Medical exemptions from safety belt use
Exemptions to Iowa's safety belt law are allowed for certain medical reasons. The medical conditions which may warrant an exemption from safety belt use, recommendations for the issuance of such medical exemptions, and requirements of the law or regulations concerning medical exemptions are discussed in the following guidelines issued by the Iowa DOT.
Guidelines for exemption
Iowa Code § 321.445, which went into effect July 1, 1986, requires drivers and front seat occupants of motor vehicles to wear properly fastened safety belts. However, exemptions can be granted to a person possessing a written form signed by a physician/chiropractor stating that the person is unable to wear a safety belt or harness due to physical or medical reasons.
The physicians/chiropractors of Iowa have strongly supported the use of safety belts for many years, recognizing the fact that the mortality and morbidity incurred by unrestrained drivers and passengers in motor vehicle crashes are greater than by those properly restrained. Two decades of realworld experience have proven belts prevent or mitigate serious or fatal injuries by about 50 percent. In Iowa, the use of safety belts could prevent an estimated 100 to 150 deaths each year.
Experience in countries where belt use is required has shown that less than 1 percent of all motor vehicle related injuries are caused by the belt per se. Such injuries predominantly occur under conditions where an unrestrained occupant would be much more seriously injured.
The safety belt law provides no categorical, specific or routine medical grounds for granting a medical exemption. Each case should be decided on its own merit. If a medical exemption is granted, it should be issued for a valid medical reason.
Because of the benefits of using a safety belt, physicians/chiropractors should weigh very carefully the advantages of reducing the risk of injury or death to the patient who drives against any medical reason the patient may give for seeking an exemption from using a safety belt. If a person is fit to be in control of a vehicle, the evidence indicates he or she is fit to wear a safety belt. Furthermore, physicians/chiropractors should be extremely reticent in granting medical exemptions to patients who are primarily passengers. If such patients are genuinely unable to use a safety belt, or decline to use it, they should be advised, and strongly urged, to ride in the back seat of the motor vehicle where it may be relatively safer to ride without a belt.
Safety belt use or nonuse may become evidence in court. Physicians/chiropractors are encouraged to keep a record of any medical exemption granted, the reason for it, the date it was granted and its expiration date.
Medical reasons for exemption
Some of the medical reasons that may be presented by patients for obtaining a medical exemption include certain musculoskeletal conditions and deformities, pregnancy, scars, pacemakers, ileostomies or colostomies, conditions of the breast, disabling conditions, unusual body size or shape, or psychological conditions. Many of the reasons presented result from lack of knowledge of the purpose and correct adjustment of the safety belt itself.
Musculoskeletal conditions and deformities
A correctly applied safety belt should not restrict the motion of patients with arthritis of the neck and shoulders while driving. If the rotation of the neck is limited and the trunk cannot be rotated while backing up the motor vehicle because of the safety belt, the patient may be informed that is legal to remove the safety belt when backing up.
Certain severe abdominal skeletal conditions, such as rheumatoid spondylitis, ankylosed major joints, deformity or fusion of the spine or major joints, other gross musculoskeletal deformities, or orthopedic devices such as body casts, may make it impossible for the patient to fasten a safety belt properly. In such conditions, a medical exemption may be considered.
Ileostomies and colostomies
Ileostomies and colostomies in persons of average size and build do not interfere with the use of a correctly applied safety belt. Persons with ileostomies and colostomies who have been involved in major vehicle crashes while wearing a safety belt have occasionally suffered irritation of the exposed mucosa, with some bleeding and even tearing of the mucosa from the stoma wall caused by sudden constriction by the safety belt. Such injuries are relatively minor in comparison to what could be expected from not wearing a safety belt.
Based on research to date and experience from countries with compulsory safety belt use law, pregnancy — no matter at what stage — is not a valid reason for exempting safety belt use. In studies of belted pregnant women involved in motor vehicle crashes, it has been shown that there has been no increase in injuries to the fetus, or in fetal loss or abortion as a result of proper use of a safety belt.
