Federal Air Surgeon’s Medical Bulletin Federal Air Surgeon’s 2016-1 MEDICAL BULLETIN

Vol. 54, No. 1 Aviation Safety Through Aerospace Medicine

In This Issue From the Federal Air Surgeon’s perspective... From the Federal Air Surgeon Pilot Fitness Aviation Rulemaking Pilot Fitness ARC Recommendations ...... 1 Committee Recommendations Student Pilot Certificate Changes...... 3 BY JAMES R. FRASER, MD, MPH AME Seminars ...... 4 Reader Response to “Analyzing Age Trends” . 5 n the Spring issue of the associations, pilot representative Federal Air Surgeon’s Medi- organizations, and international Case Report: Aortic Stenosis ...... 6 I cal Bulletin, I discussed the aviation industry associations. Dr. Case Report: Atrial Fibrillation ...... 8 formation of the Pilot Fitness Avia- Mike Berry, Deputy Federal Air Sur- Case Report: Traumatic Brain Injuries ...... 10 tion Rulemaking Committee (ARC) geon, from the FAA Office of Aero- and told you that I would report to space Medicine served as the ARC *NEW* AME I.Q...... 12 you when they completed their rec- co-chair. Dr. Penny Giovanetti, Man- Pilot Guilty of Submitting False Info to FAA .. 13 ommendations. ager Medical Specialties, from the OAM New Hires & Farewell ...... 13 The ARC was chartered by the FAA Office of Aerospace Medicine FAA to consider specific objectives served as an ARC member and chair AME Links ...... 13 and tasks in a forum for the U.S. avi- of the Medical Working Group. AME Guide Updates ...... 13 ation community to discuss and The ARC developed eight rec- List of 2015 Bulletin Articles ...... 14 provide recommendations to the ommendations. Several of these FAA on pilot mental fitness for duty. recommendations suggest actions Federal Air Surgeon’s Medical Bulletin The ARC was chartered after the the FAA and air carrier community Commercial Aviation Safety Team could take to address pilot mental From the Office of Aerospace Medicine (CAST) considered the circumstanc- fitness issues through education, Library of Congress ISSN 1545-1518 es surrounding the Malaysia flight outreach, and training initiatives. Federal Air Surgeon 370 and Germanwings flight 9525 Others address reporting mental James R. Fraser, MD, MPH events. CAST determined it did not health issues, operational proce- Editor have all of the needed expertise to dures, and aircraft design. Gena Drechsler examine pilot mental fitness issues The ARC believes the best strat- Cover art courtesy of (that is, issues affecting a pilot’s egy for minimizing the risks related CAMI IZone Team emotional state, mental health, or to pilot mental fitness is to create The Federal Air Surgeon’s Medical Bulletin is pub- cognitive ability to safely conduct an environment that encourages lished for aviation medical examiners and others their duties), and a committee of and is supportive of pilot voluntary interested in aviation safety and aviation medicine. The Bulletin is prepared by FAA’s Civil Aerospace medical and aviation industry pro- self-disclosure. However, even Medical Institute with policy guidance and support fessionals with expert knowledge within a supportive environment from the Office of Aerospace Medicine. Authors on pilot mental fitness issues was the group identified many barriers may submit articles and photos for publication to: best suited to explore the topic. to voluntary self-disclosure. It is Federal Aviation Administration, CAMI The ARC membership and clear even when symptoms are rec- P.O. Box 25082, AAM-400, Attn: FASMB Editor working groups consisted of a ognized, pilot mental fitness self Oklahoma City, OK 73125 Email: [email protected] broad representation of people in- reporting may be perceived as a cluding aerospace medicine, psychi- high risk situation. There may be If you would like to be notified by email when the new atric, and psychological medical misperceptions that all mental ill- edition of the Federal Air Surgeon’s Medical Bulletin becomes available, please send an email with your experts from both inside and out- ness is career ending. Financial and request to: [email protected] side the FAA, FAA Flight Standards career implications for professional Service, U.S. aviation industry trade (Continued on page 2)

Vol. 54, No. 1 Page 1 Federal Air Surgeon’s Medical Bulletin 2016-1

(ARC Recommendations—continued from page 1) during the pilot hiring process nor as to report and seek help for mental part of routine FAA aviation medical health issues. pilots can be significant even for short examinations beyond those which al- 4. Air Carrier Education term medical disqualification. There- ready exist. Air carrier operators should be en- fore, it is critical that the pilot commu- Rationale: The Aviation Rulemak- couraged to implement mental health nity receive healthcare and support ing Committee (ARC) found no con- education programs for pilots and su- information that is timely, accessible, vincing data to conclude that adding pervisors that improve awareness and and accurate. The best approach to psychological testing to the hiring pro- recognition of mental health issues, re- address misperceptions is to expand cess or to the routine medical exami- duce stigmas, and promote available the use of pilot support programs, ed- nations enhance the ability to assess resources to assist with resolving men- ucate the air carrier and pilot commu- the mental fitness of the pilot work- tal health problems. nities on mental fitness for duty issues, force. Rationale: Improved mental health and ensure pilots experiencing such 3. Pilot Assistance Programs literacy is associated with earlier re- issues are cared for in a confidential, Air carriers should develop effective porting and improved treatment out- non-stigmatized, and safe environ- pilot assistance programs. comes. ment. Aviation medical examiners Rationale: An environment needs 5. Informational Material on Pilot Sup- (AMEs) play a critical role in this pro- to be created where pilots feel com- port Programs cess. fortable disclosing mental fitness is- Additionally, the ARC believes a The FAA should assemble and dis- risk mitigation process should be used seminate information on benchmark by air carriers and pilot representative The ARC believes the best pilot support programs, which includes organizations to create an environ- pilot assistance programs, to serve as a ment where early reporting, appropri- strategy for minimizing the resource for air carriers to develop new or improve existing programs. ate treatment, and rapid return to the risks related to pilot mental flight deck are the expectation. Early Rationale: There is a need for more identification of mental fitness issues fitness is to create an opportunities for sharing best practic- leads to better results. A holistic ap- es among air carriers. Providing the proach to educating and addressing environment that encourages basic description, function, and bene- fits of pilot support programs will en- pilot mental fitness issues offers the and is supportive of pilot best opportunity for a positive out- courage air carriers to implement come. voluntary self-disclosure. some or all of these programs. Imple- The eight recommendations in- mentation of the full complement of clude: these programs is considered a best sues. Pilot support programs should practice. 1. Enhance AME Training provide the opportunity for a pilot to 6. Medical Professional Reporting The Federal Aviation Administra- disclose a mental fitness concern and tion (FAA) should ensure all Aviation if appropriate, receive temporary re- Encourage advocacy for a uniform Medical Examiners (AME) demonstrate lief from flight duties and be referred national policy on mandatory reporting knowledge in assessing basic mental to professional resources. The success- of medical issues that affect public safe- health concerns, and enhance AME ful implementation of pilot support ty. training on this topic. programs benefits from a joint collab- Rationale: In the United States, Rationale: Many AMEs have lim- oration between the air carrier to in- medical professional reporting re- ited psychiatric education and experi- clude senior management support, its sponsibilities are unclear. Reporting ence. It is desirable to expand general pilot representative organization, and requirements and guidelines vary by knowledge regarding mental status pilot peer volunteers. The trusting re- State and by licensing boards. The per- assessment and mental health. This lationship with a fellow pilot in a peer ceptions of adverse legal consequenc- could be accomplished by restructur- supported program may provide the es of reporting appear to be greater ing the AME basic and refresher cur- best opportunity to identify and en- than not reporting. AMEs are expected ricula, with the goal to enhance the gage an individual requiring assis- to report issues potentially affecting AME’s ability to identify warning signs tance. To encourage use, pilots must public safety, but among medical pro- and refer the pilot for evaluation and be handled in a confidential, non stig- fessionals at large, concerns exist appropriate intervention. matized, and safe environment. If a about professional and legal liability for violating patient privacy. 2. Psychological Testing culture of mutual trust and coopera- It should be noted there exists a The ARC does not recommend man- tion is maintained, pilots are less likely to conceal a condition, and more likely concern that universal implementation dating formal psychological testing (Continued on page 3)

