Introduction This handbook provides information and guidance to the medical examiner who performs the commercial driver medical examination. Determining driver medical fitness for duty is a critical element of the FMCSA safety program. Specialists, such as cardiologists and endocrinologists, may perform additional medical evaluation, but it is the medical examiner who decides if the driver is medically qualified to drive.
Load, secure, and unload cargo — Federal Motor Carrier Safety Administration (FMCSA) guidelines do not specify the number of pounds a driver must be able to lift. However, the Centers for Disease Control and Prevention (CDC) table of General Physical Activities Defined by Level of Intensity lists "loading and unloading a truck" as an example of a vigorous activity that requires the individual to exert greater than 6.0 metabolic equivalents (MET) in performance of the activity. Perform vehicle checks — Grip strength, upper and lower body strength, range of motion, balance, and flexibility are required to inspect the engine, brakes, and cargo. Vision and hearing are used to identify and interpret changes in vehicle performance. FMCSA Commercial Driving Facts and Research Office of Analysis, Research, and Technology The Federal Motor Carrier Safety Administration (FMCSA) Office of Analysis, Research, and Technology (ART) provides the transportation industry and the public with analytical reports on trends, costs, fatalities, and injuries in large truck and bus crashes. ART research and data help identify factors that contribute to crashes. FMCSA uses this information to develop effective countermeasures that will reduce the occurrence and severity of crashes.
General CHD recommendation summary The qualified driver with CHD should: Secure clearance from a cardiovascular specialist who understands the functions and demands of commercial driving. Tolerate cardiovascular medication and be: Knowledgeable about medications used while driving. o Free from side effects that compromise driving ability. o Compliant with the ongoing treatment plan. Acute Myocardial Infarction The first few months following an acute myocardial infarction (MI) pose the greatest risk of mortality, with the majority of deaths classified as sudden death. Current opinion among clinicians states that post-MI drivers may safely return to any occupational task provided there is no exercise-induced myocardial ischemia or left ventricular dysfunction. Waiting Period Minimum — 2 months Decision Maximum certification period — 1 year Recommend to certify if: The driver: Is asymptomatic. Tolerates medications. Has a satisfactory exercise tolerance test (ETT). Has a resting left ventricular ejection fraction (LVEF) greater than or equal to 40%. Has no electrocardiogram ischemic changes. Recommend not to certify if: The driver has: Rest angina or change in angina pattern within 3 months of examination. Ischemic changes on rest electrocardiogram (ECG). Intolerance to cardiovascular therapy.
Recommend not to certify if: The driver has: Symptoms of dyspnea, palpitations, or syncope. Pulmonary valve peak gradient greater than 50 mm Hg in the presence of a normal cardiac output. Right ventricular pressure greater than 50% systemic pressure. More than mild right ventricular hypertrophy noted by echocardiography. More than mild right ventricular dysfunction noted by echocardiography. More than moderate pulmonary valve regurgitation noted by echocardiography. Main pulmonary artery diameter more than 5 cm noted by echocardiography or other imaging modality. Monitoring/Testing The driver should have annual cardiology evaluations by a cardiovascular specialist who is knowledgeable in adult congenital heart disease and who understands the functions and demands of commercial driving. The driver should have an annual medical examination. To review the Congenital Heart Disease Recommendation Table, see of this handbook. Respiratory (b)(5) The commercial driver spends more time driving than the average individual. Driving is a repetitive and monotonous activity that demands the driver be alert at all times. Symptoms of respiratory dysfunction or disease can be debilitating and can interfere with the ability to remain attentive to driving conditions and to perform heavy exertion. Even the slightest impairment in respiratory function under emergency conditions (when greater oxygen supply may be necessary for performance) can be detrimental to safe driving. There are many primary and secondary respiratory conditions that interfere with oxygen exchange and may result in gradual or sudden incapacitation, for example: Asthma. Carcinoma. Chronic bronchitis. Emphysema. Obstructive sleep apnea. Tuberculosis. In addition, medications used to treat respiratory conditions, both prescription and those available without a prescription, may cause cognitive difficulties, compound the risk for excessive daytime sleepiness (EDS), or cause other forms of incapacitation.
