Ask the Aviation Medical Examiner Sergio B. Seoane, M.D., Col., CAP Chief, CAP National Health Service FAA Senior Aviation Medical Examiner

AME – Aviation Medical Examiner Aviation Medical Examiner (AME) is a physician designated by the FAA and given the authority to perform flight physical examinations and issue aviation medical certificates. AMEs are practitioners of Aviation Medicine Many AMEs are also qualified in other medical specialties The International Civil Aviation Organization have established basic medical rules for determining whether a pilot is fit to act in that capacity, and they are codified in Annex 1 to the Convention on International Civil Aviation. Must be a Physician to be an AME, cannot be ARNP or PA

Assisted Special Issuance Process (AASI) A several years ago, FAA introduced the Aviation Medical Examiner Assisted Special Issuance process (AASI) AASI permitted AMEs to issue applicants a special issuance certificate at the time of examination, provided the applicant had complied with a previously defined set of conditions. The AASI process eliminated the wait time for a subset of airmen, but there were still a large number of pilots who had to wait for the FAA to make a decision in their case.

New and Improved FAA Aeromedical Certification In 2011-2012, the Federal Air Surgeon, Fred Tilton MD decided to reduce the number of medical conditions requiring a special issuance. Dr Tilton has identified 18 medical conditions that will no longer require a special issuance, Protocols for 11 of them have been issued to AMEs The rest will be published in 2013-2014 These 18 conditions account for 10 to 15 percent of the special issuances.

April 2013 AME Changes Conditions the AME Can Issue (CACI) Conditions that previously required an initial FAA Special Issuance authorization before the AME could issue a medical certificate Now, the AME is authorized to directly issue the medical certificate. The pilot does not need to wait to receive the Medical Certificate from the FAA

April 2013 AME Changes Conditions the AME Can Issue (CACI) Arthritis Asthma Glaucoma Hepatitis C Hypertension Hypothyroidism Migraine Chronic Headaches Pre-Diabetes (IFG) Metabolic Syndrome Impaired Fasting Glucose Glucose Elevation Renal Cancer

April 2013 AME Changes The criteria and the required medical documentation has NOT changed The only difference is that the local AME can issue the medical certificate without approval from FAA Aerospace Medical Certification Division in Oklahoma City This should result in the Airman obtaining the FAA Medical Certificate sooner

April 2013 AME Changes The recovery time after coronary artery stenting has been decreased from 6 months to 3 months

AME AVIATOR FAA

Legal Authority of Designated Aviation Medical Examiners Title 49, United States Code (U.S.C.) (Transportation), sections 109(9), 40113(a), 4701-44703, and 44709 (1994) formerly codified in the Federal Aviation Act of 1958, as amended, authorizes the FAA Administrator to delegate to qualified private persons; i.e. designated Examiners, matters related to the examination, testing, and inspection necessary to issue a certificate under the U.S.C. and to issue the certificate. Designated Examiners are delegated the Administrator's authority to examine applicants for airman medical certificates and to issue or deny issuance of certificates.

Aviation Medical Examiner Population (3,465 as of March 31, 2012) 90 countries (Includes Guam, Marshall Islands, Saipan, Pacific Island Trust Territories, Puerto Rico and Virgin Islands) AMEs who are pilots 47% Female AMEs 7.5% 5/7/12

Distribution of AMEs by Region 5/7/12

Nine FAA Regions Similar to CAP Regions

Distribution of AMEs by Region AMEs/Senior AMEs 100% 0% 5/7/12

Distribution of AMEs by Medical Specialty Family Practice / General Practice 49% Internal Medicine 19% Aerospace Medicine 8% Occupational / Industrial Med 6% General Surgery 3% Ophthalmology 2% Emergency Medicine, Orthopedic Surgery, Otorhinolaryngology, OB/GYN, Urology 1% All others <1% (ea) 5/7/2012

AME Age Trends

Distribution of AMEs by Number of Medical Exams Performed Annually 39% 30% Percent of AMEs Number of AMEs 18% 4.3% 5% 2% 0.8% 1.4% 0.05% 2/14/11

