2002-3, volume 40-3

02-3Fall 2002

U.S. Department of TransportationFederal Aviation Administration

Federal Air Surgeon’sMedical Bulletin

Aviation Safety Through Aerospace MedicineFor FAA Aviation Medical Examiners, Office of Aerospace Medicine

Personnel, Flight Standards Inspectors, and Other Aviation Professionals.

HEADS UP

2 Editorial: PilotsAbusing Alcohol

3 Certification Issuesand Answers

4 An Accident Story6 FAA Mail Important7 Pilot’s

ChecklistforPhysicalExamSuccess

8 AME Shorts: ConciseCertification Topics

9 Hydrocephalus andSeizures

11 Meningioma in anAirman

12 YourLetters

13 OAMNews

14 Health ofPilots:Who’s inCharge?

16 AME Seminars

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Continued on page 6...

FAA Changes Foreign Pilot CertificationBy FAA Aviation News


New FAAAdministratorSworn In

Marion Clifton Blakeywas sworn in September13, 2002 as the 15th Ad-ministrator of the Federal Aviation Ad-ministration, replacing Jane Garvey,whose five-year term expired on August 4.

“I was deeply honored when PresidentBush asked to me to lead the FAA, shesaid in an address to agency employees.“Now that I am on board, I am excited bythe opportunity to work with you on thechallenges facing the agency.”

Prior to being named FAA Adminis-trator, Ms. Blakey served as Chairman ofthe National Transportation Safety Board.As Administrator, she is responsible forregulating and advancing the safety of thenation’s airways as well as operating theworld’s largest air traffic control system.

"

Ms. Blakey

AS A RESULT OF THE MANY governmentalchanges that have occurred since the

September 11, 2001, terrorist attacks, onJuly 16, 2002, FAA stopped issuing USpilot certificates to foreign pilots basedupon their foreign pilot licenses. Thatban continued until FAA’s Flight Stan-dards Service issued a notice late in Julyexplaining its new issuance process.

The basic process has not changed. How-ever, foreign pilots wanting a US privatepilot certificate issued on the basis of theirequivalent foreign private pilot or higherlevel pilot certificate must now submit to

FAA at least 60 days in advance the follow-ing information as part of a pre-applicationprocess. The FAA will use the informationto verify the authenticity of the applicant’spilot certificate. Complete instructions andthe new Verification of Authenticity formare available on the Internet at http://registry.faa.gov. The applicant must sub-mit either the completed form with therequired attached documents or a legiblehand-written or type-written letter with thefollowing:

Misuse of the AME DesignationBy Richard F. Jones, MD, MPH

Aviation Medical Examiners who issuemedical certificates by mail, withoutever seeing the pilot, perform cursoryexaminations, and allow para-professional medical personnel toperform examinations are subject to thetermination of their AME designation.

ONE OF THE REGULATORY RESPONSIBILI-TIES of the Aerospace Medical

Education Division (AAM-400) is tomonitor the performance of aviation medi-cal examiners (AMEs). It has come to myattention in a variety of ways that someAMEs may be misusing their designa-tions. As a result, this division will beginto emphasize the surveillance aspects ofour duties.

We occasionally receive calls from AMEs’offices asking if mid-level or non-AME

2 T h e F e d e r a l A i r S u r g e o n ' s M e d i c a l B u l l e t i n • Fall 2002

By Jon L. Jordan, MD, JD

The Federal AirSurgeon’s Column

Federal Air Surgeon’sMedical Bulletin

Secretary of TransportationNorman Y. Mineta

FAA AdministratorMarion C. Blakey

Federal Air SurgeonJon L. Jordan, MD, JD

EditorMichael E. Wayda

The Federal Air Surgeon’s Medical Bulletinis published quarterly for aviation medicalexaminers and others interested in aviationsafety and aviation medicine. The Bulletin isprepared by the FAA’s Civil Aerospace Medi-cal Institute, with policy guidance and supportfrom the Office of Aerospace Medicine. AnInternet on-line version of the Bulletin isavailable at: http://www.cami.jccbi.gov/AAM-400A/fasmb.html

Authors may submit articles and photos forpublication in the Bulletin directly to:

Editor, FASMBFAA Civil Aerospace Medical InstituteAAM-400P.O. Box 25082Oklahoma City, OK 73125e-mail: [email protected]

Alcohol AbuseBy Jon L. Jordan, MD, JD

POTENTIAL DRUG AND ALCOHOL ABUSE

in aviation has been a long-termconcern of the Federal Aviation Ad-ministration and especially, the Officeof Aerospace Medicine. Going back tothe early 1970s, the leadership of thethen-Office of Aviation Medicine rec-ognized that the potential for alcohol-ism in flight deck crews probably was atleast comparable to what could be foundin the general population.

At the same time, it was also recog-nized that the routine physical exami-nations of airmen were not identifyingsignificant numbers of airmen who haddrinking problems. In addition, a con-servative approach to the medical certi-fication of airmen with a history ofalcohol abuse appeared to be drivingairmen “underground.”

In an effort to cure what was be-lieved to represent a significant safetyproblem for the air carrier industry, theFederal Air Surgeon began seeking waysto improve the identification of alco-holic airmen. The objective was toremove those airmen from their safety-related duties, get them into treat-ment, and if possible, return them topiloting duties.

The early years of attempting tobuild a means for identifying pilotswith alcohol problems were marginallyproductive, and it was not until aggres-sive involvement of the Air Line PilotsAssociation in the mid-70s that signifi-cant headway was made in the initia-tive. Through a grant by the NationalInstitute for Mental Health, the Hu-man Intervention and MotivationStudy spawned a cooperative enter-prise between the FAA and the aviationcommunity to deal with alcohol abuseby air carrier pilots.

The program was founded, in part,on the concept that, if pilots could bereturned to duty within a reasonableperiod of time following rehabilitationand commitment to abstinence fromalcohol, more pilots with alcohol prob-lems would self-identify or be identi-fied by peers. That is precisely whathappened.

As an added measure to deal withconcerns regarding drug and alcoholabuse in aviation, Congress enacted the

Omnibus Transportation EmployeeTesting Act of 1991. This Act codifiedthe FAA’s existing anti-drug programand led to the implementation in 1994of alcohol testing requirements for seg-ments of the aviation industry. Underthese regulations, testing for alcohol isnow required for certain workers in theindustry, including pilots. These testsare required randomly, post accident,for reasonable cause, return to duty,and follow-up after return to duty.

You’ve probably seen or heard,through the news media, incidents ofpilots who have reported for duty un-der the influence of alcohol and withblood or breath alcohol levels in excessof FAA regulations. In many of thesecases, security personnel— and not co-workers of the pilots— have been re-sponsible for reporting the pilots whoappear to have recently used alcohol.Alcohol testing under FAA’s regula-tions has, in most reported cases, con-firmed the suspicions of the securitypersonnel.

It is disturbing that pilots wouldreport for duty with any levels of bloodor breath alcohol. The threat to safetyshould to be apparent to everyone andthe threat to aviation careers, if nothingelse, ought to prevent this from hap-pening. It is also disturbing that secu-rity personnel seem to have become thefirst line of defense in identifying theseproblem pilots. This is the case, how-ever, and it has become obvious that wemust now carry out some careful intro-spection to determine what more mightbe done to prevent these incidents fromoccurring.

I began this column with the thoughtthat the physical examinations of air-men have not proved effective in iden-tifying many pilots with alcoholproblems. I cannot help but wonder,however, whether this is because alco-hol abuse is difficult to identify througha routine physical examination or be-cause the examining physician has failedto see or ignored obvious clinical signs.This is something you might considerwhen you examine your next airman.Confronting the airman whom yoususpect has an alcohol problem couldbe a major contributor to safety and, inthe long run, a service to the airman.

JLJ

Consider this when you exam-ine your next airman: Alcoholabuse, while difficult to identifythrough a routine physical ex-amination, remains a majoraviation safety concern.

