Okay, next module. Epilepsy, seizures, and loss of consciousness. We have lots of things that fit into this. This is one of the slightly more complicated, but slightly more guidance rich sections. So, start as we always do with one of the questions. Do you have a head or brain injury, seizures or epilepsy, fainting or passing out, dizziness, headaches, numbness, tingling, memory loss, stroke, mini-stroke, IETIA, or any other paralytic issues or weakness. Another great regulation, physically qualified if they have no established medical history or clinical diagnosis of epilepsy or any other condition likely to cause loss of consciousness or any ability to control a commercial motor vehicle. So, a lot of those loss of consciousness may be things, may fit under here. Remember, we also talked about that in cardiovascular. It may fit under there. So, the question is you've got to evaluate it and make sure it's evaluated both ways. One of the biggest frustrations I run into is that, you know, etiology unknown, syncope of unknown origin kind of thing. And they're always clear to go back to work the day after it happens. Problem is where they can't have been set twice. And the question is what kind of work have they had? What was the situation that incited that loss of consciousness? So, that really is one of the challenges because the ER releases them, the family docs release them, the internists release them, and you really just don't know what the risk of this recurring. And this may be one of those situations where I may send a question to both the specialist, cardiologist, and neurosaying. They operate a commercial motor vehicle. This is the job description. This is the job demands, dot, dot, dot, dot, dot. Are they at risk of recurrence of this over the next six to 12 months? And, you know, I may not know the answer because it's kind of like, eh, I'm not sure. But they have a little bit of a leeway if you truly have one of those we don't know what happened. So, epilepsy is a chronic condition. So, it's really not they had a single seizure, suddenly they have epilepsy. They had a single seizure. Once they've had that second seizure, it's assumed that they have that clinical diagnosis of epilepsy. Diagnosis results from that warning, loss of voluntary control, loss of consciousness. The following are not qualified. Individual has a medical history of a seizure disorder or epilepsy unless they meet certain criteria. So, if they have a history of it and it's been resolved and they're off medications, they can be qualified. And you don't need an exemption and we'll talk about the specifics on that. If they have recurrent clinical diagnosis of epilepsy, still having seizures, they cannot be qualified. If they're taking an anti-seizure medication to prevent seizures, they cannot be qualified. Now, the reason I'm saying it that way is because there are a lot of anti-seizure medications that are being used for other reasons. They're FDA approved. It's not off-label use necessarily. So, when you see something written on the page, don't assume that it's seizures, but also don't assume that it's not. So, if the driver says, oh, I'm taking this for my pain, get it in writing. You know, I'm a big fan of trust but verify. And I am really bothered by examiners that tend not to get medical records. You've heard me talk about it and Mike talk about it as well. Get the records and look at them. Your medical history on your drivers may or may not be reliable. That's the only thing I can say about that. They may have selective recall. They may also not have great understanding. Do you have or have you ever had heart disease? Well, I don't know, I had my bypass and now I'm fine. And that's what a lot of them will believe. So, they're not necessarily trying to mislead you. So, get the information and look at the records. So, if it's medication, it can be used for seizures, but it's a different story. And we're going to look at this because this is confusing and I have another doc that I work with who has been arguing it doesn't make sense. And I'm like, OK, let's take it step by step by step. Single unprovoked seizure. One time we have no idea, I'm sorry, single unprovoked loss of consciousness. They passed out, they didn't seize. We don't know what caused that. The examiner tries to figure out why it happened, but oftentimes you can't figure it out. The medical examiner does that evaluation. If the individual is not taking any type of seizure medication, therefore the treating providers are assuming it is not a seizure. He had a loss of consciousness. Remember, not everything that has a tonic-clonic movement is a seizure. People may have a vagal-vasal episode and have a couple of tonic-clonic movements associated with that. It does not mean they have a seizure disorder. You make an individual basis working with the treating provider of, we don't know why this happened, that loss of consciousness is likely to happen again. Whether or not it does, the recommendation is a six-month wait to make sure it doesn't recur. Now, I'll be really honest, one of the conditions that really concerns me now is POTS syndrome. All of a sudden I'm seeing everybody diagnosed with POTS. The problem is they may be fine. They may do okay-ish with their compression