This topic will be another one that's easily tested because it's a regulation. So recall that there are four non-optional regulations, vision, hearing, epilepsy and insulin use. We're going to touch on non-insulin as well briefly. All right. So we start out with the form, diabetes, blood sugar, yes, no, not sure. I have a lot of people that have pre-diabetes. Oh, what would you do for that? I take metformin and glipizide. Oh, okay. Well, you have diabetes. So this regulation looks a little different, right? It's the insulin that's the regulation, not the diagnosis. So you can have diabetes and drive a commercial vehicle unless you're on insulin. So there's a subtle difference in this regulation. It doesn't really talk about type 2 diabetes specifically. But keep in mind that diabetes is a multi-system disease that affects pretty much every system in the body. So a lot of those things that we worry about with diabetes are also relevant to other organ systems. There are no medical advisory criteria for this regulation, okay? So this is still 391.41, which is the overarching physical qualifications for drivers. And so what do you do? If you take insulin, you can't drive, right? And they got rid of the exemption, right? So you're disqualified. You are, but you can get the alternative. So this is 391.46, the alternative insulin standard. Like the alternative vision standard, it replaces the old exemption program. Because this is regulatory, it's testable. Hint, hint, wink, wink, nudge, nudge. So you have to meet the following criteria. One, you have to be otherwise qualified, okay? Including NSP, they mentioned that. And they have to be evaluated by the treating clinician. And they define that, as Natalie pointed out earlier, the person who's taking care of the diabetes. It does not require an endocrinologist anymore. It can be the family doctor, the pediatrician, the chiropractor, whatever. And that's state, the state manages that. That treating clinician must, of course, complete the form, in this case, the MCSA 5870. And then, well, just like with the vision, alternative vision standard, within 45 days prior to their commercial driver medical exam. It's one of my pet peeves, it's not a DOT physical, it's a commercial driver medical exam. All right, so, and they also mentioned that you have to have their exam annually. So a diabetic on insulin, the maximum certification period is what? One year, that's testable, okay? So again, you meet the standards in this, meet the other standards of 391.41. They have to have the MCSA 5870, which, again, is maintained as part of the medical record. And obviously, they have to be free of complications from the diabetes, we'll touch on that. Again, the examiner, just like, this is all just like the vision, the medical examiner uses independent judgment to determine qualification. They're not qualified if they're not stable on their insulin or properly controlled, but they don't define those terms for you. And there's some permanently disqualified conditions here as well. One is severe non-proliferative diabetic retinopathy or any proliferative retinopathy. Those disqualify you permanently. There is a requirement for three months of electronic blood glucose self-monitoring records. Now, if they don't have those, now, we'll touch on a couple things. First of all, they provide the treating clinician, not you. You can see them if you want, but they have to provide it for the treating clinician. And that is found on the MCSA 5870, whether they provided it or not. If the answer is no, because maybe they're a new start and you still feel comfortable certifying them, you can give them three months to get it. And then they come back for a new exam with a new MCSA 5870, and then at that point, if all is well, you can give them up to 12 months. Now, electronic blood glucose monitoring records are not the same as a little notebook that the guy keeps in his pocket. It's electronic blood glucose self-monitoring records, self-monitoring records. I had a guy that one of my APP saw who his wife did it for him and kept a rack of it in a notebook. Very, very organized, but that doesn't meet the standard. So they detail this a little more in the regulation. They have to have an electronic glucometer that stores the readings, of course, the date and time. You've got to be able to electronically download them. The printout must be provided again to the treating clinician at the time of the form being completed that they were seen in the office. They have to be compliant. This one. Okay. So some of you may remember the old exemption program, which predates this, which discusses ... They had a lot of criteria, and then they did talk about what happens if there's a severe hypoglycemic episode. Well, that's all gone away, of course, with the exemption disappearing. So they do talk about severe hypoglycemic episodes, and what they now say is you've got to stop driving your commercial motor vehicle and report that ASAP to the treating clinician as soon as it's, quote, reasonably practical. Again, it's not defined. They define the severe hypoglycemic episode has not changed in its definition. It requires the assistance of others, results in loss of consciousness, seizure, or coma. So basically, they have an emergency where they need help. Not just my sugar went low, I felt a little