the role of aviation medicine
TRANSCRIPT
Aerospace Medical Association
THE
ROLE OF AVIATION MEDICINE
Dr Ioannis Dimitrakopoulos
Authorised Medical Examiner JAR-FCL3 Class 1&2
Aerospace Medical Association
AVIATION MEDICINE
Branch of Preventive Medicine
that deals with the clinical and
preventive medical requirements
of man in atmospheric flight
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Approach to Aviation Medicine
AVIATIONNormal Physiology
Abnormal environment
CLASSICALAbnormal Physiology
Normal environment
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HISTORY OF AVIATION
MEDICINE
With the advent of powered flight at the
beginning of the 20th century, there was a
need for selection of those who wished to fly.
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HISTORY OF AVIATION
MEDICINE Fitness criteria were
developed, and the
determination of
who met the criteria
and who did not
created the need for
a physician trained
to make this
determination.
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THE FLIGHT SURGEON Initially this was driven by a need for
qualified military pilots to fly planes in war
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THE FLIGHT SURGEON Main function was
to first develop and
then apply physical
qualifications for
flight duty
Driven by high
losses of life due to
physically
unqualified pilots
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THE FLIGHT SURGEON
During World War II
many technologic
advances led to increasing
functions in research to
develop means of
extending man’s ability to
function in an
increasingly hostile
environment.
Led to aeromedical
research
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THE FLIGHT SURGEON
Increasing numbers
of aircrew needed
to man the
warfighting
aircraft
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HISTORYAfter World War II the technologic
advances were applied to the airline
industry. Increases in aircrew led to
increases in civilian aviation medicine.
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HISTORY
In the 1960’s advances
were made to meet the
challenge of manned
flight beyond the earth’s
atmosphere. . .Aviation
Medicine evolved to
Aerospace Medicine
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WHAT DOES AN
AEROMEDICAL DOCTOR
(FLIGHT SURGEON) DO ?
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He takes care of the Aviator…a
physiologically normal individual
who works in the hostile environment
of flight
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THE HOSTILE
ENVIRONMENT OF FLIGHT
Man is an earth-bound creature who
must have protection to enter the
hostile environment of atmospheric or
space flight
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Highest Human Habitation...18,000 ft
Environmental RequirementsOxygen
OXYGEN UNDER
PRESSURE NEEDED
PRESSURE SUIT NEEDED
ARMSTRONG’S LINE
TROPOPAUSEMt Everest
29,028 ft
Andes Mt Whitney
TROPOSPHERE
STRATOSPHERE
SEA LEVEL
OXYGEN
NEEDED
0
10
20
30
40
50
60
70
760
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As altitude increases,
available oxygen decreases
0
10
20
30
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Press Alt in
mm Hg Thou. Ft
Aerospace Medical Association
Environmental RequirementsOxygen
Lack of oxygen will
affect the brain and
cause fatigue,
sleepiness, headache,
dizziness, blurred
vision and will
eventually cause you
to lose consciousness.
Oxygen must be
provided at high
altitudes
10,000 MSLHYP XIA
Aerospace Medical Association
Environmental RequirementsOxygen
A flight surgeon
must be able to
recognize when
problems are due to
lack of oxygen
Altitude chamber
training helps
aircrew to discover
their own hypoxia
symptoms
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Environmental RequirementsPressure
Normal atmospheric
pressure at sea level
is 760 mm Hg
As you go up in
altitude, atmospheric
pressure decreases.
SEA LEVEL
OXYGEN UNDER
PRESSURE NEEDED
PRESSURE SUIT NEEDED
ARMSTRONG’S LINE
OXYGEN
NEEDED
0
10
20
30
40
50
60
70
760
523
349
226
141
87
54
34
Press Alt in
mm Hg Thou. Ft
Aerospace Medical Association
Environmental RequirementsPressure
As atmospheric pressure
decreases, the air tends to
expand and get thinner
The human body has
several responses to
changes in atmospheric
pressure.
GAS
EXPANSION
FL 430
FL 350
FL 250
FL 180
BOYLE’S LAW
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There are several places in the human body where
air can get trapped. The ear, the sinuses, and the
stomach and intestines are a few examples.