stockings, but in my mind they still remain at risk of a syncopal episode. It's trying to get the treating providers to really understand what those risks may be. That's a single, unprovoked loss of consciousness. Single, unprovoked, non-epileptic seizure, i.e., cause is unknown and there's no clear trigger. This is not somebody who has a history of epilepsy, so it's a single seizure. Who was treated with anti-seizure medication or left untreated may certify the driver if they are off anti-seizure medication and seizure-free for five years. Unprovoked seizure, untreated, or treated, they can be certified if they're seizure-free and off medication for five years. So if it was untreated, five years. If it's untreated, if it's treated with seizure medication, it's five years from when the seizure medication stopped. Okay? Can I keep going? If they've had a single provoked epileptic seizure, non-epileptic seizure, or loss of consciousness, you know exactly why it happened. You want to look at the risk of that recurring. They had a metabolic abnormality because they took their medication and their medication caused their potassium and magnesium to drop down and they seized. Or they had an infection. Or they were dehydrated. What is the likelihood of that recurring? So single, provoked, non-epileptic, i.e., first one seizure. May certify if they fully recover, has no residual complications, is not taking the anti-seizure medication. Once they go on anti-seizure medication, all bets are off and it changes. And seizure recurrence and exposure to the inciting factor is unlikely. They may be certified. There is no specific time. So as I often tell drivers, I'd rather know why you had your seizure. I can get more information. Not knowing is more problematic. Okay? So it's known, provoked, single seizure, wait until they resolve. Now, the really challenging ones are the ones that have had an alcohol withdrawal seizure. I am not going to bring them back quite so quickly. I want to make sure that they have been fully evaluated and probably treated for the underlying reason for the condition. And pretty comfortable, it's unlikely to recur. Medical history of seizures. This person with that known seizure history. If they are off medication and seizure-free. So if they had a seizure problem when they were in their teens, not even talking about febrile seizures of childhood, if they've been seizure-free and off medication for 10 years, they can be qualified. Now, this is all medical advisory criteria. Is it a little squishy one way or the other? Yeah, kind of, sort of, maybe. But probably you want to go pretty close to it. So if it's nine years, 350 days, and he has this fantastic job, and yeah, you probably could do it. It's kind of like a doctor or provider that writes, may lift no more than 37 pounds. And I'm using 37 because it's a really weird number, but how do we know it's not 35 or 40 before they have a problem? This is the same thing. There's nothing magical about that last day of the ninth year, that on the first day of the 10th year, they're okay. So again, that's the parameter. You want to stay pretty close to that. If they're unsure about whether or not to qualify a driver, the examiner may, if the driver meets all other medical standards, including if they need to get an exemption or a skill performance evaluation certificate, if they need to have an exemption for hearing, if they need an exemption, the alternative standard for vision or for diabetes, if they meet everything else, then they can be referred to FMCSA to see if they meet the requirements for needing a seizure exemption. Now, the federal seizure exemption, we're going to talk about that a little bit later on. So the individuals diagnosed, treated or untreated, 10 years off medication and seizure-free, single episode, treated or untreated, five years off medication and seizure-free. Loss of consciousness, unknown, at least six months. Loss of consciousness, known. As long as it's not going to happen again. Okay? We're good on that first part. Good. Okay. Talking about single, unprovoked. This is from the handbook as opposed to the medical advisor criteria. It pretty much repeats the same thing, but sometimes maybe in a slightly different wording, which maybe will make it easier to understand. Single, unprovoked, it's not epilepsy. It's most likely to recur in the first five years. Risk factors, history of neurologic insult or stroke, abnormalities on EEG, focal lesion, family history. Once they had that second seizure, they don't fall into this category anymore. They now have an established history of epilepsy. Some of the considerations, both seizure-free and off medications, at least five years. If it's one seizure, medical diagnosis of epilepsy has been ruled out, i.e. they have a very significant foci that puts them at increased risk of having recurrent seizures. You get the EEG, you get the CT, and there's something going on there. Yeah, maybe it's five years, but you probably want to keep a closer eye on that longer. And they certify off medication and seizure-free five years. Single, provoked seizure, we talked about it the same thing. It may include alcohol or illicit drug withdrawal. There's going to be a lot more going into that. It's not just going to