Vol. 54, No. 1 Page 2 Federal Air Surgeon’s Medical Bulletin 2016-1

(ARC Recommendations—continued from page 2) Student Pilot Certificate Changes: of mandatory reporting require- AMEs Stopped Issuing Student Pilot ments may deter individuals from Certificates April 1, 2016 seeking treatment. Also, because of the current uneven legal landscape, BY STEPHEN VÉRONNEAU, MD, MS and medical ethics considerations notwithstanding, it is important fter March 31, 2016, it was were the solo flight to occur during the that existing or future pilot support no longer possible for an validity of the medical certificate. programs and policies continue to A Aviation Medical Examiner There are a variety of means by raise pilot awareness and encour- (AME) to issue a Medical Certificate and which a student pilot can apply for a age voluntary self-disclosure in a Student Pilot Certificate (FAA Form Student Pilot Certificate, which is re- confidential and safe environment. 8420-2). Changes were effected in quired only before the first solo flight. MedXPress and AMCS to prevent issu- The student pilot should contact the 7. Two Persons on Flightdeck and ance of the combination pilot and medi- Certified Flight Instructor (CFI) who Flightdeck Access cal certificate. will advise on how this is completed. The ARC recommends no chang- In response to a 2004 Congression- One can take flying lessons while apply- es to the guidance found in FAA Or- al law and FAA Flight Standards (AFS) ing for the Student Pilot Certificate. A der 8900.1, “Procedures for Open- rulemaking accomplished in January of medical certificate must also be ob- ing, Closing, and Locking Flight this year, designated AMEs stopped is- tained at some point prior to the first Deck Doors” concerning two per- suing the combination paper certificate, solo flight. sons on the flightdeck and flightdeck access. Rationale: The ARC notes that mental health episodes have oc- curred even with two persons in the cockpit, and no single safety practice can address all possible hypothetical events and other civil aviation authorities may have dif- ferent procedures best suited to their regulated air carriers and op- erating environments. 8. Aircraft Design Standards which was both a medical certificate After April 1, 2016, a Student Pilot The ARC believes existing air- and a Student Pilot Certificate. Certificate issued by the new process craft and flightdeck door design Student pilots are still required to does not expire, is made of plastic, may standards are adequate and no have at least a Third Class Medical Cer- take several weeks to process, and is changes are required by the FAA. tificate (FAA Form 8500-9) prior to only issued after a TSA vetting process. Rationale: No additional design their first solo flight, so part of the A Student pilot certificate issued prior requirements or pending technolo- quest to become a pilot will still require to April 1, 2016, has an expiration date gies have been identified that a medical certificate. As an AME you 24 months from the date of issuance for would reduce risk more than these printed that form, either the combina- an applicant older than age 40 or 60 systems currently in place. tion certificate (8420-2) or the medical months from the date of issuance for an In summary, thanks to the certificate (8500-9) from within AMCS. applicant under age 40. work done daily by AMEs and oth- While there is a minimum age re- Student pilots who are not citizens ers in our aviation community, I quirement of 16 for the Student Pilot or residents of the US continue to fol- believe our U.S. pilots undergo a Certificate, it is important to remember low the existing Alien Flight Student reasonably robust medical screen- that there is no age requirement for a Program: https:// ing. The adoption of the recom- Medical Certificate of any class. An ap- www.flightschoolcandidates.gov/. This mendations above will only make it plicant who meets the standards may is of importance to our International better. Thanks for all that you do be issued an appropriate medical certif- Region AMEs, who must advise pro- for aviation safety. icate. The student pilot could conceiva- spective student pilots to apply for the -Jim bly approach an AME as much as five student pilot certificate with the Trans- years in advance of his or her solo portation Security Administration. The flight, if under age 40. A third class AME may issue a medical certificate of medical certificate would still be valid (Continued on page 4) Vol. 54, No. 1 Page 3 Federal Air Surgeon’s Medical Bulletin 2016-1

(Student Pilot Certificate—continued from page 3) any class if the foreign applicant meets the Part 67 medical standards. Take Home Points  No further Student Pilot Certifi- cates from AMEs  The most likely source of the Stu- dent Pilot Certificate will be the student’s Certified Flight Instruc- tor (CFI)  Solo flight requirements are a min- imum age of 16, English compre- hension, Student Pilot Certificate from AFS, and a current Medical Certificate from an AME (no age requirement)  https://www.faa.gov/pilots/ become/student_cert/ For More Information: Advisory circular AC 61-65F, Certi- media/Advisory_Circular/AC_61- Dr. Véronneau is the Manager of the fication: Pilots and Flight and Ground 65F.pdf Aerospace Medical Education Division, Instructors, contains the latest guid- FAA online guidance for Student AAM-400. ance on how applicants will acquire a Pilots is at: https://www.faa.gov/ Student Pilot certificate. http:// pilots/become/student_cert/ www.faa.gov/documentLibrary/

AVIATION MEDICAL EXAMINER SEMINARS June 20-24, 2016 Oklahoma City, Oklahoma Basic (2) July 15-17, 2016 Jacksonville, Florida Refresher (1)

