I'm Dr. Naomi Wriston, and I'm going to have revision standards, and hopefully all of those in virtual land can see and hear us. I have no disclosures and will not be discussing any off-label use. I'm going to reiterate. How do I move that forward? Under this side right here. This right button. Okay. There you go. Okay. One of the things I want to reiterate from now, going on a lot of what Carl has said. When I teach medical students, I teach them that there are three hats that we wear in occupational medicine. I said, we wear the hat of protecting the patients, and all of us have learned that from the time we entered medical school. We wear the hat of protecting the employer if you're in occupational medicine, and that is like helping them with audiometric testing for hearing. We just monitor it. We wear the hat to help them with OSHA standards. But the hat that trumps all hats, and that is new to every one of us except for Lance. The hat that trumps all hats is protect the public. This whole course is about the hat, protect the public. Then we do as a sidebar, protect the patient because we don't pass them if they're not meeting minimal standards, period. If we are worried at all about whether or not they can do the job as was described earlier. The second thing we do underneath, second hat is protect the patient. Therefore, if they come in and they have massive amount of protein in their urinalysis, does not fail them. However, it behooves us to say, you've got a lot of protein that can be kidney damage. I recommend that you go to your primary care physician. We talked earlier about referrals. Notice about the diabetes part. Your job is protect the public. When I'm discussing it with my students, I say, it is like a bazooka. It is a weapon of destruction. The information that has been known is that if there is a fatal accident using a commercial motor vehicle, the average number of deaths is five, and the average cost to that company is three million dollars. Again, we protect the public against that instrument of death that they are driving. Then we also help protect the one in front of us by sharing information, etc. Notice he said, the first thing was, I have to discuss with them how not to become hypoglycemic, i.e. protect the public. But he will also say, you need to follow up. You're showing glucosuria and you may have out-of-control diabetes. This one is on vision. I'll go over the medical standards, how to perform a visual exam, discuss recording the results, and then discuss the alternative vision standard. The traditional certification, and I did not put in my slides a lot of how was it in the old days versus now. The reason I didn't do them, I'm an auditory learner, and I was afraid what you would remember when you get on the new test is something I said about the old standards. Traditionally, it says they may be certified if they have at least 20, 40 in each eye. A lot of times when we test them, we test them with both eyes. That looks like that's okay because it's 20, 40. Your brain will disregard the bad eye. A lot of those MAs or LPNs will say, well, yeah, with both eyes they can see 20, 40. It's no. With that eye you tested individually that says 20, 70, your brain's just disregarding that when you're looking with both. You're actually looking with that one eye that's good. Binocular acuity, and I taught chemistry and physics before I went to medical school. Those of you who remember the physics, your brain does the math. You've got a triangle that goes to a certain point, and you can actually know the distance because you've got two triangles with a 90 degree and your brain does the math of knowing distance. Judging distance is what binocular vision does for you. Binocular acuity of 20, 40, horizontal fields of at least 70, and distinguish red, green, and amber. I didn't know how to make a slide of the slide that I put when I taught med student. Carl mentioned using paper clips. You can grab up three or four or five of colored, how you have colored wires, and then just have them pick out. That's another thing. You can just have a little group of wires, and then they can show you, they can see red, green, and amber. This is still the vision standard. That's what you need to know. This is the vision standard. They need to be able to judge distance and see. History of eye disorders. Again, you'll want to know that. Do they have cataracts? Have they got glaucoma, macular degeneration? Remember, because then they miss out on that central with macular degeneration. Are they using ophthalmic preparations? Then you're going to write any yes answers down in the area he showed you. Central visual acuity may be performed with a Snellen chart or with a vision screening machine, but it needs to be written in the Snellen way of like 2040, 2020, 2050 on the form. Peripheral vision, you can do it with confrontation fingers, vision screener. Then color vision, again, we've gone over that with various ways you can tell that and why. Now, physical exam. You are looking to see, do they have pupillary quality, reaction, ocular motility, exophthalmos? You're looking for things that could be a problem, and you note your abnormal findings. Now, I tried to put in mind the actual examples of what you would be marking. Again, hopefully, you can see that pretty clearly. You would say either he meets the standard and it's good for two years, or meets the standard and periodic required. Now, this is something I do mostly executive physicals of expatriate and Japanese, but