Federal Air Surgeon’s Medical Bulletin Aviation Safety Through Aerospace Medicine For FAA Aviation Medical Examiners, Office of Aerospace Medicine Personnel, Flight Standards Inspectors, and Other Aviation Professionals. Vol. 51, No. 1 2013-1 Contents Federal Air Surgeon’s Medical Bulletin From the Federal air surgeon’s PersPeCtive---------------------2 From the Office of Aerospace Medicine Library of Congress ISSN 1545-1518 Civil aerosPaCe mediCal institute Celebrates 50 Years oF aerosPaCe mediCal exCellenCe ---------------------3 Federal Air Surgeon Fred Tilton, MD letters to the editor ------------------------------------------------------4 Your voiCe has been heard: ame surveY results-------------5 Editor Michael E. Wayda aviation mediCal examiner inFormation links ---------------------5 The Federal Air Surgeon’s Medical ‘tiger team’ training initiates new amCd PhYsiCians ---------6 Bulletin is published quarterly for aviation medical examiners and amCd transitions: new CertiFiCation PhYsiCians -------------7 others interested in aviation safety and aviation medicine. The Bulletin obstruCtive sleeP aPnea in a Pilot (Case rePort) -------------8 is prepared by the FAA’s Civil Aerospace Medical Institute, with ChroniC renal Failure (Case rePort)-----------------------------10 policy guidance and support from the Faa Pilot PubliCation highlights aerosPaCe mediCine -----12 Office of Aerospace Medicine. Authors may submit a rticles and photos for aerosPaCe mediCal eduCation news - -----------------------------13 publication to: CarCinoid tumor in an airman (Case rePort) -------------------14 FAA Civil Aerospace Medical Institute P.O. Box 25082, AAM-400 subaraChnoid hemorrhage (Case rePort) -----------------------16 Oklahoma City, OK 73125 2013 ame seminar sChedule ----------------------------------------17 Attention: Editor, FASMB Email: [email protected] Page 7 Page 3 Page 6 Page 12 The Federal Air Surgeon's Medical Bulletin • Vol. 51, No. 1 from the Federal Air Surgeon’s PERSPECTIVE...MedXPress Lessons Learned by Fred Tilton, MD Happy New Year, Everyone! It has been a few months since we made the use of MedXPress If you do not print an airman’s certificate before you leave mandatory for all pilots. The transition was fairly smooth, the submission confirmation screen, the system will not allow and MedXPress has made the medical application process you to print a certificate. So, remember to print before leav- much more efficient than the old paper system. However, we ing that screen— LESSON 5. Note: I do not agree with this did experience some “growing pains.” I thought it might be restriction, and you will eventually see this change.** helpful to share some of the lessons we have learned, and to Applicants do not understand why the system does not let you know that we are working hard to make this system as automatically repopulate the history information on subse- efficient and effective as it can possibly be. quent exams. They have also complained about having to In January 2013, we received a call from an aviation medi- remember exact dates from previous health professional visits. cal examiner (AME) who said that he had an airman in his MedXPress was first designed so that it would repopulate the office who was completing his MedXPress application using history. However, we had to eliminate this feature for legal the AME’s computer. The airman was attempting to enter the reasons. For example: A 25-year-old man is seeking a third- date of his most recent exam which had been accomplished in class medical certificate. He correctly marks no to Item 18 January of 2012. However, each time the airman entered the l (neurological disorders; epilepsy; seizures; stroke; paralysis; exam date, he got an error message stating that he could not etc.). When he is 28 years old, he has a seizure, which he fails enter a future date for a previous exam. Needless to say, the to report to the FAA, and he continues to fly. When he is 30, airman and the AME were very frustrated. It turns out that the he submits another application using MedXPress, and the AME had installed his computer in 2004 and never updated system populates his application with the no 18 l answer from the system clock. Consequently, the system would not let the his previous exam. Our attorneys have informed us that they airman enter a date that it “thought” was eight years into the could not pursue legal action because the airman could allege future. Remember to keep your system’s clock up to date — that he simply missed this question, and the system caused him LESSON 1. to inadvertently provide a false answer. We received calls stating that the aerospace medical certifica- In order to pursue a falsification case, the airman would tion subsystem (AMCS) would not retrieve an application when have to take the definitive action of actually marking the no a confirmation number was entered. MedXPress automatically answer on his new MedXPress application. It is, therefore, very eliminates applications if an airman has not provided the AME unlikely that we will modify the system so that it