be, okay, the seizure is done. It's going to be you have another disqualifying issue that I have to deal with. So maybe you can be qualified because of the seizure, but not because of the alcohol or other substance use disorder problem. And then you really want to go back and what's the likelihood of this seizure, this episode recurring. If it's low, examiners can qualify them. If it's not, you shouldn't qualify them. If you're not sure, you can refer them for the seizure exemption. Considerations, has the underlying conditioning resolved or has it been eliminated? Has the person fully recovered? Are there any complications? Are they taking, of course, seizure medication? And what is the likelihood of recurrence? So pretty much it's the same thing multiple times. How likely is this to recur? And are they taking anti-seizure medication? Anti-seizure medication have to be off anti-seizure medication to be qualified under the basic standard. Okay? Taking seizure medication is totally unpermitted. It's one of the absolutes. However, just like we're going to talk about diabetes, just like we talked about vision earlier, there is a variance that is available. And variance includes anything that doesn't go straight from the regulation. So the alternative vision standard is kind of a variance. A skill performance evaluation certificate is a variance. A hearing exemption or a seizure exemption is a variance. That's it. You can't put a limit if you can't lift more than 50 pounds. You can't put a restriction of can't work at night. You can't put a restriction of can't work except between the hours of da-da and da-da. The only restrictions you can place is requiring a variance, corrective lenses or hearing aid. That's it. So now we have a single provoked seizure, fully recovered neuro-residual, not taking anti-seizure medication. Loss of consciousness. Again, we have a childhood febrile seizures. Most of them occur under age five. Most of them are triggered by high fevers. Most of the time the individuals do not have recurrent seizures into adulthood. But not always. Once they have a seizure in adulthood, it's no longer considered a febrile childhood seizure and we use the first set of slides to decide what to do. That's defined by age 18? It depends on what the doctor says. They really don't define it. They're saying here's the first five years, whether it's 18, whether it's 12. But if they start having another seizure. Adult onset seizures. If it looks like more that it's an adult onset as well as a childhood. They've had childhood seizures and that really is childhood. Fever is what causes it. If you have a high fever and the seizures weren't an adult, then you still want to go through that original step of are you going to treat them or not? That's a single provoked seizure. A lot of times you have the driver say, oh yeah, I had seizures as a child. Had them up until age 10, never had them since. That's probably okay. If they had them at 15 and 18 and 21, that's epilepsy. Now if you have anti-seizure meds used for other non-seizure reasons. This is where that optional medication form comes in. An FMCSA has said over and over again and they even mention it in the handbook. That the optional, because it's not required and I'm kind of repeating that over and over again because there are some people who say, oh I have to use this form. No you don't. You'd be silly not to because it can give you lots and lots of information. So if you have a medication that's being used and you're not sure why, there's an optional form sent to the treating provider. We'll go looking at that form a little bit later on in the medication module. So anti-seizure medication not used for seizure prevention, find out why. Keeping in mind that maybe that other condition is just as problematic. They're taking an anti-seizure medication for an anger management problem. I may be concerned about that as well and that may fall then onto the mental health issues. Then we have the federal seizure exemption. This is where it gets a little confusing it seems. If they have a seizure exemption and they have a history of epilepsy they can be qualified for up to 12 years with a single unprovoked seizure. If they happen to be on medication they can be eligible for up to two years. So this is once they get the exemption and all the material is in there. You can evaluate, determine they otherwise meet the criteria and they meet the criteria that would make them eligible for a seizure exemption. To tell them to apply for a seizure exemption when they've only been two years seizure free, don't bother. It's not worth their time. It's not worth their time to even talk about it. We'll talk about what criteria FMCSA uses as their starting point. This is the form. This is the seizure exemption forms. This is how you apply for it. There's a renewal that goes after the first year and it really goes into all the different steps of what you need to do to get that seizure exemption. Your role, are they otherwise medically qualified and do they meet the criteria in the next few slides we're going to talk about. Variances, the ME may certify those who require an exemption. Again I mentioned 12 months or 24 months depending on the criteria. The motor carrier is responsible for making