Trapped Air
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Trapped AirAs you go up in altitude, air expands... if this
air is trapped, expanding air can lead to
pain. A blocked Eustachian tube could lead
to pain in the middle ear.
Eustachian Tube
Ear Drum
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Sinus Blocks and Ear Blocks
There are spaces in the
sinuses and middle ear
where air can get
trapped.
Under normal
conditions this air can
escape through
passages to the outside
(Eustachian tube)
MAXILLARY
FRONTAL
ETHMOIDS
SPHENOIDS
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Trapped Air Usually expanding air
is not a problem since
it can be released.
When you come back
down after being at
altitude, the expanded
air gets smaller... if
this occurs in a closed
space it creates a
vacuum effect...This is
a BIG problem.
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Ear Block If you fly with a cold
these passages can
swell up enough to
block the passage of
air, especially when
you are trying to get
air in to equalize
pressure on descent.
Leads to a painful ear
or sinus block!
Do Not Fly with a Cold!
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Other effects of pressure
DECOMPRESSION
SICKNESS
– Air bubbles can form in
the body if you go to high
enough altitudes
– These bubbles are made of
nitrogen and usually
dissolve as you descend.
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Decompression Sickness
– Bubbles that do not
dissolve can get
trapped in the joints
and cause pain (bends)
– If they form in the
blood and go to the
brain they can cause
serious neurologic
symptoms.
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Decompression Sickness
Prevention
Prebreathing 100% oxygen for at least an
hour before high altitude flights can
decrease the amount of nitrogen in the body
and decrease the chance of getting
decompression sickness.
Pressurized cabins or, if necessary, pressure
suits can be used.
Aerospace Medical Association
Decompression Sickness
Treatment
Decompression sickness
can often be successfully
treated in a hyperbaric
chamber which dilutes out
the nitrogen with high
pressure concentrated
oxygenHyperbaric Chamber, Brooks AFB, TX
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Acceleration Forces
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Acceleration Forces
The very rapid rate of acceleration used in most
military jet fighters and in the space vehicles
imposes another hazard on the aviator.
Acceleration results in an increase in the force of
gravity on the aviator which can be up to nine
times what he experiences on earth
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Acceleration forces tend to be directed
downward, and as they increase, they cause an
aviator’s blood to be pushed downward in his
body, moving blood from his brain to his feet.
If this force is not counteracted, the aviator
will first lose his vision (black-out) and then
consciousness (G-induced loss of
consciousness or GLOC)
Acceleration Forces
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Positive Acceleration (+Gz)(Sustained)
POOLING BEGINS
1-3 “G”
GREYOUT
3-4 “G”
BLACKOUT
4-5 “G”
UNCONSCIOUSNESS
5-6 “G”
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Acceleration
Countermeasures
To counteract this force, “G” suits have been
developed which squeeze the legs and abdomen
during high G conditions to prevent blood from
being pushed there.
G suits are made up of five interconnected
bladders covering the legs and abdominal region.
Pressurization of the bladders occurs during
increases in G forces.
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Acceleration
Countermeasures
The aviator can also do
a special “straining”
maneuver and tighten
all his muscles. An
adequate straining
maneuver can be
mastered during
centrifuge trainingCentrifuge Facility, Brooks AFB, TX
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Spatial Disorientation
A state characterized by an erroneous
sense of one’s position and motion
relative to the earth’s surface
There are three types– Type I: Unrecognized
– Type II: Recognized
– Type III: Incapacitating
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Types of Spatial Disorientation
Type 1 “Unrecognized”
– The pilot does not perceive that something is wrong
– Very dangerous in that the pilot will continue to operate his aircraft
according to his misperception
Type 2 “Recognized”
– Usually recognized in the sense that the pilot knows something is wrong or
he feels vertigo; but may not recognize it as spatial disorientation
– May be that his instruments tell him something different from the “seat of
the pants” sense
– Often the pilot can correct this by “making the instruments read right”
Type 3 “Incapacitating”
– Pilot is disoriented, knows it, but can’t do anything about it
– Overwhelmed by the strength of his vestibular response to the
disorientation
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Spatial Disorientation
SEAT-OF-THE-PANTS
VISION VESTIBULAR
ORIENTATION
AND
BODY
RESPONSES
SENSES OF
BALANCE
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Spatial Disorientation
While we are in contact
with the earth, the pull
of gravity squeezes
pressure sensors in the
various portions of the
body, thus telling us in
which direction the earth
lies.