September 8-10, 2016 Rochester, Minnesota CAMA (4) October 24- 8, 2016 Oklahoma City, Oklahoma Basic (2) December 2-4, 2016 Tucson, Arizona Refresher (1) 2 March 20-24, 2017 Oklahoma City, Oklahoma Basic (2) June 19-23, 2017 Oklahoma City, Oklahoma Basic (2) October 23-27, 2017 Oklahoma City, Oklahoma Basic (2) NOTES (1) A 2 ½-day Aviation Medical Examiner (AME) refresher seminar consisting of updates in aerospace medicine and FAA policies. Registration must be made through the Designee Registration System on the . (2) A 4½-day basic AME seminar focused on preparing physicians to be designated as aviation medical examiners. Call your Regional Flight Surgeon. (3) A 3½-day refresher AME seminar held in conjunction with the Aerospace Medical Association (AsMA). This seminar is a Medical Certification refresher, with aeromedical certification lectures presented by FAA medical review officers, in addition to other medical specialty topics. Registration must be made through AsMA at (703) 739-2240. A registration fee will be charged by AsMA to cover their overhead costs. Registrants have full access to the AsMA meeting. CME credit for the FAA seminar is free. (4) This seminar is being sponsored by the Civil Aviation Medical Association (CAMA) and is sanctioned by the FAA as fulfilling the FAA recertification training requirement. Registration will be through the CAMA Website: www.civilavmed.com

Vol. 54, No. 1 Page 4 Federal Air Surgeon’s Medical Bulletin 2016-1 Reader Response to “Analyzing Age Trends” BY WILLIAM R. KNECHT, PHD

n the last issue, we observed that aviation medical I examiners (AMEs) are working longer, on average, but decreasing in numbers. The overlay graph below showed AMEs grouped by 4-year age bins. Salmon-colored meant new hires from 2011 to 2015, purple meant AMEs staying and getting 4 years older. Sky-blue bars meant those leaving the workforce. At the time, we hypothesized that most of this looked like normal retirement with perhaps some influence of peo- ple needing to work longer, coupled with a slowdown in hiring due to a trend toward fewer pilots. But, we judged this an open issue, and welcomed your comments. and the change from 2 to 5 years for renewals under age 40. Steve also noted that “as we get closer to retirement, we tend to focus our efforts and cut back on practice complexi- ty. Aviation medicine lends itself to this.” Finally, he diplo- matically brought up the issue that “changes in health care… are putting pressure on the traditional ways we have deliv- ered care…” This last point was expanded on by Bruce Decking, MD, who hypothesized that the high retirement rates might have something to do with the ever-increasing complexity of the AME’s basic job. Bruce cited as an example the new regs on obstructive sleep apnea, which, while hopefully a relatively rare condition (3-7% of U.S. adults),1 nonetheless now in- volve the AME in pilot certification. Similar to the second law of thermodynamics (entropy is ever-increasing), as we learn more about the human body and medical practice, will the AME’s job inexorably become harder? Now, there’s a question.

Well, we got a number of reader responses that added to the discussion. One came from Stephen Replogle, DO, Dr. Knecht is an engineering research psychologist in the Of- who noted that “physicians are largely abandoning solo pri- fice of Aerospace Medicine’s Human Factors Research Divi- vate practices, and incorporating into large groups. The sion. group medical practices leave little room for time spent on an FAA physical exam.” Steve Wahls, MD, agreed, and added that “demand for ______1Punjabi, N.M. (2008). The epidemiology of adult obstructive third class medical exams has declined substantially in the sleep apnea, Proceedings of the American Thoracic Society, 5(2), last decade” due to factors such as the advent of Light Sport, 136-143.

Vol. 54, No. 1 Page 5 Federal Air Surgeon’s Medical Bulletin 2016-1 Aortic Stenosis CASE REPORT BY HUI LING LI, DO, MPH Aortic stenosis is the most common form of valvular heart disease (8) affecting 1.5 million people in the United States. A third of this population has severe aortic stenosis, of which 50% are symptomatic (9). This report presents a case of aortic stenosis in a first-class pilot and provides a review of this cardiac condition and addresses concerns for medical certification.

ETIOLOGY OF CONGESTIVE HEART FAILURE History gress to severe aortic stenosis, they develop the three cardinal symptoms Aortic stenosis is the obstruction of blood 61-year-old first-class male flow across the aortic valve. A pilot with over 17,700 hours of chest pain, syncope, and congestive Classification is based on valve area of flight time applies for a first-class heart failure (8). It is important to and mean transvalvular gradient seen medical certification but was found to note that severe aortic stenosis has a on echocardiography- mild (valve area high rate of progression to symptoms. >1.5cm2, mean flow gradient <= have moderate aortic stenosis. This 20mmHg), mild-to-moderate (valve area diagnosis was an incidental finding, The following disease progression 1.1-1.5cm2, mean flow gradient <= discovered as part of a workup for an rates have been published for this dis- 20mmHg), moderate (valve area 1.1- unrelated medical condition. The air- ease: a decrease in calculated valve 1.5cm2, mean gradient 21 to 39 mmHg) area of 0.1cm2 per year, an increase in and severe (valve area <1.0cm2 , mean man appears to be in good health and flow gradient >40mmHg) (5). The two mean pressure gradient of 7 mmHg is otherwise asymptomatic. His cardi- most common causes of aortic stenosis in ac exam is unremarkable with no mur- per year, and an increase in velocity of the United States are progressive mur appreciated on auscultation. 0.3m/s per year (7). While most sud- hardening and calcification of the aortic valve associated with aging (senile Echocardiogram shows normal left den cardiac death is preceded by the calcific aortic stenosis), and a congenital onset of symptoms, 3% to 5% of ventricle size, with ejection fraction defect of the aortic valve (unicuspid or estimated at 60-65%. The valve leaf- asymptomatic patients with moderate bicuspid) (7,9). Rheumatic disease is also lets and annulus are moderately to to severe AS resulted in sudden cardi- a culprit, but is rare in the United States heavily calcified. There is the sugges- ac death (7). Since it is impossible to (8). Bicuspid aortic valve is the most predict individual disease progression, common cause of aortic stenosis in tion of fusion of the left and right coro- military aviators. Aortic stenosis nary cusps (bicuspid valve). The calcu- regular cardiac evaluation for affected associated with bicuspid valve usually lated aortic valve area is 1.1cm2. The aviators is essential. occurs in middle age or older patients mean transvalvular pressure gradient (10). Aortic stenosis is more common in men (3). Progression of this condition is is 22 mmHg and peak transvalvular Role of the AME commonly very slow and highly variable. pressure gradient is 49 mmHg. His It is important that aviation medi- Affected individuals are generally cardiologist diagnosed moderate val- cal examiners (AMEs) recognize that asymptomatic until stenosis is severe. The vular aortic stenosis. aortic stenosis can adversely affect classic aortic stenosis murmur is a mid- systolic, crescendo-decrescendo outflow cardiac pre-load and afterload. This murmur (heard best at the upper sternal Aeromedical Issues can result in decreased cardiac output border), with radiation to the neck (7). Aeromedical concerns associated and increased cardiac workload, The triad of angina pectoris, syncope, which is further exacerbated in a flight and congestive heart failure are classic with the diagnosis of aortic stenosis end-stage symptoms of this disease (8). are significant: valve stenosis, requir- environment of reduced ambient oxy- Published data showed that the average ing valve replacement and repair and gen (7). Aortic stenosis requires that survival rate of patients with severe the risk of sudden incapacitation due the AME defer the applicant to the aortic stenosis after the onset of chest pain, syncope, and congestive heart to angina, syncope, and heart failure Federal Aviation Administration (FAA) failure were 5 years, 3 years, and 1.5 Aerospace Medical Certification Divi- (6, 9). Symptoms of aortic stenosis to 2 years, respectively (4). Surgical typically develop gradually over a pe- sion for an Authorization of Special valve replacement is the treatment of riod 10-20 years. Exertional dyspnea Issuance. Submission requirements choice for symptomatic moderate-to- severe aortic stenosis. Lacking valve or fatigue is the most common initial include all pertinent medical records replacement, 50% of patients with presenting symptom. As patients pro- (Continued on page 7) symptomatic aortic stenosis will die within an average of two years (9). Vol. 54, No. 1 Page 6 Federal Air Surgeon’s Medical Bulletin 2016-1