repopulates with a confirmation number within 60 days of application the history. The system urges the airman to print a copy of submission — LESSON 2. his application so that he can bring it with him to the exam, Airmen have wished to make corrections to a submitted and I am asking you to remind the airman to keep a copy in application, but they discovered they no longer had access. If his records so that he can use it to help him complete his next an airman calls you with this concern, simply tell him or her exam — LESSON 6. you can make the corrections in your office. You can revise In regard to the dates issue, we are looking into the possibility every item on the applicant’s history page with the exception of of the system repopulating information that will never change block 20 (Applicant’s National Driver Register and Certifying such as tonsillectomy at age 8. In the meantime, estimated dates Declarations) — LESSON 3. are perfectly acceptable — LESSON 7. I understand some AMEs are experiencing printing problems. Enough lessons for one editorial. I hope this information is Some of these problems are resolved as AMEs get more familiar helpful. If you have other concerns or suggestions, please let us with the system. However, there also appear to be some issues know immediately. We will do our best to find a resolution to with Adobe Reader, the free PDF Reader application. We are all your issues so that we can provide the most “user friendly” working to simplify the printing process, but in the meantime system for you and the airmen you serve. if you experience any printing problems, you can email us at And, as always, thank you so much for all you do for our [email protected], and we will help you airmen and protecting the safety of the national airspace. resolve your problem — LESSON 4. —Fred **Note: This paragraph clarifies the previous version originally published on 2/8/2013. 2 The Federal Air Surgeon's Medical Bulletin • Vol. 51, No. 1 TThhee FFeeddeerraall AAiirr SSuurrggeeoonn''ss MMeeddiiccaall BBuulllleettiinn •• VVooll.. 5500,, NNoo.. 44 23 CUTTING THE RIBBON. Commemorating CAMI’s 50th anniversary, officials and visitors rededicate the CAMI building to signify completion of an extensive renovation project—and the beginning of the second 50 years. Shown include (L-R) Dr. Antuñano, Dr. Fraser, Lindy Ritz, Peggy Gilligan, and Michael Huerta. Civil Aerospace Medical Institute Celebrates 50 Years of Aerospace Medical Excellence Refurbished and Ready for 50 More Years A celebration was held on December 12, 2012, “The Institute has certainly set the gold standard in its commemorating the fiftieth anniversary of the commitment to ensure the safety of every person involved Civil Aerospace Medical Institute (CAMI) in in aviation—on the flight deck, in the cabin, control tower Oklahoma City, Okla. Then-Acting Administra- and maintenance bay,” Peggy Gilligan said. “All of us who fly tor Michael Huerta and Associate Administrator for Aviation are deeply grateful for their contributions.” Over the last half Safety Peggy Gilligan joined Director of the Mike Monroney century, CAMI has dealt with more than 20 million medical Aeronautical Center Lindy Ritz, CAMI Director Melchor applications, and currently manages the medical certificates for Antuñano, and Deputy Federal Air Surgeon James Fraser roughly 400,000 U.S. pilots each year. CAMI staff manages to reflect on highlights of the medical research and the many aerospace medicine, education, scientific research, and occu- educational programs and achievements made at CAMI over pational and environmental health, in addition to supporting the last 50 years. the FAA Academy and the Transportation Safety Institute. “For the past CAMI’s contributions to aviation safety span the entire 50 years, CAMI has range of human involvement in aviation systems including been at the nexus of the identification and mitigation of medical and performance aerospace medical risk factors during flight to breakthroughs in crash safety research, education, design and aircraft evacuation. CAMI researchers create and and certification, apply aviation-specific medical knowledge to enhance aviation Administrator Huer- safety. CAMI’s programs communicate vital aeromedical safety ta said. “CAMI is information to the civil aviation community. working to make sure Other contributions include drop-down oxygen masks, that the human body evacuation floor lights, and water survival techniques. can keep pace with the By using the latest medical technology to assess an airmen’s human spirit’s desire FAA Administrator Huerta medical fitness to fly and always putting safety first, CAMI to expand the envelope has helped the FAA achieve the most flexible, pilot-friendly of flight. All of this is possible because of the men and women medical certification program in the world. who keep this place running. The public service you exude, The four-story CAMI facility was recently refurbished, and the professionalism for which you’re known … well, that comes included a time capsule reminding future generations of the from the deep seeds of character that were sown long before accomplishments made to date. Staff is eager to focus on the you came to the FAA. Everywhere I look here at CAMI, I see future, though, upholding the world-class tradition they have a pride, a desire to go above and beyond,” he added. built at CAMI. Here’s to 50 more! —Information from AVS Flyer TThhee FFeeddeerraall AAiirr SSuurrggeeoonn''ss MMeeddiiccaall BBuulllleettiinn •• VVooll.. 