I think this is the section where you're going to really start seeing a lot of the, you know, considerations may include, which are going to be repetitive throughout the next seven modules, well, six modules. You're going to see a lot of, this is the condition. Use your judgment. So, we'll try our best, but I think, unfortunately, it's not what anybody really wanted. This is cardiovascular and hypertension. Starting, as always, with the questions. Questions are basic. Do you have or have you ever had? The have you ever had is a really important question because the knows. It says, I mean, one thing, the not sures bother me. Do you not know if you've ever had a heart disease? Do you not know if you've ever had a high blood pressure? And, again, it is not a do you currently have. It is a have you ever had. Also, when you're looking at the have you ever had a shortened medical certificate, not sure. To me, I always read a not sure as yes, and I ask for information. So, that's how I look at that. Now, blood pressure, read it carefully. Physically qualified to drive a commercial motor vehicle if they have no current clinical diagnosis of high blood pressure, likely to interfere with safe operation of or the ability to operate a commercial motor vehicle safely. Doesn't have any numbers in it. There have never really been numbers in the blood pressure standard. We all, not we all, but many of you are aware of the old 140 over 90 and the disqualified 180 over 110. And you may have seen the 2013 medical expert panel report that said, oh, no, no, no, no. These are the new blood pressure guidelines. And you may have seen, I think it was a 2021 draft that had all new blood pressure guidelines still using the old medical advisor criteria. But lo and behold, we now have the new and revised old medical advisor criteria from 2000 and never. It says hypertension unlikely to interfere. That's okay. We know that. Guidance on the stages is based on Federal Motor Carrier Advisory Panel from 2002. And it was adopted from the 6th. Not 8, not 7, but the 6th back from 1997. So these are our blood pressure guidelines. Doesn't mean it's absolute and doesn't mean you have to follow. But as Dr. Berneking said, if you decide not to follow, this is one of those you probably need to document why you're not. So what does it tell us? The old 160 over 90. 140 over 90 is good. If it is between 140 to 159, over 90 to 99, that's low risk. But you can give them one year. If they come back and it's less than 140 over 90, then you can give them the two year after that. If they come back and it's still above, you can give them three months, one time, theoretically one time. However, if you look at the old handbook, it says the one time, three months is discretionary. So remember, this is advisory. So they bring the blood pressure down, but it's not less than 140 over 90. And you want to go ahead and give them three months and they come back and it's now really, really close. And they've seen their doctor. There's nothing saying you can't give them a second three months. That was advisory. On the other hand, if it's been three months and they haven't gone to their doctor at all, maybe you don't want to give them a second three months. So this is where that common sense comes in a little bit. It also is there's no right answer. They're going to examine you and say, three months, you're not there, forget it, get lost. Blood pressure 160 over 179 is stage two. And this one gets a one time three month certification to bring their blood pressure less than or equal to 140 over 90. It is 140, boom, and 90, boom. It is not both of them have to be in the bad range. They both have to be that you look at both of them. If either one of them is out of the, quote, acceptable range, the guidance, you hear the emphasis, is this is what you do. Use your common sense. Document if it's different. Now, they also talk about 180 over 110 is being at much higher risk of having an event and putting the person at risk of impairment. And therefore, the recommendation is at 180 over 110, you disqualify them. That might be a reasonable thing to do. The blood pressure should be less than 140 over 90. And once it's less than 140 over 90, then it's that you can qualify them for six months and six months every thereafter. Now, what happens if it was 180 over 110 and now all of a sudden it's down at one, I don't know, let's say 42 over 94? Might you give them something? Yeah, you might. That's guidance. If they haven't seen their doctor at all, would you give them anything? Probably not. But this is what the advisory criteria, you should definitely consider it and probably follow it, but it's not absolute. If the examiner doesn't know what the blood pressure was when they started out, you know, you're just the first person I've ever seen you. I know you have high blood pressure. I don't know whether or not it was in the 180 over 110 range or if it was down at the 160 over 95 range. The recommendation there is one year if you're not sure, which is good because you don't want to have it for six months for everybody. Talks about medications and treatments. Some of the treatments have side effects, which may cause sedation. So it's important that an examiner evaluate the medications the individual is taking to see if it causes unacceptable side effects. That should be kind of common sense with any medication regardless of the