Okay, welcome everybody. It's three o'clock. We're back to play again. You got another about probably 45 minutes or an hour with me, and then we're going to have Dr. Wriston do a little bit. So, somebody in chat already. How long we have access to these slides. I think the answer is for a long, long time. I actually just answered this question for Dr. Wriston. Several days after the conference because it takes us a while to get all the recordings together. You all who registered for this conference will have access to the recordings of these classes right now for about a year. And that's through the AOA on demand learning. And you'll also have access to the slides. The slides I believe that I have access to through the app. Yes. And that I mean they're not going to go away tomorrow though it'll be there for a while. Yes, that would be right it is recommended to take your test sooner rather like I, my plans take my test, I, the anniversary date of my test was 10 years ago, yesterday. So I will be, I will need to recertify soon. And I think the slides are also available, I believe, if I go to the AOC OPM website and look under. So the question, the question was, was on the website and the short answer is there sort of they're available if you follow the app, the links that got you to this class, you're set. They're not on the, on the public part of the AOC OPM website but they are on the link for this class, and they those, even if we update the slides if FMCSA changes something, you'll see the current slides. Well they will in the app, Dr. Warrants, but I don't go back and alter each web page, because that would be years and years of web pages. So yeah, no, because I do a new web page for each time the class is taught. Okay, so you have access to this set of slides for a long time. Okay. Let's see what happens. Oh just your mom, she's okay. So, this is the same thing I talked about before, three separate activities, the operators license, the medical, and the drug and alcohol testing, and we just care about the part that's in the pink, that's us. So, when you issue an MCSA medical form, the MCSA 5876 medical certificate, you get to decide how long it's good for, can never be good for longer than two years, could be good for as little as one day. I mean I wouldn't, you're going to make, I don't know why you want exactly one day, but it would, but you could do that if you wanted to. You have the permission from FMCSA to issue it for any period of time, two years or less. And keep in mind, any medical certificate can operate any commercial motor vehicle. So, how do we decide what like what's the process we go through when we do a seat, when we do a driver exam. First step, make sure they are who they say they are. So you want to see a state issued or government issued photo ID. I recommend you ask if they have a prior medical card and asked to see it because it might help you. Geez, if they were on a one year card before and now they didn't tell me any medical conditions we get to talk about why that was true. The health history form, the 5875 is completed and signed by the driver. Anything they indicated is a yes, you have to write something about, doesn't have to be very long, but you have to at least talk about it and document it a little bit. Did they have any prior limitations, surgery, illness or injuries in the past, hospitalization, surgery, changes, new medical, current medical complaints, any of those things, you have to document any of their yes answers. And obviously if you see something that they forgot to ask about, like they've got a prosthetic arm which might not be a question, ask about it and document it in that same space. Are there current medications or supplements with potential side effects? And again, talking about that, recreational addictive substances, including nicotine and alcohol and all those sorts of things. And anything else that could impair their ability to safely function. You'll cover all these normal things that you're kind of used to when you do a history. You'll do a urine dip test. You'll look for specific gravity, protein, blood and glucose. And if you're so inclined. If you can use the regular, you know, 10 thing dipstick so you look for other things, or you can just you can buy this version. If you buy the OB ones there, but they cost more, you can just get these tests. I'm not gonna explain why this is true but the 10s, because I have to buy them from for when I do the FAA things, the 10 dipstick things are like, like $7 for 100 of them, or, or you can buy the ones that only do the four, and they'll be like, like $15 for 100 of them. I don't know why, probably because just a smaller market. You'll do either a whisper test for audiometric testing. You'll do a vision test for distance only we don't care about close or anything or intermediate in visual acuity horizontal fields of vision and the presence of binocular vision. You may need other testing that you think is important based upon their history and there's some specific conditions require additional testing that we'll talk about. So what do you need for equipment, you need some sort of a way to do distance vision you can use an eye chart. If you use an eye chart. Make sure your staff is doing it correctly. You don't just have it up on the wall and say I stand kind of over there someplace, and then just ask them to read the chart in to figure out where if it's a 20 foot chart, you put a mark on the floor where 20 feet is from That sounds stupid but I've been to, I've, I personally have had my vision tested, and they literally said just stand over there somewhere. And I'm like, is this far enough away. And I'm like, I go that's fine. And I'm so I they did their thing, and I read their little numbers and everything and then I finally got, I got to walk up and I'm like, I'm maybe, maybe five feet from the chart, maybe, and it was a 10 foot chart. Now, not all 20 foot charts was a 10 foot chart I was five feet away, I have noted what that means. I just don't know. So, just make sure that they're doing it correctly. You need some way to do color vision. It is not in Carl's personal opinion. I think it's not adequate to look at the eye chart and set and point the green line and say what color is this line point the red lines and what color is this line, because yes they are red and they're green, but they're, they're, they're, they're obvious and knowable in advance. And I'd much I prefer I whenever I'm on the road I use my paperclips. That's okay too, because they're in a random order. And what I say here is, which is the green one, which is the yellow one which is the red one if they can pick those out. We're good they've got adequate color vision, you don't need to see her or anything so they just need to know, red, green and amber. You have to know if you're going to be able to tell whether it's red on the traffic light. No, no, that's actually it can't be, it can't, it has to be based on the color, not on the position of the traffic light. That's one of the differences because these guys are driving big really heavy things that stop slowly. And a farm to earth lantern would be another way, and a farm to earth lantern does yellow, red and green if you want to use a farm to earth lantern have at it. I've never done that I've always done, I, the paperclips work fine. As long as they can differentiate the three colors. The thing is, I want them to know it's a red light, it's a red light they're coming up to when they're half a mile away not when they're 30 feet away. Right, that's my that's the real issue because I at least especially out in the big flat parts of the country. So when I say which is the red one. Going to the red one that's recognizing. I can't just say I guess you would say what color is this and give me and they get a one in three chance, but they'd be to get them all right all correct. I find that paperclips be pretty efficient and I've got the, I have the little skinny paperclips for for on the road and I have a bigger set of paperclips I use in the office. You have a dipstick urine thing, and you can buy whatever kind you want. My recommendation not a requirement is that you also have a finger stick glucometer available, they're about $20 or 30 20 $30. And the last one I bought came with 