Well, good afternoon. I'm James Frazier. I have the honor and pleasure to do the clinical aerospace medicine review. This is my 19th year to do this. But right from the beginning, I want to tell you that each of the years that I've done this, I've updated my slides with the most recent FAA changes. And now as a retired guy, I serve as a consultant to the Allied Pilots Association. They represent the 16,000 plus American airline pilots. So I stay up to date with all the FAA changes. The last Wednesday of the month, I'm always looking for the current updates in the AME guide. And I am certainly more familiar with the AME guide, more so than I ever was when I was doing this for eight years as the deputy federal air surgeon. And then my last three years with the FAA as the federal air surgeon. So I feel quite comfortable with the AME guide that continues to get better and better. And I feel like I am certainly up to date with the aerospace medicine as it pertains to the FAA. And more on that later. So before I get started, let me do just a brief intro so you'll know where I'm coming from. I am not an ologist of any kind. And when we have the opportunity for questions here in a couple of weeks, you'll know I'm not an ologist. So keep that in mind. So just in terms of where I'm coming from, I started life in the Navy and I did a family practice internship at what was then Naval Regional Medical Center Charleston. Following an internship, I did the required Navy seasoning and served as a general medical officer. In my case, I was a squadron medical officer for a destroyer squadron out of Charleston and went on two deployments and had some great adventures. I subsequently went back to the family practice residency at Charleston. I completed the residency and stuck around Charleston as FP staff for a short time until the Navy sent me to the Philippines. I then served in the Philippines and ran an FP clinic for three years and had so much fun that I went to the other side of the world to Scotland and served as the officer in charge and ran an FP clinic in Scotland for three years. I love family practice, but I did not want to return to teaching. And I had always wanted to learn how to fly and become a naval flight surgeon, so I did the great thing that you can do in the Navy. I applied to be a flight surgeon. The Navy sent me to flight surgeon training in Pensacola, Florida. They taught me to fly, and I've been in aerospace medicine ever since. So, following flight surgeon training, the Navy gave me the opportunity to complete a second residency in aerospace medicine. And in the Navy, a residency in aerospace is pretty much a one-way ticket to a aircraft carrier. In my case, I had the pleasure to serve as the senior medical officer on board the USS Theodore Roosevelt, where I supported a medical staff of 62 in a 67-bed hospital. As the senior medical officer, I was responsible for the health of 6,000 people on board and approximately 12,000 personnel attached to the carrier battle group. Following my tour on the Theodore Roosevelt, I served as the force medical officer for the Commander Naval Air Force Atlantic Fleet. And as the force medical officer, I had medical oversight for the medical departments and hospitals aboard all East Coast aircraft carriers, as well as 18 Naval Air Station branch medical clinics and more than 100 positions. So, I completed my career as the command surgeon serving at the Naval Safety Center in Norfolk. Here, I had the opportunity to help train and provide medical oversight to all Naval flight surgeons. I was responsible for reviewing the aeromedical analysis and the mishap investigating report on all Navy and Marine Corps aviation mishaps. I also had the opportunity to participate in safety initiatives at the highest levels of Naval aviation. The very last thing I did in the Navy just before completing or just before retirement was serving as a member of the Columbia Accident Investigation Board, but that's another story. So, the Navy gave me some wonderful opportunities and I would do it again in a heartbeat. Following retirement, I was able to apply for the senior executive service and was fortunate to be selected. And they sent me to headquarters at FAA in Washington, D.C. So, I made the move from Norfolk, Virginia to Alexandria, Virginia, same state, different world. So, at FAA headquarters, I served two years as the manager of medical specialties, then was selected to be the deputy federal air surgeon where I served eight years, and finally was selected to be the federal air surgeon where I completed my three years before retirement from the FAA in 2017. So, like the Navy, the FAA provided me with some wonderful opportunities and I would do it again in a heartbeat. So, with that, you'll see before you here the educational objectives. We're going to talk about the specifically disqualifying conditions, certainly the philosophy, the FAA philosophy regarding acceptable and unacceptable medications. And as a result of this training, you will hopefully become familiar with the FAA process of determining complex cases. We're going to go through 55 clinical cases, and you may have noted there's a lot of slides. I can assure you we will not be looking at 341 slides. Having done this for 19 years, I learned long ago you can't discuss every slide. So, I'll be fast-forwarding through the slides you see in the presentation to the aeromedical concerns and disposition. So, if you're like me, if you have the time, I encourage you to read the additional slides that contain the clinical material, but certainly we'll be mostly touching on the aeromedical concerns and disposition. So, in many of these cases, you'll be asked, what would you do as an AME? The purpose of this training, however, is not to train you to be an AME. The purpose is to teach you sound aeromedical thinking as it would be done in the FAA. Why the FAA? The FAA is the one common language that we have amongst us. Clinical aerospace medicine, of course, covers the entire spectrum of medicine. So, it's quite an extensive topic, and I found that a discussion of these clinical cases works quite well. My references are, of course, Code of Federal Regulation Part 67, something I know well, like the back of my hand, as well as the AME guides and the standard aeromedical text, DeHart-Ernstein and Russ Raymond's text of clinical aviation medicine. Much of the material comes from the American Society of Aerospace Medicine Specialist Practice Guidelines, and I've been told by many of my colleagues that that's an excellent source to study in preparation for the boards. So, with that, let's launch into the conditions that are specifically disqualifying. There are six cardiac, there are three neuro, there are five psychiatric, and one endocrine. And I will talk about each one of these specifically disqualifying conditions in the 55 clinical cases that we'll be discussing. So, as far as these specifically disqualifying cases are concerned, you'll soon learn that it's kind of tricky. Most of these specific disqualifying conditions can be waived or special issued with the appropriate follow-up and testing. However, some, like epilepsy, psychosis, and bipolar disorder are showstoppers unless you can convince the FAA that you were incorrectly diagnosed. So, we'll discuss each of those cases in one of the 55 clinical cases that we'll be running through. So, first, let's talk about the FAA philosophy regarding the use of medicine. The FAA does not approve medicines. The FDA does that. We do a careful evaluation of the airman with the specific conditions. It's the condition of the airman that's important and not use of meds. Use of meds is reported on each FAA medical application. So, the AMEs are required