Pilots, Docs Tackle Pilot Health and Occupational Safety

August 7, 2014 - A distinguished panel of aviation medicine experts discussed a wide range of current aeromedical topics during a panel, “Pilot Health and Occupational Safety,” held last Thursday afternoon at the ALPA Air Safety Forum in Washington, D.C.

“Capt. John Taylor (ExpressJet), ALPA Aeromedical chairman, moderated the panel made up of Dr. Jim Fraser, FAA Federal Air Surgeon; Dr. David Salisbury, director of Medicine, Civil Aviation, Transport Canada; and Dr. Quay Snyder, ALPA Aeromedical advisor.

Obstructive Sleep Apnea
Acknowledging that FAA policy on obstructive sleep apnea (OSA) is “the elephant in the room,” Fraser announced that the FAA has developed draft policy on OSA that has “addressed the concerns of ALPA and other stakeholders.” Those concerns arose last autumn when Fraser’s predecessor as Federal Air Surgeon, Dr. Fred Tilton, published an editorial in an aeromedical journal outlining an FAA proposal to require automatic OSA testing of all airmen above a specific Body Mass Index (BMI) regardless of other physical characteristics or symptoms.

“We backed off and pled guilty to not working as closely with stakeholders as we should have,” Fraser declared. “We met with ALPA and other stakeholders in January and heard your concerns. We hope to be ready to go with the new policy by the end of the year.”

Snyder noted, “Now we have not only a more streamlined process [for dealing with OSA and airman medical certification], we’ve been getting pilots the treatment they’ve needed. Pilots who’ve been diagnosed with OSA and gotten the proper treatment have told us, ‘I never knew I felt so bad until I felt so good.’ It’s been a nearly universal statement.”

In response to a question from the audience, Salisbury said “CPAP [continuous positive airway pressure, delivered by a small, portable machine] is the gold standard” for treating snoring and OSA.

Airman Certification Issues
In March 2013, the FAA embarked on a major change in its handling of electronic applications and records; the result had the unintended effect of greatly increasing the time FAA needed to process applications for medical certificates.

“We’ve worked with our IT people to fix it,” Fraser said. “The long-term average processing time for a certificate has been 30-40 days; in the last month, however, we’re under 30 days. Also, we have 3,400 AMEs (FAA-designated aviation medical examiners), and we work very hard to train them and to keep them up to date on changes in policies and procedures.”

Taylor asked, “What’s the biggest day-to-day issue you face that we can help with?”

Fraser replied, “I would like to urge every pilot to give us the information we need, up front. Right now, about 92 percent of pilots walk out of their AME’s office with their certificate in hand. I would like to raise that number.” Salisbury added, “What you’re talking about is ‘proactive disclosure’—you need to give us the information we need so we can help get you back in the air, or stay in the air."

Snyder agreed, “When a pilot provides incomplete information, it slows down the process. Dr. Fraser’s office works very closely with us. We have quarterly meetings to discuss ways we think it could work better. His office has been incredibly responsive in making those changes. We also work very closely—on a daily basis—with the FAA’s Airman Medical Certification Division in Oklahoma City.”

Mandatory Reporting?
Asked if he expected that pilots would eventually be required to provide all of their medical records to the FAA, Fraser said, “Based on my experience, no. The medical privacy rules are pretty strict. I don’t expect to see that in my lifetime.”

“Nor in mine,” added Salisbury. “If you have a condition, I need to know what’s going on—but I don’t have to have your entire medical record to do that.”

Taylor observed that, in the United States, diabetes is on the rise, but that Canada and the United States handle medical certification of diabetic pilots differently.

“About 20 years ago,” Salisbury explained, “a court told us that we had to look more closely at the individual case. So we began certifying diabetic pilots on an individual basis. We started with the recreational pilot permit—day VFR only, and only one passenger. We now have about 15 years of experience—and about 100 cases of insulin-dependent pilots flying at the ATPL level. It’s been a very successful experiment.”

In the United States, Fraser noted, the FAA has provided special issuance third-class airman medical certificates to insulin-dependent pilots who have certain protocols. “I’m very proud of the fact that we’ve worked with the American Diabetes Association and recently met with a panel of endocrinologists,” he added. “We’re not there yet, but I’m convinced the science will come, and we’ll be able to give special issuance first-class certificates to pilots who are insulin-dependent but well controlled and stable. It’s a technical issue of continuous monitoring, especially in the cockpit, in case the pilot has a hypoglycemic episode in flight.” (Note: Dr. Snyder and Dr. Martin of the ALPA Aeromedical Office participated in this meeting to represent the pilots’ perspective.)

Fraser reported, “We now have several hundred very successful stories of pilots certificated to fly while using one of the four antidepressants that we’ll now approve for use while flying. We’re looking at expanding the population. For example, some pilots are prescribed antidepressants to treat obsessive compulsive disorder, so we’re looking at that.”

Snyder indicated that the testing requirements and costs associated with SSRI evaluations have been reduced by the FAA as more data supports the safety of this policy.

Pilot Self-Assessment
Fielding an audience question about pilot self-assessment of fitness for flight, Salisbury replied, “There’s an old saying in medicine: ‘A doctor who treats himself has a fool for a patient.’” While all three physicians on the panel agreed with the value of pilots using the popular mnemonic aid, IMSAFE, to assess their fitness for flight, they cautioned against trying to self-diagnose conditions that could be potentially serious. Instead, they urged all pilots to develop a good relationship with their individual aviation medical examiner or aeromedical experts such as the ALPA Aeromedical Office.

Meds vs. Conditions
Snyder indicated that the ALPA Aeromedical Office receives many calls daily from pilots asking, “Can I take this medication and fly?” He explained, “Our initial response is not usually ‘Yes’ or ‘No’; it’s ‘Why are you taking the medication? What is the underlying condition?’ The underlying condition is more important than the medication itself.” Given that information, the pilot is given appropriate guidance on using the medication and flying.

Fraser agreed and added, “I continue to be amazed by the number of toxicology reports” from investigations of fatal accidents involving general aviation pilots that showed the pilots had ingested diphenhydramine (Benadryl). “Too many pilots fail to appreciate the risks of over-the-counter medications—the sedating effects of antihistamines in particular,” he warned. “You may be awake, but your mental faculties are impaired, and you make mistakes.”

Cargo FTDT
On the subject of the “carveout” that exempted the all-cargo airline industry from FAR Part 117, the FAA regulations that established science-based flight- and duty-time limits and minimum rest requirements for the passenger airline industry effective early this year, Fraser declared, “It’s not those of us in the trenches, in the Aviation Medicine or Flight Standards parts of the FAA, who are opposed to including cargo pilots in FAR Part 117. But there’s a big political side to the argument.”

Substance Abuse Disorders
Fraser said he was proud of his association with the HIMS program, the substance abuse treatment program that ALPA began in 1972 and continues to administer under an FAA grant. Snyder noted, “We’ve now helped a number of pilots return to the cockpit and saved their careers after they’ve entered the HIMS program.”

Asked if new criteria included in the latest revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would result in changes to Transport Canada policy regarding treatment and recertification of pilots suffering from substance abuse disorders, Salisbury responded, “No. There really isn’t going to be a change in policy from our standpoint.”