Federal Air Surgeon's Medical Bulletin - FAA

14 Pages·2012·0.92 MB·English

Federal Air Surgeon’s
Medical Bulletin
Aviation Safety Through Aerospace Medicine
Vol. 50, No. 3 For FAA Aviation Medical Examiners, Office of Aerospace Medicine Personnel,
U.S. Department of Transportation
2012-3 Flight Standards Inspectors, and Other Aviation Professionals.
Federal Aviation Administration
Hooray! that says: “A letter of authorization
New Rule Now In Effect (or SODA) describing any such
limitations must be kept with this
Hello, everyone. It’s official: certificate at all times while exer-
Effective July 20, individuals with cising the privileges of an airman
a special issuance are no longer required certificate.”
to have their authorization letter with We are working on the program-
them while aviating. I realize that I ming changes necessary to modify
informed you about this change in my MedXPress, but we cannot modify the
last editorial, but this is such a significant By Fred Tilton, MD paper forms because it would not be
change that I think it bears repeating. cost effective to do so before October 1.
The news may not amount to a the International Civil Aviation Author- We also do not plan to issue replace-
hill of beans to many of the pilots you ity (ICAO) that took place in 2007. At ment certificates to everyone who has
examine simply because most of them that time, the auditor, without consult- been issued a certificate with the obsolete
meet Federal Aviation Administration ing the ICAO Medical Officer, insisted language. So, for some time, individuals
medical standards and do not require a that ICAO International Standards will be carrying certificates with the
special issuance (waiver). In fact, many and Recommended Practices (SARPS) outdated language on the back.
of them may not even be aware that required that we include all disqualify- I also want to make it clear that even
there are such letters, but they probably ing medical conditions on an applicant’s though the entire note will go away, air-
will be affected by this change as they medical certificate. men with a SODA will still be required
get older and might require a special While we vigorously pushed back, to have their SODA with them when
issuance of their own. we could not convince the auditor they fly.
The requirement to carry the letter that he was wrong. However, we were You may be asking yourself, What can
stemmed from an audit of the FAA by finally able to get him to agree that the I do? You might be surprised to know
disqualifying information was contained that you interact with airmen more than
in the authorization letter, and that we anyone else in the FAA. So if any of the
Contents
could meet the intent of the SARPS by airmen you examine have special issu-
Letters to the editor . . . . . . . . .2 requiring the individual to carry the ances, please take a few extra minutes
three oAM stAff honored by letter while flying. to explain these changes.
AsMA . . . . . . . . . . . . . . . . . . .3 Shortly after we announced the re- If you have questions about this issue
oAM PhysiciAns on cALL . . . . .4 quirement to carry the letter, we began or any other issue, call your Regional
Post-trAuMAtic stress disorder .5 to get complaints from airmen and avia- Flight Surgeon. He or she is “up-to-
coMMon ecG issues . . . . . . . . . .6 tion organizations that the obligation to speed” on all of the latest information
ecG norMAL VAriAnt List . . . . .6 show it to inspectors was an unnecessary and is ready to help so that we can
PiLot sAtisfAction surVey . . . . . .7 violation of the airman’s privacy. We provide the best service to the airmen
trAnsVerse MyeLitis . . . . . . . . . . .8 agreed with them and so did the ICAO we support.
cArdioVAscuLAr diseAse And Medical Officer, and he helped us get Thank you for your help with imple-
stentinG . . . . . . . . . . . . . . . .10 the ruling reversed. While it has taken menting these changes, and as always,
WALLenberG’s syndroMe . . . . . .12 a long time, we are finally there, but we thank you for everything you do for the
forM 8500-8 PhAse-out still have a couple of issues to deal with. airmen you take care of.
APProAchinG . . . . . . . . . . . . .13 The paper medical certificates Cheers!
AMe scheduLe . . . . . . . . . . . . .14 and the computerized MedXPress —Fred
certificates have a note on the back
Glaucoma case report comments issue a certificate and could type it on
a 1929 manual Smith Corona type-
Dear Editor,
writer—basic, primitive, but still very
The article…about Glaucoma [Case
reliable—what if any of the above go
Report by Joseph A. Lopez, MD, Fed-
down while examining an airman who
eral Air Surgeon’s Medical Bulletin, vol.
Dear Dr. Nattis, needs his or her certificate to fly? Will we
50, no. 2, pg. 12] was informative and
The Aerospace Medical Certification have available blank certificates to print
mostly correct. One glaring point that
Division’s general policy is that we prefer
in case of an above failure in any of the
should be made is that the eye specialist
reports from a medical specialist who is
above chain of complex interfaces…?
should be an ophthalmologist. Not an knowledgeable in the treatment of such
optometrist. Optometrists may not have conditions and has experience with the clini- A.J. Bogosian, MD
Anacortes, Wash.
the training needed to properly evaluate cal treatment and potential complications
a patient for the extent of glaucoma, (glaucoma, in this case). Dr. Lopez’ article
usually needs supervision by an oph- mentions, more than once, that we require Hello, Dr. Bogosian,
thalmologist, and cannot treat patients a report from a treating eye specialist, and There is something to be said for the
does comment, in parentheses, optometrist reliable 1929 Smith Corona typewriter; I
with laser or surgery if indicated. Also,
or ophthalmologist (page 12). A summary of have a healthy respect for them, as many
annual exams for follow up of glaucoma
the potential multiple complexities of glau- are still in use today. However, the enhance-
is inadequate. The American Academy
coma (insert, page 13), is also mentioned. ments we are making to our technology
of Ophthalmology recommends fol- The AMCD will not accept unsatisfactory infrastructure and our applications truly
low up appropriate with the extent of reports regarding history of glaucoma, or are for the benefit of AMEs and pilots. Our
disease, and certainly more frequent pre-glaucoma deemed necessary for treat- user community is more “computer savvy”
than annually. ment. Follow-up reports, for aeromedical than ever before; in fact, many believe we
Richard Nattis, MD purposes, are usually required annually, are “behind the power curve” when it comes
Long Island, N.Y. although the eye specialist may require more to the use of technology.