5500,, NNoo.. 44 23 Letters to the editor MedXPress Question And Another MedXPress Question Dear Editor: Dear Editor: Prior to MedXPress, the information submitted The AME is about to transmit new exam, and by the pilot was correct (hopefully) up to the date has in hand a Letter of Authorization, but not an of the flight physical, because that was the date the AASI (AME Assisted Special Issuance). The airman pilot submitted the form. is not yet “due” for a new exam (for example, class With MedXPress, however, the information is 3). Can the AME print a certificate, even though a correct up to the date the form is submitted, but new exam was not done, and the airman is not on that can be up to two months prior to the date of an AASI letter? How does that work? the flight physical. Since things may happen at any Peter Lambrou, MD time, therefore, it is entirely possible that something Moon Township, Pa. noteworthy may occur between the time the form is submitted and the physical is actually completed. Dear Dr. Lambrou: This aspect has not, to the best of my knowl- If the airman is approved for a special issuance edge, been taken into account when MedXPress with an interim issuance (the AMCD letter should was mandated. specify), then you can print the interim certificate Larry E. Nazimek Chicago, IL through AMCS. After logging in to AMCS, click on the search Dear Mr. Nazimek: applicants tab and search for the airman. Once Thank you for your question. As you know, you the airman’s name is displayed, check the lower may input your history into MedXPress up to 60 portion of the screen for the associated list of exams. days prior to your AME exam. However, you are If the airman is eligible for an interim certificate always responsible for notifying the FAA about (a certificate between exams), there will be a link any changes in your medical history. in the upper right-hand corner of that list called So, as you stated, changes may have occurred “interim cert.” Click on that link to bring up that would affect your medical certificate. You the certificate printing screen. You will update the are required to notify your AME at the time of expiration date contained in the limitation and your exam to any of these changes. The AME certify that the airman provided the appropriate has options in their system, AMCS (Aerospace documentation. After printing the certificate, you Medical Certification Subsystem), to update your should mail all the supporting documentation to history as needed. the AMCD. Note to AMes: We need your detailed comments in block Jana Weems 60. This provides the examiner with an opportunity to report AMCD Program Analyst a detailed summary of the history, and any changes in airman history all summarized in block 60. You must comment on each ‘yes’ answer in block 18, each abnormal physical exam fund- ing, and any changes to page 1 of the AMCS record (which is the MedXPress history reported by the airman). This should include any changes that have occurred in the medical history prior to the AME exam. Richard Carter, MD Certification Division Medical Officer 4 The Federal Air Surgeon's Medical Bulletin • Vol. 51, No. 1 TThhee FFeeddeerraall AAiirr SSuurrggeeoonn''ss MMeeddiiccaall BBuulllleettiinn •• VVooll.. 5500,, NNoo.. 44 45 Your Voice Has Been Heard: AME Survey Results Aviation Medical Examiner Information Links By Katrina Avers, PhD AME Guide The civil aerospace Medical Institute (CAMI) recently www.faa.gov/go/ameguide distributed a survey to aviation medical examiners (AMEs) to evaluate the degree of satisfaction with services and identify specific areas of improvement for aerospace medical certifica- AME Training Information tion services. The polls have closed and we received a record www.faa.gov/go/ametraining number of responses from AMEs (n=1,879) from each region in the United States. Your voice has been heard and your rec- ommendations for improvement are being reviewed by each AMCS Online Support respective office. www.faa.gov/go/amcssupport Overall, the majority of AMEs (more than 88%) reported being satisfied with aerospace medical divisions and offices. Most reported being satisfied with products and tools (for ex- Regional Flight Surgeon Contacts ample, EKG, 77% satisfied; Aerospace Medical Certification www.faa.gov/go/rfs Internet Subsystem, 88% satisfied; MedXPress, 84% satisfied; OAM website, 83% satisfied). Although most AMEs reported satisfaction, they identified opportunities for improvement. Pilot Safety Brochures AMEs prioritized their recommendations for each division or www.faa.gov/go/pilotsafetybrochures office. The top ten recommendations include: 1. Electronic notification