(Continued from page 6) verse change in the airman’s medical Williams & Wilkins, 2008: 333- condition and current medical reports 334. and a current cardiology evaluation are favorable. The AME must submit 6. FAA data internal database with an M-mode, 2-dimensional and the airman’s application and the re- [Accessed 16 December, 2014]. Doppler echocardiogram. AMEs con- quired reports to the Aerospace Medi- 7. Rayman, Russsell. “Valvular heart fronted with aortic stenosis should cal Certification division for review. diseases.” Rayman’s Clincal Avia- either defer or call and speak with a tion Medicine, 5th Edition. New regional flight surgeon or the Civil Aer- References: York: Castle Connolly Graduate ospace Medical Institute (CAMI) on- 1. 14 CFR, Chapter 1, Subchapter D, Medical Publishing. 2013. call physician to obtain verbal authori- part 67 Medical Standards and 8. Rogers, Fleix. “Aortic stenosis: zation. The airman will receive a one- Certification. http:// New thoughts on a cardiac disease year certification if asymptomatic and www.gpo.gov/fdsys/granule/CFR- of older people.” Journal of Ameri- has an unremarkable cardiology evalu- 2012-title14-vol2/CFR-2012- can Osteopathic Association, 2013; ation with the following echo results: title14-vol2-part67 [Accessed 13 113(11): 820-826. valve area > = 1cm2, peak transvalvu- December, 2014] 9. “U.S. Aortic stenosis disease preva- lar pressure gradient < 60 mmHg, and 2. Aerospace Medical Disposition. lence & treatment statistics.” Uni- mean transvalvular pressure gradient Office of Aerospace Medicine versity of Maryland Medical Cen- < 40 mmHg. For the symptomatic air- Guide for Aviation Medical Exam- ter. http//umm.edu/programs/ men with valve measurements contra- iners. https://www.faa.gov/ heart/services/services/cardiac- ry to these parameters, they will most about/office_org/ surgery/valve-surgery/facts likely require valve replacement and headquarters_offices/avs/offices/ [Accessed 17 December, 2014]. will be required to follow the FAA aam/ame/guide/dec_cons/disp/ 10. Van Syoc, Dan and Kruyer, William. valve replacement protocol thereafter. [Accessed 13 December, 2014] “Clinical Practice Guideline for For 2013, the FAA issued 420 Au- 3. “Aortic Stenosis.” Mount Sinai Hos- Aortic Stenosis.” Aerospace Medi- thorizations for Special Issuance for pital. http://www.mountsinai.org/ cal Association, May 21, 2012. aortic stenosis—29 for first-class, 41 patient-care/health-library/ http://www.asams.org/ second-class, and 350 for third-class diseases-and-conditions/aortic- guidelines/Completed/NEW% (6). stenosis-adult [Accessed 13 De- 20Aortic%20Stenosis.htm. cember, 2014] [Accessed 13 December, 2014] Outcome 4. Aronow, Wilbert S. “A review of Aortic stenosis is disqualifying for the pathophysiology, diagnosis, Hui Ling Li, DO, MPH, Lt Col, USAF, MC, medical certification under Title 14 of and treatment of aortic valve ste- FS, was a resident in aerospace medi- the Code of Federal Regulation (CFR), nosis in elderly patients.” Hospital cine at United States Air Force School of revised part 67, section 67.113 (1,2). Practice. 41, 4, October/November Aerospace Medicine when she wrote The airman in this case was granted an 2013: 66-76. this case report at the Civil Aerospace Authorization for special issuance un- 5. Davis, Jeffrey R. “Clinical aerospace Medical Institute. der Title 14 of CFR, section 67.401 cardiovascular medicine.” Funda- (1,2). The certificate expires in 1 year. mentals of Aerospace Medicine, 4th An AME may recertify him in after this edition. Philadelphia: Lippincott time period if there has been no ad-

