Return to work

as a public
driver after
Suryo MCI
Wibowo, MD, MOHS
 Introduction

Driving is a universal activity in all big

cities around the world.
Ordinary drivers of private vehicles,
may spend an average of 250 h a year
at the wheel.
For professional or vocational drivers
the figure is many times higher.
People who live in urban communities
rely upon the motor car for such things
as getting to work, shopping, visiting.
 Introduction
Commercial/public driver population

Prevalence of cardiovascular disease

Powerful impact on the health and safety

 Case report

A 45 years old work as an urban public transport

driver, comes to clinic complaining of chest
discomfort. He describes the discomfort as a
severe, retrosternal pressure sensation that had
awakened him from sleep 3 hours earlier. He
previously had been well but has a medical
history of hypertension since five years ago, take
medication only when he had headache. He has a
30 years history of smoking (2 pack per day). He
denied that he had diabetes mellitus and
?? Return to work
? ?
How long is the period of time off work required
? Ris
When
for the we can certify
patient thatacute
following
to work after their MI?
infarction?
a patient can return
myocardial

? C
How
Is
for
about
there any the

kapacity
even
thesudden
work
patient?
environment?
risk for repeated
limitation heartrestriction
or work attack or
death if he back to the same work

?
How about the safety for his passengers and
Can the patient work again as an urban public
other traffic users if he work again as an urban
transport driver?

Tolerance
public transport driver?
Risk
Risk refers to the chance of
harm to the patient, or to the
general public, if the patient
engages in specific work
activities.
 Risk
In the CAD population, sudden cardiac
death is a well-recognized phenomenon.

While death is termed “sudden” in epidemiological literature, it

may not be instantaneous; there may be preceding symptoms.
Clearly, the patient who experiences chest pain during driving
does not pose the same risk as the driver who has a sudden
ventricular arrhythmia while behind the wheel.

[1] Epstein AE et al. Personal and public safety issues related to arrhythmias that may affect consciousness: implications for regulation and physician recommendations.
Circulation. 1996; 94: 1147 – 1166.
 Risk Establishing Risk for Commercial Drivers

Risk is an expression of the probability of an event

occurring over a certain period of time.
The level of risk must be considered within the
context of the setting and activity in question and what
society considers acceptable.
Determining "acceptable risk" becomes a matter of
public policy. Therefore, the decision to certify or
disqualify a commercial driver is both a medical and a
societal decision.
 Risk Establishing Risk for Commercial Drivers

Should you restrict your cardiac patient from driving?

The fundamental question when deciding if a driver should

be certified is whether the CMV driver has a cardiovascular
disease that so increases his/her risk of sudden death or
incapacitation that the driver endangers his/her health and
safety and the health and safety of the public sharing the
road with them.
Physicians are obliged to disclose this risk to their high-risk
patients and to advise them not to drive.
Risk Establishing Risk for Commercial Drivers

According to Task Force Report for the European Society of

Cardiology by Petch MC et al, a person should be advised not to
drive if he/she suffers or has suffered from any of the following
conditions:
q angina pectoris (stable or unstable);
q myocardial infarction, CABG, PTCA;
q peripheral vascular disease;
q hypertension;
q aortic aneurysm including Marfan syndrome;
q heart failure;
q heart and/or lung transplantation, and other heart diseases.

[1] Petch MC et al. Driving and heart disease. European Heart Journal (1998) 19, 1165 – 1177.
Risk
Establishing Risk for Commercial Drivers

• Group 1 comprises drivers of ordinary

motor cycles, cars, and other small vehicles
with or without a trailer (A, B, B + E, and
sub-categories A1 and B1).
• Group 2 includes drivers of vehicles over
3.5 metric tonnes (3500 k) or passenger
carrying vehicles exceeding eight seats
excluding the driver (C, C + E, D, D + E,
C1, C1 + E1, D1, D1 + E1).
• Drivers of taxi cabs, small ambulances, and
other vehicles form an intermediate
category between the ordinary private
driver, and the vocational driver.
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Establishing Risk for Commercial Drivers
 Risk Establishing Risk for Commercial Drivers

Assessing the risk of harm to patients and bystanders

The risk of harm (RH) to other road users posed by the driver with heart
disease is assumed to be directly proportional to the following:
• time spent behind the wheel or distance driven in a given time period
(TD)
• type of vehicle driven (V)
• risk of sudden cardiac incapacitation (SCI)
• the probability that such an event will result in a fatal or injury-producing
accident (Ac)
Expressing this statement as Formula: R =T X V S X XA
H D CI c
 Risk Establishing Risk for Commercial Drivers

CHD and motor vehicle crashes

Petch, MC. Task force report. Driving and heart disease. Eur Heart J. 1998; 19:1165 – 77.
 Risk Establishing Risk for Commercial Drivers

Sudden death and the incidence of crashes

Some studies reported the “surprising finding" that a significant

“surprising finding"
number of drivers who died suddenly did not cause serious injury to
other members of the community. It is postulated that drivers who have a
myocardial infarction experience warning symptoms, which allows them
to take action to prevent a serious accident.

