insulintreated diabetes mellitus (ITDM) whose physical conditions are adequate to allow method to prevent the effects of diabetes and treatment depends …
DEPARTMENT OF TRANSPORTATION FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION DOCKET NO FMCSA 200523151, RIN 2126AA95: Qualifications of Drivers Diabetes Standard Comments of the Bus Industry Safety Council BISC and the American Bus Association ABA On the Advance Notice of Proposed Rulemaking June 15, 2006
The Bus Industry Safety Council BISC and the American Bus Association ABA appreciate the opportunity to comment on the Federal Motor Carrier Safety Administrations FMCSA Advance Notice of Proposed Rulemaking ANPRM in the above titled proceeding The ABA is the premier private bus industry trade association The ABA is home to some 3500member companies and organizations and approximately 800 bus operator companies The bus operator members provide all manner of transportation services to the public including: fixed route scheduled service, charter and tour, airport shuttle and commuter services The Bus Industry Safety Council BISC is an ABA supported organization composed of the safety, security and operations chiefs of private bus carriers and organizations in the United States Each organization has serious concerns about the FMCSAs proposal to amend its medical
qualification standards to allow the operation of commercial motor vehicles CMVs in interstate commerce by drivers with
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insulintreated diabetes mellitus ITDM whose physical conditions are adequate to allow them to operate safely and without deleterious effects on their health 71 Fed Reg 13801
ABA and BISC understand that FMCSAs revision of the current standard requiring drivers with ITDM to apply for exemptions from the current rule prohibiting such drivers from operating in interstate commerce would be to conform with the changes in FMCSAs existing authority to establish, review and revise physical and medical qualification standards for drivers made by the enactment of the Safe, Accountable, Flexible and Efficient Transportation Equity Act: A Legacy for Users SAFETEALU ABA and BISC understand that SAFETEALU requires that the FMCSA develop standards to allow at least some drivers with ITDM to drive in interstate commerce In light of this, the above organizations have the following comments and suggestions For the sake of clarity, these comments will key on the specific Requests for Information and Comments listed in the ANPRM 71 Fed Reg 1380313804
Before
responding to FMCSAs specific requests for information and comments ABA and BISC offer the following as a brief summary of their concerns with respect to allowing over theroad passenger bus drivers with ITDM to operate in interstate commerce Diabetes is a serious disease Uncontrolled diabetes can be extremely dangerous, resulting in loss of vision, damage to the nerves, blood vessels, kidney and increased risk of heart attack Moreover, diabetes cannot be cured, it can only be controlled by diet, exercise, oral medication or by administering insulin See, American Diabetes Association web site An insulin treated diabetic may be a successful employee in many professions but treatment
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with insulin is not a sure method to prevent the effects of diabetes and treatment depends crucially on the individuals discipline in adhering to administering insulin when required Failure to adhere to the insulin regimen can lead to diabetic neuropathy, which causes the gradual loss of sensation in the hands and feet damage to the retina and hypoglycemia in which blood sugar falls to abnormally low levels which can lead to loss of consciousness
ABA and BISC set out the above to
reinforce the point that when these effects are considered in the context of the transportation of passengers, the effect is much more devastating Other modes of passenger transportation have recognized this fact and have acted on it for the safety of the public For example, a person may not become a train engineer if he or she suffers from epilepsy, diabetes or have any other medical condition that could cause them to become unconscious http://wwwcareersinrailorgasp?actionarticleID22 6/8/2006 The Federal Aviation Administration FAA restricts persons with insulintreated diabetes to third class airman medical certificates A person holding a third class medical certificate is ineligible to provide commercial passenger transportation See, http://flight physicalcom/pilot/pilotfaqhtm 6/8/2006 In addition, individuals with ITDM are required to meet stringent standards regarding medical history, periodic medical examination and records reviews and medical certification for even this third class certificate See, American Diabetes Association, http://wwwdiabetesorg For the overtheroad bus industry and the passengers who travel with us, the issues of passenger safety are
identical to those of the rail and airline industries In fact, the private overtheroad bus industry carries
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more passengers in one year than the airlines and more passengers in one week than Amtrak does in a year
A fully loaded passenger bus can carry fiftyfive people A driver with ITDM who forgets his insulin protocols and loses consciousness due to low blood sugar or loses feeling in his hands or feet or who experiences vision problems is as much of a threat to the public safety as a rail engineer or a commercial airline pilot with the same condition In the opinion of ABA and BISC this threat is magnified when the ITDM driver is on a charter or tour, or on a long scheduled service run or away from home for any length of time In those cases, it is likely that no one on the bus will be familiar enough with the drivers medical condition or history to alert the driver when the drivers blood sugar level is low or when the drivers judgment may be impaired In addition, long distance scheduled runs and charter trips are also the very ones in which access to emergency medical care for the driver may be limited The point of this recitation is to reinforce our view
