Federal Air Surgeon’s Medical Bulletin Aviation Safety Through Aerospace Medicine Vol. 48, No. 4 For FAA Aviation Medical Examiners, Office of Aerospace Medicine Personnel, U.S. Department of Transportation 2010-4 Flight Standards Inspectors, and Other Aviation Professionals. Federal Aviation Administration Introducing the FAA’s Aviation Safety Partnership Pilots have new resources available By Harriet Lester, MD ere’s a fact for you: 2 EDDITORIALITORIAL: WOORKINGRKING TTOO HNearly half of all avia- IMMPROVEPROVE CEERTIFICATIONRTIFICATION tion medical examiners (AMEs) are also pilots. 3 CEERTIFICATIONRTIFICATION UPPDATEDATE: In view of this statistic, MEEDICATIONSDICATIONS, PAARTRT IIII the Eastern Region Division of Aerospace Medicine and 4 AAMEME UPPDATESDATES: the Civil Aerospace Medical QUUALITYALITY STTANDARDSANDARDS, Institute recently partnered COOLORLOR V IISIONSION TEESTINGSTING with the FAA Flight Stan- dards FAASTeam (Federal 5 LEETTERTTER TTOO TTHEHE EDDITORITOR: Aviation Administration INFORMATION FOR PILOTS. AMEs at the recent VIISUALSUAL ACCUITYUITY PRROBLEMOBLEM Safety Team) on a new safety Arlington, Va., seminar also participated in an information session with FAASTeam staffer Felice initiative. Brunner (at computer). They received aviation safety- Together, we hope to pre- related materials and viewed live links to online sources 6 WHHOO’S WHHOO IINN AEEROSPACEROSPACE of pilot information. Shown with Brunner is AME MEEDICALDICAL EDDUCATIONUCATION vent accidents and continue Fitzwilliam King, MD, from Travelers Rest, S.C. to “tip” the safety in the right direction. general aviation. This number, which What inspired the collaboration was came from an informal survey of my 7 22010010 EEAAAA AIIRRVEENTURENTURE the unfortunate reality that over the past fellow Regional Flight Surgeons, is not OSSHKOSHHKOSH REEPORTPORT decade roughly 15 AME-pilots have a hard statistic and does not include died in aircraft accidents, primarily in Continued on page 5 AEROSPACE MEDICINE TEAMS UP AT OSHKOSH. 8 P AAPILLARYPILLARY THHYROIDYROID CAANCERNCER The Great Lakes CAASESE REEPORTPORT Regional Medical Division provided a service booth for 1100 ALLPHAPHA--1-A1-ANNTITRYPSINTITRYPSIN pilots attending the DEEFICIENCYFICIENCY CAASESE REEPORTPORT recent AirVenture 2010 airshow. Shown are Federal Air Surgeon Fred Tilton (right) 1111 NEEWW THHEMEEME SEEMINARMINAR welcoming Secretary DÉÉBUTSBUTS AATT ASMMAA of Transportation Ray LaHood. Working certification cases is AMCD Manager Warren Silberman 1122 AVVIATIONIATION MEEDICALDICAL EXXAMINERAMINER (center). In the SEEMINARMINAR SCCHEDULEHEDULE background is Acting Great Lakes Regional Flight Surgeon Matthew Dumstorf. (More, page 7.) Working Together to Improve the Certification Process

I hope you all had a safe and enjoy- Review and interpret. You are also able summer. responsible for reviewing and interpret- The Office of Aerospace Medicine is ing the tests you order. For example, an in the Federal Aviation if you perform an ECG as part of an Administration (FAA) Aviation Safety FAA examination, you need to assess line of business that is responsible for the the results. A new right bundle branch medical certification of approximately block or multiple PVCs should be 600,000 pilots and 16,000 air traffic worked up. We have received ECGs controllers. We receive and review about in conjunction with issued certificates 450,000 airman medical applications By Fred Tilton, MD where the airman should have been sent each year. I am focusing my comments to the emergency room for admission on pilots, but the certification of air to the coronary care unit! traffic controllers is equally important. This summer we reviewed the medi- Your comments are needed. You Medical certification is a complex cal certification process and identified must comment on each “yes” answer process. Fortunately, in the last few opportunities for improvement. As a in block 18 and each abnormal physical years, the United States Congress has result of the review, I have directed my examination finding in block 60 of the authorized resources that have allowed staff to implement several changes. We FAA Form 8500-8. While, technically us to add quality assurance staff and also identified five ways that you, as speaking, there is nothing to prohibit the continue to enhance our electronic aviation medical examiners (AMEs), use of “Previously Reported, No Change airman medical certification systems. can help us improve the quality and the (PRNC),” in section 60, please do not efficiency of the certification process: do so. We need a brief but informative Federal Air Surgeon’s Limit unnecessary deferrals. Some narrative that documents your discus- Medical Bulletin medical applications must be deferred, sion with the airman. Library of Congress ISSN 1545-1518 such as the first application after a myo- Emphasize MedXPress. Encourage Secretary of Transportation cardial infarction. However, we receive all applicants to use MedXPress. It will Ray LaHood many deferrals (e.g., simple hyperten- save you and your staff time and elimi- FAA Administrator sion) that could have been issued at the nate errors associated with transferring J. Randolph Babbitt time of examination had the AME just the applicant’s history from paper to the read and followed the online guide. Federal Air Surgeon electronic system. My personal AME Fred Tilton, MD Every time you unnecessarily defer an has directed his staff to tell applicants application you create delays. The air- that he will not see them unless they use Editor man has to wait for certification, and Michael E. Wayda MedXPress. NOTE: Presently, techni- you us to use the time we should cal issues preclude the use of MedXPress The Federal Air Surgeon’s Medical Bul- have been spending working a more for air traffic controller examinations. letin is published quarterly for aviation difficult case that actually required medical examiners and others interested in aviation safety and aviation medicine. our attention. We need your help to be successful. The Bulletin is prepared by the FAA’s Civil Call for help. If you have questions, Working together, we have the op- Aerospace Medical Institute, with policy c a l l you r Reg iona l Flig ht Su rgeon. We portunity to significantly improve the guidance and support from the Office of often authorize an AME to issue an medical certification process and pro- Aerospace Medicine. An Internet on-line version of the Bulletin is available at: www. airman medical certificate after such vide much better service to our aviators. faa.gov/library/reports/medical/fasmb/ discussions. Even if we do not autho- Thank you again for everything you rize you to issue a certificate, we can do for us and your airmen. Authors may submit articles and photos for publication in the Bulletin directly to: give you advice that you can pass on to the applicant. —Fred Editor, FASMB FAA Civil Aerospace Medical Institute AAM-400 P.O. Box 25082 Oklahoma City, OK 73125 E-mail: [email protected]