T h e F e d e r a l A i r S u r g e o n ' s M e d i c a l B u l l e t i n • Fall 2002 3

Certification IssuesBy Warren S. Silberman, DO, MPH

This will test your knowledge of medical certification procedures. See howwell you can do on this test. If you ace them all, Dr. Silberman would liketo hear from you. —Ed

I am going to try something a little different for this issue of the Bulletin. I’vemade up some questions to challenge the aviation medical examiner’s expertise. Allof these questions come from the Guide for Aviation Medical Examiners, October1, 1999 edition. As always, there is a teaching point for each of these questions.

1What is the name of the “waiver”that the FAA uses for medical

conditions that can change over time?(See page 4 for correct answers.)

2What is the name of a “waiver” fora medical condition that is static,

such as monocular vision?

3Six of the FAA’s 15 SpecificallyDisqualifying Conditions are car-

diac-related. What are they?

4What are the minimum age re-quirements for the various air-

man certificates (for powered air-craft; fill in the blanks. )?A. Student pilot ____B. Private pilot ____C. Commercial pilot ____D. Airline transport pilot ____

5 Which regulation governs theprohibition of operations during

a medical deficiency?

6 An airman (age 39) may receive a3rd-class medical certificate that is

valid for 36 months. True or false?

7Which of the following can theFederal Air Surgeon do with an

Authorization for Special Issuance(waiver)?A. Time limitation placed on medi-cal certificateB. State on the Authorization andmedical an operational limitationC. Can only be granted for a limited2nd-class medicalD. Condition the continued effectof the Authorization and any 2nd- or3rd-class medical certificate basedupon it, on compliance with a state-ment of functional limitations.

8 An Authorization granted to aperson can be withdrawn if the

holder fails to provide the medicalinformation needed by the Federal AirSurgeon for certification under theSpecial Issuance section of 67.401.True or False?

9 You can issue a student pilot/medical certificate (FAA Form

8420-2, yellow form attached to Form8500-8) to an airman who is 15 y/o.True or False?

10You may issue an airman a med-ical certificate if he/she checks

“yes” to question 13 on the front sideof the FAA Form 8500-8 (Has yourAirman Medical Certificate ever beendenied, suspended, or revoked?) basedon the airman’s word. True or False?

11When an applicant for medicalcertification has asthma that

requires the use of medication, whatdata should you provide the AMCD?A. Type of medicationB. Side effects of medication(s), if anyC. Nature and severity of residualsymptomsD. Electrocardiogram

12Applicants who have had myo-cardial infarction, angina pec-

toris, cardiac valve replacement, per-manent cardiac pacemaker, or whohave undergone percutaneous trans-luminal angioplasty, stent insertion,atherectomy, or coronary artery by-pass grafting may be certified for 1st-,2nd-, or 3rd-class medical certificates.Which controlling statute applies?A. 14 CFR Part 61.53B. 14 CFR Part 61.23C. 14 CFR Part 67.401

13For consideration, applicantsfor medical certification with a

history of peptic ulcer within the past___ months or a bleeding ulcer withinthe past ___ months must provideevidence that the ulcer is healed. (Fillin the blanks.)

14 Which of the following infor-mation must be provided to the

AMCD for consideration after treat-ment for peptic ulcer?A. Confirmation of lack of symptomsB. Tests for H. pyloriC. Radiographic or endoscopic evi-dence of healingD. Medication used

15Which of the following skinconditions warrant deferral to

the AMCD?A. Malignant melanomaB. Basal cell carcinomaC. Skin manifestation of lupuserythematosusD. Raynaud’s phenomenon

Dr. Silberman manages the Civil Aero-space Medical Institute’s Aerospace Medi-cal Certification Division.

Answers on page 4...


Continued #

1. A: Authorization for Special Issu-ance (AME Guide, page 3).

2. A: Statement of Demonstrated Abil-ity (SODA; AME Guide, page 3).

3. A: Angina pectoris, coronary heartdisease that has required treatment or,if untreated, that has been symptom-atic; myocardial infarction; cardiac valvereplacement; permanent cardiac pace-maker; heart replacement (AME Guide,page 3).

4. A: A – 16; B – 17; C – 18; D – 23(AME Guide, page 5).

5. A: Title 14, CFR 61.53 (AMEGuide, pages 7 - 8).6. A: True (AME Guide, page 7).

7. A: A, B, & D (AME Guide, page12.)

8. A: True (AME Guide, page 12).

9. A: False. The AME may not issue astudent pilot certificate (FAA Form8420-2) to an applicant who is less than16 years old. A medical certificate (FAAForm 8500-9) may be issued to anapplicant irrespective of age. (AMEGuide, pages 19 and 20).

10.A: False. An AME may only issue amedical to an airman who checks “Y”to #13, if (1) the applicant provideswritten evidence from the FAA that he/she was subsequently medically certi-fied and the examiner is authorized toissue a renewal certificate or (2) theexaminer obtains verbal or written au-thorization from the Regional MedicalOffice or the Aerospace Medical Certi-fication Division (AMCD) (AMEGuide, page 21).

11.A: A, B, & C (AME Guide, page47).

12.A: 14 CFR Part 67.401, Authoriza-tion for Special Issuance (AME Guide,page 47).

13.A: 3, 6 (AME Guide, page 51).

14.A: A, C, & D (AME Guide, page51).

15.A: A, C, & D (AME Guide, page53).

"

Answers to Quiz from page 3Tapestry of Disaster: An Accident StoryBy Parvez Dara, MD, FACP, ATP, CFII, MEI

When we commit anerror it is generally an

isolated one, and we getaway with it. This getting-away mentality reinforces

the behavior as beingokay. But start stitching aseries of these scenariostogether, and a tapestry

of disaster unfolds.

OFTEN, IN HIS MOST REFLECTIVE

moments, he would extol themany virtues of flying; the

splendor of sights, of new places butmostly of its freedom. He was 60 onhis last birthday, a 35-year Vietnamveteran with an artificial leg flyingwith a 2nd class certificate and a SODA.

He flew with precision, dedicated tohis hobby and mode of transportation.Every flight was enriching to him. Hecarried his task of flying with zeal, fromchecklist to checklist, double-checkingwhile motoring one to two miles aboveterra firma.

So on that cold, rainy night in Octo-ber, when I got the news of his planecrash, it scared me, then chilled me, andfinally numbed me. He was, in mymind, going to be an old pilot, for hewas never bold. He flew this immacu-lately dressed Mooney 201. But thecrashed plane was a Cherokee Six.

He apparently flew it with the gustlocks still attached!

The plane had taken-off, gained 500feet and then, predictably, plowed intothe woods. This man, in life a sticklerfor checklists, in death was now theobject of a storm of controversy and wasleaving a legacy of stuff that he wouldnot have been proud of.

They tried to piece together the shat-tered dreams of his mind and the asso-ciated features of the ill-fated flight onthat rainy night in October. “Accidentsdon’t just happen,” said the aviationcounselor from the FAA, “Planes don’tjust fall out of the sky.” There is sometruth to this, if you were to evaluate thecumulative vapor trail that eventuallycondenses into the big splash, multi-plicity of factors have been involved.

Let’s look at the so-called 10-17%catastrophic engine failures in pistonaircraft. I am not a betting man, but Ican wager that most, or all of them, gaveplenty of warning signals and hence,could have been averted. The gremlinsmay have shown up in a previous flight,in the pre-flight, or in the intuitive feel.The oil analysis may have revealed the

chewed metal in the filter, maybe theneed for more oil, a blob of oil on theground, or discordant magnetos. Inflight, it may have been a change of theaircraft’s behavior, in its speed, sound,dynamics, the hum, and all of the subtlenoises that we are attuned to in thecockpit. This subtle vapor trail of metal,sound, feel, and dynamics is there forus to recognize.

When we commit an error it is gen-erally an isolated one, and we get awaywith it. This “getting away” mentality,unfortunately, reinforces the behavioras being okay. But start stitching aseries of these scenarios together, and atapestry of disaster unfolds.

Imagine a series of cards with ran-dom holes in it reflecting the error-prone deficiencies of human beings(Figure 1). Each little hole reflects anact of omission or commission (failingto check the trim, or the fuel quantity,and so on; you get the point). Once inan unfortunate while, when those holesline up in sequence, an accident occurs.