I recently made sure I did some of the DOT and the TA physicals just to know what the new forms are like. You may say meets the standards, and then go down there under that meets standards, but periodic monitoring required. I may say meets standards for two years because in our EMR, it'll populate the date of 2025 for you, but wearing corrective lenses. You can see that right here. You might mark that one, then mark this one. Just to know that that is how the form looks, and then how you would mark it if they've got to have their glasses to do it, and then sign and all of the other. Now, monocular vision history. Prior to 2005, I said I wouldn't go do this, and I've got it in a slide. But anyway, it's okay to certify monocular vision if it's been greater than six months since the loss of eye. Any idea why that would be okay? Kind of. Your brain has figured it out. It may be the number of white lines or whatever, but your brain has started. Or always, if you were born that way, they figured by the time you were old enough to drive, your brain wasn't trying to do that triangular math, that it had figured it out. 2012 to 2022, 321. They determined that vision waiver is required, and you're issued a medical card indicating it must be accompanied by a monocular vision waiver. We would have marked it needs a waiver on our form in the past. They would start the FMCSA waiver application, and would discover they need a special eye exam, etc., and submit it to the FMCSA. Up until 321.22, we had, which is he was saying, I don't know exactly what date, that that's 321.22. When he said, as of this month, they can't drive under a vision waiver, that's going to happen 321.23. A driver would wait many months and then get a waiver. The alternative vision standard, and that's what it's called, the new alternative vision standard eliminates the need for a federal vision exemption program, and allowed us to certify them, in consultation with an eye specialist, ophthalmologist or optometrist. So don't send them to their family doctor for this, it has to be an eye specialist, utilizing the new vision evaluation form 5871. By the way, if you have an EMR, I put, we added four to it, and that's the 5871, and the 5875, and then the one for medication, that is, this one is required. This is a required form, if you're going to have to use it. The medication form is a, you can use it if you want to. And this then, and up to one year, I can tell you, I wrote a lot of tests in my life, so if I were going, this would be on the test, is how long could you certify someone, if they're under the alternative vision standard. I don't know anything about the test, but I also have tried to use in all of my slides, questions that were actually on the retraining, because I think on a new test, that may be the sort of thing we're gonna see. So I've actually quoted some of those actual questions from the retraining in my presentation. So the monocular vision new system started 3-22-22, the day after. Also known as the alternative vision standard, it replaced the monocular vision waiver or the grandfathered. The waivers and grandfathering expires 3-22-23. So we've only got a few more days left, otherwise they have to go under the alternative. All previously waivered drivers must meet the new standard to be certified with their next examination. So due to the publication, this provision will be eliminated March 22nd, 2023. Okay, this is the actual FMCSA rule that goes through all of this for you. That this is, it meets the standard under 391.41, or they can be evaluated by an ophthalmologist who has filled out form 5871. And then the examination by the medical examiner, at least annually, we got that one right. If that's on the test, we know alternative vision, it'll be one year or less. Carl's already gone over, it could be one day, one year or less for that. Who does not satisfy with the worst eye, either the distant visual acuity standard, must be medically examined and certified as physically qualified by those eye specialists under 391.43. The examination must begin not more than 45 days after the ophthalmologist optometrist. Now that's an important, that one I think is a significant amount also. So you want that exam to have been done no longer than 45 days after. Why do I tell you that? Because for examination pending, let's say they bring this form into you. Their company is savvy enough that they say, take that form, get it to your doctor, because we all know you only see out of one eye, have that filled out when you go in, so we don't have to go without a driver. So in that case, you look at something and you go, oh, the cataract, I don't know, we probably should have somebody check your cataracts or whatever. You've got that form, then you could do an examination pending. But what if they got that form filled out 60 days ago? You can't use it. So that's the other thing I want you to know. It has to be within 45 days of your getting this certificate. Next, monocular vision definition. In the better eye, they have 20, 40, at least 70 degrees for their field of vision, and they can determine, obviously, color. We know that one. And in the worst eye, it's less than that. So then you would go, that's monocular vision. We've already talked about the triangle and the distance. So then you would go to 5875 is where you would document it. So that's what that was, and he's shown you that before. And is it monocular vision? Yes. Has he been referred to an ophthalmologist? Yes. And have you received