can i drive? - apccrc vi_dr. angus chu.pdf · 2017-12-05 · 2. liability to sudden attacks of...

Can I drive? Dr. CHU Angus

Asso Consultant (Rehab) Tuen Mun Hospital

My declaration of interest

• I have nothing to declare

Case sharing: M59 LS

• School bus driver

• HT

• IHD with old MI in 2006; 2VD with CABG

• Complete CRP in 2006; post TMT 10MET

• Driving license renewal annually from 2006 - 2012

• TMT repeated every 2 yearly

• Intermittent booster training required to maintain ex capacity

IHD for commercial driver

• Annual assessment is required!

• 8 weeks following an uncomplicated MI

• Can resume if:

– Absence of symptoms AND no drug for symptoms control

– Normal TMT up to stage III Bruce or equivalent

– Absence of arrhythmias

– Satisfactory LV by echo or other appropriate ix

Exercise capacity can be trainable in some patients

Reaching the age of 60

• TMT repeated in 2013: 6MET and AF

• Coro: patent grafts

• Cardiac: NVAF and start anticoagulant

• CHADS2 score 0 = 1.9% annual stroke rate

• CHA2DS2VAS score 1 = 1.3% annual stroke rate

• Condition for commercial driving not met

• Advise against driving commercial vehicle and he agreed to retire

M42 Businessman

• Domestic driving

• OSA on CPAP; BMI 25.4

• NSTEMI 1/2015

• Echo impaired LV; LVEF 35%; basal septal HK

• DM on OHA with good control

• Coro 2/2015: TVD and successful PCI to mLCx and RCA leaving D2 and dLAD medical treatm

• TMT: 7.2MET ECG no ischaemic changes

What will be your advise?

M57 Coach Driver

• Coach driver

• Recurrent NSTEMI 2/2015 uncomplicated

• DM on metformin only

• Hyperlipidaemia

• Echo EF 61% otherwise essential normal

• Coro: dRCA 95% with PCI successful

What will be your advise?

M56 NEAT driver

• Inferior STEMI on 9/2015 alert on arrival

• Collapse in AED pulse non detectable

• VF

• Normalized with 1 single shock 150J and amiodarone

• PPCI o RA ad staged PCI to LCx done

• Echo 60%

• Already RTW as supporting duty

Fitness to drive after medical illness

Fitness to drive after medical illness

Is the patient having a health risk below the societal expectation?

Public safety

Traffic accidents due to medical illness is not common

Human error 94.7%

Deficiency in vehicle 3.2%

Deficiency in road desgin

1.7%

Medical illness 0.4%

Cause of Traffic Accidents

Petch MC. Eur Heart J. 1998 Aug;19(8):1165-77.

Driver condition in MVA in Ontarior (2001)

Caused by a driver with a medical-physical defect

Caused by driver impairment with alcohol or drugs

Fatal Collisions N = 1251

20 (1.6%) 204 (16%)

Personal injury collisions N = 102,519

491 (0.4%) 3073 (3%)

Property damage collisions N = 316,167

474 (0.1%) 5650 (1.8%)

Total Medical related

Fatalities Injured (severe)

Injured (minor)

2009 14316 4 0 3 3 2010 14943 5 0 2 5 2011 15541 6 3 2 2

RTA Hong Kong (2009 – 2011)

RTA due to sudden sickness of drivers of commercial vehicles

Press release http://www.info.gov.hk/gia/general/201212/05/P201212050263.htm

RTA due to cardiac collapse not common

Epilepsy 39%

Blackouts 21%

DM on insulin 18%

Cardiac 8%

Stroke 7%

Others 7%

Cause of 2000 RTA involving collapse at wheel, based on police reports

Parsons M. Q J Med 1986; 58: 295–303.

• London (England) Transport system (1949 – 1959)

• 220 000 driver-years

• 46 drivers loss consciousness at the wheel

Norman LG: Lancet 1960; 1 (7133): 1039-1045

32

14 MI 12 5 3

LOC vehicle moving cannot stop accidents

Very few collapse behind the wheel result in accident

Sudden death behind the wheels

0

5

10

15

20

25

While driving In parked vehicle

non CAD

CAD with no collision

CAD with collison

Antecol DH Am J Cardiol. 1990;66(19):1329-35.

