What would you do?

[TheLoneWolf]

60 year old female, retired school teacher seen post-op TKA for uncontrolled pain. History of failed back syndrome after 7 spine surgeries. Fusions of L1-S1 and C4-6 complicated by infected hardware and multiple revisions. On fentanyl patch, Lyrica, hydromorphone for BTP at home. No aberrancy, not sedated, follows up with neurologist who is the opiate prescriber. Mentioned that the knee arthritis leading to TKA secondary to a recent car accident. Per patient, she was driving and lost control of her car in a residential area, jumped curb, knocked over a fence and drove through several people's fences and backyards before slamming into a tree. She strongly hinted that the accident was secondary to sedation from the pain meds. She said she was so relieved that she did not drive into a pool and drown. In my head, I was much more concerned that she could have potentially hit and killed children playing in their yard, though I got the impression the risk of such may not have occurred to her, egocentric.

I thought the best course was to have her voluntarily turn in her driver's licence and immedately cease driving. If she refused then contact the DMV to inform them of the situation.I don't think an evaluation of driving fitness is appropriate for her. Assuming she continues to drive and had caused bodily injury, does the prescribing physician assume liability? What if the same situation, could a physician be liable assuming no prior problems? Also, patient travels between different states frequently and I would guess enforcing bans on driving when she is out of state would be harder if she happens to have out of state license.

Anyone have any prior experience with this?

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[drusso]

60 year old female, retired school teacher seen post-op TKA for uncontrolled pain. History of failed back syndrome after 7 spine surgeries. Fusions of L1-S1 and C4-6 complicated by infected hardware and multiple revisions. On fentanyl patch, Lyrica, hydromorphone for BTP at home. No aberrancy, not sedated, follows up with neurologist who is the opiate prescriber. Mentioned that the knee arthritis leading to TKA secondary to a recent car accident. Per patient, she was driving and lost control of her car in a residential area, jumped curb, knocked over a fence and drove through several people's fences and backyards before slamming into a tree. She strongly hinted that the accident was secondary to sedation from the pain meds. She said she was so relieved that she did not drive into a pool and drown. In my head, I was much more concerned that she could have potentially hit and killed children playing in their yard, though I got the impression the risk of such may not have occurred to her, egocentric.

I thought the best course was to have her voluntarily turn in her driver's licence and immedately cease driving. If she refused then contact the DMV to inform them of the situation.I don't think an evaluation of driving fitness is appropriate for her. Assuming she continues to drive and had caused bodily injury, does the prescribing physician assume liability? What if the same situation, could a physician be liable assuming no prior problems? Also, patient travels between different states frequently and I would guess enforcing bans on driving when she is out of state would be harder if she happens to have out of state license.

Anyone have any prior experience with this?

Counsel all patients to not operate a motorized vehicle or machinery if feeling altered from ANY medication--benadryl, blood pressure meds, psych meds, analgesics, etc.

 

[PainDrain]

She has a choice. Her medications or her license, she can’t have both.

 

[painfree23]

advise not to drive, document the hell out of it, let his neurologist know and document that as well. We can't babysit every patient.

 

[PainDrain]

advise not to drive, document the hell out of it, let his neurologist know and document that as well. We can't babysit every patient.

Advise away but you can still be held liable. This person has a proven hx of causing a MVC while impaired; continuing to prescribe and allowing them to have a license is a recipe for disaster.

 

[painfree23]

Advise away but you can still be held liable. This person has a proven hx of causing a MVC while impaired; continuing to prescribe and allowing them to have a license is a recipe for disaster.

liable even though another provider is prescribing opiates??

From OPs post: "On fentanyl patch, Lyrica, hydromorphone for BTP at home. No aberrancy, not sedated, follows up with neurologist who is the opiate prescriber."

 

[101N]

Order a driving evaluation from the DMV.

 

[willabeast]

Order a driving evaluation from the DMV.

YES! This is by far the best approach. At least in California it is. From what I understand, the California DMV does their own evaluations regarding driving ability. They will test her skills while taking her meds. It being tough to sue the State and being experts on driving The State is in the best position to decide.