Vol. 54, No. 1 Page 7 Federal Air Surgeon’s Medical Bulletin 2016-1 Medical Certification of Pilots With Atrial Fibrillation CASE REPORT BY JOHN M. HATFIELD, DO, DC, MPH Atrial fibrillation (AF) is the most common, sustained, cardiac arrhythmia and is associated with a reduction in cardiac output, as well as peripheral embolization and stroke. Hypertensive heart disease and coronary heart dis- ease are the most common underlying disorders associated with AF in developed countries, and affected patients may be at increased risk for mortality. Nevertheless, assuming the airman meets certain criteria, AF is a condition that is medically certifiable through the Federal Aviation Administration (FAA). History Outcome n 86-year-old, male, general The AME may reissue an airman’s ETIOLOGY OF ATRIAL FIBRILLATION A aviation pilot with approxi- medical certificate under the provi- AF affects anywhere between 2.7 million mately 1,500 hours of flying time is sions of an AASI, if the applicant pro- and 6.1 million American adults, and that number is expected to double over applying for reissuance of his third- vides the following: the next 25 years. Common precipitating class medical certificate. He has a his- •An initial SI granted by the FAA; factors include alcohol, emotions, and tory of atrial fibrillation, which was •A summary of the applicant’s med- even exercise. The prevalence increases with advancing age: only 1% of patients initially discovered during a 2010 hos- ical condition since the last FAA medi- with AF are <60 years of age. For pitalization for gallstones/pancreatitis. cal examination, including a statement individuals of European descent, the Additionally, he has a history of an ab- regarding any further episodes of AF; lifetime risk of developing AF after 40 dominal aortic aneurysm repair, a Mal- •The name and dosage of medica- years of age is 26% for men and 23% for women. In African Americans, lory-Weiss tear, hypertension, tion(s) used for treatment and/or pre- although risk factors for AF are more dyslipidemia, hypothyroidism, and gly- vention, with comment regarding side prevalent, the incidence of AF appears cosuria. His current medical conditions effects; to be lower. are stable, and his treatment regimen, •A report of a current 24-hour AF is often associated with structural heart disease and other co-occurring as noted in a recent correspondence Holter monitor performed within last chronic conditions, and the mechanisms from his primary care provider, con- 90 days; and causing and sustaining AF are sists of warfarin (Coumadin) 2.5 mg •A minimum of monthly Interna- multifactorial; thus, AF can be complex and difficult for clinicians to manage. daily, simvastatin 20 mg daily, levothy- tional Normalized Ratio (INR) results Symptoms of AF range from nonexistent roxine 130 mcg daily, sildenafil citrate for the prior 6 months, for those being to severe. Frequent hospitalizations, (Viagra) 100 mg as needed, Vitamin D treated with warfarin. Incidentally, it is hemodynamic abnormalities, and 50,000 units weekly, as well as a daily generally advised to assess bleeding thromboembolic events related to AF result in significant morbidity and capsule of fish oil and a multivitamin. risk with the HAS-BLED tool (2) and to mortality. AF is associated with a 5-fold No other medications were noted. assess stroke risk with the CHA2DS2- increased risk of stroke, a 3-fold After the diagnosis of AF in 2010, VASc tool, in patients with AF. When increased risk of heart failure, and a 2- fold increased risk of both dementia and the patient’s aviation medical examin- compared to the older CHADS2 score, mortality. In the absence of a reversible er (AME) requested an initial Special CHA2DS2-VASc performed better in precipitant, AF is typically recurrent (8). Issuance (SI), even though this medical predicting patients at high risk, and Current literature indicates that alcohol condition is disqualifying under Title those categorized as low risk by consumption, even at moderate intakes, is a risk factor for AF (9), as are 14 of the Code of Federal Regulations, CHA2DS2-VASc were truly at low risk negative emotions such as anger, Part 67. This SI required a decision at for thromboembolism. Warfarin anti- anxiety, sadness, and stress. Happiness the FAA level and, fortunately for the coagulation titrated to an INR of 2.0- appears protective (10). Finally, a recent meta-analysis suggests that pilot, the SI was granted. At this time, 3.0 is recommended (required by the vigorous exercise (in men) is associated however, the pilot is in need of a SI re- FAA) for the average patient with a with increased risk, while moderate newal. AF is one of the 25 diagnoses CHA2DS2-VASc score ≥2 unless con- physical activity (in both sexes) lowers that can currently be reissued by the traindicated (e.g., history of frequent the incidence of AF (11). Therefore, the best current lifestyle advice to decrease AME, for all classes of airmen, in ac- falls, clinically significant bleeding, or the risk of AF is to drink minimally, cordance with the AME Assisted Spe- inability to obtain regular INR). Either exercise moderately, and laugh frequently. cial Issuance (AASI) protocol (1). (Continued on page 9) Vol. 54, No. 1 Page 8 Federal Air Surgeon’s Medical Bulletin 2016-1

(Continued from page 8) INRs were acceptable, a recent exer- 3. QxMD online CHA2DS2-VASc Score warfarin or aspirin can be used for the cise stress test was within normal lim- calculator. Accessed 8 Oct 2015 average patient with a CHA2DS2-VASc its, and two recent 24-hour Holter from: http://www.qxmd.com/ score of 1 depending on physician dis- monitor tests (and a transthoracic calculate-online/cardiology/ cretion and patient preference. Aspirin echocardiogram) were also read as cha2ds2-vasc-stroke-risk-in-atrial- 325 mg daily is recommended for the normal, so he was issued an AASI for fibrillation average patient with a CHA2DS2-VASc his AF. Moreover, he was issued CACIs 4. Johnson, BD; FAA Medical Certifi- score of 0 (3). for his hypertension and hypothyroid- cation Standards briefing; present- Furthermore, the FAA now allows ism. This will allow him to fly for the ed at CAMI on 17 Dec 2014. the treatment of persistent AF with the next 12 months. 5. Guide for Aviation Medical Exam- medications dabigatran (Pradaxa), iners, FAA, Last Updated 30 Sep 2015. Accessed 15 Oct 2015 from: apixaban (Eliquis), and rivaroxaban Aeromedical Concerns http://www.faa.gov/about/ (Xarelto). However, dabigatran is not Aeromedical concerns for AF are office_org/headquarters_offices/ acceptable if the airman is ≥ 75 years thromboembolism, side effects from avs/offices/aam/ame/guide/ old, had a stroke within the last 6 the medication(s), and symptoms re- media/guide.pdf months, has significant valve disease lated to the AF itself, especially if the 6. Guide for Aviation Medical Exam- or a prosthetic valve, has renal impair- ventricular rate is rapid. Incapacita- iners, FAA CACI Conditions. Ac- ment with creatinine clearance of < 30, tion secondary to a stroke is clearly cessed 8 Oct 2015 from: http:// is on other thrombin inhibitors, has the most worrisome thromboembolic www.faa.gov/about/office_org/ ulcerative gastrointestinal or other event. Long-standing, persistent headquarters_offices/avs/offices/ bleeding disorders, or is taking more (previously referred to as chronic) AF, aam/ame/guide/certification_ws/ than the Food and Drug Administra- as is evident in this patient, is charac- 7. Rayman, RB, et al; Rayman's Clini- tion’s recommended dosage of the terized by hemodynamic and sympto- cal Aviation Medicine; 5th Ed., medicine. Also, apixaban and rivaroxa- matic stability, and adequate patient 2013, Page 78. ban are not acceptable in airmen with performance is more readily estab- 8. 2014 AHA/ACC/HRS Guideline for prosthetic heart valves. These two lished simply because the rhythm is the Management of Patients with medicines will require a two-week ob- persistent. Thus, the recommendation Atrial Fibrillation, Volume 64, Is- servation period, and will require fol- to return to flying status is often easier sue 21, 2 Dec 2014, Pages e6–e7. low-up every 6 months for first- and to make with persistent, as compared 9. Larsson et al; Alcohol Consump- second-class medical certificate hold- to paroxysmal (e.g., self-terminating or tion and Risk of Atrial Fibrillation: ers, and 12 months for third-class intermittent) AF, particularly after the A Prospective Study and Dose- medical certificate holders (4). documentation of adequate ventricu- Response Meta-Analysis; J Am Coll The AME must defer to the FAA's lar rate control (7). Cardiol 2014; 64: 281-9 Aeromedical Certification Division or 10. Lampert et al; Triggering of Sympto- matic Atrial Fibrillation by Negative Regional Flight Surgeon if: References Emotion; J Am Coll Cardiol 2014; •Holter Monitor demonstrates non- 1. Guide for Aviation Medical Exam- exercise heart rate >140 or <40 64: 1533-6 iners, Special Issuances, AASI for 11. Sanghamitra et al; Meta-Analysis on (average rate >90) beats per minute or All Classes. Accessed 8 Oct 2015 Association of Different Intensities pauses >3 seconds during waking hours, from: https://www.faa.gov/about/ of Physical Activity with Risk of •More than 20% of INR values are office_org/headquarters_offices/ Atrial Fibrillation; J Am Coll Cardiol <2.0 or >3.0, or avs/offices/aam/ame/guide/ 2015; 65: Issue 10S •The applicant develops emboli, special_iss/all_classes/ thrombosis, bleeding that required 2. QxMD online HAS-BLAD Score cal- John M. Hatfield, DO, DC, MPH, MOH, Lt Col, medical intervention, or any other car- culator. Accessed 8 Oct 2015 from: USAF, MC, FS, is a resident in aerospace diac condition previously not diag- http://www.qxmd.com/calculate- medicine at the United States Air Force nosed or reported (5). online/cardiology/has-bled-score- School of Aerospace Medicine (USAFSAM). He wrote this case report while at the Civil bleeding-in-atrial-fibrillation Fortunately for this gentleman, his Aerospace Medical Institute/USAFSAM. Vol. 54, No. 1 Page 9 Federal Air Surgeon’s Medical Bulletin 2016-1 Traumatic Brain Injuries CASE REPORT BY BENJY PARK, MD, MPH Each year more than 1.7 million traumatic brain injuries (TBI) occur in the United States, resulting in over 50,000 deaths and 275,000 hospitalizations (1). Falls comprise the majority of external causes of TBI contributing to more than 60% among adults over 65 years of age (1). This article presents a case report of a first-class pilot who experienced TBI from a fall and includes the aeromedical issues associated with TBI.