closely timed evaluations. The first-class In response to your question — yes, we
pilot, then, will typically get a time-limited will have a mechanism in place for you in
certificate for 12 months, even if the treat- the event of a failure that prevents you from
ing eye specialist is following more closely. accessing the AMCS. We are analyzing dif-
The pilot jeopardizes timely certification ferent solutions and will advise you of the
Federal Air Surgeon’s if the eye report is vague, incomplete (for solution prior to going “paperless.”
example, history is lacking), and as Dr. Nat- David Nelms
Medical Bulletin
tis implies, the AMCD judges the medical AMCD Program Analyst
Library of Congress ISSN 1545-1518
report (glaucoma) to be inadequate—for
Secretary of Transportation example, if the doctor is not a medical spe-
Ray LaHood cialist knowledgeable about the condition.
HuntInGton’s DIsease
Richard Carter, DO
FAA Administrator (Acting)
AMCD Staff Physician
Michael Huerta
Dear Editor,
Federal Air Surgeon Blank certIfIcates to prInt? Concerning the article on Hun-
Fred Tilton, MD tington’s disease in the recent Bulletin
Editor Dear Editor, [“Huntington’s Disease,” Federal Air
Michael E. Wayda Some concerns with the paperless Surgeon’s Medical Bulletin, vol. 50, no. 2,
record—which indeed is not paperless p. 16], it appears that the pilot described
The Federal Air Surgeon’s Medical
since we have to print out the certificate. had no disease or symptoms of disease;
Bulletin is published quarterly for aviation
medical examiners and others interested in We have now introduced a number he only reported the genetic marker for
aviation safety and aviation medicine. The of complex systems into issuing the potential (probable) illness in the future.
Bulletin is prepared by the FAA’s Civil medical certificate—now we must have What was the basis for potentially dis-
Aerospace Medical Institute, with policy functioning computers (we will not qualifying this individual who presented
guidance and support from the Office of even begin to express the frustration no evidence of disease? Are we going to
Aerospace Medicine. Authors may submit with the PC and its evolution and op- be requiring everyone who has a defined
articles and photos for publication in the erating systems), Internet connections marker for future genetic disease to be
Bulletin directly to: which where I practice go down with extensively evaluated (as this individual
Editor, FASMB regularity, and of course printers and was) prior to any evidence or symptoms
FAA Civil Aerospace Medical Institute their limited life expectancy—with the of the disease?
AAM-400
“OLD” system if all else failed I could George W. Jackson, MD
P.O. Box 25082
Associate Clinical Professor
Oklahoma City, OK 73125
Duke University
E-mail: [email protected]
Continued on page 3
2 The Federal Air Surgeon's Medical Bulletin • Vol. 50, No. 3 •
Huntington's from page 2 subtle but potentially important cognitive with this approach is that individuals with
deficits may develop before diagnostic neurodegenerative disease are often un-
Editor’s Note: This is a very interesting threshold is reached [1]. aware of developing cognitive difficulties
case. We would not have been aware that the I do wish to correct the statement: “Al- (anosognosia), and regular screening such
individual had tested positive for the gene for though only 50% of those testing positive as annual administration of Cogscreen-AE
Huntington’s disease if he had not voluntarily for the disease actually develop symptoms, or equivalent neuropsychometric testing
had himself tested. However, once we were currently there is no further predictive would help detect cognitive decline that
informed, we had no choice but to ask for capacity to determine who will become ill would impair safe operation of an aircraft,
additional information to be sure that he was and who will remain disease-free.” In fact, potentially before the aviator or their peers
not symptomatic for the disease. We have not the disease has nearly 100% penetrance for may readily recognize a deficit.
initiated a genetic screening program nor do those testing positive (>42 CAG repeats). As
Richard Ronan Murphy, MBChB
we intend to do so. you mentioned, disease severity, and earlier
onset is associated with greater number of
References
In reply to: Huntington’s Disease: Case CAG [cysteine-adenosine-guanine] repeats,
1. Duff K et al. Mild cognitive impairment
Report, by Robert Craig-Gray, MD and you may have intended to refer to the
in prediagnosed Huntington disease.
I would like to thank Dr. Craig-Gray findings that 50% of the variability in disease
Neurology, 2010. 75(6): p. 500-7.
for reporting this case that demonstrates severity and age of onset are explained by
many of the concerns faced when evaluating CAG repeat length [2]. 2. Andrew SE et al. The relationship
potential sequelae of neurological diseases The number of CAG repeats in humans between trinucleotide (CAG) repeat
on aviator performance, as well as the com- is highly variable, but the normal range is length and clinical features of Hun-
plexities that aviation medical examiners 11-34 CAG copies, and more than 42 repeats tington’s disease. Nature Genetics, 1993.
must deal with when confronted by rare indicates a confirmed genetic diagnosis 4(4): p. 398-403.
diseases or diseases usually managed under of Huntington’s gene in most labs. That
3. Killoran A. Analysis of the behavioral fea-
the care of specialized providers. Hunting- being said, individuals with an “intermedi-
tures conferred by the intermediate allele
ton’s disease poses some particularly difficult ate” number of CAG repeats (34-42 CAG
for Huntington disease in the Prospective
challenges, as most individuals remain nor- repeats), still demonstrate a behavioral
Huntington At Risk Observational Study
mal through much of their early life, with phenotype, with depressive features relative
(PHAROS). Abstract from the American
a wide range in the age of onset, and once to normal healthy controls [3], and at the
Academy of Neurology Annual Meet-
the disease becomes manifest, progressive upper end of this range, the full Hunting-
ing, 2012, New Orleans, La.
neurological and psychiatric problems ensue ton’s phenotype is incompletely penetrant.