200 strips. I guarantee they'll go out of date before I ever use them. Let me see if I can do this I might be able to I go to participants, hold on I think I can do it participants, and I go to you all. Okay, and I think I'm still alive. I'm still alive, and I think I got everybody now okay, so I think that that fixed. And the reason you've got the glucometer there is if somebody tests, if somebody dips, if somebody's urine dips positive for glucose. The question is, do they have uncontrolled diabetes, or is it something else. And so I want to dip, I want to do the finger stick to figure that out. So that's what that's for. Yeah. So do they have an effort limit on the sugars. We'll come back to that they do. It's 400, but they do. But my question is, an undiagnosed diabetic is not safe. That's the other reason you do it. Okay, so if they're undiagnosed if you've got a positive test and you say are you diabetic and the guy says I'm not diabetic. I'm, and, and they've got a positive, you know, you're in dip thing, and, and any kidney disease they go nope, and you go okay, and you check their finger stick, and your finger sticks 300. They're now an untreated diabetic and that's not okay to certify. Now, when they go see their family doctor they get put on metformin, they can come back, and you can certify them. Okay, but you can't be you can't have a diagnosis we've identified it's untreated. That's not okay. That makes sense. And that's what the glucometer lets me differentiate those people. I don't know if that's changed. Also, true, but a lot of this stuff has changed since the last time. I think I've got that in the last module here. It's sort of frustrating to me because they've kind of gotten rid of telling us anything. So, so that's but that's what the glucometer is for is it's what I did when I when I was in a clinic with lots of other people. If their dip your UA was positive for glucose. I wanted them to immediately do a finger stick. Okay. And I said for my little stand my little sort of standalone clinic. I bought a glucometer. It was literally, it was less than $30 they came with 100, I'll be, I will never use that many, but I probably was using five or 10 a year. I just want to, they test positive on that. I want to know are these uncontrolled diabetic, or is this somebody who's like when the SGLT three inhibitor people to sorry. this, or is it because they're just a wild uncontrolled diabetic I can't tell if I don't know what their sugar is, or, or my one where the kid went, and it was a youngster who really want to find a 16th birthday to do a solo, and he tested positive. This kid had had a breakfast of three donuts before he came to see me. And just had a tiny little bit I mean it was the lightest color of Abby normal that you could have. And so we I mean and as we immediately his finger stick his finger stick was like 118. He's not uncontrolled diabetic. Okay, but I wouldn't have known that if I didn't have that, if I didn't, what couldn't do the finger stick. The finger stick. If you're worried about this, the finger stick is a clear wave things if you're in a clear wave, you need to clear clear waiver to do the urine dip anyway. And you can also the finger stick under say, clear waiver. And that's that's my recommendation, because uncontrolled diabetes is, but can die diagnosed and control the spine, we can work with that. Are they using a hearing aid. Was there abnormal fundoscopic exams all these things go on your form. Do they are they using corrective lenses they need money. Are they monocular. Is there anything else that I want any other testing that I have, and sometimes they bring me stuff like here's the, here's my last echo or here's the last thing for my sleep study or whatever it was, and I will that's wrong note that at least briefly on that form, so that at least the form references these other records that I am considering. We do it when do is and physical, this is something that Liz gave me into a couple years ago, these things are a godsend. So they're kind of a quick book exam we have to use still use the best clinical judgment. These, these pantaloons. They're not that expensive, and they give you an opportunity to get somebody where you can examine them without them sitting there in their underwear. Okay. If you do a lot of women you'll need a top to go with this. But it gives it makes it a lot easier to see stuff like that big, that big zipper thing over their chest. And I use them, I got the reason because I was doing use them to do. I am he's like lower extremity or back injuries when I need to say I need to get to their legs, and they should in January, they're all wearing long pants. This was a way to fix that. And then I said, I got, I don't know, 100 of them for like $30. But if you notice the blood pressures are much lower. Yes, you said blood pressure will be lower if you clothe the people a little bit. We're going to record the basic vital signs their height their weight, their heart rate and regularity their blood pressure, the UA visual acuity color discrimination, just check marks on the form, you got to fill out the, you got to fill out the form. You can't record this in a different place it needs to be on the form it's actually in the rules. If you've got if you've imaged the form somehow, and there are a couple of these tablet based online systems to do this. That's fine as long as it follows the same format. I don't want to get to do their eyes. People are reacting like I look at the back of their eyes don't make sure they don't have like a brain tumor going on. Ears, the throat and neck, kind of normal exam for those parts. Liz you want to inspect the chest, surgical cars scars zippers down their sternum, big lumps by their shoulder, all those things are kind of important. It is amazing. The number of people that I see for CDL exams, or occasionally FAA exams that forget. Oh Doc I forgot to mention that heart surgery, or that pacemaker I have or that ID that I they put in. It's amazing how bad people's memories are for things like that. You do want to ask what they took the heart look for other things that might have to with heart disease. Mercury down, listen to their lungs. You look for you know abnormal chest motion we're back to looking for signs of surgery to find that sometimes back to the abdomen more inspection little surgical scar looking. Are there any abnormal masses. If they're if I if they're skinny enough that you can pull this off, look for abdominal aneurysms that works in some people less well and others spine, especially if they're, you know, if they're not barely able to move that worries me. Okay, extremities I'm looking at, you know, is there anything abnormal that I'm able to identify, I test, I test range of motion and strength within what I call the normal ranges of motion, I do see doing a bench and the other, you know, arms out, you know, test strength, test strength, test strength, lift their knees up test strength, straighten their legs out, bend their legs, ankle dorsiflexion plantar flexion, because all that stuff is part of driving. And I do want them to have adequate grip and prehensions they can move their hands and grip tight enough to hold on to a steering wheel that obviously is a key neurologic exam again I'm looking for stuff that's abnormal I don't usually do a Robert unless I have some reason to do one. I do look for tremor and for weakness. Their cognitive signs is, are they kind of normal ish, or is there something going on that has me worried. And if because I said this is a pretty cognitively challenging job, even if they could physically drive the vehicle they have to be able to find their way. And, you know, if that Alzheimer's patient goes on the drive in their, you know, Chevy Malibu, and ends up 350 miles away in the middle of New Jersey. That's challenging if in the middle of nowhere in the woods that could be a disaster. That's from that's my search and rescue stuff. But if they do that same drive in there, you know, 80,000 pound combination truck full of coal man up in New Jersey. It's a whole nother level of problem. These are things we may want to think about getting a specialist evaluation, especially if you're concerned about something going on with their, their eyes. If you do your