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. 4 • Medications, Part II Certification Update As you know, the combined use of oral agents and beta-blocking medications is he following is the second part Information About Issues limited, but Januvia can be used. Tof a long list of medications and Byetta (exenatide) is an injectable conditions that we refer to when mak- medication that is used with any of ing certification decisions. (See Part I, the other oral agents. The restriction “Policies and Unacceptable Medica- with this medication is that the air- tions,” FASMB, Vol. 48, No. 3, p. 3.) man must wait for 2 hours after use Anticoagulation. The advent of the before flying. Byetta is also acceptable International Normalized Ratio (INR) with beta-blocking medications. The has permitted the Federal Aviation new Byetta-type medication, Victoza Administration to allow airmen with (liraglutide), has not been approved by a variety of conditions to gain medical the FAA as yet. certification with a waiver. Conditions The other oral agents acceptable with such as mechanical valve replacement, By Warren S. Silberman, DO, MPH beta blockers are metformin, either of deep venous thrombosis, pulmonary the thiazolidinediones, and acarbose embolus, and chronic atrial fibrillation more that two tablets daily. Remember (Precose). are just some of the conditions we al- here, it is the condition that you must Diabetes mellitus treated with low. The INR levels must be within the consider. Enbrel (etanercept) has been insulin (authorized for third-class parameters set by the condition. The used in the treatment of both types of only). The FAA accepts all forms of airman MUST have monthly INR levels colitis. Etanercept is acceptable, but it insulin, as well as the different ways in done. One of our requirements is that will require yearly status reports. which it is administered. We also ac- 80% of the levels must be within the Cancer therapy. In general, in- cept the combined use of insulin and parameters established by the condition. travenous cancer therapies will delay oral hypoglycemic agents, but insulin Antiseizure medications. Recall certification decisions. The FAA wants and beta blockers are an unacceptable t hat epi leps y is one of t he 15 speci f ic a l ly to wait until the airman has completed combination. disqualifying medical conditions. We treatment, even if the treatment is adju- Glaucoma treatments. Most do not permit the use of any of these vant. Besides the side effects of the actual forms of treatment are acceptable. medications for their intended use or treatments, the specific cancer that is Prostaglandins such as Xalatan for use in any other condition. You being treated and the psychological is- (latanoprost), Lumigan (bimato- may see physicians use the antiseizure sues that can occur while the airman is prost), and Travatan (travoprost); medication gabapentin (Neurontin) coming to grips with this malignancy be t a-bloc ker s suc h a s Ti mopt ic (t i mo - for painful peripheral neuropathy or are grounds to wait until the treatment lol maleate) and Betoptic S (betaxolol); carbamazepine (Tegretol) for trigeminal has been completed. the alpha-adrenergic agonist Alphagan neu r a l g ia . I n bot h of t he se ci rc u m st a nc- There are exceptions to many of (brimonidine); and carbonic anhy- es, the medications are not acceptable. our policies. For example, the use of drase inhibitors such as Trusopt (dor- Baldness remedies. Propecia (fin- tamoxifen (Nolvadex) to reduce the zolamide) are all acceptable. However, asteride), as an ointment for use on the risk of is acceptable in parasympathomimetic agents and scalp, is used for male pattern baldness. aviation environment. epinephrine are not acceptable. This is acceptable, but it would be ap- Diabetes mellitus treated with Chronic myelogenous leukemia. propriate for to obtain a note from the medications. The FAA accepts all This condition was not acceptable to treating physician that the airman using oral hypoglycemic agents, but there the FAA until there was good success finasteride has no side effects. are policy exceptions. The more recent with the medication Gleevec (imatinib Colitis. Acute exacerbation of any medication Januvia (sitagliptin) can mesylate). This medication has allowed form of colitis is disqualifying, and only be used with metformin and/or us to grant authorizations to many air- the airman cannot be cleared until in the thiazolidinediones. We also accept men. It requires a status report every remission. So, as I have told you many Januvia and both of the above medi- 6 months and complete blood count, times, equivalent doses of prednisone cations. We do not accept the use of but airmen on this medication have greater than 20mg are not acceptable. Januvia and a sulfonylurea. If Januvia done well. Steroid enemas or foam instillation into is being used as the initial treatment Depression. In April 2010, the Of- the rectum for proctitis is acceptable. for diabetes, then the airman must wait fice of Aerospace Medicine announced Loperamide (Imodium) is used for for 60 days to be considered, but if it is that we will allow airmen with a diag- diarrheal symptoms and is acceptable being added to the medication regimen, nosis of depression to fly while using as long as the airman is not taking t hen t he a irma n need on ly wa it 14 d ay s. four of the selective serotonin reuptake

Dr. Silberman manages the Aerospace Medical Certification Division. Continued on page 4

The Federal Air Surgeon's Medical Bulletin • Vol. 48, No. 4 • 3 Medications from page 3 AME Updates theme, your Regional Flight Surgeon Quality standards for designees is your key point of contact if you’re inhibitors (SSRIs). The airman must getting close and could potentially have have been on the same medication By Brian Pinkston, MD, MPH a problem meeting these requirements. for 12 months. The only acceptable These dates are hard dates, and failure medications are fluoxetine (Prozac), s some of you may remember to train on time is currently the lead- sertraline (Zoloft), citalopram (Celexa), from the Federal Air Surgeon’s ing cause for involuntary termination and escitalopram (Lexapro). Medical Bulletin in 2005 (Vol. of AMEs. The policy is explained in detail in A The Federal Register (www.thefederal 43, No. 2), the General Accounting Currently, the second most-common register.com/d.p/2010-04-05-2010-7527). Office issued a report in October 2004 reason for AME termination is failure Still acceptable is the previous on aviation safety that focused on the to perform at least 10 exams per year. policy whereby the airman was tak- designee systems within the Federal Although this seems like an easy num- ing any one of the SSRIs but had Aviation Administration (FAA). Since ber to achieve, and it is the minimum discontinued the medication (hope- that time, the FAA has been focused number determined to keep current fully because of improvement). The on improving designee management, with AME Guide and other policy policy that the airman will need to with the Federal Air Surgeon’s Office c h a n ge s, m i l it a r y A M E s of ten h ave d i f- be off the medication for 90 days and playing a leading part in this program. ficulty sustaining this level. The main provide a current functional status As AMEs, we play a crucial role in reason is that they may have a large report remains unchanged. en su r i n g s a fe t y i n t he av iat ion t r a n spor- demand at one base and then move to Hepatitis C. Interferon alpha or tation system. Accordingly, the FAA has another job or base that doesn’t allow the use of a pegylated interferon al- initiated a system over the past few years for enough exams. pha