Medical Bulletin - Federal Aviation Administration

16 Pages·2009·0.25 MB·English

Federal Air Surgeon’s
Medical Bulletin
Aviation Safety Through Aerospace Medicine
02-1 For FAA Aviation Medical Examiners, Offi ce of Aerospace Medicine Person- U.S. Department of Transportation
Spring 2002 nel, Flight Standards Inspectors, and Other Aviation Professionals. Federal Aviation Administra-
Aeromedical Certifi cation Update
HEADS UP
Revised Policy Announced on Special Issuance Procedures
By Warren S. Silberman, DO, MPH
2 Editorial: Doing
to get authorization to issue special issuance
Things Right DR. JON JORDAN, the Federal Air medical certifi cates.
Surgeon, is continually looking for Before this change, these cases would
4 Case Study:
ways to improve medical certifi ca- have been deferred to the AMCD for dis-
Vasovagal
tion while still maintaining the integrity of position. This change, however, substantially
Syncope the process outlined in 14 CFR 67.401. He increased the workload of the ACMD and
gave us a “heads-up” in his column in the pre- regional staffs—but is very effective and will
4 Environmental
vious issue of the Federal Air Surgeon’s Medical be continued.
Issues: PBDEs Bulletin on one such initiative [“Responding The initiative we are implementing with
to Medical Progress,” FASMB, winter 2001, this issue of the Bulletin will help to further
5 AME Profi le:
page 2]. Well, ladies and gentlemen, here is reduce certification delays and AMCD
L.S. Moore, MD the essence of our initiative. Upon publica- workload. For all 21 medical conditions,
tion of this edition of the Bulletin, we plan identifi ed below, Federal Aviation Adminis-
6 Alaska Capstone
to implement this action. tration (FAA) staff physicians will make the
Project Dr. Jordan has identifi ed 21 medical initial certifi cation decisions and grant the
conditions that are suitable for this new Authorizations. The Authorization letter will
7 Web Site
initiative. Each of these conditions requires be accompanied by attachments that specify
Simmering the issuance of a medical certifi cate and what treating physician(s) information the
an Authorization for Special Issuance of a airman must provide to request the re-issu-
8 Sleep Disorders
Medical Certifi cate (Authorization). They ance of the medical certifi cate. Also included
10 Color Vision in will also require special follow-up medical will be the criteria for when the AME should
evaluations to help ensure that the airman’s defer issuance. This new initiative is limited
Black & White
medical condition remains stable. to airmen seeking third-class medical cer-
13 Your Letters In the past, the special medical evalua- tifi cates, and FAA medical staff will review
tions had to be submitted to the Aerospace each issuance.
13 AME Seminars Medical Certifi cation Division (AMCD) The 21 conditions include the follow-
for review before a new medical certifi cate ing:
14 Health of Pilots: was issued. Because of the heavy workload √ Asthma, chronic obstructive airway dis-
Scoring Points for at the AMCD, some airmen experienced ease, and sleep apnea
√
Aviation Safety delays in obtaining their new medical cer- A history of atrial fi brillation and parox-
tifi cates. These delays are frustrating for the ysmal atrial tachycardia
√
airmen, for the aviation medical examiners Chronic lymphocytic leukemia, colon
E (AMEs), and for the certifi cation staff at cancer, Hodgkin’s lymphoma, lymphoma,
R Oklahoma City. and prostate cancer
√
A So, a little over a year ago, Dr. Jordan Heart murmur (non-physiologic)
H With directed that improved lines of communica- √ Arthritis (rheumatoid and variants),
S m atio n P atie nts tcieornti fib cea etsitoanb slitsahffe,d a nbdet rwegeieonn AalM mEeds,i cAaMl stCafDfs √ cDoileitti-sc,o anntdro ullreodl idthiaiabseitses mellitus
T hYios uIr nfSto raff a n d tmaone eAdxiMpcaeEdl p ittroeo ctbholeen mtcaescr.tt T iafin hc iaAst MpiornoC coDefs sap iehrnmycsoeicnui arwangi toehrs √√√ GHHlyiasptuoecrrotyhm oyafr omaindidgis rmoaci nuaelna dsry hhnyydpproeormttheeynrsoioidnism
regional fl ight surgeon directly by telephone
Continued on page 3...
The Federal Air cases, examination reports had to be
Doing Things
Surgeon’s Column reconstituted from notes and in other
cases, no information on examinations
R i g h t could be found.
In the case of the second AME, no
fi les could be made available to the FAA
...Pays huge dividends for
indicating that examinations had been
everyone concerned
performed or what the results of the
examinations may have been. Therefore,
SINCE FIRST JOINING the Federal we had no way of knowing whether the
Aviation Administration in 1969, pilots had been properly issued their
I have witnessed a dramatic change Jon L. Jordan, MD, JD medical certifi cates.
in the character and quality of the Avia- Although we made every attempt to
tion Medical Examiner (AME) system. ‘The consequences...were that accommodate the pilots impacted by
I think this change is attributable to a the AMEs’ inaction, for a number of
the image of the certifi cation
number of factors. These include the the pilots there was a cloud over their
system was signifi cantly dam-
establishment of more comprehensive certifi cation, and it was necessary that
aged, pilots were substantially
AME selection criteria, better oversight they undergo repeat examinations.
of the system by both our regional fl ight inconvenienced, and resources The consequences of these episodes
surgeons and the Aerospace Medical were expended to correct the were that the image of the certifi cation
Education Division, enhanced training problems.’ system was signifi cantly damaged, pilots
methodologies, and better communica- were substantially inconvenienced, and
tion between AMEs and FAA medical resources were expended to correct the
personnel. Perhaps, however, the most impor- problems. Because of the magnitude of
tant factor has been the willingness of these problems, the designations of the
AMEs to adapt to technological change AMEs were terminated.