AME Distribution by Length of Service 352 270 144 308 184 363 294 151 101 181 99 197 79 246 36 141 64 23 70 18 4 1 AMEs Senior AMEs 2/14/11

AME Exams – CY 2011 1/26/12

Aeromedical Certification Requests 1095 applications per day (2011) 33,312 applications per month (2011) 1/26/12

Certificates Not Issued 56 18,971 1616 35,421 6322 1/26/12

Certificates Issued by AME And Reversed by AMCD Medical Certificates FY 2008 FY 2009 FY 2010 2011 TOTAL CERTIFICATES REVERSED 1937 2181 2616 2204 ADMINISTRATIVE OR LEGAL DENIAL 1079 1044 1333 1102 REVERSALS DUE TO AME ERROR 858 1137 1283 REVERSAL ERROR LETTERS 206 211 204 165 1/26/12

Most common causes for problems with issued certificates Jan to June 2011 compared to prior period Block Description Occurrences July–Dec 2010 Jan–Jun 2011 17 Unacceptable Medication 7 13 58 ECG 15 21 18h High or low Blood Pressure 6 18V DUI 1 18a Headache 18M Mental/Depression 18X Rheumatoid Arthritis 18 g Heart Problem 18J Kidney stone 18u Admission to Hospital 18x Prostate cancer surgery, parathyroidectomy, cataract surgery 18D Retinopathy /DM on treatment 42 Arthritis Please note that there can more than one error in a single case

Final Denials for 2011 Total Denials: 5,012 Denial for Failure to Provide or Failed to Pursue: 4,646 92% of Airman Fail to Provide info! Final Denials (When all information requested is provided): 366 400,000 only 366 Denied by FAA .09% 1/26/12

Final Certification Denials 2/14/11

Medical Certificate Timeline FIRST CLASS: Airline Transport Pilots Valid for 12 months under 40, 6 months 40 and over SECOND CLASS: Commercial Pilots, Flight Navigators and Flight Engineers Contract Air Traffic Control Tower Operator Valid for 12 months THIRD CLASS: Private and Recreational Pilots Valid for 60 months under 40, 24 months age 40 and over

FAA Authority to Disqualify 1994, Bullwinkel vs. FAA & NTSB, challenged FAA authority to disqualify medications in absence of a disqualifying medical condition As a result, the Federal Air Surgeon was given the authority to deny any “medications or other treatment that (a) makes the applicant unable to safely perform the duties or exercise the privileges of the airman certificate that the applicant holds or for which the applicant is applying; or (b) may reasonably be expected, within 2 years after the finding, to make the applicant unable to safely perform those duties or exercise those privileges.”

Not everyone is Healthy 650,000 Pilots in the USA 400,000 Medicals Issued by FAA every year They are not all healthy The number of prescriptions for Type II Diabetes Drugs has doubled between 2002 and 2005, in children ages 5-19 years. From 0.3 per thousand to 0.6 per thousand. There was a 106% increase in prescriptions for diabetic drugs in children ages 10-14 years from 2002-2005.

How Healthy do you need to be? You do not have to be very healthy You need to be good enough Kind of like being a pilot…. You need to be healthy enough so you are not going to suddenly become incapacitated while operating an aircraft Key Word…”Sudden Incapacitation”

FAA Concerns Aeromedical Significant Disorders Occurs suddenly or unpredictably Is or may be incapacitating Progresses at an unpredictable rate May degrade flight safety

The aviation environment is very complex and dynamic Good Health is critical functioning is this environment.

Two key elements for safe flying Aircraft Performance Airman Performance Both need to be adequate

Medical Certification of Airmen Special Issuances – Cardiovascular (2005) Problem Class 1 Class 2 Class 3 Total Bioprosthetic Valves 33 38 135 206 Mechanical Valves 169 235 Pacemaker 37 53 276 355 Defibrillator 2

FAA Policy on Medications FAR 61 FAA Policy on Medications FAR 61.53, prohibits acting as pilot-in-command or in any other capacity as a required pilot flight crewmember if that person: “Knows or has reason to know of any medical condition that would make the person unable to meet the requirement for the medical certificate necessary for the pilot operation, or: “Is taking medication or receiving other treatment for a medical condition that results in the person being unable to meet the requirement for the medical certificate necessary for the pilot operation.”