Autopsy finding

CAP 374B reg 9 Road Traffic (Driving licences) Regulations – Physical fitness

First schedule 附表1 enact since 1964

1. Epilepsy; 2. Liability to sudden attacks of disabling giddiness or

fainting due to hypertension OR any other cause; 3. Mental disorder for which the applicant for the licence, or,

as the case may be, the holder of the licence is liable to be detained under the Mental Health Ordinance (Cap. 136) or is receiving treatment as an in-patient in a mental hospital within the meaning of that Ordinance;

4. Any condition causing muscular incoordination; 5. Uncontrolled diabetes mellitus; 6. Inability to read at a distance of 23 metres in good

daylight (with the aid of spectacles or other corrective lenses, if worn) a registration mark;


7. Any other disease or disability which is likely to render him incapable of effectively driving and controlling a motor vehicle or suitably adapted motor vehicle to which such licence refers without endangering public safety, provided that deafness shall not of itself be deemed to be any such disability


Not Liability to sudden

incapacitation

Physical and mental

ability to control

Effective Driving

Who is responsible to report?

• License applicants (i.e. driver) are required to report

• Fail to report will render one liable to a fine of $2000

• Medical practitioner are NOT required and cannot report without consent

During this period, the licence holder normally retains legal entitlement to drive

During the evaluation process

• Patient should be advised whether or not it is appropriate for them to continue to drive during this period.

• If they choose to ignore medical advice to cease driving, there could be consequences with respect to their insurance cover.

• This should also be documented formally and clearly in the notes

During the evaluation process

Hong Kong vs. UK

Hong Kong United Kingdom

Law 7 items only No commercial/ private differentiation

More elaboration; Group 1 (car) vs. group 2 (large vehicle)

Notification Patient Patient

Physicians’ role Provide information AND determination of fitness

Provide information ONLY

Decision TD Officer (AO) followed Dr. recommendation (but asked for elaboration if obvious discrepancy)

Medical advisor of DVLA

Guidelines RehabAid – Medical guidelines for fitness to drive commercial vehicles (Endorsed by TD)

Driver & Vehicle Licensing Agency guidelines updated almost every year

From Law to clinical practice

• Endorsed by Transport Department • Revised edition in 2006 • Aim to ensure the fitness to drive of each patient is

assessed consistently

Other countries’ recommendation

Australia DLA

Canada CMA driver’s guide

UK DVLA

US NHTSA

1998 1991

2001 2000 2009

2003 2006 2010

2006 2012 2012

2012 2013

2016 2014

2016

DVLA UK 2016

• The societal expectation is objectively defined:

– 20% likelihood of an event in 1 year (Gp 1)

– 2% likelihood of an event in 1 year (Gp 2)

• Taxi driver are recommended to meet the same medical standards as bus and lorry drivers

• Clear Physician and applicant responsibility incorporating with GMC standard

GMC guidance about if patient not comply

• DRIVER IS LEGALLY RESPONSIBLE

• Doctor should explain their condition may affect their ability to driver and their duty to report

• If he refuses, they should be suggested to seek 2nd opinion and should advise not to drive meanwhile

• If still not comply, persuade +/- seek family support

Assessment of fitness to drive

• Commercial vs. private

• Modifiable vs. non modifiable factor

• Collaboration between specialists

Vehicle type Description Class

Private vehicle Private car 1

Small commercial vehicle Light goods vehicle 2

Passenger vehicle Taxi 6

Large Passenger vehicle Public light bus 4

Private bus 5

Public bus 9

Public bus – franchised 10

Private light bus 17

Large commercial vehicle Medium goods vehicle 18

Heave goods vehicle 19

Articulated vehicle 20

Other vehicle Government vehicle 16

Motor cycle 3

Motor tricycle 22

Special purpose vehicle 21

Higher standards for commercial driving

• Longer hours at the wheel;