Federal Air Surgeon’s
and to become more involved in provid- Doing things right pays huge divi-
Medical Bulletin ing services to pilots that facilitate their dends for everyone concerned. As you
medical certifi cation. While the AME will see by reading Dr. Silberman’s
system has improved signifi cantly over article in this issue of the Bulletin [page
Secretary of Transportation
the years, every now and then problems 1], we are broadening the involvement
Norman Y. Mineta
surface that need to be addressed and of AMEs in certain elements of the
FAA Administrator
corrected. certifi cation process, with the objective
Jane F. Garvey
As you know from reading the of improving our services to airmen.
Federal Air Surgeon Guide for Aviation Medical Examiners Our success in doing this is highly de-
Jon L. Jordan, MD, JD and by attending AME seminars, we pendent upon the willingness of AMEs
expect AMEs to promptly forward the to participate and the care that is taken
Editor
results of medical examinations to the to ensure that correct certifi cation deci-
Michael E. Wayda
Aerospace Medical Certifi cation Divi- sions are made.
The Federal Air Surgeon’s Medical Bulletin
sion (AMCD). Failure to do so can In initiating this action, we are relying
is published quarterly for aviation medical
have signifi cant impact on airmen and on AMEs to carefully follow the require-
examiners and others interested in aviation
damage the effectiveness of the medi- ments of the Authorizations granted by
safety and aviation medicine. The Bulletin is
cal certifi cation system. In addition, it the agency. Unless this care is taken, we
prepared by the FAA’s Civil Aerospace Medical
may have signifi cant implications for run some risk that the initiative will “bog
Institute, with policy guidance and support from
the Offi ce of Aerospace Medicine. An Internet the AME, both in terms of continued down” the certifi cation process—and
on-line version of the Bulletin is available at: designation as an AME and possible the process will be impeded, rather
http://www.cami.jccbi.gov/AAM-400A/ liability if a medically related accident than improved.
fasmb.html occurs. We are counting on all of you who
In the last year or so, I have become participate in the process described by
Authors may submit articles and photos for
aware of two instances in which AMEs Dr. Silberman to “do it right.” In spite
publication in the Bulletin directly to:
have failed to submit examination results of the two situations I related in this
Editor, FASMB
to the AMCD. In one case, the AME article, I believe that you will.
FAA Civil Aerospace Medical Institute
blamed a secretary for the problem. He I also believe that we will be much
AAM-400
P.O. Box 25082 made an attempt to repair the damage further along in our objectives of pro-
Oklahoma City, OK 73125 by searching his fi les and belatedly sub- viding quality service to the aviation
e-mail: [email protected] mitting “lost” examinations. In some community.
JLJ
2 The Federal Air Surgeon’s Medical Bulletin (cid:129) Spring 2002
Certifi cation from page 1 AN EXAMPLE OF THE TYPE OF INFORMATION THAT WILL BE REQUIRED AND CONSID-
ERED ACCEPTABLE FOR AN AME TO ISSUE A CERTIFICATE
AFTER AN AUTHORIZATION HAS BEEN GRANTED
Each pilot’s medical condition will
be assessed on an individual basis, History of Paroxysmal Atrial Fibrillation
and the special medical information Information required
requested may vary, depending on the 1. A summary of how the airman has done since the last FAA examina-
circumstances. tion to include mention of any further episodes
AMEs may not issue medical cer-
2. Current medications and any side effects
tifi cates to airmen who have one of the
identifi ed conditions unless: 3. 24 hr. Holter Monitor
(1) The airman has an Authorization No Issuance permitted if:
granted by the FAA, 1. There is a recurrent episode of fi brillation
(2) The airman has all the information
2. Chronic fi brillation occurs
required by the Authorization,
3. The airman is placed on anticoagulation
and
(3) The required medical information
indicates no adverse change that plete and comply with all the requirements sion to the FAA.
necessitates deferral to the AMCD in the Authorization. All information must
Q— What if the time for the pilot to sub-
or to the regional fl ight surgeon. be favorable to the pilot, and it must be
mit the follow-up information does not
The following questions and answers consistent with the guidance information
coincide with the time for another regular
are provided to help further explain the provided to the p ilot at the time the Au-
FAA examination? Should I conduct a new
new process. thorization was granted.
examination anyway?
Q— How will I know if it’s okay for me to
Q— If the treating physician and I don’t A— No. The interval between required
issue a medical certifi cate to a pilot who has
agree with the criteria established by the FAA follow-up examinations may be less than
one of the 21 listed medical conditions?
for recertifi cation of the pilot, is it okay if I the intervals between regularly required
A— You may only issue if the pilot has issue a certifi cate? FAA examinations. If this is the case, a new
an Authorization letter granted by the
A— No. For purposes of assuring uni- regular FAA examination is not required.
FAA. The letter will specifi cally permit
formity in our decision making, the
you to issue a certifi cate, usually with a Q— If no regular examination is required,
guidance must be followed consistently,
time limitation, if the pilot has all the may I charge the pilot a fee for reviewing
and you must defer the issuance. If, upon
information requested by the FAA and if the medical information and issuing a new
further review the FAA agrees that there
the information is favorable according to certifi cate?
has not been a signifi cant change in the
the FAA criteria. pilot’s condition, the FAA will issue the A— Yes. You may charge a reasonable
Q— How will I know what special follow- certifi cate. fee for providing this service to the pilot.
The amount of the fee is a matter to be
up information is required and what criteria
Q— I am concerned that I may overlook determined by the AME and must be ac-
should be used to determine that it’s okay
something and make a mistake. Will the ceptable to the pilot.
to issue a new certifi cate?