The first priority to safety remainstrying to patch the holes in each ofthose successive cards. Learning the artof flying, practicing it, constructing apractical checklist for all possibilities,and never taking flying for granted. Forinstance, every time before I fly into anairport, I look at its layout to see on


departure where a straight-in engineout on take-off or landing would savemy bacon. Not much but it keeps yourguard up.

Consider the big boys who dream of

flying Mooneys but are stuck with theBoeings: They, too, can have a bad day.The flapless take-off in Detroit, Mich.,led to hundreds dead – a minor mistakethat led to a major tragedy. A Conti-nental aircraft was about to land gear-up at the Newark airport until advisedby an American pilot on the ground toput the wheels down. Mistakes fromshoddy cockpit behavior, taking thingsfor granted, or having the attitude that“I am the greatest” will bite.

Flying in low overcast without theprerequisite experience or attempting acrosswind landing beyond your abili-ties speaks volumes of the male gender.Some of the newly minted and evenlong-time pilots with little weather ex-perience who venture into the grayunknown of an overcast day just for arush or, better, stupidity, how can youjustify that with anything but the re-mark, idiots?

There are preconditions for theseunsafe acts (Shappell & Wiegmann,2000):Substandard Conditions ofOperators• Adverse mental states• Psychological states• Physical and mental limitations.

We have discussed some of themabove.

Substandard Practices of Operators• Cockpit Resource Management andPersonal Readiness

The former is not flying with ad-equate charts, plates, or lack of their

utility, etc.The latter is when your in-

stinct tells you, “It is not good togo even on severe clear and amillion,” so heed it.

Now, I’ll get back to thestory. My veteran aviatorwould occasionally drink beerbut cognizant of the regula-tions, he would wait eighthours before flying. He mostlyflew his Mooney, where hischecklist was always danglingfrom the mixture control knob

and he never allowed himself to rush.On the fateful night, he had con-

sumed alcohol nine hours before, buthe also had taken an over-the-countermediation for allergies, which it turnsout, decreases the alcohol metabo-lism in the body (slows the break-down of alcohol, hence the effects ofalcohol are prolonged in the body).He was flying an aircraft that he wasnot totally familiar with, and all histell-tale readiness checklists were notpresent to help him where they usu-ally presented themselves before flight,and he was in a rush to pick up hisfriend from an airport only 20 milesaway before a line of thunderstormscame through (that friend owned theCherokee).

Now you see that in his cards allthe holes had lined up (Figure 1). Acareful, analytic mind reduced in alac-rity, unencumbered by the weight ofhis previous knowledge through theharmful effect of persistent alcohol inhis body, failed to see the cues ofimpending disaster. Having foundnone of the patterned elements thathad kept him safe all along, hisclouded brain edged him on that dayand sought to play its own game ofchance.

There are many lessons to learn fromthis story. My own guidelines are asfollows; add on to them as you please:• Know your limits• Observe those limits• Develop good habits – use checklists• Follow those habits• Rectify a “getting away” scenario; donot amplify it• Be constructively critical of each flight• Even the best pilots make mistakes –minimize the number and break thechain• Always think about where is the pos-sible error• If intuition tells you something iswrong, prove the intuition to be wrongbefore proceeding. Intuition is mostlyright.• Alcohol, with or without medicines,is dangerous• Ground yourself voluntarily if youneed to for any medical reason. Deathis not an option.• Improve technique; periodically prac-tice safe flight with an instructor• If flying a different aircraft, becomethoroughly familiarized with it beforeflight• Do not violate the rules; they are theproducts of previous tragedies• Good decisions are born of goodjudgments, and good judgments areborn of prepared, rested, and alert minds• Fly safe – always

ReferenceShappell SA and Wiegmann DA (2000).

The Human Factors Analysis and Clas-sification System. Washington, DC:Office of Aerospace Medicine Techni-cal Report DOT/FAA/AM-00/7.

"

Dr. Dara is an aviation medical examinerwho specializes in hematology and oncologyin Toms River, N.J.; he is also a pilot with theratings of Airline Transport Pilot, CertifiedFlight Instrument Instructor, and Multi-Engine Instrument with more than 2,400hours in the air. He is a director of theMooney Aircraft Pilot Association and afrequent speaker at ground and flight safetyseminars.

Latent Failures

Latent Failures

Active Failures

Failed or

Absent Defenses

Unsafe

Supervision

Preconditions

for

Unsafe Acts

Unsafe

Acts

MISHAP

Figure 1. The "Swiss Cheese" model of human error causation (Shappell & Wiegmann, 2000).


• Name of person• Permanent home of record. If thepaperwork is to be mailed to a separatemailing address, that information mustbe attached to the package• The name of the country that issuedthe foreign pilot license• The name of the FAA Flight Stan-dards District Office (FSDO) wherethe applicant plans to apply for a UScertificate• A statement that the foreign pilotlicense is not suspended or revoked• A legible copy of all of the pages ofthe foreign pilot license• A legible English translation of thelicense if it is not in English• A legible copy of the foreign medicallicense or endorsement, as appropriate• A legible copy of a driver’s license,passport, or other photo ID

Send all of this information to :Federal Aviation AdministrationAirmen Certification BranchAFS-760P.O. Box 25082Oklahoma City, OK 73125FAX: (405) 954-4105

The Airmen Certification Branchwill authenticate the information withthe appropriate foreign civil aviationauthority. If the information is correct,the Airmen Certification Branch willsend a Verification of Authenticity let-ter to the designated FSDO. The letter,which expires in 60 days from the dateof issuance, is used by the named FSDOas the basis for processing the applicant’scertification application. If the letterhas expired or not been received by theFSDO, they cannot process theapplicant’s paperwork.

The Title 14 Code of Federal Regu-lations, Section 61.75 (Private pilotcertificate issued on the basis of a for-eign pilot license) application processremains the same.

"

Foreign Pilots from page 1 Medical Certification Applicants:Be Aware of FAA CorrespondenceYour FAA Mail Is ImportantBy Charles P. Nicholson, Jr., MD, Senior Aviation Medical Examiner

MANY AVIATORS CONSIDER

their Federal AviationAdministration medical

certificate to be almost sacred (nointention to be sacrilegious)! How-ever, the lackadaisical, often seem-ingly irresponsible attitude someapplicants for the certificate ex-hibit regarding correspondence fromthe FAA does not support or confirmthe high esteem in which the certifi-cate is regarded.

The intent of this article is to informapplicants to be aware of all correspon-dence from the FAA regarding theirmedical certificate.

In practically every situation in whichthere is a “discrepancy” in meeting thecertification standards, the applicantreceives a letter from the FAA regardingthe “discrepancy.” For example, if theapplicant has a history of kidney stone(s)or high blood pressure requiring medi-cation for control, the FAA sends theapplicant a letter acknowledging thehistory and describes what will be re-quired for continued certification.

Applicants who require a SpecialIssuance receive Letters of Authoriza-tion that state the authorization period,specific actions required to maintaincertification, and it may authorize anaviation medical examiner to issue an-other certificate if the stipulations inthe Letter are met.

I am repeatedly surprised—and dis-appointed—by the nonchalant attitudethat some applicants display regardingthese letters! Typical comments include,

√ I don’t remember receiving aletter√ My wife must have thrown itaway√ I guess I forgot to bring it withme...You get the idea! We AMEs receive

copies of the letter and show it to theapplicant. You can imagine the re-sponses and comments we observe!

Applicants, be attentive to all corre-spondence from the FAA regarding yourmedical certificate. Read the correspon-dence and comply with the request(s).Keep it in a safe, convenient (easy-to-remember) place, review it before thenext application, and take it to yourAME’s office at the time of your medi-cal examination.

Few things are as important to usaviators as our medical certificate. Wemust expend all effort to maintain it!

"

Dr. Nicholson, an AME since 1975, practices in Concord, N.C., is also very active in aviationand says he has “always wanted to be a pilot.” Dr. Nicholson is an instrument-rated private pilotwith ATP, CFII, and multi-engine ratings; he is also an Aviation Safety Counselor and amember of the Experimental Aircraft Association’s Aeromedical Advisory Council.

