Federal Air Surgeon's Medical Bulletin • Vol

Home , Guanadrel

Federal Air Surgeon’s Medical Bulletin Aviation Safety Through Aerospace Medicine Vol. 48, No. 3 For FAA Aviation Medical Examiners, Office of Aerospace Medicine Personnel, U.S. Department of Transportation 2010-3 Flight Standards Inspectors, and Other Aviation Professionals. Federal Aviation Administration

WAKE UP!! It was approximately 3:00 a.m., so Fatigue, Poor Sleep Affect Safety they were returning at the worst pos- By Fred Tilton, MD sible time with respect to their circadian rhythm cycle, and they were exhausted. 3 C EERTIFICATIONRTIFICATION UPPDATEDATE: ello, everyone, and welcome to They had configured the airplane for UNNACCEPTABLEACCEPTABLE MEEDSDS Hsummer. landing. The autopilot was engaged, and “Wake up!” is not what one wants to they were flying a coupled ILS approach. hear on the flight deck. The pilot told me he woke up when the 4 AAAMAM STTAFFAFF MEEMBERSMBERS REECEIVECEIVE A former airline pilot recently told me auto-throttles retarded at the beginning INNDUSTRYDUSTRY AWWARDSARDS this story about one of his missions. He of the final descent to the airport. and his crew were completing a round- He looked over to discover that his 5 LEETTERSTTERS TTOO TTHEHE EDDITORITOR robin trip with several intermediate stops copilot was fast asleep. that had taken up most of their crew Fortunately, the story has a happy duty day. This was the third day in a row ending. He yelled at his co-pilot to wake 6 CYYSTICSTIC FIIBROSISBROSIS ((CCAASESE REEPORTPORT) that he and his copilot had flown. They up, and they completed an uneventful had left their home domicile in the late landing. Everyone went home safely to afternoon, so they had been up several their families, and no one outside of the 8 AAMEME REESOURCESSOURCES hours before their departure. flight deck was ever aware of these events. Continued on page 2 8 SLLEEPEEP APPNEANEA BRROCHUREOCHURE PUUBLISHEDBLISHED In Memoriam Dr. Smith was both a Senior AME and Human Intervention Motivation Dr. Margaret Dennis Smith, a Study (HIMS) program sponsor for 8 MEEDICATIONSDICATIONS AANDND FLLYINGYING dedicated pilot and Aviation Medi- the Federal Aviation Administration. BRROCHUREOCHURE REEVISEDVISED cal Examiner since Her love of aviation was deep and com- 1994, tragically mitted. Dr. Smith found the time to passed away in a fa- make flying a significant part of her 9 OPPTICTIC NEEURITISURITIS ((CCAASESE REEPORTPORT) tal aircraft accident life. In many ways, she represented the involving her single- true spirit of American medicine. Her 1100 TRRANSIENTANSIENT GLLOBALOBAL AMMNESIANESIA IINN engine Cirrus SR22 extraordinary kindness and profes- AANN AIIRLINERLINE PIILOTLOT ((CCAASESE REEPORTPORT) on Monday July 5, sionalism have been a great benefit to

2010. She was pilot- Revock Jeff Photo by FAA the health and well-being of our pilot ing her plane on a trip from Plattsburgh, community. 1122 HEELLOLLO, AMEAMES! N.Y., to her home base in New Jersey, Dr. Smith was Senior Associate along with two other family members, Dean and Professor of Clinical Medi- 1122 A VVIATIONIATION MEEDICALDICAL EXXAMINERAMINER who also died in the accident. cine at New York Medical College, as SEEMINARMINAR SCCHEDULEHEDULE She was an accomplished rheu- well as the Program Director for Inter- matologist, educator, avid flyer and nal Medicine at St. Vincent’s Hospital talented AME. Few will impart to in Manhattan, N.Y. 1122 ORRDERINGDERING FOORMSRMS AANDND others as much as Dr. Margaret Smith. She was a distinguished physician, SUUPPLIESPPLIES MAADEDE EAASYSY Her devotion to her family, colleagues, professor, and program director for resi- patients, and airmen was immense. dents at St. Vincent’s Hospital. Continued on page 11 from page 1 WAKE UP I hope you will agree that fatigue is Obviously, a similar set of circum- a safety risk factor and that it is very stances could have ended in disaster. important to do all we can to mitigate The aviation community is well aware the risk. I hope that you will also agree that fatigue can be a major safety issue. that untreated OSA is a fatigue risk, and The Federal Aviation Administration there are probably a significant number has drafted a notice of proposed rule- of undiagnosed pilots who should be making on pilot flight duty and rest. receiving treatment. It has been forwarded to the Depart- Therefore, we have added an OSA ment of Transportation for review and lecture to the AME seminar curricu- clearance, and I expect that it will be lum, and we have developed an OSA published for comment in the Federal brochure (see article, page 8). In the By Fred Tilton, MD Register later this year. coming months, we will be giving OSA R e se a rc h i s a l so bei n g done to ident i f y increased emphasis. These are some of what else can be done to combat fatigue help to mitigate one cause of fatigue in the other things you may see: and make flying even safer. our pilot population. We are developing • Enhanced guidance for pilots, em- These projects are very important, initiatives to improve our ability to ployers, and physicians regarding and I am sure that they will help to en- identify and assure appropriate follow- the identification and treatment of hance the safety of the national airspace up for airmen who are suffering from individuals at high risk. in the future. obstructive sleep apnea (OSA). • Modification of the AME Guide to However, I want to let you know that Obstructive sleep apnea risk varies add a BMI calculator and to include the Office of Aerospace Medicine is with respect to gender, age, and body questions regarding risk factors and/ working on a project that I believe will m a s s i nde x ( BM I ) . It i s more c om mon i n or a history of OSA. males, and the more obese an individual • Addition of a BMI calculator to Federal Air Surgeon’s is the more likely he or she is to suffer the Airman Medical Certification Medical Bulletin from OSA. The evidence is clear that Subsystem. Library of Congress ISSN 1545-1518 OSA is markedly under-diagnosed and • Screening requirements for pilots at Secretary of Transportation therefore left untreated. high risk of OSA. Ray LaHood The National Transportation Safety • Required treatment and follow-up FAA Administrator Board has also cited several incidents for individuals with OSA. J. Randolph Babbitt where fatigue and OSA were considered I believe these initiatives are very Federal Air Surgeon to be contributing factors in incidents. important. You can help by taking a Fred Tilton, MD A preliminary literature review revealed: couple of extra minutes to assess your • Some of the high-risk criteria for pilots’ OSA risk. Ask them if they snore Editor Michael E. Wayda OSA are: obesity; new onset hy- or if they experience day time sleepiness. pertension or hypertension that is If they answer yes or if they are hyper- The Federal Air Surgeon’s Medical Bul- uncontrolled, or that requires two tensive and have a high BMI, it is pos- letin is published quarterly for aviation medical examiners and others interested or more medications for control; sible that they are suffering from OSA. in aviation safety and aviation medicine. and type 2 diabetes. Talk to them about OSA and consider The Bulletin is prepared by the FAA’s Civil • Loud snoring is an indicator of OSA. recommending that they see a specialist Aerospace Medical Institute, with policy • It is fairly easy to screen for OSA. for further evaluation. guidance and support from the Office of • OSA causes fatigue and daytime If it turns out they have OSA and Aerospace Medicine. An Internet on-line sleepiness. receive proper treatment, they will most version of the Bulletin is available at: www. faa.gov/library/reports/medical/fasmb/ Analysis of the Civil Aerospace Medi- likely come back and thank you because cal Institute 2009 medical certification they will feel so much better. Authors may submit articles and photos database indicates that 0.39 percent of And, who knows? it is possible that for publication in the Bulletin directly to: over age-20 pilots have a diagnosis of these simple measures may help to prevent Editor, FASMB OSA. So, it appears that there are a the next accident. FAA Civil Aerospace Medical Institute AAM-400 significant number of pilots with un- Thanks for “listening,” and thanks P.O. Box 25082 recognized OSA because the prevalence again for all you do for us and your Oklahoma City, OK 73125 of OSA in the general population varies airmen. E-mail: [email protected] from 2.0 to 7.5 percent. —Fred