treatment. Whether it's for hypertension, diabetes, cardiovascular disease, neurologic disease, schizophrenia, anything it might be, one of the big pieces is what are the potential side effects. You're dealing with one potentially sedating drug, that's one situation. Two potentially sedating drugs, that's a different situation. Three potentially sedating drugs, you may have to think about this one totally differently. This is why we go back to the Med A is not good but not horrible. Med B is not good but not horrible. Med C, same thing. By the time you get to that combination, it may not be safe for that individual to drive. That is an individual assessment. So for high blood pressure, looking at whether or not these medications may cause problems. They also may lead to syncope because the person may have their blood pressure drop so low that they pass out. So are they stable on that medication or not? Have they had episodes of hypotension on that medication or not? And then secondary high blood pressure, that's due for things like pheochromocytoma, renal artery stenosis. You evaluate them giving the same criteria and then they may need surgery, they may need some other intervention. But you look at them from the same number, guidelines, should, but. Wriggle room. One of the things they talk about is blood pressure taken during the exam is the criteria to be used. So I love the, I have white coat hypertension, I get nervous, I'm coming in for my certification exam. Dot, dot, dot. I'm about five foot two. If I scare you, you've got a bigger problem than that. Because you're going to be driving on the highway with a lot of people who don't know how to drive very well. You're going to be hauling hazardous material that may blow up behind you. You may be trying to know that you have to get to point B by X time or your income, your compensation for that trip you just run gets dropped down. You've got to get because if you don't get there by a certain time, there's no one to help you unload that load. So if looking at me and being afraid of me is going to stress you, I'm worried about you driving in the ice and snow and other adverse weather conditions. That's hypertension. Basically, it's common sense. Is the person, does the person have high blood pressure? Yes. Does it need to be monitored? Well, yeah. They're going to their doctor probably at least once a year if it's stable and controlled. Are there medications that can cause side effects that make them unsafe to drive? Absolutely. So that's what you've really got to decide. Generally, it's a one-year recertification. One of the few places they actually give us a recommended certification duration. Now we're moving on to cardiovascular. This is one of my favorites. Because if you really read it and think about it, it doesn't say much of anything. A person is physically qualified to drive a commercial motor vehicle if that person has no current clinical diagnosis of myocardial infarction. If they're infarcting in my office, I'm not going to qualify them. Angina pectoris, same thing. Coronary insufficiency, thrombosis, or any other cardiovascular disease of a variety known to be accompanied by. Syncope, dyspnea, collapse, or congestive cardiac failure. I think that's almost every cardiovascular condition that may be accompanied by. But how likely may it be accompanied by? And how serious may it be? And that now is all up to us. So current clinical diagnosis, current diagnosis, doesn't matter whether it's stabilized or not. It falls under this regulation. And known to be accompanied by is defined, and I love defining a word with the same word, is accompanied by or is likely to cause. That hasn't really helped me. It's likely like a 10% or a 75% likely to. That's where we've got to use our medical judgment. That's where you've got to decide, is this person, yeah, they're not going to have a problem with it, but maybe in the remote when it gets worse. Or, hey, this person has really severe aortic stenosis. They're at really high risk of significant arrhythmia or significant death. Coronary artery and pacemaker insertion are remedial procedures, and they're okay. Then, one of the very, very few, implantable defibrillators or cardiovascular defibrillators are installed to address an ongoing underlying cardiovascular condition and are likely to cause syncope or collapse as a result of the underlying condition and as well as when they discharge, and therefore are probably not reasonable for being certified. And we'll talk about exactly where it says that in the handbook. Likely not to be, and there's always a but. Anticoagulation therapy, look at the underlying medical condition and determine whether or not that person has a problem. It used to be that if they had cerebrovascular disease and were on an anticoagulant, you didn't want to qualify them. Now it's look at the situation and understand what anticoagulant are they on. We're not using warfarin as we did in the past. It's a little bit different. Is there still a risk of bleeding? Absolutely. Is that an acceptable risk? Maybe. Do you want to talk to their treating provider if you're concerned? Absolutely. So again, it's really not an absolute, but it's thinking. It's using medical knowledge and medical judgment. When you go through the medical examiner handbook, it lists a whole bunch of cardiovascular conditions. There are essentially no waiting periods. There are no