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The following content of the Guide for Physicians in Determining Fitness to Drive a Motor Vehicle, 7th edition, (1997) has been revised to include an update published in 2002, with changes as noted in the Section 7.3 on Seizures. The latest revisions, published in March 2006, are not incorporated here but are available on the Home page for viewing and printing as .pdf files. A new BC Guide is currently under development with expected publication in 2007. This website was prepared with the agreement of the
BCMA Emergency Medical Services Committee and the Office of the Superintendent of Motor Vehicles of British Columbia ************************************************************* GUIDE FOR PHYSICIANS IN DETERMINING FITNESS TO DRIVE A MOTOR VEHICLE 1997 A publication of THE BRITISH COLUMBIA MEDICAL ASSOCIATION 1665 West Broadway, Suite 115, Vancouver, BC V6J 5A4 The printed form of this document is produced and distributed by THE MOTOR VEHICLE BRANCH as a service to British Columbia Physicians. ©COPYRIGHT This information is protected by copyright. No part of it may be reproduced in any form without permission in writing from the British Columbia Medical Association. B.C.M.A. (Rev. 01/97) TABLE OF CONTENTS SECTION 2 – VISION SECTION 3 – HEARING SECTION 4 – CARDIOVASCULAR DISEASES SECTION 5 –CEREBRAL VASCULAR DISEASES SECTION 6 – PERIPHERAL VASCULAR DISEASE SECTION 7 – DISEASES OF THE NERVOUS SYSTEM SECTION 8 – RESPIRATORY DISEASES 9.0 THE ROLE OF METABOLIC DISEASE IN DRIVING 9.1 DIABETES MELLITUS 9.1.1 Class 5 - Private Drivers 9.1.2 Professional Drivers Guidelines for the Annual Medical Re certification of Insulin Treated Individuals 9.2 RENAL GLYCOSURIA 9.3 HYPOGLYCEMIA 9.4 THYROID DISEASE 9.5 PARATHYROID DISEASE 9.6 PITUITARY DISEASE 9.6.1 Posterior Deficiency 9.6.2 Anterior Deficiency 9.6.3 Acromegaly 9.7 ADRENAL DISEASE 9.7.1 Adrenal Cortical Hyperfunction 9.7.2 Adrenal Cortical Hypofunction 9.7.3 Hyperfunction of the Adrenal Medulla 9.8 OBESITY SECTION 10 – RENAL DISEASE SECTION 11 – MUSCULOSKELETAL DISABILITIES SECTION 12 – PSYCHIATRIC DISEASE SECTION 13 – DRUGS SECTION 14 – ALCOHOL SECTION 15 – THE AGING DRIVER SECTION 16 – ANESTHESIA AND SURGERY SECTION 17 – GENERAL DEBILITY SECTION 18 – MEDICAL EXEMPTIONS FROM WEARING A SEATBELT SECTION 19 – MEDICAL STANDARDS FOR MOTORCYCLISTS APPENDIX SECTION 1 – INTRODUCTION1.0 THE PHYSICIAN'S GUIDEThis Guide has been prepared by the British Columbia Medical Association to help physicians determine whether their patients are medically fit to drive a motor vehicle safely. Although the standards of fitness recommended are essentially the same as the standards found in similar Guides produced by the Canadian, American and British Medical Associations and the National Safety Code of Canada, suggestions from the specialty sections of the British Columbia Medical Association have also been incorporated. The major difference between the British Columbia Guide and those produced by the other organizations lies in the fact that this Guide offers the examining physician considerably more detailed advice than other similar publications. During the past thirty years many physicians have asked about the relationship between a number of the less common medical disabilities and driving safety. The more specific recommendations to be found in this Guide are offered in response to these inquiries. 1.1 BASIS FOR RECOMMENDATIONThere is still comparatively little scientific evidence available that can be used to assess the degree of impairment to driving that results from most medical disabilities; nonetheless scientific evidence is increasing. These recommended standards, therefore, are mainly empirical in nature and represent only collected expert medical opinions. They are intended to impose no more than common sense restrictions on drivers with medical disabilities. Every physician who examines a patient for the purpose of determining fitness to drive must always consider both the interest of the patient and the welfare of the community that will be exposed to the patient's driving. In the course of the examination, the physician should look not only for physical disabilities but should also endeavor to assess the patient's mental and emotional fitness to drive safely. Either a single major impairment or multiple minor defects may make it unsafe for the person to drive. 