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. 48, No. 3 • Policies Certification Update Bioaeronautical Sciences Research and Laboratory at the Civil Aerospace Information About Current Issues Unacceptable Medications Medical Institute, under the leadership of Dr. Dennis Canfield, is performing ince the most common error that research to see if they can determine an aviation medical examiner the most appropriate dosing interval. Smakes is placing an airman on In the meantime, we have changed a medication that is unacceptable, I this to five dosage intervals. In other thought I would spend the next several words, if the directions on the label say columns going over “policies” and spe- to take the medication every six hours, cific medications that are unacceptable the pilot should wait at least 30 hours to the FAA. after taking the last dose to fly. Those of you who have heard me Specific Medications speak at seminars know that when you By Warren S. Silberman, DO, MPH Antihistamines. Let’s begin our want to decide whether a medication discussion of medications with the is acceptable or not, you should first have asked about the medication or antihistamines. The FAA does not ac- consider the medical condition that treatment. cept the use of sedating antihistamines. caused the need for it. For example, if If we discover side effects that are We do not accept the use of Benad- an airman has osteoarthritic knees and incompatible with aviation duties after ryl (diphenhydramine) and Zyrtec the treating physician places the airman we accept a medication, we will re- (cetirizine), which are two of the more on Ultram (tramadol), this would not review our policy, check the computer c om mon ly pre scr ibe d d r u g s. We a l so do be acceptable. However, if the physi- d at a ba se to se e how m a ny a i r men of e ac h not accept Astelin (azelastine), which cian prescribed the non-steroidal anti- class reported taking the medication, is a nasal spray and interestingly, a inflammatory Naprosyn (naproxen), and perhaps even change the drug’s sedating antihistamine. We do accept that would be fine. My concern as an acceptance. A recent example is the the use of Claritin (loratadine) and AME would be: Does the airman have medication Chantix (varenicline), the Clarinex (desloratadine), which are the range of motion and strength to non-nicotine drug used for smoking ces- non-sedating. Even though we realize manipulate the rudder controls? sation. When the news broke that some that informing the airman not to take Another guideline you should con- Chantix users had demonstrated unde- his/her sedating antihistamine for five sider is that, unless the medication is in a sirable behavioral changes—hostility, dosing intervals (to be legally able to category of medications that we already agitation, depressed mood, suicidal fly) may be the improper treatment for accept, a medication in a new category thoughts or actions—while using the a particular condition, we would accept or even a medication that has a slightly medication to help them quit smoking this statement in block #60 of the FAA different mechanism of action that has and that some people had these symp- medical exam. That is, if we see that some different side effects will not be toms when they began taking Chantix, the airman is taking an unacceptable considered by the FAA until one year and others developed them after several medication but the AME noted in Block after Food and Drug Administration- weeks of treatment or after stopping 60 of our exam form that the airman approval. So, for example, consider beta- Chantix, we convened our Pharmacy was informed not to take the medication blockers. If a new one were approved by and Therapeutics Committee. The for let’s say 48 hours prior to flight, we the FDA, more than likely it would be group agreed that these effects were not would not deny the airman for tak- acceptable and allowed upon release. compatible with the safet y of f light and ing an unacceptable medication. This We want to see what the effects of a notified all the airmen that were taking disclaimer only applies to antihistamines. medication are on the general popula- Chantix to cease its use or not fly while Selective serotonin reuptake tion before considering it for approval. they were undergoing withdrawal. inhibitors. I hope everyone has The FAA will not approve a medica- Dosing Interval become familiar with our new pol- tion just at the request of a pharma- One last policy point. Up until icy on antidepressant medications ceutical company. We will consider a the past year, if an airman had taken (www.faa.gov/licenses_certificates/ new medication if we start seeing its an unacceptable medication, we rec- medical_ certification/specialissuance/ use in our aviators or if one of the pilot ommended waiting for two dosage antidepressants/). We currently only advocacy organizations requests our intervals before flying. We are now will allow the long-term use of four review because some of their clients reviewing our policy. Our exceptional SSRI medications. They are Prozac (fluoxetine), Zoloft (sertraline), Celexa Dr. Silberman manages the Aerospace Medical Certification Division. Continued on page 4