AMCD medical staff or the regional fl ight
A— When the medical certifi cate Authori- surgeons be reviewing my work? Q— I have a very busy medical practice and
zation is granted, the pilot is provided with can devote only so much time to performing
A— Yes. The medical staff at the AMCD
specifi c information on what is required for FAA examinations. Do I have to participate
or the region will review each issuance of
a special issuance in the future, how often in this new initiative?
a certifi cate under an Authorization.
it is required, and what criteria are used to A— No. Pilots with Authorizations have
decide whether a new certifi cate may be Q— Will this procedure extend to all classes the option of having their required follow-
issued. The pilot is directed to make all of of medical certifi cates? up information reviewed either by AMEs
this information available to the AME. A— No. Initially, this procedure will apply or by the FAA medical staff. We would like
only to third-class Authorizations. for you to participate in this initiative, but
Q— Suppose the pilot has an Authorization,
if you are unable to do so, it is okay.
and the medical information presented by Q— If I am uncertain whether to issue
the pilot looks okay, and I believe there’s the airman a medical certifi cate, may I call (cid:52)
been no change in his or her condition—but the AMCD or my regional fl ight surgeon
one of the requested pieces of information for advice?
is missing— may I issue a certifi cate?
A— Yes, but if you cannot make contact
A— No. The information must be com- with FAA staff, you must defer the deci-
Dr. Silberman manages the Civil Aerospace Medical Institute’s Aerospace Medical Certifi cation Division.
The Federal Air Surgeon’s Medical Bulletin (cid:129) Spring 2002 3
Vasovagal Syncope Episode in an Airman
Environmental and Safety
Case Study, by Leonid M. Katkovsky, MD Issues Associated With
PBDE Flame-Retardants
This is the case study of a 43-year-old white male who applied for a third-class By Arvind K. Chaturvedi, PhD
medical certifi cate on 11/03/99. His application was deferred to the Aerospace
Medical Certifi cation Division (AMCD) for further evaluation because he had
Abstract: Polybrominated diphenyl ethers
experienced an episode of syncope in September 1998. (PBDEs) are extensively used as fl ame-
History. The applicant’s cardiologist provided the most recent (11/23/98) com- retardants in many commercial products,
plete history and physical examination. Tilt table study of 12/09/98: strongly including aircraft materials. These ethers
The applicant has had 4-5 episodes of suggestive of hypervagotonia syndrome have been detected in various parts of the
pre-syncope since 1997. He described with a drop in blood pressure to 70/31 environment, but not much information is
them as a lightheaded feeling with a and a junctional rhythm of 63 during available about their environmental toxic-
change in his vision but no syncope. Isuprel infusion with tilting. He became ity. PBDEs are effective in saving lives by
The episode of frank syncope took lightheaded (with no visual symptoms preventing fi res. Therefore, there is a critical
place while he was recuperating from mentioned) and presyncopal but did need for the evaluation of the merits and
a viral syndrome with diarrhea, fever, not have frank syncope. demerits of PBDEs.
and malaise. He had no episodes on At that time, trial beta-blocker
exertion and denied any chest pain, therapy with Lopressor 25 mg PO BID TO PREVENT the occurrence of fi re, PBDEs
(polybrominated diphenyl ethers) are
shortness of breath, or vertigo. He also was recommended, based on the results
used as fl ame-retardants (Fig. 1; 1-4) in
denied any TIA symptoms or focal of the tilt table test (TTT).
the housing, back covers, and electronic
neurologic symptoms. He was allergic Aeromedical Disposition. If an
parts of color televisions and personal
to sulfa drugs; took 1 multi-vitamin/ airman suffers a syncopal episode and
computers; in textile coatings; and in seats
day. Medical history was unremark- reports this to the AME, he/she should of cars, buses, and aircraft. In aircraft seats,
able, with no hypertensive or cardiac obtain all the information surround- PBDEs are generally used in upholsteries
risk factors. A review of systems was ing the event (s). We needn’t tell you and polyurethane foam-based cushions. The
otherwise negative. that the history of the event is most PBDE-treated urethane foam is preferred in
Social history. He is a non-smoker; important. When you have all of this seating, since PBDEs neither discolor the
married, with no children; no record in hand, you can give the AMCD or foam nor decrease its durability. PBDEs
of alcohol abuse. the regional medical offi ce a call. If the could also be present in commercial prod-
ucts used in other foams, fabrics, panels,
Surgical history. In 1965, “lazy eye” syncope is shown to be vasovagal, the
potting compounds, and other materials
surgery was performed. likelihood of medical certifi cation is
used on aircraft.
Physical exam. Well-appearing good. Should the airman procrastinate
airman in no distress. Blood pressure: with the supporting documentation,
132/88 and 122/86 in right and left the AME should defer the case.
arms (respectively) without orthostatic The terms vasovagal syncope, neuro-
changes. Pulse: regular at 68 BPM; cardiogenic syncope, and neurally medi-
weight: 189 lb; height: 6’2”. Neck: ated syncope are synonymous. However,
no jugulovenous distention. Carotids: if the individual has a cardiac arrhyth-
3+ and symmetric without bruits. No mia such as asystole or bradycardia,
thyromegaly or masses. Chest: Clear. it is called malignant cardioinhibitory
Heart: PMI–normal. S1&S2 –normal; syncope. It is the latter form of syncope
no S3 or S4 clicks, murmurs, or rub. that the AMCD does not grant medical
Abdomen: soft, nontender, no organ- certifi cation until a suffi cient period of
Chemically, PBDEs are aromatic hydro-
omegaly or masses. Extremities: pulses observation is done. If, with adequate
carbons and are only slightly soluble in water
3+, symmetric; no edema, cyanosis, history, the airman can prove that it was
(1-4). Most of the PBDE congeners found
or clubbing; no venous varicosities. only vasovagal syncope, then certifi ca-
in commercial fl ame-retardants are lipo-
Neurologic: oriented x 3 with normal tion is usually granted. An airman with philic, bioaccumulating, and bio magnifi ed.
mood and affect. Generally non-local recurrent episodes of vasovagal syncope These industrial chemicals are considered
exam. ECG: normal sinus rhythm is not granted medical certifi cation. to be environmentally persistent organic
with normal tracing. CXR: negative. pollutants, as they tend to concentrate at
Holter monitor: no arrhythmias. 2-D nonpolar surfaces of soil particles and in
echo cardiogram of 12/09/98: normal. living organisms, and to degrade slowly
Continued on page 12... in the environment. PBDEs accumulate
in sediment and biota, and apparently
Dr. Katkovsky was a resident in Aerospace Medicine at the Civil Aerospace Medical
Institute when he wrote this report. Continued on page 16...