to talk about these medicines in the presence or absence of side effects. So, there is no specific list of medications. We learned long ago that a specific list was impossible. Not only are there literally tens of thousands of medicines that we would keep track of, but certainly it's not the medicine in and of itself that's disqualifying, but the specific medical condition. In terms of individual caveats, we don't typically allow investigational or experimental drugs, and we expect the medicine to be taken at no greater than the maximum dose recommended by the manufacturer. We expect that the medicine not have frequent side effects, which is basically 1%. And we look for black box warnings. Certainly, those medications that have black box warnings, whether it be cardiovascular or neurological, is not something we would allow. So, typically, we wait, and after the FDA approves the medicine, the medication, we wait for one year, and then typically, we would begin allowing airmen to use those medicines. There are some exceptions for well-known categories of antibiotics and antihypertensives. And in these cases, we may allow a medicine before the one-year time period. The new biologic agents, such as the immune modulators, like Internacept for severe rheumatoid arthritis, or Remicade for ulcerative colitis or Crohn's, those kind of medicines, we consider each and every medicine because they have such individual side effects that we certainly look hard at those. Use of a drug that is off-label certainly raises some concern, but it's not a showstopper. We are not the FDA police, and we allow these medicines as long as they are available. As long as they don't have side effects or are used in doses that aren't recommended by the manufacturer. As you're aware, certain drug combinations may be unacceptable. And, of course, we frequently reconsider our position, and as time comes, we have an excellent PharmD that can assist us in changing our view on a particular medicine as being acceptable or not. So, notwithstanding, there are a few medicines or classes of medicines for which Airmen medical certification is not possible. And all of these are easily found in the AME guide, in the pharmaceutical section, and the Do Not Fly, Do Not Issue section. So, these include the anti-seizure medicines, the psychotropic medicines, including antipsychotics, anxiolytics, mood stabilizers, and ADHD medications, narcotics, sedative hypnotics, antihistamines, with the exception of some of the truly non-sedating antihistamines, and that would include loratadine, fexofenadine, and desloratadine. We do allow these. Varenicline, we do not allow. And I will tell you a short story about Varenicline. We at the FAA are certainly interested in keeping our Airmen healthy. So, when Varenicline was being studied, we were quite excited. Varenicline was certainly very successful in helping Airmen stop smoking. And of course, smoking is a major risk factor leading to coronary artery disease. So, when the FDA approved Varenicline, we waited the one year, and then began allowing Airmen and air traffic controllers to use Varenicline. However, as is not uncommon, when large number of people start taking medicines that are allowed, you begin to see side effects that weren't notable in the smaller clinical studies that were initially done. And this was, of course, the case with Varenicline. As you are aware, patients or Airmen taking Varenicline can experience suicidal ideation and psychosis. Neither one of these are good. If you're a pilot in the cockpit or an air traffic controller controlling traffic. So, me and my colleagues looked at the available data, and we quickly determined that Varenicline should no longer be allowed to be used. So, we looked at our database. Finding the Airmen that were using Varenicline was the easy part. But with physicals that can go between up to five years for Airmen under the age of 40, there were certainly lots of Airmen that could have begun taking Varenicline that were not in our database. So, we worked with the unions, we worked with the Airmen advocacy organizations, and we quickly put out the word that because of the risk of suicidal ideation and psychosis, Varenicline was no longer allowed. So, this was picked up by the press. And very quickly, we had calls from my colleagues in the other transportation agencies, railroad, maritime, federal highways. When asked why we no longer allowed Varenicline, we shared with them the data, and they too made Varenicline a disqualifying medicine for their operators. Likewise, my colleagues overseas and the ICAO certificating authorities called. We shared the information with them, and they too made Varenicline a not allowable medicine for their transportation operators. So, at the end of one week, I went home over the weekend and thought, damn, we do good work. Not only had we made air travel safer, we'd made transportation safer for all modes of transportation, not only in the U.S., but overseas. So, I was feeling pretty good about myself. Then I came back to work on Monday, only to learn that several of my colleagues in the American Medical Association, and I'll spare the specialty, but had gone to the post and alleged that the FAA had obviously caved to the pressures of the tobacco lobby. I was so pissed when I heard this, to think that fellow physicians would accuse me and my colleagues to purposely take actions that would allow airmen and air traffic controllers to continue smoking really irritated me. So, I counted to 10. I went outside and had a cigarette. Just kidding about the cigarette, but we did share our data with my colleagues and haven't heard anything since, but that was my first introduction to politics inside the beltway at headquarters FAA. I subsequently learned that politics was not something you would typically discuss when you are a federal servant, federal civil servant, and I learned this because in February of 2009, you may remember there was a Bombardier that crashed in Buffalo. The subsequent investigation showed that it was a perfectly good airplane, but the two pilots were basically very inexperienced. They didn't know how to handle a stall, and they were fatigued. So, because of this crash that killed 50 people, 49 on board and one on the ground, Congress required us to make some changes, which we did, and we subsequently came up with the flight duty and rest, which required airmen to have some 1,500 hours of training before we allowed them to fly in the cockpit, carrying tickets, carrying passengers, and we had serious restrictions on how long airmen could work due to the fatigue that was involved in this mishap. I subsequently would lecture at the annual Airline Pilots Association Safety Seminar, and I would talk about these changes. So after going through the scripted part of these presentations, the floor would open for questions. So we had a FedEx pilot that stood up and asked why cargo pilots were not included in the flight duty and rest in the new guidance that the FAA had published. And I started out on the right foot. I said that cargo pilots are subject to the same causes of fatigue as pilots that carry passengers, probably even more so because they fly on the wrong side of the clock. And other cargo pilots make frequent short hops into various cities throughout our country, which is very fatiguing in and of itself. So if I would have stopped there, I would have been okay. But I went on and said, basically it was a political decision. Well, that was the wrong thing to say because there were several dozen reporters in the audience of the hundred or so aviators that attended, and they were fast scribbling notes. The next day, one of these reporters was Jim Hall, former chair of the NTSB. And