I think we're ready to go. So let's talk. We're gonna talk about hypertension a little bit. You're gonna see this a lot. I don't know about you, but it's not uncommon for patients to walk into my office at 200 over and over. Okay, just stand by, stand by. Okay, so this is the rule. They can't have a current diagnosis of high blood pressure, likely interfere with their ability to operate a commercial motor vehicle. That's all the concrete guidance we get from FMCSA right now. So hypertension is common. It is, a lot of people have it, and everybody here knows that. Hypertension by itself is unlikely to cause problems driving a vehicle. Hypertension causes all sorts of end organ damages with organs like the brain that are kind of important to driving and the heart. And as people get older, blood pressure goes up and you can double, as it says, you can double mortality. Every time you increase 20 millimeters systolic or 10 millimeters diastolic, you double the mortality. And people who have experienced mortality don't drive well. So, and the older you get, the more likely it is you're gonna have high blood pressure. This is the original recommendation from FMCSA. This was the thing when I, you'd spent a long time trying to explain this to people, this little chart to people and how it applied. For a little while, it went away. It's sort of back. We'll come back to that. This is the regulation. The writing's way too small. Let's zoom in a little bit. So that table is based on JNC-6, okay? From way back in 1997. That is not the current recommendation for cardiologists. I think we're up to eight, maybe even nine at this point. It's still eight, okay, sure. Nine's coming soon, because they do it about every five years. And they haven't, they've updated some since then. And so the recommendation for what they thought was safe blood pressure has changed. There's still defined stage one hyper, so let me back up for a second. This part, this, all the stuff that's in red, this is directly out of the Code of Federal Regulations. This is still there, okay? And so this is still in the regulations. They didn't take it away. I don't exactly know how you implement it, but it is still there. And so we talk about stage one, stage two. This is stage one hypertension. Then blood pressure getting you into stage two, which it also says, it says under stage two, so I'm in the second paragraph. Over 160, 179, over 100 to 109 is considered stage two hypertension. Then it says the driver is not necessarily unqualified during evaluation and institution of treatment, okay? That's what's in the regulation that we're supposed to sort of follow. And then it specifically says you can go one time, three month card. So that's kind of still in the rules, okay? Stage three does have a high risk of an acute event. So their kind of cutoff would be, I guess, 179 over 109. And you'd never certify above that. So at least that's sort of a cutoff. But then no matter what you get, you always want to get below 140 over 90, which is still a health-related recommendation. I'm not opposed to that from a health perspective. So you can do lots of different treatment things. People can lose weight. They can learn to meditate, do all sorts of stuff. And a lot of that is effective. We do want to make sure people aren't using medications that will make them somnolent or sync up while they're driving. I would follow, and we'll talk about medications in a few minutes. If you think about secondary hypertension, although that's not something you're going to do, you should send back to see their doctor when they're on four meds and nobody's thought to look for a cause. So we're still in regulations. So again, 160, 179 over 100 to 109. Give them a three-month card. And then when they get it back below 140 over 90, they can get a one-year card. This is, so this is, that's the, that's what's in the regulation, even though their book disagrees with their own regulation. So I went and looked at JNC8, and this is their actual recommendation. And so they're recommending that for people over 60, this is an example, that we would look, cut them off at 150 over 90. That's what's in, that is the current recommendation of JNC8, okay? Cut off to start treatment. Yes, start, initiate treatment with a target. The key word here is target of 150 over 90, okay? So it's not just, you ought to think about maybe treating them, treat them to under 150 over 90. So JNC8 says that for us old people, I'm almost old enough to, for that applies to me, you're allowed to get up to 150 over 90. For, if you look in the right-hand side, we're back at 140 for people less than 80. Once you get over 80, I don't think they care. So in the book, the other thing you can look at is the medical review, the medical expert panel. This is right out of the textbook. The, that one that, remember, really short in 1920, 2020, and 2021 got a little bit longer. They put high blood pressure back in, but rather than saying, this, these are the rules for high blood pressure. What they said is, there's a lot of things, ways you might want to consider high blood pressure in somebody who's driving. They gave us that table, the old table that we've had for 35 years. It had its flaws, but at least we understood it. And they gave us this, okay? So as long as somebody doesn't, so, and with some weird stuff in it, is it on that? No, it's on the next. Hold on, where'd it go? Nope, must be on the next slide. So this is the table that's in the current, it's in the medical handbook. And it's also, it's an