SHAREThis Information WithYour Staff and Patients


A Checklist for Pilots Approaching the Flight PhysicalPreparing for a Medical Certification Physical and Avoiding the Guesswork

By Robert J. Gordon, DO, Senior AME, Edited by Donald Ross, DO, Senior AME

This checklist was prepared by two long-time aviation medical examiners who know the value of good preparation by theapplicant for medical certification. Although this checklist is not an FAA-generated or approved device, you might wantto consider making a similar checklist available to your pilots. —Ed

PILOTS, YOUR AVIATION MEDICAL EXAMINER

(AME) wants you to pass your medical exam.We know how important that continuing

to fly is to you because most of us are pilots too.If you have any problems, your AME, the FAA,and your personal physician will work with

you to resolve them. We want you to be happypilots and to leave our office with your medicalcertificate in hand. With that in mind, here is achecklist to follow during your approach to land-ing in our office. If you follow it, taking off againwill be a piece of cake.

$$$$$Do not forget your eyeglasses.$Make sure you have a current eye exam and glasses, especially if your near/far vision has changed.$Bring your Special Issuance letter from the FAA with you to the exam.$ If you have a Special Issuance medical, mail in all necessary medical information requested bythe FAA by the required date.$Bring all medical information outlined in your Special Issuance letter.$Do not forget to tell your AME if you have one of the 15 disqualifying conditions: diabetes mellitusrequiring hypoglycemic medications; angina pectoris; coronary heart disease that has been treatedor, if untreated, that is symptomatic or clinically significant; myocardial infarction; cardiac valvereplacement; permanent cardiac pacemaker; heart replacement; psychosis; bipolar disorder;personality disorder that is severe enough to have repeatedly manifested itself by overt acts;substance dependence; substance abuse; epilepsy; disturbance of consciousness without a satisfac-tory explanation of the cause; and transient loss of nervous system function(s) without a satisfactoryexplanation of the cause.$Bring all required medical records from your personal physician regarding any chronic medicalcondition. (Examples: hypertension and asthma)$See your personal physician for evaluation and treatment prior to medical exam if you haveborderline high blood pressure.$Avoid coffee, decongestants, cigarettes, or any other stimulants prior to your exam. These all mayraise your blood pressure.$ If you have a family history of diabetes mellitus (or other familial diseases), you need to haveperiodic checks with your personal physician prior to medical exam.$ If you have a family history of diabetes mellitus, avoid large amounts of sugar prior to the exam.Urinalysis will show positive sugar if large amounts are consumed prior to exam.$Mark on question 17a. (under Medications) if you are taking a prohibited medication on a regularbasis.$Do not forget your SODA (Statement of Demonstrated Ability; e.g., color vision defect).

"


AME ShortsConcise Certification TopicsBy Warren S. Silberman, DO, MPH

ECG Transmissions ReminderAccording to AME Order 8520.2E

2/1/99 (which is the regulation thatcovers all AMEs), all US senior aviationmedical examiners must transmit theelectrocardiograms that are performedas part of the 1st-class examination. Theorder specifies that Effective October 1,1999, all Senior AMEs must electroni-cally transmit to the Aerospace MedicalCertification Division the electrocardio-gram data for 1st-class medical certifica-tion examinations.

You should recall that all 1st-classairmen, at their first exam after reach-ing age 35, must have a baseline ECGand then every year after age 40. Interna-tional senior AMEs have been and con-tinue to be exempt from this requirement.

You do not have to transmit the ECGif you perform it as part of an Authoriza-tion for Special Issuance. An examplewould be our requirement for an ECGfor the initial work-up for hypertensionon medications. The ECG does not have

to be transmitted, but it must be mailedto the Aerospace Medical CertificationDivision (AMCD) in Oklahoma City.

Also, if you transmit the ECG, youdo not have to send the hard copy in.

Suspicious AirmenImmediately report to the AMCD

those airmen who have partially com-pleted their airman medical certificateapplication and then decided to leave theoffice before you had the opportunity tocomplete the physical examination. Youshould be particularly suspicious of air-men who inadvertently disclosed a posi-tive history of medical problems or theuse of medications and then left theoffice because they changed their mindsabout the disclosure.

These airmen may attempt to go toanother AME and not disclose theirmedical problems to obtain a medicalcertificate.

Please mail these particular cases into the AMCD as soon as they occur.

EnvelopesAs you may recall, in July 2002, we

sent all aviation medical examiners newenvelopes. The reason for this was that

the current envelopes did not have acorrect computer code and return zipcode. Continuing to use this envelopewould have resulted in the Postmastercharging us an additional fee for eachletter.

In revising the envelope, we alsodecided to reduce its size so that itcould fit without folding into our let-ters to you and airmen. This is becausewe had purchased a new folding andenvelope-stuffing machine and there wasa problem about folding and stuffingenvelopes with this piece of equipment.

Well, the new, smaller envelopeswere too small. So, we did some evalu-ation and testing and have decided torevert to using the original-size enve-lopes—with the revised code and re-turn zip code.

You should have received a supplyof these new envelopes in the mail andare to contact the Aerospace MedicalEducation Division if you require moreof them:FAA Civil Aerospace Medical Institute

Shipping Clerk, AAM-400P.O. Box 25082

Oklahoma City, OK 73125"

Dr. Jones is the manager of the Civil Aerospace Medical Institute’s Aerospace Medical Education Division.

providers can perform FAA medicalexaminations under AME supervi-sion. Disgruntled airmen sometimestell us when the person who signedtheir certificate did not perform theexam, and some AMEs also report simi-lar suspicions about competing physi-cians. The frequency of these events hasrecently increased. The most disturb-ing report so far involves a pilot Website chatting about an AME who issuesmedical certificates by mail, withoutever seeing the pilot. Of course, mostAMEs have heard anecdotal reportsfrom pilots of examiners who performcursory or no examinations.

In paragraph 11a.(2)(e) of FAAOrder 8520.2E, it clearly states, as acondition of designation, that AMEs

Misuse from page 1 “Personally conduct all examina-tions….” The paragraph further speci-fies that “paraprofessional medicalpersonnel (e.g., nurses, nurse practi-tioners, physician assistants, etc)….”may contribute to, but not performthe examination; non-AME physi-cians are likewise limited. Paragraph15b.(3)(c) states “disregard of, or fail-ure to demonstrate knowledge of, FAArules, regulations, policies, and pro-cedures” and “unprofessional perfor-mance of examination” are groundsfor termination of the AME designa-tion. Staff members, mid-level, andnon-AME providers who do not re-port the activities listed above areaccessories in violation of federal regu-lation and may be prosecuted with aguilty AME.

We are exploring ways to identifyAMEs that misuse their designations.One consideration is putting the in-formation contained here in publica-tions read by airmen, asking them toreport when the signatory of theirmedical certificate is not the personwho examined them. It would cer-tainly help if more providers and staffmembers reported inappropriate prac-tices; this can be done anonymouslyby calling the regional flight surgeon’soffice or AAM-400.

I know these violations of the FAA’strust are not the rule and involve only afew AMEs. It is too bad that the imagesof the large number of conscientiousAMEs must be tarnished by these few.For those of you who follow the rules,thanks. Keep them flying—SAFELY!

"


Case Report

Hydrocephalus and SeizuresBy Meire Gonzaga, MD

Summary: Individuals with a history or presence of any neurologicalcondition or disease that potentially may incapacitate an individual shouldbe regarded as initially disqualifying. Issuance of a medical certificate to anapplicant in such cases should be denied or deferred, pending furtherevaluation. This applicant has been ten years without seizures, two years offmedication, and was surgically treated at an adult age; thus, his chances ofhaving another seizure are low. If certain examinations do not show anyabnormalities, he can be certified for a 3rd-class medical.

A 32-YEAR-OLD MALE was seen by anaviation medical examiner to ob-

tain his 2nd-class medical certificate.The applicant related a history of neu-rosurgery in 1989.

History and FindingsThe patient had been diagnosed

with arrested symptomatic non-communicating hydrocephalus dueto aqueductal stenosis, for which thetreatment of choice is stereotacticallydirected third ventriculostomy. Atthat time, he complained of frequentheadaches and decreased visual acu-ity. Papilledema was found on fun-duscopic exam, with enlarged blindspots indicating increased intracra-nial pressure. He had no evidence ofother neurological deficits.