• Threat avoidance vigilant activity

• Additional laborious tasks;

• Bearing responsibility for the passengers;

• Consequences of a crash involving buses, or dangerous goods vehicles are more serious

Risk of Harm Formula

• RH to other road users posed by driver with cardiac disease is directly proportional to:

– Time spent behind the wheel (TD)

– Type of vehicle driven (V);

– Risk of sudden cardiac incapacitation (SCI);

– The probability that such an event will result in a fatal or injury producing accident (Ac)

RH = TD x V x SCI x Ac (0.02)

Jung W. Eur Heart J. 1997 Aug;18(8):1210-9.

Sudden cardiac incapacitation

• With reference to the Airline pilot standard

• This is somewhat arbitrary • Max acceptable rate of fatal

accidents of all causes

Spencer MB. Road Safety Research Report No. 40. Department of Transport: London, Dec 2003


• With reference to the Airline pilot standard

• This is somewhat arbitrary • Max acceptable rate of fatal

accidents of all causes • < 1 % (1:102) being caused by

medical illness



• However not all medical incapacitation will result in accident




• 1:103 estimated chance of causing accident




• 1:103 estimated chance of causing accident

• 1 year = 10 4 hours • 1 event per 100 years = 1% per yr


10METs = 1% rule?

• Seattle Heart Watch: – 2373 CHD male patients FU 5 year

– Low risk defined by exercise test: Bruce III (or > 9min), 85% age predicted HR and <1mm ST dep

– Annual rate of sudden cardiac incapacitation = 0.942%/year

Bruce RA, Fisher LD. J Occ Med. 1989;31:124-33.

• CASS identified an extremely low risk group with an annual mortality of ≤1% who complete Bruce III with <1mm ST dep

Weiner DA. J Amer Coll Cardiol 1984; 3: 772–9

Commercial driving after CHD

Country Year Exercise capacity Reassessment

United Kingdom

2016 Exercise test (Bruce III) < 3 y

Australia 2016 Exercise test (≥ 90% of the age/sex predicted ex capacity according to Bruce or eq)

Annual review

Canada 2012 By NYHA functional class (TMT not needed) + angiographic requirement

3 -5 years depend on age; annually if symptomatic

New Zealand 2009 Exercise test > 9 min Bruce Not stated

Risk of Harm Formula

• RH to other road users posed by driver with cardiac disease is directly proportional to:

– Time spent behind the wheel (TD)

– Type of vehicle driven (V);

– Risk of sudden cardiac incapacitation (SCI);

– The probability that such an event will result in a fatal or injury producing accident (Ac)

RH = TD x V x SCI x Ac (0.02)

Jung W. Eur Heart J. 1997 Aug;18(8):1210-9.

Commercial vs. private

Factors Commercial Private Modifiable

Time 6 hr/day = 0.25 1hr/day = 0.04 Yes/ No

Vehicle 1 0.28 No

SCI 1%

Ac 0.02 0.02 No

Annual risk of death to others

1:20000 1:20000



Vehicle 1 0.28 No

SCI 1% ?

Ac 0.02 0.02 No


1:20000 1:20000




Vehicle 1 0.28 No

SCI 1% 22% Possible

Ac 0.02 0.02 No


1:20000 1:20000



• Annual assessment is required!

• 8 weeks following an uncomplicated MI

• Can resume if:

– Absence of symptoms AND no drug for symptoms control

– Normal TMT up to stage III Bruce or equivalent

– Absence of arrhythmias

– Satisfactory LV by echo or other appropriate ix

Exercise capacity can be trainable in some patients

Coach driving

• Large passenger vehicle

• Sole duty

• SL and counsel against driving the coach before assessment and report to TD

• Explained the risk if not report

• See if alternative placement available


• If driving dangerous goods against with no exception

• CABG/ PCI 12 weeks + same criteria as MI

• Cardiac arrest: not normally qualified unless single episode during early MI

NEAT driver

• No separate recommendation for arrhythmia mentioned in HK guidelines

• DVLA: If a transient arrhythmia occus during an ACS, the guidance relating to ACS takes precedence