certain that that exemption has been granted just like hearing. It is not your job to follow them and make sure they get the exemption. Your job is to determine A, are they otherwise medically qualified and B, do they meet the criteria that FMCSA has used as the basis. Now again, it's two years, stable treatment. If they have stable treatment for one year, 10 months and 28 days, doesn't mean it's not reasonable for them to apply. Whether FMCSA's reviewer will be, ah, ah, you've got to wait the extra 30 days, I can't tell you that. But again, this is guidance. And medical, the employer is responsible for making certain they have the information. Now what happens, when will they consider an applicant for a seizure exemption? They have an established history of seizures. Seizure free, 8 years. On or off medication, if they're taking anti-seizure medication it must be at least 2 years, ah, stable dosage. So it's 2 years stable, 8 years seizure free, on or off that medication. That's the exemption. Not just off medication, normally it would be 10 years off medication, exemption 8 years, on or off, 2 years stable dose. Single unprovoked, this is where you can be certified up to 2 years. Seizure free for 4 years, normally it's 5, but it's 4 years on or off medication. As long as the medication is stable for 2. So if they're on medication for 2 years, dose hasn't changed, they stay on their medication, they've hit 4 years, single unprovoked, then they can be eligible for that exemption. They look at whether it's a high risk or a low risk of recurrence, and the low risk is medication, non-penetrating head injury, low subconscious in less than 30 minutes, metabolic derangement, or alcohol or illicit drug withdrawal. Now, you may decide that they're not qualified because they haven't demonstrated a really consistent, sustained remission from use of these substances that may cause them to be unqualified under a different regulation. If you feel that they're stable for that, then you can refer them for that seizure exemption. So far, so good? I have a question. Yeah. Why would you have an exemption to stay with or without medication, if they're on medication? In other words, if you're taking medication, this would imply that it doesn't make a difference if you're on medication or not, which actually, literally, supports. But the question is, why not do the whole thing without medication? Because right now, this is what FMCSA is doing. They have their guidelines, examiners, just like the FAA has certain criteria where you can qualify them, no problem. There are other criteria, it used to be sleep apnea, for example, where it was a deferral. And then the regional flight surgeon would look at it and say, yeah, or no, or pass it up to the county. So this is really, because the regulation itself has not changed. So this is the force of law. I'm sorry? This is the force of law, that advisory that... This is a seizure exemption program. Just like for vision and insulin-treated diabetes. That was a prohibition. You may not be driving if you don't meet the 2040 in each eye separately, both eyes together. You may not be certified if you're taking insulin. What they've done over the years is they've looked at it and said, well, we think that some people who are closely followed probably can be certified and drive safely if they're taking insulin, if they don't meet the vision requirement. This is the same way. Is FMCSA moving toward probably letting examiners decide, using this criteria of, have you been seizure-free for a reasonable period of time on your medication with a stable medication dose? Yeah, there's definitely that's in the plan. Whether it's gonna be happening in the next two years or five years, I don't know that at this point, but that certainly is one of the plans. And then part of the problem is there's a lot of complications, a lot of differences and nuances that examiners should think about. Some examiners will understand, some may not, but moderate to high risk of seizures, this is something they probably would not give an exemption to. If they've had a non-penetrating head injury with more than 30 minutes loss of consciousness, if they have hemorrhage with stroke, if they've had infections, intracranial hemorrhage, post-op complications from a surgery with the brain, the things that had that seizure foci still there, would they remain even on medication at lifelong risk of recurrent seizure? So there's high risk situations, they probably would not be granted an exemption. So that's what makes that a little bit different. Talk about Meniere's, if you think back to the olden days again, Meniere's was like disqualifying, Meniere's causes dizziness, it may or may not cause sedation, it may or may not cause other problems, and it's really up to the examiner to evaluate on a case-by-case basis whether or not the individual should be qualified considerations, how often do they have their symptoms, what's the severity of the symptoms, what symptoms do they have associated with the headaches, what symptoms are associated, loss of vision, and oftentimes they'll lose hearing, but they still may meet the hearing requirement, and has treatment been shown to be effective and safe? So Meniere's is like everything else, evaluated on a