dr. tara worron, dc p 630.554 - illinois dot medical...
TRANSCRIPT
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Dr. Tara Worron, DC
p 630.554.9323
Worron Family Chiropractic
1144 Douglas Rd
Oswego IL 60543
IllinoisDOTMedicalExam.com
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Updates on the new DOT exam, certified medical examiners, why the
change happened and what it means for you
What to expect at your exam
Hypertension … one of the biggest reasons for a reduced certification time.
Current regulations and guidelines surrounding Sleep Apnea
How do you know you need a Sleep Apnea test?
Comfortable, confident and know being treated fairly
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National Registry of Certified Medical Examiners (NRCME) - otherwise known as the National Registry had an effective date of May 21, 2012 and a compliance date of May 21, 2014
So, effective May of last year, Medical Examiners had to meet new requirements in order to perform and sign off on a DOT exam
1. Maintain a valid State license
2. Complete an Accredited Training program
3. Pass the National Registry Certification Test
4. Complete periodic re-training (every 5 years)
5. Complete re-certification testing (every 10 years)
Dr. Tara Worron 630.554.9323
www.IllinoisDOTMedicalExam.com
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Federal Motor Carrier Safety Administration (FMCSA) - will monitor and audit performed medical examinations for errors and omissions
• Was established on January 1, 2000
• It is one of nine DOT administrations
• It is focused on reducing crashes, injuries and fatalities
involving large trucks & buses
Dr. Tara Worron 630.554.9323
www.IllinoisDOTMedicalExam.com
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Mission Statements
National Registry of Certified Medical Examiners (NRCME)
"To improve highway safety by producing trained, certified medical examiners who can
effectively determine if a CMV drivers health meets the FMCSA standards.“
Federal Motor Carrier Safety Administration (FMCSA)
"To promote safety of America's highways through pro-regulation and implementation of
medical regulations, guidelines and policies that ensure CMV drivers engaged in
interstate commerce are physically qualified to do so."
Dr. Tara Worron
"To be your advocate between the NRCME & FMCSA and get you certified."
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Severity of injury in an accident is relative to velocity change.
2x weight = 6 fold increased risk
Dr. Tara Worron 630.554.9323
www.IllinoisDOTMedicalExam.com
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When is a Medical Certificate Required?
Before first operating a Commercial Motor Vehicle
(CMV). Drivers who are attending driving school have a
commercial learners permit.
At least every 2 years, or more frequent as determined
at the discretion of your Medical Examiner.
Whenever the driver's ability to perform his or her normal
duties have been impaired by a physical or mental injury
or disease.
Dr. Tara Worron 630.554.9323
www.IllinoisDOTMedicalExam.com
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Medical Standards
• These are Codified
Federal Regulations (CFR)
that are laws and must
be followed
Medical Guidelines
• These assist in the evaluation
of drivers and are based on
expert review and
considered "best practice"
• * These are up to the
discretion of the Medical
Examiner
Dr. Tara Worron 630.554.9323
www.IllinoisDOTMedicalExam.com
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Examples of Medical Standards & Medical Guidelines
Medical Standard
Code 49 CFR 391.4 (b) (5)
This code states that a person is physically qualified to drive a commercial motor vehicle if that person has no established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with their ability to control and drive a commercial motor vehicle safely.
Medical Guideline
Do not certify a driver when they have a diagnosis of Myasthenia Gravis (MG)
Myasthenia gravis is a chronic autoimmune neuromuscular disease characterized by varying degrees of weakness of the skeletal (voluntary) muscles of the body. The name myasthenia gravis, which is Latin and Greek in origin, literally means "grave muscle weakness." -National Institute of Neurological Disorders and Stroke
* When the certification decision does not conform with the guidelines, the reason must be noted on the medical exam form and the driver can be certified
* Medical examiner discretion always wins out.
