3.1.3 Heavy Commercial Transport Drivers (Class 1 and 3)

The high noise level in the cab of most heavy commercial vehicles tends to mask extraneous warning sounds such as emergency vehicle sirens even when ear protectors are worn to selectively attenuate the lower frequency vehicle sounds. Nevertheless, commercial vehicle driver trainers and many commercial vehicle drivers believe that a sense of hearing does contribute significantly to safe driving since the first warning of a potentially dangerous vehicle malfunction can often be heard before it can be detected in any other way. It is recommended, therefore, that persons driving heavy commercial vehicles (class 1 or 3) should not have an uncorrected hearing loss greater than 55 decibels, averaged at 500, 1 000 and 2 000 Hz in their better ear.

3.2 MEASUREMENT OF HEARING LOSS

3.2.1 If a hearing impairment is suspected, persons who are applying for a licence to drive a passenger carrying vehicle or heavy bus or truck (class 1, 2, 3 or 4) should be referred to an Otolaryngologist, Audiologist or to a Hearing Clinic operated by the B.C. Ministry of Health for a pure tone audiogram.

3.2.2 Taxicab drivers who use a hearing aid must be tested in a sound field by the I.S.O. standard method.

3.3 HEARING AIDS

Hearing aids are of little or no help to the operator of a large passenger bus or heavy truck because the ambient noise level, that frequently reaches 80 to 100 decibels in a diesel powered vehicle is amplified by the hearing aid to the same extend as the warning signals, the driver should be able to hear and therefore continue to mask these sounds. In addition, the constant amplification of the background noise over many hours of driving leads to irritation and fatigue that can be only relieved by reducing the volume of the aid to ineffective levels or turning it completely off.

Although hearing aids are much more reliable now than they used to be, there is still no absolute assurance that they will not fail at a crucial time or more importantly, that the operator will always have replacement batteries available as they are needed.

For these reasons, it is felt that, in the interest of public safety, passenger bus drivers and heavy commercial vehicle drivers (classes 1, 2, 3 or 4) should be able to meet the recommended hearing standards without the use of a hearing aid.

3.4 VESTIBULAR DISORDERS

A loss of the sense of balance can seriously affect driving ability. Patients with acute labyrinthitis or positional vertigo with horizontal head movement should be advised not to drive at all until their condition has subsided or responded to treatment. Patients who are subject to recurrent attacks of vertigo that occur without warning, should also not drive any type of vehicle until it is certain that their spells of dizziness have been controlled or have abated.

SECTION 4 – CARDIOVASCULAR DISEASES

4.0 CARDIOVASCULAR DISEASES

There has been a great deal of discussion but little conclusive evidence produced about the role of cardiovascular disease as a cause of motor vehicle crashes. The number of variables that must be taken into account make it almost impossible to estimate the probability of a driver with a cardiovascular condition having a sudden loss of consciousness, or an attack of pain or weakness while driving, sufficient to cause a loss of full control of a vehicle. There is as well, little agreement as to where to draw the dividing line between a risk, that is acceptable, and one that is not. It is, however, generally agreed that professional drivers who operate taxis, passenger buses and trucks for a living, should be expected to meet higher medical standards than persons who limit their driving to private vehicles. Not only are the consequences of a crash involving a bus or truck likely to be much more serious, but also very few professional drivers are able to leave their vehicle in the middle of a shift, should they suddenly become ill miles away from home. In addition, commercial vehicle drivers are often called on, as part of their normal duties, to travel great distances, load and unload heavy cargo, attach and detach chains, restore shifting loads and carry out emergency roadside repairs, all of which can be much more physically demanding than driving their vehicle.

The recommendations made in this section are based on the Consensus Conference held by the Canadian Cardiovascular Society in 1991 and reported in the Canadian Journal of Cardiology, Volume 8, number 4, May 1992. Permission to base our recommendations upon this report has been received from the Chairman of that Conference.

GENERAL PRINCIPLES

In assessing the fitness of the cardiac patient to drive, a physician must consider, first of all, the patient's symptoms. As has been pointed out by the Canadian Cardiovascular Society, the symptoms have a notorious way of changing whenever some privilege or economic benefit is involved.

These recommendations on cardiovascular diseases are taken from the report of the consensus conference of the Canadian Cardiovascular Society. This conference was chaired by Dr. James Brennan who has given his approval to the request that this section be based on his report. That committee has proposed the following functional classifications

CLASS I

Clinical or objective diagnostic evidence of heart disease without functional limitation. The patient must be able to complete stage two of a treadmill exercise test using the standard Bruce protocol without developing symptoms or objective evidence of impairment of cardiac function.

CLASS II

Clinical or objective diagnostic evidence of heart disease with mild functional impairment and symptoms only on major physical effort. Ability to complete at least stage two of a treadmill exercise on the Bruce protocol.

CLASS III

Clinical or objective diagnostic evidence of heart disease with moderate impairment of cardiac function and symptoms on light physical activity. Ability to complete at least one minute of stage two of a treadmill exercise on the Bruce protocol.

CLASS IV

Clinical or objective diagnostic evidence of heart disease with severe impairment of cardiac function and symptoms at rest.

This classification into four classes takes into consideration not only symptoms but also objective evidence e.g., exercise induced ECG ST segment changes.

The patient in class 4 is functionally incapable of driving.

Individuals in class 1, 2, and 3 have adequate functional capacity to operate virtually any type of motor vehicle however, the patient whose job description entails driving may be restricted from performing other job related tasks by the presence of moderately disabling symptoms and symptoms that have independent prognostic implications. The guidelines presented in the following section apply only to patients in functional classes 1 to 3. Where functional class 1 is specified as a qualifying criterion in these guidelines it should be determined by exercise testing. A patient who is able to complete stage two of a treadmill exercise test using the standard Bruce protocol without developing symptoms or objective evidence of impairment of cardiac function would be in functional class 1.

If a driver has more than one cardiac condition e.g.: valvular heart disease plus chronic atrial fibrillation, the criteria for each condition should be satisfied before approval to drive is given. The guidelines do not apply to acute conditions, that leave no long-term alterations in cardiac structure or function. Except where otherwise stated, it is recommended that the commercial driver undergo cardiac reassessment every year and the private driver, every two years.

DEFINITIONS

Private Driver: one who:

• drives less than 36,000 km/year or spends less than 720 h/year behind the wheel;
• drives a vehicle weighing less than 11,000 kg.;
• and does not earn a living by driving.

Commercial Driver: any licensed driver who does not fulfill the above definition of a private driver.

Cerebral Ischemia: transient loss or near-loss of consciousness, loss of vision or loss of postural support or other neurological incapacitation due to a reduction in cerebral blood flow.

Left ventricle (LV) classification ( as assessed by echocardiography, radionuclide angiography or direct contrast angiography):

Class I: Ejection fraction more than or equal to 80% of normal value for the technique used.

Class II: Ejection fraction more than or equal to 60% of normal for the technique used.

Holter classification (as assessed by at least 20 h of ambulatory electrocardiographic monitoring).

Class I: Average 10 or less premature ventricular complexes (PVCs)/h and no episodes of ventricular tachycardia more than three beats in duration with an average cycle length 500 ms or less.

Class II: NO episodes of ventricular tachycardia more than three beats in duration with an average cycle length 500 ms or less.

Waiting period: the time interval following onset of a disqualifying cardiac condition, initiation of a stable program of medical therapy or performance of a therapeutic procedure (whichever is applicable) during which driving should generally be disallowed for medical reasons.

If more than one waiting period would apply (e.g., commercial driver treated with coronary angioplasty {waiting period one week} following an acute myocardial infarction (MI) {waiting period three months}, the longer one should be used.

Satisfactory control of paroxysmal tachyarrhythmia means one of:

For Ventricular Tachyarrhythmias:

• Induction of the tachycardia by programmed electrical stimulation prior to medical, surgical or ablative therapy followed by documentation of noninducibility after initiation of therapy, plus a three-month waiting period.
• Documentation of at least 70% reduction in isolated PVC frequency and at least 90% reduction in ventricular couplets and triplets frequency and elimination of all episodes of ventricular tachycardia more than three beats in duration at a cycle length of 500 ms or less, plus a six-month waiting period. This applies only to individuals with an average of 30 PVCs/h or more on pre-therapy Holter monitoring.
• One-year waiting period after initiation of empiric medical therapy.

For Supraventricular tachyarrhythmias:

• Induction of the tachycardia by programmed electrical stimulation prior to medical, surgical or ablative therapy followed by documentation of noninducibility after initiation of therapy, plus a one-month waiting period.
• Three-month waiting period after initiation of empiric medical therapy.

SPECIFIC GUIDELINES

For each condition there is a list of recommendations, all of which should be met if the patient is to receive medical approval to drive. In many cases these recommendations are different for private and commercial driving.

It is essential to review the Definitions and General Principles sections when interpreting the following guidelines:

4.1.A CORONARY ARTERY DISEASE

General Recommendations

All drivers with coronary artery disease should satisfy the following criteria:

Private driving: Appropriate waiting period

Commercial driving: Appropriate waiting period

- Functional Class I

- LV Class I + Holter Class II or

- LV Class II + Holter Class I

2) Additional specific recommendations and waiting periods

a) Acute MI, unstable angina pectoris:

Private driving: Waiting period one month

Commercial driving: Waiting period three months

b) Stable angina pectoris ("Stable" means no change in the frequency, duration or ease of provocation of symptoms during the specified waiting period {the onset of which may be determined retrospectively}).