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THE SEAT-OF-THE-
PANTS SENSE
FORCE OF GRAVITY
GRAVITY
PLUS
CENTRIFUGAL
FORCE
Spatial Disorientation
In flight, however, G-
forces combine with the
pull of gravity to make
the seat-of-the-pants
sense completely
unreliable as an attitude
indicator.
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INNER EAR PERCEPTION PROBLEMS
OTOLITH
ORGANS
SEMICIRCULAR
CANALS
Sense rotation
Spatial Disorientation
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Aviation Medicine
Thus, there are many problems with the abnormal
environment encountered in aviation. The flight
surgeon is just one of many highly trained
individuals working to minimize the effects of
these adverse effects so that man can continue to
have mastery over the air.
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ΑΠΑΙΣΗΔΙ ΙΑΣΡΙΚΗ ΚΑΣΑΛΛΗΛΟΣΗΣΑ
ΚΑΣΑ JAR FCL3 ΓΙΑ ΔΠΑΓΓΔΛΜΑΣΙΔ
ΥΔΙΡΙΣΔ
Παποςζίαζη: Ι.Δημηηπακόποςλορ ,Γενικόρ Ιαηπόρ
Εξοςζιοδοηημένορ αεποϊαηπικόρ εξεηαζηήρ
Authorised Medical Examiner AME
θαλνληζκνύο ζηνλ
ΔΠΙΥΔΙΡΗΙΑΚΟ,
ΣΔΥΝΙΚΟ ΚΑΙ
ΙΑΣΡΙΚΟ ηνκέα ηεο
ΠΟΛΙΣΙΚΗ ΑΔΡΟΠΟΡΙΑ
Με ζκοπό ηην αζθάλεια ηων πηήζεων…
…oδήγεζε ζηα ηέιε ηνπ Β’ παγθνζκίνπ πόιεκνπ
ζηελ ίδξπζε ηνπ
ICAO 1944(International Civil Aviation Organisation )
ECAC 1955European Civil Aviation Conference ην
(αληεπηζηέιινλ κέινο ηνπ ICAO)
JAA 1990Joint Aviation Authorities CYPRUS agreement
(αληεπηζηέιινλ κέινο ηεο ECAC)
Από ηνλ JAA εθαξκόδνληαη ηα
JARs:
Joint Aviation Requirements: Κνηλέο
Αεξνπνξηθέο Απαηηήζεηο
ΑΦΟΡΟΤΝ Δ ΜΗΥΑΝΙΚΑ ΜΔΡΗ ΚΑΙ ΠΡΟΩΠΙΚΟ
ύκθσλα κε ηελ ππ. αξ. 3922/91
(νδεγία ηεο ΔΔ)
“όια ηα θξάηε κέιε ηεο πξέπεη λα
εληαρζνύλ ζηνπο θόιπνπο ηνπ JAA
θαη λα εθαξκόζνπλ ηα JARs”
Η ελαξκόληζε
επηηπγράλεηαη κέζα από ηελ
ζπλεξγαζία θαη ηελ εθαξκνγή ησλ
θνηλώλ θαλνληζκώλ σο θνηλέο
απαηηήζεηο
JOINT AVIATION REQUIREMENTS
JARs
JAR’s: Joint Aviation
Requirements
Απαηηήζεηο θαηά JAA
Για αδειοδόηηζη
(FCL - Flight Crew Licensing)
JAR FCL-1 Αεποπλάνα
JAR FCL-2 Ελικόπηεπα
JAR FCL-3 Ιαηπικέρ απαιηήζειρ
Tα JARs ικανοποιούν ηα κπιηήπια ηος ICAΟ και μάλιζηα είναι πιο αςζηηπά!