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Dr. Tara Worron 630.554.9323 www.IllinoisDOTMedicalExam.com
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Disqualifications
The medical examiner can use their discretion in all areas
of the exam, however there are 4 regulations that must be
followed. The examiner must disqualify the driver who fails
to meet the physical qualification requirements cited in the
regulations for:
1. Vision parameters (unless accompanied by an exemption)
2. Diabetes requiring insulin (unless accompanied by an exemption)
3. Hearing loss
4. Epilepsy
Dr. Tara Worron 630.554.9323
www.IllinoisDOTMedicalExam.com
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Exemptions
An exemption provides a temporary regulatory relief from one or more regulations for commercial drivers.
Two Federal medical Driver Exemption Programs are:
1. Vision Exemption Program
2. Diabetes Exemption Program
www.IlliniosDOTMedicalExam.com
www.fmcsa.dot.gov
* The Medical Examiner CANNOT issue the exemption for you.
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* The medical examiner can start the exemption program application by first
determining if the driver is otherwise medically qualified except for monocular vision or
the use of insulin.
* Copy of your medical exams, employment history, driving experience and motor
vehicle records must be submitted with the application.
* 180 days of receipt
Vision Exemption Program
• Allows some drivers with
monocular vision to drive
Diabetes Exemption Program
• Allows some drivers with diabetes mellitus who uses insulin replacement to drive.
• Diabetes Mellitus is a chronic disease in which there are high levels of sugar in the blood/urine.
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Dr. Tara Worron 630.554.9323 www.IllinoisDOTMedicalExam.com
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All exemption programs are for drivers who intend
to operate CMVs in interstate commerce as the
FMCSA does not have statutory authority to grant
exemptions from states’ intrastate requirements.
Interstate = trade, traffic or transport involving the crossing of a State boundary
Intrastate = trade, traffic or transport within a single State
Updated: January 21, 2015
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Components of the physical exam
General appearance
Eyes
Ears
Mouth & Throat
Heart * HTN
Lungs & Chest * Sleep Apnea
Abdomen & Viscera
Genito-urinary System
Extremities
Spine & other musculoskeletal
Neurological
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General Appearance
Abnormalities with posture, limps or tremors
Overall appearance, demeanor and responses to questions
Markedly overweight
Signs of drug abuse
Signs of current alcohol abuse
Issue with balance
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Eyes
Pupils equally reactive to light
Abnormal eyemovements
Looking for imbalances, irregular movements
Cataracts
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Ears
We will be looking in your ears
Scarring of the tympanic membrane
Anything blocking the external canal
Perforated ear drums
Essentially we are looking for anything that would account for hearing loss or a
disturbance in balance
Meniere’s Disease (disorder of the inner ear that can affect hearing and
balance and be associated with severe & unpredictable bouts of dizziness and
hearing loss) can significantly interfere with driving and task performance
Surgery? Possible but few guarantee no hearing loss
Effective April 1, 2014 the FMCSA is reviewing this issue in relation to certification
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Mouth & Throat
Deformities likely to interfere with breathing or swallowing
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Heart
Heart must be examined for murmurs, extra sounds, enlargement and a
pacemaker or implantable defibrillator
Legs evaluated for pitting edema & other signs of cardiac disease
Essentially the examiner is looking for any abnormalities that indicate the
driver has current heart disease accompanied by and/or likely to cause
symptoms of
shortness of breath
Sudden loss of consciousness
Collapse
Heart failure
And if there is a condition, can it be corrected, stabilized, managed and well
tolerated with Rx and/or surgery
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Hypertension BP 139/89 or lower 2 year certificate
140/90 - 159/99 Stage 1 Hypertension 1 year certificate (see example) & done annually thereafter Rechecks should be ≤ 139/89. If 140/90-159/99, certification may be extended one time for 3 months
160/100 - 170/109 Stage 2 Hypertension one time 3 month certificate (gives you time to decrease BP) if ≤ 139/89 on the recheck, get a certification for one year from the date of the original exam certified annually thereafter
180/110 Stage 3 Hypertension cannot certify even temporarily If ≤ 139/89 on the recheck, done every 6 months thereafter
* Annual recertification is expected if the medical examiner does not know the severity of HTN prior to treatment
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Dr. Tara Worron 630.554.9323 www.IllinoisDOTMedicalExam.com