FAA Policy on Medications In addition, FAR 91.17, prohibits the use of: “any drug that affects the persons faculties in any way contrary to safety.” “Severe Head Cold” maybe a “medical deficiency” under FAR 61.53

Why the FAA Denies Certain Medications Not exclusively the Medications, but rather the underlying medical condition associated with the Medications Potential for Sudden Incapacitation All Medications are evaluated based on this concept

Generally Disallowed Medications Anticoagulants Antiviral Agents Anxiolytics (anti-anxiety) Barbiturates Chemotherapeutic Agents Hypoglycemic Mood Altering Antidepressants (exceptions, 4/2/2010: Fluoxetine (Prozac), Sertraline (Zoloft), Citalopram (Celexa), or Escitalopram (Lexapro)  Narcotics Sedating Agents Antihistamines Decongestants Tranquilizers Stimulants (Diet Medications) Experimental or Investigational Medications Muscle Relaxants Motion Sickness Anticonvulsants Steroids Lomotil There is no “Official FAA Medication List” The condition is often the disqualifying issue, not the medication

Over The Counter Medications Antihistamines and Decongestants Any drug that produces drowsiness or other central nervous system effects and experimental or investigational drugs are prohibited

Medications NOT Authorized Anticoagulants (Maybe Yes, Maybe No --but ASA, Plavix OK…warfarin/coumadin…it depends…often yes) Mood Altering Medications Sedatives No investigational Drug Treatments No one currently receiving Radiation Treatment Anti-seizure Medications Antidepressants (off smoking cessations medications for 30 days before flying is OK) Except –need “SI”..Fluoxetine (Prozac), Sertraline (Zoloft), Citalopram (Celexa), or Escitalopram (Lexapro) 

AOPA Database This database is compiled by the AOPA Medical Certification Department and is based upon confirmation with the FAA Aerospace Medical Certification Division in Oklahoma City. The list includes both allowed and non-allowed medications and, for the allowed medications, the conditions under which the drug is considered acceptable for flight duties. Although a medication might be listed as allowed, there are variables with each individual's situation that could render a particular medication inappropriate for flying because of case history or adverse side effects. For example, some medications are used "off label," meaning that a drug is prescribed for symptoms that do not fall within the FDA's approval guidelines for that drug. The FAA might not allow an otherwise acceptable drug in this circumstance. http://www.aopa.org/members/databases/medical/search_faa_meds.cfm

What the FAA doesn't know will not Hurt you In a fatal crash, the remains of the crew will be tested for Prescription and Over the Counter Medications 140,000 substances can be screened for by the FAA Civil Aerospace Medical Institute In General Aviation, several hundred substances are routinely screened for after an accident In Commercial Aviation, several thousand substances are screened for DNA in the future – Genetic Markers to determine: Fatigue, Lack of Sleep

It’s a Crime to Lie or Mislead Whoever in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact, or who makes any false, fictitious or fraudulent statements or representations, or entry, may be fined up to $250,000 or imprisoned not more than 5 years, or both" (Title 18 U.S. Code. Secs. 1001; 3571). TWO TYPES OF FALSIFICATION Intentional False Statement – A False Representation of a Material Fact Made with the Knowledge of Falsity Fraudulent Statement A False Representation of a Material Fact Made with the Knowledge of Falsity Made with the Intent to Deceive and Relied Upon by Another

FAA Form 8500-8 No more paper Form 8500-8 Only online as of: 10/1/2012 If you make a false statement..60 day suspension Revocation of your Medical The revocation will always show up on your airman record, you will never get another Medical from the FAA

FAA Policy Regarding Falsification Revocation of BOTH Medical Certificate and Airman Certificate Revocation of Airman Certificate because you the Lack of Qualification of Hold Airman Certificate

