Federal Air Surgeon’s Medical Bulletin Aviation Safety Through Aerospace Medicine Vol. 45, No. 2 For FAA Aviation Medical Examiners, Office of Aerospace Medicine Personnel, U.S. Department of Transportation 2007-2 Flight Standards Inspectors, and Other Aviation Professionals. Federal Aviation Administration

QUICK FIX Fifteen per cent of airmen responded 4 Pilot Feedback on Aviation “No” when asked, “Did the aviation HEADS UP Medical Examiners medical examiner (AME) with whom 2. Editorial: XPress Launched By Richard ‘Dick’ Jones, MD you had the appointment review your medical history with you?”; 7% said 3. New Regional Flight the history was reviewed by a non-AME Surgeon in Southern PROBLEM physician, 15% by a non-physician, and Results of the 2006 FAA Aerospace the remaining 79% said there was no Medical Services Airman Customer history review. Four per cent of airmen 4. Certification Updates, Satisfaction Survey are in! A total of reported their evaluations were not done Issues and Answers 15,755 surveys were received by airmen by the person with whom they had the and 6,425 were returned, a 41% response appointment; of these, 70% were done 6. OAM News rate. There were many interesting find- by non-physicians, 17% by a non-AME •HQ Manager Selected ings in these results that we can cover physician, and 13% said they were not •Annual OAM Awards Ceremony Held another time in this space, but today examined at all. I want to focus on only a couple of Continued on page 3 problem areas.

AME Independent Medical Sponsors Needed Training Available for Treating Substance Abuse in Pilots By Michael A. Berry, MD 7. Case Report: Metastatic Hurthle Cell Carcinoma he Federal Aviation Administration HIMS concept is based on a cooperative Tneeds more experienced aviation and mutually supportive relationship 8. Case Report: Complex Partial medical examiners to become trained between pilots, the Federal Aviation Seizures as Independent Medical Sponsors for Administration, and management to ef- the Human Intervention Motivation fectively address the problem of substance Study, better known as the HIMS pro- abuse in pilots. With proper treatment, 10. Case Report: Lower gram. There are many portions of the the rehabilitation of airline pilots with Extremity Amputations country with few or no such aviation alcohol or substance abuse problems can medical examiners. The continued suc- be successful and cost-effective. 12. AME Seminar Schedule cess of this extremely important safety The major components of the FAA program is dependent on experienced, program are: diagnosis by an trained well-trained AMEs. addiction professional, treatment, com- prehensive continuing care, long-term Background monitoring, and total abstinence from HIMS was initiated in the early 1970s alcohol. A pilot must be evaluated and in the industrial setting because it is the monitored by an experienced and spe- most effective place to intervene in the cially trained aviation medical examiner addiction process. The program grew out who acts as the pilot’s sponsor. of a study grant from the National Insti- tute for Alcohol Abuse and Alcoholism Continued on page 3 and the Air Line Pilots Association. The Xpress Has Departed the Fix criminal charges were filed against ELLO EVERYONE. We l a u n c h e d t h e 45 airmen for: Social Security fraud, latest release of the Document making and delivering a false official HImaging and Workflow System writing, and making false statements to (DIWS), FAA MedXPress (Xpress), on a government agency. These pilots had the West Coast on April 16. their airman and medical certificates X Pre s s w i l l be ava i l a ble to t he c ent r a l revoked, paid monetary fines, and part of the country in mid-May, and were placed on probation; a few were everyone else in mid-June. For those of convicted of Social Security fraud. you who have not heard about XPress, The foundation of the medical cer- don’t be alarmed. You will receive a tification system is truthfulness. We lot more information about it in the must be able to rely on the information coming weeks. XPress allows pilots to provided to us by our airmen. I believe fill out their Application for Airman t h at t he s y stem i s i n herent ly s a fe be c au se Medical Certificate, FAA Form 8500- By Fred Tilton, MD most people are honest. However, at 8, online; and then transmit it directly least in California, some people were into DIWS. When the airman arrives willing to break the law and risk their at your office, you can call up the form flying privileges, their reputations, in your system and use it to complete airman elect to do so. However, I realize and possibly their flying careers by the physical. that this is a giant leap, so we are start- falsifying their medical certificate ap- Paperless Process Planned ing slow. Neither you nor the airman is plications. Such falsifications could also Our goal is to eventually have a sys- presently required to use XPress. have affected the safety of the National tem t h at i s ent i rely paperle s s. I n f ac t , it i s For the airmen who want to use it, Airspace System. already possible to accomplish an exam we are recommending that they print FAA medical certification history using without paper if both you and the a paper copy and bring it with them to shows that we are able to medically your office. If you are prepared to use qualify most applicants, even those XPress, you can retrieve the electronic with potentially disqualifying medical Federal Air Surgeon’s version from our Web site, complete conditions. The unfortunate California Medical Bulletin the physical, document your findings, experience demonstrates that there Library of Congress ISSN 1545-1518 and transmit the completed exam to us are significant consequences when an Secretary of Transportation without ever touching a piece of paper. If applicant falsifies his or her medical Mary E. Peters your office is not ready to take the total certificate application. FAA Administrator electronic leap, you can have the airman Please discuss this issue with your Marion C. Blakey “do it the old-fashioned way.” applicants when they come to your of- Further Refinements Coming fice for their examination. Inform them Federal Air Surgeon I think you will also be glad to about these events, and let them know Fred Tilton, MD know that we are currently working on that we will do everything we can to Editor another release that will allow you to help them become medically certified. Michael E. Wayda print certificates. We are very excited You should also let them know that The Federal Air Surgeon’s Medical Bulletin about XPress. It will help speed up the once they have falsified their medical is published quarterly for aviation medical physical examination process, reduce certificate application, there is no way examiners and others interested in aviation transmission errors, and make us all to turn back. In my opinion, the risk safety and aviation medicine. The Bulletin is more efficient. is not worth it! prepared by the FAA’s Civil Aerospace Medical Operation Safe Pilot New Regional Flight Surgeon in Institute, with policy guidance and support from In 2004, the Inspectors General Southern the Office of Aerospace Medicine. An Internet f rom t he Depa r t ment of Tr a n spor t at ion On a much more pleasant note, on-line version of the Bulletin is available at: and the Social Security Administration I want to take this opportunity to www.faa.gov/library/reports/medical/fasmb/ jointly initiated an investigation in announce that we have a new South- Authors may submit articles and photos for central and northern California called ern Regional Flight Surgeon. Susan publication in the Bulletin directly to: Operation Safe Pilot. Their purpose Northrup took over the reins on April was to determine if there were people 30 from David Millett, who retired in Editor, FASMB FAA Civil Aerospace Medical Institute who were fraudulently collecting Social January. Susan is a wonderful addition AAM-400 Security benefits for total disability to our FAA team, and I know you will P.O. Box 25082 and/or falsifying their FAA medical ap- have fun working with her. You can read Oklahoma City, OK 73125 plications. Indeed, they actually found all about her on page 3 of this issue. e-mail: [email protected] such individuals, and as a result, federal —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. 45, No. 2 • Susan E. Northrup, MD, American Board of Preventive Medicine’s of several other committees. She has MPH certification in both specialties. been elected to the American Board A colonel in the U.S. Air Force of Preventive Medicine as one of the A Biography of Reserve, Dr. Northrup has more three aerospace medicine members. She the New Southern than 600 hours of flying. Prior is the president-elect of the Civil Avia- Regional Flight assignments include Chief of Op- tion Medical Association and editor of Surgeon erational Medicine for the USAF their FlightPhysician newsletter. at Bolling AFB, Chief of Aerospace In addition, she is a member of the DR. SUSAN E. NORTHRUP, Medicine at Pope A FB, N.C., and International Academy of Air and recently selected by the Feder- as Flight Surgeon for the 69th Space Medicine, the Society of United al Air Surgeon as the Southern Fighter Squadron, Moody AFB, States Air Force Flight Surgeons, the Regional Flight Surgeon, was Ga., during and after Desert Storm. Reserve Flight Surgeons Association, born in Dayton, Ohio, and She transitioned to the USAF Re- the Airline Medical Directors Associa- graduated from The Ohio State Uni- serve in 2001 as the Reserve Consultant tion, the American Medical Association, versity in 1985 with a commission via for the HQ ARFC/SGP. Her civilian the American College of Preventive the Air Force Reserve Officer Training position until 2005 was as Delta Air Medicine, the American Legion, and Corps. She graduated from The Ohio Lines’ regional medical director for the Reserve Officer Association. From State University College of Medicine in air crew and passenger health services. 2002 to 2005, she chaired the medical 1989 and interned in Family Medicine Since 2005 she performed Reserve du- committee of the Air Transport Associa- at The Ohio State University Hospital ties as the Chief, Reserve Consultant to tion, setting airline industry standards in 1990. the Chief of Clinical Services, Air Force and medical response plans for the She then entered active duty at Moody Reserve Command and the Chief of the U.S. carriers. AFB, Ga., and earned a Masters of Public Reserve Line of Duty Board. A private pilot and the co-owner Health degree from the University of Active in professional organiza- of a Harvard Mark IV Warbird, Dr. Texas in 1994, the USAFSAM Residency tions, Dr. Northrup is a Fellow of Northrup lives in Peachtree City, Ga., in Aerospace Medicine in 1995, and the the Aerospace Medical Association, with her husband and their two sons. USAFSAM Occupational Medicine co-chairs their scientific program and 4 Residency in 1996. She obtained the registration committees, and a member