The Federal Air Surgeon's Medical Bulletin • Vol. 48, No. 3 • 3 Certification Update from page 3 Lomotil (diphenoxylate and atropine). The medication (citalopram), and Lexapro (escitalopram). The airman will Imodium (loperamide) is acceptable, but please inform us have to request special issuance and provide the FAA with why the medication is being used, especially if the airman is a workup, as described at our Web site (above). An airman taking more than two tablets a day. This would be another may still be able to fly 90 days after discontinuing the use example of the condition making the determination. of any antidepressant, once we have a chance to review the Antihypertensives. Antihypertensive medications are medical history and a detailed, current status report provided seen regularly by us, as they are the most common medical by the treating physician. Recall that it is the medical condi- condition we accept. There are more than 37,000 hypertensive tion first, not the treatment, when making a determination airmen flying that are being treated with medications. Cur- about a therapy! rently, there are six medications we do not accept: reserpine, Antiepileptics. We do not accept the use of antiepileptic alpha methyldopa, guanadrel, guanethidine, guanabenz, (antiseizure) medications as treatment for any medical condi- and clonidine. tion. These medications have side-effects that are incompatible Alpha-blockers. I n t he pa st ye a r, we h ave be en re c on sider- with flying. An example here might be the use of Neurontin ing the use of alpha-blocking medications and are currently (gabapentin) in the treatment of a neuropathy. We do not accept not accepting the use of Catapres (clonidine). We are still these medications because a seizure or epilepsy is obviously a discussing the other alpha-blockers and have not made a final condition that is not acceptable for flight. These medications determination. Those that are being used to promote urine also have side effects that are incompatible with flying. flow in men with prostatism are still acceptable. Examples Antispasmodics. The use of antispasmodics for diarrhea, are Cardura (doxazosin), Hytrin (terazosin), and Flomax abdominal cramping, etc. are not acceptable. Some examples (tamsulosin). of such medications are Bentyl (dicyclomine), Levsin (hyo- That is all for now. Be sure to read the next issue for a scyamine), Librax (chlordiazepoxide and clidinium), and continuation of this series on medications. 

Three AAM Staff Receive Industry Awards Dr. G.J. Salazar received the John A. The Aerospace Medical Association (AsMA), representing Tamisiea Award for his “outstanding contribu- physicians and medical professionals with knowledge of the tions to aviation medicine in its application to flight environment, presented its annual awards on May 13 the general aviation field.” Dr. Salazar is the in Phoenix, Ariz. Southwest Regional Flight Surgeon and is also “This year our FAA folks cleaned up,” said Dr. James responsible for the development of the night Fraser, Deputy Federal Air Surgeon. vision goggle orientation facility at the Civil Winners are: Dr. Melchor Antuñano, who Aerospace Medical Institute. received the Louis H. Bauer Founders Award for his internationally recognized expertise in CAMI Video Wins Telly Award aerospace medicine. Dr. Antuñano, director of The Civil Aerospace Medical Institute earned the television the FAA’s Civil Aerospace Medical Institute, industry’s equivalent of an Academy Award for its “Stress in has led teams of aeromedical specialists in the Aviation” video. CAMI’s Airman Education Team’s video won generation, administration, and promulgation a bronze award in the Employee Communication category of both national and international aeromedical from the 31st Annual Telly Awards. A collaboration with the planning and policy, and he holds senior lead- FAA’s Media Solutions team, the video describes the causes ership positions with numerous international aeromedical of stress in the human body, the aviation environment, and organizations. how to better cope with these stresses. The high-definition video is the third in a planned ten-part Dr. Warren Silberman received the series on human factors. The fourth video, “Risk Manage- Theodore C. Lyster Award for his “out- ment in Aviation,” was just released. standing achievement in the general field of “Our mission is ‘safety through education,’ and the videos aerospace medicine.” He was cited for having reinforce what we teach in our Crew Resource Management “significantly improved civil aeromedical Program,” said team member J.R. Brown.“We’ve already certification polices and practices for pilots made 32 videos with Media Solutions, and we give away over of all classes through his medical training 5,000 free DVDs each year, or anyone can download them and administrative skills.” from our Web site.” To view the videos, go to www.faa.gov/library/online%5Flibraries/aerospace%5Fmedicine/ —Excerpts from AVS Flyer aircrew/hf%5Fvideos/.

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. 48, No. 3 • Vision Standards Medications List Needed

Dear Editor, Dear Editor, The [online] AME Guide [www.faa.gov/ I have been an AME since 1996. I take about/office_org/headquarters_offices/ this position very seriously and take some avs/offices/aam/ame/guide/app_process/ pride in that I try to do a very good job in exam_tech/item51/et/] says: “Near visual acu- doing it and not have casual sloppy work done. ity and intermediate visual acuity, if the latter is I would think this attitude is both good for our required, are determined for each eye separately pilots and AMCD [Aerospace Medical Certifica- and for both eyes together. Test values are recorded tion Division]. It is very hard to keep up with all both with and without corrective glasses/lenses the medications that can affect our pilot’s medicals. when either are worn or required to meet the I admit I have made errors in not seeing some standards. If the applicant is unable to meet the medications that were not approved for some of intermediate acuity standard unaided, then he/ my pilots then requiring more work for AMCD, she is tested using each of the corrective lenses or the pilots, and myself. I recently spoke to my glasses otherwise needed by that person to meet Regional Flight Surgeon’s office re a medication distant and/or near visual acuity standards. If the status for flying when [name in the] Great Lakes aided acuity meets the standard using any of the Office had a reference for meds and was able to lenses or glasses, the findings are recorded, and assist me. My question is then, why can there not the certificate appropriately limited. If an appli- be a medications directory/list of unapproved cant has no lenses that bring intermediate and/ medications accessible to us as AMEs to assist or near visual acuity to the required standards, or us via computer while we are doing the airman better, in each eye, no certificate may be issued, exams? Once the directory is started it wouldn’t and the applicant is referred to an eye specialist be that difficult to update periodically as time for appropriate visual evaluation and correction.” and new drugs came along. A directory easily ac- I thought things changed so that you do not cessible would in the long run save a lot of time have to check vision with and without corrective for everyone. I always feel like a failure when I do lenses. Do we really have to remove the corrective not appreciate an unacceptable medication, and lenses (contacts) when checking vision? I do not like feeling as though my AME work is Thanks, less than perfect. Joseph Kearns, MD Gary Swann, DO Moses Lake, Washington Maumee, Ohio

Dear Dr. Kearns, Dear Dr. Swann, You do not need to check your pilots without Aeromedical guidance about specific medica- correction for any of the visual acuities, but tions or classes of medications can be found in we must have the values for each eye separately the Pharmaceuticals section of the AME Guide and bilaterally. If they do not meet standards (www.faa.gov/about/office_org/ headquarters_ in either eye, have the airman complete a Form offices/avs/offices/aam/ame/guide/pharm/). 8500-7. If he/she still does not meet standards, Unacceptable medications can be found within you will need to call us, as we will have to give the hyperlinks in this section. To make this the airman a request for a medical flight test. information easier to find, we are adding a new Generally, we have the AME issue a medical item to the Pharmaceuticals section – tentatively certificate with the restriction VALID FOR titled “Disqualifying Medications.” This will STUDENT PILOT PURPOSES ONLY. That summarize the medications for which you allows them to practice until they can take a must defer. Look for it in the AME Guide in medical flight test for a SODA. If the airman the coming month. In the meantime, please see has a great deal of flight experience and the Dr. Silberman’s “Certification Update” column visual acuity is not way out of standards, we in this issue of the Federal Air Surgeon’s Medical may even issue a SODA based on operational Bulletin [page 3], “Policies and Unacceptable experience. Medications.” Warren S. Silberman, DO Arleen Saenger, MD Manager, Aerospace Medical Certification Division Manager, Aeromedical Standards and Policy Branch