Recommend not to certify if: The driver: Has not completed the minimum waiting period seizure free and off anticonvulsant medication. Does not have clearance from a neurologist who specializes in epilepsy and understands the functions and demands of commercial driving. Monitoring/Testing You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver medical fitness for duty. The driver should have at least biennial medical examinations. Vertigo and Dizziness The normal ability to maintain balance and orientation while operating a commercial motor vehicle (CMV) depends upon peripheral nervous system (PNS) sensory input from three major systems and the appropriate motor integration in the central nervous system (CNS). The three PNS sensory systems are vestibular, visual, and proprioception. Inappropriate interactions of these systems or interactions within the CNS may produce an unsafe degree of vertigo or dizziness that endangers the health and safety of the driver and the public. The most common medications used to treat vertigo are antihistamines, benzodiazepines, and phenothiazines. Use of either benzodiazepines or phenothiazines for the treatment of vertigo would render the driver medically unqualified. Special consideration should be given to the possible sedative side effects of antihistamines. The medical examiner should determine if these drugs produce sedation in the individual driver. Waiting Period Minimum — 2 months asymptomatic with diagnosis of: Benign positional vertigo. Acute and chronic peripheral vestibulopathy. Decision Maximum certification — 2 years Recommend to certify if: The driver has a diagnosis of: Benign positional vertigo and has completed the appropriate symptom-free waiting period.
Post-accident drug and/or alcohol testing is required for all fatal crashes and when the driver is cited for a moving traffic violation. Reasonable suspicion testing is conducted when a trained supervisor or company official observes behavior or appearance that is characteristic of drug and/or alcohol misuse. Random drug and/or alcohol testing is conducted on a random, unannounced basis just before, during, or just after performance of safety-sensitive functions. 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. Employer responsibilities include: 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. Employer responsibilities do not include: Providing SAP evaluations. Paying for driver SAP evaluation, education, or treatment. For more information see Federal Motor Carrier Safety Administration Web site . Advisory Criteria/Guidance Alcoholism Except where absolute criteria exist (i.e., a current clinical diagnosis of alcoholism), as a medical examiner, you make the final determination as to whether the driver meets the Federal Motor Carrier Safety Administration (FMCSA) medical standards for driver certification. 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. If you believe immediate testing for alcohol is warranted, contact FMCSA or contact the employer of the driver directly for information on controlled substances and alcohol testing under Part 382 of the Federal Motor Carrier Safety Regulations. A driver MUST submit to alcohol testing if there is reasonable suspicion that the U.S. Department of Transportation (DOT) prohibitions concerning alcohol are violated. Suspicion MUST be based on specific observations concerning driver behavior, speech, or body odor.
ATRIAL SEPTAL DEFECTS 2002 Cardiovascular Conference Report Recommendation Tables, Page 124 DIAGNOSIS PHYSIOLOGY/ FUNCTIONAL CERTIFICATION RE-CERTIFICATION Atrial Septal Defect (ASD): Ostium Secundum Small ASD = favorable. Moderate to large ASD = unfavorable. Yes if: Asymptomatic. No if: Symptoms of dyspnea, palpitations or a paradoxical embolus; Pulmonary hypertension; Right-to-left shunt; or Pulmonary to systemic flow ratio > 1.5 to 1. Yes if: At least 3 months after surgery or at least 4 weeks after device closure; asymptomatic and clearance by cardiologist knowledgeable in adult congenital heart disease. Annual Evaluation by cardiologist knowledgeable in congenital heart disease including echocardiogram. Annual Evaluation by cardiologist knowledgeable in adult congenital heart disease every 2 years.