Kerwin AJ. Sudden death while driving. Can Med Assoc J, Vol 131, August 15, 1984. Page 312
 Risk Establishing Risk for Commercial Drivers

Sudden death and the incidence of crashes

In Trapnell and Groff’s study of 50 cases of proven MI:
• 32 men drove tanker fuel trucks,

• 7 drove 2.5-ton delivery trucks, and

• 11 drove panel or pickup trucks incidental to their

jobs.
Although 12 of the initial attacks occurred during the
scheduled work period, no vehicle crashes resulted.
 Risk Establishing Risk for Commercial Drivers

Sudden death and the incidence of crashes

Thirty-five of the 50 returned to driving.

Five of the 35 probably had second infarctions.
● Two of the five were found at the side of the road in their trucks,

● two died at service stations, and

● one, who had stopped driving three years before, died while working

as a guard.
● So, four of the drivers died while driving on the job and were

apparently not involved in accidents; it is possible that some

of them may have recognized trouble in time to stop.
 Risk Establishing Risk for Commercial Drivers

Sudden death and the incidence of crashes

The most comprehensive and detailed account to sudden death in drivers is that of
Myerburg and Davis, who analyzed 1,348 cases of sudden death due to CHD
between 1956 and 1962 in Dade County, Florida.
Only about 26% of the victims had been known to have coronary disease; 41%
had had no previous heart trouble, and 33% had had symptoms not recognized as
being of cardiac origin.
Of 37 truck drivers who died 13 were in their trucks at the time but had only
minor or no accidents.
Of 32 other public vehicle drivers 5 died at the wheel, again without other serious
incident.
Of the 52 who died while driving private vehicles 32 were able to stop without
causing damage, 15 caused minor property damage and 5 caused minor injuries in
other people.
 Risk Establishing Risk for Commercial Drivers

Sudden death and the incidence of crashes

Reasons for the relatively low incidence of crashes resulting from

sudden death of the drivers include:
• Drivers with significant CVD are disqualified from driving at their commercial
driver medical examination;
• Drivers at highest risk of cardiovascular collapse, for example in the first month
or so following myocardial infarction, are not driving; and
• Many persons do not feel well in the six to 24 hours preceding their infarction and
cancel their plans to drive.

Braunstein, JB; Blumenthal, RS. Ischemic heart disease in Cardiovascular advisory panel Guidelines for the medical examination of commercial motor vehicle drivers. Federal
Motor Carrier Safety Administration – US Department of Transportation. Page 15.
Capacity
Capacity refers to concepts such as
strength, flexibility, and endurance.
These are measurable with a fair
degree of scientific precision.
Actually, “capacity” indicates that
the individual is already maximally
trained and fully acclimated to the
job or activity in question.
Capacity Assessing work capacity/capabilities

History: Physical:
• Signs on
Review of prior and
current symptoms examination
● arrhythmias
• CP, dyspnea,
orthopnea, etc
● JVD
● edema
Evidence of ● chest exam
improvement with
treatment? Descriptions
• Review previous
of exertional tolerance and current
(routine activities, work records
simulations)
Current medicines
 Capacity Assessing work capacity/capabilities
Exercise EKG

Better for assessing isotonic exercise/work

(walking, running etc)
Results in  cardiac output, BP remains stable
through  peripheral vascular resistance,
Exercise testing may not yield good estimate
of capabilities for isometric work (lifting,
static exertion)
BP elevates without reduction in PVR
 Capacity Assessing work capacity/capabilities
Some numbers

3.5 METs : Bartending, frequent walking with 10lb objects (many office jobs)
4 - 5 METs : Painting, masonry work, light carpentry
5 - 6 METs : Lighter digging, shoveling
6 - 7 METs : Heavier or more frequent shoveling
7 - 8 METs : Carrying 50-60 lbs; sawing hardwood
 Capacity Assessing work capacity/capabilities