Private driving: Waiting period one month

Commercial driving: Waiting period three months

c)Suspected asymptomatic coronary artery disease, e.g., positive exercise test, old MI on ECG, asymptomatic ST depression on Holter - No additional recommendations, - No waiting period

Note: Normal coronary angiogram, negative stress-radionuclide myocardial perfusion scan or negative stress-echocardiogram overrides the general requirements of Section A1.

d) Coronary angioplasty:

Private driving: Waiting period 48 h

Commercial driving: Waiting period one week - reassessment at six months with clinical evaluation and exercise test

e) Coronary bypass surgery:

Private driving:Waiting period one month

Commercial driving: Waiting period three months

3) Left main coronary artery disease

Notwithstanding any of the foregoing recommendations, angiographic demonstration of 50% reduction in the diameter of the lumen of the left main coronary artery should disqualify the patient for commercial driving, and 70% narrowing should disqualify for private driving, unless treated with coronary bypass surgery.

4.1.B DISTURBANCES OF CARDIAC RHYTHM

1. Ventricular fibrillation, sustained ventricular tachycardia

"Sustained" ventricular tachycardia is defined as having a cycle length of 500 ms or less and lasting at lease 30 s or causing hemodynamic collapse.

These arrhythmias render the victim permanently medically unfit to drive, except in the following circumstances:

• if the episode occurs in the acute phase of an MI, criteria for acute MI may be applied.
• if due to a reversible condition, the patient may resume driving a private vehicle one month (or a commercial vehicle three months) after correction of the condition
• if satisfactory control has been achieved, the patient may resume driving a private vehicle but not a commercial vehicle.

2. Nonsustained paroxysmal tachycardia, paroxysmal supraventricular tachycardia, paroxysmal atrial flutter or fibrillation

a) With no associated cerebral ischemia and no underlying heart disease

Private and commercial: No restriction

b) With ventricular pre-excitation and no associated cerebral ischemia

Private driving: No restriction

Commercial driving: Satisfactory control

c) With associated cerebral ischemia

Private and commercial: Satisfactory control

d) With underlying heart disease

Private and commercial: Satisfactory control

3. Chronic atrial flutter or fibrillation

a) With no underlying heart disease and no associated cerebral ischemia

Private and commercial: No restriction

b) With underlying heart disease

Private driving: No associated cerebral ischemia

Commercial driving: No associated cerebral ischemia

• Waiting period one month
• Anticoagulant therapy (atrial fibrillation only)

4. Sinus node dysfunction ("sick sinus syndrome", sinus bradycardia, sinus exit block, sinus arrest)

Private driving: No associated cerebral ischemia

Commercial driving: No associated cerebral ischemia

No pauses more than 3 X during waking hours on Holter monitoring

5. Atrioventricular and intra-ventricular block

a) First-degree AV block, right bundle branch block, left anterior fascicular block, left posterior fascicular block

Private and commercial driving: No restriction

b) Left bundle branch block, bi-fascicular block, Mobitz Type 1 second-degree AV block, bi-fascicular block plus first-degree AV block

Private driving: No associated cerebral ischemia

Commercial driving: No associated cerebral ischemia

No Mobitz type II or third-degree AV block on Holter monitoring

c) Mobitz type II second-degree AV block, alternating right and left bundle branch block, right bundle branch block plus alternating left anterior and left posterior fascicular block

Private and commercial driving: Disqualification

d) Acquired third-degree AV block

Private driving:No associated cerebral ischemia

QRS duration less than 110 ms

No pauses more than 3 X during waking hours on Holter monitoring - Waiting period six months

Commercial driving: Disqualification

e) Congenital third-degree AV block

Private driving:No associated cerebral ischemia

Commercial driving:No associated cerebral ischemia

QRS duration less than 110 ms

No pauses more than 3 X during waking hours on Holter monitoring

6. Artificial cardiac pacemakers

Note: The criteria listed in this section override those listed in Sections B4 and B5.

Private driving: Waiting period one week

No cerebral ischemia

ECG rhythm strip shows normal sensing and capture

Device is performing within manufacturer's specifications

Commercial driving: Waiting period one month

No cerebral ischemia

ECG rhythm strip shows normal sensing and capture

Device is performing within manufacturer's specifications

Pacemaker output pulse at least 3x the measured stimulation threshold

7. Implantable cardioverter/defibrillator devices

The patient who has had one of these devices implanted should be considered unfit to drive a commercial vehicle. Private driving may be permitted if:

• the device was inserted as a prophylactic measure in a patient without a documented episode of ventricular tachycardia or fibrillation and there are no other disqualifying criteria;
• the device has delivered no shock or antitachycardia pacing therapy and at least one year has elapsed since implantation; or
• following insertion of the device, criteria for satisfactory control are met.

4.1.C VALVULAR HEART DISEASE

1. Medically treated or untreated valvular heart disease (including percutaneous-valvuloplasty)

a) Aortic stenosis

Private driving: Functional Class I or II

No associated cerebral ischemia

Commercial driving: Asymptomatic

Functional Class I

Estimated aortic valve area more than 1.0 cm2 assessed by echocardiography or cardiac catheterization

LV Class I or LV Class II + Holter Class II

b) Aortic regurgitation, mitral stenosis, mitral regurgitation

Private driving: No associated cerebral ischemia

Commercial driving: No associated cerebral ischemia

Functional Class I

LV Class I or LV Class II + Holter Class II

2. Surgically treated valvular heart disease

a) Mechanical prostheses, mitral bioprostheses or valvuloplasty in patients not in sinus rhythm

Private driving: Waiting period six weeks

• No thromboembolic complications on anticoagulant therapy

Commercial driving: Waiting period six months

• No thromboembolic complications
• Anticoagulant therapy
• Functional Class I
• LV Class I or
• LV Class II + Holter Class II

b) Aortic bioprostheses, mitral bioprostheses or valvuloplasty in patients with sinus rhythm

Private driving: Waiting period six weeks

• No thromboembolic complications

Commercial driving: Waiting period three months

• No thromboembolic complications
• Functional Class I
• LV Class I or
• LV Class II + Holter Class II

4.1.D CONGESTIVE HEART FAILURE, LV DYSFUNCTION, CARDIOMYOPATHY

Private driving: (Functional Class I or II) - No restriction

Private driving: (Functional Class III) - LV Class I or LV Class II + Holter Class III

Commercial driving: Functional Class I

• LV Class I or

• LV Class II + Holter Class II

4.1.E HYPERTROPHIC CARDIOMYOPATHY

Private driving: No associated cerebral ischemia

Commercial driving: Functional Class I

• No associated cerebral ischemia
• Holter Class II
• LV outflow tract gradient less than 30 mmHg at rest, as assessed by Doppler or cardiac catheterization

4.1.F CONGENITAL HEART DISEASE

No diagnosis - specific recommendations are made. Assessment should be based on functional capacity and the presence or absence of myocardial ischemia, cardiomyopathy, valvular heart disease or disturbances of cardiac rhythm and should adhere to the relevant guidelines in the preceding sections.

4.1.G CARDIAC TRANSPLANTATION

Private driving: Waiting period two months

Commercial driving: Waiting period six months

• Functional Class I
• LV Class I or
• LV Class II + Holter Class II

4.1.H CARDIAC INFECTIONS

Patients with an acute infection of pericardium or myocardium should not drive any motor vehicle of any type until they have fully recovered from their illness. Patients with subacute bacterial endocarditis should also discontinue driving because of the risk of embolism.

4.2 ABNORMAL BLOOD PRESSURE

4.2.1 Hypertension

Hypertension, other than uncontrolled malignant hypertension, is not by itself a contraindication to the operation of any class of motor vehicle, although the complications that can arise from increased blood pressure such as cardiac, ocular or renal damage may well preclude safe driving. Sustained hypertension above 170/110 is, however, often accompanied by complications that make driving dangerous and these patients must be evaluated very carefully.

Higher standards are required of passenger, transport and commercial vehicle operators than of private vehicle drivers. If a professional driver is found to have a blood pressure of 170/110 or higher, the investigation must include an electrocardiogram, chest x-ray, fundoscopic examination and a BUN, and if a marked deviation from normal is found, the patient should be referred to an internist for an opinion.

The long term risks associated with sustained hypertension over 170/110 are such that patients, who are unable to reduce their blood pressure to a level below this figure, should not be recommended for licencing as professional drivers (class 1,2,3, or 4).

4.2.2 Hypotension

Hypotension is not a contraindication to the operation of any type of motor vehicle unless it has caused episodes of syncope. If syncope has occurred, the patient should discontinue driving. If it is possible to prevent further attacks by treatment, it is then safe to resume driving a private vehicle but not heavy transport or commercial vehicles.

4.3 ANTICOAGULANTS

Although the use of anticoagulant drugs is not by itself a contraindication to driving any class of motor vehicle, the underlying condition that led to prescribing the anticoagulant may be incompatible with safe driving.

SECTION 5 – CEREBRAL VASCULAR DISEASES

5.0 THE ROLE OF CEREBROVASCULAR DISEASE IN DRIVING

Early cerebrovascular insufficiency can cause disabling symptoms that are very difficult to detect. If there is reason to suspect that there might be a problem, a searching history and a careful evaluation of the degree of disability present, is probably the best method of determining fitness to drive. A road test may also be helpful but cannot always be fully relied on to reveal the true extent of the disability because of the fluctuating nature of the symptoms.

