Monday 5 November 2018

Clear crumblies off the road

I caught a snippet on the wireless where they interviewed Desmond O’Neill, Director of the National Office for Traffic Medicine. Yes, there is such a thing. It's hard to work out how big the quango is because a) O'Neill has day-jobs as TCD's Professor of Medical Gerontology AND Consultant in Geriatric and Stroke Medicine at Tallaght Hospital and b) the NOTM is under the umbrella of the RCPI Royal College of Physicians in Ireland.

Aside-o-rant: What is it with all the Royals, already? Royal College of Surgeons, RCPI, Royal Dublin Society. and whole raft of organisations where the great and the good hobnob together. Do we not live in a Republic?

What are we talking about here? Let us consider the NOTM's definition: The term “traffic medicine” evolved to embrace all the disciplines, techniques, and methods aimed at reducing the harm traffic crashes inflict on human beings. This includes medical and surgical care provided to crash victims, improving vehicle crashworthiness, developing better safety belts and brakes, designing safer roads and traffic control systems, training and educating drivers, research into the biomechanics and epidemiology of traffic crashes, and developing and enforcing traffic safety policies. The best-known element of traffic medicine is the need for medical certification showing fitness to drive.

Aha! That's why the Office is headed up by a Geriatric specialist. They have just launched new 7th Edition October 2018 guidelines so that doctors are well informed when they certify that their patient Bridie O'Crumble is fit to drive. The guidelines are issued by the RSA = Road Safety Authority = Údarás Um Shábháilteacht Ar Bhóithre. My late lamented mother-in-law got the cert from her GP whenever she asked for it despite getting through a quite remarkable number of wing-mirrors in her declining years. I'm sure Bridie similarly gets a pass because the doctor would rather please her client than please the unknown parents of the child who will be killed when Bridie has a senior moment while driving. Will the new guidelines help get some rational decision-making into the process of certification? I don't think so because the 'guidelines' are 126 pages long! I cannot imagine what the full report looks like - it must fill the boot of Bridie's doctor's car. I also cannot imagine a busy GP reading through such a mass of information when they haven't time to read their copy of The Lancet and the BMJ. Certification is not only about oldies; here are the chapter headings.:
  • Neurological disorders incl epilepsy and seizures
  • Cardiovascular disorders  
  • Diabetes Mellitus  
  • Psychiatric disorders
  • Alcohol & Drugs misuse and dependence  
  • Visual Disorders 
  • Renal disorders
  • Respiratory and sleep disorders incl. Obstructive Sleep Apnoea Syndrome OSAS
  • Miscellaneous 
That has the ring of sense, my father was late onset diabetic and a bit of a boy-racer. Our greatest fear was not that he would fall into a diabetic coma at the wheel and write himself off; but that he'd fall asleep at the wheel and plough into a line of kids waiting for the school-bus. That is a real and present danger for diabetics but OSAS seems a bit odd in this context. Sleep apnoea is a condition where the soft pallet at the back of the mouth collapses during sleep and stops air making it to the lungs; this causes a micro-wake which opens up the gullet; sleep returns; apnoea follows; repeat until frazzled or death ensues. If you're asleep enough to experience apnoea you surely shouldn't be driving! On that face of it, including OSAS in the list of driving contra-indications seems nutty. But the disturbance of normal night-time sleep leads to daytime tiredness and that has the potential to cause fatalities.

I'm sure that there are GPs across the country who wish they had time to read through these guidelines because the compromises to safe driving are so many and varied. What's required is for one of the GPs to read the whole document and write an executive summary that can capture the most likely events / conditions that will have the greatest adverse effect and lay them out as bullet points on a single side of A4. That might be fit for purpose.

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