is unacceptable for treatment of to ensure we all met quality standards Other common issues that may Hepatitis C. PEGylation is the process required of such an important position. result in AME termination include: of attaching one or more chains of a For AMEs, these quality standards 1) issuing certificates inappropriately substance called polyethylene glycol are primarily comprised of three major when the AME should have deferred (also known as PEG) to a components: currency in training, cur- or denied, 2) deferral or denial of a molecule such as interferon. Interferon rency in examination performance, and certificate when it was appropriate to will be slowly released into the body, proper decision-making in aeromedical issue, 3) repeated delays in transmis- but it does not react to PEG. Thus, dispositions. As you may remember, sion of the 8500-8, and 4) failure to PEG helps provide a protective barrier refresher training is required every provide a current address. Some other around interferon so it can survive in 3 years. Online MAMERC training more rare reasons include performing the body longer. The airman must may substitute for in-person seminar examinations on relatives and repeat- be disqualified until the treatments training every other training cycle, edly performing studies not required by have been completed. This type of but an in-person seminar is required the examination or providing extensive interferon can cause depression and at a minimum of every 6 years. There workups not warranted in order to make seizures. are a number of permutations on this an aeromedical disposition. Continued on page 5 Multiple sclerosis. The use of in- terferon beta-1b (Betaseron) is used in treatment of multiple sclerosis. While AME ALERT the condition itself may be unaccept- COLOR VISION TESTING able, the FAA has accepted the use of Today’s aviation environment is becoming increasingly dependent upon this medication in mild cases. Even color vision. Based on this reality, the Human Factors Research Division though the side effects are similar to at the Civil Aerospace Medical Institute recently completed a study on interferon alpha, they are not as com- color vision, including the comparison of currently used color vision monly seen. tests. Although this study validated most of our currently approved color This list does not amount to the vision tests, two devices were found to inadequate to test for color vision. complete list of medications that we These devices are the Titmus II and the Optec 5000. These devices are consider during certification decisions still adequate for their other vision testing functions but may no longer be regarding the use of medications by used for color vision testing for FAA examinations. airmen. Remember, it is not only the Currently approved color vision tests include: the Dvorine Pseudoisochromatic medication, itself, to consider but the Plate Test, the Ishihara 38-plate, Ishihara 24-plate, Ishihara 14-plate, Keystone Telebinocular, Keystone Orthoscope, OPTEC 2000, OPTEC 900, condition that caused the need for it th nd that is the main factor to think about Richmond HRR 4 Edition, AOC HRR 2 Edition, Anomaloscope Plate when going after a waiver. Test-5 (APT-5), Titmus, Titmus 2a, Titmus i400, the Waggoner PIPIC, the Waggoner HRR, the Cambridge Colour Test, the Colour Assessment and  Diagnosis Test (CAD), the Oculus Anomaloskop, and the Cone Specific Contrast Test (CSCT).

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. 4 • AME Updates from page 4 FAASTeam from page 1 Federal/Military/International AMEs. The FAASTeam Although these requirements do levy mission: Three of these fatalities occurred in an increased vigilance on your part to To improve maintain standards, they are consistent the Eastern Region alone during my the Nation’s with increasing requirements through- tenure here. There are currently just aviation safety out the U.S. medical system over the over 3,000 AMEs nationally in the record by category we surveyed. conveying safety principles and past few years. As such, we appreciate practices through training, outreach, all you do to meet the standards year to We want to make AMEs aware of and education. year. You are truly a national treasure. available FAA pilot safety resources, In the end, through hard work and particularly those of you who are Attending were 167 AMEs—and diligence, most of us have met the new pilots. It is our hope that you will they loved it. In fact, many took ad- challenges exceptionally well. In fact, access these resources as pilots and vantage of the FAASTeam interactive of the nearly 3,700 AMEs, only a few share them with the pilot community. demonstration and took brochures per year fail to sustain these standards. To learn more about the FAAS- home to share with others. If you have questions, plea se contact Team’s nationwide services, check out We are very excited about our new me at [email protected] or your their Web site: http://www.faasafety. safety collaboration with Flight Stan- Regional Flight Surgeon so we can help gov/about/mission.aspx. dards and the possibility of helping you you avoid these pitfalls, if possible. At the August 2010 Eastern Region and your pilots fly more safely! Please keep in touch, keep your AME Seminar held in Arlington, After all, safety is our passion and address current, and ensure your em- Va., we invited the FAASTeam to the FAA is ready and willing to provide ployees are verified every 90 days in share their resources with AMEs. resources to keep our skies—and our the Aerospace Medical Certification Felice Brunner, Communications AMEs—safe. Subsystem if they are using it. and Exhibit Team Manager for the Dr. Lester is the Eastern Regional Flight FAASTeam, set up a demonstration Surgeon; Program Analyst Mindy Zalcman Dr. Pinkston manages the Aerospace table, complete with informational in the Region’s Aerospace Medicine Division Medical Education Division. brochures, and a computer with live also contributed to this article.  links to fascinating data.  Letter to the Editor Dear Editor, Visual Acuity Problem the problem is solved. If the vision still [This is a] partial follow up to a letter does not correct to standards, perhaps in Vol. 48, No. 3 [FASMB, Letters to there is an eye condition that the airman the Editor, “Vision Standards,” p. 5] will require a waiver for, or perhaps the concerning vision standards. airman will not be able to be corrected There is one area of the vision stan- to standards. In this case, you must dard that still confuses me concerning defer, unfortunately, and we will have a second class physical. What if a pilot to issue permission for a medical flight applies for a second class but cannot test and Statement of Demonstrated meet the standard of 20/20 visual acuity even with correction? Or, if one Ability (SODA), assuming the applicant eye meets the 20/20 standard [but] returns to you and doesn’t send the form the other cannot for whatever reason? to us. If you get the FAA eye exam form Given the fact that pilots can be certi- completed, you can call your regional fied with monocular vision, what op- medical office or AMCD with those tions, if any, do Class two applicants Dear Dr. Turrisi, results. An FAA physician could give you have in this setting? Obviously, they If the airman does not meet vision permission to issue a medical certificate do not pass the basic vision standards. standards, you cannot issue the medical with the restriction “Valid for Student But is there a SODA or other vehicle certificate. You should send the airman to Pilot Purposes Only” to allow the air- possible for them? an eye specialist for an examination and man time to practice before taking the have an FAA eye exam form (FAA Form medical flight test. Thanks, Brian Turrisi, MD 8500-7) completed. If an eye exam shows Warren S. Silberman, DO Washington, D.C. that this just requires a correction to an Manager, Aerospace Medical existing corrective lens prescription, then Certification Division