duration of certification. And the common statement is ME must evaluate on a case-by-case basis to determine whether the individual meets the cardiovascular standards. Now remember, what is the cardiovascular standard? That one right there. What we have is some really nice parameters which should have been starting points, but examiners, employers, and TPAs kind of took them as must, and that's why we're at right now, which is where we probably should have been all along to some extent of using what's current. What's the best way to stay current with what we should do on these examinations? Attend an update on cardiovascular disease, on diabetes. What's the current best practice? What is the risk of incapacitation from this condition? That's your best way of knowing whether or not the person should be qualified. Other information. Fundamental testing of the cardiovascular assessment to establish whether the person has a cardiovascular disease accompanied by or likely to. Get information from the treating provider, as well as the individual. Evaluate the physical, psychological, and environmental factors, and certification depends on a judgment of everything. FMCSA says you've got to use your clinical judgment. This is one of those heart and bum thoughts that if you don't understand the diagnosis, prognosis, treatment, potential complication, and so forth of a given medical condition, you don't have sufficient knowledge to make that risk assessment. Is that person safe to drive that bomb, that tanker truck on public highways? These are all the medical conditions that are listed. You may note that it starts on page 28 and goes all the way down through page 42. Sounds like a lot, but it's the same words on every page. Just about. General statements. Has the treatment been shown to be adequate, safe, and stable? Well, that should be common knowledge when you're looking at an employee or a patient. Whether the individual has been evaluated and treated by a cardiovascular specialist. Well, depending on where they're located. If they're in New York City, yeah, they're probably a cardiovascular specialist that are like, yeah, I'm not dealing with this. I'm going to refer them. And then you're up in northern Maine where there's nobody for miles and miles and miles. So again, do they really need to be seen by a specialist? Maybe. Has the etiology been identified? Why do they have cardiomyopathy? Why do they have an EF of 20%? Well, that may impact whether or not I'm going to say, you're disqualified, don't ever come back, or you're disqualified, why don't we see you in about six months and maybe things will stabilize. Or maybe they have some kind of alcohol use disorder and that's what caused their cardiomyopathy. And you want to think about that as well. Are they still symptomatic? Well, if they're still symptomatic and short of breath and having dizziness and having palpitations, may not be stable enough to put them in behind a truck. And have they demonstrated compliance with ongoing treatment plan? Those questions you can take and put for every single medical diagnosis with only a word or two changes. So that's basically your starting point. You then have to use your medical training, medical knowledge of, is this person safe enough? And this is all a risk assessment. Abdominal aortic aneurysm, what do they tell us? Well, the risk of rupture increases if the aneurysm increases in size. Monitoring may be advised or is advised. They don't tell us what that magic number is because there is no magic number. Talk to the surgeon, talk to the cardiovascular specialist. Is surgery recommended and the patient refuses? Well, to me, that's a risk, that's a problem. Mike, are you looking for something? Can I take away a page that you need it? It's in Module 1. So the question is, is the surgeon saying I need to operate and the person saying no? Is the surgeon saying, you know what, you've been at this measurement for the past 10 years, we're going to keep on following you, maybe that number's okay. So this is where it goes back to the magic number shouldn't be a magic number. You've got to work with the specialist. For the thoracic, now, less than 5 centimeters are asymptomatic and not likely to burst. Now, interesting that here they gave a number, which is actually different than some other numbers that have been in different drafts. So that 5 centimeter, more than is probably a concern and less than probably isn't, but you still want to go back to that individual case and say, what is the surgeon saying? If they're saying it's fine and it's been stable, then that's different than, hey, it was like 3 a year ago and now suddenly it's 5. Well, that's not stable. So you've got to use your individual judgment. What about implantable defibrillators? Implanted to address an underlying cardiovascular disease that's likely to cause collapse. Remembering that the implantable defibrillators have a couple of different things that go along. We used to always talk about it as, this is not like, ooh, I feel a tickle. This is, ouch, that elephant just jumped on my chest. They're pretty impactful when they fire. They're a lot better than they were when they first started being used. But do they terminate the arrhythmia all the time on the first shock? No. Is the person incapacitated when that arrhythmia happens? Until the shock happens, yes. So this is one of the few areas, FMCSA says, and