to AME of changes in deferral status Medical Certification Information 2. Online tracking of deferrals www.faa.gov/go/ame/ 3. Publish unofficial list of disallowed medications with trade and generic names 4. Ability to retrieve a MedXPress application without a MedXPress Login & Help confirmation number https://medxpress.faa.gov 5. Electronic notification to applicant of changes in deferral status 6. More online training options MedXPress Video Page 7. Ability to retrieve an imported pending MedXPress www.faa.gov/tv/?mediaId=554 application deleted by mistake 8. Conduct an online review of recent changes to AME FASMB Archives processes 9. Provide feedback on inappropriate deferrals www.faa.gov/go/fasmb 10. Provide advanced training to expand AME-assisted special issuance authority CAMI Library Services Some recommendations may not be immediately feasible due www.faa.gov/go/aeromedlibrary to financial, technological, or regulatory constraints. Future issues of the Federal Air Surgeon’s Bulletin will discuss how your suggestions are being used to improve aerospace medi- cal certification services. A special thanks to all of you that responded to this survey! Q Dr. Avers is a research psychologist in the Aerospace Human Factors Research Division at the Civil Aerospace Medical Institute. TThhee FFeeddeerraall AAiirr SSuurrggeeoonn''ss MMeeddiiccaall BBuulllleettiinn •• VVooll.. 5500,, NNoo.. 44 45 ‘Tiger Team’ Training Initiates New AMCD Physicians Combined Effort Accelerates Certification Process By Richard Carter, DO, MPH The “Tiger Team” is a special project initiated by Aerospace Medical Certification Division (AMCD) manager Dr. Courtney Scott, continuing a process initiated by Dr. Warren Silberman to improve customer service and reduce the backlog of certification cases. Previous Tiger Team efforts have been successful, so Dr. Scott again called on new hires Drs. Joe Ray and Matt Dumstorf, with Dr. Judy Frazier and the assistance of Dr. Harriet Lester, to jointly process a backlog of complex certification cases while taking on-call inquiries from AMEs. The Tiger Team training program was conducted on Janu- ary 18, 2013. Tiger Team efforts, combined with additional certification work by Regional Flight Surgeons, eliminated more than 200 deferred exam cases. If you had called in that day for certification assistance (AME verbal authorization to issue), you INTO THE FRAY. Drs. Richard Carter and Judy Frazier (back row) talked to Dr. Lester and had the opportunity to participate. explain the intricacies of medical certification to Dr. Joe Ray and Dr. Matt Dumstorf (left-right). This virtual, online Tiger Team joined a team of medical of- ficers at work in a CAMI conference room in Oklahoma City to simultaneously attack the backlog of medical certification cases and helped to quickly bring the new AMCD doctors up to full speed in certification tasks. Thus, the Tiger Team kicked off a five-week AMCD train- • AMCD is also much more closely integrated with Regional ing program to introduce new hire staff to AMCD policies and Flight Surgeons, such that we can say with great confidence: procedures—the “new” AMCD that is rapidly evolving with We are all on the same team. a goal to further minimize delays in certification. There is no • Some of the most difficult medical certification challenges single solution, but rather a combination of strategies that will (think – drug and alcohol issues, complex cardiac disease, be used to reach this goal. For example, etc.) are getting a fresh look to determine what we really • The AMCD on-call program has been expanded to include need for reports and testing. many Regional Flight Surgeons, all for the purpose of giving • During the week we launched the Tiger Team, another you a verbal authorization to issue with minimal delays. major activity also was conducted by AMCD. Dr. Brian • There are new staff doctors you will be talking to when Johnson and Dr. Ben Zwart held an intense cardiac panel you call in—to include Drs. Roger Bisson, Ray, and discussion with the Federal Air Surgeon’s top cardiology Dumstorf–although they are not really new to most AMEs consultants. New policies will be developed from this [see article on page 7]. process to address certification decisions – all for the better! • The AMCD has integrated some internal certification processes more closely with our “Reviewers” (LIE – Legal In summary, this is not your “grandfather’s certification Instrument Examiners), also to minimize delays, particu- division,” and we will continue to endeavor to provide safe, larly on deferred exams. effective, and efficient medical certification. • AMCD medical officer staffing is improving to better Dr. Carter is a Certification Division Medical Officer. handle the case workload. Q 6 The Federal Air Surgeon's Medical Bulletin • Vol. 51, No. 1 TThhee FFeeddeerraall AAiirr SSuurrggeeoonn''ss MMeeddiiccaall BBuulllleettiinn •• VVooll.. 