4 The Federal Air Surgeon’s Medical Bulletin (cid:129) Spring 2002
AME Profi le: Louis S. Moore, MD
Dr. Louis Moore is a practicing aviation medical examiner who has specialized in aviation medicine for more than 41 years. He is a pilot who
enjoys fl ying Cessnas, also has a glider rating, and as the president of his fl ying club, is active in the aviation community. His fi rst solo fl ight was
in 1942. This 78-year-old physician had a few observations to make about some of the articles that appeared in the winter 2001 issue of the Bul-
letin, and we present them here, verbatim, to describe his views about fl ying, aviation medicine, and related issues. —Ed.
designers had better start that might have had to turn back and
I enjoy reading the Bulletin
putting a portta potty in in each case was able to assure the pilot
and usually fi nd one or two
the cockpits. The hassle that it was safe to go ahead. Think of
articles of special interest to me.
to get to the restroom is the thousands of dollars it would cost to
I have been a pilot for 53 years
so bad that service in the turn a plane back when it is three hours
and an AME for 41 years, but
cabin is disrupted and out of New York for Paris.
still have a few things to learn.
the pilots are even cut- In two cases, I was given a bottle
I would like to comment on
ting back on their fl uids of wine by the cabin crew and in two
several items in the current issue
- which is not at all a I received a formal letter of thanks six
and would ask you to pass on my
good idea. weeks letter. In one case, there was no
comments where appropriate.
response at all. No one offered me an
Dr. Jordan [editorial, page 2]-
Pg 8 - Transoceanic Emergency: upgrade or passes or even tickets to
Changes in certifi cation process: Most
That passenger sure picked the right Disney World.
of the changes through the years I have
fl ight to have his syncopal episode. The If a passenger offers to get “bumped”
considered to be helpful in improving
handling of that situation was textbook when there is overbooking, he may get
effi ciency without jeopardizing safety
perfect! a free ticket to anywhere plus a few
- such as reducing the hearing test to
Which brings me to my subject. hundred dollars. If the industry would
spoken voice, both ears.
Many doctors now routinely refuse to offer some really worthwhile rewards for
I would like to fi nd a way to make
identify themselves to the cabin crew our help, it would make us feel more
the color vision test more practical
and might even refuse to respond to a appreciated. They could even offer an
since the pseudoisochromic plates are
call for help. I consider this unethical, upgrade to a doctor who volunteers as
much too sensitive and result in a lot
unprofessional, immoral, and a few he comes on board if there are seats
of expensive hassle for marginal pilots.
worse epithets. I am proud of my posi- available - or maybe just a good meal,
A simple red-green-blue-yellow-white
tion and feel I have an obligation to for a change.
lamp would be great. I think I could
help in every situation — deal with the Please pass this along to someone
build one from Radio Shack parts for
lawyers later. in the industry who might see some
about $15.00. At present my pilots
They claim they fear a lawsuit, but value in it.
must make arrangement and go 100
I think this is a paper tiger. I doubt if
miles away to take a simple test. The
there has ever been a successful lawsuit Pg. 13 - AME fees [Training
other option would be to authorize
against a doctor for rendering assistance Notes]:
the AME to conduct the test at a local
in fl ight. Years ago I charged class one and
tower-controlled airport.
The airline industry, with a little help two pilots a bit more than class three.
I think the new standards for blood
from you people, might put this myth Then I got to thinking —These guys
pressure are a bit low since this level does
to rest with a little research. Check out are trying to make a living and they are
not indicate a risk in the near future,
the malpractice carriers and see if they putting money in my pocket twice a year,
which is what the exam is all about.
have ever had a claim paid, or even why should they pay more? For the class
Assistance from Oke City is always
one fi led. three, fl ying is optional, and I only see
great! — prompt and courteous.
If my guess is correct, this could be them every two years. Now I have a fl at
Delegating responsibility: This is
widely publicized to the medical pro- fee and I chose the low end of the scale. I
a tough one and will depend as much
fession and maybe get some of these sometimes charge extra when I handle a
on the experience and skill of the AME
cowards to stand up and be counted. complicated case with more paperwork.
as the specifi c item involved. An AME
At the same time, put out information Hey, fellows, give it a thought.
who is a pilot and does 600 exams a year
about the on-board medical equip-
is obviously better equipped to make a
ment and the telephone consultations Louis S. Moore, MD
judgment call. I wish all AMEs (and
available. Naples, Fla.
tower operators) were active pilots.