BUNDLE BRANCH BLOCKS AND HEMIBLOCKS 2002 Cardiovascular Conference Report Recommendation Tables, Page 100 DIAGNOSIS PHYSIOLOGY/ FUNCTIONAL CERTIFICATION RE-CERTIFICATION Bundle Branch Block Axis Deviation Progression of disease in the conduction system can lead to third degree heart block with total loss of electrical connection between the atria and ventricles causing syncope or sudden death. Yes if: Asymptomatic. (Depends on risk from underlying heart disease.) Yes, if treated for symptomatic disease (see pacemaker); No disqualifying heart disease; Cleared by cardiologist. No, if symptomatic. Every 2 years. Annual
COMMERCIAL DRIVERS WITH KNOWN CORONARY HEART DISEASE (CHD) (Continued) 2002 Cardiovascular Conference Report Recommendation Tables, Page 37 DIAGNOSIS PHYSIOLOGY/ FUNCTIONAL CERTIFICATION RE-CERTIFICATION Post Percutaneous Coronary Intervention (PCI) Rapid recovery for elective PCIs for stable angina. Delayed re-stenosis is the major PCI limitation and requires intensive secondary prevention. Yes if: At least 1 week after procedure; Approval by cardiologist; Tolerance to medications. ETT 3 to 6 months after PCI. No if: Incomplete healing or complication at vascular access site; Rest angina; Ischemic ECG changes. Annual Recommend Cardiologist examination. Biennial ETT at minimum (If test positive or inconclusive, imaging stress test may be indicated). Post Coronary Artery Bypass Surgery (CABG) Delay in return to work to allow sternal incision healing. Because of increasing risk of graft closure over time, ETT is obtained. Yes if: At least 3 months after CABG; LVEF > 40% post CABG; Approval by cardiologist; Asymptomatic; and tolerance to medications. Annual After 5 years: Annual ETT. Imaging stress test may be indicated.
CONGENITAL HEART DISEASE 2002 Cardiovascular Conference Report Recommendation Tables, Page 128 DIAGNOSIS PHYSIOLOGY/ FUNCTIONAL CERTIFICATION RE-CERTIFICATION Patent Ductus Arteriosus (PDA) Small = favorable. Moderate to large = unfavorable. Yes, if small shunt. No if: Symptoms of dyspnea or palpitations; Pulmonary hypertension; Right to left shunt; Progressive LV enlargement or decreased systolic function. Yes if: At least 3 months after surgery or 1 month after device closure; None of above disqualifying criteria; Cleared by cardiologist knowledgeable in adult congenital heart disease. Annual Annual Should have evaluation by cardiologist knowledgeable in adult congenital heart disease. Coarctation of the Aorta Mild = favorable. Moderate or severe = unfavorable prognosis. Yes if: Mild and unoperated; BP controlled; and No associated disqualifying disease. No Annual Evaluation by cardiologist knowledgeable in adult congenital heart disease recommended. Coarctation of the Aorta after intervention Unfavorable prognosis with persistent risk of cardiovascular events. Yes, if perfect repair (see text p. 115 and 116). Annual Evaluation by cardiologist knowledgeable in adult congenital heart disease required.
CONGENITAL HEART DISEASE (Continued) 2002 Cardiovascular Conference Report Recommendation Tables, Page 129 DIAGNOSIS PHYSIOLOGY/ FUNCTIONAL CERTIFICATION RE-CERTIFICATION Pulmonary Valve Stenosis (PS) Mild and moderate = favorable. Severe PS may be unfavorable, associated with arrhythmias and rarely sudden death. Yes, if mild or moderate. No if Symptoms of dyspnea, palpitations or syncope; Pulmonary valve peak gradient >50 mm Hg with normal output; RV pressuve >50% systemic pressure; >mile RVH; >mild RV dysfunction; >moderate pulmonary valve regurgitation; or main pulmonary artery >5cm. Yes if: 3 months after surgical valvotomy or 1 month after balloon valvuloplasty; None of above disqualifying criteria; Cleared by cardiologist knowledgeable in adult congenital heart disease. Annual Evaluation by cardiologist knowledgeable in adult congenital heart disease. Annual Recommend evaluation by cardiologist knowledgeable in adult congenital heart disease. Other causes of right ventricular outflow obstruction in persons with congenital heart disease. Double chambered right ventricle. Infundibular pulmonary stenosis. Supravalvar pulmonary stenosis. Pulmonary artery stenosis. Yes if: Hemodynamic data and criteria similar to individuals with isolated pulmonary valve stenosis who are eligible for certification. Annual Recommend evaluation by cardiologist knowledgeable in adult congenital heart disease.
