Federal Air Surgeon’s Medical Bulletin Aviation Safety Through Aerospace Medicine Vol. 50, No. 3 For FAA Aviation Medical Examiners, Office of Aerospace Medicine Personnel, U.S. Department of Transportation 2012-3 Flight Standards Inspectors, and Other Aviation Professionals. Federal Aviation Administration

Hooray! that says: “A letter of authorization New Rule Now In Effect (or SODA) describing any such limitations must be kept with this ello, everyone. It’s official: certificate at all times while exer- H­Effective July 20, individuals with cising the privileges of an airman a special issuance are no longer required certificate.” to have their authorization letter with We are working on the program- them while aviating. I realize that I ming changes necessary to modify informed you about this change in my MedXPress, but we cannot modify the last editorial, but this is such a significant By Fred Tilton, MD paper forms because it would not be change that I think it bears repeating. cost effective to do so before October 1. The news may not amount to a the International Civil Aviation Author- We also do not plan to issue replace- hill of beans to many of the pilots you ity (ICAO) that took place in 2007. At ment certificates to everyone who has examine simply because most of them that time, the auditor, without consult- been issued a certificate with the obsolete meet Federal Aviation Administration ing the ICAO Medical Officer, insisted language. So, for some time, individuals medical standards and do not require a that ICAO International Standards will be carrying certificates with the special issuance (waiver). In fact, many and Recommended Practices (SARPS) outdated language on the back. of them may not even be aware that required that we include all disqualify- I also want to make it clear that even there are such letters, but they probably ing medical conditions on an applicant’s though the entire note will go away, air- will be affected by this change as they medical certificate. men with a SODA will still be required get older and might require a special While we vigorously pushed back, to have their SODA with them when issuance of their own. we could not convince the auditor they fly. The requirement to carry the letter that he was wrong. However, we were You may be asking yourself, What can stemmed from an audit of the FAA by finally able to get him to agree that the I do? You might be surprised to know disqualifying information was contained that you interact with airmen more than in the authorization letter, and that we anyone else in the FAA. So if any of the Contents could meet the intent of the SARPS by airmen you examine have special issu- Letters to the Editor ...... 2 requiring the individual to carry the ances, please take a few extra minutes Three OAM Staff Honored by letter while flying. to explain these changes. AsMA...... 3 Shortly after we announced the re- If you have questions about this issue OAM Physicians On Call . . . . . 4 quirement to carry the letter, we began or any other issue, call your Regional Post-Traumatic Stress Disorder . 5 to get complaints from airmen and avia- Flight Surgeon. He or she is “up-to- Common ECG Issues ...... 6 tion organizations that the obligation to speed” on all of the latest information ECG Normal Variant List . . . . . 6 show it to inspectors was an unnecessary and is ready to help so that we can Pilot Satisfaction Survey . . . . . 7 violation of the airman’s privacy. We provide the best service to the airmen Transverse Myelitis...... 8 agreed with them and so did the ICAO we support. Cardiovascular Disease and Medical Officer, and he helped us get Thank you for your help with imple- Stenting ...... 10 the ruling reversed. While it has taken menting these changes, and as always, Wallenberg’s Syndrome. . . . . 12 a long time, we are finally there, but we thank you for everything you do for the Form 8500-8 Phase-Out still have a couple of issues to deal with. airmen you take care of. Approaching...... 13 The paper medical certificates Cheers! AME Schedule...... 14 and the computerized MedXPress certificates have a note on the back —Fred Glaucoma Case Report Comments issue a certificate and could type it on Dear Editor, a 1929 manual Smith Corona type- The article…about Glaucoma [Case writer—basic, primitive, but still very Report by Joseph A. Lopez, MD, Fed- reliable—what if any of the above go eral Air Surgeon’s Medical Bulletin, vol. down while examining an airman who Dear Dr. Nattis, 50, no. 2, pg. 12] was informative and needs his or her certificate to fly? Will we The Aerospace Medical Certification have available blank certificates to print mostly correct. One glaring point that Division’s general policy is that we prefer should be made is that the eye specialist in case of an above failure in any of the reports from a medical specialist who is above chain of complex interfaces…? should be an ophthalmologist. Not an knowledgeable in the treatment of such optometrist. Optometrists may not have conditions and has experience with the clini- A.J. Bogosian, MD the training needed to properly evaluate cal treatment and potential complications Anacortes, Wash. a patient for the extent of glaucoma, (glaucoma, in this case). Dr. Lopez’ article usually needs supervision by an oph- mentions, more than once, that we require Hello, Dr. Bogosian, thalmologist, and cannot treat patients a report from a treating eye specialist, and There is something to be said for the does comment, in parentheses, optometrist reliable 1929 Smith Corona typewriter; I with laser or surgery if indicated. Also, have a healthy respect for them, as many annual exams for follow up of glaucoma or ophthalmologist (page 12). A summary of the potential multiple complexities of glau- are still in use today. However, the enhance- is inadequate. The American Academy coma (insert, page 13), is also mentioned. ments we are making to our technology of Ophthalmology recommends fol- The AMCD will not accept unsatisfactory infrastructure and our applications truly low up appropriate with the extent of reports regarding history of glaucoma, or are for the benefit of AMEs and pilots. Our disease, and certainly more frequent pre-glaucoma deemed necessary for treat- user community is more “computer savvy” than annually. ment. Follow-up reports, for aeromedical than ever before; in fact, many believe we Richard Nattis, MD purposes, are usually required annually, are “behind the power curve” when it comes Long Island, N.Y. although the eye specialist may require more to the use of technology. closely timed evaluations. The first-class In response to your question — yes, we pilot, then, will typically get a time-limited will have a mechanism in place for you in certificate for 12 months, even if the treat- the event of a failure that prevents you from ing eye specialist is following more closely. accessing the AMCS. We are analyzing dif- The pilot jeopardizes timely certification ferent solutions and will advise you of the Federal Air Surgeon’s if the eye report is vague, incomplete (for solution prior to going “paperless.” Medical Bulletin example, history is lacking), and as Dr. Nat- David Nelms tis implies, the AMCD judges the medical AMCD Program Analyst Library of Congress ISSN 1545-1518 report (glaucoma) to be inadequate—for Secretary of Transportation example, if the doctor is not a medical spe- Ray LaHood cialist knowledgeable about the condition. Huntington’s Disease FAA Administrator (Acting) Richard Carter, DO Michael Huerta AMCD Staff Physician Dear Editor, Federal Air Surgeon Blank Certificates to Print? Concerning the article on Hun- Fred Tilton, MD tington’s disease in the recent Bulletin Editor Dear Editor, [“Huntington’s Disease,” Federal Air Michael E. Wayda Some concerns with the paperless Surgeon’s Medical Bulletin, vol. 50, no. 2, p. 16], it appears that the pilot described Federal Air Surgeon’s Medical record—which indeed is not paperless The had no disease or symptoms of disease; Bulletin is published quarterly for aviation since we have to print out the certificate. medical examiners and others interested in We have now introduced a number he only reported the genetic marker for aviation safety and aviation medicine. The of complex systems into issuing the potential (probable) illness in the future. Bulletin is prepared by the FAA’s Civil medical certificate—now we must have What was the basis for potentially dis- Aerospace Medical Institute, with policy functioning computers (we will not qualifying this individual who presented guidance and support from the Office of even begin to express the frustration no evidence of disease? Are we going to Aerospace Medicine. Authors may submit with the PC and its evolution and op- be requiring everyone who has a defined ­articles and photos for publication in the erating systems), Internet connections marker for future genetic disease to be Bulletin directly to: which where I practice go down with extensively evaluated (as this individual Editor, FASMB regularity, and of course printers and was) prior to any evidence or symptoms FAA Civil Aerospace Medical Institute their limited life expectancy—with the of the disease? AAM-400 “OLD” system if all else failed I could George W. Jackson, MD P.O. Box 25082 Associate Clinical Professor Oklahoma City, OK 73125 E-mail: [email protected] Duke University Continued on page 3