QUICK FIX from page 1 AME SPONSORS from page 1

RESULT HIMS Training We have long received anecdotal other than an AME, the examination reports from pilots that we have AMEs must be repeated by another AME and The next HIMS training seminar in our system who do not perform ex- we investigate the AME whose practice will be conducted in Denver, Colo., aminations up to FAA standards. We was involved for other similar instances September 10-12, 2007. If you are now have some quantification of the of policy violations. interested in attending or would like problem. It is particularly disturbing more information about becoming an that airmen are having medical exami- SOLUTION AME Independent Medical Sponsor, nations and histories done by non-physi- All AMEs must ensure they person- please contact: cians and non-AMEs. This practice is ally perform examine all applicants for Michael A. Berry, MD a direct violation of federal regulations, whom they issue a medical certificate FAA Headquarters, AAM 200 which stipulate that all FAA examina- and personally review each medical 800 Independence Ave., SW tions must be performed by AMEs history with the applicant. Any de- Washington, DC 20591 and that AMEs must be physicians. viation from this policy will warrant (202) 267-8035 When it comes to our attention that an termination of the responsible AME’s 4 examination has been done by someone designation. Dr. Berry manages the Medical Specialties 4 Division at Federal Aviation Administration Dr. Jones manages the Civil Aerospace Medical Institute’s Aerospace Medical Education Division. headquarters in Washington, D.C.

The Federal Air Surgeon's Medical Bulletin • Vol. 45, No. 2 • 3 TurboMedical looks just like the rial in this issue of the Bulletin [see Certification FAA medical form. If an airman pres- page 2]. Please do not confuse the two Update ents you with an AOPA TurboMedical forms—they are not the same. form, you may accept it. However, there By the way, the Federal Air Surgeon’s Information About are then a couple of extra steps you will Medical Bulletin covers many different Current Issues be required to take. Assure that the air- subjects. I strongly suggest that you man has signed the TurboMedical form. share it with members of your staff By Warren S. Silberman, DO, MPH T hen t a ke a n of f ici a l FA A me d ic a l e x a m and that you also make it available in form (Form 8500-8) and have the air- your waiting rooms for others to read URBOMEDICAL U PDATE: As you may man sign the front side of that form as if they wish. Trecall, the Aircraft Owners and well. Use the medical certificate from Finally, in a recent review of issued Pilot’s Association (AOPA) developed the FAA form to get the “FF” num- medical certificates, we found that the capability for its members called ber. Then attach both forms together, approximately 90% of AMEs had not TurboMedical. TurboMedical allows and submit them just as if the airman i nc lude d proper re st r ic t ion s on t he me d- an airman to go into the AOPA Web were completing only the official FAA ical certificates of airmen who reported site and complete the front side of the form. If the airman refuses to sign a taking the acne medication Accutane FAA Form 8500-8 (medical history). blank 8500-8, the airman will have to (Isoretinoin). Accutane may cause a Positive responses to questions prompt transfer all the information from the decrease in night vision. Therefore, all the airman with educational informa- TurboMedical to our form. airmen taking this medication must tion on how the FAA wants him or I understand that some AMEs have have the restriction: NOT VALID FOR her to respond and links the airman to confused the TurboMedical form with NIGHT FLYING. We are sending the different places on their Website, such the new FAAMedXPress that we have affected airmen corrected certificates, as AOPA’s list (not FA A-sanctioned) of talked about in previous bulletins and and the AMEs who issued the medical acceptable medications. that Dr. Tilton discusses in his edito- certificates will receive an error letter.