He was treated with a ventriculos-tomy without complications. Aftersurgery, he began having generalizedseizures and was treated with carb-amazepine 200 mg twice daily. Inspite of the medication, he continuedhaving headaches. An EEG showed aright-sided grade 2 dysrhythmia. AMRI of the head demonstrated apatent ventriculostomy. The mecha-nism of the headaches was obscure,but his neurologist suggested a“subclinical seizure with seizure

DiscussionHydrocephalus results from one

of three causes: over-secretion of cere-brospinal fluid (CSF), obstruction ofCSF pathways, or impaired absorp-tion of CSF. The first two causes arerare. Hydrocephalus due to over-se-cretion of CSF is thought to be sec-ondary to a tumor of the choroidplexus. Hydrocephalus caused by theobstruction of CSF pathways is usu-ally due to the aqueduct of Sylvius(aqueductal stenosis) and can be sec-ondary to a congenital malformation,tumors, and/or scarring.

The third and most common causeis impaired absorption of CSF. Thisis present in communicating hydro-cephalus, which may present withnormal or elevated intracranial pres-sure, may be idiopathic, or result frommeningitis or subarachnoid hemor-rhage (7). Epilepsy is commonlyassociated with shunt-treated hydro-cephalus. Its relation to the shuntingprocedure and the criteria identify-ing postoperative epilepsy remaincontroversial. Many studies have in-vestigated the etiology of epilepsy inpatients with hydrocephalus. The re-sults are conflicting as the incidenceof epilepsy in hydrocephalus rangeswidely from 9 to 65% (3).

The terms “epilepsy” and “seizure”are used very liberally in the literatureand thus contribute to the high num-ber of reported cases of epilepsy. For

equivalent headaches” or “ seizureaura, both of which are quite infre-quent. His visual symptoms improved.A funduscopic exam revealed definiteimprovement of the papilledema andnormal blind spots bilaterally. His mostrecent seizure was in 1989.

During neurological follow-up, heattempted to lower his carbamazepinedose, but his headaches became worse.In June 1995, the patient presentedfor a certification exam, during whichhe was denied due to a diagnosis ofepilepsy and treatment with carb-amazepine. Subsequently, in June1996 patient had an EEG that showednonspecific slow waves in the righttemporal lobe, that may in part bedue to medication effect. A head MRIwith 3rd ventricle flow analyses dem-onstrated 3rd ventriculostomy pa-tency, with moderate to markeddilatation of most of both lateral ven-tricles. In December 1996, the use ofcarbamazepine was suspended. OnAugust 6, 1998, the patient againapplied for a 2nd-class medical certifi-cate. He remained symptom-free andoff medications. His physical examwas within normal limits. Again, thecase was deferred to the FAA Aero-space Medical Certification Division(AMCD).


Dr. Meire Gonzaga was an international exchange physician from Irmandade Da Santa CasaDe Misericordia De Sao Paulo University School of Medicine in Sao Paulo, Brazil, when shewrote this case report at the Civil Aerospace Medical Institute.


a patient to be diagnosed with epi-lepsy, seizures must occur repeatedlyand should not be caused by acuteillness such as fever, electrolyte imbal-ance, or trauma (1).

A seizure is a paroxysmal event dueto abnormal, excessive, hypersyn-chronous discharges in the centralnervous system (CNS) and can havevarious manifestations, ranging fromdramatic convulsive activity to ex-perimental phenomena not reliablydiscernible by an observer (4). Themeaning of the term seizure needs tobe carefully distinguished from thatof epilepsy. Epilepsy describes a con-dition in which a person has a currentseizure due to a chronic, underlyingprocess. This definition implies that aperson with a single seizure, or recur-rent seizures due to correctable oravoidable circumstances, does not nec-essarily have epilepsy. Thus, epilepsy,or seizure disorder, is defined as twoor more, recurrent, unprovoked sei-zures (2, 4, 5). Piatt and Carlson (6)report that epilepsy is common amongpatients with hydrocephalus, and therisk of the development of epilepsycontinues indefinitely for those pa-tients. They studied 464 patients withhydrocephalus. The onset of epilepsymay precede, coincide with, or followthe diagnosis of hydrocephalus, andthe current analyses extending 15 yearsfrom diagnosis of hydrocephalusshowed no point beyond which hy-drocephalic patients can be consid-ered out of risk. The cause ofhydrocephalus was strongly associatedwith the risk of epilepsy (patients withposthemorrhagic hydrocephalus hadmore chance of epilepsy). Surgicalcomplications were only weakly asso-ciated with risk of epilepsy. A signifi-cant bias of this paper was the author’sdefinition of epilepsy as the long-term administration of antiepilepticdrugs for suppression of seizures (6).

In a study by Klepper et al. (3) of182 patients with hydrocephalus, 20%developed epilepsy. The incidence ofepilepsy varied according to the etiol-ogy of hydrocephalus: posthemor-rhagic (5%), postinfectious (4%),connatal/miscellaneous/unknown(3%), myelomeningocele (2%), tu-mor/arachnoidal cyst/aqueduct steno-sis (0%), and poor functional status.They concluded that epilepsy is re-lated to underlying encephalopathy,rather than to surgical intervention.Thus, epilepsy as a complication ofintracranial shunting might be over-estimated in the literature (3). Oneshould also consider that the youngerthe patient at the date of operation,the greater the chance of his develop-ing an epileptogenic scar (8).

Aeromedical DispositionThe Guide for Aviation Medical Ex-

aminers (September 1996) indicatesthat individuals with a history or pres-ence of any neurological condition ordisease that potentially may incapaci-tate an individual should be regardedas initially disqualifying. Issuance of amedical certificate to an applicant insuch cases should be denied or de-ferred pending further evaluation.Symptoms or disturbances, which aresecondary to the underlying condi-tion and may be acutely incapacitat-ing, include pain, weakness, vertigoor incoordination, seizure or a distur-bance of consciousness, and visualdisturbance or mental confusion.

Returning to our patient, he didsuffer a seizure after surgery for hy-drocephalus due to aqueductal steno-sis, so he had seizures and not epilepsy.He has been ten years without sei-zures, two years off medication, andwas surgically treated at an adult age;thus, his chances of having anotherseizure are low.

So after evaluation, the AMCDdetermined that he needs to have acomplete, current neurological evalu-ation. The report must address thestatus of the shunt and include a newEEG to check the hyper-excitable fo-cus. If the exams do not show anyabnormalities, he can be certified fora 3rd-class medical. He will requirefollow up every six months and, if hecontinues without any changes, heshould be eligible for a 2nd-class cer-tificate in two years.

References1. Commission on classification and Ter-

minology of the International LeagueAgainst Epilepsy. Proposal for RevisedClassification of Epilepsy and Epilep-tic Syndromes. Epilepsy, 30(4):389-99,1989.

2. Hastings JD. Tonic-Clonic Seizures:Certifiable in Airmen? Federal AirSurgeon’s Medical Bulletin, 2:10-11,1998.

3. Klepper J, Busse M, Strasburg HM,and Sorensen N. Epilepsy in Shunt-Treated Hydrocephalus. Developmen-tal Medicine & Child Neurology,40:731-36, 1998.

4. Lowenstein DH. Seizures and Epilepsy.Harrison’s Principles of Internal Medi-cine, 14th ed, 365:2311-23.

5. Marks WJ, and Garcia PA. Manage-ment of Seizures and Epilepsy. Ameri-can Family Physician, April 1998.

6. Piatt JH, and Carlson CV. Hydro-cephalus and Epilepsy: An ActuarialAnalysis. Neurosurgery 39(4):722-8,1996.

7. Rocca JA Benign, CommunicatingHydrocephalus and a Ventricul-operitoneal Shunt. Federal Air Surgeon’sMedical Bulletin.1:6-7, 1996.

8. Varfis G, Berney J, and Beaumanoir A.Electro-Clinical Follow-up of ShuntedHydrocephalic Children. Child’s Brain,3:129-39, 1977.