2 T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 50, No. 3 • Huntington's from page 2 subtle but potentially important cognitive with this approach is that individuals with deficits may develop before diagnostic neurodegenerative disease are often un- Editor’s Note: This is a very interesting threshold is reached [1]. aware of developing cognitive difficulties case. We would not have been aware that the I do wish to correct the statement: “Al- (anosognosia), and regular screening such individual had tested positive for the gene for though only 50% of those testing positive as annual administration of Cogscreen-AE Huntington’s disease if he had not voluntarily for the disease actually develop symptoms, or equivalent neuropsychometric testing had himself tested. However, once we were currently there is no further predictive would help detect cognitive decline that informed, we had no choice but to ask for capacity to determine who will become ill would impair safe operation of an aircraft, additional information to be sure that he was and who will remain disease-free.” In fact, potentially before the aviator or their peers not symptomatic for the disease. We have not the disease has nearly 100% penetrance for may readily recognize a deficit. initiated a genetic screening program nor do those testing positive (>42 CAG repeats). As Richard Ronan Murphy, MBChB we intend to do so. you mentioned, disease severity, and earlier onset is associated with greater number of In reply to: Huntington’s Disease: Case CAG [cysteine-adenosine-guanine] repeats, References Report, by Robert Craig-Gray, MD and you may have intended to refer to the 1. Duff K et al. Mild cognitive impairment I would like to thank Dr. Craig-Gray findings that 50% of the variability in disease in prediagnosed Huntington disease. for reporting this case that demonstrates severity and age of onset are explained by Neurology, 2010. 75(6): p. 500-7. many of the concerns faced when evaluating CAG repeat length [2]. 2. Andrew SE et al. The relationship potential sequelae of neurological diseases The number of CAG repeats in humans between trinucleotide (CAG) repeat on aviator performance, as well as the com- is highly variable, but the normal range is length and clinical features of Hun- plexities that aviation medical examiners 11-34 CAG copies, and more than 42 repeats tington’s disease. Nature Genetics, 1993. must deal with when confronted by rare indicates a confirmed genetic diagnosis 4(4): p. 398-403. diseases or diseases usually managed under of Huntington’s gene in most labs. That 3. Killoran A. Analysis of the behavioral fea- the care of specialized providers. Hunting- being said, individuals with an “intermedi- tures conferred by the intermediate allele ton’s disease poses some particularly difficult ate” number of CAG repeats (34-42 CAG for Huntington disease in the Prospective challenges, as most individuals remain nor- repeats), still demonstrate a behavioral Huntington At Risk Observational Study mal through much of their early life, with phenotype, with depressive features relative (PHAROS). Abstract from the American a wide range in the age of onset, and once to normal healthy controls [3], and at the Academy of Neurology Annual Meet- the disease becomes manifest, progressive upper end of this range, the full Hunting- ing, 2012, New Orleans, La. neurological and psychiatric problems ensue ton’s phenotype is incompletely penetrant. unrelentingly. It would be of interest to know how many Dr. Murphy is an AME, a board-certified A medical status report was obtained CAG repeats this airman had. neurologist, and is a fellow in mental health from this airman’s neurologist and revealed You mention that the airman should also research with the Veteran’s Administration no detectable neurological disease or dis- report any changes in his medical condition Mental Illness Research, Education, and Clini- ability. It is encouraging that this aviator immediately to the FAA and cease aviation cal Center, with clinical faculty appointment also presented with no abnormalities on operations per Title 14 CFR §61.53, which to the University of Washington Neurology neuropsychological testing; however, it is restricts operation of an aircraft with any department. important to know that even in early disease, medical [known] deficiency. One difficulty Q

Three OAM Staff Honored by the Aerospace Medical Association

n an unusual and welcome surprise, were both made Fellows of AsMA on Although not related or married to two Office of Aerospace Medicine the same night. The story gets even anyone else who received an AsMA Istaff members were elected Fellows better. Aerospace Medical Education award this year, CAMI’s Research of the Aerospace Medical Association Division Manager Brian Pinkston and Physiologist David “Andy” Self received (AsMA) and one received a prestigious his wife, Cheryl Lowry—a U.S. Air the AsMA Arnold Tuttle Award for national award during Honors Night Force Flight Surgeon—were also among original research, which investigated celebrations at the AsMA 83rd Annual the 24 AsMA Fellows elected for 2012. the physiological responses to altitude Scientific Meeting held last May in “It was quite a surprise,” said Federal hypoxia. This information is used to Atlanta, Ga. Air Surgeon Dr. Fred Tilton. “I’ve never address improvements in countermea- Eastern Region Flight Surgeon seen relatives elected before, and I’ve sures and oxygen equipment design for Harriett Lester and her sister, Benisse never seen a husband and wife elected commercial and general aviation. The Lester, the Chief Medical Officer for the before. And here we have Brian and his research was published as an Office Federal Motor Carrier Safety Admin- wife, and Harriet and her sister—who is of Aerospace Medicine Report and in istration (FMCSA) and a FAA senior basically my counterpart at FMCSA— the Aviation, Space, and Environmental aviation medical examiner (AME), all elected at once!” Medicine Journal. —From AVS Flyer 6/7/2012