Dr. Murphy is an AME, a board-certified
unrelentingly. It would be of interest to know how many
neurologist, and is a fellow in mental health
A medical status report was obtained CAG repeats this airman had.
research with the Veteran’s Administration
from this airman’s neurologist and revealed You mention that the airman should also
Mental Illness Research, Education, and Clini-
no detectable neurological disease or dis- report any changes in his medical condition
cal Center, with clinical faculty appointment
ability. It is encouraging that this aviator immediately to the FAA and cease aviation
to the University of Washington Neurology
also presented with no abnormalities on operations per Title 14 CFR §61.53, which
department.
neuropsychological testing; however, it is restricts operation of an aircraft with any
important to know that even in early disease, medical [known] deficiency. One difficulty
Q
Three OAM Staff Honored by the Aerospace Medical Association
In an unusual and welcome surprise, were both made Fellows of AsMA on Although not related or married to
two Office of Aerospace Medicine the same night. The story gets even anyone else who received an AsMA
staff members were elected Fellows better. Aerospace Medical Education award this year, CAMI’s Research
of the Aerospace Medical Association Division Manager Brian Pinkston and Physiologist David “Andy” Self received
(AsMA) and one received a prestigious his wife, Cheryl Lowry—a U.S. Air the AsMA Arnold Tuttle Award for
national award during Honors Night Force Flight Surgeon—were also among original research, which investigated
celebrations at the AsMA 83rd Annual the 24 AsMA Fellows elected for 2012. the physiological responses to altitude
Scientific Meeting held last May in “It was quite a surprise,” said Federal hypoxia. This information is used to
Atlanta, Ga. Air Surgeon Dr. Fred Tilton. “I’ve never address improvements in countermea-
Eastern Region Flight Surgeon seen relatives elected before, and I’ve sures and oxygen equipment design for
Harriett Lester and her sister, Benisse never seen a husband and wife elected commercial and general aviation. The
Lester, the Chief Medical Officer for the before. And here we have Brian and his research was published as an Office
Federal Motor Carrier Safety Admin- wife, and Harriet and her sister—who is of Aerospace Medicine Report and in
istration (FMCSA) and a FAA senior basically my counterpart at FMCSA— the Aviation, Space, and Environmental
aviation medical examiner (AME), all elected at once!” Medicine Journal.
—From AVS Flyer 6/7/2012
The Federal Air Surgeon's Medical Bulletin • Vol. 50, No. 3 • 3
OAM Physicians On Call Issue when you can. A phone call to or otherwise send in duplicates of the
Part 1 the AMCD is not always required. The same reports. Simply put, AMEs can
protocol section of the AME Guide lists issue cases that allow for an Eligibility
Standing By To Help
conditions allowable for AME to initial Letter (see below list – note, this is not a
By Richard Carter, DO, MPH
issue (example, hypertension, diet/exer- complete list of conditions that qualify
cise control of diabetes). Complications for an Eligibility Letter but a sample
a vIatIon meDIcal examiners, we can occur, and we invite you to call of typical questions/conditions AMEs
challenge you to limit unnecessary about abnormal labs, ECGs, etc. AMEs frequently call about. See also the list
deferrals, which helps us to minimize that do initial issue will need to send in of ECG Issues on page 6.).
the backlog of deferred exams. Key to medical reports. DO NOT mail, fax, Continued
this initiative is an appeal to you to issue
certificates when you can. conDItIons tHat allow tHe ame to Issue
The following two lists from the
• Motion sickness – resolved.
Office of Aerospace Medicine (OAM)
• Myringotomy – resolved.
should help you reduce the number of
• Eardrum perforation – resolved.
unnecessary phone calls to Aerospace
Medical Certification Division (AMCD) • Esophoria/exophoria – no adverse complications, no diplopia.
in Oklahoma City for verbal authoriza- • LASIK – less than two years – we need 8500-7. If favorable, issue.
tions. If you have an unusual case and • LASIK – more than two years – comment no adverse complications (AME
need guidance, though, please call. comments block 60), issue.
The medical officers (AMCD, • Acute nephritis, 3 months status post, resolved, issue with favorable reports.
Regional Flight Surgeons, and Inter- • Kidney stone history, no retained kidney stone.
national/Military Regional Office) are • Melanoma, < .75 mm, favorable report, issue.
available to you for such case discus- • Hypertension (see Hypertension Protocol).
sions. A team effort is needed to make • Diet/exercise diabetes (see Diet/Exercise Diabetes Protocol).
this process successful.
• Multifocal intraocular lens (see Protocol for Binocular Multifocal and
In Part 1 of this article, we address Accommodating Devices).
examples that do not require you to call
• Musculoskeletal injury (see Musculoskeletal Protocol).
us (see list this page). Print the list, and
• Benign prostatic hypertrophy/medication, examples (note: AMCD does re-
paste it in a handy spot for reference.
quire comment in block 60 that the following medications are well tolerated):
Calling AMCD/RFS is easy. Call
♦ Detrol (tolterodine): acceptable
our designated number (include Web
♦ Enablex (darifenacin): acceptable
link to AMCD and Regional Flight
♦ Vesicare(solifenacin): acceptable
Surgeon phone numbers). You can
♦ Avodart (dutasteride): acceptable
call the AMCD or a Regional Flight
♦ Santura (trospium): acceptable
Surgeon for verbal authorization.
♦ Uroxatral alfuzosin): acceptable
Whom to call. We advise, in general,
♦ Flomax (tamsulosin): acceptable
that third-class airman inquires should
♦ Rapaflo (silodosin): acceptable
go to your Regional Flight Surgeon.