5500,, NNoo.. 44 67 Transitions in the AMCD: New Certification Physicians Four physicians have joined the staff of the Aerospace Medical Matthew Dumstorf, MD, MS, since 2006 was the FAA’s Certification Division to replenish the void created by recent Deputy Regional Flight Surgeon for the Great departures and will be assisting the other staff physicians soon. Lakes Region. As the Deputy in Great Lakes, he managed the office’s Airman Medical New AMCD Supervisory Physician Certification program, Aviation Medical Penny Giovanetti, DO. Dr. Giovanetti joined the FAA from Examiner program, and AME Surveillance private practice in Physical Medicine and program. His time as Deputy afforded Dr. Rehabilitation. She retired from the US Air Dumstorf opportunities to interact with air- Force in 2007 after a 27-year career as a flight men, AMEs, and air traffic controllers, while surgeon, staffer, and commander. She held continuing his professional pursuits in the numerous positions in aeromedical standards interest of aviation safety. to include the Tactical Air Command Surgeon’s Dr. Dumstorf began his medical career as an urgent/acute Office, Air Force Surgeon General’s Office, and care staff physician in the Dayton, Ohio, area in 2001, while the U.S. Air Force Academy. She was Vice Wing working on his Aerospace Medicine degree. He went to American Commander of the 311th Human Systems Airlines as the Area Medical Director at Chicago’s O’Hare airport Wing, host to the USAF School of Aerospace Medicine. She holds in 2004, and he was also the Independent Medical Sponsor for a Doctorate in Osteopathic Medicine from Des Moines University, more than 50 pilots that were in the FAA’s Special Issuance/ Master’s degrees in Preventive Medicine and Environmental Health HIMS program for substance abuse/dependence problems. In from the University of Iowa, and National Security Strategy training addition, he completed nearly 90 DOT random drug testing from the National War College. She is board certified in Aerospace verifications as a Medical Review Officer. Medicine and Occupational Medicine, a Fellow of the Aerospace He is a Diplomate of the American Board of Preventive Medi- Medical Association, and the winner of the Howard R. Unger cine in both Aerospace Medicine and Occupational Medicine, Award for the best published paper by a United States Air Force an Associate Fellow of the Aerospace Medical Association, and flight surgeon. Dr. Giovanetti is also a licensed private pilot. he is a member and the current treasurer of the Airline Medical Director’s Association. Profiles Joseph Ray, MD, finished medical school on a United States Dr. Roger Bisson returns to Medical Certification after an eight- Air Force Health Professions Scholarship month hiatus and the opportunity to telework program and then practiced at Tyndall AFB from home became an option. He had spent in Panama City, Fla., on active duty. Fol- five years in the Aerospace Medical Certifica- lowing a lengthy period in private practice, tion Division, separating from the agency in he became an aviation medical examiner in January 2012 to join his wife, who is an active- the New England area in 2007. He joined duty physician assigned to RAF Lakenheath, so the New England Region as the Deputy “home” in his case involves teleworking from Regional Flight Surgeon in 2009. He is the United Kingdom. board certified in both internal medicine Dr. Bisson, a federal retiree, was rehired by and emergency medicine. the Office of Aerospace Medicine as a “mission essential retired annuitant.” He will help AMCD decrease the backlog of case work The most recent review physician to depart, Dr. Bill Mills, is and minimize certification delays of deferred exams. transferring to the Civil Aerospace Medical Institute’s Aerospace A pilot for 40 years, Dr. Bisson has 30 years’ experience as a flight Medical Research Division after almost 15 years in the AMCD. surgeon and has been an FAA aeromedical examiner for many of For the majority of this time, he was the CAMI contact point those 30 years. He is board certified in Aerospace Medicine. He has for the Alcohol and Drug Unit. He reports he has long had an served as flight surgeon for the SR-71 and U-2 blackbirds and was interest in research and obtained a PhD from the Biostatistics the first B-1B bomber weapon system flight surgeon. Dr. Bisson and Epidemiology Department at the University of Oklahoma has authored 17 publications related to research interests in hu- Health Sciences Center in 2005 to help prepare for this career man performance, fatigue, and long-duration flight. He supported switch. He will be working on the Medical Research Team of more than 14 space shuttle missions as Chief of Space Operations the Aeromedical Protection and Survival Laboratory. “I will Medical Support, DoD Manned Spaceflight Support Office. He miss my usual interactions in the Certification Division and is the recipient of the Theodore C. Lyster Award for outstanding the rest of the certification community,” he says, but anticipates contributions to the field of aerospace medicine, as well numerous “exciting new challenges” in medical research. other honors. Q TThhee FFeeddeerraall AAiirr SSuurrggeeoonn''ss MMeeddiiccaall BBuulllleettiinn •• VVooll.. 