Job description:
Always request
Assess static vs dynamic work
Other stressors (temperature, psych)
Other exposures (CO, cigarette smoke)
Simulated work (+/- exercise EKG) may be better in judgment of
capabilities than testing in lab setting
Specialist opinion: but beware of conservatism
 Capacity Assessing work capacity/capabilities
Some guidance
Average energy demands of job can safely be  40% of peak workload
Peak energy demands of job should be < maximum workload achieved on
testing

Thus individual generating 8+ METs can be reasonably asked to work at light-

medium physical demand level
Over half of post-CABG patients considered “totally
disabled” could have safely performed their normal duties
or equivalent work, based on exercise testing results
Lundbom J, et al. Exercise tolerance and work
abilityfollowing aorto-coronary bypass surgery.
Scand J Soc Med 1994;22:303-8.

Consider in the disabled individual:

§ Inadequate treatment
§ Depression
§ Whether accommodation or changing non-
essential requirements of job will allow return
§ Socio-economic explanations
 Capacity Assessing work capacity/capabilities
What about exercise-testing of asymptomatic workers?

Predictive value of positive test is low in younger asymptomatic

individuals: High false-positive rate requires additional work-up
in many cases
May have better predictive value in > 40yo with other risk factors
(smoking, obesity, +FH, hypercholesterolemia, etc)
 Capacity Assessing work capacity/capabilities
Fitness-for-duty Evaluations

Many safety-sensitive jobs (fire, police) have qualification

requirements based on exercise testing or physical fitness
standards
Principles outlined in last slide apply: predictive value may be
low in younger/healthier workers

Be careful not to exclude asymptomatic workers on basis of

positive exercise test only
ADA conflicts: May not be limited in performance of job
 Capacity Special work problems and restrictions

Lifting weights

Those with moderate to severe restriction may need to be confined to a maximum

of 10 lb (4,5 kg) or an equivalent degree of force on levers, turning wheels, and
similar machine controls
Physical effort requirements well above normal, such as work ini foundries and
forges, may well be reasons for barring such employment in patients with heart
disease, especially those with symptoms of shortness of breath or angina.14
Rapid and tightly controlled pacing of work, such as on assembly lines, has not
been shown to be a precipitating factor for myocardial infarction and should not
inhibit a normal return to work after a heart attack.
If employees were managing satisfactorily before their infarction they may well
manage afterwards if they are not severely disabled by shortness of breath or angina.
Returning to their own work, where social support is provided by former rather
than new colleagues, may be less of a problem than trying a new task.14
 Capacity Special work problems and restrictions

Management roles and shiftwork

If all has been well before the illness, returning to the same job may be
the least stressful option.
Permanent night working can be easier if it has been managed well
previously. At night, organizations tend to function more routinely with
less interference from peripheral parts of the undertaking. The co-
operation amongst members of a team may well be higher and
productivity can appear better.
 Capacity Special work problems and restrictions

Working time regulations

Health assessments are required under these regulations if the

individual is a night worker and suffers from a medical condition which
may be made worse by night work. Some heart and circulatory
disorders, particularly those which affect physical stamina, will come
into this category. The worker may need to be transferred to the day
shift if the assessment so indicates.
 Capacity Special work problems and restrictions

Toxic substances

Work involving exposure to certain hazardous substances may aggravate pre-existing

coronary heart disease and careful consideration should be given to patients who are
returning to jobs involving exposure to chemical vapours and fumes.
• Methylene chloride
• Carbon monoxide
• Carbon disulfide
• Nitroglycerine
• Trichloroethylene or 1,1,1-trichloroethane
• Chlorofluorocarbons (CFCs): CFC-113 and CFC-22
Certain industrial workers will need proper assessment of their workplace by an
occupational physician together with an occupational hygienist, so that they can be
advised on their suitability for work handling chlorinated hydrocarbon solvents or
 Capacity Special work problems and restrictions

Confined spaces

People with heart disease or severe hypertension may need to be excluded.

Certain occupations may require the use of special breathing apparatus, either routinely
(e.g. asbestos removal workers), or in emergencies (e.g. water workers handling
chlorine cylinders).
The additional cardiorespiratory effort required while wearing a respirator,
combined with the general physical exertion, usually means that people with a
previous history of CHD need to be excluded from such work.
 Capacity Special work problems and restrictions

Hot conditions

Working in hot conditions may prove difficult for some patients with heart disease.