the documentation from the ophthalmologist? Hopefully we can mark that yes at the exam. But if not, you could, oh, I'm getting ahead of myself, but I'm gonna ask you this question. Okay, you get down to there. He had no clue that he wasn't seeing that well out of the other eye. Or in the past, we failed them. They actually had had contacts made so they could see one up close and one distance. And in the past, you said to them, then you go get a pair of glasses that when you're driving, you are able to see. Or they may have had LASIK surgery done like that, and they failed unless they could get a pair of glasses that made them 20, 40 in each eye, right? Now they come in and they go, I had LASIK surgery. That is why it's that way. Now what I can do is let them take that, what is it? 5871 to their doctor, and we'll have the criteria for when that will pass them. Monocular vision, the driver has their eye doctor complete 5871, remember that. They must use the form. I told you there are three forms that are required by the federal government, FMCSA. One is 5871 if we need it, and that 5875 and 5876. Okay, so those are the three forms that are a must. The exception is you can or cannot use the medication form to document. The CDME exam within 45 days. So you got that for the test if it's on there. I don't know that it will be, but none of you will miss that one. And you determine if the driver meets the standards of everything else, then you could certify them. Now the driver takes this to the form, this to it. This explain the information to the ophthalmologist and the optometrist, because again, and I've got it later in here, who ultimately, the ophthalmologist sends it back and says, they're good to go. So do you pass them? It depends who gets the ultimate say on who gets to come back on you and sue you because you did a lousy job as a medical examiner. Who gets to decide about your license? Who gets to put the signature down? You do. So in this case, you are the specialist. You gather information and you make the determination. So he fills this out. You have sent him the rules that are required and he takes it. He can be either optometrist or ophthalmologist. And he tells, now, Biggie, I'm gonna go through and this may be in later slides. I hadn't looked at him last night. I put this together a week or two ago. Okay, current diagnosis. He tells you the stability. This is a progressive eye disease, which means the person got it done two weeks ago, but it's MS or it's something that would cause progressive problem. It has to be stable. You had an injury. This is where your eye is stuck at. They did LASIK surgery. It's as good as they can get it. So you have monocular vision, but it is not getting better. It's worse. It's stable. That's another. You've got the perimetry and exams more often than annually. You know, they'll tell you that. And then this is the form they actually fill out. And it's easier to, I hope those of you in virtual land can blow that up a little. So this goes through and I have found with specialists where one, I think Carl mentioned that the orthopedist wouldn't even bother with it. I try to do, in this case, it's two pages, but anytime I'm asking for information, cardiac, whatever, I try to get it on one page. You send it in there and give them two lines they have to fill out and sign, okay? For example, if I want a cardiac, I don't need their ream of information a lot of times. I need them to say, when was the last stress test? What was the ejection fracture, et cetera? So I have found it very good. I'll say, take it, have them fax it back to me if I'm gathering information. So this is a pretty easy form, as you can see, and will not take a lot of time by them. The CDAD, the Commercial Driver Medical Examiner Reviews, the 5871, they make sure the driver's evaluation meets the minimums and they, because you've set the minimums to them, you put it into your medical records with the rest of the FMC as they form and what if you disagree? I underlined it. You make the final certification decision. Now this, when you see FMCSA up there, that is directly from an FMCSA retraining quote and statement. So you have the Bible for how to do driver exam, if you see that on my slide. So he is not physically qualified if the individual deficiency is not stable. He is not physically qualified if sufficient time has not passed since the vision deficiency became stable. And what is that? Why is that? The brain hasn't adapted yet. So there has to be a certain amount of time that it's been at that, that we now know he can do the the vision. Even though the ophthalmologist has provided their input, we still have the ability to request additional testing. And the final is that, that hasn't been, that's been stated enough. The individual is not physically qualified if his visual is not at least 20-40, with or without correction, in the better eye, and it isn't stable, and there hasn't been sufficient time passed. So two different ways, same thing. And no, right, no, they do not, they have not. So they, to my knowledge, they have not. The only thing that is here, my personal experience, over my career, I've had about 10 people that became monogamous. And about a third of the people could drive the next day and are just fine. About a third of the people take a little while to adapt, and they do just fine. That last third ain't never going to drive safely at all. I had one guy, he was three years out, and he, his wife would let him drive the lawnmower, and he would