• Ditropan (oxybutynin); antispasmodic/anticholinergic: is NOT acceptable
The AMCD more commonly answers
for aeromedical purposes.
calls about first- and second-class pi-
• Gout/medication, examples (note AMCD does require comment in block
lots, and specifically detailed medical
60 that medications are well tolerated):
inquires (for example, central serous
♦ Colcrys (colchicine): allowable.
retinopathy, renal cancer). Many AMEs
♦ Uloric (febuxostat): allowable.
already do this. The AMCD number
♦ Zyloprim (allopurinol): allowable.
405-954-4821/option 6, links you to
♦ Benemid (probenecid): allowable.
dedicated operators that will route you
• Erectile dysfunction meds, example (note AMCD does require comment in
to the physician on call. Please follow
block 60 that medications are well tolerated):
operator instructions; you will be asked
♦ Viagra (sildenafil citrate): 6 hrs. no fly.
your AME number, PI or application
♦ Levitra (vardenafil): 36 hrs. no fly.
ID number. If we are not immediately
♦ Cialis (tadalafil): 36 hrs. no fly.
available, we will try to call back the
same day. We may also ask for an after- • Asthma, and medication, is rarely used.
hours call back number (usually your • Peptic ulcer (see Peptic Ulcer Protocol).
cell number), as we may call back after • Cholelithisis, asymptomatic: issue.
normal work hours. • Traumatic pneumothorax, 3 months status post, resolved: issue with
favorable reports.
4 The Federal Air Surgeon's Medical Bulletin • Vol. 50, No. 3 •
Example: The airman provides a Post-Traumatic Stress Disorder
summary report from the urologist, his-
Case Report, by Nathaniel B. Almond, MD, MPH
tory of kidney stones, now resolved. The
most recent imaging (kidneys, ureter,
Airmen may present for Background
and bladder) demonstrates no retained
kidney stone. The AME does issue, trans- evaluation with a history of post- a 32-year-olD male with 100 flight
hours applied for first-class medi-
mits the new exam, and faxes reports to traumatic stress disorder (PTSD)
cal certification with ongoing PTSD
the AMCD (fax [phone]), with
or with ongoing symptoms of
due to a stressful event 8 years ago
a coversheet. Do you need to call? The
PTSD. A thorough history is while in the military. During convoy
answer is no. Again, do not mail, fax, or
otherwise send in duplicate reports, as this important for confirming that operations in enemy territory, he drove
a vehicle over an improvised explosive
creates delays in certification. symptoms have resolved and
device (IED), causing it to detonate and
Team effort. We need your help to that the airman is not taking
the vehicle to catch fire. While escaping
limit unnecessary deferrals. Many com-
medication for PTSD. This article from the vehicle, he was shot multiple
plex medical conditions do eventually get
presents a case report of a first- times in the arm and leg, but he did not
a waiver (Special Issuance or Statement
sustain any head injury. He now admits
of Demonstrated Ability), and we will class pilot applicant with ongoing
to generalized anxiety, fear of meeting
help you with the certification process. symptoms of PTSD and includes a
new people, and weekly nightmares and
Many thanks to the Regional Flight brief review of PTSD.
Surgeons that have assisted us with the Continued on page 7
on-call program. Have you experienced
calling the AMCD in Oklahoma and
been surprised to be talking to Dr.
Goodman in California or Dr. Lester Post-traumatiC stress DisorDer etiology
in New York? Regional Flight Surgeons PTSD is an anxiety disorder that occurs after the experience or witnessing of
have assisted us by taking calls for us, a traumatic event. The person’s response to the event must involve intense
so we can balance our on-call workload fear, helplessness, or horror. Symptoms vary but can be classified into three
with demands of our backlog of deferred categories: 1) reexperiencing of the traumatic event, 2) avoidance of situations
cases waiting for review. Thanks to associated with the trauma and numbing of general responsiveness to keep
Drs. Ray, Goodman, Salazar, Lester, from thinking about the event, and 3) symptoms of increased arousal . Symp-
Northrup, and Jones for participating toms from all three categories must be present for more than 1 month, and the
in this special certification project. The disturbance must cause clinically significant distress or impairment in social,
Aerospace Medical Certification Divi- occupational, or other important areas of functioning. The many symptoms
sion medical staff, Drs. Courtney Scott, that people with PTSD may experience include anxiety, hyper-vigilance, hyper-
Brian Johnson, Bill Mills, Ben Zwart, arousal, avoidance, reexperiencing the event (e.g., nightmares, flashbacks, or
and Steve Schwendeman all participate intrusive thoughts), anhedonia, reduced ability to feel emotions, being easily
in the on-call process. startled, difficulty concentrating or completing tasks, bursts of anger, insomnia,
Good news. Dr. Judy Frazier is and irritability (1,2).
now fully trained and ready for calls, PTSD is a common diagnosis: 6.8% of Americans will experience PTSD in
so you will be talking to her soon! The their lifetime. It is particularly prevalent in those who have served in combat,
International AMEs communicate including aviation personnel. (3) Thirty percent of Vietnam veterans have PTSD,
with the International Regional Flight while PTSD prevalence estimates in veterans from Iraq and Afghanistan has
Surgeon Office, Dr. Brian Pinkston, ranged from 6 to 20% . Depression and alcohol use are also common with
and International Program Analyst PTSD. The onset of symptoms in relation to the event, as well as the duration
Leah Olson. We coordinate efforts of symptoms, greatly varies (1,2).
with the International office to address
Treatment of PTSD includes cognitive behavioral therapy and anti-depressant
International AME inquires. Together,
medication (selective serotonin reuptake inhibitors). Policies and programs exist
this team effort expedites the medical
across many organizations to assist individuals exposed to stressful events in an
certification of pilots.
effort to minimize PTSD symptoms. These programs range from Traumatic Stress
In Part 2 of this series, we will discuss
Response within the Department of Defense to the Critical Incident Response
details of the verbal authorization needed
Program by the Airline Pilots Association. For example, the Critical Incident
for Special Issuance.