 

[TheLoneWolf]

Order a driving evaluation from the DMV.

Assuming she gets approval to continue driving by the DMV, and is continued on her medications, will she require a new driving eval by the DMV every time she has a dose escalation given her prior mvc accident history?

 

[101N]

The DMV does a good job. When I've sent folks for these they haven't kept their license.

 

[PainDrain]

The DMV does a good job. When I've sent folks for these they haven't kept their license.

101N. Is your avatar Forrest Tennant?

 

[lobelsteve]

Tie her Neurologists hands. MVA due to sedation as reported by patient in your office. Personal liability will fall on the Neurologist for ongoing prescribing if he does not notify DMV to take away license.

This is her opportunity to come off meds. Continued use despite harm and a loss of control have occurred here. Pain? Whatever. Life and death issues first. Liability for patient and provider and society are second. CC to Neurology of exactly what I said. Print PDMP on her in a month and if ongoing Rx, notify DEA/medical board.

I had a longstanding patient DUI when in CA last year. She came back to GA after 5 mo in jail for DUI/fleeing seen. Asked for meds, got counseling. Will check pDMP next week and see if anyone got duped.

 

[101N]

101N. Is your avatar Forrest Tennant?

No it's Lynn Webster

 

[Ducttape]

letter to DMV stating that patient is a danger to herself or others if she maintains her license on her present dose of meds. detail that you do not believe the patient should be allowed to be evaluated for driving capacity until she has met certain criteria:

- mandatory taper of opioid medication, to ( 90 and as low as possible if over 90 MED, and probably off if <90. maybe butrans, but wouldnt recommend tramadol.

- full review of all meds (ill bet she is also on a muscle relaxant) with cessation of most if not all of them.

-neurologist should do a full dementia workup, also, consider geriatric evaluation​

-then and only then, an assessment of driving ability after she has tapered off sedating medications.

.

 

[Blitz2006]

I agree with what everyone says, but for discussion/learning purposes, would you all be just as aggressive in counselling/DMV referral if this was her 1ST MVA?

 

[lobelsteve]

I agree with what everyone says, but for discussion/learning purposes, would you all be just as aggressive in counselling/DMV referral if this was her 1ST MVA?

Nah, sit on it, let her die in next MVA with your charts showing all that was just said. Might get manslaughter due to lack of action. Let's see what happens to the deputies in FL who waited outside the school while the shooting goes on. Same thing.

Or, try and save lives. Man up. NOW!!!

 

[Blitz2006]

Nah, sit on it, let her die in next MVA with your charts showing all that was just said. Might get manslaughter due to lack of action. Let's see what happens to the deputies in FL who waited outside the school while the shooting goes on. Same thing.

Or, try and save lives. Man up. NOW!!!

I hear ya.

But I ask because let's say this was 1st MVA. It doesn't necessarily mean it was secondary to opioids, right?

Also, stupid question time, but what's the HIPAA on this? Can we report patient info to DMV without patient consent?

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[lobelsteve]

I hear ya.

But I ask because let's say this was 1st MVA. It doesn't necessarily mean it was secondary to opioids, right?

Also, stupid question time, but what's the HIPAA on this? Can we report patient info to DMV without patient consent?

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Raise your right hand.....
knew or should have known.

See HIPAA thread.

 

[lord_jeebus]

Check your state laws. You may already be obligated to report the patient to the DMV based on what you know. In California (the only state I am familiar with), you are legally mandated to report any patient with lapses in consciousness. So, if you failed to do so and the patient had an accident, you would potentially not only be liable but also open to criminal charges.

 

[Ducttape]

I agree with what everyone says, but for discussion/learning purposes, would you all be just as aggressive in counselling/DMV referral if this was her 1ST MVA?

How many do you need to become concerned?

 

[Blitz2006]

How many do you need to become concerned?

I personally would be concerned even with one MVA. Just wondering what I should do if a patient experiences this, as I have yet to encounter a situation like this.

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