drive over the flowers. And he drove into the lawnmowers. And probably bumped into chairs at the house. So yeah, it doesn't get there. So you have to have that person, you have to have the person, you have to have one of those two groups, the first two. The person that's never going to go, if they, if they're not driving their own vehicle, and I would ask that question directly, if they've driven for six months without any accidents, they haven't driven their own vehicle yet, or their family is terrified to ride with them, probably wouldn't give them a medical. They're not regular from a monocular vision perspective. Okay, yeah. I think that's very reasonable. And you'll see later about the road test too, so there's a little second check if they're new to driving. Okay, road test. Oh, okay, there it is. Okay, so let me just go back to this again. You would say, how would you fill this one out? If you're using the monocular standard? How long would you give them? So you would say meet standards, but periodic monitoring required, right? So you check the third one. And why? And what would you put on that paper? That line? Monocular vision. Okay. And then you would say they were qualified for a year. We've all got that one. We won't miss that one. And will we mark a company by a waiver? No, because there's only two things and that's my next talk whenever I give it. Okay. There's only two things and you're not going to miss those on the test either. There's only two things that are going to be a waiver or an exemption. Okay. So you would just mark wearing or wearing corrective lenses. He may need corrective glasses to get 2040 in the good eye, but you would mark monocular vision one year and wearing corrective glasses in that case. Okay. Road test for all new monocular drivers. Again, this is if they're new, this is done by the company that's having them drive the truck, not by us. We don't have to set up. Oh, I say done by the motor carrier after the medical exam, before commercial driving and the carrier issues a certificate to their file. And that is just a test that what we've determined that they can judge distance. Remember, I like to think of it as an instrument of death that they called into the seat. Yes. If somebody has had loss of vision for 20 years, no other health issues. Right. And they've been driving for 20 years. Yes. Why could not they have a two year? Because you have to be perfect if you want to. Well, you've got one eye and you want to make sure because even on high blood pressure medicine, I give them one year. So if, yeah, so that that's why, you know, the rule is no more than one year because now you've got one eye and you've got to keep that one as good as you can, et cetera. So it's and so if they have anything, anything, I don't give them the two year. Is that the rule? No, that is a rule. Yeah. I. And that for if you look at the form, that form has blocks that I can't answer. But they use they use I word that I don't know what they mean. And so but they want them to do an eye exam. And if they say the good eye is good, have a good time driving. This is this is trying to get us to do the work. And so I'm figuring out which I think is fine. I mean, I think we can answer this. I agree with you. That guy doesn't worry me at all. I mean, the guy it's just but it's just the way they at least now they don't get a waiver anymore. We can just do it all here. But we've got to go get to that. It's the same form that I've got models for before because it's an alien to DC. We didn't get a waiver back, which takes off the road for a while. Right. They can just they can just go to it and we can do it. Yeah. Going to DC. Correct. OK, yes. You may have already said this, but since you need the optometrist form first, if they show up to you first, without that, you can make them pending for 45 days. No. OK, so that is a great question. What do you do in that case? The person comes in and they they they have a CDL, they're driving on their CDL and they still as someone recommended, why don't we have them come in 45 days before it expires? They come into your office and now you discover they have 20, 30 in one eye and 20, 70 in the other. They just had eye surgery and they got. OK, and now they're 20, 30 and 20, 70. OK, now we know that if they still have time left on their license and you're trying to they had glucosuria and you're trying to determine what's going on, what they walked in, everything looks pretty good. Then they could you might do determination pending on that glucosuria. Right. And they could drive on their old driver's license. Right. And we haven't endangered. What's our biggest task? Protect the public. However, we now have somebody and we don't know if he's adapted. So what do you have to do to that day? He walks in and you discover he's 20, 70. What do you how do you have to mark that paper? I guess you have to disqualify. OK, this paper would have to be marked disqualified. Period. Right now, he's got the his his license. Now, how soon do you have to get that into FMCSA? Two days, right? What happens then if he drives on his old one when he has one at FMCSA that says he is disqualified? Right. And that that's a really good question because that's how you think it all through. So if they are a danger and not knowing if they can judge a distance with that vehicle of destruction, then you would disqualify them. They could not drive until he gets in and we find out and then we find out, well, actually, he's been driving for three