Issues and Answers—Case Presentations in Malignancies

A 50-year-old male airman comes nswer: No. Any malignancy is A 45-year-old female airline into your office for an FAA Adisqualifying. If an airman reports transport pilot with a first-class 1 second-class medical examina- a medically disqualifying condition, 2 medical certificate had infil- tion. He reports that he had cancer you may not issue a certificate without trating ductal breast cancer. After an of the descending colon six months verba l or w r it ten per m i s sion f rom eit her axillary lymph node dissection, her ago, and a resection left him with a your Regional Medical Office or the pathology report showed that 11 out permanent colostomy. He provides Aerospace Medical Certification Divi- of 17 nodes were positive. Her only you with the medical records from his sion. This is true even if the airman has medication was tamoxifen (Nolvadex). hospitalization: the history and physi- provided all the documentation that we What actions would you take for her cal examination, discharge summary, would require. medical certification? operative and pathology reports, and a In general, the FAA does not grant nswer: In the past, we would have CEA (carcinoembryonic antigen) level. medical certification to airmen with Adenied such airmen and required The pathology report indicates that the malignancies until one year after treat- that they be grounded for three years. tumor did not penetrate the serosa of the ment. In this particular case, however, The only node-positive airmen we al- bowel. The tumor was low in the colon we felt that the airman was sufficiently lowed to go right back to flying were and required a colostomy. The airman out f rom h i s su rger y. He prov ide d a l l t he those with positive nodes in the axillary did not receive any treatment other necessary documents needed to make tail of Spence. However, we now grant than the surgery, and his current CEA a decision, and we granted medical certification to individuals with axillary antigen and blood counts are normal. certification. The airman was placed on node positive disease upon the conclusion His colostomy has been functioning a six-year Authorization for Special Issu- of their treatment. The applicant must well, and he is being regularly observed ance (waiver), requiring yearly current have a brain MRI with no evidence of by his physician. If the examination was status reports and carcinoembryonic metastasis and a negative chest scan. otherwise unremarkable, would you is- antigen levels. sue this airman a medical certificate? Continued on page 5 Dr. Silberman manages the Civil Aerospace Medical Institute’s Aerospace Medical Certification Division.

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. 45, No. 2 • ISSUES & ANSWERS from page 4 ‘In general, the FAA does not grant medical Annual follow-up status reports with certification to airmen with malignancies until either a chest X-ray or CT scan of the one year after treatment.’ chest and an MRI of the brain will be required for five years. A 48-year-old female second- and 75% in larger ones. The presence ‘Any malignancy is class airman who flies for a of positive cervical nodes means a disqualifying.’ 4 small commercial operation higher recurrence rate but not a higher presented with a solitary thyroid mortality rate. The peak ages for this mass one year ago. A nuclear scan tumor are from 30 to 50. The female- A 50-year-old airman with a and needle biopsy of the mass dem- to-male ratio is 3 to 1. Treatment is third-class medical certificate onstrated thyroid cancer, and a total total thyroidectomy for tumors that 3 has chronic myleogenous leu- thyroidectomy was performed. The have spread to the cervical nodes, kemia, Philadelphia chromosome- pathology report came back as papil- and usually I 131. Follow-up for this positive. The airman is taking Gleevec lary thyroid cancer with four lymph tumor includes yearly status reports (imatinib mesylate). He provides you nodes. She provided the necessary and a serum thyroglobulin level. If with a favorable medical status report reports, and the AME properly de- the level is elevated, it usually means and complete blood count. The white ferred the case. Would you grant this recurrence (2). blood cell count and the platelet airman a special issuance? count are within normal limits. Can NSWER: Yes, we frequently grant References this airman gain third-class medical Afull privileges to airmen with 1. Harold CE, Priff C (2008). Physi- certification? this malignancy through the special cian’ Drug Handbook, 12th edition; pages 630-1; Philadelphia, PA: Lip- NSWER: Yes. Gleevec inhibits issuance process. Papillary carcinoma pincott Williams and Wilkins. ABcr-Abl tyrosine kinase, which is is the most common thyroid malig- the abnormal tyrosine kinase that the nancy, with >70% of thyroid tumors 2. Thyroid nodules. EndocrineWeb. Philadelphia chromosome creates in of this type. Cervical metastasis to com. www.endocrineweb.com/nod- ule.html. (Accessed 3/10/2007). this form of leukemia (1). We require lymph nodes in the neck is present them to provide a status report and com- 50% of the time in small tumors 4 plete blood count every six months.

Outdated ECG Machines to be Deactivated June 1

N MAY 26, 2006, the Aerospace If you utilize one of these machines, Support Line at (800) 681-8687. They OMedical Certification Division you will need to acquire equipment are able to answer compatibility ques- (AMCD) sent all Senior AMEs a letter compatible with our server capability. tions and guide you in setting up test advising them that one of the servers For more information, please refer to the transmissions, etc. receiving transmissions from some ECG document that was attached to the May You must notify the AMCD re- machines will be deactivated on June 26, 2006, letter: “Options for Participa- garding arrangements you have made 1, 2007, which requires you to make tion in the FAA ECG Administrative regarding this matter. alternate arrangements for first-class Dat a Sy stem.” T h i s doc u ment i s a g u ide Thank you for your attention to this pilot ECG transmissions. The affected for making arrangements for transmit- important matter. ECG machines are: ting ECGs to the Aerospace Medical MANUFACTURER MODEL NUMBER Certification Division and includes Warren S. Silberman, DO, MPH GE/Marquette MAC 6 the name and phone number of several Manager, AMCD GE/Marquette MAC 8 manufacturers of ECG equipment. Civil Aerospace Medical Institute GE/Marquette MAC 12 GE/Marquette MAC 15 NOTE: If you are purchasing 4 GE/Marquette MAC PC equipment, it is imperative that you GE/Marquette MAC VU first consult with the FAA Technical