5.1 TRANSIENT ISCHEMIC ATTACKS

5.1.1The abrupt onset of a partial loss of neurologic function persisting for less than twenty-four hours and clearing without residual signs (TIA), should not be ignored in anyone who drives a motor vehicle since it forewarns of the possibility of a later stroke. Available data indicates that after the first warning symptoms there is a five to six percent chance per year of a stroke occurring. Some evidence indicates that the first 3 months after the onset of a TIA carries a slightly higher risk. A second or third TIA in patients who wish to continue driving warrants a thorough investigation because of the risks involved. Every effort should be made to reduce any risk factors found to be present.

5.1.2 Professional drivers (class 1, 2, 3 and 4) who have a TIA should be advised to stop driving while the cause of their attack is being investigated. It is not possible to make a general statement about the hazard of permitting professional drivers to continue working after a TIA because of the multifactorial etiology of this condition. Although the decision must be individualized the patient should, at the very least, be expected to reduce and where possible eliminate all of the presently accepted risk factors and remain under close ongoing medical observation.

5.2 CEREBROVASCULAR ACCIDENTS

Patients who have had a stroke can usually resume driving a private motor vehicle if they have made a good recovery. They must, however, always be carefully evaluated to make sure that there are no signs of an impending recurrence and no undetected visual field defects.

Where there is a residual minimal loss of motor power, the Driver Examiners for the Motor Vehicle Branch are in the best position to judge the person's ability to drive by means of a road test. It may be necessary to restrict the person to driving a vehicle equipped with an automatic transmission or modified controls.

The physician should take particular care to note any changes in personality, alertness or decision making ability, that, even though quite subtle and inconsistent, could significantly affect driving ability. Such a person may be able to drive quite well one day and be incompetent the next. The patient may even be reported for erratic driving and yet do quite well on a driving test.

Patients who have had a stroke and subsequently resume driving, should always remain under regular medical supervision since the episode may be the forerunner of a gradual decline in their thinking processes. Sometimes the denial of freeway or high speed driving may be all that is required.

SECTION 6 – PERIPHERAL VASCULAR DISEASE

6.0 ARTERIAL ANEURYSM

An arterial aneurysm is potentially dangerous if it is expanding and there is a possibility of a sudden rupture or if it contains a thrombus, that may throw off emboli. A patient with an aortic aneurysm should have the benefit of the opinion of a vascular surgeon and an estimate of the size of the aneurysm should be provided by the physician when completing the Driver's Medical Examination Report for the Motor Vehicle Branch. Ongoing review of the patient is required and at the present time it seems to be generally accepted that an aneurysm that is larger than 5 cm should be treated by surgery in order for the patient to be licenced to drive any type of motor vehicle. When there has been satisfactory recovery following surgery the patient may drive any type of vehicle, assuming that no other medical conditions exists.

A symptomatic cerebral aneurysm that has not been surgically repaired is an absolute barrier to driving any class of motor vehicle. Following successful treatment the individual may drive a class 5 vehicle after a period of three months and be eligible to drive commercial vehicles after being symptom free for six months.

6.1 PERIPHERAL ARTERIAL VASCULAR DISEASES

Reynaud's Disease, Buerger's Disease and Arteriosclerotic Occlusions, if of sufficient severity to cause claudication, may preclude driving and always requires careful evaluation and regular ongoing surveillance.

6.2 DISEASES OF THE VEINS

Patients with deep venous thrombosis, with or without evidence of infection, should not drive because of the danger of embolization and pulmonary infarction. Following appropriate treatment with an anticoagulant and with approval of the patient's physician any type of motor vehicle may be driven.

SECTION 7 – DISEASES OF THE NERVOUS SYSTEM

7.0 THE ROLE OF THE NERVOUS SYSTEM IN DRIVING

Every motor vehicle driver must be able to carry out a continuing series of complex muscular movements without hesitation and with great precision in order to operate a motor vehicle safely in present day traffic and under all extremes of weather and road conditions. This requires a good level of intelligence, complete control over all muscle movements and freedom from the distracting influence of severe pain. A safe driver must, in addition, always be alert, fully conscious and speedily capable of appreciating and responding to changing traffic patterns and road conditions.

The more common neurologic conditions that can adversely affect driving ability are discussed in the sections that follow.

7.1 FEBRILE OR TOXIC CONVULSIONS

A history of febrile convulsions in early childhood or of convulsions that can be directly related to a toxic illness either in childhood or adult life from which there has been a complete recovery, need be of no concern when evaluating a person for a driver's licence.

7.2 SYNCOPE

A history of syncope must always be treated seriously since a person who loses consciousness while driving can scarcely avoid a crash. A single occurrence that can be fully explained and that is not likely to recur, may call for no more than careful observation for a few months, but persons who have a history of having a number of fainting spells should not drive until the cause has been determined and successful corrective measures taken.

7.3 SEIZURES

Note to Physicians: The waiting period before driving after an epileptic seizure has been reduced from one year to 6 months. Updated pages to replace this section of the Guide were distributed with the mailing from the College of Physicians and Surgeons of BC during August 2002.

7.3.1 A person who has a spontaneous epileptiform seizure should not drive again after the event until a complete neurologic examination has been carried out to attempt to determine the cause. If the patient is diagnosed as having epilepsy and placed on antiepileptic medication, the physician should withhold a recommendation to licence until:

7.3.1.1   The person has been seizure free on medication for not less than 6 months, in order to make certain that a drug level has been achieved that will prevent further seizures and that can be maintained without side effects that could affect  the patient's ability to drive safely; (May 2002)

7.3.1.2 The attending physician feels quite confident that the person is a conscientious and reliable patient who will continue to take the prescribed antiseizure medication as directed, who will carefully follow the physician's instructions and who will promptly report any further seizures.

Patients who meet the above criteria can resume driving a private motor vehicle (class 5 and 6) without undue risk provided the antiepileptic medication has no effect on their alertness and muscular co-ordination. They should however, in the interest of safety, be advised not to drive for long hours without rest, not to drive when fatigued and to avoid the excessive use of alcohol.

7.3.2 Patients who have had surgical treatment to prevent epileptic seizures should have been free of seizures for 12 months after the surgery before being recommended for licencing. (May 2002)

7.3.3 It is unsafe for a person who must take antiepileptic medication to prevent seizures to operate passenger carrying or commercial transport vehicle (classes 1,2,3 or 4) because of the greater degree of certainty required that they will not have a seizure while driving. Professional drivers are often unable to avoid driving for long periods of time under extremely adverse conditions or avoid highly stressful or fatiguing situations that could act to precipitate another seizure. Unfortunately, seizures do sometimes recur even after many years of successful treatment, however, individuals may drive any class of vehicle if they have been seizure free for 10 years on or 5 years off medication. (May 2002)

7.3.4 Since a single, unprovoked seizure is not necessarily diagnostic of epilepsy, decisions regarding possible licence suspension must be individualized to the particulars of each case. The opinion of a neurologist should be obtained and individuals holding a class 5 and 6 licence may require suspension of driving privileges for up to 6 months.

7.3.5 Professional drivers who have had a single spontaneous epileptiform seizure should be told to stop driving passenger-carrying or commercial vehicles (classes 1,2,3, and 4) at once because of the greater degree of certainty required that another seizure will not occur while they are driving. If a complete examination by a neurologist does not suggest a diagnosis of epilepsy or some other condition that precludes driving, the risk of further seizures is then usually low enough that it is safe to recommend a return to professional driving when the patient has been seizure free without medication for 12 months.

7.3.6 Persons with epilepsy whose seizures have only occurred while they were asleep or immediately after awakening for at least five years, can be recommended for a private licence (class 5 and 6). Provided they have the approval of a neurologist and remain under close observation, this restriction of five years may be reduced on the recommendation of the neurologist. They should not, however, drive commercial trucks or passenger-carrying vehicles because some patients with nocturnal epilepsy do, with the passage of time, begin to have daytime seizures.

7.3.7 Since some patients with fully controlled seizures whose antiepileptic medication is being withdrawn by their physician, do have a recurrence of their seizures, persons whose medication is being discontinued, should always be cautioned that they could have further seizures. They must not drive for a period of three months from the time that their medication has been discontinued. Patients whose seizures recur after discontinuing their antiepileptic medication on their physician's instructions, can again drive safely when they have resumed the medication, provided they had previously been seizure free for one year and their physician is satisfied that the medication is adequate. Patients with epilepsy whose antiseizure medication has been discontinued, can safely drive any class of vehicle when they have been seizure free off medication for five years. They may drive any class of vehicle if they have been seizure free for ten years whether on or off medication.

7.3.8 A patient who has stopped taking antiseizure medication against their physician's advice should never be recommended for relicencing until the physician feels quite confident that antiepileptic medication is again being taken as prescribed and that the patient will conscientiously follow medical advice in the future.

7.3.9 Patients who must take antiepileptic medication to prevent seizures and who are known to drink to the point of being impaired, should never be recommended for any class of licence, since they often fail to take their medication at the required intervals while they are intoxicated. In addition, alcohol appears to precipitate seizures in some patients with epilepsy. Where a licence has been denied because of a drinking problem any application to re-issue a licence should be accompanied by evidence of satisfactory attendance at an Alcohol Treatment Centre.

