People around Australia were shocked when four-year-old Brax Kyle, who was walking hand-in-hand with his father, was struck and killed by an out-of-control car in a medical centre carpark at Berwick, in Melbourne’s south-eastern suburbs.
Detective Sergeant Mark Amos said the four-wheel-drive careened over a median strip into the carpark of the Epworth Medical Centre. “As he was negotiating a left-hand bend, the driver for some reason failed to take the bend,” he said.
The second shock came when it became clear that the driver was a 56-year-old man who had reportedly been returning home after dialysis treatment.
The Twittersphere lit up following this revelation, with the majority of tweets asking why the man had been allowed to drive, followed by a general consensus that no-one on dialysis should be allowed to drive. Full stop.
Brax’s shocking and tragic death has not only sent our community into mourning, it has shone a light on a question that dialysis patients and many clinicians have mostly ignored or side-stepped:
Can or should a patient drive after dialysis treatment?
Dialysis patient or not, as we age, most people begin to suffer from problems with eyesight, muscle, bone, nervous system and even mental impairments that can cause a significant drop in the ability to drive safely. Fortunately, in most jurisdictions, guidelines exist for testing and restricting drivers who, for whatever reason (age or infirmity) are no longer fit to drive. The decision to revoke a driving licence is clear cut and unlikely to change.
What about dialysis patients? In my experience (and for most people with health problems), my fitness to drive comes and goes as my health improves and deteriorates.
At first, when I was close to needing dialysis, my high creatinine and fluid levels made me tired and lethargic, slowed my thinking and concentration and gave me gastro problems. I was certainly not driving during that period.
It was the same for my first few dialysis sessions. Julie took time off and drove me to each session. It took me a few sessions to find my feet again: getting used to dialysis, handling the fluid shift, managing my blood pressure, etc. However, after the first few weeks, my creatinine level fell, I was no longer overloaded and my symptoms faded. After discussions with Julie and the Unit Manager, I began driving again.
Twenty -odd years later, I’m still driving. Mostly. Now and then I pick up a bug or some ailment that puts me low. At those times, common sense takes the wheel, and either I or Julie (mostly Julie – she has the power of veto!) decide that I’ll sit in the passenger seat. A family member drives me, or I get a cab or Uber.
On the odd occasion that I become unwell at dialysis, Unit staff (who also have the power of veto) either ask me to wait until I am fully recovered, or Mr/Ms Uber takes over. (This doesn’t mean I’m happy with the decision, but in my heart, I know it’s right.)
This informal, collective decision approach works well, with incidents like the one at Berwick being extremely rare. Twitter buzz suggests that this driver had both BP problems and was in his first weeks of dialysis. Alternatively, it may have had nothing to do with dialysis – heart failure, epilepsy, whatever, there could be many other culprits. Certainly, this incident needs closer examination as a one-off, rather than assuming that the process needs upgrading.
But, following predictable overreaction by the Twitterati, and I’m sure new risk management initiatives by medical boards of management, there is likely to be a push to formalise the decision-making process; possibly to take it out of our hands.
To drive or be driven is not a new question. Most kidney and dialysis blogs have regular “Should Dad drive after dialysis?” queries and conversations, pretty well reinforcing the status quo: Loved ones and/or unit staff have the final say.
In 2010, doctors at the Department of Nephrology at the Marshfield Clinic in Marshfield, Wisconsin released a paper: Assessment of Self-Perceived Risk and Driving Safety in Chronic Dialysis Patients. The paper outlined how they had provided a questionnaire to 186 dialysis patients, to identify high-risk driving behaviours and risk factors for impaired driving (see left – click to enlarge).
They found a significant difference in dialysis patients’ perception of their driving skill and reality. Of greater concern was the non-recognition of the problem by the patients themselves. And thus the need for an external, objective, fit-to-drive assessment, ideally by those closest to the patient.
- Safe driving guidelines for dialysis patients
- Education/tools for identifying unfit to drive patients for dialysis unit staff.
The strength of these recommendations is that it keeps the decision with the people who have intimate knowledge of the patient and removes the temptation to impose a one-size-fits-all solution. e.g. yet another regular visit to the nephrologist looking to find an ideal BP or run a cognition test.
The Safe Driving Guidelines are clear, simple and most importantly, already exist. With a little customisation for local conditions and regular application, they could readily become part of the operating procedures of each Unit, joining those of needling, infection control, etc.
While the existing unit procedures help prevent disasters inside the unit, these guidelines could help prevent disasters outside the unit.
One thing we all want is to help ensure that a tragedy like Berwick doesn’t happen again.