History inferior frontal lobes and source imag- TRAUMATIC BRAIN INJURY CLASSIFICATION 62-yr-old right-handed male es on MRA showed evidence of methe- Generally, TBI can be classified as either A first-class pilot with over moglobin at the site of his injury sug- focal or diffuse, where focal injuries are 20,000 hours of flight time applied for gestive of subacute injury. There was localized and occur at the site of impact, a first-class medical recertification 12 no evidence of encephalomalacia sug- and diffuse injuries are widespread resulting from the shearing of axons months following an episode of synco- gestive of an old injury. After cardiac secondary to acceleration and pe resulting in head trauma with brief and neurologic work up, it was deter- deceleration forces (8,9). There are loss of consciousness and approxi- mined that the episode of syncope was several classification schemes on the mately 30 minutes of amnesia. He held likely secondary to a vasovagal event severity of head injury and is usually based on clinical factors, including the an airline transport certificate and with resultant TBI from the fall with duration of LOC, amnesia, the GCS, and flew for a major airline. evidence of brain contusion and sub- neural imaging (9,10). The Department Upon landing at an overseas loca- acute blood demonstrated on brain of Defense and Department of Veterans tion, the airman reported feeling ill MRI/MRA. Affairs stratify severity based on length of LOC, alteration of consciousness and with two brief episodes of lighthead- post-traumatic amnesia, neuroimaging, edness that resolved spontaneously. Aeromedical Issues and the GCS measured at or after 24 After eating breakfast the following Aeromedical concerns following hours.9 To be classified as mild, morning, he was outside walking TBI include residual neurologic or structural imaging must be normal with when he felt a prodrome of lighthead- neurocognitive deficit, as well as risk LOC 0-30 minutes, and post-traumatic amnesia no longer than 1 day. However, edness and nausea followed by synco- of sudden incapacitation from post- this airman’s head injury would be pe. The next event the airman recalled traumatic seizures (2,3). Any function- considered greater than mild by most was being evaluated at a local emer- al neurologic deficit must be deter- criteria as his MRI/MRA had findings gency department where he had a GCS mined by the aviation medical exam- consistent with blood/brain contusion. Clinical TBI severity does not necessarily iner (AME) with consultation from a (Glasgow Coma Score) of 14, and a equate to aeromedical TBI severity due normal non-contrast CT scan of the neurologist. Depending on the deficit to the unique aeromedical risks head. A physical exam showed super- will determine the disposition of the associated with operating aircraft. ficial abrasions and a small laceration airman’s functional status. Loss of to his occiput, with an otherwise non- strength, sensation, or even proprio- are specified within the Guide for Avia- focal neurologic exam. Witnesses to ceptive sense can diminish the air- tion Medical Examiners (4) and in- his fall stated that 30 minutes had man’s ability to properly operate the cludes, but is not limited to the “core elapsed from the time of his fall and mechanical as well as tactile aspects of test battery,” which provides a stand- his evaluation in the emergency de- the aircraft. ardized basis for the FAA review of partment. Post-traumatic neurocognitive cases (4). Upon his return to the United deficits can be assessed by ancillary The risk of post-traumatic seizure States, the airman was referred to a neuropsychological testing, with ma- is difficult to predict, however, it in- neurologist who reported a normal jor depressive disorder being the most creases with the severity level of TBI. neurologic exam. Ancillary studies common and disabling condition fol- Risk factors for later seizures include including an awake and sleep- lowing TBI (3). Other conditions that older age, LOC and amnesia greater deprived EEG were reported as nor- might be seen by the AME include di- than 24 hours, skull fracture, and mal. An MRI of the head and neck 2 minished cognitive functioning, anxie- brain contusion with subdural hema- weeks post-injury showed increased ty, and even personality changes (3). toma (2). Pharmacoprophylaxis with signal on T2 weighted images to the Specific neuropsychological studies (Continued on page 11)

