American Osteopathic College of Occupational and Preventive Medicine OMED 2016 Didactic Sessions.

Disclaimer

The views expressed here are not This is Aerospace Medicine necessarily the views of the Department of Transportation or the Federal Aviation Presented by Chuck DeJohn, D.O., M.P.H., FAsMA Administration. Vice President, Education and Research Aerospace Medical Association

Overview Definition

• Aerospace medicine – the medical study of physiological and psychological Introduction disorders associated with atmospheric or Flight Environment space flight. Also called aviation Clinical Aerospace Medicine medicine. Operational Aerospace Medicine What’s Changing – PBR II

Brief History of Flight Medicine

• 1903 First powered flight Brief History of Aerospace Medicine o Wright brothers o Kitty Hawk, NC

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Brief History of Brief History of Flight Medicine Flight Medicine • 1915: Aviation • 1920s: US military medicine driven by realized need for WWI high losses of experts in aviation life due to physically medicine unfit pilots o 90% physiologic o Flights surgeon events/pilot error class of April 29, o 8% mechanical 1922 o 2% air-to-air combat o School led by Louis Bauer

Brief History of Brief History of Flight Medicine Flight Medicine • High visibility accidents and • 1925 Air Mail Act: Powered flight increased air traffic led to presented new physiologic Federal Regulations: Crash of TWA Flight 599, F-10 Trimotor, on demands such as altitude exposure. March 31, 1931 killed Notre Dame coach Knute Rockne o Part 61 Certification: Pilots, Flight Instruments and Ground Instructors o Part 67 Medical Standards and Certification o Part 91 General Operating And Flight Rules o Part 121 Operating Requirements: Domestic, Flag and Supplemental Operators o Part 135 Operations Requirements: Commuter and on-demand and rules governing persons on-board such aircraft

Aerospace Medicine Practitioners

• Address needs of all who work, recreate, and travel in Aerospace Medicine Practitioners the air, sea, and space • Trained in medicine, with special knowledge of operating in extreme environments of flight, undersea, and space • Uniquely equipped to make decisions on selection and retention of aviators, divers, and space mission and space flight participants.

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Aerospace Medicine Aerospace Medicine Practitioners Practitioners

Armed Forces across the globe • Aviation Medical Examiners (AMEs) Crew & Passenger Health Military Safety Policy Certification & Appeals • Trained, designated and supervised by the FAA

Regulatory Compliance Airline Aeromedical Examiner • Examine/certify civilian pilots Medical training & oversight FAA/DOT • Training provides an understanding of aviation related Departments Accident Investigation Evaluation & treatment : problems, physiology, standards, and administrative pathologic bubble Aerospace formation Medicine processes Physicians Osteo & soft tissue Astronaut selection & • One week course with mandatory refresher courses radionecrosis training Hyperbaric Space Wound Infections Medicine Agencies Clinical & basic science studies Thermal burns Space Development of Support to space agencies & Medical countermeasures Operations commercial space ventures Longitudinal Health

Aerospace Medicine Aerospace Medicine Practitioners Practitioners

• National Aeronautics and Space • Military Flight Surgeons Administration (NASA) Flight Surgeon • Caring for aviators and their families, manage Duties aerospace medicine and public health • Medical care for astronaut corps and their families programs within the military • Astronaut selection and mission training • Special training programs: • Develops physiologic countermeasures for spaceflight • Residency in Aerospace Medicine (RAM) • Research promoting a better understanding of medical issues associated with spaceflight environment

Aerospace Medicine Advanced Training in Practitioners (Non-Physicians) Aerospace Medicine

• Aerospace Experimental • Flight Nurses • Civilian Residencies Psychologists • Human Factors • University of Texas - Medical Branch • Aerospace Physiologists Engineers • Wright State University • Bioenvironmental • Industrial Hygienists • Civilian Fellowships Engineers • Radiation Health • Cognitive Psychologists Professionals • Mayo Clinic • Environmental Health • Systems Engineers • Military Residencies Professionals • US Navy • US Army • US Air Force

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Stressors of Flight

• • Barometric pressure changes • Dehydration The Flight Environment • Imobility • Vibration • Temperature extremes • Acceleration •

Cabin Altitude

• First pressurized high altitude passenger airliner The Flight Environment o 1939 Boeing 307 Hypoxia Stratoliner