"

Hydrocephalus from page 9


Case Report

Meningioma in anAirmanBy Pankaj D. Sheth, MD, MPH

A 44-YR.-OLD FAMILY PHYSICIAN, athird-class pilot with 200 hours

of flying experience, applied for therenewal of his medical certificate. Hehad a left parietal, 2.5 cm.-size menin-gioma surgically removed on 2/4/99near the saggital sinus, 4 cm behind thecoronal suture (which is about the sen-sory strip). He still had residual numb-ness in the right lower extremity definedas crural paresis. He did not have anyseizures after the surgery and was offanticonvulsants for one year.

Symptoms. His symptoms beganin the summer of 1998, with numb-ness in his right little toe; going to thelateral aspect of his right foot, calf,thigh, and groin. It spread to theright abdomen, spared the chest, butsometimes went to the right side ofhis face. It came spontaneously andresolved fairly quickly without anytreatment. The whole phenomenalasted about 2-3 minutes, with a fre-quency of 8-9 times per day. He de-nied weakness, headache, rashes,bladder, or bowel problems.

He had a Jacksonian sensory type ofseizure six months prior to surgery andhad balance problems. He went to theemergency room and was diagnosed ashaving left parietal meningioma by MRIon 1/6/99. His meningioma was re-moved on 2/4/99.

Post-operatively, he was started onDilantin prophylactically; later wasswitched to Tegretol, which he wasweaned off after several months. Hewas also on Decadron in tapering doseand Coumadin for postoperative deepvein thrombosis. He also had right footweakness post-operatively, for whichhe used AFO for short time.

History. Heartburn, relieved byMylanta; bilateral knee ligament lax-ity; T & A; hospitalized for pneumo-nia once.


MeningiomasMeningiomas are mostly benign tumors that appear to arise from

arachnoidal cap cells; therefore, they can occur wherever there is dura.They may invade the skull but almost never invade the brain. They aremore common in females (in 7th decade) than males (in the 6th decade).Meningiomas can also occur in childhood. They account for about 25% ofall CNS tumors and are second only to gliomas. Common sites are alongthe sagittal sinus, over cerebral convexities, in cerebellar pontine angle, andthe spinal cord dorsum. They are usually supratentorial.

Etiology. Genetic alteration: Cytogenic examination of chromosomeswithin brain tumor cells often reveals loss of genetic material from long arm ofchromosome 22q (deletion). Malignant meningiomas are associated withdeletion of loci on chr.1p, 9q, and 17p. Exposure to ionizing radiation is adocumented environmental risk factor for the development of brain tumors.It is common in patients who have neurofibromatosis.

Meningiomas have receptors for sex hormones, and patients with breastcancer are at increased risk. Receptors found are for progesterone, estrogen,androgen, dopamine, and beta-receptor for platelets derived growth factor.The role of head trauma is dubious in the development of meningioma inlater life.

Clinical presentation. Clinical presentation of meningiomas depends upontheir location and size. Most meningiomas are asymptomatic and found to beless than 2 cms. at autopsy or incidental findings at the time of an MRI. Thepatient may present with seizure, headache, and focal neurologic deficit. Visualloss may result from a compression of the optic nerve, but anosmia and mentalstatus changes are often unrecognized. There may be tenderness to pressure orpercussion of the skull over the site of a meningioma.

Diagnosis. Plain radiographs of the skull show changes like calcificationand hyperostosis or thinning of adjacent skull tissue in 50-60% of cases.Non-contrast CT shows a well defined, hyper-dense mass with coarsecalcification. Small meningiomas are better visualized on CT than MRI.MRI is the commonly ordered diagnostic test after a thorough neurologicalexamination.

Treatment. The primary treatment for symptomatic meningioma issurgery. Meningiomas are not always curable, even if they are completelyexcised. The recurrence rate depends on the completeness of removal, thetumor’s site, and its biological aggressiveness. Even after complete removal,the recurrence rate varies from 8 to 20% over 10 years. For patients withobvious residual tumors, the recurrence rate can be as high as 55% over 10years.♦ External beam radiotherapy has control rates of 50 to 90% at 10 years.Stereotactic radiosurgery, using a linear accelerator or gamma knife, limits theradiation to surrounding brain tissues and, while it has promising results,followups are too short to construct firm conclusions.♦ Thirty percent of all meningiomas have estrogen receptors and can be treatedwith antiestrogen Tamoxifen and medroxyprogesterone acetate. Seventy toeighty percent of meningiomas have progesterone receptors and can be treatedwith antiprogesterone mifepristone (RU486). Multicenter studies are cur-rently evaluating the efficacy of this approach.♦ Corticosteroids are used as supportive therapy to reduce peritumoral edemafor short durations♦ Anticonvulsants are generally used for convexity meningiomas for 6-12months post-operatively♦ DVT precaution used for short-term during post-operative period


Dr. Sheth was a resident in Aerospace Medicine from Wright State University, rotating at theCivil Aerospace Medical Institute when he wrote this report.

Social history. Denies use of alco-hol or smoking.

Current medication. Aspirin,Pravachol.

Physical examination. Height 78”,weight 253 lbs., BP 128/84, pulse 60BPM. Remainder of the physical wasnormal on 3/2/01.

Certification outcome. As per ap-proved aviation medical examiner pro-tocol, an epileptic, to be eligible formedical certification must be seizure-free for 10 years and off anticonvulsantmedications for at least 3 years. After10 years, full neurological evaluationwith EEG will be required for consid-eration. For provoked single-seizure,when the cause is corrected, then themedical certificate is considered withas little as one year after recovery with

full neurological evaluation. This ap-plicant falls between the category ofbeing epileptic and having a single pro-voked seizure.

Also, for an intracranial tumor (men-ingioma), before eligibility for medicalcertification can be recommended, theapplicant will require a full neurologi-cal evaluation, plus appropriate labora-tory and imaging studies. Mostimportantly, the meningioma wouldrequire removal. If the finding is of abenign supratentorial tumor, then hemay return to flying status after a satis-factory convalescence of at least 1 year.

With the scenario presented above,the medical certificate was deferred bythe aviation medical examiner. How-ever, with a normal, full neurologicalevaluation by a neurologist and normalMRI report, the applicant would beeligible for a medical certificate.

ReferencesConn’s current therapy (Rakel’s textbook)

1998, page 971.

Dejong’s The neurologic examination text-book, 5th edition, by Armin F. Haerer,pages 674-5.

Harrison’s Internal medicine textbook,14th edition, 1998, pages 2398-2403.

Rabinowicz AL, Weiss MH, and DeGiorgioCM. Compulsive polydipsia followingmeningioma resection: An epilepticphenomenon? Journal of Neurosur-gery.75 (5): 798-9, Nov. 1991.

Mut M., and Soylemezoglu F. Intra-parenchymal meningioma originatingfrom underlying meningioangioma-tosis. Journal of Neurosurgery. 92(4):706-10, Apr. 2000.

Merck manual, 7th edition, pages 1446-47.

Samuels MA. Office practice of neurol-ogy,1996, pages 849-54.

"

Meningioma from page 11

ALTERNATIVE COLOR VISION

TEST A WINNER

Dear Editor:I wanted you to know that a recent

article in the FASMB [Color Visionin Black and White, spring 2002, p.10] was right on point for me. My 3rd-class medical comes up next month. Iwas nervous about the test for shapesin a field of colored dots. Your articlepresented several alternatives if addi-tional testing is necessary.

I called my eye doctor and took thefirst alternative test as a practice run.And I passed with (pardon the pun)flying colors.

Mike RuffPampa, Texas

FATIGUE COMMENTS

Dear Editor:Re: Fatigue and Desynchronosis in

Aircrew (FASMB, summer 2002, p. 8).NASA’s studies have shown that for

Letters to the Editor

long flights, that it is beneficial to haveplanned rest periods whereby one cock-pit crewmember can take a nap. Forthose flights where crews could takethese planned naps, they had far fewermicrosleeps during later phases of theflights than did the aircrews in thecontrol group.

Some foreign carriers permit theseplanned rest periods, but the FAA doesnot. I have heard that the policy is,along with other crew duty/rest require-ments and limitations, being lookedinto, but it has been quite a few yearssince NASA did some of these studies.