The Federal Air Surgeon's Medical Bulletin • Vol. 48, No. 3 • 5 Medical Certification for Pilots With Cystic Fibrosis CYSTIC FIBROSIS Case Report, by Raymond J. Clydesdale, DO, MPH Cystic fibrosis is a life-threatening, hereditary disease that affects ap- The average life expectancy for cystic fibrosis patients has gone up dramatically proximately 30,000 Americans. The over the last few decades. As such, cystic fibrosis patients are exploring opportuni- disease is characterized by a build ties once unimaginable. Therefore, it is reasonable to expect an increasing number up of mucus in the body’s organs, of cystic fibrosis patients to seek FAA medical certificates. The AME must carefully most notably the lungs and pancreas. weigh the aeromedical risks for this unique population. This article presents one As mucus continues to accumulate such young applicant seeking a third-class student pilot’s medical certificate. in the lungs, clearance becomes extremely difficult. Airways can History significant bronchiectasis. Pulmonary become inflamed and infected, n the summer of 2009, an 18-year-old function tests (PFTs) were conducted leading to distorted airways, poor air Imale applied for a third-class medical pre- and post-bronchodilator. FEV1 exchange, and ultimately, premature certificate at his local aviation medical and FVC/FEV1 were all approximately death. examiner’s office. The young man’s 110% of predicted. The common defect is in the func- clinical history revealed the chronic Aeromedical Concerns t io nal c a p acit y o f c ys t ic f ib r o sis t ran s - and normally deteriorating condition The Cystic Fibrosis Foundation membrane conductance regulator of cystic fibrosis. The applicant was ac- ( CFF ) w a r n s c y st ic f ibrosi s pat ient s t h at (CFTR) protein. The CFTR protein companied by his mother who emphati- unless they have no lung disease at all, acts as a channel connecting cel- cally stated to the AME that she fully t he y shou ld “avoid jobs or ac t iv it ie s t h at lular cytoplasm to the surrounding supported her son’s endeavors and that expose you to changing atmospheric extracellular fluid. A thicker mucus is left to accumulate, as chloride cystic fibrosis had not restricted any of conditions (e.g., flying airplanes, scuba ions are unable to traverse the CFTR his physical activities (to include long- diving).” The CFF specifically warns channel. The ciliated cells of the distance running on the high school patients about hypoxia and the dan- bronchial epithelium are unable to track team). gers of blebs (citing pneumothorax as move freely in this more viscous The astute AME completed the un- a concern) (1). Intuitively, the risk of environment, causing cystic fibrosis remarkable physical exam and dutifully sudden incapacitation from a ruptured patients to feel like they are “trying annotated the applicant’s medication bleb would be foremost on an aviation to cough up paint.” history: Flonase, two sprays daily; medical examiner’s mind. A close sec- Several genetic mutations have been Miralax, one capful daily, Albuterol ond would be the risk of a more subtle, found to cause a defective CFTR nebulizer, three times a day; ADEKS, hypoxia-induced incapacitation from protein. The good news is that cystic two pills daily; five Pancreacarb MS- remodeled pulmonary airways. fibrosis patients are living longer. Part 16 with meals and three with snacks; Spontaneous pneumothorax is com- of the outlook improvement may Ursodiol, 300mg each morning and mon for cystic fibrosis patients, occur- be due to genetic testing, allowing 600mg each evening, MVI daily; and ring in one of 167 patients per year. It us to identify more mild cases that Dornase Alfa (Pulmozyme) daily. The typically occurs in older patients and would not have been identified a few applicant was then instructed to provide those with more severe airway disease decades ago. In the 1950s, a cystic fibrosis patient was not expected further pertinent medical information (2). Several studies performed in the to live long enough to attend grade in the form of a narrative from his treat- 1960s were designed to evaluate the be- school. ing pulmonologist. The narrative was havior of blebs and bullae when exposed to include a complete medical history to r apid at mospher ic c h a n ge s. On ly one Fifty years later, the median predicted age of survival was 32. By 2008, the (hospitalizations, procedures, chest X- bleb was noted to increase in size, and median predicted age of survival rose ray, and an evaluation of pulmonary none of the 19 patients experienced to 37.4 years (10). It is possible that function tests). An overall characteriza- a pneumothorax (3). However, the the milder genetic variants are over- tion of his lung function and prognosis studies were limited by the technology represented among FAA applicants. for the near future would complete the of the day, and there are clinical data exam. that suggest the risk is real. In a review The Class-3 applicant completed of spontaneous pneumothoraces in Air the requirements with a favorable letter Force aviators, there was a clear predi- from his treating pulmonologist, who lection for occurrence during altitude described the young man’s cystic fibrosis chamber training, with nearly all hap- Continued as “mild.” His chest X-ray revealed no pening just after rapid decompression