Cabin Altitude Hypoxia

• The absence of an adequate supply of oxygen to the • Cruise altitude tissues, most significantly critical organs (brain, eyes, 25,000 – 51,000 ears, vestibular) to maintain normal physiologic function feet • Signs • Cabin altitude o Increased breathing rate, confusion, lethargy, loss of coordination 6500 – 8000 feet • Symptoms • Respiratory compromised patients could o Breathlessness, dizziness, headache, poor judgment, possibly be at risk for hypoxia lightheadedness, delayed reaction time, tingling, , drowsiness, loss of peripheral vision, euphoria

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Types of Hypoxia Hypoxic Hypoxia

• Hypoxic hypoxia • Caused by a decrease in the partial • Stagnant hypoxia pressure of oxygen due to an increase in • Hypemic hypoxia altitude o Occurs at the level of the lungs • Histotoxic hypoxia

Stagnant Hypoxia Hypemic Hypoxia

• Caused by mechanical pooling of the • Decrease in oxygen carrying capacity of blood blood POSITIVE G FORCE • Caused by o Smoke and fumes o Smoking o Anemia o S/P blood donation

Factors Affecting Histotoxic Hypoxia Hypoxia Tolerance • The inability of cells to take up or utilize • Not under physician • May be under oxygen from the bloodstream, despite the control physician control normal delivery of oxygen to cells and o Altitude o & drug use o Exposure time o Smoking tissues o Rate of ascent o Physical activity o Caused by drugs o Age o Illness & disease (cyanide), alcohol, carbon cell o Natural adaptation monoxide o Fatigue

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Use of Portable Oxygen Approved POCs Concentrators • Must be one of the 24 FAA approveddevices • AirSep FreeStyle • Invacare XPO • AirSep LifeStyle • Invacare Solo2 • Supply of fully charged batteries for no less than 150% for • AirSep Focus • Oxlife Independence the duration of the flight and ground connection time • AirSep FreeStyle 5 • Oxywell (Model 4000) • Extra batteries must be protected in carry-on baggage from • Delphi RS-00400 • Oxus RS-00400 short circuits and physical damage • DeVilbiss Healthcare iGo • Precision Medical EasyPulse • Inogen One • Respironics EverGo • Must be able to respond to the unit’s warning alarms • Inogen One G2 • Respironics Simply Go • May operate POCs while seated and when moving about • Inogen One G3 • SeQual Eclipse the cabin • Inova Labs LifeChoice • SeQual eQuinox (Model 4000) • Inova Labs LifeChoice Activox • SeQual SAROS • Must be properly stowed when not in use • International Biophysics • VBOX Trooper LifeChoice

Venous Thromboembolism (VTE) • Risk factors for the development of VTE o Immobility - flights greater than 4 h o Recent surgery o Recent trauma The Flight Environment o Abnormalities of blood clotting o Previous or family history of DVT Immobility and o Malignancy o Venous Thromboembolism o Estrogen: OC or HRT o Increasing age over 40 years o Chronic heart disease o Obesity o Chronic venous insufficiency

Venous Thromboembolism

• Prophylaxis o Increased mobility o Antiembolism stockings o Anticoagulation with low molecular weight The Flight Environment heparin (LMWH) or warfarin

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Airsickness Airsickness

• Caused by conflicting signals to the brain • Symptoms o Visual signal indicate no movement o Increased salivation and swollowing o Vestibular signals indicate movement o and vomiting o Conflicting signals result in nausea, and o Headache sometimes vomiting o Dizziness o Cold sweat o Drowsiness

Airsickness Airsickness

• Factors affecting airsickness • Prevention Diet: Low fat diet, breads, cereals, o Alcohol o vegetables, fruits o Illness • Treatment o Fatigue Natural: ginger-ale, foods with natural ginger o Stress o OTC: antihistamines () o Fear o o Prescription: Transdermal patch, , antivert

SCUBA Diving and Flying

• Compressed air is used during Self Contained Underwater Breathing (SCUBA) diving OXYGEN NITROGEN The Flight Environment TRACE Flying After Diving 80% 20%

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SCUBA Diving and Flying Diving and Flying

• As pressure increases during a dive nitrogen is dissolved in • Current recommendations from the blood Professional Association of Diving • Decompression illness (DCI) is caused when nitrogen Instructors (PADI) and Diver’s Alert dissolved in the blood comes out of solution forming Network (DAN) bubbles inside the body during depressurization (during climb) o Single dives - A minimum pre-flight surface o (DCS) - bubbles form in tissue and resulting interval of 12 hours local damage (i.e. joint pain) o Repetitive dives or multiple days diving - A o Arterial gas embolism (AGE) - bubbles enter the lung circulation, travel through arteries and cause remote tissue damage by blocking blood minimum pre-flight surface interval of 18 flow at a small vessel hours

