if the driver has: 3 items
• No residual disqualifying physical impairment. • Successfully completed counseling and/or treatment. • No current disqualifying alcohol-related disorders.
Employer responsibilities do not include: 2 items
• Providing SAP evaluations. Paying for driver SAP evaluation, education, or treatment. When an interstate driver tests positive for alcohol or controlled substances under Part 382, who allows the driver to return work?* The SAP provides the driver with documentation allowing the driver to return to work.
Implications of single vs multiple medication regimens include ........
• Single drug well tolerated might include ACE inhibitors. • Multiple medications at or near maximal dosage may indicate poor hypertension control and likely increase risk of medication side effects.
Medical Guidance for Neurological Conditions: general guidelines for waiting periods include:
• Start dates. • Reasons to restart. • Length of waiting period. Conditions of waiting period. (e.g., seizure free, off anticonvulsant medication).
Important considerations for medication use while driving, Does the Driver: 5 items
• Understand and comply with medication plan, including monitoring? • Know what warning signs might indicate medication toxicity, interaction, etc.? • Store medications properly when driving long haul or cross country? • Read and understand warning labels on medications and supplements? • Consult the treating healthcare professional and/or a pharmacist before using new medication or combining medications while driving?
Do Not Certify and Recertification Issues According to regulation, do not certify the driver who: 3 items
• Uses a mind or body-altering substance, illegal or legal, in a manner that interferes with safe driving. • Abuses alcohol and/or drugs. Has a current clinical diagnosis of alcoholism.
Stage 1 Hypertension - Recommend Not to Certify if the Driver Has: 3 items
• already has a one-time, 3-month certificate for elevated BP or hypertension and BP greater than 140/90. • A history of stage 3 hypertension and BP greater than 140/90. • BP greater than or equal to 180/110, regardless of any other considerations.
Stage 3 Hypertension The driver may not be certified and for how long until the driver's BP is ........
≤ 140/90, .and then will be eligible only for certification for 6 months at a time.