The Federal Air Surgeon's Medical Bulletin • Vol. 48, No. 4 • 5 Who’s Who in Aerospace Medical Education Denise Patterson ([email protected]; (405) 954- Current information for calls to the 4830) – AME Training Program Analyst. Ms. Patterson By Janet Wright supports the Basic AME seminars, CAPAME and MCSPT training, and military and organizational seminars. e are beginning a new year here in the Aerospace Medi- Gary Sprouse ([email protected]; (405) 954-4831) – Wcal Education Division (AMED), and as with all new AME Training Program Analyst. Mr. Sprouse is responsible beginnings, there are a few endings as well. This past year, for the AME theme seminars and MAMERC, and he also we have a few new faces and are saying goodbye to some old manages forms and brochure distribution. friends who have retired. Dr. Richard Jones, MD, our divi- Deanie Davis ([email protected]; (405) 954-4257) sion manager, retired in December 2009 and now travels only – AME Records Clerk. Ms. Davis manages the mountains when he wants to. Longtime AMED employee Barb Ross of paperwork required for designees. She interacts with the also retired. We welcome a new manager, Brian Pinkston, Regions in making sure that all documentation is complete MD, and a new office administrator, Frances Parker, to our and accurate, and she maintains demographic information group, as well as analyst Gary Sprouse. on each AME. The following lists all Division personnel, with their contact Susan Buriak ([email protected]; (405) 954-4378) information and a brief description of their responsibilities. – Program Manager, Quality Assurance and Curriculum Brian S. Pinkston, MD ([email protected]; (405) Development. Ms. Buriak manages quality assurance and 954-6205) – Manager, Medical Education Division. Dr. data collection activities, curriculum development, and Pinkston is also the Regional Flight Surgeon for the Inter- implementation of technology . national, Military, and Federal AMEs. Mike Wayda ([email protected]; (405) 954-6208) – Frances Parker ([email protected]; (405) 954-6205) Writer/Editor. Mr. Wayda publishes the Federal Air Surgeon’s – Office Administrator. Ms. Parker assists with all aspects Medical Bulletin, pilot safety brochures, and technical reports of the education division and will direct you to the person for the Civil Aerospace Medical Institute. most able to help resolve your concern. Rogers Shaw ([email protected]; (405) 954-6212) Bobby Ridge ([email protected]; (405) 954-4829) – Team Lead, Airman Education Program. Mr. Shaw leads – Senior AME Program Analyst. Ms. Ridge heads the Re- a team of instructors who conduct aviation physiology and gional Program Analysts’ team, making sure that all over- survival training. Team members include: sight requirements per congressional mandate are complete Larry Boshers ([email protected]; (405) 954-7767) and accurate. Ms. Ridge also represents the AME designee J.R. Brown ([email protected]; (405) 954-6211) program at the national level. Don Demuth ([email protected]; (405) 954-6207) Jan Wright ([email protected]; (405) 954-4803) – Eric Simson ([email protected]; (405) 954-6198) Team Lead, AME Education Program. Ms. Wright manages Roger Storey ([email protected](405) 954-6209) all aspects of AME seminars, develops training programs, Kathy Wade ([email protected] (405) 954-4398), and is responsible for the Continuing Medical Education Librarian, and Roni Anderson (roni [email protected] accreditation process. (405) 954-8231), Library Assistant, provide expert service in Leah Olson ([email protected]; (405) 954-4832) – locating library resources pertaining to aerospace medicine International/Federal/Military AME Program Analyst. Ms. and human factors topics. Olson manages AME designations, terminations, and support for international, military, and federal AMEs. Other Resources AMCS Help Desk 9-amc-aam-certification@faa. gov; (405) 954-3238). Call the Help Desk if you are having problems logging into or using the Aerospace Medical Certification Subsystem. Please do not call this number for help with medical certification questions. This is for AMCS computer system questions only! Medical Certification questions (405) 954-4821). Use this number when you need assistance with an airman medical certification issue. This is a heavily used number, so you may need to leave a message. Someone will return your call as quickly as possible. Alternatively, questions about the AME program, airman examinations, training, or AME designation can also be answered by any Regional Flight Surgeon’s office. The list of telephone numbers may be found online at www. faa.gov/licenses_certificates/medical_certification/rfs/. NEWEST AMED TEAM MEMBERS. (L-R) Dr. Brian Pinkston, Manager; Gary Sprouse, Program Analyst; and Frances Parker, Office Administrator. 

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. 4 • From the Trenches Some highlights of the week included Dr. Kowalsky Retires 2010 EAA AirVenture visits to our booth by U.S. Secretary Oshkosh Report of Transportation Ray LaHood and Dr. Nestor Kowalsky, the Great FAA Administrator Randy Babbitt…a Lakes (AGL) Regional Flight Surgeon, Another ‘outstanding show’ retired at the end v i sit i n g c a rd iolog y c on su lt a nt Dr. John By Matthew F. Dumstorf, MD of August 2010 Raniolo, who prov ide d muc h a s si st a nc e after seven years for several days...Dr. Tilton gave a well- of service with the he Experimental Aircraft Associa- attended and informative presentation Federal Aviation Ttion’s AirVenture 2010 was held in in the FAA Safety Center Forum…a Administration. He Oshkosh, Wis., from July 26–August 1. spectacular air and fireworks show lit managed and led The Great Lakes Regional Office pro- up the sky after nightfall on Saturday (a the office through vided a presence for the entire week of first for this event), and generally mild a number of transi- the airshow with a customer service booth weather endured throughout the week, tion periods and significant events. within the FAA’s Aviation Safety Center. making for a comfortable environment Two of the major programs within Throughout the week, we assisted for both working and enjoying the show. the office, the Airman Medical Cer- 800-plus airmen with inquiries about On a personal note, this was my tification Program and the Air Traffic the status of their airman medical cer- fourth AirVenture show that I have Controller Health Program, increased tificate applications, explained various worked for the FAA as a flight surgeon their staff size by one program analyst FAA medical certification policies and within the Great Lakes Region. This during Dr. Kowalsky’s time in the of- fice. Another analyst was added to procedures, gave