1.2 LEVELS OF MEDICAL FITNESS REQUIRED BY THE MOTOR VEHICLE BRANCHThe Motor Vehicle Act requires the Superintendent of Motor Vehicles "to be satisfied as to the fitness of an applicant to drive" before issuing a licence and provides the authority for the Superintendent to "require a licensed driver to be examined as to the applicant's fitness to drive". Fitness is considered to mean fitness in the medical sense. Although, the final responsibility for determining medical fitness is with the Superintendent by statute, great weight is placed on the recommendations of the British Columbia Medical Association as outlined in this Guide in determining whether a person is medically fit to drive a motor vehicle. The Superintendent requires a higher level of fitness from professional drivers who operate passenger carrying vehicles, trucks and emergency vehicles. These drivers spend many more hours at the wheel often under far more adverse driving conditions than do the drivers of private vehicles. They are usually unable to select their hours of work and cannot readily abandon their passengers or cargo should they become unwell when on duty. Professional drivers may also be called upon to undertake heavy physical work such as loading or unloading their vehicles, realigning shifted loads and putting on and removing chains. In addition, should a crash occur, the consequences are much more likely to be serious particularly where the driver is carrying passengers or dangerous cargo such as propane, chlorine gas, toxic chemicals or radioactive substances. Persons operating emergency vehicles are frequently required to drive while under considerable stress by the nature of their work, and often in inclement weather where driving conditions are less than ideal. This group, too, should be expected to meet higher medical standards than private drivers. 1.3 RESTRICTED AND CONDITIONAL LICENCESPatients with health problems that preclude full licensing may be recommended for a restricted licence or one that requires the driver to comply with certain conditions. Elderly drivers who have no single medical contraindication to driving but who show the early manifestations of a number of chronic conditions such as failing eyesight, slowed responses or a tendency to become confused in fast or heavy traffic may still be able to drive safely if they are restricted to familiar local streets or to driving only during daylight hours, perhaps at a reduced speed. Sometimes no freeway driving may be all that is necessary. Conditional licence's should be recommended whenever it is felt essential that a patient remain under close medical observation because of a chronic progressive disability or a medical condition that is prone to sudden and unpredictable relapses. Where a conditional licence is recommended the patient is required to agree to the conditions before a licence is granted and the attending physician may be asked whether he/she is willing to provide the medical supervision required to make driving safe. (See appendix for specimen form and examples of types of restriction that may be required). 1.4 DRIVER'S MEDICAL EXAMINATION REPORTIf, after completing a driver's medical examination, a physician is undecided about a patient's fitness to drive, consideration should be given to arranging for consultation with an appropriate specialist. A copy of the Consultant's report should accompany the medical form when it is returned to the Motor Vehicle Branch. Where no opinion is given or where the report differs significantly from previous reports submitted by other physicians or with statements made by the driver, the Superintendent of Motor Vehicles will ask the Motor Vehicle Branch's Medical Consultants for a recommendation. 1.5 REPORTING MEDICALLY UNFIT DRIVERSThe Motor Vehicle Act requires the attending physician to warn patients not to drive, temporarily or even permanently, if in the physician's opinion, it is unsafe for them to do so. If the patient disregards the physician's advice and continues to drive, the Act states: SECTION 221 “Every legally qualified and registered psychologist, optometrist and medical practitioner shall report to the Superintendent the name, address and medical condition of a patient sixteen years of age or over who a) in the opinion of the psychologist, optometrist or medical practitioner has a medical condition that makes it dangerous to the patient or to the public for the patient to drive a motor vehicle; and b) continues to drive a motor vehicle after being warned of the danger by the psychologist, optometrist or medical practitioner. It is important to note that the physician is not required to report unless, in his/her opinion, the patient has a medical condition that makes driving unsafe and, in addition, the patient continues to drive after being warned that it is unsafe to do so, but increasing numbers of physicians are reporting medical conditions even though they do not know if the patient is continuing to drive. The attention of physicians is drawn to the information letter issued by the Canadian Medical Protective Association in the winter of 1991, volume 6 number 1 where problems of certifying a patient's fitness to drive are discussed. Physicians are urged to use the Motor Vehicle Branch form "Report of a Medical Condition" (see appendix) in which they can state that their patient may have a condition that could make it dangerous for them to continue