Pregnant women should be instructed to position the belts correctly; the lap part should lie comfortably below the anterior superior iliac spines and the diagonal part across the costal margin, the sternum and clavicle. Thus, no part of the harness is allowed to compress the uterus.
Pacemakers are commonly implanted in the upper right part if the anterior chest just below the clavicle in about 85 percent of the patients, and on the left side in about 15 percent. In general, safety belts do not cause discomfort to the pacemaker wearer or damage to the pacemaker itself.
If the pacemaker has been recently implanted and the surgical wound is still painful, a foam pad may be taped to the skin overlying the pacemaker to prevent any irritation while the safety belt is being used.
Should the wearer of a pacemaker be involved in a motor vehicle crash and the pacemaker receive a direct blow by the safety belt, the wearer should, as a precaution, have the pacemaker checked by his or her physician/chiropractor for any malfunction. Such malfunctions, however, have not been observed clinically or experimentally.
Well-healed scars present on the chest or abdominal wall are not harmed by a correctly positioned safety belt. Occasional irritation and pain have resulted from prolonged wearing of a safety belt, often too loosely positioned which allows a certain amount of friction and movement over parts of a scar.
Recent tender or painful scars may require a foam pad taped to the skin to prevent irritation and pain to the area over which the safety belt lies.
Physically disabled persons permitted to drive with a restricted driver's license will benefit from the use of safety belts because of the stabilization provided by the restraints. The guidelines for musculoskeletal conditions and deformities also apply to physically disabled persons.
Conditions of the breast
Breast irritation (mastitis) is rarely caused by belt use. When the safety belt is repositioned or the tension of the safety belt is reduced by use of a comfort clip or the "window shade" feature, the condition usually is resolved within a short time.
Special height or weight conditions
Persons five feet tall or less may complain that the shoulder harness safety belt crosses their neck, causing them discomfort. These persons should be referred to their car dealers for possible adjustment of the height of the seat, installation of a power seat, or the repositioning of the upper seat belt mounting point using a drop link. Adjustment of the position or tension of the safety belt with a comfort clip or the "window shade" feature may also help to alleviate the problem. Persons who are extremely obese and complain the safety belt does not reach across their abdomen should be referred to their automobile dealers for medication of the existing belt, a safety belt extender, or for the belt's replacement with a more appropriate one. If none of these alternatives are feasible, an exemption may be considered.
Patients manifesting severe claustrophobia can often be helped to accept safety belts by an explanation of the need and reasons for their use. A demonstration of the use of safety belts as part of the operation of a motor vehicle could serve to overcome such phobias.
Recommendations for exemption
- A medical exemption should only be granted for a sound medical reason.
- A request for medical exemption must be carefully reviewed and the patient should be given all possible encouragement to adapt the restraint system to the patient's conditions (i.e., adjusting the position and height of the car seat, and adjusting and positioning the safety belt) before making a decision.
- If a medical exemption is granted, a record should be kept by the physician/chiropractor of the medical reason given by the patient for the exemption, the documentation of the basis for which the medical exemption was granted, the date it was granted, and the expiration date.
- For temporary conditions, a medical exemption should be granted for periods of no more than six months, and renewed as necessary.
- A patient who is primarily a passenger and who is unable or who categorically refuses to use a safety belt should be advised to ride in the back seat of motor vehicles.
How to obtain an exemption
- A medical exemption may be granted only by a licensed physician/chiropractor.
- An Iowa Medical Safety Belt Exemption form, provided by the Iowa DOT, must be completed by a physician or chiropractor. The exemption shall not exceed 12 months, but may be renewed if necessary.
- The patient's name, date of birth and address, the date of issuance of the exemption, a clear statement of medical exemption from belt use, and the physician/chiropractor's signature must appear on the certification.