fundus copy examination, and it looks like there's some eye disease going on. I would want an ophthalmologist give me an opinion. One of the things we're really looking for is if you can't think about just two things is, do they have a diagnosis of x. And then does that whatever x is interfere with your ability to drive is treated adequately that's one kind of question. The second question is, at least in my group is, do these people have a diet and undiagnosed condition of x because I don't know how it is in your area but in my part of the country, guys only go to the doctor, when they're quote from them nearly dead, or their wife makes them, or the woman makes them, whether it's the wife or the girlfriend. If one of those two things doesn't happen, they are not going to the doctor, and I find all sorts of undiagnosed stuff, both in the in in drivers but also my coal miners, the number of coal miners I've sent to go see their doctor about something like that was super important. Just baffles me. I'm English language, it's in the standard FMCSA has made it very clear we are not responsible for that assessment. So, now, you have to be able to communicate with the driver applicant. Well enough to take a history. There's a translator involved, maybe you speak whatever language they speak, that's all okay they don't have to speak English have to answer questions in English. But you have to be able to take a good history, and then you do a medical exam. The company gets to decide whether they speak English sufficiently for the tasks at hand. Virginia, if you don't speak English, it's gonna be a major problem where she was in Texas. If you don't speak Spanish, and you're going out onto the onto the like the oil and gas sites, it's going to be a major problem, because you can't talk to the people that are working on the drill site. Okay, so it's just how that's interpreted I don't really know, but it's not our deal. We are expected to provide counseling to the drivers. So if we, we see them and they're on a medication when you talk about side effects I could affect them that smoking is bad for you that drinking too much is bad for you all that stuff we're on the hook to want to go over with the driver. Okay, so what I'm here is referred non disqualifying medical conditions that require care. If you do that you will probably never have a malpractice case in your entire career is not doc. That's the thing that gets our docs in trouble is if you have, if you note something and don't actively refer them to go get care. That's your biggest risk. You mean tell them that they need to go to care actually put a referral in. It would be whichever works in your system. If it's a completely standalone clinic I have nobody to refer them to, but I will tell them that they need to go see their primary care doctor right now because they've got this, you know, concerning murmur or whatever. And I document I tell them I documented. I'm fine. If you're a system where you can put a referral in. And some systems. Sometimes you can sometimes you can, then you could do that. There's nothing wrong with doing that. If that's allowed in your, in your environment. The, the, like if you're in the VA or for the Kaiser Permanente system where anybody can send a referral to anybody, then that's a different if you're if you have to get permission from if you're not their PCP and it requires PCP permission, you send to the PCP, right. But that's just, it just depends on the system you're in, but you definitely tell them and document it and document it two or three times that's all okay. So, if they if they use here if they use contact lenses recommend they have either more contact lenses, or that they have lenses available especially if they're over the road they probably have lenses so if they have a, they have to not wear their contacts because of some allergies some other eye problem. They aren't trapped in Indiana, because we wouldn't want anybody to be trapped in India. If they use hearing aids carry spare batteries, and maybe the old pair of hearing aids if they still have them. Tell them they need to be there if they sit in the car, sit in their truck for too long all in the same time, they will get themselves in dbt risk they should stop at rest areas every so often get up and walk around, pump their legs while they're sitting there, all those things help. Do they carry some sort of glucose. Do they. Huh. They'll see this. Yeah, this could be a test question. Do they have a. What is their plan to measure their glucose. The old recommendation from FMCSA when they when they gave insulin waivers was one hour before you started within the last hour before you started the drive, then every four hours while driving as a minimum. And if it's electronic that's okay. What's their plan Like at what point will they do something? Will they stop driving or will they take their glucose? When do they, like, when do they pull off the road? And can they detect when their sugars are low and what do they do when that happens? You know, do I, as soon as you get that symptom, whatever their symptom is, they feel flushed or whatever it is that happens to them when their sugar's low, do they just pull immediately to the side of the road? And check their sugar? Like right now, the next place is the place to pull off the road, do you do that? Or do you wait till you get to the next rest area half an hour from now? You have to talk those things through with the driver so that there's a concrete plan. And again, document that stuff. Are they allowed to continue driving when they have low? Well, if they're above 100, which may be low for them, then the answer is yes. But what's their plan? And so the old waivers were actually, they had to get your sugar back up above 100 before you were supposed to stop, like right now stop, and then check your sugar. And if you're under 100, you do whatever you do to get your sugar back up. When you get to get above 100, then you can start driving again. That's what the old waiver was. Now, if they're not on insulin, if they're on insulin, this all should come from the treating clinician. They're not on insulin, there's no recommendations for anything. It's not even in the book. As far as I can tell, non-insulin treated diabetes is not a medical condition according to FMCSA. So you have to kind of work that through with them. Like I said, I want people to be able to work, but I want it to be safe. So we're gonna talk about these unusual circumstances like that, and then make a plan. Little risk assessment. Can the driver do all these things the driver has to do? Can they monitor the complex driving situation? Can they work extended hours without breaks? And again, it may be that they know they need to keep food with them and eat every so often. That's all okay if that's where they're at. For any diagnosis, is it stable? Is it progressing? Do we need ongoing monitoring? Is the treatment working? Are there side effects? Is likelihood of gradual or sudden incapacitation? I mean, at the end of the day, almost everything we worry about is about this, if they can do the work. If they don't have a cognitive or missing body part or something, or dysfunctional body part, it's really risk of sudden incapacitation. That's really our focus. These are the six disqualifying ones. Hearing, vision, methadone, current alcoholism, epilepsy, sort of schizophrenia, but not exactly, schedule one medications, and use of controlled substance without a prescription. Those are the hard disqualifications. I would argue that an implantable cardiac defibrillator probably belongs in there too. The medical expert panel in 2017 said that, but it never made it into the book. Okay. They did a whole report on cardiac defibrillators, and their point was from the time of need of need until the time of discharge is typically 20 to 30 seconds, when you have a nobody driving the truck. And then they get defibrillated, which does not make people better drivers. And then they've got to recover from being defibrillated and get brain blood going. Even if their heart restarts, it's got to get back to your brain. So you've got like a minute with nobody driving the truck. Well, no, all those things are correct. Yeah. So they've got like a minute with nobody driving the