driving. The recommendation concerning the status of the licence then becomes the responsibility of the Medical Consultants working within the Motor Vehicle Branch. Physicians should use all their influence in urging a patient who has a medical condition that makes the patient an unsafe driver, to refrain from driving if the condition is temporary, and to surrender the driving licence if the condition is likely to be permanent. The name of the reporting physician is not released. However, all documentation contained in a driver file is now subject to the provisions of the Freedom of Information and Protection of Privacy Act. If a physician expects written communications to remain confidential this expectation should be explicitly mentioned in that communication. It should also be noted that no legislation presently exists in British Columbia protecting physicians from a lawsuit by a patient denied a driver's licence for medical reasons. A driver who is reported will have the licence cancelled immediately if the Superintendent feels the hazard to the patient and the public is extreme. In most instances, however, the driver will first be asked to have a Driver's Medical Examination Report completed by his family physician and no action will be taken until this more detailed report is received. 1.6 RESPONSIBILITY FOR DETERMINING ABILITY TO DRIVEAlthough the physician is asked to evaluate a patient's medical fitness to drive safely, the person's actual ability to drive may be determined by a Motor Vehicle Branch Driver Examiner through a driving test and the decision to issue or refuse a licence is made by the Superintendent of Motor Vehicles. A physician who is uncertain about the fitness of an elderly patient or someone with a significant physical or mental handicap should never hesitate to recommend a practical road test as another avenue for assessing fitness to drive. The situation may arise either when the physician is completing a medical examination that has been made as a result of a request to the patient for a medical report or in a situation where the physician finds himself/herself faced with the obligation of section 221 of the Motor Vehicle Act. The road test would follow the completion of the report and it’s review by the Medical Consultants in the Motor Vehicle Branch. (See appendix for forms 2351 and 2011) 1.7 REVIEW PROCEDURES1.7.1 A decision by the Superintendent of Motor Vehicles to refuse the class of licence applied for or to cancel or restrict a driver's licence for a medical reason cannot be overruled.The Superintendent is, however, always prepared to reconsider the decision on the request of the affected person. 1.7.2 A request for a review must be made in writing by the driver, not by the attending physician, and should be sent to the Superintendent of Motor Vehicles, Parliament Buildings, Victoria, BC V8T 5A3. The fee for the review is fifty dollars ($50.00) in advance, and payable to the Minister of Finance. 1.7.3 A physician who wishes to support a patient's request for a review should write to the Superintendent stating clearly the medical reason why the physician feels the patient should be granted the class of licence the patient has applied for or should not have the licence cancelled or restricted. 1.7.4 The review procedure is as follows: 1.7.4.1 The Motor Vehicle Branch's Medical Consultants are asked to make certain that the patient's medical file is complete and up-to-date and that the specific medical reason(s) why the licence was refused, cancelled or restricted are fully and clearly stated. 1.7.4.2 The patient's complete medical file together with all available supporting medical information is then sent for review to two physicians from the appropriate specialty, nominated by the British Columbia Medical Association. The reviewing physician may ask for additional medical examinations as well as additional laboratory or other tests before making a recommendation to the Superintendent. Any costs involved would be the responsibility of the patient (see 1.9). The Superintendent of Motor Vehicles will, in making a decision, take into consideration the opinions and recommendations received from each of the following: the attending physician and the Consultants who have seen the patient, the British Columbia Medical Association as set out in the Guide to Physicians, the Motor Vehicle Branch’s own Medical Consultants and the two independent medical specialists who reviewed the patient's medical file. The Superintendent will determine what weight to give to the recommendations received from each of the groups named in the proceeding section and is responsible for making the final decision. 1.8 CHANGES TO THE PHYSICIAN'S GUIDEPhysicians who disagree with the medical standards in this Guide, or who find the Guide to be ambiguous or feel that it does not address a medical problem adequately are invited to write to the Chairman of the "Medical Guide to Driving" committee through the Association's offices in Vancouver. 1.9 PAYMENT FOR MEDICAL AND LABORATORY EXAMINATIONSPATIENTS ARE RESPONSIBLE FOR PAYING FOR ALL THE MEDICAL REPORTS AND LABORATORY EXAMINATIONS CARRIED OUT FOR THE PURPOSE OF OBTAINING OR RETAINING A DRIVER'S LICENCE EVEN THOUGH THESE EXAMINATIONS OR TESTS MAY HAVE BEEN REQUESTED BY THE SUPERINTENDENT OF MOTOR VEHICLES. THESE EXAMINATIONS ARE NOT COVERED BY THE BRITISH COLUMBIA MEDICAL PLAN OR PAID FOR BY THE MOTOR VEHICLE BRANCH. 1.10 ROUTINE MEDICAL REPORTSIn British Columbia, all licence drivers are required to have a medical examination and submit a medical report at the ages shown below:
1.11 CLASSES OF DRIVERS’ LICENCESBritish Columbia drivers’ licence's are divided into classes and permit the holder to drive the type(s) of motor vehicle, that fall within that class. SECTION 2 – VISION2.0 THE ROLE OF VISION IN DRIVINGGood visual function is essential for safe driving and any significant loss of a visual function such as visual acuity or field of vision, cannot help but diminish a person's ability to operate a motor vehicle safely on today's congested high-speed roadways. A driver with a marked visual defect may fail to perceive a potentially dangerous situation altogether or see it too late to avoid a crash. The loss of visual functions, such as colour vision or depth perception, is not generally felt to be too hazardous and can usually be compensated for quite adequately. The physician should, however, always make a point of telling the patient about the nature and extent of these disabilities if they are detected during an examination. 2.1 VISUAL ACUITYA driver's visual acuity must at least be such that he or she has time to read, understand and act on standard traffic control signs while moving at the maximum posted speed, not only in daylight but also in darkness. 2.2 FIELD OF VISIONAn adequate field of vision is as important to safe driving as is good visual acuity and any marked binocular field defect can make driving dangerous. The most common ocular causes of visual field loss are glaucoma, retinal, and neurological disorders. If a field defect is suspected the patient should be evaluated by either a 1) Goldmann Field with lll3e test object or 2) Humphrey 120 or 246 point screening field. 2.2.1 HemianopsiaBoth a complete homonymous and a bitemporal hemianopsia are incompatible with driving a motor vehicle of any class. 2.2.2 QuadrantanopsiaA complete homonymous superior or inferior quadrantic field loss is also incompatible with safe driving. An intact field in the right superior quadrant is essential in order to check the vehicle "blind spot" before making a lane change to the right. Similarly, an intact field in the left inferior quadrant is necessary in order to check the vehicle "blind spot" before making a lane change to the left. However, if the field extending from about 10 degrees above to 10 degrees below the horizontal meridian remains intact, it may be possible to operate a private (class 5) vehicle without undue hazard provided the driver avoids congested streets and high rates of speed. 2.2.3 ScotomaThe effect of an area of reduced vision (scotoma) in the visual field on driving safety depends on the size and location of the lesion. A large central scotoma, such as occurs in age related macular degeneration, will result in the patient being unable to pass the required test for visual acuity. Paracentral scotomas, that are large or dense, as in glaucoma or retinitis pigmentosa, can be extremely hazardous, especially when they occur in the horizontal meridian, especially if they are overlapping in the two eyes. Unfortunately, paracentral scotomas may not be detected by routine visual field procedures, indeed in such cases central vision may be deceptively good. 2.3 RECOMMENDED VISION STANDARDS2.3.1 Visual AcuityMinimum Corrected Visual Acuity Recommended
2.3.2 Horizontal Field of Vision
2.4 MONOCULAR VISIONSeveral recent studies have shown that one-eyed drivers with no useful vision in the other eye have significantly more accidents than persons with binocular vision. Since a person with monocular vision normally loses about 40 percent of lateral vision, perception delays occur due to the driver having to scan the blind area periodically with the central vision of the good eye. In one study, the time needed for perception of an object using one eye was about twice that needed using two eyes. A one eyed driver is also particularly susceptible to the effect of glare from oncoming headlights when traveling at night, since monocular drivers can not avert their central vision and at the same time, maintain the required periodic watch on their enhanced blind spot. The risk of a one eyed driver temporarily losing adequate vision due to a foreign body or infection can also not be ignored. >For these reasons, one-eyed drivers should not be recommended for licensing as class 1,2,3 or 4 drivers. 