7.3.10 Alcohol withdrawal, after a bout of heavy drinking, can cause seizures in both normal people and in patients with epilepsy. Antiepileptic medication is not indicated for normal individuals following a withdrawal seizure. Neither of these groups should, however, be recommended for relicencing until the physician feels quite certain that they will abstain permanently from all further drinking. As a very minimum, a patient who has had an alcohol withdrawal seizure should not drive again until they have abstained from alcohol for at least six months and should have attended an alcohol treatment program. A statement indicating successful attendance in the program should be received from the Director of the Alcohol and Drug Centre involved.

7.3.11 Auras. Patients with auras (simple partial seizures) with somatosensory or special sensory symptoms or those patients with non disabling focal motor seizures in a single limb, provided that there is no impairment in their level of consciousness and provided that these seizures are unchanged for greater than one year may be eligible for a class 5 or 6 licence dependent upon the opinion of a neurologist.

7.4 SLEEP DISORDERS

There are a number of conditions definable by clinical and polysomnographic criteria that cause excessive daytime sleepiness that, if severe, may be incompatible with driving any class of vehicle. These include (but are not limited to ) narcolepsy, sleep apnea, post-traumatic hypersomnia, periodic limb movement disorder, sleepiness associated with depression and idiopathic hypersomnia. If such a diagnosis is being considered, driving should be avoided until the pattern and severity of the daytime sleepiness has been thoroughly assessed.

7.4.1 Narcolepsy

Although true narcolepsy is uncommon, persons who are prone to falling asleep suddenly and without warning, cannot drive any type of vehicle safely. If they respond favourably to treatment by having no periods of uncontrollable sleepiness for a period of three months and, in addition, show no side effects from their medication they can usually drive private vehicles (class 5 and 6) without undue risk, but should not operate commercial transport or passenger-carrying vehicles since the consequence of a crash, should they fail to take their medication and fall asleep, is too great to accept.

7.4.2 Sleep Apnea

Patients with severe sleep apnea or other syndromes that chronically interfere with sleep are at increased risk of an accident or injury while driving because of daytime sleepiness. Sleep apnea is often accompanied by obesity, a condition affecting many professional drivers. Patients with a history of pathologic daytime sleepiness should be referred to a Consultant for further assessment. If their condition is severe enough to impair driving ability, they should not be allowed to drive any class of motor vehicle until the condition has been adequately investigated, treated, and controlled.

7.5 DISORDERS AFFECTING COORDINATION AND MUSCLE STRENGTH AND CONTROL

Loss of muscle strength or coordination occurs in a wide variety of disorders, each of which poses a special problem. Included in this group of diseases are such conditions as paralysis due to poliomyelitis, Parkinson's disease, multiple sclerosis, cerebral palsy, the muscular dystrophies, myasthenia gravis, or tumor of the brain and spinal cord, spina bifida, organic brain damage following a head injury or stroke, and many others.

In the early stages of some of these conditions, no driving restrictions need be placed on the patient; in more serious cases, it will be immediately obvious that the applicant is unable to drive safely. It is sometimes possible, for a driver who has a mild loss of muscle strength or control, to have special controls added to their vehicle. The Provincial Driver Examiners know what controls are available and where they can be purchased. After the controls have been installed the applicant must, of course, then satisfy the Driver Examiner that he/she can drive safely.

If the disorder is not progressive, one medical examination and road test will usually suffice. If, however, the condition is one that usually tends to grow worse, the patient must be followed closely and driving discontinued when the disability reaches a point that makes driving unsafe. If the condition is also accompanied by a slowing of the thought process, impairment of memory, judgment or behaviour, or is liable to lead to a loss of consciousness, then the patient should be told to stop driving.

7.6 SEVERE PAIN

Severe pain from such causes as a migraine headache, trigeminal neuralgia or lesions of the cervical or lumbar spine can decrease concentration or limit freedom of movement to a degree that can make driving extremely hazardous,   This is of particular concern when the patient earns a living by driving because professional drivers may have responsibilities that prevent them from stopping even if the pain becomes severe enough as to be disabling. Additionally prescription and over the counter painkillers may interfere with the driver's ability to drive safely.

7.7 HEAD INJURIES

Drivers who have had a recent head injury should always be examined with particular care to determine if there is any evidence of confusion or other symptoms that would make them temporarily unfit to drive. Although a minor head injury should not impair driving for more than a few hours if at all, a more serious injury that results in even minimal residual brain damage should, without fail, be fully evaluated before driving is resumed. The major factors that may prohibit driving for an extended period are loss of good judgment, decreased intellectual capacity, posttraumatic seizures, visual deficiencies and loss of motor power. A person with post traumatic amnesia following a blow to the head should not drive any type of motor vehicle without first having a very thorough medical examination by a specialist or specialists with training in head injuries. It may also be necessary to check the patient's cognitive function.

<7.8 INTRACRANIAL TUMORS

A patient who wishes to resume private or professional driving after having had an intracranial tumor resected must be evaluated with great care.

7.8.1Where a patient's judgment, coordination, visual fields, sense of balance, motor power and reflexes are all found to be normal after the removal of an intracranial tumor, there is usually no reason to recommend any permanent driving restrictions. If a seizure occurred either before or after the removal of a tumor, the patient should have been seizure free for at least one year with or without medication before resuming driving. No general recommendation can be made about driving after the removal of a malignant or metastatic brain tumor. The opinion of the consulting neurologist and the surgeon who removed the tumor should always be sought and each case evaluated on an individual basis. If there is a possibility that the tumor could recur the physician should always make quite certain that the patient has a full understanding of the condition before sending a medical report to the Motor Vehicle Branch. Where the Superintendent of Motor Vehicles refuses to issue the class of driver's licence requested because of information provided on a medical report, the Superintendent must tell the affected person the reason for refusal. It would be very unfortunate if a patient's first knowledge that a tumor could recur would come from someone other than the attending physician.

SECTION 8 – RESPIRATORY DISEASES

8.0 THE ROLE OF RESPIRATORY DISEASES IN DRIVING

Some respiratory diseases may if severe enough, interfere with the safe operation of a motor vehicle. Any marked decrease in the ability of the lungs to provide sufficient oxygen to the brain can lead to impaired judgment, reduced concentration, slow response time and physical weakness.

The National Safety Code for Motor Carriers describes four levels of respiratory impairment:

1) No Impairment.

2) Mild Impairment - dyspnea when walking quickly on level ground or when walking uphill; can keep pace with people of same age and body build on level ground but not on hills or stairs.

3) Moderate impairment - unable to keep pace with people of same age and body build when walking on level ground; dyspnea when walking up one flight of stairs.

4) Severe impairment - dyspnea after walking more than 100m at own pace on level ground; dyspnea sometimes at rest.

8.1 CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Driving can be dangerous for a patient with marked emphysema and a road test should always be recommended if the physician has any doubt. Physicians can get some guidance by use of the levels of impairment described above. Patients with level 1 or 2 respiratory impairment can probably drive all classes of vehicle. More severe impairment would suggest that a class 5 driver's licence should be considered. Patients with severe impairment (level 4) who require supplemental oxygen must be restricted to a class 5 licence and a road test using the supplemental oxygen is mandatory. Because of the progressive nature of this condition, patients who need supplemented oxygen while driving must remain under close and regular supervision.

At a future date it is hoped to provide a more scientific classification of respiratory impairment based not only on symptoms but also on spirometry, diffusing capacity and VO2 max calculations.

8.2 PERMANENT TRACHEOSTOMY

A person with a permanent tracheostomy who has no difficulty keeping the opening clear of mucous should be able to drive any class of motor vehicle provided that the medical condition that made the tracheostomy necessary, does not itself preclude driving.

SECTION 9 – METABOLIC DISEASES

9.0 THE ROLE OF METABOLIC DISEASE IN DRIVING

Disturbances in the functioning of the endocrine glands may be the source of many symptoms ranging in severity from generalized asthenia, muscle weakness and spasms, to sudden episodes of dizziness and unconsciousness. Patients with suspected or confirmed glandular disabilities should therefore, always be carefully evaluated to make certain that their symptoms do not make them unsafe drivers. The following are among the more common metabolic conditions that physicians may be called on to assess because of their potential for interfering with driving safety.

9.1 DIABETES MELLITUS

A driver's medical examination of a patient with diabetes should always include a full review of the patient to exclude progressive proliferative retinopathy, neuropathy, nephropathy and cardiovascular disease of a degree that would preclude the class of licence requested.

Since patients with diabetes mellitus that is well controlled by diet alone or by a combination of diet and oral medication are at minimal risk of either going into a diabetic coma or of having a severe hypoglycemic reaction, they can therefore usually drive all types of motor vehicles with relative safety provided they have a good understanding of their condition, follow their physician's instructions about diet, medication and the prevention of complications, and remain under regular medical supervision to ensure that any worsening of their condition or development of complications does not go undetected.

9.1.1 Class 5 - Private Drivers

Patients who require insulin to control their diabetes who are under regular medical supervision by an Endocrinologist or an Internist and who conscientiously follow their physician's advice particularly about diet, exercise and weight control can drive private and light commercial vehicles (class 5) without undue risk provided they have a good understanding of their diabetic condition and the close interrelationship between diet, exercise, and insulin demand. They must also have no history of severe hypoglycemic episodes or episodes of diabetic coma having occurred in the last 18 months. Severe hypoglycemia is defined as a hypoglycemic reaction that required outside intervention to abort, or one that produced a loss of consciousness. There must also be no history of impairment due to the abuse of alcohol or drugs.