this is a great thing from the new handbook, when the driver says, why? They do not prevent the arrhythmias. They remain at risk of being collapsed and therefore does not satisfy the cardiovascular standard. So implantable defibrillators, in general, haven't gotten to the next slide yet, are not compatible with certification. Nor are implantable defibrillators that also have a pacemaker piece. So we see a lot of the dual-chamber pacemakers with an implantable defibrillator. Which is another whole issue. How long has the dual-chamber pacemaker really qualified and are they stable and controlled? How long has the pacemaker been in place? Have they had follow-up testing? Has the testing shown that the pacemaker is firing frequently? If the pacemaker is firing that frequently, are they asymptomatic when the pacemaker fires? Now, what happens when the implantable defibrillator has been disabled? Well, what's the underlying reason? We still have hypertrophic cardiomyopathy with a depressed ejection fraction and they said, turn it off. Well, I really don't think I should, but if you turn it off I can be certified. Common sense would say, no. That's not somebody we want to certify. You've had your ICD in for 10 years, it's never fired. Your EF had been 25 and now it's 55. That's a different situation. Work with the cardiologist and find out. FMCSA has been accepting exemption requests for implantable defibrillators for years. They have not yet approved one. I do expect we'll see one shortly after this handbook comes out. That's all, folks. What tests can be done as part of an evaluation for cardiovascular disease? Exercise stress test? That's all it says. Tells you what an exercise stress test is. It doesn't tell you how to interpret it. And echocardiography. Now, what about the acute MI? Well, first few months, greatest mortality. Is that 1, 2, 3, or 5? Got to work with the treating provider. Cardiologist recommends an exercise stress test 4 to 6 weeks after an MI and repeat it at least every 2 years. Cardiologists don't recommend either of those things. Is it reasonable to ask cardiologists, does this person need that? Maybe. But there's no strong recommendation. That's one of those read-between-the-lines kind of recommendations. So think, what do cardiologists say in the community at this point in time? And I'm going to show a couple of slides that make this even more confusing. Cabbage, they generally take about 3 months for the sternum to heal. Remember, we're not approving them to go and sit in a truck and just, like, sit and drive. They're loading, unloading, working with load-securement devices. Most thoracic cardiothoracic surgeons are going to say, no heavy lifting for at least 3 months. Maybe that does make sense. Maybe it means following up. They talk about that they have a high risk of reocclusion after 5 years and maybe, you know, may necessitate a stress test, but maybe not. On the other hand, there are individuals who have their cabbage and have cardiovascular disease still in other vessels and probably need follow-up stress tests sooner than that. So get the records and look at them. Don't just ask, how do you feel? Don't just ask, what's your doctor telling you? You've got to look at the records. If you're seeing a patient and they've seen three other specialists, you kind of probably want to see the records from that specialist to make your decision. This is no different. They define heart failure. They define heart failure, but injection fraction of 55 to 70 is normal, 40 to 55 is below normal, slightly below normal, 35 to 39 is moderately below normal, and less than 35 is severely below normal. At which point are we concerned? Well, certainly at 35. Are we concerned at 40? Maybe. What's the overall picture look like? What's their exercise tolerance test show? And again, one of the things I like to always bring... Again, I'm walking across the room. In my opinion, one of the things that drive me a little crazy is the persantine or the chemical stress test. My first question is, why? Oh, because their legs hurt them and they get fatigued if they walk. So, again, what kind of stress test was done may also make your decision of are they capable of performing all the duties that may be required of a commercial motor vehicle operator, including driving and non-driving tasks. So that pharmacologic stress test may give you some information on why it was done. Well, he's healing from an ulcer on his foot because he's a diabetic. It may still be a concern. But again, he may have a sprained ankle from jumping off the bandwagon when his college football team lost again. That person is a different situation, and maybe in that case it's okay to do the persantine. But they're probably not going to be qualified anyway because they probably can't walk very well. So, again, it's looking at that big picture, and maybe you can redo that stress test when they're able to do it. Heart transplantation. Again, they're not automatically disqualified. There's no real recommendation on the when. And what are the questions we want to consider but are not limited to? Do they have signs of cardiovascular disease? Are they symptomatic? If they're symptomatic and short of breath and can't walk more than a block, they're probably not stable. Has the treatment been effective, adequate, safe? Well, that's one of the key things we're going to look at. Do they demonstrate compliance