Η Διιάδα ελαξκνλίζηεθε κε ηελ
Δπξσπατθή λνκνζεζία κε ην ΠΓ
247/02 πνπ απνηειεί αθξηβή
κεηάθξαζε ησλ JAR FCL3 όζν
αθνξά ζηελ πηζηνπνίεζε ηαηξηθήο
θαηαιιειόηεηαο
Από ηα JARs εθδίδνληαη ηα θάησζη
πηζηνπνηεηηθά:
Ι) επαγγεικαηηώλ ρεηξηζηώλ
Class 1
ΙΙ) ηδησηώλ ρεηξηζηώλ
Class2
Η εθαξκνγή ησλ JARs FCL-3 ζπλδέεηαη
άξξεθηα κε ηελ
i) Αεξνηαηξηθή Αξρή (AMS)
ii) ηα εμνπζηνδνηεκέλα θέληξα αεξνπνξηθήο
Ιαηξηθήο (AMCs)
iii) έλα εμεηδηθεπκέλν ζώκα ηαηξώλ,
Δμνπζηνδνηεκέλνη Ιαηξνί Δμεηαζηέο
(ΑΜΔs= Authorized Medical Examiners)
ΣΑ JARs FCL3 ΑΠΟΣΕΛΟΤΝ ΕΝΑ
ΑΠΟΚΕΝΣΡΧΜΕΝΟ ΤΣΗΜΑ
ΙΑΣΡΙΚΗ ΠΙΣΟΠΟΙΗΗ ΓΙΑ ΣΟΤ
ΥΕΙΡΙΣΕ ΣΗ ΠΟΛΙΣΙΚΗ
ΑΕΡΟΠΟΡΙΑ
εμεηαζηή ΑΜΔ, φπσο δηαηππψλεηαη ζηα JAR
FCL 3, ΠΔ 247/02/3.090 θαηέρεη
πξσηεύνληα ξόιν ζηε
α) δηαπίζησζε ηεο ηαηξηθήο θαηαιιειφηεηαο
ησλ ρεηξηζηψλ
β) ζπκβάιιεη ζηελ αζθάιεηα πηήζεσλ
απνθιείνληαο αηθλίδηα αληθαλφηεηα ηνπ
ρεηξηζηή ιφγσ πξνβιεκάησλ πγείαο
Οη ΑΜΕs απνηεινχλ ηε βάζε γηα ηελ Ιαηξηθή
εμέηαζε θαη πηζηνπνίεζε ηεο ηαηξηθήο
θαηαιιειφηεηαο ησλ ρεηξηζηψλ.
Σα AMCs (Κέληξα Αεξνπνξηθήο Ιαηξηθήο)
απαξηίδνληαη θπξίσο απφ ΑΜΕs θαη είλαη
πξνυπφζεζε ν δηεπζχλσλ ελφο AMC θαη ν
αλαπιεξσηήο ηνπ, λα είλαη εμνπζηνδνηεκέλνη
απφ ηελ ΤΠΑ γηα ηελ δηελέξγεηα
αεξνταηξηθψλ εμεηάζεσλ Σάμεο 1
Οη εμνπζηνδνηεκέλνη εμεηαζηέο γηαηξνί,
ΑΜΕs,
δηελεξγνύλ θαη ζπληνλίδνπλ ηηο ηαηξηθέο
εμεηάζεηο πνπ είλαη απαξαίηεηεο γηα ηελ
έθδνζε, αλαλέσζε ή επαλεπηθύξσζε
πηζηνπνηεηηθνύ ηαηξηθήο θαηαιιειφηεηαο
Τπνγξάθνπλ ην πηζηνπνηεηηθό ηεο
θαηεγνξίαο γηα ηελ νπνία έρνπλ
εμνπζηνδνηεζεί.