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. 48, No. 3 • (4). For cystic fibrosis, the likely culprit and a high morbidity/mortality in the References of spontaneous pneumothorax is air two years following a pneumothorax. 1. Ferrin M, Cianci K, Finnerty M, et al. trapping caused by mucus plugging and Even when comparing cystic fibrosis Cystic fibrosis in the workplace. Cystic Fibrosis Foundation, 2003. inflammatory changes. The resultant patients of similar pulmonary function increase in volume and pressure in the impairment, patients with a history of 2. Flume PA, Strange C, Ye X, et al. Pneu- mothorax in cystic fibrosis. Chest 2005 alveoli can lead to pressure differentials pneu mot hor a x h ave a muc h h ig her rel a- Aug; 128:720-8. at the parietal pleura and, ultimately, tive risk of dying (2). It may be prudent 3. Luks AM, Swenson ER. Travel to high rupture (5). to consider not granting an FAA medical altitude with pre-existing lung disease. An AME would not find cystic fibro- certificate to any applicant with cystic Eur Respir J 2007; 29:770-92. sis listed under Disease/Condition for fibrosis that has a history of spontaneous 4. Voge VM, Anthracite R. Spontaneous Item 35 (LUNGS & CHEST) in the pneumothorax. pneumothorax in the USAF aircrew AME Guide. Instead, there are several The other aeromedical concern is population: A retrospective study. Aviat categories that cystic fibrosis could fall hypoxia. Although PFT studies have Space Environ Med 1986; 57:939-49. u nder, to i nc lude : 1) C h ron ic bronc h it i s, been inconsistent at high altitude, hy- 5. Flume PA. Pneumothorax in cystic emphysema, or COPD; 2) pulmonary poxia studies have consistently revealed fibrosis. Chest 2003 Jan; 123:217-21. fibrosis; 3) spontaneous pneumothorax; the degree of hypoxemia is directly 6. Cademartiri F, Luccichenti G, Palumbo 4) bronchiectasis; and 5) other diseases related to the severity of the disease. AA, et al. Predictive value of chest CT or defects of the lungs or chest wall that Despite the impaired oxygenation, test in patient with cystic fibrosis: A single- center 10-year experience. AJR 2008 require use of medication or that could subjects revealed no clinical symptoms Jun; 190:1475-80. adversely affect flying or endanger the and are, perhaps, already acclimated to 7. Helbich TH, Heinz-Peer G, Eichler I, applicant’s well-being if permitted to low oxygen conditions (8,9). et al. Cystic fibrosis: CT assessment of fly. The most appropriate category is Outcome lung involvement in children and adults. #5, although work-up requirements The AME deferred issuance of a Radiology 1999 Nov; 213:537-44. from the other categories are useful in third-class medical certificate to the 8. Coker RK, Shiner RJ, Patridge MR. Is determining this applicant’s fitness to FAA. Based upon the airman’s history air travel safe for those with lung disease? fly. These include current PFTs, a chest and complete documentation, the air- Eur Respir J 2007; 30(6):1057-63. X-ray, all pertinent medical history and man was granted an Authorization for 9. Martin SE, Bradley JM, Buick JB, et information, a recent evaluation by a Special Issuance, which would expire al. Flight assessment in patients with pulmonologist with a statement regard- after one year. The airman was to fur- respiratory disease: Hypoxic challenge testing vs predictive equations. Q J Med ing symptomology/associated illnesses/ nish a current status report from his 2007; 100:361-7. name and doses of medications with attending physician to include interim 10. Cystic Fibrosis Foundation. Fre- comment regarding side-effects, and a history, prognosis, follow-up plan, type, quently Asked Questions. www.cff.org/ clear statement regarding any history dosage, frequency of use, side effects of AboutCF/Faqs/. Accessed 30 Nov 2009. of pneumothorax. current medications, results of a current The most predictive tests for spon- PFT, a chest X-ray, and any current stud- taneous pneumothorax risk in cystic ies deemed appropriate. The treating Acknowledgments fibrosis patients are PFTs, specifically physician was to forward these items Patrick A Flume, MD predicted values for FEV1 or FEV1/ to the Aerospace Medical Certification Professor of Medicine and Pediatrics FVC (2). Chest X-rays and CT scans Division about two months prior to the Medical University of South Carolina have not been reliably predictive for expiration of the Special Issuance. Moni- Jeb Pickard, MD, FCCP, FAsMA pneumothorax (6,7). When FEV1 is toring this patient’s PFTs is currently the Pulmonologist <50% of predicted or FEV1/FVC is best means of routine evaluation. The <50% (the FAA uses the value of <70% airman must understand unequivocally as discriminators of lung function in that if he suffers a spontaneous pneu- ot her c ond it ion s ), c y st ic f ibrosi s pat ient s mothorax, he must immediately report About the Author Ray “Doogie” Clydesdale is currently a third- have a marked increase in their risk for this change in condition to the FAA year Resident in Aerospace Medicine com- spontaneous pneumothorax. Secondary and cease all flying activities. As treat- pleting his occupational medicine year at the spontaneous pneumothorax (i.e., due to ments improve and the life expectancy USAF School of Aerospace Medicine. underlying lung disease) is associated for cystic fibrosis patients gets longer,  with a much greater risk than that seen more cystic fibrosis patients will seek with the primary form. For those with a opportunities like flying. There are cur- history of pneumothorax, the aeromedi- rently 113 third-class medical certificate cal concerns are a high recurrence rate holders with cystic fibrosis.

The Federal Air Surgeon's Medical Bulletin • Vol. 48, No. 3 • 7 AME Resources MEDICAL FACTS FOR PILOTS Sleep Apnea Brochure Published brochures By Mike Wayda AM-400-09/3 Acceleration in Aviation: G Force HE O BSTRUCTIVE S LEEP A PNEA brochure, announced in the 2010-1 issue of the Bulletin, has been printed and AM-400 (rev.6/97) Alcohol and Flying Tis available to you for distribution to airmen. AM-400-95/2 Altitude Decompres- The issue of sleep apnea surfaced two years ago when a sion Sickness commercial aircraft with three crewmembers and 40 passen- gers overshot its landing destination as both pilots slumbered and the aircraft flew AM-400-09/1 Aviation Safety along on autopilot. The pilots awoke and landed the aircraft uneventfully—but Courses with major questions to answer about being late at the gate. The National Trans- OK-05-0270 Carbon Monoxide portation Safety Board determined that contributing factors to the incident were the captain’s undiagnosed obstructive sleep apnea and the flight crew’s exhausting AM-400-09/3 Circadian Rhythm work schedule, which included several consecutive early-start mornings. AM-400-04/1 Civil Aerospace The implications for pilots and crewmembers are significant. It has been sug- Medical Institute gested that people with mild-to-moderate obstructive sleep apnea (OSA) can show performance degradation equivalent to 0.06 to 0.08 blood alcohol levels, which is A M - 4 0 0 - 03 / 2 D e e p Vein T hr o m b o sis the measure of legal intoxication in most states. Most pilots will not fly intoxicated, OK-07-193 Fatigue but sleep deprivation may be causing the equivalent effects. Typical symptoms of OSA include difficulty in concentrating, thinking, or AM-400-09/2 Fit for Flight remembering; daytime sleepiness, fatigue, and the need to take frequent naps; AM-400-98/23 Hearing and Noise headaches, irritability, and short attention span. If OSA is suspected, the only way it can be accurately diagnosed is with a sleep AM-400-91/1 Hypoxia study. If confirmed, the brochure lists several methods for treatment: behavioral OK-06-148 Laser Eye Surgery changes, dental appliances, continuous positive airway pressure therapy, medications, and surgery. AM-400-10/3 COMING SOON: Laser Hazards in Navigable Airspace Medications and Flying Brochure Revised AM-400-10/2 List of FAA Pilot New Information Requires Update Physiology Brochures OK-05-0005 Medications and Flying THE FEDERAL AVIATION ADMINISTRATION recently revised the dosing interval standard to reflect a longer waiting time between AM-400-10/1 Obstructive Sleep taking medicine with known side effects until going flying. The Apnea new standard was increased from two to five dosing intervals. OK-08-639 Oxygen Equipment For example, if the directions on the bottle say to take every six hours, wait until at least 30 hours after the last dose to fly. The OK-06-002 Pilot Medical Certification previous standard required two dosing intervals, or in this (six- AM-400-98/2 Pilot Vision hour) example, 12 hours after the last dose to fly. The specific paragraph modified now reads, “If the label warns AM-400-91/2 Seat Belts and Shoulder offf significant side d effects, do not fly after taking the medication until at least five Harnesses maximal dosing intervals have passed. For example, if the directions say to take AM-400-95/1 Smoke! every 4-6 hours, wait until at least 30 hours after the last dose to fly.” Also, revised is “Never fly after taking a new medication for the first time until AM-400-03/1 Spatial Disorientation: at least five maximal dosing intervals have passed and no side effects are noted.” Seat of Your Pants Aviation medical examiners are asked to discard all Medications and Flying pilot AM-400-00/1 Spatial Disorientation: safety brochures currently in stock and have them replaced with a new version. To Visual Illusions order a new supply of this informative brochure (ordering no. OK-05-0005), and to order any of the brochures listed in the sidebar, contact: AM-400-05/1 Sunglasses for Pilots FAA Civil Aerospace Medical Institute AM-400-01/2 Your Pilot Medical Shipping Clerk, AAM-400 Application P.O. Box 25082 Oklahoma City, OK 73125 (405) 954-4831 E-mail: [email protected]

