Evaluating fitness to drive in the ED


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Approach to evaluating patients' fitness to drive during an ED encounter.
Review of health advocacy and legal obligations from a Quebec standpoint
Audience: Medical students and residents in a small group environment

Published in: Health & Medicine, Sports
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Evaluating fitness to drive in the ED

  1. 1. Our role as health advocates and our legal responsibilities Farooq Khan MDCM PGY2 FRCP-EM McGill University July 19 2010
  2. 2. Objectives  To review common conditions that may impair driving  To employ a simple approach towards evaluating fitness to drive in the ED  To understand the health advocate role and legal obligations of the EP within the Quebec healthcare system with regards to driving fitness
  3. 3. Common concern..?  21 year old male presents with delayed seizures post-TBI  58 year female with lupus presents with with CRAO  47 year old male with new onset Parkinson’s disease  68 year old female presenting with a mechanical fall who is found to have early dementia  29 year old female with pseudotumor cerebri who undergoes dilatation for fundoscopy
  4. 4. Should these patients be driving?  What is our role as physicians in determining fitness to drive?  How do we go about doing it?  What, if any, are our legal obligations?
  5. 5. Why do we care?  Medically unfit drivers contribute to 100 motor vehicle related fatalities every day in North America  Worldwide 5000 pedestrians per year are killed by medically unfit drivers  Doctors have a responsibility to protect the public and serve as health advocates  These drivers and their victims end up in our EDs  An epidemiological study at Sunnybrook trauma center in 2008 found  37% of drivers admitted for MVC had reportable conditions  Fewer than 3% were actually reported  85% of those patients had visited a doctor in the past year  In most of Canada and the US, reporting medical conditions that impair driving is mandated by law
  6. 6. How?  Think of whether or not the patient can fulfill all the required functions of driving Can they operate the various controls? (pedals, steering wheel, indicators, mirrors, etc) ○ Motor skills, coordination, balance Is their sensory perception adequate? ○ Audition, vision, touch/proprioception Do they possess the mental faculties? ○ Memory, judgment, vigilance
  7. 7. Observe your patients as they enter the examining room  General appearance: hygiene, grooming, hemiplegia, glasses, involuntary movements  Mobility: gait, speed, posture, balance, need for assistance, transfers  Handshake: grip strength, upper extremity ROM  Conversation: audition, confusion, coherence, mental status, dysarthria, EOM, social appropriateness
  8. 8. Historical elements of concern  PMH: CVA, DM, CAD, arrythmias pacer/ICD, aneurysms (all types), dementia, epilepsy, neurodegenerative disorders, glaucoma, cataracts, macular degeneration, sleep apnea, substance abuse  Medications: psychotropics (benzos), antiarrhythmics, anticonvulsants, narcotics, muscle relaxants, EtOH and illicit drugs, mydriatics, cycloplegics
  9. 9. Historical elements of concern  Prior visual/auditory problems  Unexplained LOC  Evidence of memory loss (especially in elderly, obtain collateral history)  Decrease in ADLs, IADLs  Pain, limited neck movements  Vertigo/dizziness  Palpitations
  10. 10. Driving history  How the patient arrived  Type of vehicle (truck, motorcycle, etc.)  Previous accidents, infractions  Change in driving habits Voluntarily imposed limits (avoiding rush hour, or driving at night) Long distance driving Races  Presence of alternate driver  Professional driver (bus, taxi, etc)
  11. 11. Physical exam  VS: arrythmias, bradycardia, hypotension  Visual acuity and gross visual fields  Neck mobility (particularly rotation)  CVS: aortic stenosis murmur  Abdo: AAA  Extremities: sensory/motor deficits, limited ROM, amputation  Gait: assisted, antalgic, paretic, loss of balance  Mental status: low MMSE, psychomotor retardation, attention deficit, apraxia, lack of judgment or planning
  12. 12. So now recap  Is there a medical condition (intrinsic to the patient or acquired through therapy) that decreases the patients aptitude to drive or renders it unsafe?  What kind of conversation should you be having with your patient?  How long should they avoid driving?  Should they be giving up driving altogether?  What kind of modifications will allow them to retain their licenses?  What resources can help you and your patients?  Occupational therapy, neuropsychiatric evaluation, specialized evaluating MDs.  Public transit, Transport adapté, community services