CONGENITAL HEART DISEASE (Continued) 2002 Cardiovascular Conference Report Recommendation Tables, Page 130 DIAGNOSIS PHYSIOLOGY/ FUNCTIONAL CERTIFICATION RE-CERTIFICATION Ebstein anomaly Mild = favorable. Moderate and severe variants = unfavorable. Yes if: Mild; Asymtomatic; No intracardiac lesions; No shunt; No symptomatic arrhythmia or accessory conduction; Only mild cardiac enlargement; Only mild RV dysfunction. No if: (see text, p. 117) Yes if: At least 3 months post- surgical intervention; None of above disqualifying features. Annual Evaluation by cardiologist knowledgeable in adult congenital heart disease. Annual Echocardiogram and evaluation by cardiologist knowledgeable in adult congenital heart disease required. Tetralogy of Fallot Unfavorable in the unrepaired state. Repaired = variable prognosis. No, if uncorrected. Yes if: Excellent result obtained from surgery; Asymptomatic; No significant pulmonary or tricuspid valve regurgitation; No pulmonary stenosis; No history of arrhythmias; No residual shunt. Annual Evaluation by cardiologist knowledgeable in adult congenital heart disease required, including EKG, 24 hour Holter Monitor, exercise testing, Doppler Echocardiogram.
HEART TRANSPLANTATION 2002 Cardiovascular Conference Report Recommendation Tables, Page 154 DIAGNOSIS PHYSIOLOGY/ FUNCTIONAL CERTIFICATION RE-CERTIFICATION Heart Transplantation Special attention to: Accelerated atherosclerosis, transplant rejection, general health. Yes if: At least 1 year post- transplant; asymptomatic; stable on medications; no rejection; Consent from cardiologist to drive commercially. Biannual Clearance by cardiologist required.
HYPERTENSION 2002 Cardiovascular Conference Report Recommendation Tables, Page 55 DIAGNOSIS PHYSIOLOGY/ FUNCTIONAL CERTIFICATION RE-CERTIFICATION Essential Hypertension Evaluate for other clinical CVD including TOD†; Presence of TOD, CVD or diabetes may affect therapy selected. Yes, if asymptomatic. Rarely disqualifying alone. Stage 1 (140-159/90-99 mm Hg) Usually asymptomatic; Low risk for near-term incapacitating event. Yes Rarely disqualifying alone. Annual BP <140/90 at annual exam; If not, but <160/100, certification extended one time for 3 months. Stage 2 (160-179/100-109 mm Hg) Low risk for incapacitating event; risk increased in presence of TOD; Indication for pharmacologic therapy. Yes One time certification for 3 months. Yes, at recheck if: BP <140/90mmHg Certify for 1 year from date of initial exam. Annual BP <140/90. Stage 3 (>180/110 mm Hg High risk for acute hypertension-related event. No Immediately disqualifying; Yes, at recheck if: BP <140/90 mm Hg; Treatment is well tolerated. Certify for 6 months from date of initial exam. Every 6 months; BP <140/90. Secondary Hypertension Evaluation warranted if persistently hypertensive on maximal or near- maximal doses of 2-3 pharmacologic agents; May be amenable to surgical/specific therapy. Based on above stages. Yes if: Stage 1 or nonhypertensive. At least 3 months after surgical correction. Annual BP <140/90 † TOD – Target Organ Damage – Heart Failure, Stroke or Transient Ischemic Attack, Peripheral Artery Disease, Retinopathy, Left Ventricular Hypertrophy, Nephropathy. Examiner may disqualify a driver if TOD significantly impairs driver’s work capacity. Driver should have no excess sedation or orthostatic change in BP.
PACEMAKERS (Continued) 2002 Cardiovascular Conference Report Recommendation Tables, Page 102 DIAGNOSIS PHYSIOLOGY/ FUNCTIONAL CERTIFICATION RE-CERTIFICATION Neurocardiogenic Syncope Excellent long-term survival prognosis but there is risk for syncope that may be due to cardioinhibitory (slowing heart rate) or vasodepressor (drop in blood pressure) components, or both. Pacemaker will affect only cardioinhibitory component, but will lessen effect of vasodepressor component. No, with symptoms. Yes if: 3 months* after pacemaker implantation; Documented correct function by pacemaker center; Absence of symptom recurrence. Annual Documented pacemaker checks; Absence of symptom recurrence *Three months recommended due to possible vasodepressor component of syndrome not necessarily treated by pacing.