Response Program works to mitigate PTSD through pre-incident education
Q and post-incident accident crisis intervention through crewmembers who have
received counseling training. Both primary prevention rapid response to victims
is important in both the civilian and military settings of traumatic events (2,3,4).
Dr. Carter is a medical review officer in
the Aerospace Medical Certification Division.
The Federal Air Surgeon's Medical Bulletin • Vol. 50, No. 3 • 5
10 Common Electrocardiogram Issues
ECG Normal Variant List
...And What To Do About Them When Performing Certification ECGs
These are considered normal ECG vari-
ants and not reasons to defer the applicant
1. If an airman has a heart rate less 7. An airman with a new onset of • Sinus bradycardia. Age 50 and
than 50, have the airman exercise a complete left bundle branch younger — if the heart rate is 45 or
greater; age 50 and older — if the
in place and repeat the ECG. If block is to provide a cardiovascular
heart rate is 49 or greater
the heart rate goes up above 50, evaluation and a pharmacologic
• Wandering atrial pacemaker
send us both ECGs (in case this nuclear stress test. This is one of
• Low atrial rhythm
happens again down the road), the conditions where we will accept
• Ectopic atrial rhythm
and you can clear the airman. a pharmacologic stress test. Airmen
• Indeterminate axis
with a LBBB demonstrate what ap-
2. This also goes for a significant
• First-degree AV (atrioventricular)
pears to be an area of ischemia in
first-degree AV block. Exercise the block with PR interval less than
the septum, and the pharmacologic
airman in place, and if the block 0.21 in age 50 and younger
stress test helps better determine if
becomes less, you may clear the • Mobitz Type I Second Degree AV
airman. there is actual ischemia. (atrioventricular) block (Wencke-
bach phenomenon)
8. An airman with left anterior or
3. If an airman has a heart rate over
• One premature ventricular con-
posterior hemiblock must demon-
110–sinus tachycardia, perhaps—
traction or atrial contraction on a
strate an absence of coronary artery
have the airman relax a bit and 12-lead ECG
disease, so a maximal nuclear stress
repeat the graph. If the rate drops • Incomplete RBBB
test is required.
below 110, send us the graph and • Intraventricular conduction delay
clear the airman. 9. Limb lead III is the most variable • Early repolarization
4. Two or more premature atrial lead. This lead sometimes is af- • Left ventricular hypertrophy by
fected by respiration, which can voltage criteria only
contractions or ventricular con-
falsely indicate that the airman had • Low voltage in limb leads (may be a
tractions on an ECG requires
a previous inferior infarction. So sign of obesity or hypothyroidism)
the applicant to have a maximal
if you have a small R-wave with a • Left axis deviation, less than or
nuclear stress test. If this has been
equal to -30 degrees
deep S-wave in that lead, and even
previously worked up, you do not
• rSR’ in leads VI or V2, ORS interval
perhaps in lead aVF, you need to
need to provide a new evaluation.
less than 0.12 msec R>S wave in
perform an ECG in inspiration
5. If the airman demonstrates new VI without other evidence of right
and again in expiration. If the
ventricular hypertrophy
onset of complete RBBB (right
S-wave disappears and you get a
• Sinus arrhythmia
bundle branch block); in other
larger R-wave, you can clear the
• Sinus tachycardia: Any age — if the
words, this has not been seen on
airman—but don’t forget to pro- heart rate is less than 110
previous graphs, then you are to
vide us all these graphs. • Left atrial abnormality
have the airman undergo a maximal
10. An airman who has ST- and T-wave • Short QT
nuclear stress test. Note: All stress
testing in first- and second-class changes that suggest ischemia or Note: If a first-class airman does
left ventricular hypertrophy re- not have a current resting ECG on
airmen should be maximal nuclear
quires an evaluation if one has not file but we have any type of stress
stress testing (unless we specify
test (pharmaceutical stress, Bruce
been previously performed for this
otherwise in our letter to you).
stress, nuclear stress, or stress echo-
reason. These situations require a
6. An airman who has an incom- cardiogram) that was accomplished
cardiovascular evaluation, perhaps
within the last year, we can accept
plete RBBB pattern on previous
an echocardiogram, and definitely without writing out for a current
electrocardiograms, and then
a maximal nuclear stress test. resting ECG; however, we do need
demonstrates a complete RBBB,
the tracings from any of these tests.
does not require an evaluation. A cardiac cath and a Holter monitor
test are not acceptable in place of a
resting ECG.
6 The Federal Air Surgeon's Medical Bulletin • Vol. 50, No. 3 •
PTSD from page 5 Under Title 14 of the Code of Federal References
Regulations (CFR) parts 67.107, 67.207, 1. American Psychiatric Association. Diag-
flashbacks. He also admits to drinking and 67.307, (c) No other personal- nosis and statistical manual of mental
heavily on and off in the years since ity disorder, neurosis, or other mental disorders, DSM-IV, 4th ed. Washington,
DC: APA; 1994.
the event. Currently, he does not drink condition that the Federal Air Surgeon,
alcohol. He is divorced. He currently based on the case history and appropri- 2. U.S. Department of Veteran’s Affairs.
has a 30% disability rating for PTSD ate, qualified medical judgment relating “What is PTSD?” obtained 3/10/11
from the Veteran’s Administration. His to the condition involved, finds: from National Center for PTSD at
www.ptsd.va.gov/
psychiatric exam is notable for anxious 1. Makes the person unable to safely
affect but is otherwise normal. perform the duties or exercise the 3. Takla NK, Koffman R, Bailey DA.
privileges of the airman certificate Combat stress, combat fatigue, and
Aeromedical Concerns applied for or held; or psychiatric disability in aircrew. Aviat
Space Environ Med 1994; 65:858-65.