extract from the medical expert panel from 2013. They just took that panel, that table verbatim. So somebody has essential hypertension, and if they don't have any target organ damage and they're asymptomatic, you just, it's not gonna be, this disorder is rarely a spot-flying letter. Now, my understanding of essential hypertension is it's not caused by something external. So I think it's most, not everybody, but 95% plus of people with hypertension, it's essential. The table says that if it's asymptomatic and there's no target organ damage, it's not disqualifying, you just give them a two-year card. I think that's what that says. I think. If you keep going down, this is the same, this is, so. Could you go back one? Sure. Where it says recertification by annual, that's two years. Every two years, not twice a year. Correct. Twice a year, that's every two years. Don't approve if they have symptomatic hypertension. I'm not sure I know what that is. Maybe, okay. They're horrible headaches or something, I don't know. So this is another hypertension recommendation, and this is continuing down their own, the table that's in the guidebook. So hypertension less than 160 over 109, can get, I think, a one-year card. And- Even though the last table said two years. Huh? Even though the last table said two years. Well, yeah, we're into this, what's essential. I don't even, I think using the words essential hypertension, and then with no numbers, I don't even know what that means. So here, what I think this says is if you're less than 160 over 109, then they're low risk for hypertension-related acute incapacitation, which is truly what we care about. And then you can give them a one-year card as long as they stay below 169 over 109. No history of hypertension. Well, they're not on meds yet. I think that means they're not on meds. And they- Does not use any- I think that means they've never been on meds, right? No history of. So if they've been on, if they were on meds before and kind of ran out and stopped taking them, which is of course never happens to any of our patients, and does not use any hypertensive medicines, then you can certify them for a year. This actually doesn't, the numbers are different, but it doesn't disagree with the concept that was in the old table. Okay, so that's what we have to pay attention to is the thing in the red box. Don't certify them if their blood pressure is less than 169 over 109, and they have a history of stage three hypertension, which has two different definitions if you notice in this table. And then the blood pressure, and don't certify if they're over 170 over 110. So that's what it says in the purple box, right? That's a hard stop. I think that's the hard stop is 170 over 110, I think. What's that grade three? What's that grade two? Huh? That's grade three. No, that's grade two. Grade three is I think 180. We'll see that in a second. So if blood pressure is greater than 180 over 110, is considered stage three, because I had to look this up so I could make sure I could keep them straight. So if they've ever been over 180 over 110, and now they're less than 170 over 110, you can certify them for a year maximum. Unless they've ever had stage three hypertension. That says not approved if they're 169, less than 169. With the history of stage three. The history, it's the history of stage three. So if they were ever over 180 over 110, then you can, and I think history means ever, then you can't certify them. I haven't a clue. Now, if you're the only doc for 100 miles in any direction, and you've seen this person for their whole life, you might be able to pull this off. That is not how it works where I am. Most people don't, they don't even know they have a blood pressure, let alone what it is, or it's always been normal doc. When, and now they're, you know, 210 over 130. I must be excited mom in your office. Okay. And then, so I can recertify them as long as they stay under 170 over 110 for one year, as long as they've never been over 180 over 110. Just to come back, you said if they were stage three, they can no longer do so. No, if they were stage three, they get a six month card difference. This is, I can certify them, but if you go over here, they get a shorter card. This is, this is, I'm, messenger craziness, okay? Because I can't follow where they're going. The, one of the options you have, because you're supposed to use best medical judgment, other agencies have come out with coherent guidelines. This is one of the areas where what I personally do is I start out with the FAA rules. Because their goal was, is the risk of, their concern is a risk of short-term incapacitation. And so they use 155 over 95. If you're 155 over 95 or less, your airplane, your airline pilot flying home could be that guy or that girl. And so don't, I don't worry about that. The FAA thinks about these things hard. FMCSA apparently doesn't think very hard very often. They just concatenate a lot of stuff together and let you decide. So they've, the FAA's got a hard cutoff, 155 over 95. I kind of go with that. So you can still use the old chart. When you read the book, what the book says is, it has the old chart and says, this is a way to think about blood pressure. And then there's this table and says, this is another way to think about blood pressure. That non-site, I think it's for your stage three, they can't be recertified. No, if you keep going, is it on the next one? Yeah, so this is the person that was ever in stage three. And what this says is six, it may be on the next. As you