9.1.2 Professional Drivers

Professional drivers with class 1 and 3 licences who operate heavy trucks over long distances can have great difficulty maintaining the essential balance between insulin dose, food intake, and physical exertion because they are often required to work long and irregular hours, travel long distances in the worst possible weather and perform unexpected heavy physical labour such as the application and removal of tire chains. To add to the problem truck drivers by the nature of their work are often unable to stop work if they become ill while on duty, even though an acute illness can make it very difficult for them to keep their diabetic condition under proper control. Their meal times may frequently be delayed and on occasions may have to be skipped altogether.

The Canadian Diabetic Association has recommended that diabetics treated with injectable insulin who hold commercial licences should observe the following guidelines for driving:

Guidelines Applying to the Initial Application for a Commercial Licence

1) Applicants must present records of the past 24 months of medical care.

2) Completion of a form by the applicant and by an Internist or Specialist in Diabetic Care is required (see appendix for copy of the necessary forms).

3) The applicant must supply a Certificate of attendance at a Diabetic Clinic.

4)A complete physical examination including full ophthalmological examination by an Ophthalmologist is required.

5) Laboratory tests. Two hemoglobin hbA1C are to be done six weeks apart and within the past 2 - 4 months.

6) Log of blood glucose measurements performed at least twice daily for the last six months or since diagnosis if onset of diabetes occurred in the last six months.

9.1.2.1 Professional Drivers Class 1 - 4

EXCLUSION CRITERIA

At this time it is felt unwise to licence insulin using diabetic drivers to operate passenger-carrying vehicles, emergency vehicles, or to carry hazardous goods and this will only be permitted under special circumstances and after stringent review. Professional drivers requesting class 1 or class 3 licence should comply with the recommendations of the Canadian Diabetic Association as follows:

THERE MUST BE:

1) No episode of hypoglycemia requiring the need for intervention by an outsider for correction within the previous two years, or producing loss of consciousness even if spontaneous recovery occurred.

2) No episodes of hypoglycemia appearing in the absence of warning symptoms ("Hypoglycemic Unawareness").

3) No uncontrolled diabetes with persistent severe hyperglycemia, ketosis, or ketoacidosis, or Hemoglobin A1c> 12%.

4)There must be:

· adequate self-monitoring, i.e.: frequent, daily home blood glucose measurements performed reliably,

· adequate knowledge of causes, symptoms and treatment of hypoglycemic reactions

5) No visual impairment or progressive proliferative retinopathy.

6) No clinically obvious peripheral neuropathy with loss of function.

7) No cardiovascular disease with arrhythmia, angina, or myocardial infarction within the last year.

8) No renal disease with serum creatinine in excess of 250 Micromoles/L.

Guidelines for the Annual Medical Recertification of Insulin Treated Individuals

All insulin-using commercial drivers are required to have an annual medical examination and re-certification. The required data will consist of:

· Medical records for the past twelve months.

· A complete physical examination including an examination by an ophthalmologist.

· Laboratory tests (HbA1C). Two tests at three months interval. Log of blood glucose measurements performed for last six months.

The exclusion criteria are the same as those that exist for the initial application for a commercial licence plus evidence of inadequate blood glucose monitoring during driving and non- observance of the guidelines for driving listed below.

Guidelines for Driving

1) Supplies required to be carried on their person at all times while driving include:

· Self-monitoring equipment.

· A source of rapidly absorbable glucose.

· Insulin and syringes/pump/injector.

2)          Blood glucose concentration must be tested within an hour before driving and approximately every four hours while driving. Driving should be stopped in presence of glucose values below 6 mmol/L (108 mg/dl), until glucose values have risen by food ingestion.

3)          Driving should be limited to a maximum period of 12 hours in the day, with a maximum of six consecutive hours between meals. The schedule of work to be adopted should be approved by the treating physician as compatible with the insulin regimen.

Physicians should be aware that the Medical Consultant's report only forms part of the material considered by the Superintendent of Motor Vehicles when making the decision to issue or deny a licence. The driving record of the individual forms an essential part of the material that is considered.

9.2 RENAL GLYCOSURIA

Patients with renal glycosuria can drive any type of motor vehicle safely.

9.3 HYPOGLYCEMIA

Patients who become faint or unconscious from spontaneous episodes of hypoglycemia cannot drive any type of vehicle safely. Those with milder symptoms, who have never lost consciousness or the ability to respond normally to external stimuli, can operate private vehicles without excessive risk but should not be recommended as fit to drive passenger-carrying or commercial vehicles until this problem has been overcome.

9.4 THYROID DISEASE

9.4.1     Patients with marked hyperthyroid disease should not drive until this condition has been corrected because of the frequent co-existence of cardiac symptoms, muscle weakness, and emotional disturbances.

9.4.2     Persons with severe untreated myxedema or cretinism should not drive. Those patients who respond well to treatment may be recommended for a road test, which is probably the most practical way of determining whether they have recovered sufficiently to drive safely.

9.5 PARATHYROID DISEASE

Patients with hypoparathyroidism with symptoms of muscular weakness and hypotonia should not drive. If their symptoms respond well to treatment they should be able to drive all vehicles without undue risk.

9.6 PITUITARY DISEASE

9.6.1 Posterior Deficiency

Patients with diabetes insipidus should not drive commercial or passenger transport vehicles until stabilized with treatment. It is safe for them to drive motor vehicles under careful medical supervision when treated unless visual disturbance or other disabling central nervous system symptoms develop.

9.6.2 Anterior Deficiency

Patients with Simmond’s Disease with spontaneous hypoglycemic episodes should not drive until fully treated. If it is possible to relieve their symptoms with treatment and prevent hypoglycemic episodes, it is safe to drive all motor vehicles.

9.6.3 Acromegaly

Patients with acromegaly or gigantism who have started to develop muscle weakness, pain, easy fatigue, visual disturbances, cardiac enlargement or intractable headaches should discontinue all driving. After full treatment, and if vision is satisfactory, all driving is safe.

9.7 ADRENAL DISEASE

9.7.1 Adrenal Cortical Hyperfunction

Patients with adrenal cortical hyperfunction (Cushing’s Disease) who have developed muscle weakness and osteoporosis should be advised to stop driving. If they improve after treatment, they may again be recommended for all vehicle driving, but must remain under close medical supervision.

9.7.2 Adrenal Cortical Hypofunction

Patients with adrenal cortical hypofunction (Addison’s Disease) should not drive if the destruction of their adrenal tissue is part of more a generalized disease such as tuberculosis or sarcoidoses. If the condition is due only to cytotoxic necrosis of the adrenal glands without systemic disease and their symptoms of hypotension and asthenia are well controlled by replacement therapy, they can drive a private motor vehicle (class 5), provided they remain under close medical supervision.

9.7.3 Hyperfunction of the Adrenal Medulla

Hyperfunction of the adrenal medulla due to the development of a pheochromocytoma with headache, dizziness, or blurred vision, is a contraindication to the operation of any type of motor vehicle unless these symptoms are completely relieved by removal of the tumor.

9.8 OBESITY

A grossly obese driver may not be able to respond rapidly enough to a sudden emergency situation and may not be able to operate the controls properly. If the examining physician feels that an obese patient might have difficulty driving safely, a road test should be recommended.

SECTION 10 – RENAL DISEASE

10.0 THE ROLE OF CHRONIC RENAL FAILURE IN DRIVING

Patients with chronic renal failure were, until quite recently, usually so incapacitated that questions about their ability to drive safely seldom, if ever, arose. However, since the advent of hospital and home based intermittent hemodialysis dialysis programs and the development of portable equipment for continuous peritoneal dialysis, such patients are now often able to continue driving.

10.1 INTERMITTENT HEMODIALYSIS

A patient with chronic renal disease who requires intermittent hemodialysis to maintain good health may not always be able to obtain a satisfactory dialysis at the required intervals. This could be due to a concurrent medical problem or, in the case of a person away from home, to being able to obtain a dialysis at the time one is required. At the present time, a person who requires intermittent dialysis and who wishes to drive more than one or two days distance from home, cannot do so safely without first making firm arrangements in advance, through his physician for dialysis at a conveniently located hospital. In British Columbia, unanticipated winter storms and blocked highways may defeat even the most carefully made plans.

10.2 CONTINUOUS PERITONEAL DIALYSIS

Patients with chronic renal failure who are able to manage the apparatus associated with continuous peritoneal dialysis by themselves, or with the help of the spouse, can probably drive more or less as they wish, limited only by their ability to carry or obtain a continuing supply of fresh dialysis fluid. The possibility of medical complications or difficulties with the dialysis procedure must, however, always be kept in mind.

10.3 RECOMMENDED DRIVING RESTRICTIONS

It is felt that persons with chronic renal failure, who are otherwise in good health, and who are on either intermittent hemodialysis or continuous peritoneal dialysis, can drive any class of motor vehicle safely. Patients on intermittent hemodialysis must be warned never to venture beyond the range of their customary hospital or home based dialysis unit without first making a firm appointment for dialysis elsewhere.

Patients on continuous peritoneal dialysis must have adequate replacement fluids and be knowledgeable about carrying out their dialysis procedures and seeking immediate assistance if problems should arise. All commercial drivers must be under the supervision of a Nephrologist or an Internist and are required to have an annual medical review by an Internist or a Nephrologist and their type of work must guarantee that they will be able to receive appropriate dialysis therapy. In making their plans to travel further afield, they must take into consideration unanticipated winter storms, blocked highways and the demands of their work.