5500,, NNoo.. 44 67 Obstructive Sleep Apnea in a Pilot By J. Ron Allen, MD, MPH Insufficient sleep is an ever-worsening public health problem within the United States. This growing problem is linked with motor vehicle accidents, aircraft mishaps, industrial disasters, medical and other occupational errors.1 Obstructive sleep apnea (OSA) is a major contributor to the insufficient sleep epidemic. It is estimated that OSA affects 4-7% of middle-aged adults, 70% of the clinically obese population, 30-50% of those with heart disease, and 60% of those suffering strokes.2 This article presents a case of a third-class pilot with OSA and the related aeromedical concerns. History A 65-year-old male third-class pilot with 650 hours Obstructive sleep ApneA of flight time presented to his AME for his medical The growing obesity problem for the United States is leading to a recertification with a new diagnosis of obstructive sleep apnea. subsequent obstructive sleep apnea epidemic. This rise in OSA He had been relatively healthy previously with only a docu- has become a concern not only for the impact on the individual mented history of hypertension. Over the past couple of years, but on the safety of the population as well. The National Highway his blood pressure had become increasingly difficult to control Traffic Safety Administration reports people with OSA have a and required escalating doses of atenolol to achieve control, six times greater risk for automobile accidents. Drowsy drivers with his current requirement being 100mg daily. He had been account for 100,000 accidents, with 1,550 fatalities and 40,000 snoring for years; his weight was steadily on the rise, with his injuries annually.5 The National Sleep Foundation estimates that BMI increasing from 41 to 43.5 kg/m.2 He was sent for a poly- sleep deprivation and sleep disorders cost the United States somnograph secondary to his symptoms and risk factors that more than $100 billion annually when lost productivity, property included: obesity, daytime fatigue, hypertension, and snoring. damage, and medical expenditures are taken into account.6 This He denied routinely taking naps and stated that he had never growing problem for the aviation community was highlighted fallen asleep while he wanted to remain awake, including while in February 2008 when a commercial aircraft with three crew- driving and flying. The polysomnograph was positive with an members and 40 passengers continued past their scheduled AHI of 21.3. He was titrated with CPAP to a pressure of 10 cm destination. The National Transportation Safety Board concluded during the split-night protocol. He attempted to use the CPAP that the captain’s undiagnosed OSA and the flight crew’s recent machine at home but did not tolerate it for various reasons. He work schedule contributed to both the pilot and the first officer switched to a mouth guard specifically designed for OSA and falling asleep and subsequent missed arrival.2 Thankfully, no one reported improvement. He remained mildly sleepy during the was injured, but this case highlights the importance of OSA in day with minimal snoring at night, confirmed by his wife. He today’s aviation environment. The increasing OSA population, was sent for a maintenance of wakefulness test, which he was combined with other fatigue risk factors of alcohol, time zone able to remain awake throughout; however, due to continued changes, and irregular work schedules, presents a significant daytime somnolence, he was denied re-certification. He will risk to aviation safety. be able to re-apply once he has been adequately treated and OSA is a treatable condition with many well established treat- therapeutic benefit can be validated. ment options, including weight loss.7 The issue then becomes Aeromedical Issues recognizing the risk factors, especially the modifiable ones, and increasing the population’s self-recognition of the warning Daytime drowsiness and the implications for flight safety is signs, as well as AMEs awareness of the disease and responses an obvious aeromedical concern. However, the implications and on history that are suggestive of OSA. Daytime somnolence, severity of the situation may not be fully appreciated by airman. uncontrolled hypertension, snoring, a narrow oropharyngeal It has been reported that people with mild to moderate OSA airway, and a BMI >30 should all alert the clinician to a possible can have degradation in their performance that is equivalent to issue of OSA.8 Prevention, recognition, and treatment will lead a blood alcohol level of 0.06-0.08%, legal intoxication in most to safer skies through mitigation of an unnecessary risk. states.2 Not only is the degradation in performance concerning, but micro naps and the inability to maintain wakefulness while flying may be hazardous. Issues with concentration, attention span, memory, headaches, and irritability are all associated with OSA. These present unique risks in the aviation environment. The direct effects of OSA and one’s ability to fly are very concerning. Secondary complications and comorbid conditions Continued on page 9 8 The Federal Air Surgeon's Medical Bulletin • Vol. 51, No. 1 TThhee FFeeddeerraall AAiirr SSuurrggeeoonn''ss MMeeddiiccaall BBuulllleettiinn •• VVooll.. 