  13. 13. Ethical and legal considerations  Ethical principles at odds Patient privacy, confidentiality and autonomy Public health, protecting other citizens from dangerous drivers  Physicians in Québec do not revoke licenses. The SAAQ makes that decision. Reporting is discretionary not mandatory  The Code de sécurité routière authorizes physicians to break confidentiality and inform the SAAQ when patients are judged to be inapt at driving
  14. 14. Ethical and legal considerations  Our ethical and professional obligation is to inform our patients of their condition and the risk if they continue to drive  Recommend that they discontinue driving until an exhaustive evaluation can be carried out  If it is felt that the patient will not respect the recommendation and continues to be a danger to others, then the physician is duty bound to inform the SAAQ  Inform patients of your decision to report and document carefully!  Seizure disorders, EtOH and drug abuse, and psychiatric disorders are high risk diagnoses for litigation  Physicians have been found liable for failure to report
  15. 15. Take home messages  Keep fitness to drive in the back of your mind  When a condition of concern presents itself, take a couple of extra minutes to assess the situation  Advise your patients of the risk involved, and take action if the patient’s behaviour is a danger to self or others
  16. 16. Contact the SAAQ  SAAQ: Service de l'évaluation médicale - QUÉBEC Postal address : Société de l'assurance automobile du Québec Service de l'évaluation médicale C. P. 19500 QUÉBEC (Québec) G1K 8J5 Telephone: 418 643-5506 or 1 800 561-2858  Highway Safety Code: Regulation respecting access to driving a road vehicle in connection with the health of drivers, R.S.Q., c. C- 24.2, r.0.1.0001 http://www2.publicationsduquebec.gouv.qc.ca/dynamicSearch/telecharge.php?type=3&file=/C_24_2/C24
  17. 17. References  Collège des médecins du Québec, L’évaluation médicale de l’aptitude à conduire un véhicule automobile, Guide d’exercice, Montreal, Collège des médecins du Québec, mars 2007 [En Ligne] http://www.cmq.org/fr/MedecinsMembres/Ateliers/~/media/9DADF56514BB48D2B0C70568F96FB8FF.ashx?41016  American Medical Association National Highway Traffic Safety Administration. Physician’s Guide to Assessing and Counseling Older Drivers, [Chicago (Illinois), American Medical Association, September 2003]. [Online] http://www.nhtsa.dot.gov/people/injury/olddrive/physician_guide/PhysiciansGuide.pdf.  Canadian Medical Association. Determining Medical Fitness to Operate Motor Vehicles, CMA Driver's Guide 7th edition., Ottawa, Canadian Medical Association, 2006. [Online] http://www.cma.ca/index.php/ci_id/18223/la_id/1.htm  Canadian Cardiovascular Society Consensus Conference 2003. Assessment of the Cardiac Patient for Fitness to Drive and Fly: Final Report, [Ottawa, Canadian Cardiovascular Society], 2003. [Online] http://www.ccs.ca/download/consensus_conference/consensus_conference_archives/2003_Fitness.pdf  Collège des médecins du Québec. Aspects légaux, déontologiques, et organisationnels de la pratique médicale au Québec: ALDO-Québec, Montréal, Collège des médecins du Québec, mai 2006. [En ligne] http://www.cmq.org/aldofrancais.aspx  Société de l’assurance automobile du Québec. Guide de l’évaluation médicale et optométrique des conducteurs au Québec, 1re éd. rév., Québec, Société de l’assurance automobile du Québec, 1999. [En ligne] http://www.saaq.gouv.qc.ca/documents/documents_pdf/permis/guidemed.html  Redelmeier, D., Venkatesh, V., Stanbrook, M.. Mandatory Reporting by Physicians of Patients Potentially Unfit to Drive. Open Medicine, North America, 2, Feb. 2008. [Online] http://www.openmedicine.ca/article/view/141  European Commission. Transport, Road Safety  Diabetes and Driving in Europe: A Report of the Second European Working Group on Diabetes and Driving, [Brussels,European Commission, July 2006]. [Online] http://ec.europa.eu/transport/roadsafety/behavior/doc/diabetes_and_driving_in_europe_final_1.pdf.  Epilepsy and Driving in Europe: A Report of the Second European Working Group on Epilepsy and Driving, [Brussels, European Commission], April 3rd 2005. [Online] http://ec.europa.eu/transport/roadsafety/behavior/doc/epilepsy_and_driving_in_europe_ final_report_v2_en.pdf.  New Standards for the Visual Functions of Drivers: Report of the Eyesight Working Group, [Brussels, European Commission], May 2005. [Online] http://ec.europa.eu/transport/roadsafety/behavior/doc/new_standards_final_version_en.pdf