some airmen “instant year, for the first time, I chose to camp the staff with the startup of the Avia- reviews” of their cases (to some, we even on the Experimental Aircraft Associa- tion Medical Examiner Surveillance issued certificates on the spot, always t ion’s g rou nd s i n my t r avel t r a i ler, r at her Program. a favorite service of the airmen!), and than at a local hotel. I was overwhelmed Other significant events that occurred handed out numerous informational by t he a mou nt of pe ople t h at e x per ienc e during Dr. Kowalsky’s tenure include flyers about disease protocols, aviation the show in this fashion. EAA’s Camp four separate air traffic controller physiology, CAMI operations, and other Scholler literally becomes its own small candidate hiring exercises in calen- aviation medicine educational topics. town for the week, complete with all dar years 2008 and 2009, the 2010 Those attending the airshow and of the conveniences that one would closing of the Medical Field Office working our booth for Aerospace Medi- need for a week-long stay, even a Wi-Fi at the Aurora, Ill., Air Traffic Control cine included Federal Air Surgeon Dr. service. I certainly plan to experience Facility, and the transition of those Fred Tilton, Aerospace Medical Cer- AirVenture again in future years in medical services to local AME of- tification Division (AMCD) Manager this fashion. fices and the AGL Regional Medical Dr. Warren Silberman, AMCD Staff It was another outstanding show, and Office. We hosted an AME seminar Physician Dr. Arnold Angelici, Great I departed Oshkosh with a bittersweet in Minneapolis, Minn., in 2008, and a Civil Aviation Medical Association Lakes (AGL) Regional Flight Surgeon feeling. While disappointed that this meeting at the Mayo Clinic in Roch- Dr. Nestor Kowalsky, AGL Regional year’s show had come to an end, I was ester that was sanctioned by the FAA Deputy Flight Surgeon Dr. Matthew also already looking forward to next as an AME Seminar. Dumstorf, AGL Flight Surgeon Dr. year. I hope to see as many of our read- Throughout his time in the Great Lakes Marvin Jackson, AGL Airman Medi- ers as possible at this premier airshow Region, Dr. Kowalsky pursued one of cal Certification Program Analysts event next year. his professional passions as he served Joan Morgan and Maureen Stephens, Dr. Dumstorf is the Acting Great Lakes Re- as a resource for the Human Interven- and AGL Airman Medical Certification gional Flight Surgeon. tion Motivation Study program, which Program Assistant Cliff Heart.  is dedicated to pilots with substance abuse or dependence problems. AIRMAN EDUCATION. Dr. Kowalsky has completed a re- Team members pause to markable career within Aerospace show off their GYRO- 2 spatial disorientation Medicine, and his presence and simulator to Secretary contributions to the FAA’s Office of of Transportation Ray Aerospace Medicine will be missed. LaHood (center) and We wish him all the best in his retire- FAA Administrator Randy ment years. Babbitt (left) at Oshkosh. The GYRO-2 gave 285 airmen a realistic —Contributed by Matthew demonstration of spatial Dumstorf, MD, Acting disorientation during the AGL Regional Flight Surgeon seven-day airshow.

The Federal Air Surgeon's Medical Bulletin • Vol. 48, No. 4 • 7 Papillary Cancer modified radical neck dissection or re- Case Report, by Mary T. Brueggemeyer, MD peat neck exploration may be required in cases of recurrent disease resistant to radioactive . The risks of surgery are recurrent laryngeal nerve injury Papillary is the most common differentiated thyroid cancer, char- and hypoparathyroidism with hypo- acterized by slow growth, local recurrence, and low mortality. Adequate surgical calcemia; both are potentially chronic treatment with postoperative radioiodine ablation and thyroid-stimulating hor- conditions that could impact the abil- mone suppression is recommended for the best outcome. Aeromedical concerns fo- ity to fly safely. Permanent recurrent cus on remission from disease, side effects, and complications of treatment and laryngeal nerve injury occurs in 1-1.5% manifestations of hypo- and . Most aviators with this condition of cases, and temporary nerve injury are able to obtain a Special Issuance. This article presents the case of an aviator occurs in 2.5-5% of cases (3). Nerve with locally recurrent . injury can result in airway compromise, aspiration and pneumonia, and poor voice quality. Poor voice quality may HISTORY 149 and a stimulated PET scan showed impact safe radio communications. he airman is a 45-year-old third- disease in the right cervical lymph Permanent hypoparathyroidism with Tclass pilot with 405 hours of nodes. In November 2008, he under- hypocalcemia occurs in 0.4 to 13% flying. In July 2005, he developed a went modified radical neck dissection of cases and can result in paresthesias, febrile illness with facial and upper-arm for I-131 resistant disease that revealed tetany, bronchospasm, mental status neuropathy. He was diagnosed with 5/12 lymph nodes positive for tumor. changes, seizures, , and ehrlichiosis complicated by Guillain- He underwent postoperative external cardiac arrhythmias (3), all of which Barré syndrome (GBS). The GBS beam radiation therapy (EBRT) to the are not safe in the aviator. required treatment with Gabapentin neck. His thyroglobulin levels dropped and hyperthyroid- and Tramadol, which led to denial of to 0.2 in July 2009, and a stimulated ism may also be of concern in the aviator. his medical certificate application. He PET scan was negative. He is currently Aviators will be placed on thyroxine to recovered from the GBS and was able on Synthroid () 150 mcg/ treat the hypothyroid state after total to be weaned from all medications. day with low TSH levels. thyroidectomy and to suppress TSH However, during the work-up for the AEROMEDICAL CONCERNS levels. Patients free of disease at low febrile illness, a mass in the right thyroid Aeromedical concerns for malig- risk for recurrence may have the TSH lobe was identified. Biopsy revealed nancy can be divided into two cat- reduced to the lower limit of normal (0.3 papillary of the thyroid. egories: cancer with risk for metastasis to 2 mU/L); those free of disease but He underwent total thyroidectomy in and side effects, and complications of at high risk of recurrence should have September 2005 that showed a 3.5 cm treatment. Papillary thyroid cancer is a the levels reduced between 0.1 to 0.5 papillary cancer of the thyroid with 2/2 slow-growing malignancy that is char- mU/L; and those with persistent disease paratracheal nodes positive for tumor. A acterized by local recurrence, usually should have the levels reduced below whole body radioiodine scan (RxWBS) in the cervical lymph nodes. Distant 0.1 mU/L (2). Suppression to very low showed no metastatic disease. He was metastasis at the time of diagnosis oc- levels of TSH creates a subclinical state classified as T3N1aM0, Stage I, based c u r s i n 2 -10 % of c a se s, w it h pu l mon a r y of thyrotoxicosis that could exacerbate on his age of 45 years. He underwent (67%) and skeletal (25%) being the angina in patients with ischemic heart 131-I ablation in November 2005. most common. Brain metastasis is rare. disease, cause atrial fibrillation, left Preoperative thyroglobulin levels were Metastatic disease can be detected with ventricular hypertrophy, and