Honesty Best Policy If you are taking a prohibited Medication and you LIE, and the FAA finds out, they may press charges, but you will NEVER get another Medical under ANY circumstances. If you are taking a prohibited Medication and you state the truth, your Medical will be denied, if you apply at a future date and are not longer taking the Medication, you will almost certainly be approved for an FAA Medical. FAA wants to encourage honesty, punish those who are not honest

Follow the Rules If you Fly with prohibited substance, you are in violation of your Medical and FAA regulations Any Life Insurance, Accident Insurance, Aircraft Insurance, Liability Insurance will no longer be valid since you are not in compliance with FAA Regulations

Certification of Airman Approximately 400,000 applicants annually Approximately 25,000 Special Issuances per Year 400 Pilots in USA with Diabetes requiring Insulin (3rd Class Medical) Cardiovascular conditions most common in Airmen Final Denial are approximately 0.1%

Privacy of Medical Information Within the FAA, access to an individual's medical information is strictly on a "need-to-know" basis. The safeguards of the Privacy Act apply to the application for airman medical certification and to other medical files in the FAA's possession. The FAA does not release medical information without an order from a court of competent jurisdiction, written permission from the individual to whom it applies, or, with the individual's knowledge, during litigation of matters related to certification. The FAA does, however, on request, disclose the fact that an individual holds an airman medical certificate and its class, and it may provide medical information regarding a pilot involved in an accident to the National Transportation Safety Board (NTSB) (or to a physician of the appropriate medical discipline who is retained by the NTSB for use in aircraft accident investigation. FAA Aviation Medical Examiner Guide, Version IV, July 31, 2005

Disqualifying Medical Conditions Angina pectoris Bipolar disorder Cardiac valve replacement Coronary heart disease that has required treatment or, if untreated, that has been symptomatic or clinically significant; Diabetes mellitus requiring insulin or other hypoglycemic medication Disturbance of consciousness without satisfactory medical explanation of the cause Epilepsy Heart replacement Myocardial infarction Permanent cardiac pacemaker Personality disorder that is severe enough to have repeatedly manifested itself by overt acts Psychosis Substance abuse and dependence; Transient loss of control of nervous system function(s) without satisfactory medical explanation of cause

Did not pass your Medical? SODA Statement Of Demonstrated Ability (SODA) may be granted in lieu of an Authorization Medical condition or defect that is static and nonprogressive One time test, usually not repeated Assisted Special Issuance For Disease Protocols Special Issuance An airman who is medically disqualified for any reason may be considered by the FAA for an Authorization for Special Issuance of a Medical Certificate

One Eyed Pilot One Arm Pilot Can you get a Medical with only one Eye or with one Arm? Can you get a Medical with Skeletal Deformities or after a Stroke? What about a Prosthesis? Deafness? For medical defects, which are static or nonprogressive in nature, a Statement of Demonstrated Ability (SODA) may be granted in lieu of an Authorization.

SODA Statement Of Demonstrated Ability At the discretion of the Federal Air Surgeon, a Statement of Demonstrated Ability (SODA) may be granted, instead of an Authorization, to a person whose disqualifying condition is static or nonprogressive and who has been found capable of performing airman duties without endangering public safety. A SODA does not expire and authorizes a designated Examiner to issue a medical certificate of a specified class if the Examiner finds that the condition described on the SODA has not adversely changed In granting a SODA, the Federal Air Surgeon may consider the person's operational experience and any medical facts that may affect the ability of the person to perform airman duties including Essentially a Flight Test performed by FAA Examiner

Cardiovascular Disease in Pilots Disease 1st 2nd 3rd Class Class Class MI 420 398 2916 CABG 373 358 3149 PTCA 385 295 1810 PTCA with Stent 477 390 2460

Cardiovascular Disease I 10,000 Pilots Flying in USA with Heart Disease with Special Issuance Pacemaker, most pilots certified with Special Issuance (wait 2 mo & stress test) Heart Murmurs usually OK if evaluation negative Most Valvular Heart Disease OK (Mitral Insufficiency, Mitral Regurgitation, MVP, Aortic Insufficiency, Aortic Stenosis) Atrial Fibrillation OK Hypertension OK (30,000 Pilots fly with HTN on Medications) Coronary Artery Disease OK (if < 50% Lesion, LV ok, Stress Test normal)