High ambient temperatures vasodilatation of the

Significant heat radiation from hot surfaces or liquid vessels in muscle
metal and skin.
added to the physical strain of heavy work

Compensatory vascular
Reduced cerebral Reduced central
and cardiac reactions to
or coronary blood pressure
maintain central blood
artery blood flow
pressure

The resulting weakness or giddiness could prove dangerous. Since many cardioactive
drugs have vasodilating and negative inotropic actions, some reduction in dosage may
be necessary in such circumstances.
 Capacity Special work problems and restrictions

Cold conditions

Cold is a notorious trigger of myocardial ischaemia and caution must therefore be

exercised for individuals who suffer from CHD.
Impaired circulation to the limbs will result in an increased risk of claudication, risk of
damage to skin (frostbite), and poor recovery from accidental injury to skin and deeper
structures.
Cuts and bruises from accidental contact with furniture, machinery, etc., or from
dropped objects may not heal at all well in the presence of circulatory restriction, and
there could be a risk of the onset of gangrene and the subsequent need for disabling
operations. Limbs at risk need adequate protection continuously while at work.
 Capacity Special work problems and restrictions

Driving

Ordinary driving may be resumed 1 month after a cardiac event, provided that the driver does not
suffer from angina which may be provoked at the wheel.
Vocational driving may be permitted at 6 weeks, subject to a satisfactory outcome from non-
invasive testing.
Ordinary driving licence holders do not need to notify the DVLA, Swansea, if they have made a
good recovery and have no continuing disability, but vocational drivers must notify the DVLA.
Insurance companies vary in their requirements but most policies are temporarily invalidated by
illness.14
 Capacity Special work problems and restrictions

Electromagnetic fields

Industrial electrical sources such as arc welding, faulty domestic equipment, engines, anti-theft
devices, airport weapon detectors, radar and citizen’s band radio, can all potentially affect
pacemakers but, in general, the patients has to be very close to the power source before any
interference can be demonstrated, and the pacemaker abnormality is confined to one or two
missed beats or reversion to the fixed mode. The number of documented cases of interference in
the UK is fewer than three a year.
 Capacity Special work problems and restrictions

Travel

Following a cardiac event such as myocardial infarction, individuals should

convalesce at home and should not travel until they have been assessed by their
physician at 4 – 6 weeks.
Those with no evidence of continuing myocardial ischaemia or cardiac pump
failure can then travel freely within the UK for pleasure, e.g. holidays.
Business and overseas travel is more problematic because the physical and
psychological demands are greater.
Additional difficulties for the overseas traveller include the uncertain provision of
coronary care facilities in some countries and the justifiable reluctance of
insurance companies to provide health cover.
Such travel is best deferred until 3 months have elapsed and any necessary further
investigations and treatment have been carried out to ensure cardiovascular fitness.
Tolerance
Tolerance is a
psychophysiologic
concept.
It is the ability to tolerate
sustained work or activity
at a given level.
Symptoms such as pain
and/or fatigue are what
limit the ability to do the
 How to evaluate work ability
algorithm
What is the job in question?
What is the job description?
What this patient is expected to do at work?

What is this patient’s medical problem?

What are the objective signs of pathology?
What are the symptoms?
Is this permanent or temporary?
Is this problem improvable with time, or medical treatment, or exercise
(which includes work)?

Total disability?
 How to evaluate work ability
algorithm
Total disability?

Yes No

Is there significant risk of substantial harm with work activity?

Yes No
Work restriction on
the basis of risk

Is this patient actually able to physically do the task in question

(not considering symptoms, but ability)
 How to evaluate work ability
algorithm
Is this patient actually able to physically do the task in question
(not considering symptoms, but ability)

Yes No

Consider tolerance Work limitation

wants to do the job does not like doing the job based on tolerance
for symptoms like pain and fatigue
Yes
Is there severe objective pathology present
that makes physician agreement on work
Certify that he/she is
problems based on tolerance likely?
medically able
 How to evaluate work ability
algorithm
Is there severe objective pathology present
that makes physician agreement on work
problems based on tolerance likely?

Yes No

Certify that work “problems” and the objective pathology is

are present “on the basis of
believable symptoms and
severe objective pathology,”
but certify that the patient
may work despite the
symptoms if he or she wishes.
only mild or moderate, certify
that the patient may work at
the job in question, but that
he/she describes symptoms at
a certain level of work
activity.
Thank you