work your way down, these are, what I did was I took, so you could read them. This is all one chart. And I took the chart and chopped the chart up so we could actually see it on the screen. So this is, if we continue down the chart, if they're greater than 170 over 110, and this is a stage of hypertension carriers, high risk, and it says you can't certify them. But if they, you can recertify them if they get under one. So it's this whole chart, the whole thing makes no sense. The math does not make sense. And I'm just, I'm not gonna defend it. It doesn't make any sense. For testing purposes, this might appear on the test. For practical purposes, this is almost unusable. And I don't know how to make heads or tails out of it because it doesn't make any sense. I tried, I really tried to figure this out. And I sat there and drew like numbers and charts and put stuff down. And I said, okay, so I went from one row to the next row. And the rows of the chart came through with each other. Yeah, I don't know what they're trying to get at. So if the F, if, go ahead. Patient has this funny hand saying, could you certify this person for six months? If they had a low pressure of greater than 170 over 110, but now they're at less than 169 over 109. You could, yes, Dr. Chi will not. And that's the only recommendation I would give for testing. Like I said, Carla and I haven't seen any tests yet. So we don't know, we don't, do we know when we take this test? We think it's gonna be under older, new guidance? No flippin' idea. They won't tell us. We agree with you. Yeah, that's why I was, I really wanted to take the test before this, but I needed a card issued to me, a certificate for the class issued to me in 2023 to be eligible to take the test. So hopefully that will happen tomorrow. That obviously has a history of running way behind on their initial projections. By, well, I mean, yeah, the five-year restart, the 2017 five-year restart was issued in 2022, just saying. Okay, so there was a question. Why could we not give a three-month card to decrease blood pressure to 120 over 90 if it were 120 at the first visit? So the answer to your question is you absolutely could if you want to work, if you're working with them on health, or then you could definitely use that, you could definitely say, I'll give you a three month card to get your blood pressure under better control. That is absolutely within your purview. And clinically, it's a good choice. It is the, whether it's not necessarily what the, it's not the limit imposed by the regulation. And so, yeah, you're allowed to do a three month card. The one thing to keep in mind, if you've been doing these for a long time, this is a reminder, we used to was, that we could issue you, I mean, like before this whole regimen started in 2010, okay, I could issue you a three month card to get your blood pressure fixed. You would come back in three months, we would recheck your blood pressure only, and then issue you a card for the rest of the year. Can't do that anymore. So when they come back for that, at three months for that recheck, it's a brand new exam, and you got to do the whole thing, and you're gonna issue them a brand new card. But just be aware of that, that, yeah, because that, so when you see them, the only time you're allowed to, you can do determination pending for 45 days, and then issue them the card based on the date of the original exam. Okay, that's the only thing you can do. And then that's only if there's data that you're missing. I want you to get, bring me the report from your neurologist or whatever. You can do that if you so choose, but that's not a, they don't get a card. Okay. Okay. So, oh, it's two. I touched the screen. Okay, so secondary hypertension, if you're, if they're on a lot of meds, they're gonna talk to the doctor, but the same rules would apply as far as whatever you decide your cutoff numbers are. Interestingly, so pretty consistently, 169 over one or nine is, and this one makes, this is where this makes even less sense, because if you read what's up there very carefully, so I'd give them a three month card if they're, after they fix whatever the problem was, they take out their adrenaloma or whatever it is. And then, but they can get a one year certification if they're below, as long as they're below 169 over one or nine. So I think that's their cutoff, I think. Why is everything less than and not less than or equal to, if the 170 over 110 is the? I don't know, if you're exactly 169 over 109, I suspect you get it, like maybe they'll mail you a present or something, because you exactly hit the number. But I agree with you, it's inconsistent. Sometimes they use less than or equal to, sometimes it's less than. And I just cut these, I mean, because those are greater than or equal to. So 170 greater than or equal to is their, is where they got 169 over 109, apparently you're allowed to certify. I don't know, not my chart. So just to remind you, as you go through the form, if they take medication or they say they've got hypertension, you have to review that and comment on it at the bottom of the form. Think about target organ damage. So do they have high blood? Do they have cardiovascular disease or heart failure or LVH or any of those things that are associated with hypertension, especially if she's somebody with elevated blood pressure. You do have to measure this in your office. They can't do it at the store. They can't do it across the street. They can't, their wife can't do it, who's a nurse before she comes in and write