diastolic elevated at 439 and reduced to 4.1 after imaging and thyroglobulin levels, usu- dysfunction (2,4,5,6). Aviators on life- ablation. He was started on thyroxine ally before it is symptomatic or any risk long suppressive therapy will require for replacement and thyroid-stimulating of incapacitation. Thus, the diagnosis careful monitoring of their cardiac hormone (TSH) suppressive therapy. of papillary thyroid cancer is generally status for the development of these He received a special issuance in May favorable for the return to flying. complications. Hypothyroidism will be 2007. In August 2007, he underwent The side effects and potential induced when thyroxine is withdrawn a thyrogenic-stimulated PET scan complications of treatment pose more prior to radioactive iodine imaging or that revealed persistent disease, and he threat to the aviator. Total or near-total treatment. Aviators should not fly dur- underwent a repeat I-131 ablation in thyroidectomy is the initial treatment ing this time. The use of recombinant October 2007. His thyroglobulin rose to for papillary cancer of the thyroid, and human thyrotropin (rhTSH) precludes

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. 4 • the need for thyroxine withdrawal and subsequent hypothyroidism (2). DISEASE SUMMARY Radioactive iodine treatment can Papillary thyroid cancer is the most common form of differentiated thyroid can- acutely result in sialadenitis, neck cer, representing 70-75% of thyroid cancers diagnosed in 2008. The incidence is higher in women by a factor of 2.5:1 and occurs mostly in the fourth to fifth edema, and nasolacrimal duct obstruc- decades of life. The incidence of papillary cancer has increased steadily over tion (7). Aviators should not fly while the past several decades, with the greatest increase in small (<1 cm) tumors that undergoing treatment. There is a low are identified incidentally during other diagnostic studies (1). risk of secondary malignancy (2) that is The primary method of diagnosis is by ultrasound-guided, fine-needle aspiration dependent on the amount of exposure; of the thyroid nodule. Initial treatment for papillary thyroid cancer is total or this should not impact granting of a near-total thyroidectomy and central compartment lymph node dissection. A high medical certificate in the short term. percentage of patients will have cervical lymph node involvement (20-50%) (2). External beam radiation therapy, when Better outcomes are associated with the most complete removal of thyroid tissue needed, may have acute toxicity mani- and involved lymph node tissue (2). Postoperative treatment consists of 131-I fested by skin erythema, desquamation, ablation and thyroxine suppression of thyrotropin (TSH), both associated with and mucositis of the esophagus, larynx, better outcomes. 131-I ablation is most beneficial for patients with larger (>1.5 and trachea. Late toxicity is rare and cm) tumors, residual disease, nodal metastasis, and extra-thyroidal extension (2). may involve skin telangiectasia and External beam radiation therapy to the neck is reserved for larger tumors (T4) pigmentation, which also should not and residual microscopic disease or patients with residual or recurrent disease impact flying. Esophageal and tracheal resistant to radioactive iodine (2, 3). stenosis is of more concern but occurs Initial follow-up consists of an RxWBS to identify uptake by metastatic disease rarely (8). outside of the thyroid bed and measurement of suppressed and stimulated thyro- ROLE OF THE AME levels. The results of the scan, findings at the time of surgery, pathology, Upon identification of a history of and thyroglobulin levels will define a tumor-free state and the risk for recurrence. papillary cancer of the thyroid, the avia- The tools for surveillance are imaging and thyroglobulin levels. The most sensi- tive imaging is cervical ultrasonography, which should be done 6-12 months tion medical examiner should obtain a after surgery and then annually for 3-5 years (2). Other imaging may include CT complete history concerning the stage of the neck and chest and repeat DxWBS for patients at intermediate or high of disease, treatment, and any compli- risk, and FDG-PET scans for specific circumstances. Suppressed and stimulated cations. A careful examination of the thyroglobulin levels (and thyroglobulin levels) should be done every head and neck should be performed in 6-12 months for patients who have undergone total thyroidectomy and remnant accordance with the AME Guide and ablation (2). Rising thyroglobulin levels are highly sensitive and specific for tumor history reported by the patient. The recurrence and warrant further testing and treatment (3). AME should pay particular attention to the quality of voice, deformity of a medical certificate and forward the reports of thyroglobulin, TSH and T4 the neck, and palpation of the neck for application to the Aerospace Medical levels, PET/CT scan of the neck and masses. The AME must also look for Certification Division or Regional chest, and a narrative from the treating signs and symptoms of hypo- or hyper- Flight Surgeon (10). The AME Guide physician on interim history, follow- thyroidism and metastatic disease to does not outline a specific protocol for up plan, prognosis, medications, and the lymph nodes, bone, lungs, or brain. papillary thyroid cancer. In general, side effects. Supplemental documents include treat- malignancy requires annual follow-up ABOUT THE AUTHOR ing physician notes, operative reports, for five years. LtCol Mary T. Brueggemeyer, MD, was a pathology reports, radiology reports, AEROMEDICAL OUTCOME resident in Aerospace Medicine at the USAF School of Aerospace Medicine and completed and laboratory values to include TSH, The aviator successfully recovered this article while rotating at the Civil Aero- T4 and thyroglobulin levels. It is the from surgery and EBRT without any space Medical Institute. responsibility of the airman to provide complications. His post-treatment thy- these documents to the Aerospace Medi- roglobulin levels indicated no residual REFERENCES cal Certification Division of the FAA. disease, and a PET scan was negative. 1. Tuttle RM. Overview of papillary thy- The diagnosis of malignancy is He was stable on Synthroid, 150 mcg roid cancer. Up to Date. Available at disqualifying for all classes of medical per day without side effects. His T4 was http://uptodate.com. Last updated certification (9). It is the responsibility 1.31 and his TSH was low, at 0.06. He May 13, 2009. Accessed Nov. 13, 2009. of t he a i r m a n to repor t on t he FA A For m was granted a Special Issuance for his 8500-8 a history of malignancy, details third-class medical certificate for one of treatment, and any prior denial of year. Prior to renewal, he must provide Continued on page 11