10.4 PATIENT/PHYSICIAN/MOTOR VEHICLE BRANCH CO-OPERATION

There are many concurrent medical problems that can affect a person on dialysis. These can cause a temporary or even permanent inability to drive safely. Licensing of persons on dialysis, therefore, requires the closest co-operation between the patient and physician and between the physician and the Motor Vehicle Branch. The attending physician should notify the Motor Vehicle Branch's Medical Consultant immediately if a complication arises that could make driving hazardous.

10.5 RENAL TRANSPLANT

It is felt that persons who have had a successful renal transplant and who have fully recovered from their surgery can drive any class of motor vehicle. They should, however, not resume driving passenger-carrying or commercial vehicles for at least three months after their operation.

As with dialysis, regular ongoing medical supervision is a pre-requisite to safe driving because of the possibility of a delayed rejection or other medical complication. The attending physician should promptly notify the Motor Vehicle Branch's Medical Consultant of any deterioration in the driver's condition.

SECTION 11 – MUSCULOSKELETAL DISABILITIES

11.0 THE ROLE OF MUSCULOSKELETAL DISABILITIES IN DRIVING

Every driver must be able to carry out a continuing series of complex and well-coordinated movements in order to operate a motor vehicle safely. Truck and bus drivers must in addition have good muscular strength and full range of motion in both their arms and legs in order to handle these heavier vehicles.

A driver's ability to perform the required movements swiftly, accurately and repeatedly and without undue pain must be assessed very carefully, if there is any question of a physical disability, especially where the person wishes to drive a passenger-carrying or commercial transport vehicle.

11.1 THE PHYSICIAN'S ROLE

It is often impossible for a physician to give a fully informed opinion about a physically handicapped patient's ability to drive safely since some persons can compensate for a disability of an arm or leg much more effectively than others with an identical defect. A decision to grant or withhold a licence can therefore, in many instances, best be made by an experienced Driver Examiner following an extended road test.

The physician's role in the case of a physically handicapped patient is primarily to report the etiology, nature and extent of the disability and give an opinion as to whether it is temporary or permanent and whether it is stable or likely to be progressive. If the physical disability is secondary to brain damage it is important for the physician to examine and report on the other systems that might also be affected. Particular attention should be given to reporting possible visual field defects and reduced mental capacity.

11.2 VEHICLE MODIFICATION

Persons who have a disability of an arm or leg may be required to have their vehicles modified or fitted with special controls. The need for these can best be determined by the Driver Examiner on the basis of observations made during a driving test. If special controls are needed the driver will be restricted to driving vehicles so equipped.

11.3 DISABILITIES OF THE ARMS

Many persons with an amputation, paralysis or deformity of one arm are able to drive a private vehicle safely. Some patients with a below the elbow amputation who are fitted with an adequate prosthesis may operate any class of vehicle provided they demonstrate their ability to do so as determined by an Driver Examiner.

11.4 DISABILITIES OF THE LEGS

Persons who have a below the knee amputation of one or both legs are usually able to drive any class of motor vehicle safely provided they have full strength and movement in their back, hips and knee joints and have a properly fitted prostheses. Such patients must demonstrate their ability to drive to the satisfaction of the Driver Examiner.

11.5 DISABILITIES OF HAND OR FOOT

Persons with impairment of hand or foot function may drive any vehicle provided they demonstrate their ability to do so to the satisfaction of the Driver Examiner.

11.6 SPINAL DISABILITIES

11.6.1 Cervical Vertebrae

Some degree of loss of movement of the head and neck may be permitted but the driver should then be restricted to driving vehicles equipped with both right and left outside mirrors. Persons wearing a neck brace or cast should not be approved for driving until pain and restriction of movement are minimal and external support is no longer required.

11.6.2 Thoracic Vertebrae

Persons with a marked deformity or painful restriction of motion of the thoracic vertebrae are not able to drive large commercial transport or passenger-carrying vehicles safely. Their ability to drive private vehicles can best be determined by the Driver Examiner on an individual basis. Patients wearing braces or body casts must be evaluated on the basis of their freedom from pain on movement and the extent to which their cast or brace hinders their ability to operate the controls and turn their head and body to observe approaching vehicles.

11.6.3 Lumbar Spine

Applicants for a licence to drive a passenger transport or heavy commercial vehicle should be free of pains sufficiently severe to limit movement, attention or judgment. Less stringent standards may be applied to private vehicle drivers although this group may need to be restricted to driving vehicles with power assisted brakes.

11.7 PARAPLEGIA AND QUADRAPLEGIA

These patients should be referred for assessment to the Driver Assessment Program at British Columbia Rehab in Vancouver. On the basis of a favourable recommendation from a Medical Consultant in physical medicine and rehabilitation, they then may be given a learner's licence to permit them to take driving lessons in a vehicle fitted with especially modified controls to help them compensate for their disability.

Before being allowed to drive unaccompanied, these drivers are required to pass a test given by a specially trained Driver Examiner based in the Motor Vehicle Branch's Point Grey Office in Vancouver.   If licenced they are restricted to driving a private motor vehicle (Class 5) equipped with modified controls.

SECTION 12 – PSYCHIATRIC DISEASE

12.0 THE ROLE OF PSYCHIATRIC DISORDERS IN DRIVING

It is often extremely difficult to assess the hazard to driving caused by a psychiatric disability. Certainly, many disorders of the mind are not severe enough to advise a patient to stop driving, however, the presence of such symptoms as suicidal thoughts, extreme agitation, impulsive or violent actions, delusions or hallucinations may be very dangerous in a person in charge of an automobile. The advent of ambulatory long term drug therapy has created a new challenge not just because these drugs, when given in therapeutic doses can seriously impair driving ability, particularly, if they are combined with alcohol, but also because a patient's ability to drive safely is often totally dependent on the continued responsible use of the prescribed medication.

12.1 EMOTIONAL DISORDERS

Many otherwise normal people become highly emotionally disturbed during periods of severe stress. If the disturbance is severe enough to produce symptoms such as uncontrollable crying, serious depression, slowed psychomotor activity, pre-occupation, or the loss of a sense of caution and good judgment, these persons should be warned not to drive until a solution to their problem has been found and they have made a good recovery. The possible side effects of drug therapy should also be kept in mind.

12.2 ANTI-SOCIAL PERSONALITY DISORDER

Persons who have shown a complete disregard for accepted social values or who have a history of erratic, violent, aggressive or irresponsible behaviour have been identified by crash investigators as a potentially high-risk group. A pattern of living such as that described should be a cause of concern to the examining physician and patients with these characteristics should never be approved as medically fit without the most careful consideration.

12.3 PSYCHOSES

Initially most persons with an active psychotic illness will be hospitalized and should of course not drive any class of motor vehicle. At the time of discharge the attending physician will have to decide whether the patient has recovered sufficiently to drive safely again. The physician often faces difficulties in assessing the degree of patient insight that is a most critical factor in relapse prevention and self-awareness of driving abilities. In some cases a period of observation at home may be required before the physician can form an opinion. Particular attention should be paid to a recent history of suicidal tendencies, paranoid delusions, or violent and aggressive behaviour, since safe driving calls for a high degree of emotional stability, good judgment and social responsibility. The Medical Consultants to the Superintendent of Motor Vehicles may require detailed psychiatric reports before they will be able to make a recommendation to the Superintendent concerning the patient’s ability to drive safely.

A physician who is unable to persuade an acutely psychotic person to stop driving, either directly or through relatives, should notify the Superintendent of Motor Vehicles at once.

Persons who have had more than one acute psychotic episode present an especially difficult problem particularly when they are applying for a licence to drive a passenger transport or heavy commercial vehicle. As a general rule such patients should be limited to driving a private motor vehicle (class 5) for a six-month period free from further psychiatric problems before being considered for a commercial licence. At this time a further psychiatric report would be required, to be followed by an annual report for a period of ten years from their primary care physician, accompanied by a psychiatric opinion where the patient has the benefit of consultant care.

The advent of ambulatory long-term drug therapy has created a new and particularly difficult problem for both the attending physician and the motor vehicle licensing authorities because a patient's ability to drive safely is often totally dependent on their conscientiously taking antipsychotic medication in the dose prescribed over long periods and sometimes for life.

For a variety of reasons, many patients on long-term drug therapy stop taking their prescribed medication without their physician's knowledge and in due course, relapse into another psychotic episode. This raises the question as to whether it is in the public interest to licence patients on long-term antipsychotic drug therapy to drive passenger buses or heavy commercial vehicles and how best to monitor private vehicle drivers on drug therapy who have had repeated psychotic relapses.

12.4 PROGRESSIVE DEMENTIA

The physicians who act across Canada as Medical Consultants to the driver licensing authorities reached a consensus on the advice that should be given. This is contained in the National Safety Code for Motor Carriers and is as follows:

“Dementia is a clinical term describing what is usually a progressive and irreversible impairment of memory, intellect and personality and is most commonly due to degenerative cerebral disease or multiple strokes.” Dementia, as defined here, must be differentiated from dementia that is non-progressive, such as dementia from head injury, anoxia, mental retardation, tumour or stroke and from dementia that may be treatable and reversible resulting from hypothyroidism, drug intoxication and remedial intracranial lesions.

With documented dementia, the operation of any motor vehicle is risky. Individuals identified as possible dementia must have an assessment of their cognitive functions. The Mini-Mental Status Examination of Folstein M.F., Folstein S.E., McHugh P.R. - Journal of Psychiatry Res. 12:189, 1975, serves as a useful screening procedure and can be administered easily. This test has been standardized, can be given in a short period of time and has a numerical value that is helpful in the interpretation of the results.