The primary aeromedical concern for 2. May reasonably be expected, for
this case is that the airman’s ongoing the maximum duration of the 4. Airline Pilots Association, International.
symptoms of PTSD could compromise airman medical certificate applied Critical Incident Response Program
description. Retrieved March 8, 2011
his ability to safely operate an aircraft. for or held, to make the person
from http://fdx.alpa.org/Committees/
Specifically, his symptoms such as unable to perform those duties or
CIRP/tabid/3205/Default.aspx.
flashbacks and anxiety could decrease exercise those privileges.
his ability to focus and concentrate on In this context, PTSD would be 5. Aeromedical Consultation Service.
United States Air Force Waiver
safely piloting and could be acutely considered a “neurosis or other mental
Guide. Retrieved March 8, 2011
incapacitating in the cockpit. Substance condition” (in part c). Any airman with
from http://airforcemedicine.afms.
abuse associated with PTSD and fatigue a history of ongoing PTSD symptoms
mil/w aiverguide.
resulting from nightmares may also or a history of PTSD should be deferred
6. McDonald, Tony. Email correspondence
compromise safe flying. to the FAA for further consultation.
dated 3/11/11. Naval Aerospace Medi-
In addition to this airman’s symp-
cine Institute Psychiatry Department,
toms, other symptoms of PTSD could Outcome
Pensacola, Florida.
also affect flight safety. These include The aerospace medicine residents
1) numbing of general responsiveness, discussed the case and decided more About the author
which could slow reaction times, 2) information was required regarding Lieutenant Commander Nathaniel B.
avoidance, which could affect behavior this applicant: specifically, additional Almond, MD, MPH, is a United States Naval
to make correct decisions, and 3)an evaluation of alcohol use and neuro- flight surgeon who is board certified in General
autonomic hyper-arousal state, which psychological testing, as well as original Preventive Medicine and Public Health. He
is currently a resident in Aerospace Medicine
could also degrade concentration, documentation of the diagnosis of
at the Navy’s Aerospace Medicine training
situational awareness, and the ability PTSD. The FAA denied the certificate
program at Naval Air Station Pensacola,
to manipulate controls. Anxiety might until these documents are provided for
Florida. This report was written while rotating
also originate as a fear of flying (5,6). further evaluation. If the applicant does
at the FAA’s Civil Aerospace Medical Institute.
indeed have ongoing PTSD symptoms,
he would not receive a certificate. Q
Biennial Survey of Pilot Satisfaction Initiated
By Katrina Avers, PhD
tHe offIce of Aerospace Medicine Government Performance and Results feedback that will affect all pilots. We
is mailing invitations this month Act of 1993. The information obtained hope to get a large response so that we
to a randomly selected sample of pilots is used to evaluate the degree of customer can get meaningful data to share with
to complete a survey regarding their satisfaction with Aerospace Medical you in a future issue.
experiences and satisfaction with the Certification Services, identify areas
airman medical certification process. in which the FAA may improve its Dr. Avers is a research psychologist in the
The survey is a biennial survey we services to airmen, and assess change in Civil Aerospace Medical Institute’s Aerospace
Human Factors Research Division.
administer to be in compliance with customer satisfaction as a result of those
Executive Order No. 12862, “Setting improvements. Invitees are in a unique Q
Customer Service Standards,” and the position to provide the FAA valuable
The Federal Air Surgeon's Medical Bulletin • Vol. 50, No. 3 • 7
Transverse Myelitis
etiology of transverse myelitis
Case Report Transverse myelitis is a relatively rare neurological disorder caused by inflam-
by Jonathan F. Stinson, MD, MPH mation of the spinal cord, creating a demyelinating lesion, typically involving
both sides of the cord, hence its transverse or bilateral nature. These lesions
Transverse myelitis is a rare are usually at one level only but can occasionally exist at multiple levels. The
resulting inflammation damages or destroys myelin, compromising conduction
but potentially debilitating
between the brain and muscles or sensory organs distal to the lesion. Symp-
neurological condition caused by
toms of transverse myelitis can evolve over several hours to as long as several
spontaneous, usually idiopathic weeks. It often begins as a sudden onset of lower back pain, muscle weakness,
inflammation of both grey and or abnormal sensations in the toes and feet. However, it can rapidly progress
to more severe symptoms, including paralysis, urinary retention, and loss of
white matter of the spinal cord.
bowel control. Diagnosis is made by clinical history, physical findings, and a
This case report evaluates an
spinal cord lesion seen on MRI. Some patients may recover from transverse
airline pilot with this disorder myelitis with minor or no residual problems, while others suffer permanent
and the requirements necessary to impairments that affect their ability to work or even carry out activities of
daily living. The majority of cases involve single episodes, but some can have
return the airman to flying.
a recurrence of symptoms.(1)
It is estimated that about 1,400 new cases of transverse myelitis are diagnosed
History
each year in the United States, and approximately 33,000 Americans have some
tHIs case Involves a 53-year-old
type of disability resulting from the disorder. It can occur in all age groups,
airline pilot with approximately
but peaks occur in the 10-19 and the 30-39 age ranges. There appear to be no
16,000 hours, who was in his usual state
inherited, ethnic, or gender differences in incidence. One study estimated the
of good health prior to this incident.
incidence to be about 4.6 cases per million per year.(2)
He was admitted to the hospital with
Transverse myelitis can have many different etiologies. It is thought that about
symptoms of progressive loss of light
45% are parainfectious or related to infections. Infectious agents suspected of
touch, vibratory, and position sense,
causing transverse myelitis include varicella zoster, herpes simplex, cytomegalo-
starting in his feet and working its way
virus, Epstein-Barr virus, influenza, echovirus, human immunodeficiency virus,
up to the level of the chest, including
hepatitis A, and rubella. Bacterial skin infections, otitis media, Lyme disease(5)
upper extremities from hands to mid and Mycoplasma pneumoniae have also been associated with the condition.