PACEMAKERS (Continued) 2002 Cardiovascular Conference Report Recommendation Tables, Page 103 DIAGNOSIS PHYSIOLOGY/ FUNCTIONAL CERTIFICATION RE-CERTIFICATION Hypersensitive carotid sinus with syncope Excellent long-term survival prognosis but there is risk for syncope that may be due to cardioinhibitory (slowing heart rate) or vasodepressor (drop in blood pressure) components, or both. Pacemaker will affect only cardioinhibitory component, but will lessen effect of vasodepressor component. No, with symptoms. Yes if: 3 months* after pacemaker implantation; and documented correct function by pacemaker center; Absence of symptom recurrence. Annual Documented regular pacemaker checks; and Absence of symptom recurrence *Three months recommended due to possible vasodepressor component of syndrome not necessarily treated by pacing.
SUPRAVENTRICULAR TACHYCARDIAS 2002 Cardiovascular Conference Report Recommendation Tables, Page 96 DIAGNOSIS PHYSIOLOGY/ FUNCTIONAL CERTIFICATION RE-CERTIFICATION Atrial Fibrillation Lone Atrial Fibrillation Atrial fibrillation as cause of or a risk for stroke Atrial fibrillation following thoracic surgery Good prognosis and low risk for stroke. Risk for stroke decreased by anticoagulation. Good prognosis and duration usually limited. Yes Yes if: Anticoagulated adequately for at least 1 month; Anticoagulation monitored by at least monthly INR; Rate/rhythm control deemed adequate (Recommend assessment by cardiologist). In atrial fibrillation at time of return to work; Yes if: Anticoagulated adequately for at least 1 month; Anticoagulation monitored by at least monthly INR; Rate/rhythm control deemed adequate (Recommend assessment by cardiologist). Annual Annual Annual
VALVE REPLACEMENT (Continued) 2002 Cardiovascular Conference Report Recommendation Tables, Page 81 DIAGNOSIS PHYSIOLOGY/ FUNCTIONAL CERTIFICATION RE-CERTIFICATION Atrial fibrillation. Yes if: Anticoagulated adequately for at least 1 month and monitored by at least monthly INR, rate/rhythm control adequate; Cleared by cardiologist. Annual Biologic Prostheses Antiocoagulant therapy not necessary in patients in sinus rhythm (after initial 3 mo0nths), in absence of prior emboli or hypercoagulable state. Yes if: At least 3 months post- op; Asymptomatic; None of above disqualifying criteria for mechanical valves; Cleared by cardiologist. Annual Recommend evaluation by cardiologist.*
VENOUS DISEASE 2002 Cardiovascular Conference Report Recommendation Tables, Page 147 DIAGNOSIS PHYSIOLOGY/ FUNCTIONAL CERTIFICATION RE-CERTIFICATION Acute Deep Vein Thrombosis (DVT) No, if symptoms. Yes if: No residual acute deep venous thrombosis; If on Coumadin: Regulated for at least 1 month; INR monitored at least monthly. Annual Superficial Phlebitis Yes if: DVT ruled out; No other disqualifying cardiovascular disease. Biennial Pulmonary Embolus No, if symptoms. Yes if: No pulmonary embolism for at least 3 months; On appropriate long-term treatment. If on Coumadin: Regulated for at least 1 month; INR monitored at least monthly; No other disqualifying cardiovascular disease. Annual Chronic Thrombotic Venous Disease Yes, if no symptoms. Biennial Varicose veins Yes, if no complications. Biennial Coumadin Use of INR required. Yes if: Stabilized for 1 month; INR monitored at least monthly. Annual
VENTRICULAR ARRHYTHMIAS (Continued) 2002 Cardiovascular Conference Report Recommendation Tables, Page 99 DIAGNOSIS PHYSIOLOGY/ FUNCTIONAL CERTIFICATION RE-CERTIFICATION Right Ventricular Outflow VT Favorable prognosis and low risk for syncope. No, if symptomatic. Yes, if asymptomatic. Yes if: At least 1 month after drug or other therapy successful; Asymptomatic; Cleared by electrophysiologist. Annual Recommend evaluation by cardiologist. Annual Evaluation by cardiologist required. Idiopathic Left Ventricular VT Favorable prognosis and low risk for syncope. No, if symptomatic Yes, if asymptomatic. Yes if: At least 1 month after successful drug therapy or ablation; Cleared by electrophysiologist. Annual Recommend evaluation by cardiologist. Annual Evaluation by cardiologist required. Long QT Interval Syndrome High risk for ventricular arrhythmic death. No Brugada Syndrome High risk for ventricular arrhythmic death. No