Why, therefore, in light of NASA’sstudies, does the FAA still prohibit theseplanned rest periods?

Larry NazimekChicago, IL

The author of the article, Dr. Virgil Wooten,replies:

The FAA recognizes that fatigueis a significant and important prob-lem in air operations. The FAA ismoving as quickly as possible to

address crew rest and fitness forduty issues. Because of the diver-sity of aircrews and operations, it isdifficult to formulate a single goodregulation that satisfies all concernsand individual differences. How-ever, it is likely that the currentregulations will change to reflectour new understanding of sleepphysiology and pathology. Anotherfactor to be considered is the in-creasing use of cockpit automationthat may change crew resourcesneeded for safe flight. But for now,the non-flying crew on internationalflights is not restricted but encour-aged to rest. The crew on national(CONUS) flights with no backup,i.e. no additional person(s) to alter-nate with, is not permitted to napsince they are part of the requiredactive flight crew. The FAA recog-nizes that a rested crew is a bettercrew, but they must get their restbefore or during flights when theyare not on duty.

"


Office of Aerospace Medicine NEWS

Dr. Anne Harlan, director of theFAA’s William J. Hughes TechnicalCenter in Atlantic City, N.J., visitedthe Civil Aerospace Medical Instituterecently. She is pictured here after a“spin” in CAMI’s Virtual RealitySpatial Disorientation Simulator. Dr.Harlan holds a PhD in appliedresearch psychology from Ohio StateUniversity and is a commercial,multi-engine pilot.

100% success for all sixworking in this office! TheLouisville, Ky., office staff ofaviation medical examinersDr. Glenn Stoutt (left) andDr. Mike Howard made aperfect 100% score on theMulti-Media Aviation Medi-cal Examiner RefresherCourse (MAMERC) test.Office manager KelliBenningfield (proudly dis-playing her certificate oftraining), along with fiveothers on the office staff,made their perfect scores thissummer.

NASA-FAA Study Turbulence Aloft. The Civil Aerospace Medical Institutesupported the National Aeronauticsand Space Administration who con-ducted a series of research scenariosto investigate preparing a wide-bodyaircraft cabin for oncoming air turbu-lence. Flight crews from 3 airlinesand some 70 subjects participated inthe research using CAMI’s B-747aircraft cabin environmental researchfacility in Oklahoma City during thetrials Oct. 1-3. The results will pro-vide reliable estimates for cabinreadiness requirements, a benchmarkfor developing clear air turbulencewarning systems, and further researchto prevent passenger and crew inju-ries caused by turbulence.

CAMI Director Attends HispanicSummit. Dr. Melchor Antuñano,director of the Civil AerospaceMedical Institute, was nominated byOkla. Senator Don Nickles to attendthe First National Hispanic Leader-ship Summit in Washington, DC,September 17-18, 2002. This summitprovided a forum for about 350Hispanic leaders from across thecountry to discuss a range of policyissues with members of the USCongress and the Bush Administra-tion. “At this critical time in ournation’s history, it is imperative thatour nation’s Hispanic leaders andour federal officials exchange ideasabout the most pressing issuesaffecting our families, communitiesand nation,” said Sen. Kay BaileyHutchinson, chairman of the Sum-mit. Several members of PresidentBush’s cabinet addressed theSummit’s attendees, includingHousing Secretary Mel Martinez,Education Secretary Rod Paige,Health and Human Services Secre-tary Tommy Thompson and WhiteHouse Chief of Staff Andrew H.Card, Jr. (Continued on page 16)

Nicholas A.Sabatini,associateadministratorfor regulationand certifica-tion, AVR,recentlytoured theCivil Aerospace Medical Institute.His office oversees the Office ofAerospace Medicine and is respon-sible for the certification, productionapproval, and continued airworthi-ness of aircraft; certification ofpilots, mechanics, and others insafety-related positions. Mr. Sabatiniis also responsible for certification ofall operational and maintenanceenterprises in domestic civilaviation; development of regula-tions; civil flight operations; andthe certification and safety over-sight of some 7,300 US commer-cial airlines and air operators. Hereplaced Thomas E. McSweeney,who retired about a year ago.


By Glenn R. Stoutt, Jr., MD, SeniorFAA Aviation Medical Examiner

TOPICS AND ISSUES

Health of Pilots

J u s t f o r t h e

TAG TEAM. �Doc, I think thiscrud�s under control...getready to come in here if Ineed ya!�

This column has had for itstheme the past five years thatyour own lifestyle is respon-sible for about 70 percent ofyour health problems. It is justas important to realize thatyou—even more than your phy-sician—are responsible for yourown good health.

YOU ARE PROBABLY IN CONTROL of70 percent of your personalhealth care. You own the chal-

lenge of being healthy much morethan we physicians do.

Here’s one example: An articleappeared in the newspapers in 2001stating that physicians were giving cho-lesterol-lowering medications to onlyabout one-third of the people whowould probably benefit by getting them.About 100 million Americans have el-evated cholesterol numbers to somedegree, so this information needed tobe looked into.

Why weren’t physicians prescribinglipid-lowering medication more often?Why was medication often delayed untilthe patient already had some vascularproblem, such as angina or a heartattack? Why were younger people (intheir 40s and 50s) not being treated?

All too often, the cholesterol-lowering medications were given onlyafter arteries had already been badlydamaged and clogged. How could alayperson get reliable information onthis and be able to make an informeddecision?

One has to ask the right question tothe right person (concerned, dedicatedphysician) to get the right answer. Whatare the right questions to ask on yournext visit to your personal physician?

In a televised interview, TomClancy—the hugely popular writer oftechno-thrillers—was asked how hepossibly could have gotten the vastamount of highly technical informa-tion he had, which some even sus-pected of being highly classified? Did

he have secret access to the Pentagon?His answer was simple: “You can findinformation about anything if you haveaccess to a telephone and a library.”Add a computer and search engine tothis and the knowledge of the world isavailable to you.

So, where to start? I just keyed in theAmerican Heart Association (AHA)Web site (www.americanheart.org) andfound more information on blood lip-ids (total cholesterol, HDL cholesterol,triglycerides, and LDL cholesterol) thanI could assimilate over the weekend.

A further site gave a chart, whichsimplified most of the information andgave current (updated) guidelines any-one can understand. If you don’t haveaccess to a computer, call the localAHA or go to your library for help. Anyadult should have an initial baselinelipid profile. Then ask your physicianto explain the results to you in person(not just mail them to you) and decideif anything needs to be done.

Here are the current guidelines fromthe National Heart, Lung, and BloodInstitute (www.nhlbi.nih.gov):

Step l Determine lipoprotein levels; ob-

tain a complete lipoprotein profile af-ter a 9- to 12-hour fast (overnightusually).

LDL (Low-Density LipoproteinCholesterol). This is the bad choles-terol that is responsible for blockingyour arteries, and the primary target oftherapy.Under 100 -------- Optimal (great!)100-129 --------------- Near optimal130-159 ----------- Borderline high160-189 ------------------------- HighOver 190 Very high (danger sign)

All figures represented as mg/dl(milligrams per tenth of a liter)

Total Cholesterol (TC)Under 200 ---------------- Desirable200-239 ----------- Borderline highOver 240 ------------------------ High

HDL Cholesterol (The “good” cho-lesterol; acts as a scavenger to removeLDL)Under 40 ------- Low (undesirable)60 or over -------------- High (good)

Triglycerides .Think of them as freefats in the blood. High levels are asso-ciated with heart disease.Under 200 ---------------- Desirable

Step 2Are any of your arteries diseased?

Get this information from yourphysician.

Step 3Major risk factors other than

elevated LDL

Dr. Stoutt is a partner in the Springs Pediatrics and Aviation Medicine Clinic, Louisville, Ky., and he has been an active AME since 1960. Nolonger an active pilot, he once held a commercial pilot’s license with instrument, multi-engine, and CFI ratings.

Continued #


• Cigarette smoking• High blood pressure• Low HDL (under 40)• Family history of premature heartdisease (very important risk factor; youcan’t change this, but it is a great earlywarning to monitor your heart health.)• Men 45 or over; women 55 or over• Diabetes

Discuss all these results with yourphysician, and then get an evalua-tion of your estimated total risk forfuture cardiovascular (especiallyheart) problems.