truck. Pacemakers are fine, but ICDs are not. Even if they're disc. If they're disc, if your cardiologist is willing to turn it off, then you're okay. That's my spin on it. If your cardiologist said you've, whatever that thing was, why you needed that, you've completely recovered from that so much that I'm confident turning your ICD off, then that's fine. I'll sort of, I'll, then I don't, it's not there anymore. It's just, usually then it's just a pacemaker and then that's okay. Because almost all of them are ICD pacemakers now. So if somebody's disqualified, I think it's your duty to discuss with a driver why they were disqualified and what they need to do to be able to be qualified. I think that's your job. Don't just say, I'm sorry, I don't meet the standard. The door is over there. Too bad. I don't think that's helpful for anybody. And you'll get a bad Yelp review out of it. So new form, the MCSA, I know the current form, I think this is still the current one. The medics, the information, it looks like it's in the driver has expanded just a little bit. Lower streamline. There's a section for us to actually write. It's almost big enough to write something in. The old form had this little, you get about a quarter inch of space to write your notes. And that gave us like a whole inch of space, maybe an inch and a half. You can print it out from the FMCSA website, make your own copies. And then that gives you the stuff. There's a help section that goes with the form. It's not super long, but it does walk you through the parts of the form. And there's some decision recommendations in that thing. I'd read that before I went to take a test, or I will read that before I go take a test. I'll say it that way, because I have to test this year too. So that's one of the things I'll read out there is that the instructions for the form are with the form when you print it out. And I'd read that because it's got some helpful stuff in it. Okay, so one of the things that's changed is the have you ever section has replaced the have you in the last five years section. They've added a new question about sleep studies, spend a night in the hospital, broken a bone, lipid problems, tobacco, illegal substances, or failed a drug test, and then any other health conditions. But there's a section where you can even write down the next year comforts, the BMI. So at least there's a little help there if you wanted to record those things, there's a place for them. That change from five years to lifetime will pick up a lot of stuff that, oh, that was seven years ago, I don't have to tell you about my stroke, right? So the concept of temporarily disqualified went away. We've replaced that with pending determination, gives you 45 days to figure out what you wanna do. And if there's what I call a small problem can be fixed, their glasses aren't quite good enough. Like they're not 20, 40 at distance. Maybe their blood pressure is a little bit higher than you're willing to certify them at. If you use determination pending, see, temporary disqualified is making a decision. Determination pending is saying, I don't know. And theoretically that person could keep driving for that 45 days if their old medical is still current while they fix that thing, it doesn't necessarily take them off the road. And it also gave me a place where I can now, if I can go back on the same form, because this is one of the problems where we had to like put big Xs and write all this crap. There's now a place to put your second determination. So if I do determination pending, and there's a little box that says, supplemental evaluation, and they returned to clinic and they've got new glasses. Now their vision is 20, 20 in each eye and both eyes. And I can have a place to write that. And then I can write my final disposition for the patient. Also, if they don't come back, I can go in that same box and put patient did not return after 45 days, mark disqualified, because that's what it is. And off we go. Theoretically, the FMCSA website will do that on its own. I don't trust it to do anything. Yes. Before you get full exam, now you're saying you just gotta do that one thing. If you use determination pending, you can go back and fix that. And there's one thing, oh, I'm sorry. If the person walks in without a form that they're supposed to have, they've got monocular vision or they're diabetic on insulin, and they don't come with the form, you are specifically not permitted to use determination pending. But anything that comes in at the exam that you do, and their exam has an issue, you can use determination pending. So that's the way that one works. If they don't meet the standards, if they don't meet the standards, I cannot give them a shorter serve. So if there's something where I just, I'm kind of curious about something, then I could give them a two month card or a three month card while they fix that thing. But if they don't meet, I can't say if their vision is 2060 with the best eye, I can't give them a card for any distance. And they don't meet the standard. Yeah. Go ahead. What you were asking was whether or not, if it expires in three weeks, you could only make a pending for three weeks instead of 45 days. No, you can make it for, they can get the whole 45 days. They just can't drive. Yeah, they can drive until they run out of their old car, but they can't, once their old card expires, they're done until they, so, I mean, now sometimes there's some, every once in a while, there's something where I want more information. This used to be a lot of sleep apnea. This was a constant problem. You might give them a short card to get that thing fixed without necessarily disqualifying them from driving. Because I don't think it'll cost, if you think something's gonna cost sudden incapacitation or make them unsafe from the road, you don't certify them ever. But if I think something, like you need to work on this. And I don't think, I'm trying to motivate the driver. I might give them a shorter card to kind of get that, go see your doctor about your blood pressure. Cause it's, I mean, you met the standard today, okay? By whatever standard you decide you use, by one point, and it took us five measurements of your blood pressure to get us there, okay? That person might give them a three month card to say you're not, you're gonna not be safe and you need to go take care of this. And if you don't trust them to do it, you give them a short card. And that's completely up to you. This is all the boxes. There's more boxes now. And interestingly, we have yes, no, and not sure. That's actually honest. I like that. So you can at least ask about the not sure things. And at least, you know, my mom said I might've had that when I was two. Okay, well, that gives me, that's why they don't know. And some of these are like, not everybody knows what category something that happened to them goes in. And then you can ask, right? So my, I know the rules say you have to write about all the yeses. I write about all the not sures also. So I asked about all those. So at least I know what they're talking about. Why do they think they might need to indicate that box? And, you know, you get weird stuff like, you know, some, I might have some heart thing, but I don't, is that, does it count as a pacemaker or a stent? Or was it a heart procedure? You know, they don't know what box to check. So they might click not sure. I just want to ask about those too. And this is all the drivers, right? Any other health conditions, anything they want to expand on, then they sign it. And then this is for me to write in. At least I've got a little bit of space. Have, feel perfectly free to add more paper. Okay, you can use another sheet of paper and just insert it in there right on the back. All those things are okay, because you need to have enough space to document things you need to document. When I get to the second page, this is where the actual exam goes. I'm going to put their pulse rate, their height, their weight, their blood pressure, their urinalysis results. They might need another blood pressure that goes there. Vision, hearing, physical exam. And I've got a place to put comments if I have problems. And then that's my determination form. This is the kind of the last part of the form. It's also, this