The Federal Air Surgeon's Medical Bulletin • Vol. 48, No. 4 • 9 Alpha-1-Antitrypsin Deficiency of flight may be compromised. When Case Report, by Kevin J. Brown, MD, MPH these cases are discovered, the AME will need to defer the decision granting medical certification to the Aerospace Alpha-1-antitrypsin deficiency (A1ATD) is an inherited medical disorder predis- Medical Certification Division. These posing to chronic obstructive lung disease, cirrhosis, and . airmen will require an Authorization for While not likely to result in sudden incapacitation, an understanding of A1ATD Special Issuance, and the required test- is significant to the aeromedical examiner as it contributes to pathologic condi- ing will depend on whether the airman tions that can be incompatible with medical certification. has just the lung disease or both lung and liver disease. The FAA does not istory. A 58-year-old male and pneumothorax. The liver mani- generally grant medical certification to air ambulance pilot with festations of A1ATD occur less com- airmen whose FVC or FeV1 are less than H11,300 flight hours presents monly, and the aeromedical relevance 50% of the predicted values. Values for second-class medical certification of chronic liver disease will need to be such as these will require stress testing after recently being diagnosed with determined case by case. with minute-by-minute pulse oximetry. homozygous Alpha-1-antitrypsin de- ole of the Aviation Medical Room air that ficiency (A1ATD). The airman had R Examiner. The aviation medical go down with progressive exercise will electively sought genetic testing because examiner should focus attention on the likely lead to denial. Additionally, of three siblings with A1ATD and one status of functional and physiologic patients with pulmonary bullous dis- sibling who had not been genetically impairment in patients with A1ATD. ease, especially apical blebs, should be tested but died from liver cancer. The In many cases, the degree of impair- referred for review before certification patient is very active, exercises regularly, ment will progress, and it is the AME’s is granted. Significant pulmonary bleb and noticed exertional dyspnea in the responsibility to determine when safety disease will also likely result in denial, year prior to presentation. He reports Continued he can walk briskly for about one-half mile before he needs to stop and rest. ETIOLOGY OF ALPHA-1-ANTITRYPSIN DEFICIENCY He denies chest pain, cough, hemop- tysis, edema, or paroxysmal nocturnal Alpha-1-antitrypsin deficiency is relatively common in populations of European dyspnea. He has no history of tobacco ancestry, with an estimated prevalence of one case in every 3,000 persons in the use, and has been self-medicating with United States.1 A1ATD is an autosomal recessive disorder, in which mutations in a family member’s albuterol inhaler the serine protease inhibitor alpha-1-antitrypsin (A1AT) prevents its export from 2 three times per day, with temporary where it is produced within the hepatocyte. This results in an accumulation of improvement in his exercise tolerance. A1AT within the hepatocyte, and a deficiency in circulating A1AT, which serves A pulmonary function test showed a primary physiologic purpose of protecting the fragile alveolar tissue from pro- teolytic damage.1,3 severe respiratory impairment, with an FEV1 of 22% predicted. A chest and This mechanism explains the primary pathologic manifestations commonly seen abdominal CT revealed panlobular in the lungs and liver. Severe chronic obstructive pulmonary disease can occur emphysematous changes in both lungs, in young patients, even in nonsmokers. Emphysema usually develops by the third to fourth decade of life in smokers, and the fifth to sixth decade of life in with a normal-appearing liver. Liver nonsmokers.3 Terminal respiratory insufficiency causes premature death in many function tests were normal. patients.4 Liver pathology includes liver inflammation detected by elevated liver eromedical Issues. The most , liver fibrosis, cirrhosis, and hepatocellular carcinoma.4 More rarely, A common aeromedical concerns in panniculitis, a spontaneous necrosis of the skin, can occur.3 patients with A1ATD relate to patho- Greatly under-recognized, diagnosis of A1ATD is frequently achieved via targeted logic pulmonary changes. Patients with detection in patients with a positive family history or in patients with unexplained COPD are at risk for decreased exercise premature COPD or liver disease.5,6 Treatment strategies include smoking ces- tolerance, , and decreased G- sation, preventive vaccination against hepatitis B, influenza, and Streptococcus tolerance. Furthermore, these patients pneumoniae, as well as aggressive treatment of COPD with bronchodilators, are predisposed to small airway dis- inhaled corticosteroids, supplemental oxygen, and pulmonary rehabilitation. ease, which can result in acceleration Augmentation with human plasma-derived alpha-1-antitrypsin can be employed, atelectasis. In addition, COPD is as- but the results have been disappointing in terms of preventing disease progres- sociated with bullous transformation sion. The most severe cases of COPD are considered for lung volume reduction and gas trapping, placing the airman surgery and lung transplantation. Patients with cirrhosis are considered for liver 7 at risk for pulmonary transplantation.

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. 4 • as concern over spontaneous pneumo- Papillary from page 9 New Theme Seminar thorax is high. 2. Cooper DS, Doherty GM, Haugen Débuts at AsMA utcome. Upon initial application, BR, et al. Revised American Thyroid Sleep apnea, cancer among high- Othe airman was issued a denial for Association management guidelines priority conditions addressed medical certification. However, he was for patients with thyroid nodules By Richard Carter, DO, MPH notified that his application would be and differentiated thyroid cancer. Thyroid 2009; 19(11):1167-1214. reconsidered if he provided the follow- viation medical examiners attend- Available at www.liebertonline.com/ ing the AME seminar that was ing: a narrative consult documenting doi/abs/10.1089/thy.2009.0110. A optimization of his COPD manage- held in conjunction with the Aerospace 3. Lai SY, Mandel SJ, Weber RS. Man- Medical Association’s annual conference ment as evidenced by a pulmonary agement of thyroid neoplasms. In function test meeting FAA standards, Cummings: Otolaryngology: Head (Phoenix, Ariz., May 10-13, 2010) re- an operational questionnaire (FAA and neck surgery, 4th Ed. Maryland ceived a new theme seminar that related Form 8500-20) detailing his flight Heights, MO: Mosby; 2005. Available specifically to medical certification. mission and cabin altitude operational at www.mdconsult.com/das/book/ Theme seminars emphasize such body/171166754-4/0/1263/1065. topics as neurology, psychiatry, and car- requirements, and an exercise stress test html?tocnode=49545749&fromU diology. The new Medical Certification with pulse oximetry. RL=1065.html. theme featured specialty lecture topics, 4. Fazio S, Biondi B, Carella C, et al. each accompanied by a complementary About the Author. CDR Kevin J. Brown, Diastolic dysfunction in patients on lecture on the same topic presented by MD, MPH, FAAFP, is a U.S. Naval flight thyroid-stimulating hormone sup- surgeon, board-certified in Family Medi- an Aerospace Medical Certification pressive therapy with levothyroxine: Division (AMCD) medical certifica- cine, and currently a resident in Aerospace Beneficial effect of beta-blockade. Medicine at the Naval Aerospace Medical tion officer. J Clin Endocrinol Metab 1995 Jul; The medical specialties included sleep Institute in Pensacola, Florida. He authored 80(7):2222-6. this article based on case reviews while work- apnea, cardiology, neurology, ophthal- ing with Dr. Warren Silberman at the Civil 5. Biondi B, Fazio S, Carella C, et al. mology, otolaryngology, and alcohol/ Aerospace Medical Institute. Cardiac effects of long term thy- addiction. All the topics included rotropin-suppressive therapy with References levothyroxine. Clin Endocrinol Metab medical certification discussions about 1. Silverman EK, Sandhaus RA. Clinical 1993; 77(2):334-8. how to certify an airman with one of practice. Alpha1-antitrypsin defi- these conditions. The topics selected ciency. N Engl J Med Jun 25, 2009; 6. Sawin CT, Geller A, Wolf PA, et al. for discussion were deemed the highest 360(26):2749-57. Low serum thyrotropin concentra- tions as a risk factor for atrial fibril- priority issues. 