A Public at Risk: DOT Rejects Sleep-Apnea Testingby Eli Hendel, M.D. Medical Reviewer
The Department of Transportation (DOT) recently dropped a proposal requiring sleep-apnea testing for truck drivers and train engineers during the medical-certification process.
At the same time it also de-prioritized a proposal requiring speed limiters for trucks and trains. The agency in charge of advising the DOT on these matters, the Federal Motor Carrier Safety Administration (FMCSA), decided there was not enough information to support the proposed rules. Since the population at large is exposed to commercial drivers, it’s worth a closer examination of the issues and the decision.
What is the medical certification process?
As a pulmonologist and sleep-medicine specialist, I recently applied for certification to be a Medical Examiner for individuals seeking to maintain their license as a commercial driver. So I have a professional stake in these decisions. The process to become certified as a Medical Examiner is quite extensive.
There are 13 standards used to determine a driver’s medical fitness. These include a robust evaluation of cardiac conditions, hypertension, diabetes (individuals taking insulin need a federal exemption),vision, hearing, ability to rotate the neck by a certain degree, and psychological stability. However, there are no standards for sleep disorders. This assessment is left to the discretion of the certifying examiner. It was hoped that a sleep-apnea rule would give clarity to Medical Examiners, employers, and the drivers themselves.
This decision to exclude sleep-apnea screening and limiters is surprising given recent high-profile incidents involving somnolent truck drivers, resulting in serious accidents and loss of life. One train conductor in Hoboken, New Jersey was found responsible for an accident that injured many people riding on the train that day. After the fact, he was diagnosed with untreated obstructive sleep apnea (OSA).
The Obama administration suggested that this sort of incident could have been prevented and offered one proactive approach: screening all train engineers and truck drivers for sleep apnea. This recommendation, unfortunately, turned into a politically charged and divisive idea, and the Trump administration, following its philosophy of deregulation, decided to shelve it.
The medical community is also divided on the issue. The American Academy of Sleep Medicine (AASM) strongly believes that drowsy drivers are responsible for a significant number of accidents and supports the screening of all commercial drivers for sleep apnea.
There is robust evidence that untreated obstructive sleep apnea, which results in excessive daytime sleepiness, has been the major contributing cause in a significant number of auto accidents. A study involving 316 long-distance truck drivers revealed that over 52 percent reported snoring, a major symptom of obstructive sleep apnea, and almost 30 percent stated that they had past traffic accidents. Almost one third of these accidents resulted in loss of life.
A study conducted by the University of Pennsylvania and sponsored by the Federal Motor Carrier Safety Administration (FMCSA) and the American Transportation Research Institute of the American Trucking Associations, found that almost 28 percent of commercial truck drivers had mild to severe sleep apnea.
The AAA Foundation for Traffic Safetyreleased a 2014 report indicating that an estimated 328,000 traffic accidents each year and over 6,000 fatalities were due to drowsy driving.
Nevertheless, The U.S. Preventive Services Task Force published a 2017 position statement in the Journal of the American Medical Association (JAMA) stating that, when considering healthy, asymptomatic individuals, there is insufficient evidence to support screening for sleep apnea. The group did, however, state that there may be a different recommendation in the case of “persons who work in safety-sensitive transportation occupations.”
Trucking companies concerned about liability issues are facing the risk of being sued if they try to enforce the sleep-apnea screening rules independently. A recent high-profile case went to the Supreme Court (though it rejected the case, sending it back to a lower court). It involved a driver who sued the Crete Carrier Corporation for requiring that he participate in an apnea-screening program since it violated his rights as stipulated in the Americans with Disabilities Act.
The lack of definitive recommendations and policies by the government agencies and professional agencies was a major issue in the consideration of the case by the courts.
Although currently there is no mandated requirement for the screening or treatment of obstructive sleep apnea, there are measures that companies can take to prevent potentially dangerous sleep deprivation. There are current regulations that guide how long the commercial driver can operate a vehicle and how much time must be set aside for sleep.
These regulations apply to property-carrying drivers with vehicles transporting in excess of 10,000 pounds and passenger-carrying drivers who transport more than 16 people at one time.
Specific guidelines for property-carrying drivers include:
The 11-hour-limit rule: A driver may drive a maximum of 11 hours _after _10 consecutive hours off-duty.
Rest-break rules: The driver can start a new driving experience only if eight hours or less have passed since the end of the driver’s last off-duty or sleeper-berth period (with a duration of at least 30-minutes rest).
The 60/70 hour limit rule: The driver cannot drive after 60/70 hours of duty in 7/8 consecutive days. A driver may restart a 7/8 consecutive day period only after taking 34 or more consecutive hours off-duty.
There is still some confusion regarding the rules on a record of duty status (ROD) and standardized clarification is still needed for the terms “on-duty time,” “driving time,” “sleeper-berth time,” “driving on duty,” and “on duty/not driving time.” In addition, there are other terms that apply to driver time that are sometimes combined experiences that need to be clearly and uniformly established, including “14-hour not driving-duty period,” “11-hour driving duty period,” and “60 hours/7 day limit.”
I am personally disappointed with the decision not to mandate sleep-apnea evaluations for all commercial drivers and engineers. Currently there is a strong mandate to monitor commercial drivers for hypertension, diabetes, and vision capabilities when, in fact, untreated sleep disorders are largely responsible for more accidents than those three conditions combined. I hope there will be a strong push to reconsider the decision. It might actually take consumer action to force the issue.