5500,, NNoo.. 44 89 Sleep Apnea from page 8 References 1. Committee on Sleep Medicine and Research. Sleep disorders and present challenges and hazards as well. Heart disease, hyper- sleep deprivation: An unmet public health problem. Washington, tension, stroke, myocardial infarction, heart failure, cardiac DC: The National Academies Press; 2006. arrhythmia, diabetes, and metabolic syndrome have all been 2. Brown JR. Obstructive sleep apnea: Don’t get all choked up. Fed- associated with OSA.3 These conditions may directly or indi- eral Aviation Administration Medical Facts for Pilots (brochure). rectly have severe implications for the airmen and their ability Publication No. AM-400-10/1. to fly safely 3. Ulualp S. Snoring and obstructive sleep apnea. Medical Clinics of OSA is disqualifying from flying for all classes of medical North America - Volume 94, Issue 5 (September 2010). certification in accordance with Title 14 of the Code of Federal 4. Office of Aerospace Medicine. Guide for aviation medical examin- Regulations, part 67. It requires for initial special issuance, at a ers. Online at www.faa.gov/go/ameguide/. Accessed 9 Dec 2012. minimum, a current status report, all pertinent medical infor- 5. National Highway Traffic Safety Administration: Driving safety, re- mation, medication report, and polysomnograph with titration search on drowsy driving. Online at www.nhtsa.gov/Driving+Safety/ Distracted+Driving/Research+on+Drowsy+Driving. Accessed 10 study results.4 The aviation medical examiner should be vigilant Dec 2012. for the risk factors, as well as the signs and symptoms of sleep 6. Committee on Sleep Medicine and Research. “Functional and apnea. An airman presenting with daytime sleepiness, BMI economic impact of sleep-related disorders.” From: Chapter 4, >30, or excessive snoring should alert the AME of a potential Sleep disorders and sleep deprivation: An unmet public health problem. Once a diagnosis has been established, the minimum problem. Washington, DC: The National Academies Press, 2006. requirements (above) must be submitted and, depending on the 7. Tuomilehto HP, Seppa JM, Partinen MM, et al. Lifestyle interven- treatment plan (uvulopalotophyngoplasty, continuous positive tion with weight reduction: First-line treatment in mild obstructive airway pressure, or oral device), additional testing may be re- sleep apnea. Am J Respir Crit Care Med 2009;179(4):320. quired to demonstrate therapeutic improvement and mitigation 8. Epstein LJ, Kristo D, Strollo PJ, et al. Clinical guideline for the of the more significant aeromedical safety concerns. evaluation, management and long-term care of obstructive sleep Therapeutic improvement for OSA often requires uvulo- apnea in adults. J Clin Sleep Med 2009;5(3):263. palatopharyngoplasty or continuous positive airway pressure (CPAP). Dental devices may be an alternate form of therapy About the Author as well. Regardless of the treatment course chosen, evaluation of the effectiveness of eliminating the primary aeromedical Lt Col. J. Ron Allen, MD, MPH, is a USAF flight Surgeon board certified concern daytime hypersomnolence, also known as excessive in Family Medicine and currently participating in the USAF residency daytime sleepiness, will need to be established. This can often in Aerospace Medicine program. He wrote this report while rotating at the FAA’s Civil Aerospace Medical Institute. be accomplished with a follow-up sleep study in those who have had surgery or a CPAP titration report from the initial split- Q night polysomnogram. For initial issuance, these reports, along with the airman’s acknowledged improvement in symptoms, will usually suffice. If an airman is seeking a re-issuance, then a compliance report from the CPAP machine may be required per AME Assisted Special Issuance requirements. The effectiveness of a dental device may be more difficult to analyze. A maintenance of wakefulness test (MWT) may be of benefit. In this study, the applicants are monitored similar to a polysomnograph; however, they are requested to remain awake during four 40-minute daytime test periods spaced at two-hour intervals throughout the day. These data are then compared against normative values with the endpoints being completion of the 40-minute period or sleep onset. The results determine a propensity to fall asleep during the day. These studies, along with the clinical picture and co-morbid conditions, are used to evaluate the safety of flight issue for any given airman. TThhee FFeeddeerraall AAiirr SSuurrggeeoonn''ss MMeeddiiccaall BBuulllleettiinn •• VVooll.. 