Cardiovascular Disease II Heart Attacks (MI), OK but need to wait 6 months, need cath and nuclear imaging – no ischemia Heart Valve Replacement OK (wait 6 mo)

Medical Certification of Airmen Special Issuances – Substance Abuse (2005) Problem Class 1 Class 2 Class 3 Total Alcoholism 979 354 542 1,875 Drug Dependence 43 13 17 73

Medical Certification of Airmen Special Issuances – Monocularity (2005) Condition Class 1 Class 2 Class 3 Total Monocularity 209 476 1,912 2,597

Medical Certification of Airmen Special Issuances – Diabetes (2005) Condition Class 1 Class 2 Class 3 Total Non-Insulin 493 988 3,819 5,300 Insulin 425

Epilepsy - Seizures Generally Speaking - No Way Sometimes possible, but this rare

Diabetes Usually Possible If no medications and Diet controlled – OK If on medications, need Special Issuance

Commercial Space Flight Orbital Crew Crew: To Be Determined Passengers: Medical Questionnaire with physical examination and laboratory studies Suborbital Flight Crew: Second Class Medical Certification with endorsement Passengers: Medical questionnaire without routine physical or laboratory studies

Authorization for Special Issuance of a Medical Certificate Granted by the Federal Air Surgeon Valid for a specified period Granted to a person who does not meet the established medical standards Federal Air Surgeon may consider the person's operational experience Individual must satisfy of the Federal Air Surgeon that the duties authorized by the class of medical certificate applied for can be performed without endangering public safety during the period in which the Authorization would be in force. The Federal Air Surgeon may authorize a special medical flight test, practical test, or medical evaluation for this purpose. A medical certificate of the appropriate class may be issued to a person who fails to meet one or more of the established medical standards if that person possesses a valid agency issued Authorization and is otherwise eligible. An airman medical certificate issued in accordance with the special issuance section of part 67 (14 CFR § 67.401), shall expire no later than the end of the validity period or upon the withdrawal of the Authorization upon which it is based.

Aeromedical Certification 2004 442,498 Applications Processed 12,076 Special Issuances (waivers) for significant medical conditions

Airman Certification and Hypertension American Heart Association Normal BP < 120/80 Pre-Hypertension 120-139/80-89 Hypertension > 140/90 FAA- should not exceed, seated 155/95

Initial Protocol for Hypertension Guide for Aviation Medical Examiners AME-- conduct an evaluation OR review report by the attending physician. Personal and family medical history Assessment of risk factors CHD A clinical exam and 3 BP readings separated by 24 hours ! Resting EKG

Initial HTN (Continued) Glucose, Lipid Profile, K+ and Creatinine Medications used, dosage and adverse effects Airman to wait 2 weeks upon initiation of medication or change in dosage Summarize results of evaluation in box # 60

Can You Fly Without a Medical? Glider and Free Balloon Pilots are not required to hold a medical certificate of any class. To be issued Glider or Free Balloon Airman Certificates, applicants must certify that they do not know, or have reason to know, of any medical condition that would make them unable to operate a glider or free balloon in a safe manner.

Sport Pilot Operational Limits - Max. Gross Weight 1,320 Lbs. - Max. Stall Speed 45 Knots - Max. Speed 120 Knots - Max. Two-Place - Day VFR Only - Single, Non-Turbine Engine - Fixed Landing Gear January 21, 2011

Sport Pilot (Continued) Medical Requirements - FAA medical certificate or a valid U.S. driver’s license - An individual may not use a driver’s license if: - A certificate was not issued with the individual’s most recent application; - The individual’s most recent application has been denied, suspended, or revoked; - The individual’s most recent Authorization for a special issuance medical certificate has been withdrawn