Those individuals showing a score of less than 24 on this test are ineligible to hold a driver licence of any class pending complete neurological assessment. The ineligibility to drive applies during the time of further documentation that may confirm or deny the irreversible evidence of impairment of high mental function. Persons suspected of showing poor judgment, poor reasoning ability, poor abstract thinking and poor insight should also be evaluated for driving ability even if they have a Mini-Mental Status Examination score of 24 or higher".

In British Columbia, a road test conducted by a Driver Examiner from the Motor Vehicle Branch is considered to be part of the evaluation of the individual's ability to drive safely. This should be repeated on an annual basis as long as the driver wishes to continue driving.

12.5 ADVERSE REACTIONS TO PSYCHOPHARMACOLOGIC THERAPY

Most drugs used in psychiatric therapy have some effect on driving ability particularly when they are prescribed in high doses. These effects are greatly intensified when the drugs are combined with alcohol. The physician should never neglect to advise both the patient and a responsible member of the family of the possible effects of any medication prescribed on driving ability and if high doses are necessary, the physician should warn the patient not to drive at all. Patients who are receiving electro-convulsive therapy should not drive until their cognitive sensory and motor abilities have fully recovered after each treatment.

12.6 MENTAL DISABILITY

Intelligence level by itself is not a limiting factor in ability to drive a motor vehicle. In evaluating a person suspected of or proven to have mental disability physicians should endeavour to determine whether that individual is able to understand and respond appropriately to traffic signs and signals and whether he or she has the capacity to react quickly enough to demands of normal traffic situations. This is probably best carried out by subjecting the individual to a road test by a professional driving instructor, possibly after a series of driving lessons. Individuals may be able to cope with uncongested and slower rural traffic, but be quite unable to drive safely in heavy city traffic or on high-speed freeways. In these circumstances a conditional licence restricting the individual to driving under conditions that they can handle may be recommended. Physicians should also assess if there are difficulties with emotional control or attention span that may interfere with safe driving.

Individuals who appear to have borderline abilities in these areas may also be referred for psychological testing to further elaborate on their ability to drive safely.

As with other medical conditions, higher standards of intelligence must be expected of persons wishing to drive commercial or passenger transport vehicles class 1,2,3 and 4 because of the range and complexity of driving tasks involved.

SECTION 13 – DRUGS

13.0 THE ROLE OF DRUGS IN DRIVING

There are many drugs that are known to have the potential to impair the ability to operate a motor vehicle safely. The degree of impairment varies so widely from person to person however, that it is difficult to predict whether a disabling reaction will occur in any specific incidence. For each drug there is a safe or tolerable dose but more importantly there is an impairing toxic dose. Physicians who prescribe drugs that are known to have an effect on sensory mental or physical functions have a clear responsibility to warn their patients that the drugs prescribed may affect their ability to drive a motor vehicle safely. Patients must also be warned that alcohol potentiates the side effects of a number of drugs.

13.1 SEDATIVES

Applicants on mild sedation who experience no drowsiness can usually drive any type of motor vehicle without difficulty. Those individuals on heavier sedation for therapeutic reasons or who are known to be subject to substance use disorder should not drive any type of motor vehicle. Many sedatives and analgesics can be bought over the counter in modest dose form but can be used in sufficient quantity to achieve impairment, dependence or addiction. Suspicious drug seeking behaviour may be associated with substance use disorder and "double doctoring". Physicians should also be alert to supplementation with over-the-counter medication.

13.2 TRANQUILIZERS AND ANTIDEPRESSANTS

Patients placed on tranquilizers or antidepressants should be observed carefully during the initial phase of dosage adjustment and advised not to drive if they show any evidence of drowsiness or hypotension. Patients who are stabilized on maintenance doses can usually drive any class of motor vehicle if they are symptom free.

13.3 NARCOTICS

Euphoria or depression and loss of ability to concentrate that often follow the use of heroin, morphine, and some of the synthetic narcotics such as meperidine (Demerol) are potentially dangerous and this may warrant disqualification from operating any class of motor vehicle after assessment of frequency and habituation. Persons on a formal maintenance program of methadone, prescribed by a physician, are eligible for class 5 and 6 driver's licences, on recommendation from that physician.

Physicians should also carefully observe patients who are on long term prescribed analgesic medication and warn them not to drive if they appear to be drowsy or otherwise affected.

13.4 ANTIHISTAMINES AND MOTION SICKNESS DRUGS

Drowsiness and dizziness are frequent side effects following the use of antihistamines and medication taken to prevent motion sickness. Since it is impossible to predict whether these preparations will produce a reaction, persons using drugs of this type for the first time, should be warned not to drive until they learn from experience, whether they are prone to adverse reactions.

13.5 CENTRAL NERVOUS SYSTEM STIMULANTS

Although central nervous systems stimulants such as amphetamine or cocaine may initially increase alertness and efficiency, their effect is notoriously unpredictable. Major changes in mood and behaviour can occur. If this type of drug is being used the person must always be told not only about the possible initial hazards that are a contraindication to driving but also about the highly dangerous period of depression and fatigue that can follow their prolonged use.

13.6 HALLUCINOGENS

Drugs such as LSD, STP and MDA, and Cannabis and it derivatives impair driving ability because they can drastically alter perception.

13.7 ANTI-INFECTIVE AGENTS

Heavy doses of some anti-infective agents may cause drowsiness or loss of the sense of balance. Patients should be told of these possible reactions and warned about the danger of driving if they occur.

13.8 ANTI-CONVULSANTS

Some of the drugs used to control epileptic seizures can cause drowsiness in some patients particularly when first prescribed. Patients should therefore, be observed closely and warned not to drive as long as this side effect persists.

SECTION 14 – ALCOHOL

14.0 THE EFFECT OF ALCOHOL ON DRIVING

Alcohol induced impairment is the single greatest contributor to fatal motor vehicle accidents in Canada. A blood alcohol level of 50 mg/dl may cause sufficient loss of driving skills to create a menace on the highway. Persons with blood alcohol levels of 80 mg/dl are not permitted to drive any class of motor vehicles.

14.1 ALCOHOL DEPENDENCY

Alcoholism is a serious medical disability. An applicant requesting completion of the Driver's Medical Examination Report should have this disability reported on the form. The major medical criteria for the diagnosis of alcoholism are loss of control and compulsive behaviour related to alcohol ingestion, and the presence of clinical consequences of alcohol abuse.

The clinical consequences include liver disorders, pancreatitis, chronic gastritis, and in more extreme cases, evidence of organic brain damage. Blood disorders and vitamin deficiency are also frequently found. Dependency may include evidence of withdrawal symptoms such as autonomic hyperactivity, increased hand tremor, transient hallucinations, delirium tremens or withdrawal seizures.

A simple screening test for chronic alcoholism is the CAGE questionnaire that should be used routinely in any functional inquiry (see appendix). In addition, the alcohol use disorder identification test (AUDIT) is a ten question screening tool with the advantage of detecting both excessive drinking as well as symptoms of abuse and dependence (see appendix).

A variety of expert resources exist throughout the Province to assist physicians in the assessment and treatment of patients with substance abuse disorders. Physicians who require information regarding professional standards of care for addiction medicine should contact the Chair of the Alcohol and Drug Committee British Columbia Medical Association Council on Health Promotion.

14.2 THE EFFECT OF ALCOHOL DEPENDENCY ON OTHER MEDICAL DISABILITIES

Persons who have alcohol dependency frequently have other medical disabilities and are often unable to give their other medical problems the careful attention that are required. Alcoholism is complicated by:

14.2.1 Epilepsy

Some patients with epilepsy are prone to seizures if they miss their medication for even a day, particularly when this omission is combined with insufficient sleep, emotional turmoil, irregular meals, and alcohol. For this reason, patients with epilepsy are quite unfit to drive any motor vehicle if they frequently become intoxicated.

14.2.2 Diabetes

Patients with diabetes who are on insulin, have a special problem if they become intoxicated. Not only may they neglect to take their insulin at the proper time or be unable to inject the proper quantity, but also their food intake will almost certainly get out of balance with the dose of insulin injected. Whether this results in a hypoglycemic reaction or the slow onset of a diabetic coma is immaterial. In either case, such persons should not drive at all until they no longer drink to excess.

SECTION 15 – THE AGING DRIVER

15.0 THE EFFECTS OF THE AGING PROCESS ON DRIVING ABILITY

Although the rate of physical and mental decline varies greatly from person to person, the physiologic changes that accompany aging eventually affect everyone's driving ability. The borderline is often hazy between a decline that can be compensated for by long experience and voluntary limitation of driving and hazardous deterioration.

Many drivers as they grow older find it increasingly difficult to cope with the power and speed of the modern automobile and the progressively increasing traffic congestion on both urban and rural roads. Keeping in step with the traffic on high speed freeways requires all the concentration that many younger drivers are able to muster and could be the first thing that an older patient finds difficult.

15.1 MENTAL DETERIORATION

Slowed reaction time, lack of attentiveness, poor judgment and faulty attitudes are responsible for many crashes at all ages. These factors assume an increasing importance with advancing years and an older driver who is fit enough in a physical sense may be quite unable to drive safely on today’s crowded streets, because of the inability to keep his/her mind focused on driving or attitudes towards other drivers.