ηόρνο ηεο αεξνταηξηθήο
εμέηαζεο από ηνλ ΑΜΔ
Σξέρνπζα εηθόλα ηεο
πγείαο ηνπ ρεηξηζηή
Η δπλαηόηεηα λα
αληαπνθξηζεί ν
εμεηαδόκελνο ζηα
θαζήθνληά ηνπ, ζε
ζπλζήθεο εξγαζίαο
Ο ΑΜΔ πξέπεη λα :
είλαη θαιόο θιηληθόο γηαηξόο
εμεηάδεη πξνζεθηηθά θάζε ζύζηεκα ηνπ
ππνςεθίνπ
λα εκβαζύλεη ζηηο ιεπηνκέξεηεο
Ο ΑΜΔ πξέπεη λα θάλεη ηνλ
ππνςήθην λα λνηώζεη άλεηα θαη λα
αληηιεθζεί όηη ν ζθνπόο απηήο
ηεο εμέηαζεο δελ είλαη λα ηνλ
απνξξίςεη ηαηξηθά , αιιά λα
επηβεβαησζεί ην αιεζέο γηα ηελ
θαιή θαηάζηαζε ηεο πγείαο ηνπ
ε θάζε πεξίπησζε πξέπεη λα ηεξείηαη
ην απφξξεην ηεο δηαρείξηζεο ησλ
πξνζσπηθψλ ηαηξηθψλ δεδνκέλσλ!
Γελ λνείηαη αεξνταηξηθή εμέηαζε
αξρηθή γηα επαγγεικαηία ρεηξηζηή πνπ
λα δηαξθεί ιηγόηεξν από 3-4 ώξεο ζε
θέληξν αεξνπνξηθήο ηαηξηθήο,
όπσο θαη απηή ηεο απιήο αλαλέσζεο
ζε ΑΜΔ δηάξθεηαο κηθξόηεξεο ησλ 45
ιεπηώλ ηεο ώξαο
ηε ρώξα καο δηελεξγνύληαη πεξί ηηο
4000 αεξνταηξηθέο εμεηάζεηο πηιόησλ
από 20 εμνπζηνδνηεκέλνπο ηαηξνύο
ΑΜΔs θαη δύν AeMCs εηεζίσο εθ ησλ
νπνίσλ νη 3500 πεξίπνπ ζην
ιεθαλνπέδην ηεο Αηηηθήο θαη νη
ππόινηπεο ζηε Θεζζαινλίθε
Κξηηήξηα Ιαηξηθήο Καηαιιειόηεηαο
Έρνπλ ηε δνκή ελφο πνιχπινθνπ λνκηθνχ
ζπζηήκαηνο(Regulatory Medicine)
Δηέπνληαη απφ αξρέο πνπ πξνθχπηνπλ απφ ηε
αεποϊαηπική έπεςνα κε βάζε θαη ηελ εκηίμηζη
ηηρ πιθανόηηηαρ για αιθνίδια ακαηαλληλόηηηα
θαηά ηε πηήζε πνπ ζρεηίδεηαη κε ηηο επηκέξνπο
λνζνινγηθέο νληφηεηεο θαη παζνινγηθέο
θαηαζηάζεηο θαζψο θαη ηε ιήςε θαξκάθσλ γηα
ηελ αληηκεηψπηζε ηνπο
Χο εθ ηνχηνπ ε αλαιπηηθή παξνπζίαζε ησλ
θξηηεξίσλ θαηαιιειφηεηαο γηα επαγγεικαηίεο
ρεηξηζηέο αεξνζθαθψλ δελ είλαη εθηθηή.
Επεηδή ππάξρνπλ γεληθέο αξρέο , πξνυπνζέζεηο
αιιά θαη πνιχπινθνη νξηζκνί θαη νξνινγία πνπ ε
εξκελεία ηνπο πνηθίιεη αλάινγα κε ην ηζηνξηθφ
ηελ θιηληθή θαη παξαθιηληθή εηθφλα θάζε
ππνςεθίνπ
πκπεξαζκαηηθά πξνο απνθπγή λανθαζμένηρ
επμηνείαρ ηνπ θαλνληζκνχ ζπληζηάηαη ζηνπο
ππνςεθίνπο λα απεπζχλνληαη γηα πιεξνθνξίεο ζρεηηθά
κε ηε δπλαηφηεηα ηαηξηθήο πηζηνπνίεζεο ηνπο ζην
i) Γπαθείο Αεποποπικήρ Ιαηπικήρ (AMS)
ii) ηα Κένηπα Αεποποπικήρ Ιαηπικήρ (AMCs- Κ.Α.Ι.)