you a note. You have to actually measure it in your office. There is a place to do it twice, so on the form. So if you, and just as a reminder, how are you supposed to do blood pressure? What is the official way to measure a blood pressure? Feet on the ground, legs uncrossed, feet minutes. So sitting still with your feet on the ground in a chair, right? Oh, that's true. Arm and heart level. Arm and heart level, sure. What else? Legs uncrossed. What was that? No talking. No talking, but the no talk is mostly because we mostly use sound-based blood pressure machines at this point. If you're talking, it messes up the machine. How long is a person supposed to sit in the room before you do it? 15 minutes. Yeah, 15 minutes is the actual correct answer, okay? So that whole thing where they put Reader's Digest and Highlights for Children in the doctor's office was actually functional because it gave you something to do while you're sitting. They put you in the room, sitting in the chair, not on the bed for 15 minutes while you read your Reader's Digest and hopefully you read a happy story, it's not a bad story, and then they sneak into the room and measure your blood pressure. That's the right way to do a resting blood pressure, okay? Walking in, sit down on my chair, just got here, good, come on, come on back, sit on the chair with your feet dangling in the air and measure your blood pressure right away is none of those things, okay? A lot of times people raise their arm above heart level. Okay, thanks. Yeah, anything, if they're moving their arm, I mean, you want their arm loosey-goosey kind of sitting in their lap is the right way to do this. If you don't want them holding their arm out, because anything they do that makes the muscles in their arm contract make the blood pressure numbers be higher. So you need to measure, I recommend, my personal rule is I don't fail anybody for blood pressure until I retake it myself because that's usually a little bit further along in their time in the room. And I'll do it kind of towards the end of the exam if that's been a problem, because I don't want to fail somebody on a test that somebody else did without paying attention. Does it say anything about manual versus automatic? It does not. That's up to you what you have the ability to do in your exam rooms. But how do I say this carefully? The automatic blood pressure is probably more honest than the, I tried really hard manual one. I mean, because to do a manual blood pressure by hand does take like a minute to do it right. It's not, oh, you were around 150, 40, 30, I don't know, you're wrong and there's a place and the bottom number, I think it was in the 70s. And that's because if you don't do it really slow, your numbers are, that's what you get. And that's not a very good thing. So you're going to write down the pulse rate. Is it regular, irregular, anything else you want to write about, you're welcome to do. And you will record those things in that area on the form. And they did add that second box there if you want to add a second blood pressure and the blood pressure is to be seated. So you can't lay the people down, let them fall asleep and do the blood pressure. That's not, even the form says no to that. When you document it, write something that's coherent, try to go for best, so that at least you've addressed it and at least what's the medicine they're using and how they're doing. Are they tolerating it, is it stable, all that kind of stuff. So current diagnosis of hypertension exists either when they tell you that or when the blood pressure is elevated or when they're on medicine. And mind the antihypertensives because they can be used for other medicines. Or other, I'm sorry. Antihypertensive medicines can be used for other diseases. So that doesn't, just because they're on a castor chain blocker does not mean they have hypertension. It could be for their AFib or something. And of course, these are all recommendations. Use your best clinical judgment. So a couple of scenarios here. First one, I've got a gentleman who's here for certification. He's on zinopril hydroxyazide and no targeting or damage. My blood pressure readings are 130 over 85 and 125 over 82. I may certify for? One year. One year. He's got hypertension, it's well-controlled, but he only gets a one-year card because he's got hypertension. Number two, Ms. Brown presents for initial certification. He's taking hydrochlorothiazide. I get 150 over 95 or 150 over 90 by a measure of blood pressure. What do I do with her? Huh? I think we'll eat because she's being treated. So you could do, do not certify. That's on a whole sheet based on that chart. It sort of, well, based on the JNC chart, it does. The FMCSA charts don't have ages in them. So you've got, you have options here. This is one, if we'd been doing this, this example two years ago, I had an answer for. There's a, it was a correct answer. This one, well, I could give her a one-year card because she's still under Carl's cutoff of 155 over 95. And she's way under their cutoff of 169 over 110. Okay. I could use a termination pending and tell her to go to your PCP and get her blood pressure under better control. So either of those would be a correct answer under current guidance. Okay. So, and again, that's, so just, I don't have a right answer, which is frustrating to me. Mr. Byrd presents for resurfication. You missed no medical history. He's on Coreg and Lisinopril. You see a sternotomy scar. The blood pressure readings look pretty good. What do you want to do? Ask about