Another aspect of this is the shabby
(cid:52)
treatment the doctor may get for his
Pg. 3 - Aviation bill:
help. I have intervened in three cases
With the locked cockpit doors, the
The Federal Air Surgeon’s Medical Bulletin (cid:129) Spring 2002 5
The Alaska Capstone Program: Increasing Safety Through Technology
By Kevin W. Williams, PhD
IN THE SOUTHWEST corner of Alaska,
centered around the small town of
Bethel, lies one of the largest labo- Figure 1. Capstone
ratories in the world. This laboratory is avionics displays. In-
not a building but consists of approxi-
stalled in each aircraft
mately 40,000 square miles of land, and
participating in the
its accompanying airspace, in an area
Capstone program,
known as the Yukon/Kuskokwim (or
the avionics consist of
Y/K) delta.
a multi-function dis-
Within this laboratory the Federal
play unit, the Apollo
Aviation Administration is conducting
an ongoing experiment aimed at testing MX-20 (top) and an
new avionics technology for general Apollo GX-50/60
aviation (GA) aircraft. Participants in Global Positioning
the experiment, which is called the System display.
Alaska Capstone Program, are pilots
and fl ight companies in the Y/K delta.
Approximately 150 GA aircraft have
been equipped with the advanced
avionics equipment. Figure 1 shows
the avionics that are installed in each
aircraft participating in the Capstone
program. The avionics consist of a Anchorage, Alaska: GA community under the Capstone
multi-function display unit, the Apollo • 1 out of every 58 people in Alaska program have only been generally
MX-20, and an accompanying Global is a pilot available before to commercial airlines
Positioning System (GPS) display, an • There are 6 airplanes for every 10 and high-end GA aircraft. The ability
Apollo GX-50/60. pilots in Alaska to see traffi c and weather on a cockpit
Capstone’s Objectives • There was an average of 1 aircraft display is usually provided by expensive
The purpose of this program is accident every other day in Alaska onboard detection systems. To provide
twofold. The fi rst is a test of whether or during the past 10 years such capabilities in a less expensive
not the technology can improve fl ight • There was an average of 1 aviation manner, a ground- and satellite-based
safety in Alaska by providing better fatality every 9 days in Alaska during infrastructure was created called
information to the pilot regarding ter- the past 10 years Automatic Dependent Surveillance
rain, traffi c, and weather in the vicinity • Of the commercial pilots that - Broadcast, or ADS-B. Unlike radar
of the aircraft. The second is to test the spend their 30-year career fl ying in systems, which bounce radio waves off
new avionics in a relatively controlled Alaska, more than 11% will perish in of airborne targets and then interpret
environment to aid in the transition of their aircraft, as compared to 2.5% the refl ected signal, ADS-B relies on
the technology to the entire country. of the pilots in the other 49 states. position information that is transmit-
Both aspects of the experiment are as- ted by each individual aircraft based
sisted by human factors scientists from Improving fl ight safety in Alaska on global positioning system (GPS)
the Offi ce of Aerospace Medicine, at is of major importance to the FAA. If technology.
the Civil Aerospace Medical Institute the technology being tested under the Each ADS-B equipped aircraft
(CAMI) in Oklahoma City. Capstone program can accomplish broadcasts its precise position in space
Flight Safety in Alaska this goal in Alaska, it will pave the way via a digital datalink, along with other
A look at some basic facts regarding for implementation on a nationwide data — airspeed, altitude, and whether
fl ight safety in Alaska demonstrates the basis. the aircraft is turning, climbing, or
need for improved safety. The follow- Automatic Dependent descending. This information can be
ing facts were released recently by the Surveillance – Broadcast transmitted directly from one aircraft
Alaska Capstone Program Offi ce in The capabilities being offered to the to another, or it can be transmitted
Continued (cid:190)
Dr. Williams is a research scientist with the FAA Civil Aerospace Medical Institute’s Human
Factors Research Laboratory.
6 The Federal Air Surgeon’s Medical Bulletin (cid:129) Spring 2002
to a ground station, combined with data from the Bethel region. Members
other aircraft data, and re-transmitted of the team have conducted personal THE CIVIL AEROSPACE MEDICAL
back to any aircraft within range of interviews with Capstone pilots, ad- INSTITUTE’S WEB SITE IS SIMMER-
the ground station. The information ministered questionnaires, and fl own
ING
can also be transmitted by land lines on observation fl ights during actual
or other means to air traffi c controllers day-to-day operations of the Capstone
Those creative “chefs” at the Civil
in distant locations. equipment.
Aerospace Medical Institute have been
ADS-B allows pilots in the cockpit Experiments are also under way to
busy “cooking” video programs so they
and air traffi c controllers on the ground collect both objective and subjective data
can be viewed online at the Institute’s
to “see” aircraft traffi c with much more regarding the use of Capstone equip-
Web site (www.cami.jccbi.gov). Several
precision than has ever been possible be- ment under various environmental
appetizers showing such events as im-
fore. Unlike conventional radar, ADS-B and workload conditions. CAMI’s two
pact tests have been available online for
works at low altitudes and is effective in fl ight simulators are being equipped
more than a year, but with the help of
remote areas or in mountainous terrain with Capstone avionics for use in the
advancing technology, the main course
where there is no radar coverage, or conduct of these investigations.
of items will be available soon for view-
where radar coverage is limited.
ing on your computer screen.
The Future
Cooking video means reducing
Flight Information The second phase of the Capstone
the image size to consider network
Services – Broadcast Program is about to begin in the
bandwidth restrictions, so a program
In addition to information related to southeast portion of Alaska, centered
“stream” can be easily viewed on home
other aircraft, other types of information around the Alaskan state capitol of
or corporate computers at the user’s
can be broadcast from ground stations Juneau. Capstone Phase II will include
connection speed.
to Capstone-equipped airplanes. Flight both a multi-function display and an
The menu of main course items will
information services include graphical optional highway-in-the-sky display as
include the latest productions made for
weather depictions, as well as text-based part of its avionics package. Another
pilot education by the CAMI Airman
weather and other information such as 150 GA aircraft, both fi xed-wing and
Education Program people. Some of
Notices to Airmen (NOTAM). Since rotary, will be equipped with the Phase
the titles for the pilot physiology series
weather plays a major part in many II avionics.