on a slow news day, on the following day, and on the front page of U.S. News and World Report, Jim Hall had an article that was entitled the most honest man in Washington. And went on to talk about me talking about the cargo pilots and them not being included as a political decision. Well, you might think being called the most honest man in Washington would be a good thing, but it's not. I had the opportunity to go talk to my boss, the director of aviation safety, and subsequently the FAA administrator. And I was basically counseled that we should not be talking about political decisions if you're a federal agent, and I should have caveated that in terms of risk-based decision-making and not political decisions. But fortunately, my boss stood up for me. They didn't fire me. But once again, I learned that Washington, D.C. can be a very political case, and I had to watch myself. And when I would subsequently lecture outside groups, not talk about political decisions. So, so much for the political issue that I experienced at the FAA. There's also operational federal regulations that apply. We expect that any airman using any drug should not fly if it could take away from his ability to fly safely. And we have a big section 6153, which is likewise telling all airmen they're responsible for knowing their medical condition and that they not fly if this condition would make them unsafe. And we expect them to know what medicine they're receiving, and if there is any reason this medicine would not allow them to fly safely. We frequently quote that when we send airmen notification of being allowed to be special issued when we give them a waiver. More on that later. So, we do allow sleep aids. We have several sleep aids that we allow. Certainly, Zolpidem is the one that we most frequently recommend. And as long as airmen are not abusing this, they can often use the Zolpidem to help adjust their circadian rhythms. We typically require airmen wait five half-lives before flying. There are some medicines out there that have been used for sleep that require a long wait, and we do not allow those. We do not address melatonin. And generally, we do not address supplements or herbals. Certainly, there are some of these herbals like Ephedra or St. John's Wort that certainly raise our antennas, and we look into whether the airmen might have depression. But in and of themselves, the FAA does not bother themselves with supplements or herbals. Big thing here is it's the underlying medical condition, not the medicine that's the concern. So, here we're gonna jump into cases. An airman was recently diagnosed by his family physician with hypertension and placed on medicine. Do you have concerns? Well, of course. The Framingham study showed that hypertension puts airmen at significant risk of coronary events. And we expect this to be worked up before we certificate the airmen. So, typically, we go with a BP. We expect an airman to have a BP of 140 over 90. However, we are also aware that there are airmen that have what's frequently described as white coat hypertension, meaning the physician will basically explain away a persistent blood pressure as anxiety on the part of the airmen. And we are certainly aware that white coat hypertension may indeed be early hypertension, and we expect this to be thoroughly worked up. So, hypertension is associated with significant cardiovascular events. And we'll talk more about that later. So, one of the things that is confusing is that the airmen, the FAA will allow a certificate to be issued if the airman's blood pressure is as high as 155 over 95. We do that just in terms of expediting the certification of airmen. One third of adults have hypertension. And if we were to stick with the 140 over 90 or the 134 over 85, we would put airmen at undue wait times. So, we allow 155 over 95, not because we condone a blood pressure that high, but only in terms of expediting the certification of airmen. And we expect that airmen to be worked up either by his AME or by his primary care physicians. We accept most all of the antihypertensives. We accept up to three, and you can see there are the ones that we allow. There are still some old centrally acting antihypertensive that we do not allow. So, one of the things that I want to go back and touch on is an incorrect statement there in aeromedical disposition. It says there that hypertension is one of 18 CACI conditions that can be regular issued if by the AME of all CACI conditions on the worksheet are met. There are now 22 CACI conditions. And CACI conditions are something that you need to be aware of. I would expect you will see a question that would ask you what CACI stands for, conditions AMEs can issue. I would not expect that you would be asked what the worksheet specifies, but certainly we now have 22 CACI conditions, and we will touch on many of these as we go through the 55 clinical cases. But 22 CACI conditions and conditions AME can issue is something you should be aware of. So, case two, an airman comes into your office for a routine first-class medical and is wearing a contact lens in one eye that corrects for near vision in the other eye that corrects for distant vision. Is that a problem? Well, yes, it is. Contact lens wear to correct for visual acuity is okay. The FAA even allows for bifocal contact lenses, but monovision contact lens correction is not allowed due to a loss of stereopsis and an NTSB finding that goes all the way back to a 1996 mishap at LaGuardia. Where we had a first officer that was at the controls. Basically, he took an MD-88 at LaGuardia, ran over several approach lights at the end of the runway, and no one was injured or killed, but the NTSB found that the loss of stereopsis because of the use of the near and distant contact lenses was a problem. So, our medical forms now ask if an airman is using one contact for near and one for distance, which we do not allow. So, case three, an airman with a history of melanoma with a breeze load depth of 1.2. The lesion was excised and no further therapy was instituted. Do you have concerns? And yes, you should have concerns. Here, we talk about some clinical issues. And I'm going to, as I stated, breeze through these clinical discussion. Here's the concerns. Our concern is the risk of an in-flight, incapacitating event. Of those that present with recurrent disease, 20% will present with brains to the MET, or METs to the brain. And approximately 60% of the brain METs from melanoma have led to seizures and other incapacitating neurological events. The AME guide will tell you that you can issue if the airman had a melanoma with a breeze low of less than 0.75. We expect the airman to provide a current status annually for five years. And when the breeze load depth exceeds 0.75, where there's lymph node involvement, we would expect an MRI of the brain in order to SI that airman. As you can see, first and second require a brain MRI every six months, and third class requires a brain MRI annually. Now we move on to case four. First class medical examinee informs you that three months ago, he had a central retinal vein occlusion, and his vision can only be corrected to 2200 in his right eye. The condition has fully resolved, but the Snellen chart confirms the corrected visual acuity mentioned. Do you have air medical concerns? And I hope so. 2200 is considered blindness. This airman is essentially monocular. Here, I talk about the fact that an airman needs monocular cues at greater than 200 meters. And it takes time for an airman to develop the techniques to interpret the monocular cues that substitute for stereopsis. Also an airman's effective visual field is reduced by as much as 30% by binocularity. And we would never confuse monocularity with homonymous