If your LDL is high:• Of course, no one should smoke,especially those with risk of heart dis-ease.• Reduce fat in your diet to about 10percent. Try to completely avoid satu-rated fat and trans fats.• Exercise!• Weight management. Abdominal fatis especially a risk factor.• Add soluble fiber to your diet (suchas oatmeal).

All of these measures are beneficialand should be continued permanently,but you can expect from them at mostabout 20 percent reduction in choles-terol. So what if you have done all you canwith diet, exercise, and weight loss andyour cholesterol is still high? It’s yourresponsibility to ask your physicianabout what to do. Get a specific answer.

Many physicians now think a rea-sonable choice might be this:• If your total cholesterol continues tobe 240 or over, medication shouldstrongly be considered.• If it is 200-240, ask your physician ifany other factors that make you atgreater risk indicate that you shouldtake cholesterol-lowering medication.

The FAA approves almost all of themedications now on the market to helpyou control your cholesterol. (Baycolhas been proved dangerous and takenoff the market by the Food and DrugAdministration.) The only contraindi-cation to any of these medications is ahistory of liver disorders, and so peri-odic liver-function tests are done as asafety measure.


Heart Attack SymptomsCourtesy of the American Heart Association, from Web site:

americanheart.org/

Some heart attacks are sudden and intense—the ‘movie heart attack,’where no one doubts what’s happening. But most heart attacks start

slowly, with mild pain or discomfort. Often people affected aren’t surewhat’s wrong and wait too long before getting help. Here are signs that canmean a heart attack is happening:• Chest discomfort. Most heart attacks involve discomfort in the center ofthe chest that lasts more than a few minutes, or that goes away and comesback. It can feel like uncomfortable pressure, squeezing, fullness or pain.• Discomfort in other areas of the upper body. Symptoms can includepain or discomfort in one or both arms the back, neck, jaw or stomach.• Shortness of breath. This feeling often comes along with chest discom-fort. But it can occur before the chest discomfort.• Other signs. These may include breaking out in a cold sweat, nausea orlightheadedness.

If you or someone you’re with has chest discomfort, especially with oneor more of the other signs, don’t wait longer than a few minutes (no morethan 5) before calling for help. Call 9-1-1…Get to a hospital right away.

Calling 9-1-1 is almost always the fastest way to get lifesaving treatment.Emergency medical services staff can begin treatment when they arrive—up to an hour sooner than if someone gets to the hospital by car. The staffare also trained to revive someone whose heart has stopped. You’ll also gettreated faster in the hospital if you come by ambulance. If you can’t accessthe emergency medical services (EMS), have someone drive you to thehospital right away. If you’re the one having symptoms, don’t driveyourself, unless you have absolutely no other option.

Heart Attack Warning SignsNo matter what your risk factor for

a heart attack is, you should be familiarwith the warning symptoms of a heartattack (blockage of essential blood sup-ply to the heart).

Cardiologists stress that time ismuscle. The longer blood supply toheart muscle is blocked the greater like-lihood of permanent damage to theheart. The optimum window of opportu-nity for getting help is one hour aftersymptoms begin.

Some pilots may be on overnightlayover and have some of the abovesymptoms, and decide, “I’ll just seehow I do and see my own physician firstthing tomorrow.” Bad decision.

Skin CancerAs long as we are talking about pre-

ventive care, why not consider the larg-est organ in the body, the skin? Cancer ofthe skin is not only our most commoncancer, but also the most curable—iffound early. The incidence of mela-noma, a highly dangerous type of skincancer, is growing rapidly. Early diag-nosis is most important, because if themelanoma is still in the superficial layerof the skin it is usually curable. If amelanoma has spread, the prognosis isnot so good.

The American Academy of Derma-tology (www.aad.org) is a good site forinformation on skin cancer, especiallyfacts about prevention. Another goodsite is The Skin Cancer Foundation(www.skincancer.org).

Some characteristics of melano-mas are:• Asymmetry: A line through themiddle would not create matchinghalves• Border: Irregular, scalloped, poorlydefined• Color: Varied from one area to an-other. Shades of tan, brown, or black.Sometimes even white, red, or blue.• Diameter: Greater than the diameterof a pencil eraser.


Aviation Medical Examiner2002-3 Seminar Schedule

December 2 - 6 ------- Oklahoma City, Okla. -------------- Basic (1)2003

January 10 - 12 ------- Phoenix, Ariz. ------------------------- CAR (2)March 10-14 ----------- Oklahoma City, Okla. -------------- Basic (1)April 25-27 ------------- Atlanta, Ga. --------------------------- OOE (2)May 5-8 ----------------- San Antonio, Texas --------------- N/NP/P (3)June 9-13 --------------- Oklahoma City, Okla. -------------- Basic (1)

CODES

AP/HF Aviation Physiology/Human Factors ThemeCAR Cardiology ThemeOOE Ophthalmology - Otolaryngology - Endocrinology ThemeN/NP/P Neurology/Neuro-Psychology/Psychiatry Theme(1) A 4½-day basic AME seminar focused on preparing physicians to bedesignated as aviation medical examiners. Call your regional flight surgeon.

(2) A 2½-day theme AME seminar consisting of 12 hours of aviation medicalexaminer-specific subjects plus 8 hours of subjects related to a designatedtheme. Registration must be made through the Oklahoma City AME Programsstaff, (405) 954-4830, or -4258.

(3) A 3½-day theme AME seminar held in conjunction with the AerospaceMedical Association (AsMA). Registration must be made through AsMA at(703) 739-2240. A registration fee will be charged by AsMA to cover theiroverhead costs. Registrants have full access to the AsMA meeting. CME creditfor the FAA seminar is free.

The Civil Aerospace Medical Institute is accredited by the AccreditationCouncil for Continuing Medical Education to sponsor continuing medicaleducation for physicians.

About once a month, check yourskin thoroughly. A good time is duringyour shower and drying off. (Also agood time for men, especially youngmen, to check for testicular cancer andwomen to re-examine breast tissue.)

There is no argument about thevalue of periodic breast exams and Papsmears in women. Many physiciansrecommend prostate exams and PSA(Prostate Specific Antigen) tests in men.Screening for colon cancer may savethousands of lives by testing for occult(not visible) blood, sigmoidoscopy, andcolonoscopy. Ask about these examsduring your physician visits.

You can find thousands of reputablesources that provide clearly understand-able information about any medicalcondition you can think of. Make sureyour reference material is sound.

Remember the extreme value of afamily history of disease or illness.You are at greater risk for anything thata relative or ancestor has or had. (Oneman could not remember what hisfather died of, but he said, “I don’tthink it was anything serious.”)

For your health’s sake, take charge.You are the number one person to careof “Number One.”Yours for good health and safe flying,

Glenn Stoutt"

Note: The views and recommendations madein this article are those of the author and notnecessarily those of the Federal Aviation Ad-ministration.

Health from page 15

Early Detection Aids Available

Breast Cancer. A plastic card designed tohang in the shower serves as a reminder forwomen to practice the three-step approachto breast health: mammography, clinicalbreast exam, and breast self-exam.Testicular Cancer. Aimed at the youngermale, this “Get Smart Card” includes basicfacts about testicular cancer: warning signs,incidence, what to do.How to Order. Write to:

American Cancer SocietyDiane Peterson8400 Silver Crossing, Suite HOklahoma City, OK 73132Or call (405) 782-1737

OAM NEWS from page 13

CAMA AWARD WINNER. Dr.Warren S. Silberman, manager ofthe FAA Aerospace Medical Certifi-cation Division, was awarded thePresident’s Commendation by theCivil Aviation Medical Association(CAMA) at the association’s annualmeeting in Amsterdam, Holland. Dr.Silberman, a long-time CAMA mem-ber was praised for his “constant will-ingness to support and participate inCAMA meetings,” responsiveness torequests for assistance, and “un-bounded enthusiasm for the field ofaviation medicine.”

CAMA president Dr. Robin E.Dodge made the presentation.

"

Dr. Silberman, Pictured Withthe CAMA President’s Award

2002-3, volume 40-3

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