is the one that's part of your medical record and stays. And there's a second one, a second copy essentially of this page that goes to the driver. And then I said, what they've added is if they're state, you use this box down here. If you're using, if they're an intrastate driver and using the state rules. And what I like is that they've got the place. When you do termination pending, then there's the, when was the return to the office? What happened? What was the final outcome? There's a place for all that. And then this is the certificate. Certificate will not in any way replace not in any way reflect any kind of determination pending or anything like that. Certificates only issued when they pass. There is, you don't give them a certificate if they fail. So potential exam outcomes does not meet standards. It's a hard fail. The thing that 49 CFR, that 41 qualified for your certificate, that's the, everything's perfectly okay box. Those are all what I call specials. That's the determination pending. They have 45 days to fix whatever the problem is. And then this little box on here at the bottom for incomplete examination is essential to work on doctor shopping. If you say, if they're going through the history and they got, and they check the box, it says like epilepsy or seizures. And you say, oh, you had epilepsy, I can't pass you. And the guy gets up and walks out of the room, never talks to them, never actually examined them. You'll mark that as an incomplete exam and you will turn that into FMCSA as an incomplete exam. And that way they may give them a clue to come look for that later. If that person does go get certified somewhere else, maybe they don't mention that there's seizure things. So keeping in that special department, so accompanied by a waiver, this thing here is the 1996 vision and diabetes waivers. Both of those are now dead. Well, almost dead. I think we've got three more days on the diabetes one. Or no, binocular vision. The vision waivers, they run out sometime this month. Maybe we've got a week or two. When that'll be when the last person a year ago who had a monocular vision waiver would still be on their waiver. And they will now need to meet the new monocular vision standard, which we can certify. They don't need a waiver. But the last of those waivers was issued last spring. There will be no more. And those people will now have to come under the regular monocular vision standard to go through later. As I said, this inner city zone is this 1988 driver who is now 35 years later has had no change in their medical condition, whatever it was that made them ineligible way back when. You're gonna report this all to the NRCME database. They will be checking stuff. They want you to put it in by the end of the next day. You've accessed the system through login.gov. You're gonna enter their driver data. I recommend that you type it directly from their driver's license. Like I say, give me your driver's license and put it right there and I type right off of it. So I get their middle name or their initial or whatever it is, and I get the address that's actually in their driver's license. That's what they want to have on there. Especially the name, the name must match. If they change addresses, you can use their new address but the name has to be identical. The birth date has to be identical, even if it's wrong. And the retraining says what you are to enter is what the driver says is their current. Address. And that's because they want to be able to get ahold of them. Their driver's license may have been for, in terms of address. And so this is so FMCSA, now if they're changing that often they'll probably be going again. But that is when the retraining and one of the things I've done in my slide is try to point toward the retraining because I think that will be how kind of the new test is done. So if their address changed, that's okay. But if their name, their driver's license number and their birth, they need to match the driver's license. So even if it's wrong, you put what's on the driver's license. And then your outcomes just goes in there, medically qualified, unqualified, termination pending, or I guess incomplete exam. And then the expiration date that you, when it says medical examination, medical examiner expiration date, that's the date you think their certificate should end, not the date that your certification ends, okay? Just to clarify, because it's kind of bad wording. So you're gonna do these by midnight today following the exam. I recommend doing them through the FMCSA website. That's why I do them, but I don't do a huge volume. If you've got a third-party vendor that turns them in to FMCSA, that's okay. As long as you've got it set up correctly. And you can have somebody else in your office set up as a medical examiner administrative assistant. Any human can go, with an email address, can go and create an MEAA account. And then what you do is you and they will get married on the system. You'll get their MEAA number. You'll go in and say, I would like to add an MEAA to my account. And they'll put up in their secret number. They'll then get an email that says, hey, Wernz wants you to be an MEAA on his account. Is that okay? They'll say, yes. And now that person can put in stuff for me into the FMCSA website directly. They are my, I have agreed, they are my proxy. And whatever they put in, I'm responsible for. So take them off, if they are not- Yeah, when I changed clinics, I had to remove people. And the funny thing is they can't, I can't, they fixed this now. I couldn't remove people without their permission also. So I would say, remove them. Then they say, we will contact them and ask them if they want to be removed. Yeah, they fixed that. That was stumped. I understand the marriage at the beginning wanting to be by consent. But if I say, take them off, they shouldn't have to get permission to be taken off. Anyway, so that's what I recommend. If you're using a system that will put them in, that's just fine. Get this stuff to precisely match the driver's license, which is the last name, first name, middle name. And if there's a suffix, and then the state, birth, license number, date of birth, and whether they're a CDL trainee or not. CDL or CDL trainee or not. And then state or federal standards. That needs to match what's on their license. Because if you marked that they're not a CDL driver, and they are, it won't go across the database because there's no place to, it doesn't think there's any place for it to go. You'll put in all this other stuff. It was the same information that's on the form. And in fact, I just had the system print out my certificates like it'll print the certificate for you directly. And then that's what you, I signed the driver signs it, we make a copy for the chart and it goes to the driver and I'm done. I don't have to, there's no double and triple typing of stuff. I do recommend because this system has had computer problems in the past. I would encourage that you have the PDF of the blank certification form available. Where any of you guys, I mean, if you guys are in this class, you were probably participating in 2016, 2017, where they kind of forgot to have a computer system for almost a year. And that's what we had to do for that whole year. And I'm sure everybody here went back and re-entered all the ones that had not been done. I'm sure that happened. Didn't happen in my clinic. We just said, yeah, we're not doing that. They worked with us twice and nothing still happened. So theoretically, if you get to the 45 days dispositions pending, you should get a notice to the driver that they are no longer certified. And they would theoretically retain all this invalidated stuff in their system. This is the form that goes to the driver. They need to carry this with them and share with DMV. You can get the fillable PDF. And I said, I recommend you have that available on your system someplace in case FMCSA should have IT problems in the future. And I'm waiting. I'm actually a little worried because the login.gov thing, some of the IT people discovered that people who run the login.gov were basically lying to all the agencies and charging them for stuff they couldn't do. It will not surprise me if there's an internecine war and they like turn it off