T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 50, No. 3 • 3 OAM Physicians On Call Issue when you can. A phone call to or otherwise send in duplicates of the Part 1 the AMCD is not always required. The same reports. Simply put, AMEs can Standing By To Help protocol section of the AME Guide lists issue cases that allow for an Eligibility conditions allowable for AME to initial Letter (see below list – note, this is not a By Richard Carter, DO, MPH issue (example, hypertension, diet/exer- complete list of conditions that qualify cise control of diabetes). Complications for an Eligibility Letter but a sample viation medical examiners, we can occur, and we invite you to call of typical questions/conditions AMEs A challenge you to limit unnecessary about abnormal labs, ECGs, etc. AMEs frequently call about. See also the list deferrals, which helps us to minimize that do initial issue will need to send in of ECG Issues on page 6.). the backlog of deferred exams. Key to medical reports. DO NOT mail, fax, Continued this initiative is an appeal to you to issue certificates when you can. Conditions that allow the AME to issue The following two lists from the • Motion sickness – resolved. Office of Aerospace Medicine (OAM) Myringotomy – resolved. should help you reduce the number of • unnecessary phone calls to Aerospace • Eardrum perforation – resolved. Medical Certification Division (AMCD) • Esophoria/exophoria – no adverse complications, no diplopia. in Oklahoma City for verbal authoriza- • LASIK – less than two years – we need 8500-7. If favorable, issue. tions. If you have an unusual case and • LASIK – more than two years – comment no adverse complications (AME need guidance, though, please call. comments block 60), issue. The medical officers (AMCD, • Acute nephritis, 3 months status post, resolved, issue with favorable reports. Regional Flight Surgeons, and Inter- • Kidney stone history, no retained kidney stone. national/Military Regional Office) are • Melanoma, < .75 mm, favorable report, issue. available to you for such case discus- • Hypertension (see Hypertension Protocol). sions. A team effort is needed to make • Diet/exercise diabetes (see Diet/Exercise Diabetes Protocol). this process successful. • Multifocal intraocular lens (see Protocol for Binocular Multifocal and In Part 1 of this article, we address Accommodating Devices). examples that do not require you to call • Musculoskeletal injury (see Musculoskeletal Protocol). us (see list this page). Print the list, and • Benign prostatic hypertrophy/medication, examples (note: AMCD does re- paste it in a handy spot for reference. quire comment in block 60 that the following medications are well tolerated): Calling AMCD/RFS is easy. Call ♦♦Detrol (tolterodine): acceptable our designated number (include Web ♦♦Enablex (darifenacin): acceptable link to AMCD and Regional Flight ♦♦Vesicare(solifenacin): acceptable Surgeon phone numbers). You can ♦♦Avodart (dutasteride): acceptable call the AMCD or a Regional Flight ♦♦Santura (trospium): acceptable Surgeon for verbal authorization. ♦♦Uroxatral alfuzosin): acceptable Whom to call. We advise, in general, ♦♦Flomax (tamsulosin): acceptable that third-class airman inquires should ♦♦Rapaflo (silodosin): acceptable go to your Regional Flight Surgeon. • Ditropan (oxybutynin); antispasmodic/anticholinergic: is NOT acceptable The AMCD more commonly answers for aeromedical purposes. calls about first- and second-class pi- • Gout/medication, examples (note AMCD does require comment in block lots, and specifically detailed medical 60 that medications are well tolerated): inquires (for example, central serous ♦♦Colcrys (colchicine): allowable. retinopathy, renal cancer). Many AMEs ♦♦Uloric (febuxostat): allowable. already do this. The AMCD number ♦♦Zyloprim (allopurinol): allowable. 405-954-4821/option 6, links you to ♦♦Benemid (probenecid): allowable. dedicated operators that will route you to the physician on call. Please follow • Erectile dysfunction meds, example (note AMCD does require comment in block 60 that medications are well tolerated): operator instructions; you will be asked ♦Viagra (sildenafil citrate): 6 hrs. no fly. your AME number, PI or application ♦ ♦Levitra (vardenafil): 36 hrs. no fly. ID number. If we are not immediately ♦ ♦Cialis (tadalafil): 36 hrs. no fly. available, we will try to call back the ♦ same day. We may also ask for an after- • Asthma, and medication, is rarely used. hours call back number (usually your • Peptic ulcer (see Peptic Ulcer Protocol). cell number), as we may call back after • Cholelithisis, asymptomatic: issue. normal work hours. • Traumatic pneumothorax, 3 months status post, resolved: issue with favorable reports.

4 T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 50, No. 3 • Example: The airman provides a Post-Traumatic Stress Disorder summary report from the urologist, his- tory of kidney stones, now resolved. The Case Report, by Nathaniel B. Almond, MD, MPH most recent imaging (kidneys, ureter, and ­bladder) demonstrates no retained Airmen may present for Background kidney stone. The AME does issue, trans- evaluation with a history of post-­ 32-year-old male with 100 flight mits the new exam, and faxes reports to A hours applied for first-class medi- traumatic stress disorder (PTSD) cal certification with ongoing PTSD the AMCD (fax 405-954-4300), with or with ongoing symptoms of a coversheet. Do you need to call? The due to a stressful event 8 years ago answer is no. Again, do not mail, fax, or PTSD. A thorough history is while in the military. During convoy otherwise send in duplicate reports, as this important for confirming that operations in enemy territory, he drove creates delays in certification. a vehicle over an improvised explosive symptoms have resolved and device (IED), causing it to detonate and Team effort. We need your help to that the airman is not taking the vehicle to catch fire. While escaping limit unnecessary deferrals. Many com- medication for PTSD. This article from the vehicle, he was shot multiple plex medical conditions do eventually get presents a case report of a first- times in the arm and leg, but he did not a waiver (Special Issuance or Statement sustain any head injury. He now admits of Demonstrated Ability), and we will class pilot applicant with ongoing to generalized anxiety, fear of meeting help you with the certification process. symptoms of PTSD and includes a new people, and weekly nightmares and Many thanks to the Regional Flight brief review of PTSD. Surgeons that have assisted us with the Continued on page 7 on-call program. Have you experienced calling the AMCD in Oklahoma and been surprised to be talking to Dr. Goodman in California or Dr. Lester Post-Traumatic Stress Disorder Etiology in New York? Regional Flight Surgeons PTSD is an anxiety disorder that occurs after the experience or witnessing of have assisted us by taking calls for us, a traumatic event. The person’s response to the event must involve intense so we can balance our on-call workload fear, helplessness, or horror. Symptoms vary but can be classified into three with demands of our backlog of deferred categories: 1) reexperiencing of the traumatic event, 2) avoidance of situations cases waiting for review. Thanks to associated with the trauma and numbing of general responsiveness to keep Drs. Ray, Goodman, Salazar, Lester, from thinking about the event, and 3) symptoms of increased arousal . Symp- Northrup, and Jones for participating toms from all three categories must be present for more than 1 month, and the in this special certification project. The disturbance must cause clinically significant distress or impairment in social, Aerospace Medical Certification Divi- occupational, or other important areas of functioning. The many symptoms sion medical staff, Drs. Courtney Scott, that people with PTSD may experience include anxiety, hyper-vigilance, hyper- Brian Johnson, Bill Mills, Ben Zwart, arousal, avoidance, reexperiencing the event (e.g., nightmares, flashbacks, or and Steve Schwendeman all participate intrusive thoughts), anhedonia, reduced ability to feel emotions, being easily in the on-call process. startled, difficulty concentrating or completing tasks, bursts of anger, insomnia, Good news. Dr. Judy Frazier is and irritability (1,2). now fully trained and ready for calls, PTSD is a common diagnosis: 6.8% of Americans will experience PTSD in so you will be talking to her soon! The their lifetime. It is particularly prevalent in those who have served in combat, International AMEs communicate including aviation personnel. (3) Thirty percent of Vietnam veterans have PTSD, with the International Regional Flight while PTSD prevalence estimates in veterans from Iraq and Afghanistan has Surgeon Office, Dr. Brian Pinkston, ranged from 6 to 20% . Depression and alcohol use are also common with and International Program Analyst PTSD. The onset of symptoms in relation to the event, as well as the duration Leah Olson. We coordinate efforts of symptoms, greatly varies (1,2). with the International office to address Treatment of PTSD includes cognitive behavioral therapy and anti-depressant International AME inquires. Together, medication (selective serotonin reuptake inhibitors). Policies and programs exist this team effort expedites the medical across many organizations to assist individuals exposed to stressful events in an certification of pilots. effort to minimize PTSD symptoms. These programs range from Traumatic Stress In Part 2 of this series, we will discuss Response within the Department of Defense to the Critical Incident Response details of the verbal authorization needed Program by the Airline Pilots Association. For example, the Critical Incident for Special Issuance. Response Program works to mitigate PTSD through pre-incident education Q and post-incident accident crisis intervention through crewmembers who have received counseling training. Both primary prevention rapid response to victims Dr. Carter is a medical review officer in is important in both the civilian and military settings of traumatic events (2,3,4). the Aerospace Medical Certification Division.