Sport Pilot - Medical Hold valid airman medical certificate or a current and valid U.S. driver’s license Must comply with each restriction and limitation on their U.S. driver’s license and any judicial or administrative order applying to the operation of a motor vehicle. Cannot have been denied the issuance of at least a third-class airman medical certificate (if they have applied for an airman medical certificate) Must not have airman medical certificate revoked or suspended Must not have had an Authorization withdrawn (if they have ever been granted an Authorization) May not use a current and valid U.S. driver’s license in lieu of a valid airman medical certificate if they know or have reason to know of any medical condition that would make them unable to operate a light-sport aircraft in a safe manner. Sport pilot medical provisions are found under 14 CFR §§ 61.3, 61.23 , 61.53, and 61.303). For more information about the sport pilot final rule, see: http://dmses.dot.gov/docimages/pdf89/289219_web.pdf LAST UPDATE: July 31, 2005

Antidepressants Mild to moderate depression only - no history of psychosis or suicidal thoughts 4 authorized medications: Fluoxetine, Sertraline, Citalopram, Escitalopram Special Issuance - Single medication only - Stable on medication for minimum of 1 year - Close monitoring Applications - 17 in certification review process - 3 denied

Which type of pilots do not need an FAA Medical Certificate? Free Balloon Pilots Glider Pilots Ultralight Pilots Sport Pilots

Tips for your AME Medical Examination Establish long term relationship with an AME Take your flight physical 4-6 weeks prior to the expiration of your medical certificate Bring all your medical documentation Do not drink coffee or soda prior to exam…only water Bring eyeglasses, hearing aids, seeing eye dog Bring a list of all medications and dosage (the prescription bottle)

Tips for your AME Medical Examination Make sure your vision is good, have your vision checked few weeks prior to flight physical, minimum is 20/40 for 3rd class, 20/20 for 1st /2nd class If you do not feel well or are ill….do not take the flight physical, reschedule it Check your blood pressure 4-6 weeks prior to your flight physical, must be < 155/95! Once you start the flight physical exam never leave

Tips for your AME Medical Examination Chose an AME that will be your advocate Bring any doctors notes, MRI, CT and x-ray report, all recent ER Visits Bring all recent lab reports and Hospital Records Do not get your FAA Physical if you are ill or do not feel well Be Patient…if you have a medical problem it will take time to collect and review the information

Tips for your AME Medical Examination The vast majority of physicians do not understand anything about flying an aircraft and even less about the FAA Aeromedical Certification process If you acquire a medical condition, call you AME 8-10 weeks prior to your medical. It is ok to make an appointment with an AME to review your medical status prior to obtaining your Flight Physical. If possible, go to an AME that is a pilot, he/she will be sympathetic to your desire to keep on flying (my personal opinion)

Office of Aerospace Medicine (AAM) Aviation Safety (AVS) New England Region Headquarters Regional Flight Surgeon Paul H. Clark, M.D. Deputy Regional Flight Surgeon Joseph H. Ray, M. D. Susan E. Northrup, M.D. Federal Air Surgeon Frederick E. Tilton, M.D. Deputy Federal Air Surgeon James R. Fraser, M.D. Civil Aeronautical Medical Institute (CAMI) Melchor J. Antunano, M.D. Medical Specialties Division Michael Berry, MD Southern Region

Medications Authorized by FAA New Medications - Will authorize any medication if it has been out for ONE year All Antihypertensive Medications OK All Asthma Medications OK, including steroids (prednisone) if dose < 20mg qd All anti-cholesterol Medications OK

Future Changes to FAA Aeromedical Certification Special Issuance List (2014?) Kidney stones Carotid artery stenosis Colitis Irritable bowel syndrome, Colon cancer Bladder cancer Leukemia Hodgkin’s disease Lymphoma

Airman Medical Certification Review and Appeals Process AME REGIONAL FLIGHT SURGEON AEROMEDICAL CERTIFICATION DIVISION, CAMI FEDERAL AIR SURGEON NATIONAL TRANSPORTATION SAFETY BOARD ADMINISTRATIVE LAW JUDGE FULL BOARD U.S COURT OF APPEALS SUPREME COURT

Ask the Aviation Medical Examiner Sergio B. Seoane, M.D., Col., CAP Chief, CAP National Health Service FAA Senior Aviation Medical Examiner