forearm. He had no signs of muscle In the United States, up to 21% of cases can be a presenting sign of multiple
weakness or reflex abnormalities. sclerosis.(4) It is also recognized as a complication of some autoimmune dis-
A cervical MRI revealed a 6-mm eases such as systemic lupus erythematosus, Sjögren’s, or sarcoidosis, (7) post-
lesion of the posterior part of the cervical infectious myelopathy, spinal cord infarct, and neuromyelitis optica.(2) Some
spinal cord at the C5-6 level with some cases can be the result of spinal cord infarct or be a presenting sign of multiple
sclerosis. In about 21% of cases, the etiology remains unknown, even after a
surrounding edema and swelling of the
long-term follow-up.(3)
cord at that level. MRI of brain and tho-
racic cord was normal. Cerebrospinal Treatment is dependant on determining a specific etiology and may be directed
fluid showed no evidence of inflamma- at an underlying infectious etiology, if discovered. Generalized treatments such
as corticosteroids are of use in cases secondary to the autoimmune disorders,
tion, with no white cells and a normal
but there is some debate over their effectiveness in idiopathic acute transverse
protein of 54 mg/dl. Immunological
myelitis.
studies were normal, as was an IgG
index and 24-hour IgG synthesis rate.
There were no oligoclonal bands seen,
and CFS and Lyme disease antibodies Neurology follow up at six months submission of MRI cervical spine results
were negative. Serum B-12, folic acid, revealed a stable neurological exam, and a satisfactory current status report.
and ESR were all normal. with only the residual sensory deficits
The airman was admitted to the noted before. His MRI showed im- Aeromedical Concerns
hospital and treated for five days with provement, with decreasing gadolinium These can be divided into three
high-dose IV methylprednisolone, 1gm enhancement of the C5-6 lesion and no categories: acute disease concerns,
daily, followed by a six-day taper. At evidence of new lesions. After reviewing prognostic concerns about the risk of
the time of discharge, all symptoms his case, his aviation medical examiner recurrence, and concerns about residual
resolved, with the exception of residual deferred for special issuance, which was disability.
numbness of the fourth and fifth digits granted for 12 months contingent upon
of both hands. Continued on page 9
8 The Federal Air Surgeon's Medical Bulletin • Vol. 50, No. 3 •
Transverse Myelitis from page 8 Residual Disability Concerns. References
Recovery from transverse myelitis usu- 1. National Institute of Neurological
Acute Concerns. Acutely, the condi- ally begins between two and 12 weeks Disorders and Stroke (accessed 13
March 2010) www.ninds.nih.gov/
tion is obviously disqualifying under following onset of symptoms and may
disorders/transversemyelitis/detail_
Title 14 of the Code of Federal Regula- continue for up to two years in some
transversemyelitis.htm.
tions parts 67.109, 67.209, and 67.319, patients, many of whom are left with
2. Berman M, Feldman S, Alter M, Zilber
where it states neurologic standards are: considerable disabilities. Approximately
N, Kahana E. Acute transverse myelitis:
(a) No established medical history one-third will recover, with minimal Incidence and etiologic considerations.
or clinical diagnosis of any of... (3) to no disability; about one-third with Neurol 1981;31:966-71.
A transient loss of control of nervous have significant residual recovery, and 3. Rafailidis PI, Mourtzoukou EG, Var-
system function(s) without satisfactory the remainder will never show signs of bobitis IC, Falagas ME. Severe cyto-
medical explanation of the cause. recovery. Following stabilization, the megalovirus infection in apparently
immunocompetent patients: A system-
(b) No other seizure disorder, distur- airman must be assessed by a neurologist
atic review. Virol J 2008 Mar 27;5:47.
bance of consciousness, or neurologic for residual deficits and, if significant,
4. Jeffery DR, Mandler RN, Davis LE.
condition that the Federal Air Surgeon, medical flight testing may need to be
Transverse myelitis. Retrospective analy-
based on the case history and appropri- considered. A Statement of Demon-
sis of 33 cases, with differentiation of
ate, qualified medical judgment relat- strated Ability may need to be issued. cases associated with multiple sclerosis
ing to the condition involved, finds… and parainfectious events. Arch Neurol
(1) Makes the person unable to safely Outcome 1993 May;50(5):532-5.
perform the duties or exercise the privi- This airman was fortunate to have a 5. Walid MS, Ajjan M, Ulm AJ. Subacute
leges of the airman certificate applied reversible case of idiopathic acute trans- transverse myelitis with Lyme pro-
file dissociation. GMS Ger Med Sci
for or held; or (2) May reasonably be verse myelitis. He was effectively treated
2008;6:04.
expected, for the maximum duration of with corticosteroids, and his symptoms
6. Pandit L. Transverse myelitis spectrum
the airman medical certificate applied rapidly disappeared. Six months after
disorders. Neurol India 2009 Mar-
for or held, to make the person unable the incident, he had only minimal
Apr;57(2):126-33.
to perform those duties or exercise those intermittent numbness of his fourth
7. Kovacs B, Lafferty TL, Brent LH, De-
privileges. Essentially, airmen need to and fifth digits, no loss of strength, or
Horatius RJ. Transverse myelopathy
have full control of sensory and motor any other neurological symptoms. He in systemic lupus erythematosus: An
function to safely operate an aircraft. was found ineligible for medical cer- analysis of 14 cases and review of
Prognostic Concerns. Once the tification under 14 CFR parts 67.113, the literature. Ann Rheum Dis 2000
Feb;59(2):120-4. Review.