T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 50, No. 3 • 5 10 Common Electrocardiogram Issues ECG Normal Variant List ...And What To Do About Them When Performing Certification ECGs These are considered normal ECG vari- ants and not reasons to defer the applicant 1. If an airman has a heart rate less 7. An airman with a new onset of • Sinus bradycardia. Age 50 and than 50, have the airman exercise a complete left bundle branch younger — if the heart rate is 45 or in place and repeat the ECG. If block is to provide a cardiovascular greater; age 50 and older — if the heart rate is 49 or greater the heart rate goes up above 50, evaluation and a pharmacologic • Wandering atrial pacemaker send us both ECGs (in case this nuclear stress test. This is one of • Low atrial rhythm happens again down the road), the conditions where we will accept • Ectopic atrial rhythm and you can clear the airman. a pharmacologic stress test. Airmen • Indeterminate axis with a LBBB demonstrate what ap- 2. This also goes for a significant • First-degree AV (atrioventricular) pears to be an area of ischemia in first-degree AV block. Exercise the block with PR interval less than airman in place, and if the block the septum, and the pharmacologic 0.21 in age 50 and younger becomes less, you may clear the stress test helps better determine if • Mobitz Type I Second Degree AV airman. there is actual ischemia. (atrioventricular) block (Wencke- bach phenomenon) 3. If an airman has a heart rate over 8. An airman with left anterior or posterior hemiblock must demon- • One premature ventricular con- 110–sinus tachycardia, perhaps— traction or atrial contraction on a strate an absence of coronary artery have the airman relax a bit and 12-lead ECG disease, so a maximal nuclear stress repeat the graph. If the rate drops • Incomplete RBBB test is required. below 110, send us the graph and • Intraventricular conduction delay clear the airman. 9. Limb lead III is the most variable • Early repolarization 4. Two or more premature atrial lead. This lead sometimes is af- • Left ventricular hypertrophy by contractions or ventricular con- fected by respiration, which can voltage criteria only tractions on an ECG requires falsely indicate that the airman had • Low voltage in limb leads (may be a sign of obesity or hypothyroidism) the applicant to have a maximal a previous inferior infarction. So • Left axis deviation, less than or nuclear stress test. If this has been if you have a small R-wave with a equal to -30 degrees previously worked up, you do not deep S-wave in that lead, and even perhaps in lead aVF, you need to • rSR’ in leads VI or V2, ORS interval need to provide a new evaluation. less than 0.12 msec R>S wave in perform an ECG in inspiration 5. If the airman demonstrates new VI without other evidence of right and again in expiration. If the onset of complete RBBB (right ventricular hypertrophy S-wave disappears and you get a bundle branch block); in other • Sinus arrhythmia larger R-wave, you can clear the words, this has not been seen on • Sinus tachycardia: Any age — if the airman—but don’t forget to pro- heart rate is less than 110 previous graphs, then you are to vide us all these graphs. • Left atrial abnormality have the airman undergo a maximal • Short QT nuclear stress test. Note: All stress 10. An airman who has ST- and T-wave testing in first- and second-class changes that suggest ischemia or Note: If a first-class airman does airmen should be maximal nuclear left ventricular hypertrophy re- not have a current resting ECG on file but we have any type of stress stress testing (unless we specify quires an evaluation if one has not been previously performed for this test (pharmaceutical stress, Bruce otherwise in our letter to you). stress, nuclear stress, or stress echo- reason. These situations require a 6. An airman who has an incom- cardiogram) that was accomplished cardiovascular evaluation, perhaps plete RBBB pattern on previous within the last year, we can accept an echocardiogram, and definitely without writing out for a current electrocardiograms, and then a maximal nuclear stress test. resting ECG; however, we do need demonstrates a complete RBBB, the tracings from any of these tests. does not require an evaluation. A cardiac cath and a Holter monitor test are not acceptable in place of a resting ECG.

6 T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 50, No. 3 • PTSD from page 5 Under Title 14 of the Code of Federal References Regulations (CFR) parts 67.107, 67.207, 1. American Psychiatric Association. Diag- flashbacks. He also admits to drinking and 67.307, (c) No other personal- nosis and statistical manual of mental heavily on and off in the years since ity disorder, neurosis, or other mental disorders, DSM-IV, 4th ed. Washington, the event. Currently, he does not drink condition that the Federal Air Surgeon, DC: APA; 1994. alcohol. He is divorced. He currently based on the case history and appropri- 2. U.S. Department of Veteran’s Affairs. has a 30% disability rating for PTSD ate, qualified medical judgment relating “What is PTSD?” obtained 3/10/11 from the Veteran’s Administration. His to the condition involved, finds: from National Center for PTSD at psychiatric exam is notable for anxious 1. Makes the person unable to safely www.ptsd.va.gov/ affect but is otherwise normal. perform the duties or exercise the 3. Takla NK, Koffman R, Bailey DA. privileges of the airman certificate Combat stress, combat fatigue, and Aeromedical Concerns applied for or held; or psychiatric disability in aircrew. Aviat The primary aeromedical concern for 2. May reasonably be expected, for Space Environ Med 1994; 65:858-65. this case is that the airman’s ongoing the maximum duration of the 4. Airline Pilots Association, International. symptoms of PTSD could compromise airman medical certificate applied Critical Incident Response Program his ability to safely operate an aircraft. for or held, to make the person description. Retrieved March 8, 2011 Specifically, his symptoms such as unable to perform those duties or from http://fdx.alpa.org/Committees/ CIRP/tabid/3205/Default.aspx. flashbacks and anxiety could decrease exercise those privileges. his ability to focus and concentrate on In this context, PTSD would be 5. Aeromedical Consultation Service. safely piloting and could be acutely considered a “neurosis or other mental United States Air Force Waiver incapacitating in the cockpit. Substance condition” (in part c). Any airman with Guide. Retrieved March 8, 2011 from http://airforcemedicine.afms. abuse associated with PTSD and fatigue a history of ongoing PTSD symptoms mil/waiv­ erguide. resulting from nightmares may also or a history of PTSD should be deferred compromise safe flying. to the FAA for further consultation. 6. McDonald, Tony. Email correspondence dated 3/11/11. Naval Aerospace Medi- In addition to this airman’s symp- cine Institute Psychiatry Department, toms, other symptoms of PTSD could Outcome Pensacola, Florida. also affect flight safety. These include The aerospace medicine residents 1) numbing of general responsiveness, discussed the case and decided more About the author which could slow reaction times, 2) information was required regarding Lieutenant Commander Nathaniel B. avoidance, which could affect behavior this applicant: specifically, additional Almond, MD, MPH, is a United States Naval to make correct decisions, and 3)an evaluation of alcohol use and neuro- flight surgeon who is board certified in General autonomic hyper-arousal state, which psychological testing, as well as original Preventive Medicine and Public Health. He could also degrade concentration, documentation of the diagnosis of is currently a resident in Aerospace Medicine situational awareness, and the ability PTSD. The FAA denied the certificate at the Navy’s Aerospace Medicine training program at Naval Air Station Pensacola, to manipulate controls. Anxiety might until these documents are provided for Florida. This report was written while rotating also originate as a fear of flying (5,6). further evaluation. If the applicant does at the FAA’s Civil Aerospace Medical Institute. indeed have ongoing PTSD symptoms, he would not receive a certificate. Q