months like that. Yes, he has monocular vision. Then he would come back and get the exam and you would do it. That that was a great question to bring up. Let me go. OK, so the road test. Basically, this just says three operated at least. OK, when does he not need a road test? Somebody mentioned that. It's all right. I think you did, Dennis. If he's had for at least three years, he's had that deficiency three years under. He's operated. It has a valid federal exemption. Any of that are grandfathered. We know it's been long enough that he doesn't have to have a road test. This is actually the standard. I won't read that to you. I don't think there's anything in there. And he must certify in writing to the motor carrier the date of the vision deficiency began. So that's how you would kind of know. They're making a point. I don't think this is a good example. I, for example, if you come in and you don't meet the vision standard and this is an example, somebody asked about holding them. You I might hold it because let's say they don't have a license. If I know they aren't supposed to drive, we've been through that. But if I'm just I think they need glasses and they didn't know, I sometimes will try to hold it and say, you know, go get get your glasses, get back here. But really, they should be disqualified. And then when they can come back with glasses and do it, I use a different you don't I don't use the monocular form for that. I just get the report back and they get their glasses. A lot of times I'll just retest them and go on from there. So the certification is they may be certified. That's the standard. We know that all of us hopefully could have that or they meet the requirements under the alternative vision standard, which is for monocular vision. And then you must use eighty five seventy one and it must be completed within the last forty five days. Summary. If the driver must wear corrective lenses to meet your market on there, we've been over that ad nauseum advice drivers to carry. And Carl has been over this again. I taught chemistry and physics and high school and ninth grade. People have always told me I've kept that voice and that you will hear some of this more than once. That's what I was going to say. But that's not all bad. So you see it in different modules. This is advice the drivers to take an extra spare glasses or contacts if they're going to if they require them because they need to be wearing them. Now, question, guess where these came from? OK, so this is the latest thing from FMCSA. Nobody knows what's going to be on the test. That's one advantage maybe of taking the course like in November. Maybe someone would have taken the test and we have an idea of how it's going to change. And someone told me here. Yeah, that someone in their office had taken it and they had failed the test. Well, we don't know if it's the new or the old one and whether or not once memorizing the old standards and now the new test question, they're no longer right or whether it was the new and they were memorizing the old. So we don't know. But anyway, this is from the retraining. So it should be standard now. Is it appropriate for an Emmy to place an individual in determination? Oh, dear. Going to know this answer pending in connection with the alternative vision physical qualifications. Is it appropriate to put him in determination pending while they go get that alternative vision? What's the answer? We all know that. Right. So let's go back for a second. The time that you can't is they don't show up with the form. OK, I know the problem. They show up in the form and you're not you want to talk to the doctor some more that can be determination pending. But if they don't show up with the form, that's a that you are not determination pending. That's a specific. No, there was a burden on the driver to show up with the form. They don't want this to become, oh, oh, yeah, I get another three weeks, another four weeks and drive because I didn't bother to see that Thomas. So we have just said, right, that you may hear something more than once. And so an EME may place an individual in a determination pending status only when the individual already has completed a vision evaluation by the ophthalmologist or optometrist. This status affords an individual up to 45 days. That's determination pending to provide additional information. And that was earlier in the in the lecture to discuss the like if they had cataracts that you were a little worried about and wanted them to get information on that or whatever and to complete the physical qualifications are there. That was a little difference in voice for your afternoon. Are there any questions? Can you help me with chat and if there's anything on that? And that was a pretty view for all of us who have nice. I'm from West Virginia, so my idea of a pretty view is that now we've got a bunch of chat questions. Let's go to chat. OK, go ahead and ask the questions here. Robert knows I'm Dr. Cleared. Fifty eight. Seventy one looks good. Then you do. Fifteen seventy five. Correct. Right. Finish it up. Yes. Yes. Well, yes. Thank you. Sure. If they show up with the form at the time, you can complete fifty eight. Seventy five. If you don't find out. Well, you complete fifty eight. Seventy five. Regardless, that's your physical, your history, et cetera. And now you know how to mark it. Right. Plus, you would mark it as yes, you got the report. Right. Yes. Any other questions? Dr. Lam, why don't you go ahead? I think we're going to hold on. I