with their treatment plan? Common sense. And have they been evaluated by a cardiologist knowledgeable in heart transplant? So these are all things you should consider. And then get the opinions from those specialists, and then look at the answers. And then you've got to make that risk assessment. Hypertrophic cardiomyopathy used to be a no-no. Now it's recognized that hypertrophic cardiomyopathy has a wide range of presentations. And you can't automatically assume that someone who has hypertrophic cardiomyopathy is going to die from an arrhythmia. It takes care of lots of other factors. So you need to look at what all the normal signs and symptoms are. And I included these snapshots just to show what they're telling you. They're teaching you about cardiomyopathy. Most people have near-normal life expectancies. These are the symptoms that may occur. That really is something you should know if you're doing these exams, which is why we're not going to teach it right now. And I think that the handbook is teaching to the people who don't know anything, but it's not enough to really understand that medical condition, just that little snippet on what's hypertrophic cardiomyopathy all about. Aortic regurgitation, pretty much the same thing. It goes through, what is aortic regurgitation? What are the symptoms of aortic regurgitation? And then severe aortic regurgitation may cause some problems. So, yeah, you need to know about those conditions. I don't know why I put that one there. Oh, I know, because it was regulatory guidance. I was putting that separately. But when you look at the regulatory guidance, it has all those old guidelines, which are now new again in the medical advisory criteria. And it says, can they be certified for two years? They can be, but it's up to the examiner to make that decision. Frequently asked questions. I guess because I jumped off of what was in the handbook. If the driver has lowered his blood pressure and off medications, can he be certified for two years? Yes, he can. The reason why I did that is I had the medical examiner handbook, regulation, handbook, and now I'm on the other resources. So these are the frequently asked questions. Not necessarily endorsed. And then the expert panel. The reason why I wanted to include this, I think, is one of the few modules including the expert panel reports. Because this shows you how confusing this whole thing is. When we were looking at the 2021 draft, I believe, somebody brought up and said, what about the 2013 expert panel report on cardiovascular disease? Cardiovascular disease had been looked at 2007, 2000, I think it was 11 or 12, 2013. Every single medical expert panel report is presented in a public meeting to the medical review board. The public's invited to attend and make comments. The medical review board listens, asks questions, listens to the public comments, and then they make recommendations based on the expert panel's recommendations. That has been the pattern with everything. There are many, many times where the expert panel will recommend ABCD and the medical review board will say, yes, but we're going to recommend this. The 2013 medical expert panel for cardiovascular was never presented to the medical review board. It was never available for public comment. It is significantly different from prior recommendations. But is it based on more current information? And the answer is maybe. We have several different recommendations from 2013, 2007, and 2002. What I wanted to do was just very quickly show how different these might be and not saying this one right or one's wrong. The 2009 update was presented at a public meeting and the medical reviewer said that makes sense. The 2013 was never presented and never discussed. Basically, it's just like, yeah, we do some things in some cases and we're not going to do it up, and it's up to the treating provider. It may not be a bad thing to look at and consider, whether it's 2013, whether it's 2009, but don't feel you have to follow it. Don't ever tell a driver, I have to follow this because it's the most recent one. You should consider it. Look at it and say, does it make sense? What are cardiologists currently doing? Are cardiologists generally keeping people off of heavy work, medium to heavy work, for two months? Are they generally doing it three months if it's a cabbage? Are they doing a stress test at a certain period of time? Are they saying don't do my medium to heavy work if the ejection fraction is less than 40% or 35%? You really want to talk to the cardiologist and get that information. Same thing with hypertrophic cardiomyopathy. Back in 2009, it was a no. In 2007, it was a no. In 2013, it was a yeah, we've learned a lot more about this condition than we knew back only four years ago. It's a maybe. What are the risk factors? In the medical examiner handbook, there's no discussion really on what's changed or what the risk factors might be that might be considered differently. As an examiner, you really should, not for the test, but for real life, understand what the expert panels have said and when they're from because I'm going to look a lot more at the 2013 panel even though I don't agree with a lot of what it's saying. It never went through comment of the MRB or the public, but it probably is based on more current medical information. Okay, cardiovascular. I have my own time. Yes. One quick question. How do you prep? If