his sternotomy. I'm sorry, say that again. Ask about his apparent open heart surgery. Yeah. Ask a couple of questions. Yeah. Now, not everybody with a sternotomy scar had open heart surgery. There's other things they do that way, but you got to ask some more questions. His blood pressure is fine, but I'm really concerned about the sternotomy scar. Because they sent, during Operation Desert Sandbox, they sent cardiothoracic surgeons over to do cardiothoracic surgeon things. They're used to do sternotomy scars. So if they want to get in to mess with somebody's chest, they sometimes, I met some very young people that had sternotomy scars. So, oh, do you have a heart attack or bypass surgery? And they go, no, I had shrapnel. Because that was the surgical approach the cardiothoracic surgeon chose to use to get shrapnel out of this person's lungs. So it just be, you know, you have to ask, right? So, scenario number four. Gentleman comes to your office wanting a recertification. His blood pressure is 156 over 96. He says he has white coat hypertension, and he brings a note from his PCP that says it's 140 over 90. What do you do? So we clearly, we're going to do C. We're going to do the blood pressure in our office. I don't care what it was at his PCP's office, or at Walmart, or wherever he went to get checked his blood pressure. And then my decision would be based upon that. Now, with him at 156 over 96, I don't know where you are. Use your best medical judgment. So number five. Gentleman comes to your office for a CO certification exam. Blood pressure, last year blood pressure was 184 over 112, and returned to normal after medication was started. His current blood pressure is 152 over 94, and you repeat and get 150 over 92. So, which group is he in, if you're going to use that chart? So he's been stage three in the past, and I know that, right? So, I would want, so which is he eligible for? Well, or at least over under 169. So he's actually probably okay for a one-year card. I understand, this is, I can't even explain this. I would like to have one set of recommendations that I can then explain to people. I don't have that. So if I want to use the old system with him, he would be, he'd had stage three in the past, and now he's under one, he's not under 140 over 90, so I'm gonna use this chart. So I can't even certify him at all if I use that chart. Okay, he could get a one-time certificate for three months. That would be another option, okay? Answer number two, for the same scenario, because I realized this is a problem. He'd be, so his, he was stage, history of stage three. He's now under 169 over 109, and he can get a one-year card. That's what that line says. The hard part is not knowing what they're gonna test on. That's completely correct. Huh? That is correct. This one says, except drivers with a history of stage three, and he had stage three. That's why the other- We understand. Keep going, hold on. So I might give him a three-month card. I might send to see his doctor and get his blood pressure under better control. There are a myriad of not wrong answers. I don't know which one is the most correct. One of the things I've found, and you have to kind of suss out your patient. Some patients, you'll better motivate them to treat their blood pressure by taking away their card. Some patients would rather keep driving and go see, and get the three-month card and keep driving and go see their doctor. I don't think that's wrong for this guy. He probably needs a little bit better blood pressure control, though. It's better than it was. It's improved, but it's not good. Any questions about hypertension stuff? Yeah. Yeah, how are you going to take the test questions? I don't know. So the question was asked is, how am I going to take the test questions? So what I'm going to do is I'm going to, I got a good chance to review this and try to figure it out when I was trying to make up, revise this talk. So what I'm going to do is review those again. And I'm probably going to do my, like, I'm probably going to use their cutoffs that are in the second chart as hard cutoffs. So not the CFRs are still in the accrual. Correct. Because they went as far as saying, well, you could use this or you could use that. So I don't know. I really don't know what the answer is for blood pressure. This is far more frustrating than I want it to be. Go ahead. I think so. Yes. So he's blowing through unstable. Yeah. So he had stage three in the past. Oh, wait a minute. Where'd my guy go? Hold on. There's a question I didn't get to. There you go. Does target image mean anything at all? We're supposed to take action for a patient with hypertension with a creatinine of 1.5 or cardiomegaly. So the answer to your question is I wouldn't take away their certification because they have the mild cardiomegaly or if they have mild kidney disease, but I would refer them to talk to their family doctor about that if you knew they had the creatinine. Because our test doesn't normally include a creatinine or any way we could identify cardiomegaly. But if they have that, I have no problem clinically with scaring people and saying, you know, your blood pressure's up. It's damaging your heart and your kidneys. If you don't get this fixed, you're going to end up on dialysis and with bad heart problems or just dead. I have no problem with telling people that if they're not taking care of themselves. I mean, that's our job.

truck drivers

hypertension

FMCSA regulations

blood pressure

certification

cardiovascular risks

JNC guidelines