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. 48, No. 3 • Optic Neuritis since fully recovered with 20/20 visual ETIOLOGY OF DISEASE Case Report, acu it y in each eye, norma l visua l f ield s, Optic neuritis is an acute inflamma- by Anthony W. Waldroup, MD, MPH and normal color vision testing. tory demyelinating condition of the Aeromedical Concerns optic nerve of uncertain etiology, Optic neuritis is an acute, inflamma- The airman did not meet third- in most cases, but is thought to be tory, demyelinating condition that class medial requirements per 14 CFR immune-mediated (6). There may be typically results in unilateral visual 67.303(d) (2,5) due to the diagnosis genetic susceptibility among some loss, disturbance of color vision, and of optic neuritis; and the aeromedical individuals and is more common eye pain. The manifestations of optic concerns for an airman with a history of in females (2-3:1), Caucasians, and neuritis are not conducive to safe op- optic neuritis include reoccurring visual northern latitudes, similar to multiple eration of an aircraft as pilot-in-com- disturbances that may go unrecognized sclerosis (6). mand. However, with resolution of a by the airman that may include reduced The reported incidence in the United single episode of optic neuritis, a re- visual acuity, visual field defects, and States is 5/100,000 and prevalence quest for return to pilot-in-command color vision anomalies. These symptoms 115/100,000 (3). Typically, patients duty may be considered. may be exacerbated by hypoxia, dehydra- present with acute vision loss, dys- tion, fatigue, and increased body tem- chromatopsia, and eye pain. In most History perature (e.g., Uhthoff’s phenomenon). cases, the symptoms are limited to 26-year-old female third-class air- Additionally, the Optic Neuritis Treat- one eye, but a minority of cases may include bilateral symptoms. Optic man with 78 hours of flight time ment Trial demonstrated an increased A neuritis of the inflammatory demy- applied for medical recertification 12 risk of developing multiple sclerosis elinating type has been associated months following an episode of acute after recovery from acute inflammatory with an increased risk of multiple optic neuritis. demyelinating optic neuritis. sclerosis and is regarded by many to The airman reported visual distur- Outcome be an initial manifestation of multiple bances described as spherically-shaped Based on the available scientific sclerosis in 15-20% of cases (1, 6). The “floaters” in her left eye that moved resources, the risk of this airman de- Optic Neuritis Treatment Trial showed from the top to the bottom of her vi- veloping multiple sclerosis in the five a 25% (95% confidence interval [CI] sual field, lasting for minutes to hours years following recovery from an ini- 18% -32%) 15-year risk of developing several times a day. Symptoms were tial episode of optic neuritis without multiple sclerosis, given a first episode most notable in the early morning and demyelinating CNS lesions is 16% of optic neuritis without MRI findings evening hours. The symptoms resolved and may be considerably less if there is of demyelination in the CNS, and 72% ( 95% CI 63% - 81% ) w h e n CNS le sio n s within one month. The following significant peripapillary hemorrhages, were present (4). month, the airman presented to her macular exudates, lack of eye pain, or ophthalmologist with concern regard- light perception in the acutely affected ing a “spot” in her visual field affecting eye (4). the left-lower quadrant of the left eye. With the full recovery of symptoms She repor te d f l a sh i n g l ig ht s i n her v i su a l and the low risk of sudden incapacita- References 1. Balcer LJ. Clinical practice: Optic fields when looking into headlights or tion during flight, the airman was given neuritis. N Engl J Med 2006 Mar 23; at street lights at night. A dilated retinal special-issuance medical certification 354(12):1273-80. exam revealed normal-appearing retina through the Aerospace Medical Certi- 2. Federal Aviation Administration. Guide and edema of the left optic disc; but fication Division after ophthalmologic for Aviation Medical Examiners, online no afferent pupillary defect or eye pain. evaluation and completion of a Form at www.faa.gov/about/office_org/ A neurology consult and MRI of the 8500-7. Annual follow-up requirements headquarters_offices/avs/offices/aam/ brain were obtained. The MRI with for continued authorization for special ame/guide/; accessed17 Mar 2009. gadolinium contrast demonstrated issuance include visual acuity, visual 3. Rodriguez M, Siva A, Cross SA, O’Brien enhancement of the left optic nerve field, and color vision testing that meet PC, Kurland LT. Optic neuritis: A population-based study in Olmstead without evidence of other CNS lesions. the current standards for the requested County, Minnesota. Neurology. 1995 No ot her neu rolog ic de f icit s were note d class of medical certification. Feb; 45:244-50. on e x a m by t he neu rolog i st. T he a i r m a n Other causes of optic neuropathy 4. The Optic Neuritis Study Group. Multi- was diagnosed with acute optic neuritis, include ischemic, infectious, systemic ple sclerosis risk after optic neuritis: Final and she chose not to be treated with auto-immune, toxic, metabolic, and optic neuritis treatment trial follow-up. intravenous corticosteroids. She has neoplasm (7). Arch Neurol 2008 Jun; 65(6):727-32. Continued on page 11