or something. There's weirdness going on there. And then you can print stuff. You might be able to handwrite these certificates. Not all states will accept that. Just be prepared. Go ahead. Don't have to carry the entire fiscal anymore. Oh, they never did. No, that was never ever. Wait a minute. Never ever did the driver have to carry more than this. Now, some drivers wanna have the long form because some states are like in West Virginia up until pretty recently, they were requiring the long form to go into their database because they get tired of people, of some driver downloading the form, signing it themselves and putting it in their wallet. They wanted the long form, but they never ever need to carry it with that. In Indiana we did. No, I don't think they need it with them when they're driving. Not, well, I'm sorry. Let me say this carefully. For interstate commerce, I don't know what the interstate rules are, intrastate rules are. I think you guys have intrastate rules in Indiana. I think that's right. But the feds will never make you carry the medical. Yes. Can they shrink or laminated? You can, as long as it's readable. So you can go to about a third size and you can still read. Cause you have to be able to read. That little writing that you could barely read when you started, that has to be still legible. And you can't use a microscope. So that's the problem. You can't make it a whole lot smaller. That's why they're trying to get rid of it as a thing, a piece of paper you have to carry with you. But you can definitely laminate it. They don't care about that. So you have to keep your record for three years. As we discussed earlier, you've got to be able to get them even if you don't work at the clinic anymore, and I can't imagine a clinic telling you no. I really don't. I think they would actually lose that if they tried to push that point. Oh, and you have to be prepared to telephonically verify certificates if you're asked. So if the police call and say, hey, we got, you know, Joe Schmoe that says he's got a medical certificate signed by you on this date. Can you just verify that you did that? And you just say, yes, I did. And they go, great. Or they say, no, I didn't. They said, thank you. We may have a detective come by and talk to you. And that's okay too. So the alternative vision standard, we'll go through that. That has a separate document and they have to use that form. Diabetes has a separate document. They have to use that form. If they have a waiver letter and there's still a couple of those out there, you would want to include a copy of that because that's, you need that to be issuing them. If they're like on the shorter term for diabetes, for seizures let's say there's one more or they're deaf. They don't meet the hearing standard. Those are the two that are, that are the waivers that are still out there. If they had an SPE previously, I would ask for the report. The report from that is like one page, maybe it's a page and a half. It's not very long. I'd ask for a copy. You don't have to have it acquired, but I would kind of want to know that they, that they're compliant with that process. Mostly to provide guidance because they have to go back and redo that every so often. And some of these guys that, that it used to be an SPE was once for a lifetime. That's not true anymore. And so you just have to kind of be aware of that process. If they had to see a SAP because of a drug issue, you'll put that in the folder and any health counseling, which is probably one of the main four. So let's see. Nothing new there. So they, somebody may come by and ask to see their, their medical certificate. And if any of these things happen, you know, if an investigator shows up or they want to, they think they went to multiple examiners or anything like that, be prepared to share your information. Skills performance evaluation. So this is for a fixed deficit. And you need to probably know that I probably would take the hearing aid off of here because that's, they're not doing those right now by way of SPE, but that, that may be where they go in the future to demonstrate that the person who's deaf has an alternate way to be aware of the sounds that are important to driving safely. So if they're applying for an exemption, I'm sorry, I guess this is SPS and exemptions. So if they're applying for exemption, the hearing package and the seizure package are both available on the FMCSA website. Those are the only two that are available currently. And they can fill out, there's a new application, a renewal, a release form. All those are there. If they were on a exemption for diabetes on insulin or monocular vision, they are required to use the new standard. They can't use the, if their waiver, their waiver is no longer valid. That makes sense. Because, well, within a few weeks, the monocular vision will be no longer valid. They gave the people, because they were on a one-year certificate. The last one, the last waiver was issued in March of last year. When one year from then comes around, they have to start using the regular certification process. This is what an exemption letter looks like. This particular one was for vision and it was one of the old ones. But it's that, and it both tells you what their waiver is for, who they are, and then what they have to do and provide to remain certified. It's 97% the same for like all the people that have a diabetes, all the people that have a particular kind, but there can be variations and you actually have to read theirs because they are somewhat individualized. I think I mentioned these are the only two exemptions. So if they need an exemption, they'll leave their office with a completed form and you check the box that says must be accompanied by a waiver or must be accompanied by an SPE. And if they need a new exemption, you'll help them get it, but the certificate should look the same. Same as everybody else's, just with a box check that says got to have the exemption before you can drive. And they don't have to come back to you to get that and they leave with the certificate. You don't hold the certificate, wait until they get the exemption because they'll have to submit your certificate as part of their application process because FMCSA wants to make sure that they're good for everything except the one thing they need a waiver for. That's what that process is. Skills performance valuation, it is for a fixed, usually orthopedic deficit. Okay. Unlike change over time is unlikely. You do your regular form. They leave with the regular form sign and marketing an SPE. I recommend that you help them get started on the SPE process. If I have to ever send somebody for this, I print out the SPE form for them. They unfortunately have to then take it to either an orthopedic surgeon or a PM&R person. They will not let OCDocs do this, although I really wish they would, because I think I'm pretty, I think I will pay more attention to whether their deficit is fixed than any orthopedic surgeon will, just saying. And PM&R might give you a pretty good thing. In my area, I have one PM&R doc that'll do these. Nobody else will do them, which is stupid. I mean, all you have to certify is that it's like the guy's legs not going to grow back. Okay. I just, you know, I think I could do this. I really, I really do. But anyway, so they'll refer to a SPE testing center. There are currently either six or eight of them. They're in big cities. I think I mentioned before in West Virginia, you either go to Chicago or DC. They're your two choices, maybe Chicago and Baltimore. They're your two choices. They're kind of spread out around the country. And they set that up because every state had had their own and then they didn't and they had to, and so drivers were kind of stuck. Yes, Liz. I just want to emphasize again, because they will try and trick you. It is a fixed deficit. Correct. Again, they're not going to grow a leg back. They're not going to grow an arm back. They've got missing fingers. They're not going to come back. Maybe they're, maybe their elbows bend at a 90 degree angle, whatever it is, something that's not going to change. MS is not in this category. ALS, all that, nothing that no progressive disease is this applicable for. Yes, sir. So they need an SPE for missing