case-by-case basis. Infections, common sense, has it resolved? Are they having any residual? How frequently have they had problems with this? Has the underlying infection been resolved? If everything looks fine, you're then worried about is there a risk of seizures or not? For cerebrovascular disease, you know, it's the same exact words over and over again. Has the etiology been confirmed? Is the nature and severity enough to interfere with safe operation of the commercial motor vehicle? Are there seizures present? Are they at risk of seizures? Evaluate on a case-by-case basis. Now, this is a little bit of guidance that they give to us. Maybe. Is there a risk of seizures, cerebellum, and brainstem? Generally not associated with an increased risk of seizures, but cortical and subcortical defects are. So maybe you want to have a longer waiting time after a cortical or subcortical, but maybe not so much with cerebellum or brainstem. So, you know, while they don't really give you an absolute of which to do, it's a little hint in my mind. This is a read between the lines. And one seizure after stroke may constitute a diagnosis of. The person has an abnormality in their brain that folks say is there and will remain there, so therefore maybe you don't want to have them operating a commercial motor vehicle. And they talk about people who, one in three people who have a TIA will eventually have a stroke. So, again, that waiting period's not there. We used to have a waiting period. We don't have it right now. It's really working with the treating provider, looking at what the best practice is. When does an individual with a stroke fully recover, unlikely to recur? And that's the main issue. Some of the considerations. You know, I mean, I can read that over to you, but it's the exact same phrases over and over and over again. They're common-sense phrases when you're trying to determine, can I let this person, they can go back and drive. Many states have non-commercial driving laws. Many, several states have mandatory reporting of unsafe drivers. And the healthcare provider, whatever specialty they have to be, are supposed to evaluate, can this person do their driving, driving their personal vehicle? Remember, personal vehicle's a whole lot smaller. When you have a Mazda and a giant 26,000-pound truck, the truck's going to win most of the time. The person who's driving his little Miata to and from church on Sundays has X amount of exposure time. When we think about risk assessment, the person who's driving a large truck is on the roads a lot more hours per day and more likely in odd hours, so they may be tired. They may have been driving for a long period of time. So, again, it's a very different risk equation when you're looking at the commercial motor vehicle operator than you are for the private driver. But these are the same standard questions you're going to need to ask, and bottom line, is it stable and controlled? Are they having symptoms? Is this likely to get worse? How likely is it to get worse? Pick a medical condition. Ask those same questions. And again, what did I tell you? Medical examiners should evaluate on a case-by-case basis to determine whether the individual meets the physical qualification standards. So everything is case-by-case. Now, some of the things you look at in a neurologic examination, and I kind of figured I would put these up here to show, yes, they do make some recommendations, but it should be common sense. Cognitive ability, judgment, attention, concentration, vision, reaction time, sensory or motor function, coordination and balance, and physical strength and agility. Is it reasonable to obtain physical therapy assessment? Sure. I want to see the discharge notes. Is it reasonable to get a FCE? Maybe. Is it reasonable to ask for a neuropsych evaluation? Maybe. Do you want to order these tests? Probably not. What you probably want to do is talk to the treating provider and say, hey, I'm concerned about all of these things, or your office visit records mention he was having trouble concentrating and he can't pay attention as he used to. It appears that his balance is off. Do you think that maybe a blankety-blank may be useful for bringing him back? Employers don't like it when all of a sudden examiners say, you've got to have this done, and then who's paying for it? Maybe the employer will pay for it. Maybe the employer won't. Depends on the situation. Narcolepsy and idiopathic hypersomnia. This is one of the few statements which I thought was kind of interesting that was added in. Those should be diagnosed by an overnight lab sleep study, followed by an MSLT. The couple of different sleep studies. We talked about polysomnogram, the in-lab, you're all hooked up, you're being monitored. The home sleep study, it's being done lots of different ways. There generally is a chain of custody kind of sort of in most cases, but if you really want to find out, there's ways to meet a lot of these things. The other tests that are common is back in the olden, olden days, FMCSA used to recommend a multiple sleep latency test to evaluate drivers who may be at risk of having sleep apnea. And what that was, it means go in a dark room, lay down, and see how quickly you can fall asleep. That kind of makes not a lot of