The Federal Air Surgeon's Medical Bulletin • Vol. 48, No. 3 • 9 Transient Global Amnesia in an Airline Pilot was found to have an elevated ammonia Case Report, by Lloyd W. Sloan, MD, MPH level (43 micromoles per liter, normal being 11-35) and elevated blood pressure Transient global amnesia in a pilot would have obvious and immediate conse- in the hospital. His toxicology screen quences: Inability to remember the current situation, upcoming required proce- was negative, and he denied alcohol dures, how to operate the aircraft—even one’s identity—would be catastrophic consumption. During his admission, he for flight safety, especially in the airline transport context. Depending on the eti- was seen by a neurologist, a cardiologist, ology, this could result in sudden incapacitation of the pilot and put at risk the and a gastroenterologist, but none could lives of all on the aircraft. find a specific cause for his episode. His medical history was significant History On her urging, he contacted an agent for spinal meningitis as a child, hospital 53-year-old male airline pilot ex- for his airline medical department and admission for campylobacter gastroen- A perienced what was described as asked him to arrange for transportation teritis at age 10, and sinusitis in his 40s. an episode of amnesia while driving to to an Emergency Room for evaluation. He had sinus surgery and uvulopalato- catch a flight as a passenger. He stated, He approached two police officers who pharyngoplasty for difficulty sleeping. “My body knew where to go but I felt contacted paramedics. The latter found He stated he had no specific diagnosis of strange, an out-of-body feeling” while his blood pressure and blood glucose to sleep apnea and no sleep study to date. driving from his new home to the air- be normal. There was no loss of con- He also had a herniated cervical disk port. He made it to a Starbucks en-route sciousness during the entire period and associated with an injury. The Federal but “couldn’t back-track for a while.” during his ER evaluation. At the time, Aviation Administration’s neurology He “saw a green light but barely missed he had no recall of events of that day, consultant diagnosed the pilot with hitting a car,” and felt he was “watching from departing his home that morning transient global amnesia. a movie” while walking to the terminal. to his being in the ER. He was admit- Subsequent neuropsychological Without being sure how he did it, he ted at noon that day for three days and testing found no abnormalities in cog- parked in employee parking, boarded underwent an extensive workup. nition or memory. A psychiatric evalu- the correct bus, walked to the correct His memory returned to him on the ation found him without psychiatric terminal and gate for his flight but still evening of the first day of admission, for diagnoses, but both the neurologist could not remember or connect events a total of about six hours of amnesia. His and psychiatrist were concerned that to that point. He called his wife and head CT, MRI, MRA, EEG, EKG and his episode may have been caused or told her he didn’t know where he was. lab values were normal, except that he influenced by significant stressors in his life. He stated these began after the attacks of September 11, 2001. Rather DIAGNOSTIC CRITERIA FOR DEFINITE TGA than the events of the attack, he was • Attacks must be witnessed and information available from a capable observer impacted by the decline of the airline who was present for most of the attack. industry and the economy: His pay • There must be clear-cut anterograde amnesia during the attack. was reduced, and his airline declared • Clouding of consciousness and loss of personal identity must be absent, and bankruptcy in 2005. He had also lost the cognitive impairment limited to amnesia (that is, no aphasia, apraxia, etc). three months of flight time due to the • There should be no accompanying focal neurological symptoms during the neck injury. On the advice of the union attack and no significant neurological signs afterwards. flight surgeon, he voluntarily refrained • Epileptic features must be absent. from flight duties. • Attacks must resolve within 24 hours. Aeromedical Concerns • Patients with recent head injury or active epilepsy (that is, remaining on medi- Transient global amnesia (TGA) in cation or one seizure in the past two years) are excluded (Hodges and Warlow, any pilot would have obvious and im- pp. 834 – 5.) mediate consequences. Inability to a In a review, including multivariate analysis of 143 cases, Quinette et al. (2006) remember current situation, upcoming noted no correlation between TGA and vascular risk factors. They also stated required procedures, how to operate that, “In women, episodes are mainly associated with an emotional precipitating the aircraft or execute emergency pro- event, a history of anxiety and a pathological personality. In men, they occur cedures, not to mention one’s identity, more frequently after a physical precipitating event. In younger patients, a history would be disastrous for crew resource of headaches may constitute an important risk factor.” 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. 48, No. 3 • management and flight safety, espe- Outcome Optic Neuritis from page 9 cially in the airline transport context. There was no specific etiology identi- Depending on the etiology, this could fied by the aforementioned consultants. 5. Title 14 Code of Federal Regulations Part result in sudden incapacitation of the The FAA neurology consultant noted 67.303, online at http://ecfr.gpoaccess. gov/cgi/t/text/text-idx?c=ecfr&sid=29 pilot and put at risk the lives of all on that the case met every criterion for d256d0540166238124e95ba716a52 the aircraft. TGA (see sidebar). He also noted that 4&rgn=div5&view=text&node=14:2. According to Hodges and Warlow with adequate control of the patient’s 0.1.1.5&idno=14#14:2.0.1.1.5.4.1.2; (1990), TGA does not have a single hypertension and better management of accessed 17 Mar 2009. 6. UpToDate, online at http://upto definitive etiology. General categories stressors, the patient was at very low risk dateonline.com/online/content/topic. of etiologies associated with TGA in- for recurrence. Given that his episode do?topicKey=neuro_op/7946&sel clude thromboembolic cerebrovascu- lasted less than 24 hours, and that his ectedTitle=2~150&source=search_ lar events, epilepsy, migraine, cerebral cognition, memory, and neurological result#7; accessed 17 Mar 2009. angiography, cerebral tumors and exam remained completely normal after 7. UpToDate, online at http://upto- dateonline.com/online/content/ cerebral hemorrhage. Occult alcohol resolution, the neurology consultant image.do?imageKey=neuropix/ dependence has also been implicated. recommended issuing a Class-1 Special optic_7.htm&title=Optic%20neuro The FAA neurology consultant noted Issuance medical certification for return pathy%20causes; accessed 17 Mar 2009. that TGA is often associated with to full flight status. Therefore, he was About the Author emotional stress and hypertension. given a time-limited authorization up to Lieutenant Colonel Anthony Waldroup is He also stated there is a 3% annual the end of the next fiscal year, provided a resident in the USAF Residency in Aero- risk of recurrence of TGA. He noted he met periodicity requirements for his space Medicine serving at the USAF School of Aerospace Medicine, Brooks City-Base, that the current practice of one year of annual examinations and a condition Texas. He authored this case report while grounding for non-transient amnesia update from the attending physician and training at the Civil Aerospace Medical In- is due to the risk of recurrence, which all consultants regarding hypertension, stitute. The opinions expressed in this case is higher than the risk for TGA. stressors, and mental and neurological report are those of the author and do not nec- status. essarily reflect the position or official policy of the USAF or USAF School of Aerospace Role of the AME Medicine. According to the Guide for Avia- References tion Medical Examiners (FAA, 2009),  Federal Aviation Administration (2009). medical certificates must not be DR. SMITH from page 1 issued to an applicant with medical Guide for aviation medical examiners: Aerospace medical disposition, conditions that require deferral or for Her hard work and intelligence www.faa.gov/about/office_org/head- represented the interests of physicians any condition not listed in the table quarters_offices/avs/offices/aam/ame/ that may result in sudden or subtle guide/ throughout New York. “Maggie” incapacitation without consulting was an effective advocate and a good Federal Aviation Administration (2008, listener, able to reach consensus and the Aerospace Medical Certifica- Dec.). Neurology consultant’s report. build unity. As a program director at St. tion Division or the Regional Flight Hodges JR, Warlow CP. Syndrome of Vincent’s during its recent closing, she Surgeon. Medical documentation transient amnesia: Towards a classifi- took personal charge of getting every must be submitted for any condition cation; a study of 153 cases. Journal of one of her residents placed in other to support an issuance of an airman Neurology, Neurosurgery, and Psychiatry training programs. Maggie personally 1990;53:834. medical certificate. lobbied her fellow program directors at Transient global amnesia falls un- Quinette P, Guillery-Girard B, Dayan J, et other hospitals to train her residents. al. What does transient global amnesia She was not done until everyone found der the category of “Transient loss of really mean? Review of the literature nervous system function(s) without and thorough study of 142 cases. Brain a new home. satisfactory medical explanation of 2006 129(7):1640-58. Our deepest sympathies go out to the cause” and requires disposition Maggie’s husband, Matthew Fergu- by the FAA Regional Flight Surgeon son, MD, and the rest of the family. About the Author The FAA mourns the tragic loss of or Aerospace Medical Certification CDR Lloyd W. Sloan, MD, MPH, was Dr. Margaret Smith. Her expertise Division (FAA, 2008, p. 200). The a Resident in Aerospace Medicine on ro- and service will be greatly missed by patient complied with all requests for tation at the Civil Aerospace Medical In- all of us. stitute when he wrote this case report. reports of all tests and consultation, as —Harriet Lester, MD, Eastern RFS well as correspondence with the FA A.  —Ray Basri, MD, Senior AME, Colleague — Mindy Zalcman

