Specialty Consults on DOT Physical

Close to half of your Commercial DOT Physical examinees have a significant medical condition.  Most times is easy enough to request some documentation or needed testing from the primary care treating physician.

Examples:

You have a diabetic for his DOT physical who otherwise appears healthy – you get a recent HbA1c and confirmation of oral medications from the PMD and you confirm s/he is not on insulin.  (see this article for federal diabetes exemption information).
A driver taking coumadin for DVT – confirm diagnosis, waiting period and monthly INRs are in range.
A driver’s blood pressure is a little over 140/90 – confirm home readings or those taken at the PMDs office recently, and perhaps check also that other cardiac risk factors are addressed, e.g. has had a stress test if indicated, lipids monitored and treated.

More Complicated DOT Exams

Then there are plenty of DOT physical cases where the driver has had a significant medical condition or risk factors for a condition that requires further evaluation.
As the medical examiner, in addition to obtaining any needed testing to make a determination, for these potentially more serious conditions, you also need a letter from the appropriate specialist that follows this mantra:

The specialist understands the role and function of the commercial driver and confirms the condition will not interfere with the safe operation of a commercial vehicle

When requesting a letter from any specialist or treating physician regarding a DOT physical, here are 3 things you can do to get the information you need to make a determination:

1. Send a form or letter to the specialist that says “I’ve examined Joe Driver today for his DOT physical/commercial driver exam.  He has a diagnosis of/risk factors for <any serious condition>.  Please review this information about the job of commercial driving and please provide the following information:”  Then list any tests you need, like stress tests or sleep evaluations, and indicate that you need a letter that states whether the condition is likely to interfere with the job of commercial driving.
2. Send the description of the job of commercial driving with your request.
3. Send the applicable regulations or guidelines for the specialist to address.

Indicate on your request that you will be unable to qualify the driver until this information is received.

What happens when you don’t get the information from the specialist?

I have a guy who’s sleep study last year showed sleep apnea. The Sleep Medicine provider felt it was mild enough to NOT warrant Tx with CPAP. However, the same Sleep Medicine provider will not provide a letter stating that he is safe to operate a CMV and that his diagnosis of mild sleep apnea will not impair his ability to drive.

What would your recommendation be for how to handle this?

This to me this is a red flag.  My interpretation is that the sleep medicine specialist is NOT confident in the recommendation that the driver is safe without treatment.
I have had many PMDs give a cursory note that simply says “driver does not need treatment.”  This is inadequate.  I want to know that existing guidelines and best practices are being followed and the recommendation is based on those, or if deviating from these, why.  If I am confident in the logic presented, I will include that in my documentation of the case and make my determination.
What is mild obstructive sleep apnea?  If the AHI (Apnea-Hypopnea Index) is 5, maybe that’s ok, if it’s 20, probably not.  You as the medical examiner are responsible for making that call, and assuming the liability should a sleepy truck driver crash and hurt or kill someone.
So you better make sure you are confident in your determination.  You need a reliable specialist to follow current guidelines and best practices.

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Take the guesswork out of testing and management of drivers with sleep apnea

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In a case like this, if the sleep specialist is unwilling to provide the letter, and I couldn’t make the DOT physical determination based on the results of the testing I could interpret myself, I would require the driver to repeat the testing (an inexpensive home sleep test).  If it did not confirm sleep apnea, the driver would have to go for another sleep lab test OR get an opinion from a different sleep specialist.
If I’m not satisfied with any of this, I make the determination the driver is unqualified for his DOT physical.

STOP-BANG Screening for Sleep Apnea

For screening, I recommend the “STOP-BANG” method:
Snoring-loud, as in heard easily in the next room
Tiredness during the normal waking hours
Observed Apneas
Pressure = HTN
BMI >=35 (some would argue 33 is the right number)
Age >=50
Neck Size > 17″ in males, 16″ in females
Gender – male or postmenopausal female.

When performing a DOT physical, a certain combination of these factors +/- other conditions would lead to a high risk of obstructive sleep apnea in the commercial driver and should be evaluated further.

In our course, we teach all the research available to date to give you the confidence to assess and manage these drivers appropriately, including:

• The impact obstructive sleep apnea has on large truck accidents, injuries, and fatalities
• How to use the right screening tools on every driver, every exam
• How to order a sleep test, when to consider home sleep testing (HST) vs a polysomnography
• Interpretation of the test in collaboration with a sleep specialist
• How to determine when a driver needs treatment for sleep apnea
• Recommended treatments
• Certification or disqualification criteria and appropriate intervals
• How to determine compliance with treatment and guide further certification/disqualification
• and more!

Federal Diabetes exemption

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