The Federal Air Surgeon's Medical Bulletin • Vol. 45, No. 2 • 5 Medical Specialties Division OAM NEWS Aerospace Medicine Consultants (PAMC) Manager Selected from 1982 until his appointment with the Office of Aerospace Medicine FAA. At PAMC, Dr. Berry gave airmen By R. Mark Adams medical certification examinations to a ICHAEL A. BERRY, MD, is the new large pilot patient base and was a consultant to NASA, Krug Mmanager of the Medical Specialties Life Sciences, Delta Airlines, Southwest Airlines, Continental Division in the Office of Aerospace Medicine. Airlines, ExpressJet Airlines, and others. He began his position in the Federal Avia- Dr. Berry earned a B.S. degree from Texas Christian tion Administration headquarters office on University and a medical degree from the University of November 1, 2006. Texas Southwestern Medical School. He completed the Dr. Berry is responsible for developing primary course in Aerospace Medicine at the School of aerospace medicine policies and procedures, Aerospace Medicine, Brooks AFB, San Antonio, Texas, and administering the medical appellate process, providing then earned an M.S. in preventive medicine from The Ohio oversight of employee drug and alcohol testing, managing State University. He completed his residency in aerospace and administering psychiatric and medical review officer medicine in 1978. functions, and providing aerospace medicine expertise and He has been an active member and held leadership positions advice to the Federal Air Surgeon. in many professional organizations, including the American A widely known and highly respected physician with Medical Association, the Civil Aerospace Medical Association, more than 30 years of professional experience in aerospace the Aerospace Medical Association, and the International medicine, Dr. Berry gained this experience practicing as a Academy of Aviation and Space Medicine. Dr. Berry has flight surgeon in the United States Air Force (USAF), with received numerous awards from these organizations for his the National Aeronautics and Space Administration (NASA), contributions. and as an FAA senior aviation medical examiner in private Remarking on Dr. Berry’s selection, Federal Air Surgeon clinical practice. Dr. Berry was also a designated Civil Avia- Fred Tilton, MD, said, “We are very fortunate to be able to tion Medical Examiner for Canada and is board-certified in attract a physician of Mike Berry’s stature and abilities to aerospace medicine. He is a distinguished speaker and has our organization. His management experience and excep- authored many aerospace medicine publications, including tional knowledge of aerospace medicine will be very valuable peer reviewed journal articles and chapters in textbooks. assets to the FAA and the Office of Aerospace Medicine His professional career began with service in the USAF from management team.” 1971 to 1976. Next, he was the Chief of Flight Medicine at the NASA Johnson Space Center in Houston, Texas, from 1978 Mr. Adams manages the Program Management Division at to 1981. He was a partner and vice-president of Preventive and FAA Headquarters in Washington, D.C.

2006 Aerospace Medicine Awards for Excellence and Achievement Presented

EDERAL AIR SURGEON FRED TILTON, MD, presented the THE WILLIAM E. COLLINS PUBLICATION AWARDS F2006 Aerospace Medicine Awards for Excellence and Cristy A. Detwiler, CAMI Achievement and highlighted each individual’s and team’s Jing Xing, PhD, CAMI contributions to the success of the organization. In addition, AAM MISSION SUPPORT a “Friend of AAM” award was given to an individual outside Noal D. May, PhD, CAMI of AAM who provides excellent support to AAM’s work and mission. The 2006 winners are: OUTSTANDING CUSTOMER SERVICE OUTSTANDING MANAGER Kathy E. Murby, New England Region Carol A. Kelly, Program Management Division, Headquarters FRIEND OF AAM OUTSTANDING LEADERSHIP Charles A. Davis, Office of Quality, Integration, & Executive Serv. Charles A. DeJohn, DO, CAMI FLIGHT SURGEON OF THE YEAR OUTSTANDING INNOVATOR Warren S. Silberman, DO, CAMI Richard L. Butler, CAMI INSPECTOR OF THE YEAR OUTSTANDING TEAM Ronald C. Katana, Drug Abatement Division, Headquarters ISO-9001:2000 Team, Headquarters REGIONAL EMPLOYEE OF THE YEAR (TIE) ADMINISTRATIVE EXCELLENCE (4-WAY TIE) Jeanne Rafferty, RN, Eastern Region Lisa M. McWhinney, CAMI Kara M. Semer, Northwest Mountain Region Denise D. Patterson, CAMI AAM OFFICE OF THE YEAR Lori J. Stormo, Drug Abatement Division, Headquarters Program Management Division, Headquarters Helen Hnarakis, Program Management Division, Headquarters 4

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. 45, No. 2 • Metastatic Hurthle Cell Carcinoma and Medical Certification Case Report, by Michael McGinnis, MD, MPH Thyroid carcinoma is the most common malignancy of the endocrine system. Thyroid cancers generally have a favorable prognosis but require ongoing follow-up. Surgery is the treatment of choice. Thyroglobulin can be useful tumor marker for disease surveillance. Disease impact on safety of flight is the primary aeromedical concern. Background A 65-year-old female with a history of Hurthle cell carcinoma (HCC) of HURTHLE CELL CARCINOMA: ETIOLOGY her thyroid presented to her aviation Thyroid cancer can be classified as the following (with relative medical examiner (AME) for renewal of frequency): her time-limited special issuance for her • •Differentiated (85%) second-class medical certificate. –Papillary (majority of cases) The pilot reported that she had been –Follicular doing well. Her cancer was originally –Hurthle cell diagnosed ten years ago after she noted •Medullary (8%) a lump at the base of her neck. Fine •Undifferentiated/anaplastic (5%) needle aspiration (FNA) was positive •Other – lymphoma, metastatic for Hurthle cells. Laboratory evaluation Risk factors for thyroid cancer include external radiation to the neck revealed markedly elevated thyroglobulin and familial syndromes. The general lag time from radiation exposure to levels without significant levels of anti- manifestation of disease ranges from 10 to 20 years (1). thyroglobulin antibodies. She received A FNA should be performed on any suspicious thyroid mass, as most a total thyroidectomy, which revealed cases of thyroid cancer can be diagnosed by FNA. Benign thyroid masses foci of capsular invasion. Two regional on FNA that are < 1cm in size have a low risk for future malignancy lymph nodes were positive for HCC. and may be followed without treatment. Aspiration carries a 1-5% false The pilot received adjuvant radioiodine negative rate; clinical suspicion guides the need to further pursue nega- remnant ablation and suppressive doses tive or non-diagnostic biopsies. Diagnostic work-up should also include of thyroid hormone replacement (goal laboratory testing (TSH, serum calcium, thyroglobulin level) as well as TSH < 0.1 µIU/ml). imaging (ultrasound, CT) of the neck. Unfortunately, this pilot suffered Surgery is the initial management strategy for almost all patients with multiple clinical recurrences of her thy- thyroid cancer. Common adjuvant therapy includes radioiodine remnant roid cancer over the following ten years. ablation to eliminate any residual thyroid tissue and administration of She received two courses of radioactive supraphysiologic doses of thyroid hormone to suppress TSH (2). Post- I131, as well as a course of whole-body operative chemotherapy is infrequently indicated. irradiation in unsuccessful attempts to Hurthle cell carcinoma is considered a variant of follicular carcinoma eradicate her disease. Of note, her thy- and has unique features. HCC typically does not take up iodine and is roglobulin level has remained detectable not TSH growth-dependent, thus decreasing the efficacy of radioiodine throughout. ablation as well as TSH suppression. A recent CT scan of her neck and chest Disease surveillance includes radionuclide imaging (whole body-scan- revealed low-grade lymphadenopathy ning for areas of iodine uptake) and assessment of thyroid-specific tumor of her cervical, lung, and mediastinal markers (thyroglobulin). lymph nodes. These CT results were Thyroglobulin is synthesized from thyroid tissue only. Most differentiated not significantly different from a CT tumors of the thyroid synthesize thyroglobulin; however, medullary and performed six months earlier. The pilot’s undifferentiated thyroid tumors rarely produce thyroglobulin (3). Post total specialist noted that her thyroglobulin thyroidectomy, thyroglobulin can be a sensitive marker for the continued level remained markedly elevated at presence of thyroidal tissue. Anti-thyroglobulin antibodies interfere with 420 ng/ml (normal range for the lab, the accurate measurement of thyrogloblin and are present in up to 20% 2.0-35.0 ng/ml), consistent with the of patients with thyroid cancer. The presence of anti-thyroglobulin should continued presence of her thyroid can- be assessed when initially measuring thyroglobulin levels. cer. She did not have significant levels The overall thyroid cancer death rate is <10%. There are multiple of anti- thyroglobulin antibodies. Her prognostic scoring systems for thyroid cancer. All weigh the presence of specialist noted the slow clinical course extrathyroid involvement and distant metastases; most include patient of her disease and gave her an “excellent” age and tumor size (2). Patients <45 years of age with tumor size less prognosis. The specialist stated that the than 2cm have the most favorable prognosis. chance of the pilot having an event that Continued on page 9