15.2 MULTIPLE PHYSICAL DEFECTS

An older person often has several minor physical defects, each of which if taken separately may not affect driving ability very much, but when taken together may be quite dangerous, particularly if these disabilities are accompanied by some slowing of ability to convert perception and judgment into timely action. See general debility section 17.

15.3 EXAMINING THE OLDER DRIVER

A physician who is asked to consider an older patient's medical fitness to drive may well be placed in a difficult position having been a trusted advocate over the years. The existence of conditional licences may be helpful. The patient’s physician can suggest a road test, or the Consultant at the Motor Vehicle Branch may require this to be done. Factors to be considered may include failing vision, slowing of perception, episodes of confusion and declining memory as well as physical factors such as loss of strength, arthritic joints, severe bronchitis, and the potential for sudden changes in heart rhythm. The possible side effect of prescribed drugs such as anti-hypertensive tranquilizers and barbiturates must also never be ignored.

The consumption of alcohol on a daily basis should also be queried as even small amounts, coupled with prescribed medication, can markedly influence the ability of the older driver to drive safely.

15.4 RESTRICTED DRIVING PRIVILEGES

Unless an injury or acute illness makes precipitate action necessary there may be no need to advise an older person to give up driving completely. Conditions may be suggested by the family physician or imposed by the Superintendent of Motor Vehicles restricting driving privileges in conditions such as long journeys, night driving, rush hour traffic, and high speed freeway driving. The Motor Vehicle Branch will endorse the driver's licence to indicate the restrictions recommended. See appendix form #DS0051.

15.5 PROGRESSIVE DEMENTIA

Discussion of this subject can be found in section 12.4. Physicians should note that it is a common occurrence for the Superintendent of Motor Vehicles to receive a report from the local Police describing several erratic and dangerous driving incidents that they have observed in older drivers. These reports should never be treated lightly when they are passed on to the family physician for information since they are factual, non judgmental and made by a trained observer.

SECTION 16 – ANESTHESIA AND SURGERY

16.0 THE EFFECTS OF ANESTHESIA AND SURGERY ON DRIVING

Both anesthesia and surgery can have a significant, although, temporary effect on driving ability. The surgeon and the attending physician must make certain that the patient has been warned not to drive until told that it is again safe to do so.

16.1 OUTPATIENT SURGERY

Patients undergoing outpatient surgery under general anesthesia should not drive for at least 24 hours following the administration of a general anesthetic. The pain and discomfort following even minor surgical procedures, may at times extend this period for several days longer.

16.2 MAJOR SURGERY

It is necessary to evaluate recovery after major surgery on an individual basis. The important thing is not to forget to tell the patient when driving may again be undertaken, in order to avoid an unsafe premature return.

SECTION 17 – GENERAL DEBILITY

17.0 GENERAL DEBILITY

When a patient suffers from General Debility, it is sometimes difficult to determine which symptom represents the dominant cause of ill health. Some physicians have requested guidance as to the specific cause that should be notified to the Superintendent of Motor Vehicles, or which section of this Guide should apply. For this reason, this section on General Debility   has been established. Symptoms of chronic fatigue syndrome, AIDS, malignancy, anaemia, and cognitive neuromuscular deficiencies come to mind, amongst others.

SECTION 18 – MEDICAL EXEMPTIONS FROM WEARING A SEATBELT

18.0 MEDICAL EXEMPTIONS FROM WEARING A SEAT BELT

There are no medical conditions that justify permanent exemption from using a seat belt.

SECTION 19 – MEDICAL STANDARDS FOR MOTORCYCLISTS

19.0 OPERATION OF A MOTORCYCLE

Operating a motorcycle demands a higher level of physical fitness and driving skill than driving a private passenger vehicle. Motorcyclists must frequently make decisions with lightning speed, often under driving conditions that are seldom faced by private vehicle drivers. Motorcycle operators (class 6) should, therefore, be expected to meet the medical standards for private vehicle (class 5) drivers in every respect. In doubtful cases there is less room for compromise and medical disabilities that might perhaps be overlooked in a private vehicle driver (class 5), may be quite incompatible with the safe operation of a motorcycle.

19.1 MEDICAL CONDITIONS

Medical conditions that can make driving a motorcycle hazardous and that should be looked for and evaluated with care, particularly in older patients are:

19.1.1 Depth Perception and Stereopsis

As long as motorcyclists cannot be dissuaded from weaving in and out of traffic in order to pass everyone in sight, good depth perception and stereopsis are very necessary.

19.1.2 Angina

Exposure to cold and cold winds can trigger an anginal attack in susceptible patients. Motorcycle operators who are known to be subject to angina, should therefore be evaluated with particular care and advised to avoid riding their motorcycle in cold weather.

19.1.3 Carotid Sinus Sensitivity

Carotid sinus sensitivity is a very dangerous condition in a motorcycle operator because of the tight restraining straps on most protective headgear.

19.1.4 Permanent Tracheostomy

Motorcyclist with a permanent tracheostomy must have some form of protection from the airstream fitted to their headgear.

19.1.5 Cerebrovascular Accidents

Patients who have had a C.V.A. should not resume driving a motorcycle unless they have made a complete recovery. They should not only have a full return of muscle power, but there must be no residual slowing of their thought process or loss of visual fields.

19.1.6 Intelligence

Persons of less than normal intelligence may lack the ability to make the quick decisions and execute the coordinated movements so necessary to the safe operation of a fast moving motorcycle. If the examining physician has any concern on this point, he should make his reservations known to the Motor Vehicle Branch and recommend a particularly careful road test.

19.2 MOTORCYCLE HELMETS

There are no valid medical reasons for recommending a medical exemption from wearing a motor vehicle helmet by either the driver or passenger.

APPENDIX

This Appendix contains examples of some of the forms that the Medical Consultants to the Motor Vehicle Branch may require to be completed in order to give a properly considered opinion on a driver's medical condition and it's relationship to driving ability.

There is also a copy of the conditional licence form used by the Consultants when appropriate and an expanded description of the driver licence classification.

A "job description" for a tractor-trailer driver that gives some idea of the work that they must be able to do, to which must be added the requirements of winter driving that occur in British Columbia is also provided.

JOB DESCRIPTION FOR AN OVER-THE-ROAD TRACTOR/TRAILER DRIVER

(Although a Truck Driver's job varies on a daily basis, this is a good average picture of the type of duties involved.)

Activity Summary

A driver's function in the overall trucking operation is to take loads from the consignor's door to the consignee's door. A single trip can be as short as 100 miles or as long as 3,000 miles. Enroute, the driver's day can include: securing the load, driving, filling out paperwork (keeping a log on kilometres, hours of services, expenses etc.), fueling, hooking up the electrical system, performing maintenance functions, and crawling in and out of the sleeper berth.

Work Environment

A driver typically spends 70-80% of the time in the Tractor. While driving, operators are exposed to varying traffic conditions, noise, and vibration caused by the engine, tires on the road, CB and radios. 20 to 30% of a driver's time is spent outside, exposed to dust, some diesel fumes, and the weather.

Driving Schedules

Drivers are available around the clock for trips to accommodate freight movement. A trip may require a driver to be away from home for as few as 8 hours or as long as one month. During the trips, a driver is allowed to drive a maximum of 13 hours in 24 hours. The driver may drive again only after having been off duty or in the sleeper berth for 8 hours. Some trips require continuous operation of the truck in order to meet customer requirements. This is accomplished by having one driver rest in the sleeper berth while the other drives. The company recommends that drivers drive no longer than 5 hours at a time in this type of operation.

Operating the Truck

Drivers are required to handle Tandem Tractor/Trailer equipment in all types of circumstances, including within a city, long distance highway travel, and maneuvering in the close confines of customer facilities. This activity involves unhooking the various tractor/trailer combinations, manually lowering and raising landing gear (gear capable of supporting trailers with 23,000 kg (50,000 pound loads), opening and closing cargo doors, and maintaining fuel, lubrication and coolant levels on tractors. While performing these duties, a driver spends 66-100% of the time: bending at the waist, neck, wrist and shoulders; twisting hands; twisting and rotating forearms and elbows. The driver may use hand tools during maintenance work.

Loading and Unloading

Drivers sometimes load and unload full trailers of freight weighing as much as 43.500 kg (96,000 pounds). This could involve accurately moving 45kg (100 pounds) bags or cartons to and from floor level to carts, stacks or platforms over one meter high, balancing 270 kg (600 pound) drums on their rims and rolling them into position, and accurately stowing cartons or tires overhead that weigh as much as 27 kg (60 pounds) each. This type of accelerated activity could continue after the driver has completed 13 hours of driving or unlimited hours of work. A driver typically spends 10% of his day standing and 30% walking (a distance of about 300 meters) on surfaces of concrete, wood and metal.

Tarping and Securing Freight

Drivers are required to secure freight in closed van trailers and on open top trailers. Securement may involve pounding nails and using straps and heavy chains. Drivers are required to tarp open-top trailers. This activity involves climbing to a height of 2-3 meters, balancing, and accelerated physical activity in awkward positions. Trailer tarps may be 9 meters long (30 feet) and 71/2 (24 feet) meters wide and weigh in excess of 45 kg (100 pounds) each.

Climbing In and Out

A driver may enter and exit his cab 8-10 times a day. Cab level is approximately four to six feet from ground level, with entry and exit achieved with the assistance of one or two steps and a handhold. Some deliveries or pick-ups require entering the trailer from ground level. The trailer floor level is approximately 1 1/2 meters (five feet) off the ground. Entry is achieved through the cargo loading doors with one step and no handhold