you're getting an expert opinion from the patient's cardiologist on a thing that may not be familiar with some of the standards, do you preface? Are they, ask them specifics. Are they stable? Can they drive? What are their risks? When you get that consultation, what are you asking? A lot of companies have their questionnaires made up for every different condition. There's a couple of questionnaires that are standard for diabetes, for example, for vision, for medication. For cardiovascular, it's so-and-so is being evaluated to be a commercial motor vehicle operator. This is the job description from the medication questionnaire. These are other tasks they may need to do. Now from the medical examiner handbook, those two pages of lifting, pushing, pulling, working with load-securement devices, inspecting the vehicle, and so forth, being able to reach overhead, reach underneath. Please list all cardiovascular conditions. What limitations? What recent studies have been done? Do you feel that they're safe to operate a commercial motor vehicle? I mean, and you can make this, and my staff often laughs at me because I say, make it scary. Make them have to really think. Is this person really safe? And I would even include the context of, this is not for his current employer only. A certification is good for any commercial carrier. And just, you know, what are the questions you want to know? Is he at risk of sudden or gradual impairment or incapacitation? Is he at risk of syncope, shortness of breath, chest pain, arrhythmia, et cetera, et cetera? So those are the kinds of questions you want to ask, all those considerations. And then if he says, maybe, then you've got to go figure out how maybe is that maybe. Other questions on cardiovascular or pulmonary? So for cardiovascular, it's the same questions you may consider over and over again. Is the condition stable and controlled? Are they following with a specialist? Are they compliant with treatment? Are they symptomatic? That's the guidance we have. And it really isn't very helpful, but I think it makes the examiners think. It makes examiners use current best practice. And there's a lot of subscription-based things that can keep people up to date on what the most current disability duration guidelines may be or may what the current treatment might be or what their current prognosis might be. And that's really where examiners need to start moving into. Because if we had all this guidance today, I guarantee you in 2028, it'd be out of date, half of it. And we were using guidelines based on the 1990s, which was where everything from the original handbook came from, was from the 1990s, with one exception, which was 2002. And that was the Cardiovascular Advisory Panel of 2002. Lots changed. Have you ever seen cases where a medical examiner certified somebody and then the NFCSA said no? Only if they clearly did not follow regulations. So they qualify somebody who had a seizure disorder? Yes. As Dr. Bernicke mentioned, those four absolutes. If they didn't meet the hearing requirement and weren't referred for an exemption, if they didn't meet the vision requirement and weren't qualified and did the steps, including getting the form under the alternative vision standard, if they were on insulin, if they have a seizure disorder, if they're currently taking seizure medication for a seizure disorder, not for a non-seizure disorder, yes. Other than that, it's up to the medical examiner. Where it gets tricky is if you have a crash and the plaintiff attorney says, well, they shouldn't have been qualified because their ejection fraction was 39%. And I've looked at these cases. And I'm like, yeah, there's nothing magical about 40%. Because I'm looking at it. He also reached 12 mets on his stress test. He's working out at the gym four times a week. So again, it's that individual assessment that should have always been done, but most examiners looked at this as a cookbook exam. It tells me if A, then B. If B, then C. If D, then don't qualify. This is where it should have been. It would have been nice to have a little more guidance. But I understand why they did what they did. And part of it came from Congress, which said FMCSA shall remove all prescriptive direction in the medical examiner handbook. Yes? Probably not. As part of the question was if I ask, are they safe to drive, yes, no? And the cardiologist says yes. Would I be comfortable? No. Not in isolation. Because I'm not going to ask those specific questions and count on them unless I'm like, yeah, maybe they are, maybe they aren't. I'm going to have looked at medical records. I'm going to look at medical records knowing how to read a stress test, knowing how to read an echo. Knowing how to read a sleep study. I'm going to base it on that. If I don't have enough information and I'm like, yeah, I think they're probably good enough, but I'd love to have their treating provider sign off on it, that's when I'll use that kind of question as a determination. I'll use the questionnaire to get more information and to clarify what's in the medical records. Or I'll call the doc and say, hey, your records say A, B, C, D. This is what I'm evaluating them for. Are you aware of it? Are they at risk? Like you said, any of these cardiac conditions are at risk. Correct. I am very happy when a treating provider says, yeah, he's at risk. Okay, thank you. But I'm not going to ask that question