sense to me. The FAA, on the other hand, was looking at the maintenance of wakefulness test, which says go in a dark room and try to stay awake. Either way, FMCSA is recommending that you've had that diagnosis, and then you do the MSLT to see how quickly the individual with narcolepsy falls asleep. If they fall asleep like that, yeah, you've got a problem. But what they say is medical and lifestyle modifications may help manage symptoms, but these individuals remain at risk to lose consciousness or the ability to control, so they do not meet this loss of consciousness medical standard. But remember, this is guidance, so you should never go back and say, I can't qualify you because you have narcolepsy or I can't qualify you because you have dot, dot, dot, dot. When was your last episode? Have you really been controlled for 10 or 15 years? Have you had multiple sleep latency tests? Have you had maintenance of wakefulness tests? Has everything come up normal? Are you on a medication that seems to be really super effective? So, again, this is not an absolute, but it's a, yeah, more likely than not, start from here and go elsewhere to make your final determination. Traumatic brain injury, you know, a lot of the same things. Did they lose consciousness? If so, for how long? What were their symptoms? What was the severity of the symptoms that they had? Had they had treatment? What is the treatment? And has it been shown to be effective and safe? Is the nature and severity of the underlying condition? We know the condition is traumatic brain injury. How did it happen? Likely to interfere. And then the famous medical examiner should evaluate on a case-by-case basis to determine if. That's when I point out how many pages for the topics are there. And I also say a lot of it's redundant. This is the kind of thing that's there over and over and over and over again. I tried to combine them, and it was really obvious. For syncope, you know, we talked about it. Does the individual have presyncope? Do they get a warning or not? I don't know if they're going to get a warning. They're going to pass out in the middle of driving on the I-95. They're not going to have time to pull over in time. So presyncope doesn't make me feel better necessarily. Do they have dizziness or lightheadedness? What about the medications? Do those meds cause side effects? What is the underlying cause? Is it cardiac? Is it neurologic? Is it unknown? Has it happened before? Is it likely to happen again? Are they being treated or not? Has the treatment been shown to be effective? Did they have a tilt table test? Yes, no. Did they have follow-up testing after they've been put on floor and after some other medication? So, but again, there's no absoluteness. You've got to use your common sense. You've got to use your medical judgment. You've got to use the understanding of how you diagnose, how do you treat, what's the prognosis, what's the prognosis with or without this treatment. A single unprovoked episode was mentioned earlier. Recommended a six-month wait. There's nothing magical about six months. If you're uncomfortable because, I don't know, there's something here that doesn't feel right, and you want to say, I'm not certifying you until eight, you can do that. If it's five months and it's like they've had a total workup and they didn't eat, they didn't drink, it was super hot that day, I think at five and a half months they're fine. Remember, these are guidelines, but you've got to justify why you're deviating from them. So, if something bad does happen or if EEOC comes along because the person puts a complaint that the recommendation was six months and he kept me out for eight months, document when you vary from a bit of criteria that is offered. There are two medical expert panel reports, one from 2010, actually both from 2010, presented on the same day, one on traumatic brain injury and one on stroke. I think they're pretty decent, but they're also 15 years old. So you may want to look at them not as a I should follow, but look at them as a, gee, what were the experts thinking back then? And is that still applicable today? And that's module six and we're right at lunchtime. Yes? I know what you're going to say, but it's- It depends. This form, this question of stability, is there any resources you use to define stability in any given condition? There is no specific definition for stability. It's, you're going to certify them for, in most cases, two years, sometimes one year, sometimes six months. And that's where that, is it stable enough? I think it's good enough. He hasn't had a problem for three years. I'm going to go ahead and certify him for two. Hasn't had a problem for a year. Maybe I'll certify him for six months. There really is no, and that comes out specifically in the vision, alternative vision standard, or FMCSA says, how do you define stability? And the response is even worse than mine. It depends. It's work with the treating provider to reach that. But what you said is helpful for those, you know. We hope so. Because if there's nothing written, what's been your experience over years of doing that? And what you just said, if it's been stable for three years and two, if it's stable for one, then give six months, that's helpful. But it all depends