hemianopsia, which we would never certificate. So for a sudden onset change in vision, the FAA requires that an airman be grounded for six months for allow him to become accustomed to stereopsis. At the end of this time, we allow airmen to take a medical flight test for purposes of obtaining a statement of demonstrated ability, a SOTA. And certainly that's a term that you should be aware of because we have SOTAs for many medical conditions. And these SOTAs can be obtained for any class, first, second, or third. Case five, an airman reports that he was seen in the ER for syncope. Do you have concerns? And yes, I hope so. So I wax philosophical here for the next 12 slides just because syncope is such a huge issue for so many airmen. And it frequently comes up in our deliberations at the FAA. Our concerns, any underlying condition that predisposes an aviator to suffer syncope attacks could lead to sudden incapacitation and loss of aircraft control. So for this reason, loss or disturbance of consciousness, orthostatic or symptomatic hypotension or recurrent vasodepressor syncope are disqualifying. If an AME obtains a history that is compatible with a single episode of vasodepressor or vasovagal event, they're taught to grant medical certification. And authorization for special issuance will not be required. If an airman experiences a similar event, it will require a decision by the FAA. So here I talk more about air medical disposition and what we're looking for when we look into these often difficult cases of syncope. Often it's a tincture of time. Often we wait several years if an airman has had the syncopal events and only with a wait of several years of having no problems will the FAA be willing to consider a special issuance. So case six, here we move on to an airman with a history of newly diagnosed type two diabetes. It's been started on a sulfonylurea. He's also taking medoprolol. His hypertension is well controlled. Do you have concern? Well, diabetes on oral medications is one of the 15 specific disqualifying illnesses, but we frequently special issue these airmen as long as they're not having any problem. Now, once upon a time, a sulfonylurea and a beta blocker were showstoppers, but that was only with the first generation beta blockers, which masked the symptoms of hypoglycemia. With the newer generations of beta blockers, that is no longer an issue. So all airmen receive regular issuance if their diabetes is controlled with diet and exercise. All classes can receive a regular issuance for prediabetes, metabolic syndrome, and impaired fasting glucose and insulin resistance if they meet the criteria in the CACI worksheet that we provide for these medical conditions. All classes can be granted an FSI on oral hypoglycemic or anti-hyperglycemic provided they are in good control and they have the absence of diabetic complications. All classes can also be granted an SI if they're on insulin, but we have a very stringent protocol that requires continuous glucose monitoring, and these pilots are looked at very closely, typically for first and second class pilots. However, for third class pilots, the FAA has long maintained a program where third class pilots taking insulin can fly. And in your notes, you will see the requirements that we have for third class pilots to fly while taking insulin. Here we have what we require in terms of their air medical disposition, but that's for third class. For first and second class, we certainly require a far more detailed evaluation every six months involving their insulin levels according to their continuous glucose monitoring. And it's important that you know that any class airman can apply for an SI even if they're on insulin. We have dozens of airmen that we now allow to fly as air transport pilots that are on insulin. We follow them quite closely. So here we have an airman that comes to you for a third class. She reports that she was diagnosed six months ago with a peripheral neuropathy and was given gabapentin. Should you issue the certificate? And in this case, no, you should not. Gabapentin is a seizure medicine and we do not allow seizure medicines even if they're not being used for a seizure disorder. So these medications have side effects that are not compatible with aviation duties. So let me catch up with my notes here. Okay. And case eight is that of an airman with a spontaneous pneumo. Can you grant medical certification? And the AME guide will tell you, yes, you can. If there's a history of a single event and you have X-ray evidence of resolution and there's no evidence of a condition that would be likely to cause recurrence. And here I talk about the clinical aspects of spontaneous pneumos. A major issue is recurrence. So once an airman has had a recurrent pneumo, they would expect a surgical intervention. And of course, these days are the thoracoscopic pleurodesis. Unlike the old days when I trained where you actually opened an airman and used four by fours to scar the pleura so that the pneumo would be unlikely to return. Case nine, airman presents with a pacemaker originally inserted for complete heart block. The treating cardiologist performs our required stress test for pacemaker dependency and finds the airman intrinsic heart rate was 30. Do you have concerns? Well, the airman is considered pacemaker dependent if they have a heart rate less than 40. We, for a long time, granted medical certification to third class. We did not initially allow airmen in first or second class with pacemakers. But as of August 25 of 2021, pacemakers were felt by the FAA to be sophisticated enough and failure proof enough that we began allowing first and second class airmen to be certificated with pacemakers. Case 10, here an airman presents with a history of viral cardiomyopathy. He's asymptomatic and recently had a bruise where he went 11 minutes and attained a heart rate 95% of the maximum predicted rate. An echo was performed that showed an ejection fraction of 30%. Should the AME issue the certificate? And in this case, the answer is no. The AME guide will tell you that myocarditis, endocarditis, and pericarditis must be deferred. The medical records for the event need to be obtained to confirm this was a viral cardiomyopathy and not some other form of cardiomyopathy such as that due to coronary artery disease, hypertension, or Chagas disease, the old redoubt bug that you may remember. Here, we talk about concerns and disposition and the need for the 24-hour halter. In this case, even though the airman performed well on the stress test and there were no significant arrhythmias, the ejection fraction is too low. The FAA expects to see an ejection fraction of 40% or greater. And in this case, we would follow this airman until the ejection fraction was within that range. So, here we have an airman with recent renal colic. Do you have concerns? And I, once again, talk about the clinical aspect of renal colic. And with concerns, we talk about the incidence of stones being in younger airmen. And the fact that this could be potentially a sudden incapacitating event. Here, I talk about the risk of recurrence and the disposition. In these cases, we frequently are able to certificate the airman. And this is another case where renal cocculi are one of the 22, not 18, canking conditions that can receive a regular issuance from the AME if all criteria in the worksheet are met. So, we go on to an airman that is sold. He has coronary artery disease. Do you have concerns? And I would certainly hope so. Coronary artery disease is one of the 15 specifically disqualifying conditions. Here, I talk about the fact that the risk of sudden death from an unheralded MI is eight times at the age of 40 compared to an airman at age 30. By age 