• ACS HK guidelines – Cardiac arrest: single episode early in MI – 8 weeks – Absence symptoms; 10MET; absence of arrhythmia

and satisfactory ventricular function

• Still under training: 4.3MET 7.6MET

HT

• Not if BP > 170/110 or

• DBP > 110 + end organ damage or

• Use of medication known to impair alertness or causing marked fluctuation in blood pressures (but no example)

Valvular heart disease

• Should not drive if: – Symptomatic

– History of heart failure

– Embolic episodes

– Significant arrhythmias (? What kind)

– Cardiac enlargement (? Which part)

– Abnormal ECG

– Hypertension (? Why)

– Taking warfarin

Warfarin & AF (under Valvular heart disease)

• Any arrhythmias? If presence, should not drive irrespective of controlled or not

• Any warfarin? If yes, should not drive

DVLA did not have a separate requirement for warfarin use

Federal Motor Carrier Safety Administration (US): the use of warfarin is not an automatic disqualification, but a factor to be considered in determining the driver’s physical qualification status

Canadian Council of Motor Transports Administrator: have to be on warfarin for AF and metallic valve before able to drive commercial vehicles

Heart block

• Not drive if

– AV block with Slow ventricular rate (? How slow)

– Pacemaker in situ (conditional licence allowed if cardiologist with expertise in EP after consideration the risk of PPM malfunction)

– ICD for VT/VF (no conditional if)

Other

Congenital heart disease

• Not drive if – Complex or severe disorder present

– If minor, successful repair

Dilated CMP

• Not if symptomatic (but no Ex Cap requirement)

Post heart transplant

• 12 weeks + similar to post CABG + quarterly review!

Syncope

• Mentioned under disease of nervous system

• Single explainable episode with no likelihood of recurrence will not affect eligibility

• If recurred, should not drive until – Complete full neurological investigation (?)

– Symptom free and under appropriate treatment, stable for 12 months

• Other counties’ criteria for syncope including vasovagal included as reference

Syncope and driving

• If not allow to drive because of theoretical risk? not practical

• Very common to have a single LOC at some points in our lives

• In UK 3% AED and 1% hospital admission

• 20 – 30% will recur

• 80% recur within the first 2 years

European Heart Journal 2009;30:2631

European society of Cardiology 2009

Incidence of syncope (naïve group) Framingham Heart Study

Soteriades ES et al N Engl J Med 2002;347:878

Average 0.62/100 person-years Age-adj 0.72/100 person-years

Patient with CVD has higher risk

• The age adjusted incidence among participants with CVD was ~ 2x of those w/o (1.06 vs. 0.64 per 100 person-years)

• The incidence rates of various type of syncope differs with highest among those with vasovagal 0.13 per 100 person-yrs and unknown 0.22 per 100 person-yrs

Soteriades ES et al N Engl J Med 2002;347:878

Patient with syncope

• Actuarial recurrences (driving gp) behind the wheel driving again:

– 0.7% at 6 months

– 1.1% at 12 months

Sorajja D Circulation. 2009;120:928-934

Vasovagal syncope (POST-1 and POST-2 trial FU)

Only 2 developed syncope while driving during FU = 0.62% per person-year

Tan VS. J Am Coll Cardiol EP 2016;2:203

Mean Age = 38 ±17

Syncope and driving

Factors to consider

– The potential for recurrent syncope,

– Any warning symptoms

– Whether syncope occurs while seated or only when standing

– How often and in what capacity the patient drives

– Whether any laws may be applicable

Transient LOC DLVA UK 2016 Private Commercial

Single Recur Single Recur

Prodrome +

Standing May drive May drive May drive May drive

Sitting Stop 1m and notify

Stop until risk < 20%/y

Stop 3m and notify

Stop until risk < 2%/y

Prodrome - Stop 6m if no cause

Stop 12m if no cause

Stop 12m if no cause

Stop 10y if no cause

Cardiovascular 4w if treated 6m if no cause

4w if treated 6m if no cause

3m if treated 12m if no cause

3m if treated 12m if no cause

Cough syncope 6m • Stop smoke • COAD tx • BMI <30 • Reflux tx

12m 5y from date of last episode

5y from date of last episode

Transient LOC with seizure marker

• LOC > 5 minutes

• Amnesia > 5 minutes

• Injury

• Tongue biting

• Incontinence

• Post ictal confusion

• Headache post attack.