The Federal Air Surgeon's Medical Bulletin • Vol. 45, No. 2 • 7 Complex Partial COMPLEX PARTIAL SEIZURES Seizures Complex partial seizures, while perhaps the most common form of epi- Case Report lepsy, remain an interesting diagnostic dilemma. Although they can arise By Kathleen Jones, MD, MPH from any cortical region, complex partial seizures typically arise form the Complex partial seizures arise from temporal lobe. The temporal lobe is the seat of auditory, olfactory, higher a single focus in the brain and cause visual, emotional, memory, and social functioning. It serves partly as a link 1 an impaired level of consciousness. Al- for sensory and emotional experiences between the past and present. It is though these seizures can occur at any the temporal lobe location and resultant symptomatology that can make 1 diagnosis a challenge. age, they are more common in adults. Complex partial seizures of the temporal lobe can be tentatively localized The true incidence of complex partial based on medical history and symptomatology.1 Medial syndromes tend to seizures is difficult to determine. In this have a long interval between the original insult and the onset of seizures. article, a case of complex partial seizure The aura is more likely to be characterized by a distinct rising abdominal disorder is reported in an airline trans- sensation or a feeling of fear. They often arise in individuals with a history port pilot, along with a discussion of of febrile seizures during childhood, meningitis, or mesial temporal sclerosis. Lateral syndromes have a shorter latent period and are rarely attributed to a the seizure disorder and its aeromedical childhood febrile seizure. The aura is more typically one of déjà vu, jamais implications. vu, d e p e r s o naliz at io n, o r ve r t igo. T h ey o ccur in individuals wit h h e ad t rauma, brain tumors, or cortical dysplasia. With regard to hemispheric location, right- ISTORY. A 37-year-old male airline sided seizures tend to result in distortions of visual, spatial, and geographic Htransport pilot arrived for duty, orientation. Left-sided seizures tend to impact verbal memory. appearing to be in his usual state of A complex partial seizure typically starts with a sensation of fear, a distinct 2 good health. He met his crew at the rising sensation in the abdomen, or a feeling of unreality. The sensation airport, walked though the airport of unreality is often one of jamais vu, the contrary of déjà vu, in which the terminal with his copilot, boarded the individual feels he is experiencing familiar people, places, and events as if for the first time. The patient will be noted by others to have a blank stare aircraft, and started pre-flight checks. and be unarousable. Although not universal, most patients will also have Several minutes into his checks, he an oral or motor automatism, such as lip smacking, licking lips, hand pat- recalls feeling a sense of “the picture ting, or picking at something repetitively. The seizure will last anywhere changing.” He became confused as between 30 and 180 seconds.3 Immediately postictal, the patient will often everything felt unfamiliar to him; he experience lethargy, confusion, and some degree of amnesia; will know was in a place and time he didn’t rec- that the perceptions occurred and were not real but may be unaware of the ognize. He recalls nothing else until he passage of time and the extent of the misperceptions. “awoke” feeling fatigued, disoriented, Two complications that concern. First, complex partial seizures may and confused. His copilot told him that generalize, and status epilepticus can be manifested by prolonged episodes he had been staring ahead “blankly” for of waxing and waning consciousness. Second, up to one-third of patients 2 the past minute. The copilot shook the diagnosed with temporal lobe epilepsy suffer from interictal depression. airman, but he did not respond but just The rate of suicide in individuals with this disorder is 10 times higher than that of the general population.2 Because the temporal is the most common kept picking at the leg of his pants. The lobe involved in complex partial seizures, depression is a major concern pilot then pulled himself off the flight in these patients. and went home. Diagnostic dilemma. Essentially, this is a condition in which the symptoms, Two days later, he presented himself although characteristic, are often overlooked or confused with other condi- to the university hospital, where he was tions. Among the differential diagnoses to consider are migraine headaches seen by a consulting neurologist. The and hypoglycemia. However, psychiatric conditions comprise a greater part airman confessed that this was not the of the differential list. Schizophrenia, panic disorder, and stress reactions can first such incident. He had experienced mimic complex partial seizures. Complicating this picture is that multiple at least 3 other such incidents, but interictal EEGs may be normal and the MRI negative. In fact, up to 10% of 1 none had been while at work. These patients with complex partial seizures may never have an EEG correlation. occurrences had been happening for Although 24-hour EEG monitoring may assist in reducing this number, this is the past 3 months without regularity or only true if a seizure can be induced. There are cases scattered throughout psychiatric literature documenting patients treated for psychiatric disorders predictability. He recalls one occurring that actually had a complex partial seizure disorder. The key to diagnosis while sitting in his backyard watching of complex partial seizures is, as with most of medicine, contained in the his children play in the pool. He felt history of the patient and any witnessed accounts. 