2.5 COLOUR VISIONThe inability to discriminate between red and green is not considered to be an important driving hazard for private (class 5) vehicle drivers now that the position of traffic lights has been generally standardized. The very limited number of patients with severe colour vision deficiency whose visual acuity is also affected should of course not drive. Since the consequences of an accident, should one occur, are likely to be much more serious, it is felt that persons driving passenger-carrying vehicles and large trucks (classes 1,2 and 4) should have sufficiently well developed colour vision to be able to discriminate between red, amber and green traffic signals. In British Columbia, the Motor Vehicle Branch tests every applicant for a driver's licence for colour vision deficiency using standard traffic signal light lenses in order that all drivers who lack this visual function may be made aware of their deficiency. 2.6 CONTACT LENSESProfessional drivers (classes 1,2,3 and 4) who need corrective lenses to meet the recommended vision standard are required to pass the Motor Vehicle Branch's vision screening test while wearing spectacles, and to carry their spectacles with them at all times while driving even though they normally wear contact lenses. The reason for this requirement is that they may have to remove their contacts while at work due to ocular irritation and without spectacles will not be able to meet the vision standards. 2.7 TELESCOPIC SPECTACLESTelescopic spectacles and similar low vision aids provide central magnification at the cost of a reduced paracentral field. A ring scotoma, a nearness illusion, displacement of the magnified image in a direction opposite to head movements, the effect of vibration at high magnification in reducing resolving power and fatiguing altered head posture, all add to the difficulty of seeing oncoming traffic and pedestrians in time to take corrective action. It is felt, therefore, that the use of telescopic spectacles and similar devices is quite incompatible with safe driving. 2.8 OCULAR MUSCLE IMBALANCEA mild degree of ocular muscle imbalance, when there is no diplopia within the central 60-degree of gaze is not a particular cause for concern. A greater imbalance, however, can be complicated by intermittent diplopia or suppression of central vision in one eye. Applicants who have either of these symptoms should be referred to a vision specialist for an examination before completing the Driver's Medical Examination Report. If the visual acuity in the unaffected eye is adequate, diplopia may sometimes be compensated by the use of an obscuring lens on the affected side in the case of class 5 drivers who are permitted to have monocular vision. Patients with diplopia, that can be corrected with prisms, are eligible for any class of licence. 2.9 DEPTH PERCEPTIONAutomobile crashes sometimes occur because of the driver's inability to judge distances accurately. Judging distance is, however, a skill, that can be learned, even by persons with monocular vision, based on clues such as the relative size or interposition of objects and clearness of details. A more refined form of distance judgment called stereopsis, based on binocular parallax (viewing an object from two different angles), is also possible if the patient has binocular vision. However, stereopsis, which is important in backing or parking maneuvers in tight spaces, ceases to be useful beyond about 75 feet and is thought to play only a small part in safe highway driving. A road test is the most practical way of evaluating depth perception since most instruments purporting to test for depth perception actually test for stereopsis. There are, at present, no specific standards that drivers are required to meet and the test for stereopsis carried out by the Driver Examiner is only for the purpose of making those drivers who are deficient in this function aware of their difficulty so they can make allowances in their driving. A driver who has recently lost the sight of an eye may require a few months to recover the ability to judge distances accurately. 2.10 DARK ADAPTATION AND GLARE RECOVERYThe ability to adapt to decreased illumination and recover rapidly from exposure to glaring headlights is of great importance for night driving and the partial loss of these functions in elderly patients, particularly patients with cataracts or macular disease, may at times justify limiting their driving to daylight hours. However, accurate testing procedures for these two functions are not generally available and the state of present knowledge does not yet permit formal standards to be set. 2.11 DRIVING FOLLOWING THE REMOVAL OF A CATARACTOUS LENSPatients who have had a single cataractous lens removed and who are dependent for sight on the operated eye alone will not usually have a sufficiently wide field of vision to qualify for