fingers? They need an SPE for missing fingers, basically an SPE if they can't grasp something. So if basically if they're missing their thumb and they're missing, if they're missing this, the grasper, then they need it. You need, you need, if they've got the, if they've got their big finger and their thumb, their index finger, their thumb, they can grasp. And that's adequate. If all they got left is like their little finger on their pinky, they need an SPE. And it's specific about prehensile. So they can't, if they can't grasp the wheel in a normal way, they want them to get an SPE to make sure they can do it. That makes sense. Yeah. It does not, but, but it is that if they're missing the tip of their pinky, don't worry about it. They don't need an SPE. So when, as soon as they get the SPE, they can start driving, but they would carry both the SPE certificate and the medical that you gave them with them at the time. I've only seen two people I've sent for this. One guy was from the military and the sandbox thing was missing one lower leg. I mean, he was back to playing basketball and, you know, but he had to be, and the hardest thing he'd been, his surgeon refused to do anything. I won't sign that form. Cause I don't, I don't do forms for the government. He died. That was, that's as far as he got. And I finally, I finally found a PMNR guy who I thought would be, would play game ball. I said, sure, set it down. And so we got, you know, he got his thing, went off and got his SPE and went to driving. But it was, that was a little frustrating. Okay. So medication, the CDME role, our goal is to avoid sudden incapacitation. Big question is why are they prescribed? What's the underlying disease? Think about the intended effects. Think about side effects. Think about what happens if they miss it. Okay. And all those things and will any of them cause sudden incapacitation? So I always say this, you can't be on any schedule one drugs, stop, stomp, stomp, stomp, stomp. And know what the, know what those drugs are. Marijuana, as I remind everybody is still a class schedule one drug as of today. It's your call. You can disagree with the PCP. So if there, so what my goal, my job is to look at the medications they're currently using and convince myself that it's not going to interfere with their ability to drive. So what's supposed to happen, side effects and what happens they miss. So, you know, lots of drugs from used to things. This is, this is sort of just like the FAA's focus in, in pilot exams is on things for your brain and for your heart. They care a lot about your brain, your heart, cause that's where sudden incapacitation comes from. They don't care much about the rest of your body systems. So you think, what are the brain or the heart effects of these medications? They have cardiovascular disease, hypertension, glucose seizures, you know, they said, what are they treating with medication? That's one of the key things I want to figure out. What are, will it kind of cause side effects? Can, is it going to cause hypotension either? Cause they take it or they don't take it. Now I'm not talking about badly adjusted medication. We're talking about when they're not, when they're kind of in their standard state and their combination is going to get people in trouble. Dosing schedules can be a bit of a problem. So you're driving tractor trailer and you start from here and you're going to drive to California. They're going to have to change your clocks a couple of times to be here in California and God help you in Indiana where I guess you guys are better now. You're just, here's the two times, there's not four, but yeah, but I think there's two time zones still. You guys, here's how the times it survives the state, but I think everybody's now on daily savings time. I think, I think they changed that. Anyway, so lots of times you can change. Big question. You start in, you start in the East coast and you're going to California and you're supposed to take your medicine every 12 hours. When do you take it when you get to Denver? Like just take it. Is it still five o'clock? Like it wasn't Philadelphia or is it three o'clock? And how do you keep track of that? And does that mean the other second dose is at three o'clock in the morning? How do you do that? And how do you manage that as you move to different time zones? Same question with sleep. All of a sudden, instead of taking what I call the normal dosing of diabetic medicines, I now, instead of that, I have to take the dosing around meals, but I'm eating at what used to be three o'clock in the morning. And how does emoji work when I move across times? All those, all those things you have to think about as you travel around. And what do they do for PRN pain? I always ask that or try to always ask that if they, if they have a potentially painful condition, Andrew's like, I'd be proof in town. All I like answers like occasional, like you didn't don't like that at all. And so that's what I want to ask. You can, if you take enough dexamethorphan, get a buzz off of that. That is a thing that prisoners like, like that particular avenue, but some people do that recreationally. So we don't think of that as a bad medicine until you take enough to take a lot. So there is no list of list of medications other than marijuana and methadone from FMCSA. FAA does, they still have a system like this. Unlike where, who are you? We just say just FMCSA just says like, use your best medical judgment. The FAA says we have rules and you will follow our rules and you will smile while doing it. And, but they have a no fly. They have a, they have a no fly, no issue list. And if anybody's on a medication, I encourage you to look at that list. I use that as a reference. It's public. It's on the website. If you just say no fly, no issue F FAA, no fly, no issue. You will get the list of medications. And some of it's by families. Like they don't like central acting antihypertensives, but neither do we. So you can look at, you know, it's a pretty good list of medications that you need to be concerned about, or at least think about carefully. For the oral oral diabetes medicines, what's the hypoglycemia risk? I will tell you that from occupation as an occupational health provider, I hate sulfonylureas. They are, I, at this point in time, I don't know why you ever need to use one. There are other choices that don't cause hypoglycemia, but I, my family practitioner friends or colleagues don't seem to take that same approach because the funny areas are dirt cheap. But they, they make people's glucoses bottom out when they forget to eat or can't be. And remember my truck, my truck driver guy can get stuck in the snow and he was going to stop at that rest area. That's just another three miles down the road to get lunch, but he's stuck in the snow or behind the rack or whatever, and doesn't get there for another four hours. And how does that work? So I want to make sure they've got a plan for the comment or month that they have, if they have a history of hypoglycemia, what do they, what are their plans? And do they, are there, we're going to have them stop driving. I want to, I want to work all this stuff out. Some people know when their sugar is low, when it gets below 120 and they get symptoms and they can just eat a little something and they'll cruise along just fine. Other people are just drops off and you kind of got to know where they're at. But they need to come back, you know, have food, get fully better before they start driving again. And we have to decide what the safe blue blood glucose level is for driving for the insulin people. This is on a form. There's nothing for, you have to, you have to parallel that yourself for people who are not on insulin. These are resources you might want to look at. And I said, the one thing, so this is tech support and this is the health related questions people. And you're, I've had variable success calling that number and asking a question. Mostly I, they'll, they'll answer process questions. They wouldn't answer like, I tried every which way of asking FMCSA what the outline was for this course and what we're going to test you guys on. And I, they don't answer that question. Everybody goes like this and there's, oh, talk to testing, talk to certification, talk