are Fit for Flight, Flying and Hypoxia,
aircraft accidents in Alaska, the avail- While the primary focus of the
Spatial Disorientation, plus global sur-
ability of current weather conditions, Capstone Program is on increasing
vival topics about hot and cold weather
presented in an easily interpreted graphi- fl ight safety in Alaska, the Safe Flight
survival, water survival, and how to stock
cal format, is expected to be of great 21 Human Factors Team is looking at
a survival kit with practical items for
help to Alaskan pilots. The graphical the program as a proving ground for
emergency use—a very useful subject
depiction of NOTAMS, showing, for these new types of avionics. A thor-
with spring and tornado season ap-
instance, that a runway has been closed ough human factors assessment of the
proaching.
at a particular airport, should also make instrumentation and procedures will
Other video series are being pre-
it easier for pilots to maintain awareness ensure that the pilot-aircraft interface is
pared for use by FAA aviation medi-
of important information both before optimized for safety of fl ight— wherever
cal examiners: 29 vignettes reviewing
and during their fl ights. that fl ight will occur.
clinical aerospace physiology, and 30
It is expected that, in the near future,
skits demonstrating correct actions to
CAMI’s Role these avionics systems, as well as the
take in aeromedical certifi cation cases.
Human Factors scientists from ground infrastructure to support them,
Also to be shown are the Mike Mon-
CAMI have been assisting in the Cap- will be seen in the lower 48 states, and
roney Aeronautical Center’s Mission
stone Program for several years. CAMI eventually around the world. What we
Briefi ng program and the CAMI video
scientists participated in the team that are seeing in the Capstone Program is
describing programs and activities at
selected which set of avionics would be the start of a paradigm shift in general
the Institute.
used in the Capstone Phase I Program, aviation cockpit displays. The CAMI
The programs will be viewable online
developed criterion measures for use in scientists supporting this effort are
using Microsoft Windows operating
demonstration fl ights of the selected excited to be a part of this event.
systems 98, 2000, XE, and ME; the
avionics, and developed and assisted
(cid:52) common viewer is Microsoft Media
in the administration of performance
Player.
measures of the equipment.
The FAA IntrAnet is available now.
CAMI scientists currently participate
IntErnet (the world) will be available
as members of the Safe Flight 21 Hu-
this spring after beta testing.
man Factors Team in the collection of
(cid:52)
The Federal Air Surgeon’s Medical Bulletin (cid:129) Spring 2002 7
of sleep apnea and can be used in most
Sleep Disorders In Pilots operational situations.
Nasal septal repair, turbinate reduc-
By Virgil D. Wooten, MD
tion, and nasal polypectomy, together
or alone, are important adjunctive
Aviation-related accidents are caused by human error 80% of the time. The role surgical treatments but rarely work
of sleep disorders in these mishaps is unknown and probably underestimated. when done without also enlarging
the oropharynx and/or hypopharynx.
Recognition of the causes and signs of fatigue and sleep disorders is central to safe
Uvulopalatoplasty (UPP), currently the
and effective air operations. Recognition and treatment of sleep disorders may
most commonly performed procedure
lower the rate of aviation accidents and improve operational effectiveness.
for OSA treatment, is successful less
than 30% of the time when strict cri-
Obstructive Sleep Apnea treated. OSA should also be viewed as teria (respiratory disturbance index of
OBSTRUCTIVE SLEEP APNEA (OSA) a chronic and relapsing illness, needing < 5/hr) for cure are used. The success
results from repetitive partial periodic reassessment. Before treatment rate is reduced in the obese, elderly and
or complete upper airway col- is attempted, OSA should be verifi ed those with multiple airway anatomical
lapse upon inspiration, resulting in loud and the severity quantifi ed by poly- problems. Concomitantly performing
snoring, hypoxemia, and subsequently, somnography. There is wide variation in genial tubercle advancement increases
brief arousals. It is typically progressive, individual impairment caused by OSA, the chance of cure.
especially with weight gain. and the true severity of the illness is Maxillomandibular advancement
As OSA becomes worse, oxyhe- not predictable based on history alone. is usually performed after UPP has
moglobin desaturations become more The patient’s report of improvement failed, but may be done as the primary
frequent, longer and lower. Hyperten- following treatment interventions is procedure in individuals with maxil-
sion may develop or worsen, especially not reliable, due to partial treatment lofacial problems. Glossectomy, hyoid
in the morning. response, placebo effects and fear of loss suspension, and hyoid anchoring may
The repetitive brief arousals caused of occupation or benefi ts. The Multiple pose more risk of morbidity. In-offi ce
by sleep apnea lead to the same effects Wakefulness Test, a modifi cation of the surgical procedures that minimally alter
caused by sleep deprivation. OSA pa- Multiple Sleep Latency Test, assesses the the airway are unlikely to help OSA.
tients typically complain of daytime ability to stay awake. It is probably less Radiofrequency Volumetric Tissue
fatigue, sleepiness, morning tiredness, useful than sleep testing during real and Reduction applied to the tongue base
concentration impairment, memory simulated driving and piloting tasks, but may assist in the treatment of OSA but
impairment, and irritability. The the lack of simulator testing availability still needs further investigation.