5500,, NNoo.. 44 89 Chronic Renal Failure in an Airman Applicant Case Report, by Kathleen M. Samsey, MD, MPH Chronic renal failure (CRF) due to any etiology can have a potentially devastating effect on an airman, and with rare exception, is incompatible with flight duties. This case report reviews the aeromedical concerns posed by CRF and sheds light on the FAA’s decision-making process regarding this condition. History A3 2-year-old third-class applicant’s physical exam was chrOnic renAl FAilure forwarded to the FAA’s Aeromedical Certification Division Chronic renal failure, or Stage 5 chronic kidney disease, is (AMCD) for consideration, with a history of left nephrectomy defined by the National Kidney Foundation as either a GFR at age 3 for multicystic dysplastic kidney disease. On the Form level <15mL/min/1.73 m2 (which is accompanied in most cases 8500-8, the airman reported that he was “in very good health, by signs and symptoms of uremia) or a need for initiation of other than I only have one kidney.” The airman’s primary care kidney replacement therapy (1). This definition was set forth by provider endorsed the application, stating that the applicant the National Kidney Foundation’s Kidney Disease Outcomes also had Stage 5 chronic kidney disease (of unspecified etiol- Quality Initiative (KDOQI) and their well-established clinical ogy), but that he demonstrated no hypertension and had been practice guidelines in 2002; prior to this, there was no uniform “medically stable for the past several years.” definition of chronic kidney disease, and thus no uniform ap- Likewise, the AME inexplicably also endorsed the application, proach to its screening and treatment. stating, “I would fly with him,” despite current lab values of BUN 111 mg/dL (normal 10-22), creatinine 11 mg/dL (normal The Third National Health and Examination Survey (NHANES 0.6-1.2), HCO - 18 mmol/L (normal 22-30), calcium 6.5 mg/ III, 1988-1994) estimated that 19.2 million Americans had 3 dL (normal 8.7-10.2), and phosphorus 6.2 mg/dL (normal 2.5- chronic kidney disease, 300,000 of them with Stage 5 (2). The 4.5). Most impressive was his estimated GFR of 5 mL/min/1.72 most common etiologies in the United States include vascular m2 (normal is > 59). disease, primary and secondary glomerular disease, tubuloin- This airman’s medication list included febuxostat (Uloric, to terstitial disease, and urinary tract obstruction (2). Frequent decrease uric acid), paricalcitrol (Zemplar, to increase vitamin complications of CRF include acid-base disturbance (typically D), rosuvastatin (Crestor), sodium bicarbonate, vitamin D, mixed metabolic acidosis), electrolyte abnormalities (especially Tums, and epoetin alfa (Procrit) 20,000 units monthly. hyperkalemia, hypo/hypercalcemia, and hyperphosphatemia), renal bone disease/secondary hyperparathyroidism, anemia, Aeromedical Concerns and accumulation of waste products, especially urea. The manifestations of uremia in end state renal disease can vary, With regard to cases of chronic renal failure and FAA but commonly include pericarditis, encephalopathy, peripheral decision-making, the general approach includes reviewing the neuropathy, gastrointestinal symptoms, fatigue/somnolence, relevant peer-reviewed medical literature and obtaining specialist and malnutrition (2). consultation. Often, a review is also conducted of relevant US military services’ waiver guides, as well as the published polices The indications for dialysis are not always clear and consistent; of the European Aviation Safety Agency and International Civil the decision to initiate dialysis involves a combination of objective Aviation Organization (according to personal communication and subjective parameters, with input from both the physician with Dr. Arleen Saenger, Manager of the FAA Aeromedical and patient. It is a decision that must not be taken lightly, as Standards and Policy Branch, 15 March 2011). the morbidity and mortality associated with chronic dialysis is A review of those various US military services’ waiver guides significant. The 5-year survival rate for a patient on chronic clearly delineates the aeromedical concerns related to chronic dialysis in the US is 35%; the most common cause of death renal failure. According to the US Army, “Significant renal of all patients with chronic renal failure (whether on dialysis disease may lead to chronic fatigue, near syncope, or loss of or not) is cardiovascular disease (2). Common indications for consciousness. [The] aviation environment (heat, dehydration, initiating dialysis include pericarditis/pleuritis, progressive uremic prolonged [flights]) may exacerbate such conditions” (4). The encephalopathy/neuropathy, clinically significant bleeding, dia- U.S. Navy Aeromedical Waiver Guide indicates that renal thesis attributable to uremia, fluid overload refractory to diuretics, failure can lead to fatigue, susceptibility to infection, edema, significant hypertension with poor response to antihypertensive and electrolyte disturbances (5). The U.S. Air Force waiver’s medications, persistent metabolic disturbances, persistent aeromedical concerns include “malaise and subtle declines in gastrointestinal symptoms, and evidence of malnutrition (3). general health and mental clarity” (6). Continued on page 11 10 The Federal Air Surgeon's Medical Bulletin • Vol. 51, No. 1 TThhee FFeeddeerraall AAiirr SSuurrggeeoonn''ss MMeeddiiccaall BBuulllleettiinn •• VVooll.. 5500,, NNoo.. 44 1101