Biennial Survey of Pilot Satisfaction Initiated By Katrina Avers, PhD

he Office of Aerospace Medicine Government Performance and Results feedback that will affect all pilots. We Tis mailing invitations this month Act of 1993. The information obtained hope to get a large response so that we to a randomly selected sample of pilots is used to evaluate the degree of customer can get meaningful data to share with to complete a survey regarding their satisfaction with Aerospace Medical you in a future issue. experiences and satisfaction with the Certification Services, identify areas airman medical certification process. in which the FAA may improve its Dr. Avers is a research psychologist in the The survey is a biennial survey we services to airmen, and assess change in Civil Aerospace Medical Institute’s Aerospace Human Factors Research Division. administer to be in compliance with customer satisfaction as a result of those Executive Order No. 12862, “Setting improvements. Invitees are in a unique Q Customer Service Standards,” and the position to provide the FAA valuable

T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 50, No. 3 • 7 Transverse Myelitis Etiology of Transverse Myelitis Case Report Transverse myelitis is a relatively rare neurological disorder caused by inflam- by Jonathan F. Stinson, MD, MPH mation of the spinal cord, creating a demyelinating lesion, typically involving both sides of the cord, hence its transverse or bilateral nature. These lesions Transverse myelitis is a rare are usually at one level only but can occasionally exist at multiple levels. The but potentially debilitating resulting inflammation damages or destroys myelin, compromising conduction between the brain and muscles or sensory organs distal to the lesion. Symp- neurological condition caused by toms of transverse myelitis can evolve over several hours to as long as several spontaneous, usually idiopathic weeks. It often begins as a sudden onset of lower back pain, muscle weakness, inflammation of both grey and or abnormal sensations in the toes and feet. However, it can rapidly progress white matter of the spinal cord. to more severe symptoms, including paralysis, urinary retention, and loss of bowel control. Diagnosis is made by clinical history, physical findings, and a This case report evaluates an spinal cord lesion seen on MRI. Some patients may recover from transverse airline pilot with this disorder myelitis with minor or no residual problems, while others suffer permanent and the requirements necessary to impairments that affect their ability to work or even carry out activities of return the airman to flying. daily living. The majority of cases involve single episodes, but some can have a recurrence of symptoms.(1) History It is estimated that about 1,400 new cases of transverse myelitis are diagnosed each year in the United States, and approximately 33,000 Americans have some his case involves a 53-year-old type of disability resulting from the disorder. It can occur in all age groups, airline pilot with approximately T but peaks occur in the 10-19 and the 30-39 age ranges. There appear to be no 16,000 hours, who was in his usual state inherited, ethnic, or gender differences in incidence. One study estimated the of good health prior to this incident. incidence to be about 4.6 cases per million per year.(2) He was admitted to the hospital with Transverse myelitis can have many different etiologies. It is thought that about symptoms of progressive loss of light 45% are parainfectious or related to infections. Infectious agents suspected of touch, vibratory, and position sense, causing transverse myelitis include varicella zoster, herpes simplex, cytomegalo- starting in his feet and working its way virus, Epstein-Barr virus, influenza, echovirus, human immunodeficiency virus, up to the level of the chest, including hepatitis A, and rubella. Bacterial skin infections, otitis media, Lyme disease(5) upper extremities from hands to mid and Mycoplasma pneumoniae have also been associated with the condition. forearm. He had no signs of muscle In the United States, up to 21% of cases can be a presenting sign of multiple weakness or reflex abnormalities. sclerosis.(4) It is also recognized as a complication of some autoimmune dis- A cervical MRI revealed a 6-mm eases such as systemic lupus erythematosus, Sjögren’s, or sarcoidosis, (7) post- ­lesion of the posterior part of the cervical infectious myelopathy, spinal cord infarct, and neuromyelitis optica.(2) Some spinal cord at the C5-6 level with some cases can be the result of spinal cord infarct or be a presenting sign of multiple sclerosis. In about 21% of cases, the etiology remains unknown, even after a surrounding edema and swelling of the (3) cord at that level. MRI of brain and tho- long-term follow-up. racic cord was normal. Cerebrospinal Treatment is dependant on determining a specific etiology and may be directed fluid showed no evidence of inflamma- at an underlying infectious etiology, if discovered. Generalized treatments such tion, with no white cells and a normal as corticosteroids are of use in cases secondary to the autoimmune disorders, protein of 54 mg/dl. Immunological but there is some debate over their effectiveness in idiopathic acute transverse myelitis. studies were normal, as was an IgG index and 24-hour IgG synthesis rate. There were no oligoclonal bands seen, and CFS and Lyme disease antibodies Neurology follow up at six months submission of MRI cervical spine results were negative. Serum B-12, folic acid, revealed a stable neurological exam, and a satisfactory current status report. and ESR were all normal. with only the residual sensory deficits The airman was admitted to the noted before. His MRI showed im- Aeromedical Concerns hospital and treated for five days with provement, with decreasing gadolinium These can be divided into three high-dose IV methylprednisolone, 1gm enhancement of the C5-6 lesion and no categories: acute disease concerns, daily, followed by a six-day taper. At evidence of new lesions. After reviewing prognostic concerns about the risk of the time of discharge, all symptoms his case, his aviation medical examiner recurrence, and concerns about residual resolved, with the exception of residual deferred for special issuance, which was disability. numbness of the fourth and fifth digits granted for 12 months contingent upon of both hands. Continued on page 9