iii) Τοςρ εξοςζιοδοηημένοςρ Αεποϊαηπικούρ εξεηαζηέρ
(AMEs)
Η πξφνδνο ηεο Αεξνταηξηθήο έξεπλαο θάλεη ηα θξηηήξηα
θαηαιιειφηεηαο ιηγφηεξν απζηεξά κε ηελ παξνδν ηνπ ρξφλνπ
Δελ πξέπεη λα επηθξαηεί ε αληίιεςε φηη γηα λα γίλεη θάπνηνο
επαγγεικαηίαο ρεηξηζηήο πξέπεη λα έρεη απφιπηα θαζαξφ ηαηξηθφ
ηζηνξηθφ
Τπάξρνπλ επαγγεικαηίεο ρεηξηζηέο πνπ πεηνχλ κε
πηζηνπνηεκέλα πξνζζεηηθά κέιε- βνεζήκαηα αθνήο …
Τπάξρνπλ εηδηθέο δηαδηθαζίεο πηζηνπνίεζεο ηθαλφηεηαο πηήζεο
κε (test flight) ζε ζρεηηθέο κε ηηο παξαπάλσ πεξηπηψζεηο θαη
πξνζζήθε θάπνησλ πεξηνξηζκψλ ζην πηζηνπνηεηηθφ πγείαο (π.ρ.
OML)
Ιδηαίηεξε έκθαζε δίλεηαη ζηελ αμηνιφγεζε ησλ παξαθάησ:
Καξδηαγγεηαθά (εθηίκεζε θαξδηαγγεηαθνχ θηλδχλνπ)
Οθζαικνινγηθά
Χηνξηλνιαξπγγνινγηθά
Φπρηαηξηθά
Νεπξνινγηθά
Φπρνινγηθά
Παξαθιηληθφο έιεγρνο
πρλέο εξσηήζεηο
Απαηηήζεηο όξαζεο ?
Διαθλαστικό συάλμα
(i)Καηά ηελ αξρηθή εμέηαζε ην δηαζιαζηηθφ ζθάικα πξέπεη λα είλαη κεηαμχ εχξνπο +5 έσο –6 δηνπηξηψλ
(ii)Καηά ηηο εμεηάζεηο επαλεπηθχξσζεο ή
αλαλέσζεο, ν ππνςήθηνο, πνπ ζεσξείηαη
πεπεηξακέλνο απφ ηελ Αξρή, κε δηαζιαζηηθφ
ζθάικα πνπ δελ ππεξβαίλεη ηηο +5 δηνπηξίεο
ή κε πςειφ κπσπηθφ δηαζιαζηηθφ ζθάικα
πνπ ππεξβαίλεη ηηο –6 δηνπηξίεο κπνξεί λα
θξηζεί σο ηθαλφο απφ ην AMS
Υξσκαηηθή αληίιεςε ?
σκαηνκεηξηθά ραξαθηεξηζηηθά?
Φάξκαθα θαη πηήζε?
αθραξψδεο δηαβήηεο θαη πηήζε?
Σξαπκαηηζκνί-κπνζθειεηηθά πξνβιήκαηα θαη
πηήζε?
Πξέπεη λα ηνληζηεί φηη ν θαλνληζκφο είλαη πνιχ πην επηεηθήο γηα εμεηάζεηο αλαλέσζεο ε επαλεπηθχξσζεο πηζηνπνηεηηθψλ πγείαο πηπρηνχρσλ ρεηξηζηψλ ζε ζρέζε κε ηηο αξρηθέο αμηνινγήζεηο ησλ λέσλ ππνςεθίσλ
Π.ρ. έκθξαγκα κπνθαξδίνπ
Επαλαπηζηνπνίεζε κε OML πεξηνξηζκφ κεηά απφ εμάκελν εάλ πιεξνί ζπγθεθξηκέλεο πξνυπνζέζεηο κεηά απφ ιεπηνκεξή αμηνιφγεζε
ΕΡΧΣΗΕΙ;
Δπραξηζηώ
γηα ηελ πξνζνρή ζαο