forgot to do this. I need to find you on here. OK, so I do them all. Yeah. Just allow participants to unmute themselves. OK, Dr. Lam, go ahead and you can unmute yourself and ask your question. OK, thank you so much. Hopefully this is not a redundant question. I'm a little new at this, but I was having a little difficulty following the for the FMCSA three nine one point four four. When you were talking about that example where you were filling in the that and I think it was the M.C.S.A. five eight seven five documentation, you said that don't check that box where I can't even find it anymore, where they need a like they have a medical exemption. I'm basically not understanding. I'm basically not understanding the like. OK, let me yeah, let me go over that. And by the time you're done this, you're going to have seen this for multiple times. There really are basically only two waivers now that one might mark that box, and that will be for hearing and for seizures. Oh, OK. OK. But my point being, they don't want you to you would no longer. And it was just to let you know it has changed. In the past, there was a vision waiver and we did not have this alternative vision standard. But now you would mark one year. With or without glasses, and you would put it in the line as to why you're doing one year monocular vision. So I think you would have gotten your 58, 71. So if you screen them and basically only one eye meets that 20, 40 standard, we do we still have to send them to an ophthalmologist or an ophthalmologist. But then if the if the eye doctor says, yes, they can, that's not considered a waiver anymore. It's just kind of giving you kind of the ability to be able to check that they can with that vision drive for one year. Yes, because you you have had them evaluated by a specialist. They have certified that this this is stable. It's not progressing. They didn't look back there and see something that is going to, you know, it's changing. They have certified that it's stable and that this is the vision and they agree they can seem to judge distances. And then we would certify them under the alternative vision standard. And that is where they have to produce the and it can't be a letter from the eye doctor. It has to be that MCSA. There are three forms that are required federally. That's completely correct. OK, it has to be the form. Yes, it has to be 58 71. OK. OK. Is there another question? Any other questions? Anybody else who wants to ask a question, you can unmute right now and ask your question verbally. I had a quick question. Um, so if someone's completely blind in one eye, right, and it's stable, like they can't see at all, but it's stable and not non-progressive. And they've been evaluated by their ophthalmologist and they see better than 20, 40 and the other 20, 40 or better in the other eye. They can qualify. Is that what we're saying? They can. They can. If that. Ophthalmologist build out the form for them, 58 71 and brings it to you. OK, yes. OK, thank you. You're welcome. Glad you're on board. Now, who else? Anyone else? You have a question here. So it's advantageous to do it under the main vision standard and not the alternative because you might be able to qualify for two years instead of one. That is correct. That's that's completely correct. One of the things I was trying to find this, there was some mention in the. Alternative vision standards when it comes out, and I couldn't, I was just trying to find it right now and I couldn't find it, but I will for tomorrow about doing it out of convenience and saying you can't do that. No, if they have glasses, but they just they I forgot my glasses. This my my good eye is 20, 40. My bad eyes, 20, 60. I don't make glasses. You can't use the alternative vision standard unless they are unable to fall to meet the. I don't. I will find this wording because it was it's it only said it once in the in the rule. But there was a thing where they talked about that you can. It has to be somebody who has a permanent fixed deficit of the eye that can never meet the standard no matter what you do with their glasses. And that's why I said one thing that Naomi said that I want to verify is I still think that if somebody had LASIK like near far. I still think they need glasses to drive. I think they do, but I will verify that because that would be a convenience thing. But this is intended to cover is this eyes gone. It will never see again and they want to give that person opportunity to be able to be qualified. That's what the that's what this was intended for or it just no matter how much correction you put in, you can't get them to 2020. And let me let me give an example that all of us will remember. Let's say he just forgot his glasses and he wants that. So he didn't always. What if he puts his glasses on most of the time, but then he takes them all has the brain adapted? No. So that's the reason that's that permanent thing. The brain has adapted and I know you can judge distance now. So or we said somebody can be on a required dose twice a day like of a narcotic. Carl used the example and that's and Leah's and my and our finding that that three months the person is not just is not impaired. Okay. The same way if those glasses are going out on an off just and he's under that other standard. You do not have stable vision. Okay, thank you. My glasses are unstable.

occupational medicine

public safety

vision standards

commercial driving

binocular vision

monocular vision

certification process

Dr. Naomi Wriston