if I don't think I want to go certify them. I don't want to get an answer I don't want. Yeah, I think he's probably pretty good. I'd love to see what his cardiologist is going to support me. It's kind of a CYA move. Mike, you're laughing in the back. One of the caveats I would say is if you know you're going to disqualify the guy, don't send him on a record check. Don't do that. That's just cruel. If you already know, it doesn't matter what the specialist is going to say. You're not comfortable having him drive. Just rip the Band-Aid off and go for it. Nothing pisses off a driver more than when you send them for records and they come back and you're like, This is, again, depending on the diagnosis depending on what you have. Because there are times where I will get records and I'm like, yeah, this is maybe not exactly what I thought it was going to be. Not often, but the page, the form by itself isn't always enough to give you that adequate history. Usually, yeah, I wouldn't make him go running around and give hoops to get more tests and go see a specialist. Now, get me one set of records. Well, you always can do determination pending and we'll talk about that in a minute. Yeah. Your name is on the certificate. If you're close, I just want that little bit extra. That's where you really want that. Yeah. Well, again, that's my humble opinion. Okay? Is there any sort of ethical obligation when you see someone like a chiropractor that is clearing someone that really is quite suspect based on... As a medical examiner, the medical examiner may perform these examinations if they pass the certifying exam and if they are licensed by their state to do examinations. That's it. We're not supposed to be the police of I agree, I don't agree, because you know what? That's overly prescriptive and overly delimiting. So as long as the examiner A gets the same information as examiner B, and are they going to be different? Now, the problem is when you're sitting in the employer's seat, sometimes you look at this and say, I think I want a second opinion. But again, that's you got to talk to your attorneys and see are they comfortable with that or not. So, you know, or you can say, hey, I want my drivers sort of examined only by a physician or only by a physician, nurse practitioner, or PA who's under the supervision of a physician. Can an employer actually require that they go to their person? Employer can do whatever they want. They can accept examinations through a certain network because one of the things a lot of the third-party administrators will do is they will monitor whether or not the examiner is on the national registry. Every single examination performed, the employer or the carrier must ensure that that examination has been done by somebody who is currently on the NRCMA. So a TPA takes care of that. Some of the TPAs will actually do a first pass and say, ah, you didn't cross these two Ts and dot these two Is. So that's sometimes the reason why it goes through there. That's a good question, though, too. Motor carriers can have more strict criteria than FMCSA. They can't have less. So they can require their truck drivers to demonstrate the ability to repetitively lift 75 pounds overhead while walking under a bridge. That's an essential function of the job and done to everybody. Right, and they do that because that's part of their job description for that driver. They just can't have less. They can't say, well, we don't require our drivers to be able to bend down and tie their shoes. Oh, well, that's less strict. All right, let's move on to a... Yes, one more. Go ahead. The question I had was, I had a recent case actually with an MRO where somebody came in with a hydrocodone, and I think he probably had a psych issue, too. But I asked him, well, why are you on that hydrocodone? What's going on? And he said, oh, well, you know, three weeks ago I had stents put in, and that was for my operation. And clearly he should have... I'm surprised there's not something on these forms or some form letter that companies aren't asking people. Did something change since your last physical on these things? Because he was not only just... Well, again, the question is... It's on the questions are, do you have or have you ever had? Right. Do you have a valid certificate? I'm not going to do any certificates. But that's up to the employer. That's why a lot of examiners say, you come in now. That's why when somebody's out of work, some employers say, I need you to do a medical health questionnaire. I know you were out for your knee pain, but I don't know what else happened in the six months that you've been out, so I want you to do this health questionnaire of what happened in the interim. Others will say, you know, this is what I want to do, and it all depends on what the job is. Is it safety-sensitive or non-safety-sensitive? If they're a driver, they're supposed to report it to you, and you really are that backup. So if somebody's going to do this exam, and it would be nice if they knew that, gee, I passed out two days ago while I was walking my dog, I need a new commercial driver medical exam, but chances are the company doesn't even know about that, let alone getting them getting a new exam. So the system is not perfect.

medical examiners

commercial driving

cardiovascular health

hypertension

clinical judgment

health assessment

blood pressure stages

certification eligibility