8 T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 50, No. 3 • Transverse Myelitis from page 8 Residual Disability Concerns. References Recovery from transverse myelitis usu- 1. National Institute of Neurological Acute Concerns. Acutely, the condi- ally begins between two and 12 weeks Disorders and Stroke (accessed 13 tion is obviously disqualifying under March 2010) www.ninds.nih.gov/ following onset of symptoms and may disorders/transversemyelitis/detail_­ Title 14 of the Code of Federal Regula- continue for up to two years in some transversemyelitis.htm. tions parts 67.109, 67.209, and 67.319, patients, many of whom are left with 2. Berman M, Feldman S, Alter M, Zilber where it states neurologic standards are: considerable disabilities. Approximately N, Kahana E. Acute transverse myelitis: (a) No established medical history one-third will recover, with minimal Incidence and etiologic considerations. or clinical diagnosis of any of... (3) to no disability; about one-third with Neurol 1981;31:966-71. A transient loss of control of nervous have significant residual recovery, and 3. Rafailidis PI, Mourtzoukou EG, Var- system function(s) without satisfactory the remainder will never show signs of bobitis IC, Falagas ME. Severe cyto- medical explanation of the cause. recovery. Following stabilization, the megalovirus infection in apparently (b) No other seizure disorder, distur- immunocompetent patients: A system- airman must be assessed by a neurologist atic review. Virol J 2008 Mar 27;5:47. bance of consciousness, or neurologic for residual deficits and, if significant, condition that the Federal Air Surgeon, 4. Jeffery DR, Mandler RN, Davis LE. medical flight testing may need to be Transverse myelitis. Retrospective analy- based on the case history and appropri- considered. A Statement of Demon- sis of 33 cases, with differentiation of ate, qualified medical judgment relat- strated Ability may need to be issued. cases associated with multiple sclerosis ing to the condition involved, finds… and parainfectious events. Arch Neurol (1) Makes the person unable to safely Outcome 1993 May;50(5):532-5. perform the duties or exercise the privi- This airman was fortunate to have a 5. Walid MS, Ajjan M, Ulm AJ. Subacute leges of the airman certificate applied reversible case of idiopathic acute trans- transverse myelitis with Lyme pro- for or held; or (2) May reasonably be verse myelitis. He was effectively treated file dissociation. GMS Ger Med Sci 2008;6:04. expected, for the maximum duration of with corticosteroids, and his symptoms the airman medical certificate applied 6. Pandit L. Transverse myelitis spectrum rapidly disappeared. Six months after disorders. Neurol India 2009 Mar- for or held, to make the person unable the incident, he had only minimal Apr;57(2):126-33. to perform those duties or exercise those intermittent numbness of his fourth 7. Kovacs B, Lafferty TL, Brent LH, De- privileges. Essentially, airmen need to and fifth digits, no loss of strength, or Horatius RJ. Transverse myelopathy have full control of sensory and motor any other neurological symptoms. He in systemic lupus erythematosus: An function to safely operate an aircraft. was found ineligible for medical cer- analysis of 14 cases and review of Prognostic Concerns. Once the tification under 14 CFR parts 67.113, the literature. Ann Rheum Dis 2000 condition has resolved or stabilized, the 67.213, and 67.313 but was granted an Feb;59(2):120-4. Review. concern is directed to the likelihood of authorization for special issuance for recurrence and what, if any, residual one year. This was contingent upon About the Author disability is present. Up to 21% of idio- meeting the maintenance requirements CAPT Jonathan Stinson, MD, MPH, is a pathic acute transverse myelitis cases in of his current medical certification and U.S. Navy flight surgeon board certified in the U.S. may be the presenting sign of Family Medicine and Aerospace Medicine, and providing a current status report from is currently on active duty in the U.S. Navy. multiple sclerosis, which implies a high his neurologist, including interim his- He was a resident at the Naval Aerospace likelihood that neurological symptoms tory, prognosis, follow-up plan, medica- Medicine Institute in Pensacola, Fla., when will recur. If multiple sclerosis has tions (including type, dosage, and side he wrote this article and is currently serving as been ruled out, the risk of recurrence effects), current MRI of the cervical Senior Medical Officer aboard USS Ronald is very low. spine, and the results of any other studies Reagan CVN76. that are deemed appropriate. Q

T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 50, No. 3 • 9 Back To Basics: (LAD) was 100% occluded, with his of Federal Regulations (CFR) 67.111, 14 Cardiovascular Disease distal myocardium supplied solely by CFR 67.211, and 14 CFR 67.311, respec- collateral circulation. Additionally, his tively. Stents are dealt with in a similar and Stenting right coronary artery (RCA) had a 40% fashion as myocardial infarctions, coro- Case Report, by lesion. Therefore, an angioplasty was nary angioplasty, and coronary artery Valerie Johnson, MD, MPH performed, and a drug-eluting stent was bypass graft. A six-month post-event inserted into his LAD. This procedure recovery period is necessary before Introduction was performed about 11 months ago. consideration can be made by Medical Coronary artery disease (CAD) is a He had an unremarkable recovery and Appeals. The airman needs to provide significant cause of death and perma- is back to walking/running 2-3 miles a the hospital admission and discharge nent disability in America. This con- day, 5-6 days a week. His medications summaries, cardiac catheterization dition may have an insidious onset include ramipril (Altace), clopidogrel report, and any operative reports from (Plavix), Aspirin, atorvastatin (Lipitor), whatever corrective surgical procedure but will most certainly always prog- and esomeprazole (Nexium). is performed. ress to become symptomatic or precipi- The month prior to his presentation Required information includes a tate a cardiac event. Treatment entails to his AME’s office, the airman com- current status report from the treating medical therapy alone or a combina- pleted a maximal-graded test without physician. This should address a current tion of revascularization procedures exercise-induced symptoms and normal performance assessment of the airman, and medications. This report will re- exercise ECG response. He achieved as well as an estimate of his exercise view the case of an airman with CAD 100% of his predicted maximum heart program and capacity. It should com- who underwent a percutaneous trans- rate, and his left ventricular ejection ment on the modifiable risk factors for luminal coronary angioplasty with fraction (LVEF) was 62%. His status coronary heart disease such as smoking stent placement; and the subsequent report from the cardiologist and labs history, diet, physical inactivity, obesity, ramifications on flight safety of this were favorable. A requirement for all presence of hypertension, diabetes, and condition. first- and second-class airmen is to hyperlipidemia. Weight, height, (BMI), provide the FAA with a six-month post- and blood pressure measurements event treatment coronary angiogram. should also be indicated. Background In the current case, the airman had A current list of medications with 46-year-old commercial pilot a catheterization that demonstrated a any explanation for changes in doses Apresents to his aviation medical patent LAD stent and no progression or drugs should also be forwarded. examiner (AME) for his annual second- of the RCA disease. The airman asked Any laboratory data related to this class medical exam. He has flown over his AME if this medical history and condition is required for submission; 8,000 hours and has been healthy until evaluation were acceptable to the FAA this list will include the following at a a year ago, when he felt burning and and whether he would be allowed to minimum: fasting blood sugar, total pressure in his chest while working in continue with his primary occupation. cholesterol, LDL/HDL cholesterol, his backyard. His symptoms continued and triglycerides. For third-class medi- intermittently over the weekend and Aeromedical Concerns and cal certification, a maximal stress test did not seem to improve with rest. He Role of the AME (Bruce protocol) must be performed. has been an avid runner most of his The aeromedical concern related to Ideally, this test should be completed adult life and his medical history is coronary artery disease is the possibility to 100% of the airman’s predicted significant only for hyperlipidemia for of a severely incapacitating event that maximal heart rate. 12 years. He was seen by his primary would gravely impact the performance For first- and second-class airmen, a physician and was initially treated for of flying duties.3 This may manifest maximal nuclear stress test is required. gastroesophageal reflux. However, his as sudden cardiac death, myocardial Extenuating circumstance precluding chest pressure and burning did not infarction, angina, or ventricular dys- adherence to these guidelines may be completely abate over the next 6 weeks; rhythmias. The occurrence of such considered on a case-by-case basis. Note hence, he was finally referred to a cardi- catastrophic events, both in a single- that the Aerospace Medical Certifica- ologist. His family history is significant piloted plane or commercial aircraft, tion Division will require the airman for hypertension, hyperlipidemia, and could result in dire consequences on to submit all of the ECG tracings for diabetes in his parents who are both the airman’s health and on public safety. inclusion in their AMCD medical case still alive at age 74. Coronary artery disease is disqualify- file (W. Silberman, personal commu- During his cardiology evaluation, ing for first-, second-, and third-class nication March 18, 2010). his left anterior descending artery medical certificates per Title 14 Code Continued