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. 45, No. 2 • SEIZURES from page 8 thoroughly educates the patient on the consequences of such actions for both Hurthle Cell from page 7 the scene shift into something he didn’t driving and flying. It is incumbent on recognize, that he was surrounded by the AME to carefully question patients would impair her ability to fly an aircraft as being extremely remote. unfamiliar people in an unfamiliar with this diagnosis about any continua- Given the evidence of metastatic location. He has no idea how long tion of symptoms. disease, her AME deferred her case to that incident lasted, but nobody else ASE OUTCOME. The airman in this the Aerospace Medical Certification noticed it. He remembers feeling very Ccase reported his condition after Division (AMCD) for evaluation. lethargic, uncoordinated, and dizzy experiencing a probable seizure in the Aeromedical Concerns. Safety of after he “awoke.” cockpit. He was diagnosed with complex flight is the primary concern. Individu- His medical and family histories were partial seizures and started on Depak- als with medical conditions that place negative for seizures, migraines, and ote (divalproex sodium). He continued them at risk for sudden incapacitation psychiatric illnesses. He did fall once 18 the medication for 2 months but then will not receive certification to fly. months earlier during motocross racing stopped due to side effects. Around this This pilot has lymphadenopathy and suffered head trauma, but states time, he proceeded to seek out the opin- of her neck and chest consistent with that he “probably” didn’t have any loss ions of other neurologists. All told, he metastatic thyroid cancer. The elevated of consciousness. He was on no medica- consulted 5 separate neurology practices thyroglobulin level supports this di- agnosis. tions, drank alcohol socially, and denied until the last physician concluded there The AME deferred this pilot for any illicit substance use. He smoked 1 was no evidence of a seizure disorder. certification under Title 14 of the Code to 2 packs of cigarettes daily. He was in Once he had the results of that consul- of Federal Regulations (CFR), revised the midst of a divorce and child custody tation, the airman attempted to secure Part 67, under Section 213 (b)(c). The battle. He admitted to poor sleep, perhaps the return of his medical certification. Aerospace Medical Certification Divi- getting only 2 to 4 hours each night for However, review of that consultation sion found the pilot to be ineligible for the previous several months. He also said revealed the airman had been disin- routine medical certification under that he engaged in “drive-through cook- genuous with the consultant and that the these regulations. ing” when his children were not visiting consultant had not received any records Outcome. The AMCD requires and he had been skipping meals. of the initial consultation. The airman one year of recovery after treatment Head CT, brain MRI, and EEG were had given the physician no information for metastatic cancer prior to consid- normal, as was a physical exam with a other than “decreased concentration” for eration for special issuance. The pilot’s fully documented neurological exam a few seconds. He withheld information slow progression of HCC metastatic showing no deficits. His laboratory on a witness to his seizure in the cock- disease, the low likelihood of sud- tests were normal, including glucose. pit. He also withheld any information den incapacitation, and the favorable His toxicology screen was negative. He relating to his sense of derealization, prognosis from the consulting physi- was diagnosed with probable complex the hand automatism, and the postictal cian all resulted in a favorable AMCD partial seizures. fatigue and confusion. After review of his assessment. EROMEDICAL D ISPOSITION. The FAA case, the airman was denied his medical This airman was eventually granted a Ahas determined that epilepsy and certification until he meets the 10-year special issuance by the AMCD because other seizure disorders are disqualify- seizure-free standard. her medical condition was stable, de- ing. They may be considered for special References spite being potentially progressive. An authorization letter for time-limited issuance once the airman has been 1. Devinsky O. Diagnosis and Treatment of Temporal Lobe Epilepsy. Reviews in Neu- special issuance was granted by the seizure-free and off medications for 10 rological Diseases 2004. 1(1): 2-9. Federal Air Surgeon via the AMCD ye a rs. A f u l l neu rolog ic e va lu at ion w it h a 2. Restak R. Complex Partial Seizures Present under 14 CFR §67.401. Reports of follow-up EEG is required. The potential Diagnostic Challenge. Psychiatric Times pertinent laboratory tests (thyroid for sudden incapacitation with complex 1995. 12(9). Retrieved August 5, 2004 from function, CBC, thyroglobulin and liver partial seizures cannot be overstated. URL: www.psychiatrictimes.com/p950927. html. associated enzymes), detailed specialist The sense of depersonalization and de- evaluation, and interval CTs of her neck 3. Prego-Lopez M, Devinsky O. Evaluation of realization, as well as the impairment of a First Seizure: Is it Epilepsy? Postgraduate and chest will be required for future consciousness, presents a serious threat Medicine 2002. 111(1): 34-6, 43-8. special issuance renewal. to safety. Complicating this picture is Kathleen Jones, MD, MPH, was a resident that ma ny patients (usua lly men) choose in Aerospace Medicine when she wrote this Concluded on page 12 not to report ongoing seizures so they case report while on rotation at the Civil can maintain driving privileges. Obvi- Aerospace Medical Institute. ously, it is imperative that the physician 4