50, it's 36 times greater. And by the time an airman is age 60, the risk of sudden cardiac death is 100 times greater than that airman at age 30. And as you know, sudden cardiac death is the initial presentation in more than a third of MIs. So, here we talk about concerns. Certainly, detecting the asymptomatic progression of coronary artery disease without invasive testing is a challenge. All common medications used for coronary artery disease may cause side effects, including subtle side effects of aviator performance. Now, it's because of the risk of sudden cardiac death and incapacitation that the FAA defended their old age 60 rule that was put in place back in 1959. And certainly, it was a swag when it was determined that airmen with coronary artery disease or when it was determined that age 60 was the cutoff for airmen due to this risk of coronary artery disease. The FAA defended this decision for many, many years. But it's an incredible story to be in Washington when there's an idea whose time has come. So, despite many, many years of challenges to this age 60 rule, I will be forever grateful when George Bush on 13 December 2007 signed into law the Fair Treatment for Experienced Pilots Act. If he had not done this, I would have spent the rest of my career either going to the House side or the Senate side reporting to one committee or another that we had neither evidence for nor against the safety of flight at age 60. So, when George Bush signed this into law, this allowed our pilots in the US to fly beyond the age of 60 up until the age of 65. And if they flew outside the borders under ICAO rules, they could fly up to age 65 as long as the other pilot was a pilot that was no older than the age of 60. So, we follow this very closely. When this law was passed, the FAA was charged with monitoring these changes to make sure that we are not endangering the unsuspected public. So, when an aviator has a incapacitating event, we work this up very quickly to see how old the aviator is and basically the FAA goes into high warble to determine the cause of this incapacitating event. So, it's not uncommon to have a pilot that has an MI in process of flight. I'm aware of dozens of times that this has happened. Certainly, thanks to the redundancy of two pilots, we have never lost a commercial aircraft due to a heart attack, but certainly, it's an issue that we track quite closely. And in fact, at the FAA, they tell a story about one of the first times that one of these incapacitating events occurred. They talk about an airman flying for Pan Am. Few of you may remember that old air carrier, but many years back, there was a Pan Am flight flying from Eastern Asia to LAX. In the process of flight, the pilot had an MI and experienced a sudden cardiac death, and the first officer was able to successfully land the aircraft at LAX. Everyone walked off the plane, and they were just fine. Thereafter, at LAX, the pilots were gathered in one corner, as is typical, and the first officers gathered in another corner, and you may not or you may be aware that there's a healthy antagonism between pilots and first officers. First officers make only about 60% of what that pilot makes in the left seat, so they follow the seniority list quite carefully. So, the pilots are in one corner at LAX, and they're saying, can you believe that first officer was able to take control of the aircraft and land safely, and everyone was just fine, while the first officers in the other corner were going, can you believe that first officer even noticed the captain was dead? So, there's quite the antagonism, and we follow this quite closely. Here, I talk about the FAA treatments that we allow, and as you can see, all airmen must wait three months after the coronary event before we consider them, six months, if they had a cabbage or a left main lesion, and here, I talk about disposition with what we would require for first and second class airmen, and here, what we'd require for the third class airmen, with the big difference that first and second class airmen require a repeat post-cardiac cath, which we would not require for third class airmen. So, we spend a lot of time on airmen with coronary artery disease, and for good reason. So, now we move on to an airman that has a hearing aid, do you have concerns? And here, we talk about clinical issues regarding hearing loss. I hope you have time to explore these slides, and here, we talk about concerns. Hearing loss can, of course, be the only symptom of systemic illness, so we look very closely at hearing loss that may be indicative of illnesses like diabetes, hyper or hypothyroidism, and blood cell disgraces. We'll talk about acoustic neuromas later, and of course, many aviators have noise-induced hearing loss. So, according to the FAA, we make it easy for these airmen. There are three ways to pass a hearing test. We, of course, use the standard audiometric testing, and the conversational voice test is the one most frequently used, where we simply have the airman turn his back to the AME, and the AME in a whispered voice is able to see if the airman can hear unaided. And as you can imagine, this is not a highly controlled test, but most airmen are easily able to pass the whispered voice test and receive their certificate. So, an airman that wears hearing aids can get a certificate that says they must wear hearing amplification. If there's an airman that tells the AME they hear perfectly well while wearing their headset, we can do a medical flight test, and this is another case where an airman can receive a soda if they demonstrate they hear just fine without their hearing aids wearing their headsets. Airmen that are completely deaf can receive a certificate that basically tells them they are not, and they are not valid if they fly with radio-controlled airspace. So, moving on to an airman with aortic stenosis. Here, I talk about clinical issues. Here, you see the aeromedical concerns. Valve conditions, valve replacements, one of our specific disqualifying conditions. And the FAA has recently begun allowing the TAVR procedure. In the TAVR procedure, the transcatheter aortic valve replacement, we now are able to safely certificate an airman if they are able to undergo all the required follow-up and testing. And here, I talk about the disposition and what we would require following a valve replacement for aortic stenosis. I talk about the fact that if airmen are taking Coumadin, there are specific requirements for their INR. But these days, you can see we allow the novel anticoagulants, and rarely do we see airmen that are still taking Coumadin. Most of the airmen are on davigatrin, rivaroxaban, or apixaban. And this has made this much easier for airmen that don't have to have the frequent testing like they did when they were taking Coumadin and we were looking at their INRs. We also allow airmen to have a ROS procedure. So, moving on to case 15, 35-year-old reapplying for first-class medical with unifocal PVCs, what would you think of these PVCs? So, certainly, coronary disease is the main condition that we are concerned about with PVCs. Mitral valve prolapse is another. Another concern would be whether PVCs are a warning for more serious situations such as sustained V-tach. So, we would expect astute AME when airmen are having PVCs to first have them do the flutter kick. A lot of these PVCs can disappear, as you're aware, when you get the airmen's heart rate up above 60. Here, we move on to an airman with aortic insufficiency. We talk about clinical issues. Here you see more concerns for airmen with aortic insufficiency and what we would expect in terms of a disposition. We not uncommonly have airmen that have aortic insufficiency that are found to have cystic medial