10 T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 50, No. 3 • Outcome Etiology of Cardiovascular Diseases After the airman and his AME com- pleted all the requirements listed above, Cardiovascular diseases (CVDs) continue to be a leading cause of death in the United States, according to the American Heart Association.1 In fact, CVDs his case was processed. He subsequently have accounted for more deaths annually than any other major cause of death received a Special Issuance authoriza- since 1900, except for 1918. In 2006, the U.S. prevalence of coronary artery tion, valid for 12 months. disease was 7.9% (17.6 million Americans), and CAD deaths were estimated Q at over 425,000. Airmen are required to possess a strict standard of health in References order to fly; hence, they may be considered to be healthier than the general 1. American Heart Association. 2010 population. However, it would be naïve to assume that they are immune to this Heart and stroke statistics: Up- insidious disease. Consequently, the significance of CAD in public health and date at-a-glance, 2010. www. aviation safety cannot be overlooked. Military and commercial aviation have americanheart.org/downloadable/ long recognized the role of sudden cardiac death as a (preventable) cause of loss heart/1265665152970DS-3241%20 of life and aircraft.2 Coronary artery disease is usually progressive; new lesions HeartStrokeUpdate_2010.pdf, accessed continually develop, and established lesions become narrower. Its true, natural March 16, 2010. history is not completely known because most diagnosed patients are treated 2. Strader Jr. JR, Gray GW, Kruyer WB. with medications or revascularization. Moreover, the data to predict the natural Clinical aerospace cardiovascular medi- history of aviators with CAD are lacking. However, compared with the general cine. In: Davis JR, Johnson R, Stepanek population, airmen are typically healthier, are less symptomatic, and have fewer J, Fogarty JA, eds. Fundamentals of risk factors. Aeromedical dispositions for CAD are based on clinical popula- aerospace medicine. Philadelphia: Lip- tion data and may not be completely applicable to aviators. There are studies pincott, Williams, & Wilkins, 2008: that show that the severity of the anatomic CAD strongly predicts survival and 318-48. other clinical events.2 This fact allows for regulatory bodies to consider aviators 3. Kruyer WB. Cardiology in: Rayman with varying degrees of CAD to maintain their licenses, albeit often restricted. RB, ed. Clinical aviation medicine, 4th ed. New York: Professional Publishing The risk of recurrence of a cardiac event that would compromise the safety Group Ltd, 2006: 147-276. of the airman and the safety of the public should be considered each time a 4. Oswald S, Miles R, Nixon W, et al. Review medical certification is requested by the affected flyer. Epidemiologic studies of cardiac events in USAF aviators. Aviat and long-term follow-up of healthy civilian personnel, as well as patients with Space Environ Med 1996; 67:1023-7. normal coronary arteries, as evidenced by angiography, have been performed 3 5. Cutlip DE, Chhabra AG, Baim DS, et and have established 10-year annual coronary event rates of up to 0.65%. A al. Beyond restenosis: Five-year clini- review of healthy USAF aviators revealed a five-year yearly coronary event rate cal outcomes from second-generation of 0.15% in the oldest age group (45-54 year-olds).4 These “normal” rates may coronary stent trials. Circulation 2004; then be compared to those airmen with CAD in an attempt to estimate their 110:1226-1230. risk. Moreover, a five-year study of second-generation stents identified factors 6. Waddel GA, Kruyer WB, Van Syoc such as the presence of diabetes and multivessel disease as predictors of both D. Condition: Coronary artery re- restenosis and non-restenosis events. Five-year mortality was predicted by older vascularization. In: USAF Aerospace age, reduced LVEF, and length of index lesion.5 Some of these variables can be Medicine Waiver Guide, updated followed as potential markers of disease progression. December 2008. https://kx.afms.mil/ kxweb/­dotmil/file/web/ctb_071052. Several modalities can be used to manage patients with CAD. This report will pdf, accessed March 15, 2010. only comment on revascularization. Coronary artery revascularization procedures 7. Barnett SL, Fitzsimmons PJ, Kruyer include percutaneous coronary intervention (PCI, catheter-based techniques WB. Coronary artery revascularization such as angioplasty and stent insertion) and coronary artery bypass graft surgery in aviators: Outcomes in 122 former (CABG). These methods are considered palliative due to the progressive nature military aviators. Aviat Space Environ of CAD. In cases of successful revascularization after short-term follow-up (6- Med 2003; 74(4): 389 – abstract for 12 months), future cardiac events will likely result from progression of CAD 2003 meeting. in another vessel. Novel, clinically significant lesions (>50% occlusion) may About the Author develop at other sites at annual rates of 7-15% within two years of interventional Lt Col Valerie Johnson, MD, MPH, is a procedure.6 In a USAF database, 122 former military aviators who underwent Flight Surgeon serving in the United States revascularization without prior cardiac events were followed for occurrence of Air Force. She is currently completing the an additional event. Approximately half underwent a PCI (mostly angioplasty), USAF’s Residency in Aerospace Medicine in and the other half received a CABG. No cardiac deaths were observed within the USAF School of Aerospace Medicine at five years, and only two developed a myocardial infarction (both past two-year Brooks City-Base in San Antonio, Texas. This follow-up). After the exclusion of repeat revascularizations within six months case report was written during her rotation at of the index event, the average annual event rates were 1.0%, 2.7%, and 3.6% the FAA’s Civil Aerospace Medical Institute. per year, at one, two, and five years, respectively.7

T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 50, No. 3 • 11 Wallenberg’s Syndrome Wallenberg’s Syndrome Case Report, by Wallenberg’s syndrome is a neu- John J. Venezia, DO, MPH rological condition caused by a brain stem stroke. This is also Abstract History called lateral medullary infarction Wallenberg’s syndrome is a 46-year-old male pilot applied or posterior inferior cerebellar for a second-class medical certi- artery infarction. It is due to a neurological condition caused by a fication. During the year before disruption of the flow blood brain stem stroke. It is also known A through the vertebral or posterior requesting certification, he visited a as lateral medullary infarction hospital with the single complaint of inferior cerebellar artery. This can by a thromboembolic event vertigo. Magnetic resonance imaging or posterior inferior cerebellar or the dissection of the artery artery infarction. The constellation (MRI) was accomplished but did not through aneurysm or trauma.2 reveal any abnormal lesions. The next of presenting symptoms helps The symptoms that manifest are day, he went to another hospital with a result of where the disruption to identify the location of the the same complaint, but now his symp- of blood flow occurs and can infarction. Imaging is vital to toms included left facial numbness and include: the diagnosis and cardiovascular swallowing disturbance. In addition to Symptoms the numbness, he had sensation of heat ■■Vestibulocerebellar vertigo, investigations are as essential as on the left side of the face. He had no difficulty sitting/standing due to they are with any stroke patient. significant medical history or noted pulling sensation, tilting or swaying, Treatment is based on the relief trauma. On physical exam, he had hypotonia of the upper extremity, nystagmus to the right and deviation blurred vision/diplopia, nystagmus of symptoms, which can include (very common, especially in patients of the uvula to the left. There was no a wide array of therapies from complaining of vertigo), or limb ataxia deviation of his tongue. His left finger- invasive to rehabilitative. The (usually ipsilateral to the lesion). to-nose test was poor. His left-sided ■■Sensory pain or unpleasant feel- size and location of the lesion ataxia-induced gait disturbance made ing in the face (heat sensation), loss of affects the prognosis, which may tandem gait testing impossible. His pain and temperature in the contralat- have transient to long-lasting muscle strength was reported as normal. eral trunk/limbs due to spinothalamic MRI showed a high intensity region, tract damage, and decreased corneal neurological effects. Aeromedical indicating a tiny infarct lesion in the reflex ipsilaterally. considerations are based on dorsolateral aspect of the left medulla ■■Bulbar Muscle Weakness: af- recovery from neurological deficits oblongata. Magnetic resonance angio- fecting nucleus ambiguous resulting in paralysis of ipsilateral plate, phar- that would negatively affect safe gram showed a string-shaped stenosis of the region of the proximal portion ynx, and/or larynx manifesting as aviation. dysphagia or dysphonia, contralateral of the left posterior inferior cerebellar uvula deviation. artery (PICA) with the periphery of the ■■Autonomic Dysfunction: left PICA fed by retrograde pooling from Horner’s syndrome ipsilaterally; the anterior inferior cerebellar artery. cardiogenic effects to include tachy- He was diagnosed with Wallenberg’s cardia, orthostatic hypertension, and/ syndrome. He was treated conserva- or intermittent bardycardia.3,4 tively and released 10 days later with Diagnosis ataxia and swallowing disturbances Correlation of signs and symptoms fully recovered. Six months later, he with imaging studies. had a normal otoneurologic exam and Treatment a follow-up MRI that was negative for Relief of symptoms and rehabilita- new lesions. However, residual left facial tion to recover function and/or deal with neurologic loss. numbness continued up until the time Prognosis of medical certification application. Dependant of the size and location of the area of the brain stem damaged by the stroke. It can be transient or it can be a neurological deficit that last years.2