Private Commercial

Stop and notify Stop and notify

6m off driving after last episode 5y off driving after last episode

A Multidisciplinary service model Roles and responsibilities

Cardiologists 1. Treating any reversible cause e.g. PCI, ICD 2. Secondary prevention 3. Counselling for or against driving

Rehab physician 1. Counselling on driving and vocational needs 2. Modification through exercise training 3. Exercise capacity evaluation and prescription 4. Safety precaution (e.g. post sternotomy precaution)

Nurse 1. Coordination 2. Counselling 3. Disease management approach

Physiotherapist 1. Supervised exercise training 2. Monitor the progress

Occ Therapist 1. Vocational counselling

Government: public safety

Patient’s interest

Physician obligation

• Public safety

• Has to be in proportion to actual and relative risk

• Issues to considered if driving not allowed:

– Community access

• Domestic needs – alt public transport availability

• Vocational needs – some jobs require frequent travel from one site to another (survey; construction site supervisor …)

5 important considerations

1. Equity - those with disabilities should not be unfairly disadvantaged;

2. Efficiency - the balance between the social goals and the cost, including social cost;

3. Administrative simplicity - such as monitoring and medical examinations;

4. Transparency - the acceptability of the decision to the general public; and

5. Resulting safety level is the additional number of casualties that would result

Lave LB. Risk Analysis 1993; 13(2): 327

Physicians are not well prepared

• Disease oriented vs. disability oriented

• Disabilities is multidimensional

• Lack of validated tools to measure physical and cognitive ability to driving

• Judgment and knowledge of the likelihood of a driving mishap esp. for sudden incapacitation

• Determination of risk must be followed by assignment of responsibility to stop driving

Berger JT J Gen Intern Med 2000: 15; 667

Physician as a dual agency

• Patient interests and public safety may sometimes conflicting

• Physicians acting as police may not beneficial to both patient or the society

• Patients may avoid health services all together

• This in turn preclude Dr from involvement in driver safety

Berger JT J Gen Intern Med 2000: 15; 667

What if high risk patient not report Disclose Not disclose

US (Oregon) Required; immune from civil claim

Protected from liability might face if an unreported patient causes injury to himself or others

US (Pennsylvania) Obligated law does not impose a duty on physicians to protect third parties from the actions of patients

Black L. AMA J Ethics 2008; 10 (6): 393

UK Informed DVLA if patient ignore

NOT mentioned; weigh the harms of non-disclosure against the possible harm to the patient and to doctors-patients’ trust

http://www.gmc-uk.org/guidance/ethical_guidance/28432.asp

HK Voluntary; Personal data (privacy) ordinance s59

NOT mentioned

Take home message

• Always explore occupation and driving needs

• Counsel for the risk and implication and document

• Seek specialist opinion for individual conditions

• Seek rehab physician for uncertain cases

• In rare situation, legal advice may need to be considered if you are going to bleach the patient privacy e.g. epileptics still driving

References

1. Rehabaid Centre. Medical Guidelines for Fitness to Drive Commercial Vehicles Revised Edition. Hong Kong: 2006

2. Road Traffic (Driving Licenses) Regulations Cap 374B Sched 1 [Jun 30,1997]

3. Jung W et al. Recommendations for driving of patients with implantable cardioverter defibrillators. Study Group on 'ICD and Driving' of the Working Groups on Cardiac Pacing and Arrhythmias of the European Society of Cardiology. Eur Heart J. 1997 Aug;18(8):1210-9

4. Berger JT J Gen Intern Med 2000: 15; 667

THANK YOU

can i drive? - apccrc vi_dr. angus chu.pdf · 2017-12-05 · 2. liability to sudden attacks of...

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