amount of sleep required to maintain and validated measures of fi tness for duty Narcolepsy
function may begin to increase. As in makes the MWT the most widely used An uncommon neurological ill-
sleep-deprived individuals, those having assessment for alertness. ness, narcolepsy most often begins in
OSA may tend to deny or underestimate Weight loss is helpful in obese OSA youth. It most cases, the sleepiness is
the extent of impairment caused by the persons, but unfortunately the failure extremely severe and pervasive. Affl icted
illness. Several studies have indicated rate is high. Airway devices or surgical individuals often report the inability to
that individuals with OSA have much correction are usually needed to correct stay awake even in the most stimulating
higher rates of automobile accidents, the disorder. The devices offer rapidity circumstances. Diffi culty awakening
but adequate data on aviation mishaps of treatment, reversibility, fl exibility, low in the morning is common. Sleep at-
in affl icted individuals are currently risk, and low cost when compared with tacks, or irresistible urges to sleep, are
lacking. surgeries. Compliance problems, unpre- characteristic and are often aborted or
OSA is caused by multiple airway dictable effectiveness, and the possibility prevented by naps of less than 30 min-
anatomical and medical problems. Al- of relapse limit both surgical and non- utes. Narcoleptics often report dreaming
lergic rhinitis, nasal septal deformity, surgical approaches. Nasal Continuous during naps.
nasal polyps, maxillary hypoplasia, Positive Airway Pressure (CPAP) is Cataplexy, a sudden voluntary muscle
micrognathia, retrognathia, soft palate highly effective; however, compliance weakness lasting up to fi ve minutes, is
elongation, adenotonsillar hypertrophy, can be a problem. Nasal occlusion, brought on by emotions such as laughter,
and other causes of airway reduction drying, claustrophobia, discomfort, and anger, or excitement. There is no associ-
contribute to the development of rhinitis often interfere with its use. Oral ated dizziness, or post-event fatigue. The
OSA. All must be considered and ad- appliances that protrude the mandible weakness can be generalized or affect
dressed if the illness is to be effectively are effective in mild to moderate cases specifi c muscle groups. Sleep paralysis
can occur in narcolepsy. The patient
Dr. Wooten is a special medical consultant in sleep disorders to the Federal Air Surgeon, is an
awakens fully, yet is unable to move for a
FAA aviation medical examiner, and is the Medical Director of TriHealth Sleep and Alertness
Center, Good Samaritan and Bethesda Hospitals, Cincinnati, Ohio. Continued (cid:190)
8 The Federal Air Surgeon’s Medical Bulletin (cid:129) Spring 2002
few seconds or minutes. Hallucinations or bright sleeping accommodations. and electrolyte abnormalities can ag-
are common in the transition into and Nearly all insomniacs develop poor sleep gravate RLS. Iron supplements have
out of sleep. Cataplexy, sleep paralysis, habits and frustration, which may per- been reported helpful, but because of the
and hallucinations are not always pres- petuate the problem. Therefore, good risk of iron overload, it is recommended
ent in narcoleptics. The symptoms are sleep habits and relaxation training are that ferritin and iron panels be obtained
all manifestations of aberrant control of essential to the effective treatment of and followed. A number of drugs have
REM sleep-related processes. insomnia. been reported effective in small case
Only partial and temporary control Sleep Hygiene studies. Dopamine agonists (levodopa,
of the sleepiness can be achieved with • Use the bedroom for sleep and sex bromocriptine, pergolide, pramipexole,
stimulants such as modafanil, p emoline, only—no TV, music, business, or argu- ropinirole), clonazepam, and narcotic
methylphenidate, and amphetamines. ing in bed. analgesics have been demonstrated to
Cataplexy, sleep paralysis, and hypna- • Avoid looking at the time. be the most effective, but the last two
gogic hallucinations are improved by • Avoid alcohol, caffeine, and heavy are contraindicated.
antidepressants and gammahydroxy- meals before bed. In the last 20 years, there have been
butyrate, but these medications are • Schedule a worry time, planning ses- major advances in the understanding
prohibited. sion, and wind-down time before getting of sleep disorders and their treatment.
Following an overnight poly- into bed; make lists of things to do the The aviation medicine specialist can
somnogram to verify adequate sleep next day. play a pivotal role in evaluating pilots
and absence of sleep pathologies that • Make the bedroom quiet, comfort- with sleep disorders. The recognition
could cause sleepiness and REM sleep able, dark, and secure. Use white noise and treatment of sleep disorders can
onsets during the nap trials, the diagno- generators if the environment is noisy. prevent the potentially catastrophic out-
sis of narcolepsy is made by performing Minimize disruptions, e.g., pets. comes, especially when these disorders
a multiple sleep latency test (MSLT). • Get out of bed after lying awake for are combined with fatigue-i nducing
Two or more REM sleep onsets with more than 20 minutes—do something operations.
evidence of pathological sleepiness boring or run through relaxation tech- References
are desirable to confi rm the diagnosis. niques. 1. Redline S, Strohl KP. Recognition and
The MSLT is a better measure of the • Avoid exercise and hot baths within consequences of obstructive sleep apnea
ability to sleep than the ability to stay 3 hours of bedtime. hypopnea syndrome. Clin Chest Med;
awake; therefore, it should not be used • Exercise regularly, in the morning or 1998;19:1-19.
as a test for the ability to maintain afternoon. 2. Mitler MM, Walsleben J, Sangal RB,
alertness or vigilance. Genetic testing • Keep a regular bedtime and get-up Hirshkowitz M. Sleep latency on
the maintenance of wakefulness test
for narcolepsy is not diagnostic, but time.
there is a genetic predisposition for the • Do not spend excessive amounts of (MWT) for 530 patients with narco-
lepsy while free of psychoactive drugs.
disorder. The cause of narcolepsy is now time in bed, e.g., if you can sleep only
Electroencephalogr Clin Neurophysiol;
believed to be due to degeneration of 7 hours spend no more than 7.5 hours
1998; 107(1):33-8.
CNS hypocretin-orexin cells, triggered in bed.
3. Aldrich MS, Chervin RD, Malow BA.
by unknown environmental causes in • Avoid excessive napping, which can
Value of the multiple sleep latency test
susceptible individuals. interfere with the ability to sleep at
(MSLT) for the diagnosis of narcolepsy.