on the medical condition. What's the likelihood of something happening? What's the risk of something happening? If it is, they make it a little lightheaded, but lasts a second or two, that's really different than, they may pass out. And getting it like for people with alcohol withdrawal, in my years of emergency medicine, trying to determine who's telling you the truth, whether to continue to drink or not, and where are you getting your information? Is there, okay, well, it's unlikely not to happen, but, you know, that of course depends on whether they're drinking or not. Yeah. Yeah, I mean, that's part of the problem. Your history's only as good as the individual who gives it to you, and they sign, and we'll get to that in module 10, that the information I provide is accurate and complete. Inaccurate or incomplete information may invalidate my medical certificate, or result in civil penalties. And yes, there have been drivers charged with lying on their medical examination, which then resulted in a crash. So, and certainly most employers and some examiners, when they find out a driver lied, they'll say, I won't qualify you. And guess what, I really respect those examiners. And I've had that discussion with drivers too, is like, if you don't put all your information down, and there's a crash or an incident, how long do you think it's gonna be before your employer, nope, not my problem. Yeah. They're not gonna stand behind a guy. They're gonna be like, oh, he lied on his form. And I also say, no judge, jury, investigator, law enforcement officer's gonna accept, I forgot. I just said, treat these like your taxes. You fill them out once a year, maybe, you know. You gotta treat like your taxes. The IRS isn't gonna accept the fact that you forgot to disclose that you won $20,000 gambling. The FMCSA or the NTSB or the Michigan State Police is not gonna accept the fact that you forgot to disclose that you drank a case a week and had a seizure last week. I remember whenever they're there, they'll tell you, I have two drinks a night. They actually probably have four. Is there a way in the system that you can see on the last exam? No. Is it my seizure? Yeah. That's one of the common questions, which is when you enter the results, which we'll talk about entering results in module 10 into the NRCME system, can you look at prior exams? And the answer is no. And the intent, I think, was they wanted each exam to be a discrete session. Now, what employers may do is one of the reasons I want you to go back to the same clinic is they have your past history. Employers also will do, depending on the TPA they work with, which may be, will you please review this history based on the last history? What some employers will do if they have a medical department is look at this exam versus last year's exam. But no, examiners, each one is supposed to be discrete. I think, correct me if I'm wrong, they're eventually gonna get to the point where you can at least see the outcome of a prior exam. You won't be able to see the exam itself, but you'll be able to somehow see that this was a disqualification. Kind of like what the FAA does, I can see old exams that were in there. I have a pre-exam report, but I can't see the details of anything that wasn't my exam. So. Maybe. I've heard both on that. So maybe, and when it comes to a government agency, there's so many variables, funding, political climate, et cetera, so don't take it to the bank. And most of this will go through rulemaking, which means that you're going to have stakeholders on both sides. Us who say, yes, it'd be really helpful to see if they were disqualified or if they had a one-year certification. On the other hand, you're gonna have labor or others that will say, you know, he was disqualified by this examiner for the wrong reason and then he went to the next one. I don't need every examiner in the future to start giving him a hard time because this was a six-month, it really shouldn't have been. We, Natalie talked a lot about, and we continue to talk a lot about, you know, what about this and what about that? But recall, seizures is one of those non-discretionary standards when you come to the test. So somebody comes in and they start talking about somebody with epilepsy, start thinking this regulation and what that means when it comes to picking one answer you're gonna take. But remember, they may be eligible for the seizure exemption. Right. I doubt they're gonna question you about the details of the exemption. I wouldn't count on it. But Natalie has a different take, so at least know the general broad strokes of, you know, yeah, don't send somebody for an exemption that has had been seizure-free for a year, like she talked about. But that's one of the non-discretionary ones, so make sure you understand that regulation because it's easily tested. Regulations are testable. Right. It's a regulation, not a recommendation. Natalie, did you say on the test that the review board recommendations are not? No, no. They're not even mentioned in the handbook anywhere. The only medical review board recommendation is in there, which is the 2016, it was the above year one. Oh.

epilepsy

seizures

commercial drivers

medical history

regulatory guidance

seizure exemptions

anti-seizure medication