any class of driver's licence with spectacle correction but may after full recovery, qualify for a private vehicle (class 5) licence if they are able to wear contact lenses or have had an intra ocular lens transplant. The surgeon who removed the cataract should advise patients individually when it is safe for them to resume driving. Since there may be periods when contact lenses cannot be worn because of ocular irritation it is unsafe for professional drivers (class 1,2,3 and 4) to rely on contact lenses alone to correct a visual field defect following the removal of a cataractous lens. A few patients too, who have been deprived of vision from one eye for long periods may not regain full binocular vision after otherwise successful cataract surgery. These patients may also complain of diplopia and require occlusion of the poorer eye while driving. 2.12 PATHOLOGIC LESIONS WITHIN THE EYE2.12.1 Asymptomatic LesionsPatients with the early manifestations of pathologic lesions within the eye, such as pigmentary degeneration of the retina, macular degeneration, and optic nerve atrophy or arteriosclerotic, hypertensive or diabetic retinopathy, may continue driving as long as they can meet the requirements for visual acuity and field of vision. They must, however, be followed very closely so that a worsening of their condition does not remain undetected, particularly if they are professional drivers (class 1,2,3 and 4). 2.12.2 GlaucomaPatients with glaucoma who require medication that interferes with the physiologic response of their pupils to varying light intensities may have considerable difficulty driving after passing other vehicles at night. In such cases they should be advised to limit their driving to daylight hours only. Professional drivers (class 1,2,3 and 4) who are being treated for glaucoma should also have their visual fields evaluated by formal testing if there is any question that this visual function is affected. 2.13 OCULAR CONDITIONS ASSOCIATED WITH SYSTEMIC DISEASES2.13.1 DiplopiaPatients who are subject to periods of fluctuating diplopia as a symptom of a systemic disease such as myasthenia gravis or as part of the aura of migraine, cannot drive any type of vehicle safely until this symptom has been fully controlled by treatment. Transient attacks of diplopia, that may occur, for example, in vertebrobasilar insufficiency are also incompatible with safe driving especially if they can be brought on by movements of the head and neck. 2.13.2 PtosisPatients with a fixed ptosis can drive safely provided both lids do not obscure the pupil and the applicants are able to meet the standards for visual acuity and field without having to hold their head in an abnormal position. 2.13.3 NystagmusApplicants with nystagmus can drive any class of vehicle provided they can meet the standards for visual acuity and field of vision. 2.13.4 Field DisordersA partial loss of a visual field may occur as a complication of a cerebral vascular disorder. Following a stroke, it is by no means unusual to have virtually full recovery of motor and sensory functions with a significant residual field defect, that remains undetected without a careful examination. It should be noted that a task force of the Canadian Ophthalmological Society has been struck with a view to setting some national standards for driving. SECTION 3 – HEARING3.0 THE ROLE OF HEARING IN DRIVINGThe effect of impaired hearing on driving safely is still controversial. The best available information suggests that totally deaf private vehicle drivers (class 5) do have an increased accident risk but unfortunately there is no reliable data available to show how great the hearing loss must be before an increase in the accident rate of hearing impaired drivers is detectable. There are so few drivers with impaired hearing employed as operators of cargo transport or passenger-carrying vehicles, that there is no reliable data either to support or refute the ability of persons with reduced hearing to drive commercial vehicles safely. Passenger bus and taxi drivers must be able to hear well enough to talk to their passengers. For the passengers’ safety it would also seem reasonable to expect that bus and taxi drivers should be able to hear well enough to detect external warning sounds such as sirens, horns, or bells. Truck drivers on the other hand, even with normal hearing, often have great difficulty detecting any warning sounds coming from outside of their cab because of the noise of the engine and the sound proofing that is found with increasing frequency in modern truck cabs. This has led some people to conclude that total deafness would present no safety hazard. Experienced drivers, however, have expressed the opinion that the ability to hear does help them with the driving task and have been reluctant to support the position that a totally deaf driver can drive just as safely as a driver who has at least some hearing. Until better experimental data is available, it would seem prudent to accept the advice of these drivers and recommend that totally deaf persons not be licenced to drive large trucks (class 1 and 3). 