The Federal Air Surgeon's Medical Bulletin • Vol. 45, No. 2 • 9 Medical Certification of Pilots With Lower-Extremity Amputations Case Report, by William E. Nelson MD, MPH Amputations and Limb More than 1.2 million Americans live with absence of a limb. Modern Deficiencies prosthetic limbs, talented prosthetists, and enthusiastic therapists en- able many motivated individuals with absent limbs to pursue very active More than 1.2 million Ameri- lifestyles. This article presents a case report of a first-class pilot who had cans live with loss or absence experienced a traumatic above-knee amputation and includes a brief of a limb. Over 1,000 children review of recent U.S. limb loss and amputation data, as well as aero- are born with limb deficiencies medical issues associated with amputation. each year.1 The rate of trauma- related amputations in the U.S. ISTORY. A 46-year-old male first- AEROMEDICAL ISSUES. The primary class pilot with over 12,000 hours aeromedical concern following ampu- during the mid-1990s was 5.86 H 2 of flight time applied for first-class tation is the airman’s ability to safely per 100,000 persons. Thus, medical recertification 14 months operate an aircraft; another concern is based on current population following a motorcycle accident that the airman’s ability to egress an aircraft data, approximately 17,000 resulted in an above-knee amputation. in the event of a mishap. Pain from a less trauma-related amputations are He held Airline Transport and Com- than optimally fitted prosthetic socket performed annually.3 Work-re- mercial Airman Certificates. or phantom limb pain might distract lated amputations are a subset The airman was ejected from his an airman. Diminished sensibility, of amputations associated with motorc ycle a s it col lided wit h a c a r. The loss of joint proprioception, lessened trauma. During the 1990s, impact resulted in a proximal traumatic coordination, altered range of motion, there were more than 11,000 left below-knee amputation, an open and decreased extremity strength may non-fatal work-related ampu- femur fracture, and a proximal left thigh interfere with the operation of rudder tations annually.4 The number wound. He underwent emergent irriga- pedals and brakes (in the case of lower- tion and debridement of the traumatic extremity amputation) or with the use of work-related amputations amputation, with revision to an above- of switches, dials, throttles and the has declined since the Oc- knee amputation. He returned to the yoke (in the case of upper-extremity cupational Safety and Health operating room 3 days following injury amputation.) Administration introduced a for repeat irrigation and debridement of In addition to addressing functional program to reduce amputations the amputation and wound closure. The impairment from an amputation, an in 1997, but more than 8,000 in- airman was fitted with a prosthetic limb aviation medical examiner (AME) dustrial amputations still occur and underwent 6 months of physical should consider the underlying disease each year.5,6 A large percentage therapy and gait training. that resulted in the limb loss in a case (98%) of these work-related One year following the traumatic of non-traumatic amputation. For ex- amputations affect the upper amputation, the airman was able to ample, applicants with a history of pri- extremity.6 However, 86% of ambulate 1200 feet without an assistive ma r y bone c a nc er or sof t t i s sue sa rc oma all amputations in the United device during a 6-minute walk test. (A require a period of observation following States involve the lower limb, normal distance is greater than 1000 completion of treatment, based upon the feet.) The airman scored 53/56 on a type of malignancy, as well as evalua- and 93% of these are related 2 Berg balance test. His score was less tion to exclude detectable metastasis. to peripheral vascular disease. than perfect only because he could not Applicants with a history of diabetes Approximately 115,000 lower- maintain single-leg stance for 10 sec- require evaluation, as outlined in the extremity amputations are per- onds when standing on the prosthesis. Diabetes Mellitus I and II Protocols formed each year for end-stage (A score less than 45 is significant for included within the Guide for Aviation peripheral vascular disease.7 an increased risk of falls.) The airman Medical Examiners.8 Applicants with a Based on the rate of cancer- was able to complete a 360-degree history of peripheral vascular disease related lower-limb amputations turn test of balance within the normal require a cardiovascular evaluation, (0.24 per 100,000 people), ap- time of 4 seconds and with the normal as outlined in the Vascular System proximately 710 cancer-related nu mber of le ss t ha n 8 steps. He wa s able Examination Techniques section of lower- extremity amputations to successfully negotiate stairs, ramps, the AME Guide, 9 since cardiovascular are performed annually.2 and grassy slopes. He was also able to disease is the leading cause of death in perform agility drills and changes in direction without losing his balance. 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. 45, No. 2 • AMPUTATIONS from page 10 If the applicant has a Statement of 117 second-class, 236 third-class) Demonstrated Ability (SODA) issued with lower-extremity amputations individuals who die during the first year on the basis of the amputation, then have been issued medical certificates. following amputation for peripheral the AME should issue the medical Only 1 airman was denied a certificate vascular disease.7 certificate if there has been no change during the past 3 years: An AME de- ROLE OF THE AME. The general in the conditions since the SODA was ferred a third-class certificate renewal medical standards for medical certifi- granted. If the applicant does not have for a 50-year-old airman with a right cates annotated in Title 14 of the Code a SODA, the issuance requires an FAA below-knee amputation, the result of of Federal Regulations (CFR) Parts Decision. After reviewing all medical peripheral vascular disease. The airman 67.113, 67.213 and 67.313 include no data, the FAA may authorize a Medi- had a 20-year history of Type I diabetes functional or structural disease, defect, cal Flight Test (MFT). If the airman mellitus treated with insulin, diabetic or limitation that makes the person passes the MFT, a SODA may be issued retinopathy, hypertension, and a his- unable to safely perform the duties or because an amputation is a medical tory of a transient ischemic attack and exercise the privileges of an airman.10 defect that is expected to be static, or a myocardial infarction. The Regional AMEs are authorized to examine air- nonprogressive, in nature. Flight Surgeon subsequently denied men to determine whether or not they OUTCOME. Based upon the airman’s the certificate. meet the standards. history and physical examination, 15 The AME Guide outlines the months following the amputation the References standard examination procedures airman was authorized by the FAA 1. Amputee Coalition of America. that should be used to evaluate the Aerospace Medical Certification Di- www.amputee-coalition.org/aca_ applicant’s musculoskeletal system.11 vision (AMCD) to take a first-class advocacy.html. Accessed 9 Mar In general, AMEs should note any medical flight test. Requirements for 2005. deformity, pain, weakness, loss of mo- conducting a MFT for an applicant with 2. Dillingham TR, et al. Limb amputa- tion, or lack of coordination. AMEs the absence of extremities are included tion and limb deficiency: Epidemiol- should specifically note any amputa- in FAA Order 8700.1, General Aviation ogy and recent trends in the United tion and comment on the amputation Operations Inspector’s Handbook, States. S Med J, Aug 2002; 95(8): level, stump healing, and phantom Volume II, Chapter 27, Section 2, Para- 875-83. pain. Additionally, AMEs should note graph 3, Item E (3). The requirements 3. U.S. POP Clock Projection. U.S. the comfort of a prostheses and the include assessing the applicant’s ability Bureau of the Census. www.census. applicant’s ability to use the prosthetic to reach and operate controls and to gov/cgi-bin/popclock. Accessed 11 Mar 2005. limb. While amputations generally are perform emergency procedures. static medical defects, AMEs should be Additionally, the examiner deter- 4. Brown JD. Amputations: A continu- aware that late complications can oc- mines whether the applicant should be ing workplace hazard. Bureau of cur, and therefore should be considered restricted to a specific make or model Labor Statistics. www.bls.gov/opub/ cwc/sh20030114ar01p1.htm. Ac- when an applicant with a history of am- of aircraft or an aircraft with special cessed 10 Mar 2005. putation requests a medical certificate. equipment or control arrangements. These complications include pain, skin The MFT for the pilot described in this 5. OSHA. OSHA Instruction national emphasis program on amputations. ulceration, infection, and rashes, most case report was conducted in a Level D Directive No. CPL 2-1.35. www. of which can be resolved by adjustment simulator and tested the airman’s ability 12 osha.gov/OshDoc/Directive_pdf/ of the prosthesis. to operate rudder and toe brakes with CPL_2-1_35.pdf. Accessed 10 Mar The disposition guidance in the the prosthetic leg. The simulator check 2005. Guide for Aviation Medical Examiners ride included successf ul demonstration 6. US Department of Labor, Bureau indicates that, for all classes of medi- of taxiing, braking, take off, ILS and of Labor Statistics Number of cal certificates, AMEs should submit missed approaches with crosswinds nonfatal occupational injuries and a current status report for applicants requiring braking and asymmetric illnesses involving days away from with amputation addressing functional thrust, as well as aborted takeoff requir- work1 by part of body and selected status and noting the degree of impair- ing maximum braking. The airman natures of injury or illness, 2002 ment, as measured by strength, range of successfully completed the MFT 16 Table R19. www.bls.gov/iif/oshwc/ motion, and pain.13 The report should months following the amputation and osh/case/ostb1286.pdf. Accessed 9 also indicate any medications the ap- was issued a SODA. Mar 2005. plicant is taking and any associated side Analysis of AMCD data indicates Continued on page 12 effects. All pertinent medical reports that during the past 3 years, 613 ac- should also be submitted. tive airmen (50 first-class certificates,