The Federal Air Surgeon's Medical Bulletin • Vol. 48, No. 3 • 11 A Note From “The New Doc” Ordering Forms and Supplies Made Easy By Brian Pinkston, MD By Gary Sprouse GREETINGS! After a whirlwind arrival, I am happily settled lease requisition your supplies —GG forms, envelopes, in the Aerospace Medical Education Division at CAMI, the Pand so on—from our ordering Web site. Thanks to those Civil Aerospace Medical Institute. As an early perk of the of you who have made use of this Web site, we have achieved job, I attended the Basic AME seminar held in Oklahoma City 12-16 July. Although I had been to CAMI previously a 200% increase from two years ago. for AME training, I was awestruck with the high quality of The benefit of ordering online is two-fold. First, your re- presentations given by the specialty consultants and lecturers quest is received within moments. Second, time not utilized and the seminar’s professional execution. answering phone-in requests is focused at filling requests, The CAMI altitude chamber and spatial disorientation greatly reducing your delivery time. demonstrators brought back some memories but also made Additionally, many of your needed forms are available for me excited for the future. For example, CAMI has been print directly from this Web site. Please DO NOT use the conducting cutting-edge research in hypoxia training with a partial-pressure oxygen delivery alternative to the altitude AC Form 8500-33 Requisition Card. This card utilizes an chamber. This device, the Portable Reduced Oxygen Training obsolete USPS permit number and will likely result in your Enclosure, may one day push the boundaries of training for request not being received. airmen who are unable to visit an altitude chamber. The Web site address is as follows: http://ame.cami.jccbi. Additionally, the Division is looking at new IT enhance- gov/form_and_brochure/medicalform.asp. ments to assist with AME tracking and training. Around every Are you interested in obtaining informational brochures corner I see innovation and an eye on improving products for for your airmen? Look no further, we have more than 20 AMEs and airmen. titles, ranging from Acceleration to Sunglasses. Best yet, these The next time you are in Oklahoma City, please look us up so we can show you what we are working on to better serve informative pilot safety brochures are free of charge. To you! And don’t hesitate to contact me for AME training or request, print the order form from the Web site mentioned other general AMED questions at [email protected]. above and fax to 405-954-8016. Dr. Pinkston is the new manager of the AMED. Gary Sprouse is the AMED shipping clerk. Aviation Medical Examiner Seminar Schedule 2010 August 26 – 29 Wiesbaden, Germany GAATM (1) October 7 – 9 Pensacola, Florida CAMA (2) November 1 – 5 Oklahoma City, Oklahoma Basic (3) November 19 – 21 Kansas City, Missouri Cardio (4) 2011 Basic Seminar Schedule February 28 – March 4 Oklahoma City, Oklahoma Basic (3) June 13 – 17 Oklahoma City, Oklahoma Basic (3) October 31 – November 4 Oklahoma City, Oklahoma Basic (3) CODES AP/HF Aviation Physiology/Human Factors Theme CAR Cardiology Theme N/NP/P Neurology/Neuro-Psychology/Psychiatry Theme OOE Ophthalmology-Otolaryngology-Endocrinology Theme (1) This seminar is sponsored by the German Academy of Aviation and Travel Medicine and is sanctioned by the FAA as fulfilling the FAA recertification training requirement. For more information, see the Academy Web site: www.flugmed.org. Click on EUSAM, then click on Refresher FAA/JAA (from the top menu). (2) This seminar is 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 Web site: www.civilavmed.com. (3) A 4½-day basic AME seminar focused on preparing physicians to be designated as aviation medical examiners. Call your Regional Flight Surgeon. (4) A 2½-day theme AME seminar consisting of 12 hours of aviation medical examiner-specific subjects plus 8 hours of subjects related to a designated theme. Registration must be made through the Oklahoma City AME Programs staff, (405) 954-4258 or -4830. The Civil Aerospace Medical Institute is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.

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. 48, No. 3 •