that any change in the medical standards to allow ITDM drivers to provide service in interstate commerce must be carefully controlled and monitored to prevent the deleterious effects to the driver and to the traveling public, which justly concerns FMCSA 71 CFR 13801 ABA and BISC have the following specific comments and recommendations, keyed, as stated above, to the questions posed in the ANPRM
Question 2 How should FMCSA ensure that health care professionals who might be applying any revised standards do so in a consistent and appropriate manner which ensures
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both that the physical conditions of such drivers are adequate to enable them to operate safely and that the operation of CMVs is not deleterious to their health? Answer: First, we firmly believe that consistent medical standards are necessary Specifically, health care professionals must be certified by FMCSA to provide consistent medical advice to the agency in light of their knowledge of the ITDM medical condition and the effects of that condition and in light of their knowledge of the occupational requirements of individuals holding a commercial vehicle drivers license Second, in order to ensure
consistent standards FMCSA should require health professionals to demonstrate that any such professional possesses the knowledge required to pass upon the medical condition of ITDM individuals applying for a CDL Third, in our view such a demonstration is best accomplished by an examination of health professionals seeking the power to certify individuals with ITDM This examination would test a health professionals knowledge of FMCSAs medical standards and protocols It is evident therefore that socalled self certification in which health care professionals state, without further evidence or examination, that he or she can appropriately evaluate ITDM CDL applicants, must not be allowed Fourth, ABA and BISC are convinced that health care professionals certified to evaluate ITDM CDL applicants must themselves be subject to periodic compliance reviews in order to ensure that each continues to provide consistent medical advice to the drivers and to the FMCSA Finally, as a template for a successful evaluation program for ITDM CDL applicants, ABA and BISC point to the FAA medical certification guidelines for pilots with insulintreated diabetes See, http://wwwdiabetesorg
6/8/2006 We will return to the requirements of this program and its benefits for the bus industry later in these comments
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Question 4 Should FMCSA allow medical examiners to assume responsibility for making an individual determination of the ITDM drivers ability to manage this health condition, or should the agency require the physician responsible for treating the drivers ITDM to certify the driver meets the revised diabetes standard? Answer: ABA and BISC contends that the responsibility for the ensuring that the ITDM driver is fit for duty is one that is shared by the medical examiner and the drivers treating physician We want to emphasize that the medical examiner is the one responsible for certifying an ITDM individuals fitness for duty However, only when both the medical examiner and the treating physician are engaged in the process, and with each other, can the FMCSA and the traveling public have sufficient confidence in the certification process Manifestly, the medical examiner with knowledge of the CDLs holders job requirements cannot render a full and informed certification of an individuals fitness for duty without a full consultation with the treating
physician and the latters knowledge of the individuals treatment to date, response to treatment and medical record
Question 5 Should the agency revise the medical certificate to be issued by the medical examiner to a driver with ITDM to include certification from the treating physician in addition to the medical examiner? Answer: In line with the answer to Question 4, ABA and BISC agree that the agency should revise the medical certificate issued by the medical examiner Specifically, any form relevant to this issue should be revised to add: consultation with the treating physician has been completed and the new language be certified to by the medical examiner
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Question 6 Each medical examiner has discretion to set the expiration date on a drivers medical certification so that it is valid for any period up to 24 months, based on the examiners determination of how often a driver needs to be reexamined, such as for a specific health condition eg hypertension What should the Federal standard maximum period of medical certification be for drivers with ITDM? Answer: Given the serious consequences that can obtain if an ITDM individual is improperly certified or
becomes medically disqualified at any time, ABA and BISC contend that a serious and sustained review process is necessary In this regard, we offer FMCSA the template of the FAA medical certification program for pilots with insulintreated diabetes The FAA program, which uses the guidelines of the American Diabetes Association, requires an initial evaluation of individuals with insulintreated diabetes mellitus If the individual has not otherwise disqualifying conditions, especially significant diabetesrelated complications such as arteriosclerosis coronary or cerebral disease, retinal disease, or chronic renal failure, the individual may be evaluated for a medical certificate Thereafter, the individual can be evaluated for a medical certificate if he or she: 1 Have had no recurrent two or more hypoglycemic reactions resulting in a loss of consciousness or seizure within the past five years 2 have had no recurrent hypoglycemic reactions requiring intervention by another party within the past five years A period of 1 year of demonstrated stability is required following the first episode of hypoglycemia and 3 have had no recurrent hypoglycemic reactions resulting in
impaired cognitive function, which occurred without warning symptoms within the past five years