The Federal Air Surgeon's Medical Bulletin • Vol. 45, No. 2 • 11 AMPUTATIONS from page 11 QUICK FIX 7. Sandnes DK. Survival after lower- extremity amputation. PROBLEM. Some aviation medical examiners are hand- J Am Coll Surg, Sep 2004; 199(3): 394-402. printing the medical certificate, Form 8500-9. RESULT. Recall that you must type your certificates not 8. General systemic examination techniques. Office of Aero- hand write them for reasons of legibility and to satisfy space Medicine Guide for Aviation Medical Examiners. legal requirements. FAA inspectors who ramp-check FAA. www.faa.gov/about/office_org/headquarters_ airmen may question the authenticity of a hand-written offices/avs/offices/aam/ame/guide/app_process/exam_ medical certificate. tech/item48/et/. Accessed 16 Feb 2007. SOLUTION. Complete the airman medical certificate using 9. Vascular system examination techniques. Office of Aero- either a typewriter/office computer or use the certificate space Medicine Guide for Aviation Medical Examiners. printing template from our Web site. This is a modifi- FAA. Office of Aerospace Medicine Guide for Aviation able template for use with MS Word and your printer as Medical Examiners. FAA. www.faa.gov/about/office_org/ an alternative to typing certificates with a typewriter. The headquarters_ offices/avs/offices/aam/ame/guide/app_ template provides you with a table (or chart) in which the process/exam_tech/item37/ Accessed 16 Feb 2007. airman’s information is entered. Then you are able to feed 10. 14 CFR, Chapter 1, Subchapter D, Part 67 Medical the actual certificate into your printer so the information Standards and Certification. www.faa.gov/about/of- is printed directly onto the certificate. Remember to use fice_org/headquarters_ offices/avs/offices/aam/ame/guide/ the detachable Form 8500-9—not plain paper. We are standards/. Accessed 16 Feb 2007. working on an application that will allow you to print these certificates from your office or home computer. But 11. Examination techniques. Office of Aerospace Medicine for now, we suggest that you download the template from Guide for Aviation Medical Examiners. FAA. www.faa. our Web site (along with complete instructions): gov/about/office_org/headquarters_offices/avs/offices/ www.faa.gov/other_visit/aviation_industry/designees_ aam/ame/guide/app_process/exam_tech/. Accessed 16 delegations/designee_types/ame/amcs/template/ Feb 2007. 12. Browner. Skeletal trauma: Basic science, management, and reconstruction, 3rd ed., 2003 Elsevier. Pg 2625. Hurthle Cell from page 9 13. Aerospace Medical Disposition. Office of Aerospace References Medicine Guide for Aviation Medical Examiners. FAA. 1. Thyroid cancer. In: Abeloff M et al. Clinical oncology. New York, www.faa.gov/about/office_org/headquarters_offices/avs/ London: Churchill Livingstone/Harcourt Brace; 2004:1612-21. offices/aam/ame/guide/dec_cons/disp/. Accessed 16 Feb 2. AACE/AAES medical/surgical guidelines for clinical practice: manage- ment of thyroid carcinoma. Endocrine Pract, 2001; 7(3): 203-20. 2007. 3. Whitley RJ, Ain KB. Thyroglobulin: A Specific serum marker for the management of thyroid carcinoma. Clin Lab Med, 2004;24:29-47. William E. Nelson, MD, MPH, COL, USAF, MC, SFS, was a resi- Michael McGinnis, MD, MPH, CDR, MC, USN, was a resident in dent in aerospace medicine when he wrote this case report at the Civil aerospace medicine when he wrote this case report at the Civil Aerospace Aerospace Medical Institute. Medical Institute. Currently, he is the Senior Medical Officer on board 4 the USS Nimitz. 4 2007 Aviation Medical Examiner Seminar Schedule July 13 – 15 Oklahoma City, Okla. NPN (2) August 17 – 19 Washington, D.C. OOE (2) August 27 – 31 Oklahoma City, Okla. Basic (1) September 14 – 16 Savannah, Ga. CARDIO (2) December 10 -14 Oklahoma City, Okla. Basic (1) CODES AP/HF Aviation Physiology/Human Factors Theme (2) A 2½-day theme AME seminar consisting of 12 hours CARDIO Cardiology Theme of aviation medical examiner-specific subjects plus 8 hours of subjects related to a designated theme. Registration must be OOE Ophthalmology - Otolaryngology - Endocrinology made through the Oklahoma City AME Programs staff, Theme (405) 954-4830, or -4258. N/NP/P Neurology/Neuro-Psychology/Psychiatry Theme The Civil Aerospace Medical Institute is accredited (1) A 4½-day basic AME seminar focused on preparing by the Accreditation Council for Continuing Medical physicians to be designated as aviation medical examiners. Education to sponsor continuing medical education for Call your regional flight surgeon. 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. 45, No. 2 •