training. There's no answers. I have no idea. Any questions on what it is we're doing here? So that diabetes plan, you actually come up with it with them or are you just telling them to talk about it with their doctor? No, I come up with it with them. Even though you're not the treating provider. I'm, I'm not the treat provider, but I'm providing them advice for what to do while they're driving. I don't care what they do when they're not driving. I, my only concern is that they drive safely. And so I will, yes, I will develop a plan with them for when they're driving and, and the second they got out of the truck there is between them and their PCP. I'm not changing. I won't change their treatment at all ever, but we'll just talk about, so, you know, measuring like the glucose when they're driving, what their symptoms are, you know, do they, do they carry food with them in the truck? Do they carry extra food with them in the truck? So that if they, not just their lunch, but if they get in trouble at four in the afternoon, they still have more food left. And, you know, when do they, what, at what level of glucose should they pull off the road? I will definitely talk about them, all those things with them because otherwise it doesn't happen. Yes, ma'am. I had a lot of endocrinologists that will not fill out the form and the form specifically says, whoever is giving you your insulin must fill the form out. So basically I don't do insulin because the majority of the people that are on insulin are failed type twos, which means they're non-compliant. And so, you know, those, those folks are wildly non-compliant. So, but what you're doing is exactly right. Cause the endocrinologist, they're not talking to them back and forth. They're not talking about anything. They're, they're, they're writing out a script and hopefully they're seem to go over to anyone sees below nine. And that's, that's all they go about. They don't talk about their work. They don't talk about glycemia, any of it. I mean, my wife's an endocrinologist and she basically asked me what the form was all about. Right. Okay. So I think I've got, I'm going to go through, there's a whole bunch of questions on the commentary made here was one of the participants, his wife is an endocrinologist who came to him about what this form was about for the, the, the insulin using diabetic form. So I'm going to go through a bunch of questions here. So it's the first one is if their blood sugar is 400, they're uncontrolled. Are they, they are uncontrolled even if they're on medication. I don't disagree with you from a public health, a primary care perspective, a health perspective, but from a D FMCSA perspective, they are well-controlled because it goes between a hundred and 400, not saying it's a good medicine, but it does. If they're a little high, if they don't get in trouble with passing out while they're driving. And the next one is if you're waiting on a cardiac or sleep apnea clearance, and you know, you may get it in the next few days, can you hold the form until you get the clearance? Or do you have to make a determination at that visit? So what you would do then is you would make it as a determination pending. You will give them a determination of determination pending, and then you've got 45 days to finish all that stuff up. So, and you don't need to do a new exam as long as they come back to within the 45 days for that one thing. Would you enter it into the system as again, when it's done? I would. So the question was, would I enter it in the system then? And the answer is yes, I would enter it in the system then. And then I would fix it, re-enter it when they come back and we've corrected it. Just the one page and just for that one driver. And I haven't done enough of these. Maybe you guys have done it. If you do a determination pending, you come back later. Does it bring you back up the same thing or do you have to put their information again? I don't actually know that. I think you probably do too, but I just don't know. I haven't, I've only had two that do determination pending since this system changed and then neither of them came back. So I don't know what you do next. Okay. So the next question was, in my experience, many drivers wait until there's almost no time left. Do you recommend that employees come in 45 days before their certificate is up in case they have a pending termination? The answer to that would be yes. I would certainly encourage that. I realize most people don't do it, but in some larger trucking companies, they will have the drivers come in a bit early for exactly this reason, because that way you can keep driving while you fix the medical problem. If they wait till the last day and they don't get a certificate, they can't drive tomorrow. And so that's it. It screws up the schedule for the manufacturer. If you hard fail them, then they can't drive. But there aren't very many hard fails. Seizure disorders, they come in and they seize in the office, they're not driving. But if their glasses don't meet standard, I can still let them drive while they fix it. So there aren't very many things they're going to hard fail for. On that refresher course that we had to do a couple of months ago. They couldn't what? I thought it says they're not qualified unless they did the same. Right. It did say that, but it didn't. The way that it was worded, I have to go back and re-read that. But one of the things that happened with that was that some of those questions got mixed up between the monocular standard and the regular vision standard. Because if they don't come in with the form for the optometrist or ophthalmologist, the eye form, and they're under the monocular rules, you can't certify them. You can't make determination pending. But I think if they come in in their 20, 40 in one eye and 20, 50 in the other eye, I think you can let them drive. You can determination pending them until they get it fixed. But only get that 45 days. I think that's actually correct. Because keep in mind, you can drive monocular. They'd be just under the alternative vision. I don't want to put people under the alternative vision standard unless they can't ever meet the regular standard. It's not an excuse. OK. So the next question is, if you're waiting on clearance from another medical provider, such as the PCP cardiologist or sleep specialist, anticipate you get in the next few days, can you hold the form to get the documentation? Do you have to make a determination at that visit? And the answer is, I think we said that, yes, you do have to make a determination at that visit. They don't show up. Do you then disqualify them and enter a disqualification status in the system? It would be ideal if you could keep track of that. If not, the system, theoretically, will do it for you. Although I don't trust their system any further than I can throw it. Their IT department in the past has not been the best, and I absolutely don't trust in them to actively do that. I would go in and enter it directly as a disqualification. If someone discloses a medical marijuana card, automatically disqualifying because it's presumptive use. There are hypothetical valid reasons, for example, required for prior chemotherapy, which has now been completed. I'm going to give you the answer to this. If they convince me, and this is a convince me or convince you, yes, they have a valid medical marijuana card, and they got it eight months ago, used it for three months while they're getting their chemotherapy, and now they're off their chemotherapy, and they're no longer using it, and you believe them, you could certify them. The mere presence of permission to use something, you can say they are using it, but if they are still using it every now and again, I would not issue. They're going to be drug tested. Keep in mind, they will also get a drug test at some other point in the hiring process. We won't see that, but if it's positive, they'll still fail because medical marijuana is not an excuse for a negative drug test. Thank you.

medical certification

commercial drivers

FMCSA standards

medical examiner

driver identity verification

medical history review

testing methods

medical records management

medical marijuana certification

insulin use certification

documentation accuracy