necrosis and these are airmen that will likely be denied because of the increased risk of extension of the cystic medial necrosis into the aorta and carotid arteries. Here I talk about the valve replacement again and the disposition is much like that of aortic stenosis with the valve replacement and the allowance of the Ross procedure. So now I want to move on to an airman that comes on to your office for his medical exam. He checked a yes and block 18V for a history of DUI. So what will you do with this airman? Well it depends. If the BAC is suggestive of dependence, which we define as a BAC of 0.15 or above, you must defer. However, if it's less than 0.15 and this airman has gone by the book and reported the incidents to the FAA security division, we allow the AMEs to certificate these airmen should other historic events be unremarkable. And it's important that you know that if an airman seems to forget about the fact that he had a DUI, we will learn about it from the National Driver Registry. One of the things that the FAA does, when an airman signs the paperwork to agree to a physical by a designated FAA official, i.e. the AME, he agrees to allow us to look at the National Driver Registry and with the National Driver Registry, if an airman has had a DUI that he has forgotten about, we are able to ask for additional information and depending on what that information shows, either ask the airman for subsequent evaluation or in some cases, certification. And I'll talk more about that in a case in the future. So here we have an airman who's applying, who has a history of HIV. Can you certificate this airman? No, you can't. This is an airman that we would expect you to defer. However, these airmen are frequently able to get special issuance. The FAA allows all the current CDC approved HIV therapy. You can see what we would expect to look at. However, the most important thing that we require is that these airmen have either a cog screen or neurocognitive testing because of the incidence of the dementia associated with AME and as you can, with HIV. So as you can see here, follow up for first and second with the cog screen and neurocognitive testing is every six months for first and second and every other year for third class. Here we move on to an airman applying for a certificate two months after she had an episode of DVTs. She was hospitalized and treated with heparin initially and is now on Coumadin. Do you have concerns? So here I talk about the clinical issues associated with VT, the venous thromboembolic disease. And of course, here again, in addition to Coumadin, rarely now used, the FAA allows the novel anticoagulants that we discussed previously. Here I talk about how long we would expect an airman to take secondary prophylaxis, with the major concern being recurrent. Here we talk about concerns. But airmen are typically able to get a special issuance if their Coumadin is controlling their condition. And even with airmen that are found to have hypercoagulable states, as long as they are properly treated and followed, they are given a special issuance. And we have many airmen that have had the venous thromboembolic disorder that we follow regularly and are flying safely. We move on to an airman with significant refractive error, but they correct to 20-20. So here I'm going to talk about some of the clinical issues that are associated with refractive error. And as you can see, I wax philosophical on many of these issues. Here's our obvious concern. And it's important that you realize the FAA has no standards for refractive error, unlike the military. Basically, if you can correct to 20-20, you're good to go. And it's important for you to know that the standards that you see in front of you, that for first and second, we expect an airman to correct to 20-20. Third-class airmen only need correct to 20-40. For all classes, for near visual acuity, we allow 20-40. And for first and second, we test for intermediate visual acuity and would allow an airman to correct for 20-40. So many of these ocular conditions associated with myopia or hyperopia are given a special issuance or a waiver. Case 21, an airman at his 41st birthday is expected to have his first EKG. Here you have an airman that has a right bundle branch block, should you issue. So here, this is something that we would expect you to defer. The airman will need a cardiovascular evaluation. And here we talk about what that evaluation entails. So a right bundle branch block in an otherwise healthy individual 30 years of age or younger should not require a cardiovascular exam. However, a left bundle block branch should also or should always require the cardiovascular exam and a radionuclide perfusion studies. So case 22, an airman with Meniere's disease, do you have concerns? And certainly, I would hope that you do. Here's the definition of Meniere's and the concerns with Meniere's being a very serious disease and the reasons why for an aviator. Disposition because of the unpredictable and sudden nature of the attacks of Meniere's. An airman has to be in remission for at least a year before considered. If symptoms occur after initial recovery, the airman would require several years and a tincture of time before reconsideration. So now we move on to an airman with benign positional vertigo that's now resolved. Do you have concerns? Well, the AME guide will tell you that benign positional vertigo as well as transient viral labyrinthitis can indeed be certificated. And we would expect this documentation by a complete ENT eval before issuing the medical certificate. So we move on to an airman that had a case of prostate cancer and had a radical prostatectomy. Here we talk about clinical issues of prostate cancer and the different ways in which we are following prostate cancer. Certainly watchful waiting is something the FAA will allow. It's important that you know that prostate cancer is one of our 22 CACI conditions. So if you've had an airman that has had prostate cancer that has been treated and they meet all the criteria in the CACI worksheet, these can be issued directly by the AME and given a regular issuance. So, here we move on to a very area that has been very contentious, but has had a good result. And this is an airman that reports he has a history of depression, but is well controlled on an SSRI. Do you have concerns? Well, I should hope so. And here I talk about those concerns. I talk about the fact that 16% of Americans will have a major depression in their lifetime. At any given time, the medical literature tells us that 1 in 10 Americans are taking an antidepressant. And certainly, suicide is always a concern in depressed patients. And you can see that 15% of depressed patients eventually commit suicide, the highest of all mental disorders. The risk of concurrent substance abuse is high. And here I talk about the obvious concerns with depression that I'm sure all of you are well aware of. Fortunately, major depressive disorder is treatable in up to 80% of patients. And current status of treating patients is that we expect most airmen to go on an SSRI because 50% of patients will have a second episode. And of those that have a second episode, 85% will have a third episode. So there are many cases of sadness, such as loss of a loved one, that do not meet the criteria for a major depressive disorder. And we allow airmen to be certificated if they have no reason for disqualification. But certainly, we look very closely at these airmen. And if there's a history of hospitalization, psychosis, suicidal ideation or attempt, a history of ECT or the need for multiple medications, we expect a more extensive psychological evaluation. So for many years, I would go to medical conferences, either for airmen