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Lungs & Chest
Chest wall expansion
Abnormal breathing rates
Abnormal chest sounds (wheezing)
Bluish discoloration of the skin resulting from inadequate oxygenation
of the blood
Essentially looking for the presence of an underlying lung condition
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Abdomen
Enlarged liver / spleen
Masses
Hernias
Significant abdominal wall muscle weakess
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Vascular System
Abnormal pulses
Carotid bruits (noise caused by turbulent blood flow in the carotid artery)
Varicose veins
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Genito-urinary System
Example: Hernias
These can cause the driver discomfort
Want to be certain if there is one, that they do not interfere with the drivers
ability to operate a CMV safely
Also, a driver that has not provided a urine sample cannot be certified
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Extremities – Limb impairment
Looking for deficits of the arms and legs caused by loss, impairment
or deformity
Examples
Can the driver demonstrate sufficient grasp and use of their arms to
maintain steering wheel grip
Does the driver have sufficient mobility and strength in their legs to
operate pedals properly
* May be subject to Skill Performance Evaluation
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Spine & Other Musculoskeletal
Evaluated for previous surgeries, deformities, limitations in movement and
tenderness.
Looking to see if the driver has a diagnosis or signs of a condition known to be
associated with acute episodes of:
Muscle weakness
Poor muscle coordination
Abnormal sensations
Decreased muscle tone
Pain
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Neurological
Impairments of equilibrium, coordination and speech
Looking to see if the driver has ataxia
Ataxia: is a lack of muscle coordination that can affect speech, eye movements and the ability to swallow, pick up objects and other voluntary movements that you would see in:
Multiple Sclerosis
Head Injuries
Alcohol abuse
Stroke
Tumors
Infections
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The DOT exam is basically looking for …
Any abnormal finding/s that would suggest a
condition that might interfere with the safe
operation of a vehicle
* Medical Examiner Discretion
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FMCSA just released a bulletin to Medical
Examiners and Training Organizations regarding
Obstructive Sleep Apnea
The FMCSA just put out a the new bulletin to remind healthcare professionals
“of the current physical qualifications standard and advisory criteria
concerning the respiratory system, specifically how the requirements apply to
drivers that may have obstructive sleep apnea (OSA)”
The FMCSA’s physical qualifications standard prohibit individuals from
receiving a medical examiners’ certificate to operate commercial motor
vehicles in interstate commerce if they have an “established medical history or
clinical diagnosis of a respiratory dysfunction likely to interfere with his or her
ability to control and drive a commercial motor vehicle safely” 49 CFR 391.4
(b)(5)
• OSA is considered a respiratory disorder
• But this determination needs to be based upon the severity of the case
• Medical examiner discretion applies
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What is Obstructive Sleep Apnea (OSA)?
It is a respiratory disorder characterized by a reduction or cessation (no
breathing) during sleep
During sleep, OSA blocks the airway and prevents you from breathing up to
dozens of times per hour and can often wake you up
Time in bed DOES NOT EQUAL hours of sleep
8 hours of sleep with OSA can be less refreshing than 4 hours of ordinary,
uninterrupted sleep
Needs to be coupled with symptoms
According to the recent FMCSA bulletin, it was found that OSA patients were
more likely to unintentionally swerve and strike objects. Both are serious and
dangerous reactions.
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Sleep Apnea Symptoms
• Waking up with a very sore or dry throat
• Loud snoring
• Occasionally waking up with a choking or gasping sensation
• Sleepiness or lack of energy during the day
• Morning headaches
• Restless sleep
• Forgetfulness, mood changes, and a decreased interest in sex
• Recurrent awakenings or insomnia
* OSA could therefore lead to unpredictable & sudden incapacitation like falling asleep at the wheel, contributing to the potential for crashes, injuries and fatalities
Dr. Tara Worron 630.554.9323
www.IllinoisDOTMedicalExam.com
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Sleep Apnea
In addition to cognitive dysfunction (sleepiness, fatigue), if left untreated, dramatically increases your risk for …
o Stroke
o Heart Disease
o Diabetes
o Obesity
Dr. Tara Worron 630.554.9323
www.IllinoisDOTMedicalExam.com
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Which of these can make sleep apnea worse? o Sleeping pills
o Alcohol
o Tobacco
o All of the above
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How is sleep apnea diagnosed?