condition has resolved or stabilized, the 67.213, and 67.313 but was granted an
concern is directed to the likelihood of authorization for special issuance for
recurrence and what, if any, residual one year. This was contingent upon About the Author
disability is present. Up to 21% of idio- meeting the maintenance requirements CAPT Jonathan Stinson, MD, MPH, is a
pathic acute transverse myelitis cases in of his current medical certification and U.S. Navy flight surgeon board certified in
Family Medicine and Aerospace Medicine, and
the U.S. may be the presenting sign of providing a current status report from
is currently on active duty in the U.S. Navy.
multiple sclerosis, which implies a high his neurologist, including interim his-
He was a resident at the Naval Aerospace
likelihood that neurological symptoms tory, prognosis, follow-up plan, medica- Medicine Institute in Pensacola, Fla., when
will recur. If multiple sclerosis has tions (including type, dosage, and side he wrote this article and is currently serving as
been ruled out, the risk of recurrence effects), current MRI of the cervical Senior Medical Officer aboard USS Ronald
Reagan CVN76.
is very low. spine, and the results of any other studies
that are deemed appropriate.
Q
The Federal Air Surgeon's Medical Bulletin • Vol. 50, No. 3 • 9
Back To Basics: (LAD) was 100% occluded, with his of Federal Regulations (CFR) 67.111, 14
distal myocardium supplied solely by CFR 67.211, and 14 CFR 67.311, respec-
Cardiovascular Disease
collateral circulation. Additionally, his tively. Stents are dealt with in a similar
and Stenting
right coronary artery (RCA) had a 40% fashion as myocardial infarctions, coro-
Case Report, by lesion. Therefore, an angioplasty was nary angioplasty, and coronary artery
Valerie Johnson, MD, MPH performed, and a drug-eluting stent was bypass graft. A six-month post-event
inserted into his LAD. This procedure recovery period is necessary before
Introduction was performed about 11 months ago. consideration can be made by Medical
Coronary artery disease (CAD) is a He had an unremarkable recovery and Appeals. The airman needs to provide
is back to walking/running 2-3 miles a the hospital admission and discharge
significant cause of death and perma-
day, 5-6 days a week. His medications summaries, cardiac catheterization
nent disability in America. This con-
include ramipril (Altace), clopidogrel report, and any operative reports from
dition may have an insidious onset
(Plavix), Aspirin, atorvastatin (Lipitor), whatever corrective surgical procedure
but will most certainly always prog-
and esomeprazole (Nexium). is performed.
ress to become symptomatic or precipi-
The month prior to his presentation Required information includes a
tate a cardiac event. Treatment entails
to his AME’s office, the airman com- current status report from the treating
medical therapy alone or a combina-
pleted a maximal-graded test without physician. This should address a current
tion of revascularization procedures exercise-induced symptoms and normal performance assessment of the airman,
and medications. This report will re- exercise ECG response. He achieved as well as an estimate of his exercise
view the case of an airman with CAD 100% of his predicted maximum heart program and capacity. It should com-
who underwent a percutaneous trans- rate, and his left ventricular ejection ment on the modifiable risk factors for
luminal coronary angioplasty with fraction (LVEF) was 62%. His status coronary heart disease such as smoking
stent placement; and the subsequent report from the cardiologist and labs history, diet, physical inactivity, obesity,
were favorable. A requirement for all presence of hypertension, diabetes, and
ramifications on flight safety of this
first- and second-class airmen is to hyperlipidemia. Weight, height, (BMI),
condition.
provide the FAA with a six-month post- and blood pressure measurements
event treatment coronary angiogram. should also be indicated.
Background In the current case, the airman had A current list of medications with
a 46-year-olD commercIal pilot a catheterization that demonstrated a any explanation for changes in doses
presents to his aviation medical patent LAD stent and no progression or drugs should also be forwarded.
examiner (AME) for his annual second- of the RCA disease. The airman asked Any laboratory data related to this
class medical exam. He has flown over his AME if this medical history and condition is required for submission;
8,000 hours and has been healthy until evaluation were acceptable to the FAA this list will include the following at a
a year ago, when he felt burning and and whether he would be allowed to minimum: fasting blood sugar, total
pressure in his chest while working in continue with his primary occupation. cholesterol, LDL/HDL cholesterol,
his backyard. His symptoms continued and triglycerides. For third-class medi-
intermittently over the weekend and Aeromedical Concerns and cal certification, a maximal stress test
did not seem to improve with rest. He Role of the AME (Bruce protocol) must be performed.
has been an avid runner most of his The aeromedical concern related to Ideally, this test should be completed
adult life and his medical history is coronary artery disease is the possibility to 100% of the airman’s predicted
significant only for hyperlipidemia for of a severely incapacitating event that maximal heart rate.
12 years. He was seen by his primary would gravely impact the performance For first- and second-class airmen, a
physician and was initially treated for of flying duties.3 This may manifest maximal nuclear stress test is required.
gastroesophageal reflux. However, his as sudden cardiac death, myocardial Extenuating circumstance precluding
chest pressure and burning did not infarction, angina, or ventricular dys- adherence to these guidelines may be
completely abate over the next 6 weeks; rhythmias. The occurrence of such considered on a case-by-case basis. Note
hence, he was finally referred to a cardi- catastrophic events, both in a single- that the Aerospace Medical Certifica-
ologist. His family history is significant piloted plane or commercial aircraft, tion Division will require the airman
for hypertension, hyperlipidemia, and could result in dire consequences on to submit all of the ECG tracings for
diabetes in his parents who are both the airman’s health and on public safety. inclusion in their AMCD medical case
still alive at age 74. Coronary artery disease is disqualify- file (W. Silberman, personal commu-
During his cardiology evaluation, ing for first-, second-, and third-class nication March 18, 2010).
his left anterior descending artery medical certificates per Title 14 Code Continued
10 The Federal Air Surgeon's Medical Bulletin • Vol. 50, No. 3 •