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(Continued from page 10) should be submitted as part of the dis- Injury. JAMA, May 2010;303 antiepileptic drugs is currently recom- position process. (19):1938-1945. mended by multiple organizations, 4. Specifications for Neuropsycholog- although these guidelines focus on Outcome ical Evaluations for Potential Neu- adults with severe TBI (GCS 3-8) (5). After complete review of the air- rocognitive Impairment. Office of man’s history, physical exam, and an- Aerospace Medicine Guide for Avi- Role of the AME cillary studies, the FAA Aerospace ation Medical Examiners. FAA. The neurologic standards for med- Medical Certification Division deter- www.faa.gov/about/office_org/ ical certificates annotated in Title 14 of mined a 24-month observation period headquarters_offices/avs/offices/ the Code of Federal Regulations (CFR) with required neural imaging to en- aam/ame/guide/media/ Parts 67.109 (a)(b), 67.209(a)(b), and sure resolution of post-traumatic npevalspecs.pdf. Accessed 14 Dec 67.309 (a)(b) include no disturbance blood, an updated neurologic report 2014. of consciousness or neurologic condi- from his treating neurologist with a 5. Chang BS, Lowenstein DH. Practice tion that makes the person unable to summary of the history, treatment Parameter: Antiepileptic Drug safely perform the duties or exercise plan, prognosis, and a comment on Prophylaxis in Severe Traumatic the privileges of the airman certificate cognitive function and neurocognitive Brain Injury. Neurology, Jan applied for or held (6). The AME can- testing. In cases where TBI results in 2003;60(1):10-16. not certify an airman with a history of brain contusion, neural imaging must 6. 14 CFR, Chapter 1, Subchapter D, head trauma associated with any loss be an MRI, as CT may not be sensitive Part 67 Medical Standards and or alteration of consciousness. enough to ensure the injury has been Certification. www.faa.gov/about/ The AME Guide outlines the basic resolved. While the airman already office_org/headquarters_offices/ neurologic exam to consist of 12 crani- demonstrated a normal neurologic avs/offices/aam/ame/guide/ al nerves, motor strength, superficial exam, to include a normal post-injury standards/. Accessed 14 Dec 2014. reflexes, deep tendon reflexes, sensa- EEG, he is considered higher risk to 7. Examination Techniques. Guide for tion, coordination, mental status, and sudden incapacitation from a seizure Aviation Medical Examiners. FAA. other maneuvers (7). However, in cas- secondary to findings on his MRI/ www.faa.gov/about/office_org/ es of TBI with any LOC, the AME MRA. As of this writing, the airman’s headquarters_offices/avs/offices/ should obtain a complete neurologic period of observation was ongoing. aam/ame/guide/app_process/ exam from a consultant neurologist exam_tech/item46/et/. involved with the airman’s case. This References 8. DeCuypere M, Klimo P. Spectrum should include documentation of ancil- 1. Faul M, Xu L, Wald MM, Coronado of Traumatic Brain Injury from lary studies such as neural imaging VG. Traumatic Brain Injury in the Mild to Severe. Surg Clin N Am and possible other studies to include United States: Emergency Depart- 2012;92:939-957. EEG. Neurocognitive testing should ment Visits, Hospitalizations and 9. CDC. Report to Congress on Trau- also be performed post-injury, as well Deaths 2002-2006. Atlanta (GA): matic Brain Injury in the United as on follow up after the observation Centers for Disease Control and States: Understanding the Public period. Neurocognitive testing could Prevention, National Center for Health Problem among Current be chosen from the “core test battery.” Injury Prevention and Control; and Former Military Personnel. The disposition guidance in the 2010. 2013. AME Guide states that for all classes of 2. Annegers JF, Hauser WA, Coan SP, 10. Servadei F, Teasdale G, Merry G. medical certificate requires FAA deci- Rocca WA. A Population-Based Defining Acute Mild Head Injury in sion regarding airman disposition for Study of Seizures after Traumatic Adults: A Proposal Based on Prog- an episode of head trauma associated Brain Injuries. NEJM, Jan 1998; nostic Factors, Diagnosis, and Man- with any loss or alteration of con- 338(1):20-24. agement. Journal of Neurotrauma sciousness. All pertinent medical rec- 3. Bombardier CH, Fann JR, Temkin 2001;18(7):657-664. ords to include hospital and pre- NR, et al. Rates of Major Depres- Benjy Park, MD, MPH, Maj, USAF, MC, FS, hospital records, consultant evaluation, sive Disorder and Clinical Out- was a resident in aerospace medicine when comes Following Traumatic Brain ancillary studies, and medication(s) he wrote this case report at the Civil Aero- space Medical Institute. Vol. 54, No. 1 Page 11 Federal Air Surgeon’s Medical Bulletin 2016-1 AME I.Q. BY STEPHEN P. HORNER id you know every AME is under D Surveillance! There are two ways the 1. These two examples are from an airman who answered yes Office of Aerospace Medicine inspects what to 17a, items in 18 and 19 on the 8500-8. The comments they expect. The first is the AME reject are actual comments from AMEs. Which comments would you queue, an automated system that flags poten- want to see if you were the flight surgeon making a tial errors of an issued pilot medical certifi- determination? cate or an airman's exam. The other is an in person or virtual site visit of the AME’s of- a. The first AME example: “17a: NOTED 18c: NOTED fice. This edition of AME I.Q. will focus on 18u: NOTED 18v: NOTED 19: NOTED" common errors that Surveillance Program Analysts see in the reject queue. b. The second AME example:"17a: Flonase for allergies The most common issue encountered in Lisinopril & Fenofibrate for HTN atorvastatin for the reject queue is poor AME comments or cholesterol all medications without report of side effects the use of PRNC. Let’s be very clear, the air- 18e: previously reported seasonal allergies, symptoms man can put PRNC, or Previously Reported controlled with Flonase as needed 18h: previously No Change. According to FAA Order 8000.95 reported HTN, favorable follow up stating good control, the AME responsibilities are as follows: meets CACI criteria for issuance with hypertension 18v: "When completing FAA Form 8500-8, either previously reported 2011 incident, no new or additional on paper or electronically, the AME shall per- occurrences 19: no disqualifying medical visits" sonally review and provide definitive (not just "no change" or ''previously reported" com- ments in Item 60 on all positive entries and all physical findings; and sign the FAA forms 2. These are two examples of airman who have a Condition an in ink or electronically as appropriate." AME Can Issue (CACI). Which one is correct? Why are definitive comments important? For two reasons, first when the Surveillance a. The airman entered in 17a Levothyroxine- AME Analyst reviews your transmitted exam they comments are: "17a: PRNC 19: PRNC" will have a clear, complete, and mutual un- derstanding of the airman's condition. Sec- b. The airman entered in 17a Synthroid- AME comments ond, the comments made by you upon exam, are: "17a: Patient tolerates well with no adverse effect in combination with your Aeromedical opinion 18x: Patient appears euthyroid. There are no side effects and evidence received, provide the infor- with medication. The TSH is 3.130. Pilot meets the mation necessary to determine if the airman standards for certification per FAA AME guide. CACI should or should not have been issued a qualified for hypothyroidism 19: routine checkup" medical certificate. There are specific areas we expect to see comments: 17a & b, all item 18 questions, The examples given above are real examples from your peers item 19 questions, and abnormal findings issuing airman medical certificates. All were sent to be reviewed during the exam. By getting a clear explana- by a Surveillance Analyst: two were quickly sent to file, and two tion of the airman's yes answers, a determina- were sent to AMCD for action which could result in a delay of fly- tion can be made quite easily if the exam ing status or revocation. was issued correctly and should be sent to In both of the above scenarios the correct answers are b. file or if the exam was incorrectly issued and The Federal Aviation Administration's Office of Aerospace Med- should be sent for further clarification or icine, teamed with highly professional designated physicians is revocation. essential to a safe National Air Space (NAS). Solid evidence based There is some debate as to what consti- aeromedical decisions appropriately documented in the 8500-8 tutes an acceptable or definitive comment. play a key role to aviation safety. Some excellent examples of comments from Please look in the next edition for more AME I.Q. questions, an- your peers have been listed below as well as swers and information. some poor examples. Let's test your AME I.Q. and see which comments you think are Mr. Horner is a Surveillance Program Analyst for the Western acceptable. Pacific Regional Medical Office.