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* The Epworth scale is widely used in the field of sleep medicine as a subjective
measure of a your sleepiness.
* It is now given to every driver who walks into our office for a DOT exam and
has significantly reduced the need for additional sleep studies. S
Dr. Tara Worron 630.554.9323 www. IllinoisDOTMedicalExam.com
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SCORES
Value of your responses on the 8 questions are added up
Score is based on a scale of 0-24:
0 - 7 unlikely you are abnormally sleepy
8-9 average amount of daytime sleepiness
10-15 may be excessively sleepy
may want to consider further seeking medical attention
16-24 you are excessively sleepy
you should consider seeking medical attention
Dr. Tara Worron 630.554.9323 www.IllinoisDOTMedicalExam.com
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FMCSA’s physical qualifications standards
& advisory criteria in the recent bulletin
They do not provide OSA screening, diagnosis or treatment
guidelines for medical examiners
Believes the issue of treatment is best left to the treating
healthcare professional & the driver
Medical examiners are therefore left to exercise their medical judgment and expertise in determining:
If a driver exhibits risk factors for OSA
If additional information is needed before making a decision
on issuing a certificate
If a medical certificate is issued, what is the duration
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The Agency does not require that these drivers be
considered unfit to continue their driving, only that
the medical examiner make a determination
whether they need to be evaluated and if
warranted, demonstrate they are managing their
OSA to reduce the risk of drowsy driving.
Things that also need to be considered:
Loud snoring, witnessed apneas, sleepiness during the major wake periods as
well as risk factors like body mass index (BMI), involvement in a single-vehicle
crash and neck size.
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How does neck size effect sleep?
Fat deposits crowd the airway making it more likely to:
• partially collapse leading to snoring
• completely close off leading to sleep apnea
• large tonsils, adenoids and even tongues contribute to airway restriction
Risk factor if circumference > 17" for men
> 16" for women
* used in the right context, it may be additional evidence suggesting the need for further evaluation
Dr. Tara Worron 630.554.9323 www.IllinoisDOTMedicalExam.com
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Home Sleep Apnea Test When a sleep study is needed you have options
• Current breakthrough in technology lets you do the sleep study in the privacy and comfort of your own home
• Satisfies DOT regulation
• $500 (compared to the average lab fee $3,000)
• Includes the report
Dr. Tara Worron 630.554.9323
www.IllinoisDOTMedicalExam.com
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The most common treatment for sleep apnea is a Continuous Positive Airway Pressure machine (CPAP). How does it work? Blows air to keep the airways open during sleep
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Chantix Side Effects 1. Nausea (and in rare cases vomiting)
2. Vivid, strange or unusual dreams
3. Constipation
4. Feeling sleepy
5. May be linked with a small increase in risk for *heart problems, including but not limited to heart attacks
*Disclaimer: Shortness of breath, chest pain or pressure, calf pain when walking, sudden onset of weakness, numbness or difficulty speaking
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Dr. Tara Worron 630.554.9323 www.IllinoisDOTMedicalExam.com
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In closing …
Understand that the DOT exam is designed to keep you
and the public safe
Be comfortable with what to expect at the exam
Supply the Medical Examiner with pertinent medical data
before you go for your exam (conditions / Rx)
Find a facility that you trust
Find a facility that does not have a vested interest in you
needing advanced testing or monitoring
Find a facility that is efficient, offers truck parking and gives
you a great exam at a fair price
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Dr. Tara Worron, DC
p 630.554.9323
Worron Family Chiropractic
1144 Douglas Rd
Oswego IL 60543
IllinoisDOTMedicalExam.com