Continued 12 T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 50, No. 3 • Aeromedical Issues be incompatible with safety in aircraft References As with all pathophysiological condi- operation because of long-term unpre- tions, the primary aeromedical concern dictability, severe neurological deficit, 1. Federal Aviation Administration (2011) 1 Item 46. Neurologic Part III aerospace is the risk for incapacitation (sudden or psychological impairment.” It is the medical disposition. Office of Aerospace or subtle) during flight, creating an unpredictability of this condition that Medicine Guide for Aviation Medical unsafe aviation environment. The air- requires a more extensive workup be Examiners. FAA. www.faa.gov/go/ man’s continued neurological deficit is accomplished following an adequate ameguide. concerning in this particular case. Title recovery period. In most cases involving 2. National Institute of Health (NIH). 14 of the Code of Federal Regulations, stroke, a two-year recovery period from National Institute of Neurological Dis- part 67, Item 46 (Neurologic) states, neurologic deficits is required before orders and Stroke (NINDS). NINDS “Symptoms or disturbances that are consideration for an airman medical Wallenberg’s syndrome information secondary to the underlying condition certificate. page. www.ninds.nih.gov/disorders/ wallenbergs/wallenbergs.htm. Accessed and that may be acutely incapacitating A complete neurological evaluation on 12 Mar 2011. include pain, weakness, vertigo or in must be provided at the end of this re- coordination, seizures or a disturbance covery period. Considerations are more 3. Caplan, Loius R. Posterior circulation of consciousness, visual disturbance, or likely to be in favor of the airman if the ischemia:Then, now, and tomorrow. 1 The Thomas Willis Lecture-2000. mental confusion.” cause could be identified and success- Stroke 2000; 31:2011. Although this airman’s residual fully treated. paresthesia might not be specifically 4. Caplan, Louis R. Posterior circulation cerebrovascular syndromes. Up-To Date. included in the above statement, his Outcome 2011. www.uptodate.com/contents/ persistent deficit could still be aeromedi- The case was reviewed and issued posterior-circulation-­cerebrovascular- cally hazardous. Non-incapacitating a Final Denial due to transient loss of syndromes?source=search_ neurological deficits can be just as nervous system function that is not result&selectedTitle=1~10#H7. dangerous in-flight if it is distracting resolved. Reconsideration may be given Accessed on 13 Mar 2011. from safe operation of the aircraft and if current full neurologic and cardio- needs to be considered. The AME Guide vascular exams are provided two years Q also states, “chronic conditions may from the time of incident. About the Author John J. Venezia, DO, MPH, CPT, USA, MC, FS, was a Resident in Aerospace Medicine when he wrote this report while rotating as a Resident in Aerospace Medicine at the FAA’s Civil Aerospace Medical Institute. He has recently completed a residency in Occupational Medicine and is currently serving at the United States Army School of Aviation Medicine.

Form 8500-8 Phase-Out Deadline Approaching By Brian Pinkston, MD s a reminder, MedXPress will be • Reduced filing—there is no require- • Improved visibility–as soon as the Amandatory for airmen to use after ment for the AME to keep a copy application is imported into MedX- 1 October 2012. Currently, more than of the Form 8500-8 or the medical Press, the FAA can see that an exam 43% of all medical applications are certificate information since it is kept has started. This provides coverage being conducted using MedXPress, in the Aerospace Medical Certifica- for the airman on ramp checks, as and users are enjoying the ability to tion Subsystem (AMCS). opposed to the paper system. In the review their applications for medical • Decreased AME errors—an AME latter case, the AME could issue a cer- certificates with their AMEs prior to cannot inadvertently issue a certifi- tificate that may not be visible by the the aviation medical examination visit. cate for an airman who may have a FAA until the AME has completed Using the summary page provided by recent exam pending or have an the exam in AMCS. MedXPress to the airman, the aviation administrative action that would Further information for airmen is medical examiner can let the airman preclude immediate issuance. available in the online MedXPress bro- know what type of information may be • Increased communication– he chure, located at www.faa.gov/pilots/ needed for the appointment in order to communication between AME and safety/pilotsafetybrochures/media/ expedite medical certificate issuance. airman is enhanced by the ability medxpress.pdf MedXPress provides four distinct to discuss the airman’s case before a Q advantages over the paper system: formal application is sent to the FAA. Dr. Pinkston manages the Aerospace Medical Education Division.

T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 50, No. 3 • 13 Aviation Medical Examiner Seminar Schedule FAA Civil Aerospace Medical Institute

2012 Seminars August 10–12 Washington, D.C. Neurology Theme (1) August 23–26 Berlin, Germany EUSAM (2) October 4–6 La Jolla, California CAMA (3) October 29–November 2 Oklahoma City, Oklahoma Basic (4) November 16–18 Denver, Colorado Ophthalmology-Otolaryngology-Endocrinology Theme (1) 2013 Seminars January 25–27 Tampa, Florida Cardiology Theme (1) February 25–March 1 Oklahoma City, Oklahoma Basic (4) March 15–17 Dallas, Texas Neurology Theme (1) May 13–16 Chicago, Illinois AsMA (5) July 15–19 Oklahoma City, Oklahoma Basic (4) August 9–11 Washington, D.C. Ophthalmology-Otolaryngology-Endocrinology Theme (1) September 26–28 Orlando, Florida CAMA (3) October 28–Nov. 1 Oklahoma City, Oklahoma Basic (4) November 15–17 Sacramento, California Cardiology Theme TENTATIVE (1) NOTES (1) A 2½-day theme aviation medical examiner (AME) seminar consisting of aviation medical examiner-specific subjects plus subjects related to a designated theme. Registration must be made through the Oklahoma City AME Programs staff, (405) 954-4831. (2) This seminar is sponsored by EUSAM, the European School of Aviation Medicine, and is sanctioned by the FAA as fulfilling the FAA and the JAA recertification training requirement. For more information and to register, see the EUSAM Web site: www.flugmed.org. Once there, click on EUSAM, then click on Refresher FAA/JAA (from the left menu). (3) 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. (4) A 4½-day basic AME seminar focused on preparing physicians to be designated as aviation medical examiners. Call your Regional Flight Surgeon. (5) A 3½-day theme AME seminar held in conjunction with the Aerospace Medical Association (AsMA). This seminar is a new Medical Certification theme, with 9 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. The Civil Aerospace Medical Institute is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.

14 T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 50, No. 3 •