or for AMEs. And I would be pulled aside going, Doc, I have a friend who has a friend who is taking an SSRI and he's not telling you. Or even worse, we would have an airman with all the symptoms of depression that was not taking an SSRI because they were aware that the SSRI was disqualified. So we worked very hard, long and hard, with multiple psychiatrists and psychologists. And ultimately, we determined that there was a subset of airmen that we could certificate that were taking SSRIs. And it was a big announcement on 5 April 2010, when we began allowing airmen that were on an SSRI to be considered and certificated if they were on medicines that we felt comfortable with. And you see there the four medicines that we would allow. Very recently, we have begun allowing a fifth. But as that was just recently approved, I would not expect that to show up on your test. So it's important, I think, that you know that the four medicines that you see before you is something that we would allow as long as the airman is not at high risk with the conditions that we discussed earlier. I would not expect you'd be asked about the recent bupropion that was allowed as of June 23. So before I go on, I just want to say that this is an incredible success story. The FAA now has certificated almost 500 cases of airmen that are using SSRIs. And we follow those quite closely. You probably remember back in March of 2015, there was a tragic accident when a pilot flying for German wings flew his aircraft into the French Alps, killing all on board. And following that, there at the end of my career, I made several trips over to Germany to talk to my ICAO counterparts and talk about the fact that in the FAA, we have what we feel is a very successful policy whereby we can safely follow airmen that have the follow-up and testing by their psychiatrists and psychological testing. And we do not consider it a showstopper. Certainly, some of our certificating authorities, absolute, not allowing any history of depression to ever be certificated, we feel leads airmen to situations like that of the pilot that flew for German wings, where he basically does not seek medical attention because he knows his condition is permanently disqualifying and led to the tragic outcome. We would certainly much rather know what the airman is dealing with and offer them a route back to the cockpit, and I think have been very successful in doing so. So, here we move on to an airman with Crohn's disease. Do you have concerns? And I talk about the clinical issues regarding Crohn's disease and our concerns. These patients or airmen frequently are given corticosteroids for control. And here we talk about the maximum, the 20 milligrams or equivalent that the FAA allows. And Crohn's disease is yet another one of our tacky conditions that we allow if all certification criteria in the certification worksheet are met. Here we move on to an airman with non-Hodgkin's lymphoma. Typically, we would expect these patients to be treated, and once followed for a year, we frequently certificate airmen that have had a non-Hodgkin's lymphoma. And here I talk about the disposition. Here we move on to an airman with a supraventricular tachycardia. I discuss the clinical issues with SVT. Here we talk about the disposition, and fortunately the ablation is a highly successful and a low complication mitigation factor, and that's what our airmen typically get. Here we're talking more about what the air medical disposition would entail. And we move on to an airman that is pregnant. Do you have concerns? So here we talk about the concerns. However, pregnancy is not typically an issue with an airman. There are concerns that we discuss here. And there is a recommendation for the exposure to the radiation. And you see those limits there. But as I said, pregnancy is a physiologic state. It's not a disease. We perform the exam. And if otherwise okay, these airmen are typically given an unrestricted certificate. Here we move on to an airman that has chronic renal failure. We talk about the concerns. Typically, an airman on dialysis, we would not certificate. The incidence of problems with airmen that have need for dialysis are such that we would not certificate these folks. However, that being said, patients that have the more mundane issues with renal problems can be given a CACI regular issuance if they meet the criteria in our CACI worksheet. We grant medical certificates after renal transplants. And here I talk about the FAA CACI condition. So, let's move on to the individual that has substance abuse, comes to you and tells you that she only has a couple of glasses of wine after work each day. Is that a problem? Is that a problem? Well, yeah. Certainly, someone that we've given a special issuance to for substance abuse must demonstrate total abstinence. This is a requirement for any future medical certification, and it's written into their authorization letters. Even though alcohol has never been implicated as a cause of major commercial accidents, it's frequently cited in the investigation of GA accidents with reporting of up to 5%. Here, I talk about the obvious concerns. And I talk about the disposition. And here, it's important to note that at the FAA, we have a very famous program called HIMSS, Human Interventional Disorder, and it's a program that we use to identify people motivation study is what HIMSS stands for, but it's a story that began in the 70s when the FAA, working with the pilot unions, allowed airmen a path back to the cockpit after they had been successfully treated for substance abuse. And this was a monumental move. Prior to that, any mention of substance abuse or dependence was a showstopper, and thereby airmen never reported these issues, and colleagues of airmen that were aware of colleagues that had these issues were unlikely to report these issues to the FAA. So there are many dozens of stories of pilots that were flying with substance dependence that should not have been. So by opening the pathway whereby an airman could get treated, we have now allowed some 4,500 airmen to get a path back to the cockpit. And this has been an incredible success story with our HIMSS program showing a success rate that is the envy of the treatment programs for physicians or dentists or lawyers, and we're able to do this by working closely with the pilot unions and with the required psychiatric follow-up and testing and following these airmen with HIMSS AMEs. And by doing so, we have opened up the door to allowing these airmen to ask for help and have shown the world how you can successfully run a program like this. Certainly when I was at the FAA, I could have sent personnel all across the world to talk about our HIMSS program and how successful it has been in allowing these airmen to successfully fly. Now that being said, we also allow the HIMSS program to apply to airmen that have been diagnosed with other drug problems. And I will tell you that this was a wake-up call for me working at the FAA after my 30-year Navy career. Certainly, I was familiar with the problems with drugs and had learned a lot about that in medical school and my residency. But in my time in the Navy, the medical department did not own the drug program. That was the chief of naval operations that owned the program. We, of course, were subject to Operation Golden Stream, just like other sailors, and got involved in helping airmen that had issues with withdrawal. But typically, the program was run by the line and by the requirements of the Navy for testing. So the FAA was required to do testing. And going back to 1990, when airmen that worked for 121 or 135 operations, that's basically airline transport and commercial, were required to have a drug program in place. That