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ABA and BISC also agree with the American Diabetes Association and FAAs guidelines on how an individual may demonstrate his or her fitness for a medical certification In sum, the FAA requires copies of all of the individuals medical records concerning the diabetes diagnosis and disease history and copies of all hospital records, if admitted for any diabetes related cause, including accidents and injuries copies of complete reports of any incidents or accidents, if due in part or totally to diabetes and the results of a complete medical evaluation by an endocrinologist or other diabetes specialist physician acceptable to the Federal Air Surgeon The medical evaluation must include, at a minimum, two measurements of glycated hemoglobin total A1 or AIC concentration and the laboratory reference normal range, the first at least 90 days prior to the current measurement a detailed report of the individuals insulin dosages and diet utilized for glucose control appropriate examinations and tests to detect any peripheral neuropathy or circulatory insufficiency of the extremities
and confirmation by an ophthalmologist of the absence of clinically significant eye disease finally, verification by a specialist that the individual has been educated in diabetes and its control and has been informed of any understands the monitoring and management procedures for the condition and the actions that should be followed if complications of diabetes should arise With respect to the issue of the maximum period of medical certification for drivers with ITDM, ABA and BISC can also support the FAAs program and offer it as a guide to FMCSAs deliberations in this ANPRM In sum, the individual should submit to a medical evaluation by a specialist every 3 months This evaluation must include a general physical examination and a report of glycated hemoglobin total A1 or A1C concentration The evaluation must also contain an assessment of the individuals continued ability and
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willingness to monitor and properly manage his or her diabetes, and whether the diabetes or its complications could reasonably be expected to adversely affect his or her ability to safely control a motor coach The evaluation should also take into account the individuals medications, as the
effects of diabetes seems to also be related to the types of medication taken by the ITDM individual In addition, the ITDM individual must carry and use a digital whole blood glucosemeasuring device with memory that is acceptable to the FMCSA and provide to FMCSA or the agencys designee the individuals whole blood glucose level four times a day Moreover, the individual must provide to the FMCSA, on an annual basis, confirmation by an ophthalmologist of the absence of clinically significant disease that would prevent the individual from meeting current visual standards provide to the FMCSA immediately, a written report of any episode of hypoglycemia associated with cognitive impairment, whether or not it resulted in an accident or adverse event finally, provide to the FMCSA immediately upon determination by a specialist or other physician, any evidence of loss of diabetes control, significant complications, or inability to manage the diabetes
Question 12 The TEA21 Report to Congress discusses occupational and health risks and challenges for individuals with ITDM who operate CMVs Are there additional occupational and health risks and challenges the TEA21 Report to
Congress did not discuss? Are these attributes characteristic of certain segments of the industry? Should individuals with ITDM be restricted to operating in only certain segments of the industry eg driving locally or shorthaul, but not long haul?
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Answer: As we noted at the beginning of these comments, ABA and BISC believe that the demands of the private overtheroad bus industry pose special risks for our drivers, risks that increase with the presence of even insulintreated diabetes The risks associated with diabetes, loss of feeling in the legs or loss of consciousness and impaired judgment, would be particularly devastating in the case of a bus carrying 55 passengers Diabetes is unlike, to use an example, hypertension The deleterious effects of diabetes can act with more rapidity, with little, if any, chance for a passenger or someone else to intervene in time to prevent an accident More to the point, the effects of diabetes may be undetectable to someone who does not have a relationship to the ITDM individual someone who perhaps would notice the individuals low blood sugar or instances of impaired judgment In situations where the ITDM driver is away
from home, away from primary medical care and away from friends, the opportunity to materially affect a dangerous situation is lacking This is the kind of situation that can occur when a bus driver is on assignment to a charter or tour party, or on a scheduled service fixed route run This is also the type of situation in which an ITDM individual is likely to risk being without proper medical aid In our opinion the greater the possible harm in any situation the greater the agency control should be to prevent such harm In sum, ABA and BISC contend that changes in the medical certification program for ITDM individuals should not be available for those who would serve as drivers for overtheroad buses engaged in long haul scheduled service or operations involving charter and tour groups In addition, even those ITDM individuals who will be assigned each day eg airport shuttle operations should be carefully screened before being allowed to obtain a
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CDL The safety of the traveling public imposes a higher duty on the bus industry, its personnel and should impose such a duty on those who drive the public The ABA and BISC appreciates the opportunity to submit these
comments in this very important rulemaking proceeding
Respectfully submitted:
Clyde J Hart, Jr, Esq Senior Vice President, American Bus Association Counsel, Bus Industry Safety Council th 700 13 Street, NW Suite 575 Washington, DC 20004 Phone: 202 2187228 Email chart@busesorg
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