Fitness to Fly & Return to Flight Status

• Screen passengers, aviators, astronauts, air traffic control personnel and divers o Pilots for risk of sudden in-flight incapacitation Clinical Aerospace Medicine for the duration of their medical certificate o Passengers for acute risk of an in-flight medical event for traveling in the near future

Pilots Fitness to Fly

• 15 Disqualifying Conditions (Without an SI) o Angina pectoris o Myocardial infarction o Bipolar disease o Permanent cardiac pacemaker o Cardiac valve replacement o Personality disorder that is severe o Coronary heart disease that has been enough to have repeatedly manifested treated or, if untreated, that has been itself by overt acts Operational Aerospace symptomatic or clinically significant o Psychosis o Diabetes mellitus requiring o Substance abuse Medicine hypoglycemic medications o Substance dependence o Disturbance of consciousness without o Transient loss of control of nervous satisfactory explanation of cause system function(s) without satisfactory o Epilepsy explanation of cause. o Heart replacement

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Operational Aerospace Civil Operational Aerospace Medicine Medicine • Civil Operations • Commercial air transport flight operations Deep vein thrombosis prophylaxis in • Military Operations o susceptible individuals • Medevac Operations oPotential for spread of infectious diseases • Search and Rescue Operations oEffect of cabin altitude on patients with • Diving and Hyperbaric Medical Operations respiratory complications • Aircraft Accident Investigation oEffect on electronic devices (pacemakers) oCircadian desynchronosis (west is best)

Physician Resources

Physician Resources

Physician Resources Physician Resources

Medical Considerations for Airline Travel Stresses of Flight Fitness to Fly and Medical Clearances FAA AME Guide Airline Special Services Airsickness Anemia In-Flight Medical Care Cardiovascular Diseases Reported In-Flight Illness and Death Decompression Illness Medical Considerations Before Deep Vein Thrombosis Diabetes International Travel Diarrhea Jet Lag Ear, Nose and Throat Radiation Fractures Neurology Ophthalmological Conditions Pregnancy and Air Travel Pulmonary Diseases Surgical Conditions Travel with Children

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Prior to PBR II

• All pilots were required to posses: o An FAA pilot’s Pilot Bill of Rights II certificate Signed into law July 15, 2016 ─ Ability to fly H.R. 636 (S. 571) o An FAA medical certificate issued by an AME ─ Medical fitness to fly

PBR II PBR II

• Private pilots who: • Physician checklist o Complete an online wellness course o Developed by the FAA o Posses a valid state driver’s license • Physician Attestation: “I certify that I discussed all items on this checklist with the individual during my o Can be cleared medically fit to fly by their examination, discussed any medications the individual is private physicians to operate aircraft: taking that could interfere with their ability to safely operate ─ Up to 6000 pounds an aircraft or motor vehicle, and performed an examina- ─ Up to 6 occupants tion that included all of the items on this checklist. I certify ─ Maximum airspeed 250 knots that I am not aware of any medical condition that, as ─ Maximum altitude 18,000 feet MSL presently treated, could interfere with the individual’s ability ─ Under IFR conditions to safely operate an aircraft.’’

After to PBR II After to PBR II

• Private pilots, flying covered aircraft, are required to posses: o An FAA pilot’s certificate ─ Ability to fly

o Private physician’s medical clearance, valid driver’s license and on-line wellness course ─ Medical fitness to fly

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After to PBR II After to PBR II

• Sen. James Inhofe is trying to eliminate the • Sens. Dianne Feinstein and Richard Blumenthal countered saying eliminating even the "moderate safety precaution" of physicians attestation requirement by having the doctor sign a statement that the pilot is fit to fly attaching it to a major defense spending bill "would leave pilots with the exclusive responsibility for coming to a medical judgment about their own fitness to fly, which we believe would represent an unacceptable risk to the safety of our airspace" • "Changes to civil aviation policy have no place in a military policy bill, recently negotiated compromises should not be re-litigated mere weeks after passage into law, and the safety of our airspace is too important to put at risk,"

Physician Resources PBR II

• FAA Checklist o 180 days from July • This is a very fluid situation 15, 2016 to develop • Stay tuned • FAA AME Guide o Available online

Surely, this is the end… Don’t call me Shirley!

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