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Former Vermont Pilot Pleads AVIATION MEDICAL EXAMINER Guilty and is Sentenced for INFORMATION LINKS Submitting False Medical Information to FAA Guide for Aviation Medical Examiners Register for an AME Seminar n April 25, 2016, a Newport, VT, pilot pleaded O guilty in U.S. District Court, Burlington, VT, to AME Training Information a charge of making false statements for submitting AMCS Online Support false medical information to FAA. He was sentenced to time-served, one year of supervised release, and Regional Flight Surgeon Contact Information $3,600 in fines. Pilot Safety Brochures DOT-OIG initiated this investigation in June 2014 Multimedia Aviation Medical Examiner Refresher after the pilot crashed his single-engine aircraft at the Course (MAMERC) Newport State Airport in Newport, VT, and fled the scene. The investigation revealed that he failed to dis- Medical Certification Information close to FAA his history of arrests involving driving MedXPress Login & Help while intoxicated and the use of prescribed medica- tions for a diagnosed mental condition. He also did not MedXPress: The Royal Treatment Video possess a valid medical certificate and was operating MedXPress: It’s Easy Video an unregistered aircraft. FASMB Archives The pilot was arrested in August 2015, after failing CAMI Library Services to abide by the terms of a Pre-Trial Diversion Agree- ment related to this investigation. In September 2015, he was indicted and charged with making false state- SLEEP APNEA INFORMATION ments to FAA in connection with his falsified applica- Frequently Asked Questions tion for an FAA medical certificate. Sleep Apnea Protocol Information provided by the Office of Inspector General Quick Start Guide Specification Sheet A: Information Request Office of Aerospace Medicine New Hires AASM Tables 2 & 3 Brett A. Wyrick, DO, MPH Specification Sheet B Assessment Request Northwest Mountain Region OSA Information Brochure Flight Surgeon

Stephen J.H. Ve ronneau, MD, MS Aerospace Medical Education Division Manager AME GUIDE UPDATES Warren Silberman, DO, MPH 2016 SCHEDULED RELEASE DATES Aerospace Medical Education Division Medical Officer June 29 Gena Drechsler Civil Aerospace Medical Institute July 27 Writer-Editor August 31 And a Fond Farewell to September 28 October 26 Jan Wright Aerospace Medical Education Division’s November 30 AME Program Team Lead, December 28 who is retiring this June

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ARTICLES PUBLISHED IN THE BULLETIN DURING 2015

Headline Author Issue Page Alcohol-Related Motor Vehicle Encounter With a Cow (case report) Michael Jacobson 1 8 AME Guide Updates Judith Frazier 3 3 AME Population: Analyzing Age Trends in the William Knecht 4 10 Antun ano, Dr. Melchor: Receives Top FAA Office of Aviation Safety Award Mike Wayda 4 7 Articles Published in the Bulletin During 2014 Mike Wayda 1 14 Autism Spectrum Disorder-Asperger’s Type (case report) Elizabeth Anderson-Doze 3 6 Awards Scored by OAM Announced AVS Flyer 3 14 Brugada Pattern and Syndrome (case report) Maximilian Lee 4 12 CAMI Receives Accreditation With Commendation AVSFlyer 1 5 Chaperones During FAA Examinations Advised Denise Baisden 4 4 Critical Dates in Recent Medical Certification History David Nelms 4 3 Designee Management System Coming This Summer Bobby Ridge 2 3 Epilepsy (case report) Jeffrey Woolford 4 16 Fraser, Dr. James: Receives CAMA Award AVSFlyer 1 7 Glomus Jugulare Treated With Fractionated Stereotactic Radiosurgery (case report) James McEachen 1 10 Injury Mechanism Analysis in Aerospace Accident Investigation Workshop Mike Wayda 4 4 Jones, Dr. Michael: Receives Outstanding Manager Award Mike Wayda 2 4 Male Hypogonadism, Treatment of (case report) Justin Nast 1 12 Malone, Dr. Sean: Aviation Medical Examiner With a Mission Mike Wayda 4 6 New CAMI Research Facilities Operational Mike Wayda 1 6 New Video Series Highlights Recent Updates and Common Errors Judith Frazier 1 7 Nonsustained Ventricular Tachycardia (case report) An Duong 3 12 Obstructive Sleep Apnea, Evaluation, Referred for: Letter to the Editor Walter Warren 2 3 Obstructive Sleep Apnea: Neurocognitive Decline (case report) Russell Tontz, II 2 8 Obstructive Sleep Apnea: New Guidance (Federal Air Surgeon Editorial) James Fraser 1 2 Obstructive Sleep Apnea: Screening and FAQs (Federal Air Surgeon Editorial) James Fraser 2 2 Obstructive Sleep Apnea: With Cheyne-Stokes Respirations (case report) Ajiri Ikede 2 10 Office of Aerospace Medicine Announces Personnel Changes Michael Berry 1 3 Office of Aerospace Medicine Physicians On Call, Part 5 Richard Carter 2 6 Office of Aerospace Medicine Physicians On Call, Part 6 Richard Carter 4 8 Pilot Fitness: Group Formed to Investigate (Federal Air Surgeon Editorial) James Fraser 3 2 Postconcussion Syndrome After Closed-Head Injury in an Airline Pilot (case report) Michelle Brown 3 8 Residents in Aerospace Medicine Case Reports Melchor Antunano 4 11 Right Bundle Branch Block (case report) Kevin Hettinger 4 14 Saenger, Dr. Arleen: Office of Aerospace Medicine Remembers Michael Berry 1 4 Seizures in a Sleep-Deprived Airman (case report) John Miles 2 12 Two Decades of Amazing Progress Mike Wayda 4 2 Uveal Melanoma (case report) Tim Duffy 3 10 Veronneau, Dr. Stephen: Selected New AMED Manager Mike Wayda 3 14 Wayda, Mike: Federal Air Surgeon's Medical Bulletin Editor Retires Melchor Antunano 4 17 Working Longer Mike Wayda 4 10

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