Posted by Kingman Strohl on April 03, 2003 at 19:23:16:In Reply to: Assessing Roadworthiness posted by Krishna on March 23, 2003 at 12:41:59:
Analyze the above description in detail to provide a differential diagnosis for the initial evaluation and a separate one for the current situation.
Before the crash there was history suggestive of sleep apnea (snoring, restless sleep, and daytime sleepiness) and extrinsic sleep disorder NOS (back pain with narcotic use). Sleep restriction secondary to the back pain would result in added sleep debt. The timing of the accident (afternoon circadian dip) and the circumstances (non-evasive action, and serious injury) are consistent with a fall asleep car crash. I would like to get more history from family on sleep habits and sleepiness as well as more information on medication, alcohol, and other drug/OTC/herbal use as well. Lifestyle of sleepiness is often multifactorial. More history would be needed to fully exclude depression as another cause for sleepiness.
What all would you do to address the issue of allowing this individual to resume driving?
The American Thoracic Society statement on drowsy driving suggests that in the absence of applicable state law the patient is the best source of information. The physician can alos get history from family and others about sleepiness symptoms. Neither tesing (MSLT or MWT) nor compliance at present have predictability in regard to another rflal asleep car crash. In the event that this is a commercial driver there may be a higher standard for assurance of compliance (use of monitoring) or efficacy (by MSLT or MWT the latter having less standardization). Instruction on risk factors (medications and sleep loss as well as alcohol and sedating medications) and countermeasures for drowsy driving (avoid driving when sleepy, get other drivers) may be discussed with the patient.
If the patient unwilling or unable to adhere to therapy, in the absence of a state law I would refer the patient to the Medical Board for Drivers Licence or to the Driver’s License.Detail your line of management at this point and what decisions you will make based on possible outcomes with specific key action items in your plan.
I would want to talk to the family about this problem and get a sense of commitment. The orthopedic consult could direct therapy to relieve back pain or use non-pharmacologic means (TENS unit, topical medications).
I would arrange for follow-up initially at frequent intervals intiatlly with sleep logs, checking compliance on machine, and Epworth sleepiness scale to gain trust and insight into this person’s ability to adhere to treatment. Depression may recur and need treatment. With adequate