Insomnia night.
Sleep; 1997; 20:620-9.
Chronic insomnia affects 10 to 30% Restless Legs Syndrome (RLS)
4. Morin CM, Wooten V. Psychological
of the population. Its prevalence and RLS is an annoying but non-painful
and pharmacological approaches to
importance in the aviation population condition that occurs in the evening
treating insomnia: critical issues in
is less certain. Studies of performance hours and with prolonged sitting or
assessing their separate and combined
in chronic insomniacs have given mixed lying. Involuntary jerks and twitches
effects. Clin Psychol Rev; 1996; 16:521-
results, with some studies suggesting are frequently observed while awake, 42.
performance impairments and others and usually there are rhythmic leg jerks
5. Montplaisir J, Godbout R, Pelletier
showing little, if any. Insomnia is a com- occurring about every 20-40 seconds
G, Warnes H. Restless legs syndrome
plaint that may have multiple causes. after sleep onset (periodic limb move- and periodic limb movements during
Insomnia due to anxiety and depression, ments of sleep, PLMS). The affl icted sleep. In: Kryger MH, Roth T, Dement
for example, has more bearing on fl ight individual experiences an overwhelm- WC, eds. Principles and Practice of Sleep
operations than insomnia due to sleep ing need to move the legs, which gives Medicine. Philadelphia:Saunders; 1994;
state misp erception, in which there is temporary relief. Caffeine, alcohol, 589-97.
adequate sleep but impaired ability to anticholinergics, antihistamines, anti-
(cid:52)
perceive that sleep has occurred. depressants, antipsychotics, diuretics,
More senior fl ight personnel have decongestants, and theophylline can
more diffi culty adapting to unfamiliar aggravate the condition. Iron defi ciency,
(hotel insomnia), uncomfortable, noisy, anemia, uremia, vitamin defi ciencies,
The Federal Air Surgeon’s Medical Bulletin (cid:129) Spring 2002 9
Color Vision in Black and
White: An Update
By Ingrid Zimmer-Galler, MD

THE MEDICAL STANDARDS in Part 67
specify that applicants for all
classes of medical certifi cation
have the “ability to perceive those c olors
necessary for the safe performance of
airman duties.” There is no doubt that
color discrimination plays an important
role in “the safe performance of airman
duties.”
Navigation lights, airport beacons,
runway lights, taxiway lights, aircraft
position lights, and colored light sig-
Examples of Dvorine pseudo-isochromatic plates for color
nals need to be identifi ed. Similarly,
vision testing (left: 92, right: 48).
various colors are used on aeronautical
charts as well as in the electronic fl ight
information systems in modern aircraft. be unsafe for aviation duties. Many of activities of living, it is not unusual for
Therefore, even though form vision is these individuals will also have poor student pilots to fi rst learn of a color
most important in the performance of a visual acuity. vision abnormality at their fi rst physical
pilot’s tasks, color vision clearly increases There are three classes of cones in the by an AME. Individuals who c annot
effi ciency and safety. retina, each of which absorbs light with pass the color vision test administered
Although aging and various eye a different peak sensitivity to perceive by their AME will receive a limitation
diseases may lead to acquired color blue, green, and red color. Any color of on their medical certifi cate stating “not
vision defects, virtually all clinically the spectrum may be constituted with valid for night fl ying or by color signal
signifi cant color vision abnormalities are varying combinations of these three pri- control.” There are two options available
congenital. The pilot population is still mary colors. Color defi cient individuals to the airman for removal of these restric-
predominantly male, and color vision recognize three distinct hues but have a tions from the medical certifi cate:
abnormalities are predominantly a male weakness in one of the hues. Colorblind 1) Successful completion of an alternate
disorder. With nearly 8.5% of all males individuals, on the other hand, have a FAA-approved color vision test or
having a congenital color defi ciency, it complete absence of color sensation in 2) Issuance of a SODA (Statement of
is easy to understand why color vision addition to poor central vision. Demonstrated Ability) after successful
concerns are a common problem for the For the AME, it is not important completion of a light signal test.
aviation medical examiner (AME). to classify the type of color vision The fi rst option is more desirable
Congenital color vision defects are defi ciency (for example, protanomaly, for the pilot applicant. If an applicant
sex-linked recessive traits, and only 0.5% deuteranomaly, dichromatism, achro- is unable to pass the color vision test
of females are color-defi cient. Most matopsia) but only to determine during the fl ight physical, provide a list
persons with a color vision defi ciency whether the applicant has suffi cient of acceptable alternative color vision
can distinguish some colors and should color vision to safely perform aviation tests (see list, below), and advise the ap-
not be labeled as “colorblind.” In fact, duties. FAA-approved color vision plicant to seek out an ophthalmologist
approximately one-third of affected screening tests reliably separate mild or optometrist to administer one of the
individuals have only a mild color vi- color vision abnormalities (safe for fl y- alternate tests.
sion defi ciency. Such individuals have ing) from moderate-to-severe defi cien- The tests most commonly used by
been shown to be safe in the aviation cies (not safe for fl ying). ophthalmologists and optometrists to
environment. The remaining two-thirds Because it does not affect their daily screen for color vision abnormalities
of affected individuals have moderate- are all on the list of alternately approved
to-severe color vision defects and may tests. Applicants with more severe color
vision defects (those considered unsafe
for fl ying) will not be able to pass any
Dr. Zimmer-Galler is an Assistant Professor of Ophthalmology at the Wilmer Eye of the alternate screening tests. How-
Institute, Johns Hopkins University School of Medicine. This article previously appeared
in the February 2002 Flight Physician, the newsletter of the Civil Aviation Medical
Association, and is reprinted with permission. Continued (cid:190)
10 The Federal Air Surgeon’s Medical Bulletin (cid:129) Spring 2002