wonky, I had a Snickers bar, and I'm fine. And then the treating clinician has to stabilize them, and once they're stable, they can send them back for a new exam with a new MCSA 5870. Does that happen? Probably not. But that is a requirement, and it is testable because it's in the regulation. Do they have to have you, obviously, have to go back to their provider, get the new form, and then they come back to you for a whole new exam? That is correct. That is correct. That's what's supposed to happen. That's what's supposed to happen, and I can tell you I've never seen it because it probably does. If it happens, it probably goes unreported, but that's the regulation. That's what's required. The driver has a problem, they go to their doctor, they get it taken care of, the doctor fills out a new form, they come back to you, get a new physical. It's just like there is that requirement that says if your ability to operate a commercial vehicle has been impaired by illness, you're required to have a new physical, right? So if you have a heart attack, you're supposed to have a new physical. Do they come in? Unless there's a really diligent employer, they usually don't. But this is what is supposed to happen, so keep that in mind. I didn't know. Once the training clinician clears them on that 5871, the driver says to hold on to the form and bring it to the examiner at their next examination. Yeah. Right, but keep in mind, though, that the form is only good for 45 days, right? That hasn't changed. That's different. It's a different situation. Okay. And there would be another one potentially before their exam. Okay. This is one of the things we fought because we don't think that the training clinician should put them back on the road. And it's like, no, no, the training clinician makes the determination that they can't go back because of all these criteria, and they bring it with them to their next exam. Okay, so that's good clarification. Right. So again, okay, so let's back up. Let's back up. Natalie correctly points out that they don't require a new physical under this regulation. They probably should have under the other part of the, you know, they've had something that impaired their ability to drive. That regulation still says they should have a new physical, and that's kind of where I interpret it. So this is, but by the letter of the law, let's look at it this way because that's what you'll be tested on. So if they have a severe hypoglycemic reaction, they're required to stop driving, report it to their treating clinician, they return to their treating clinician, they get the issue addressed. Once that's done, they complete a new form, then the driver is supposed to provide that to you at the next time, the next time, whenever that is, that they get the exam. And they may require a second one because if this, you know, because of the power or the timing works out. But, yeah, know this slide. Okay. Any, all of these slides about 391.46, you should study them, okay, because this is regulatory stuff. It's not optional. But yeah, this is, so yeah, that's a weird one. So here's the form. And I'm not going to go through each of it. This is for reference, okay. And again, just like the alternative vision standard, if they show up to this, I see this a lot, a driver with diabetes on insulin that shows up for an exam, doesn't know about this, you have to disqualify him. You can't put him in pending, okay. This is for your reference. There is a webinar that you can review, you know, that you can look at. All right. So this is the handbook. Now we've, so now we've moved from the regulation to the handbook. And recall, there are no medical advisory criteria regarding this particular regulation. So we've jumped over the MAC to the handbook. So, these are the, again, recall that any proliferative diabetic retinopathy or severe nonproliferative is disqualifying permanently. Okay. Now, if the treating clinician puts that on there, really that's where you should, you know, I wouldn't qualify them until you get more information. I personally, and you are allowed to, go get medical records like from the ophthalmologist that did the exam and double check that. You know, before you're going to end somebody's career, I would personally do that. It's not a requirement. The 5870 being completed by the treating clinician is sufficient and FMCSA presumes that the treating clinician fills that form out accurately. Now, that's it on type, on diabetics treated with insulin, full stop. Now, non-insulin treated diabetes, which you're going to see way more, is not addressed in a standard by itself in 391.41. And again, a lot of that stuff that we deal with, though, with diabetes will be, may be relevant under other sections, okay? So, complications of the diabetes, amputation, the loss of consciousness that comes with hypoglycemic reactions, renal stuff, et cetera. So, the important thing is that here, my message for you on this is case by case basis, okay? In my mind, there's a big difference between the driver who goes in there and sees their treating physician or ABP every three to six months. They know what their A1C is. They keep track of their blood sugar, even if they're not checking it every day. They know what medicines they're on. They know what their, you know, et cetera, et cetera. From the guy that goes in once