Guidelines to determine if a patient should not operate heavy equipment
What are the guidelines to determine if a patient should not operate heavy equipment, drive a car, or pilot a boat, aircraft, or spacecraft?
The Physician’s Guide to Assessing and Counseling Older Drivers , 2nd edition (American Medical Association and National Highway Transportation Safety Administration, 2010) states that physicians should screen for red flags such as medication use, ask about new-onset impaired driving behaviors, assess driving-related functional skills, treat underlying causes of functional decline, refer patients who require driving evaluation or specialized training to a certified driver rehabilitation specialist, counsel patients about safe driving, and follow up to see if patients have followed through on recommendations.
Patients with vertigo do not necessarily have to avoid driving. In general people with vertigo have no greater rate of accidents than the rest of the population, probably because many of them limit their driving out of caution.
A patient who has acute vertigo should be counseled not to drive or fly an airplane. A patient who is in remission or whose vertigo has ceased or is under control should be advised not to drive if vertigo recurs.
Patients should also be counseled to avoid or limit driving under conditions of reduced visibility, such as darkness, rain, fog, sleet, or snow, and under conditions of reduced road safety such as ice, snow, or a light rain that may cause hydroplaning.
Patients who must drive for long distances should be counseled to take frequent breaks in case of vertigo and to pull off the road immediately in case of an attack of vertigo.
Patients who take centrally acting medications, like antiemetics, antihistamines, or benzodiazepines, should be counseled to avoid driving after taking these medications.
In general five half-lives are required to eliminate active metabolites.
Red flags for the physician include acute and chronic medical conditions that affect motor or sensory function, sensorimotor integration, or cognitive function (decision-making, spatial navigation).
Such conditions include CVA, seizure, vertigo, arrhythmia, syncope, sleep disorders, dementia, some psychiatric disorders in which the patient may be a danger to himself or others, chronic renal failure, severe respiratory disease requiring oxygen, and some cancers that require treatment with chemotherapy.
If you advise a patient not to drive or not to operate other vehicles, then you should determine if the patient has alternate forms of transportation, such as a bus service for disabled people.
If the patient lives in a region with inadequate public transportation then he or she may choose to drive a vehicle regardless of the physician’s advice because the patient has no other way to run errands, make clinic visits, and perform other essential activities outside of the home.
In that case, referral to social services may assist the patient in finding other resources for transportation. Individuals with concern about their condition who still drive may want to use vehicle safety enhancement technologies, which include collision avoidance braking, night vision displays, and lane change warning.
One caution to potentially vestibular impaired drivers is to have them take a clinic or office equivalent of a field sobriety test, which has components of vestibular assessment, including ocular stability, gait, balance, and coordination.
If they could not pass the test then a routine police road stop could generate a driving under the influence (DUI) or driving while impaired (DWI) citation.
Individuals who must maintain especially good alertness and good spatial orientation, such as pilots and professional drivers, should be reassessed before being released to drive.
If the physician needs evidence that a patient is, or is not, safe to drive, assessment by a certified driving rehabilitation specialist (CDRS), most of whom are occupational therapists, may be indicated. To find a CDRS see the website for the Association of Driver Rehabilitation Specialists ( www.aded.net ).
Similar concerns affect the physician’s assessment for operating heavy machinery, flying airplanes and spacecraft, climbing ladders, and handling potentially dangerous equipment and materials.
Some simple guidelines can be considered. For example, a patient with active benign paroxysmal positional vertigo should not climb a ladder or perform other tasks that require looking upward or downward, until the BPPV has resolved.
Patients with vertigo and disequilibrium should not be required to run, jump, move around the environment quickly, walk on unstable surfaces, or perform tasks that may disorient them.
Pilots should avoid flying if they are prone to vertigo, especially if the episodes are recurrent, unpredictable, incapacitating, or impede performance of any pilot duties.
Generally such individuals would have an FAA Aviation Medical Examiner physical and specialty evaluation.