2. Fairbanks KD, Tavill AS. Liver disease lation in older persons. NEJM 1994; For example, with cancer, there are in alpha 1-antitrypsin deficiency: A 10(331):1249-52. new changes in certification strategy review. Am J Gastroenterol Aug 2008; because applicants with cancer are re- 103(8):2136-41; quiz 2142. 7. Tuttle, RM. Radioiodine treatment of differentiated thyroid cancer. Up to ceiving new medications and treatment 3. Fregonese L, Stolk J. Hereditary alpha- Date. Available at http://uptodate. regimens. Applicants with leukemia, 1-antitrypsin deficiency and its clinical com. Accessed Nov. 13, 2009. , , or cancer of the consequences. Orphanet J Rare Dis colon, breast, prostate, and lung—can all 2008; 3:16. 8. Brierly, JD. External radiotherapy in the treatment of thyroid cancer. Up be certified—and examiners need to be 4. Kohnlein T, Welte T. Alpha-1 antitryp- to Date. Available at http://uptodate. aware of the procedures to accommodate sin deficiency: Pathogenesis, clinical com. Accessed Nov. 13, 2009. such applicants. presentation, diagnosis, and treatment. The following are a few case examples Am J Med Jan 2008;121(1):3-9. 9. Code of Federal Regulations. Title 14 Part 67 Medical Standards of the specific certification topics that 5. Aboussouan LS, Stoller JK. Detection of and Certification. Available at were discussed at the seminar: alpha-1 antitrypsin deficiency: A review. http://ecfr.gpoaccess.gov/cgi/t/text/ Sleep apnea. New at this confer- Respir Med Mar 2009;103(3):335-41. text-idx?c=ecfr&tpl=/ecfrbrowse/ ence was Certification Sleep Apnea, 6. Hogarth DK, Rachelefsky G. Screen- Title14/14cfr67_main_02.tpl. Ac- presented by Dr. Mark Ivey, a Federal ing and familial testing of patients for cessed Nov. 13, 2009. Air Surgeon’s consultant for sleep apnea alpha 1-antitrypsin deficiency. Chest 10. Federal Aviation Administration. Appli- and pulmonary conditions. Apr 2008; 133(4):981-8. cation for Medical Certification Item Consider the risk of sleep apnea in 7. Mulgrew AT, Taggart CC, McElvaney 13. 2009 Guide for Aviation Medical a 50-year-old airman with a history of: NG. Alpha-1-antitrypsin deficiency: Examiners. Available at www.faa. ► Borderline hypertension. Current concepts. Lung Jul-Aug 2007; gov/about/office_org/headquarters_ ► Overweight (it takes both hands on 185(4):191-201. offices/avs/offices/aam/ame/guide/. the tongue depressor to see the back of Accessed Nov. 13, 2009.  his throat).  Continued on page 12

The Federal Air Surgeon's Medical Bulletin • Vol. 48, No. 4 • 11 Aviation Medical Examiner Seminar Schedule 2010 November 19 – 21 Kansas City, Missouri CAR (2) 2011 January 21–23 Jacksonville, Fla. NPN (2) February 28–March 4 Oklahoma City, Okla. Basic (1) March 25–27 Providence, R.I. OOE (2) May 9–12 Anchorage, Alaska AsMA (3) June 13–17 Oklahoma City, Okla. Basic (1) August To be determined CAR (2) October 6–8 Tucson, Ariz. CAMA (4) October 31–November 4 Oklahoma City, Okla. Basic (1) November To be determined NPN (2) CODES CAR Cardiology Theme NPN Neurology/Neuro-Psychology/Psychiatry Theme OOE Ophthalmology-Otolaryngology-Endocrinology Theme (1) A 4½-day basic AME seminar focused on preparing physicians to be designated as aviation medical examiners. Call your Regional Flight Surgeon. (2) 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. (3) A 3½-day theme AME seminar held in conjunction with the Aerospace Medical Association (AsMA). This seminar is a new Medical Certification theme, with 9 aeromedical certification lectures presented by FAA medical review officers, in addition to other medical specialty topics. Registration must be made through AsMA at (703) 739-2240. A registration fee will be charged by AsMA to cover their overhead costs. Registrants have full access to the AsMA meeting. CME credit for the FAA seminar is free. (4) This seminar is being sponsored by the Civil Aviation Medical Association (CAMA) and is sanctioned by the FAA as fulfilling the FAA recertification training requirement. Registration will be through the CAMA Web site: www.civilavmed.com. The Civil Aerospace Medical Institute is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.

AsMA Theme from page 11 ► Audiology evaluation to determine and circumstances, and court records ► Dr. Ivey offered some helpful of- hearing standards. such as the investigative reports with fice strategies and emphasized this is a A medical certificate should not be BAC and treatment records). problem that must be addressed because issued for any class if there is a recur- ► If the BAC was 0.15 or greater or the risk to aviation safety from sleep- rence of vertigo. applicant refused police alcohol testing, deprived pilots is a very serious concern. Dr. Robert Glatz, a Federal Air Sur- the AME must defer. An evaluation will He provided guidance regarding the geon’s ENT consultant, advised caution be required to include a history of the clinical interpretation of sleep tests (con- with Ménière’s disease. It is possible that event and an examination to determine tinuous positive airway , CPAP, symptoms can present again, even after if the pilot has a possible substance abuse is effective and preferred for aeromedical three months of being asymptomatic. problem. (See the online AME Guide.) purposes), treatment, and certification. Applicants should be closely monitored Ms. Janet Wright, Team Lead of Colon cancer. Colon ca ncer t hat ha s for at least a year because recurrence of the Aerospace Medical Education Divi- spread through the bowel wall ONLY vertigo is possible, for example, 8 months sion’s seminar staff, said, “We wanted requires an initial and yearly MRI of the to a year later. to do something new for AsMA, and brain if the cancer has metastasized to at Driving Under the Influence (DUI) the AMEs who attended this confer- least one lymph node. If the tumor just standards. Dr. Mills summarized the ence have commented favorably, so goes into the muscularis or penetrates newest DUI standards. Before certificat- we’re planning a similar theme seminar into the surrounding tissues of the bowel ing, an AME must consider: for the next AsMA conference.” The wall, there is no need for a brain scan. ► If the first DUI was less that 5 years next AsMA meeting will be held in Ménière’s disease. The major factors ago and the blood alcohol content (BAC) Anchorage, Alaska, May 8-12, 2011. to consider: was less than 0.15, the AME may issue,  ► Stable for at least 3 months. with favorable reports (detailed history Dr. Carter is a Medical Review Officer in the ► ENT evaluation documents remission. from the applicant regarding alcohol use Aerospace Medical Certification Division.

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. 4 •