a year because he has to because he runs out of his pills. He doesn't check his sugars. He has no idea when his last A1C was. They may have the exact same A1C, but they're not the same person. So, case by case basis. I would also point out here that FMCSA, this is in the handbook, can be certified up to 24 months of well control. All I'm going to say here is just because you can do something doesn't mean you should do it or that you have to do it. This is a you can. And again, they talk about some considerations that you could think about. If you're not comfortable as a physician or medical professional assessing diabetic issues. Let me make sure I don't have any notes on this one. So, again, are they symptomatic? I see this a lot. If an individual's urine contains an excessive amount of sugar has been addressed, they say with testing. But keep in mind, I see this all the time where there's findings in the urine and nobody's comments on it. You should comment on it. And in fact, there are medications that cause you to have blood sugar in your urine or sugar in your urine. Make a note of it. Ignoring it is not a good idea. Has treatment been shown to be safe, effective, stable, blah, blah, blah. Are they compliant? Do they take care of themselves? A lot of times if I see anything, I just have somebody write down A1C 7.5. The American Diabetes Association does not recommend using hemoglobin A1C as a marker of fitness for duty or compliance with treatment. That's all I'm going to say. They do provide you with the MCSA 5872, which is another very useful tool. You can request the treating clinician fill this out. It's not required. It's optional. But I take advantage of the tools that I'm given. So when in doubt, fill it out. All right. Talking about dialysis here and renal because renal and diabetes go together hand in hand. All right. So number one, what do you need dialysis for, right? There's something that caused it, whether it's diabetes, intrinsic kidney disease, medication, whatever. And again, this is all in the handbook now, so it's not. There's no must here. Case-by-case basis, why do they have it? Are they symptomatic? If they're on dialysis, they probably are. Ask questions. Look at the records maybe. Maybe look at their schedule. Has treatment shown? Again, these are kind of reminders about how to handle people that have diabetes. They're reminders. But you should be familiar with end-stage renal disease and the complications thereof as well as the treatments thereof because that's part of medical education. There is a report that you can look at. But again, it's not official. It's reference only, and it's dated. But it is there for you, and it's a good way for those of you not familiar with end-stage renal disease and dialysis. This is a good starting point. Okay. Again, this is not official. It's not in the handbook. It's not on the test. But this comes from this chronic kidney disease and CMV driver. And there's some suggestions that maybe people with stage 1 or 2 could probably be watched every couple years. Stage 3, maybe you should do it at least once a year. Stage 4 could be recertified at least every six months and get a cardiovascular evaluation because what kills people a lot? What's the number one cause of people dying from kidney disease? Cardiovascular complications. Okay. And they recommend disqualifying people that are being dialyzed. Recommendations. They're just suggestions. You do not have to do this. It's not required. So they will not test you on this. One of the things that I will point out to you, and you can take it or leave it, dialysis is a risk factor for sudden death. Your risk is 25% to 30% higher. Sudden cardiac death is 100% to 200% times greater in the patient on dialysis compared to the general population. And my experience is with dialysis is that you have to go someplace to get it done. And if you're trying to drive a tractor trailer from Nebraska to California and back, it's pretty unlikely you're going to be able to comply with that requirement to be able to do it. And remember, you have to certify for somebody to drive any commercial vehicle, not just the postal van that runs from Grand Rapids to Kalamazoo every night. I'm a little confused on this here, because this says disqualify, but the other slide said consider this, that, and the other thing. This is from the handbook. Yeah, but why do you have to consider this, that, and the other thing? You don't have to consider any of it. Disqualifying. This is from the Chronic Kidney Disease Medical Review Board. Again, see here, big red, not official guidance. This is for your consideration. Again, case-by-case basis, do your homework, do your due diligence. I discourage any of you from lumping people into categories and treating everybody the same way. Everybody is an individual. Treat them as such. Yep, no, you're good. So, if there's any other questions on that, but of course we'll have time at the end. We're going to blaze on and talk about, we're going to go from diabetes to psychiatry. Appropriate at Halloween. The standard does not say anything, the regulation does not say anything about the type of insulin. Insulin is insulin is insulin in terms of the regulation. Correct.

diabetes management

commercial vehicle drivers

insulin regulation

medical evaluation

retinopathy complications