3.1 RECOMMENDED HEARING STANDARDS3.1.1 Private and Light Commercial VehiclesThere is insufficient available data to justify setting a minimum level of hearing for the drivers of private and light commercial vehicles (class 5). 3.1.2 Passenger Buses and TaxisWhile some loss of hearing may be acceptable, it is felt that in the interest of passenger safety, a totally deaf person should not operate a passenger-carrying vehicle. Both bus and taxi drivers should at least be able to hear what their passengers are saying to them without having to turn their head and take their eyes from the road. The driver should also be able to hear the siren on approaching emergency vehicles and warning signals at railway crossings. To meet these criteria, the following standards are recommended: 3.1.2.1Taxicab Drivers (Class 4): who limit their driving to vehicles carrying no more than nine passengers should not have a corrected hearing loss greater than 40 decibels, averaged at 500, 1,000 and 2,000 Hz in their better ear. 3.1.2.Passenger Bus Drivers (Class 2 and 4): persons who drive passenger buses should not have an uncorrected hearing loss greater than 40 decibels, averaged at 500, 1,000 and 2,000 Hz in their better ear. 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 LOSS3.2.1 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 AIDSHearing 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 DISORDERSA 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 DISEASES4.0 CARDIOVASCULAR DISEASESThere 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:
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:
For Supraventricular tachyarrhythmias:
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 DISEASEGeneral 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 RHYTHM1. 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:
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
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:
4.1.C VALVULAR HEART DISEASE1. 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
Commercial driving: Waiting period six months
b) Aortic bioprostheses, mitral bioprostheses or valvuloplasty in patients with sinus rhythm Private driving: Waiting period six weeks
Commercial driving: Waiting period three months
4.1.D CONGESTIVE HEART FAILURE, LV DYSFUNCTION, CARDIOMYOPATHYPrivate 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
4.1.E HYPERTROPHIC CARDIOMYOPATHYPrivate driving: No associated cerebral ischemia Commercial driving: Functional Class I
4.1.F CONGENITAL HEART DISEASENo 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 TRANSPLANTATIONPrivate driving: Waiting period two months Commercial driving: Waiting period six months
4.1.H CARDIAC INFECTIONSPatients 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 PRESSURE4.2.1 HypertensionHypertension, 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 HypotensionHypotension 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 ANTICOAGULANTSAlthough 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 DISEASES5.0 THE ROLE OF CEREBROVASCULAR DISEASE IN DRIVINGEarly 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 ATTACKS5.1.1The 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 ACCIDENTSPatients 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 DISEASE6.0 ARTERIAL ANEURYSMAn 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 DISEASESReynaud'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 VEINSPatients 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 SYSTEM7.0 THE ROLE OF THE NERVOUS SYSTEM IN DRIVINGEvery 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 CONVULSIONSA 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 SYNCOPEA 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 SEIZURESNote 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 DISORDERSThere 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 NarcolepsyAlthough 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 ApneaPatients 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 CONTROLLoss 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 PAINSevere 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 INJURIESDrivers 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 TUMORSA 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 DISEASES8.0 THE ROLE OF RESPIRATORY DISEASES IN DRIVINGSome 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 DISEASEDriving 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 TRACHEOSTOMYA 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 DISEASES9.0 THE ROLE OF METABOLIC DISEASE IN DRIVINGDisturbances 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 MELLITUSA 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 re |