meaning that aviators and those that worked in those industries to include flight attendants, mechanics, dispatchers, et cetera, have testing. And this is what was a wake-up call to me because since 1990, when I left the FAA, there were over 45,000 cases of those that worked in the 121, 135 industry that popped positive. So about 2,000 cases per year. And if that number doesn't get your attention, the fact that these cases were only cases which screened for what we call the DOT fine. These are cases that, by law, the FAA is allowed to test for. That includes opiates, marijuana, cocaine, amphetamines, and PCB. That does not include the synthetic opioids like hydrocontin and oxycontin. And as you are aware, these are huge problems in medicine, and it's not something that the FAA can legally test for. Yet, this incredible number of airmen and those in our industry have tested positive. And the third thing that amazes me, that of all the categories that we're allowed to test for, routine, post-accident, follow-up, by far and away, the biggest category of positive tests are pre-employment. These are tests that must be done before someone that wants to work in 121 or 135 can get a job. So, our highly educated workforce knows that they must prove themselves drug-free before they get one of these jobs. Yet, the power of addiction is such that they can't remain off of one of these drugs that we can test for for the few days to few weeks it would take to wash out of their system. So, it has been a major wake-up call for me to see what an issue this is in aviation as well as routine medical practice. So, here I'm talking about the disposition with our HIMSS program. It gets a little more difficult with third-class aviators because they don't have the required sponsor provided by the 121, 135 entities. But, we've been able to set up support factors that allow these airmen to sometimes get certificated quicker than the two years otherwise required by the Code of Federal Regulations. So, so much for the airmen with substance abuse dependence issues. And we move on to an airman with peptic ulcer disease. Here I talk about the clinical issues and concerns. In the FAA, we do not do the routine hemoglobin hematocrit testing, but certainly if there is a workup that shows the level of hemoglobin, we would not certificate airmen with a hemoglobin less than 10 grams per cent. And of course, we allow all the prophylactic medications. Here we move on to an airman that is scheduled to spend a few years in the penitentiary for money laundering. He comes to your office and wants a third class medical certificate. So what should you do? Well, you need to take a good history and evaluate the airman's psyche. Certainly, there are conditions that would lead airmen that are in trouble with the law that we would not certificate. However, not all criminals have psychopathology. And if your evaluations are otherwise unremarkable, we allow you to grant the medical certificate. We have lots of criminals that have valid medical certificates. Here we have an airman that has COPD. Do you have concerns? And here I talk about the clinical issues regarding COPD and our medical concerns and the disposition of what we will allow. And what we would expect in order to special issue an airman with COPD. Here we have an airman that was pulled over and refused the sobriety test. What will the FAA do? So the FAA is not kind to these people. Typically, we would we consider a refusal to be one in the same with the FAA. We would consider a refusal to be one in the same as someone that is dependent on alcohol. And we would expect the workup to include seeing a psychiatrist. We would expect that airman to show evidence of treatment and successful rehab. Before we would consider certification. So here we have an airman with Hodgkin's lymphoma. We talk about some of the clinical issues. And some of the obvious concerns. And disposition. So generally, much like non-Hodgkin's lymphoma, we expect these patients to be treated and following a year, we readily special issue these airmen. It's amazing the evolution of what the FAA is willing to issue following an airman that has cancer. There are lots of new cancer drugs out there. And the FAA, I think, is very up to date and reasonable in terms of following these airmen once they've been treated and stabilized. Here we move on to an airman with Parkinson's disease. And I wax philosophical regarding the clinical issues of Parkinson's as our aviator population continues to get older. Parkinson's disease is not uncommonly one of our challenges. Certainly, we would expect a workup to look for the other causes of Parkinsonism. It is not uncommon for medication to cause the same symptoms. And here I talk about the concerns. There's not good agents that we can readily approve. The dopamine precursors can cause hallucinations. The anticholinergic agents can cause sedation and confusion. And the newer agents carry a black box warning for inducing sleep during activities of daily living to include piloting an aircraft. So, we have to evaluate these cases on a case-by-case basis to certificate those airmen that have Parkinsonism. Here we're moving on to an airman with acoustic neuroma. What concerns do you have? Here we're talking about the clinical issues. our concerns with acoustic and aroma, and our disposition. So here we typically don't allow the watchful waiting and would expect an airman have a surgery or radiation, particularly radiation with gamma knife, before we would certificate. Here we move on to an airman with retinal detachment. What concerns do you have? So, moving on from concerns to disposition, here we have an airman that typically even if their RD causes loss of vision, if they do not meet standards, could basically wait six months, get their medical flight test, and get their soda. Here we move on to an airman with ocular hypertension or glaucoma, once again, something that we increasingly frequently see as our airman population ages. And here we talk about clinical issues regarding glaucoma, concerns, and disposition. Glaucoma is yet another one of the tachy conditions, and if an airman meets all criteria in the glaucoma worksheet, our AMEs are allowed to regular issue these airmen. We've even allowed some peripheral visual field cuts to be certificated as long as we are convinced that they are stable. So here we move on to an airman with hypothyroidism. What concerns do you have? Here we talk about our concerns. A major concern being the fact that hypothyroidism can be insidious and an airman may not be aware of their performance decrement. However, hypothyroidism is very common and once again this is one of our easy and tacky conditions. Any physician can look at the TSH and the other required worksheet requirements and certificate these airmen if they meet all of the certification requirements. Hyperthyroidism is a little bit different. So we talk about the significant concerns we have with hyperthyroidism. And here we talk about the disposition. And as you probably are aware, the exophthalmos associated with hyperthyroidism can have significant issues. So we would expect ophthalmology consultation in all of these cases. So we move on to an airman with colorectal carcinoma. Here we talk about the clinical issues, our obvious concerns, the disposition. And typically, once an airman has been treated and disease-free, we are able to certificate these airmen. Colon cancer is yet again, one of our 22 key conditions and can be regular issued if they meet all of the criteria in the worksheet. Here we move on to an airman with adjustment disorders. Do you have concerns? We discussed the clinical issues associated with adjustment disorders. Certainly there are significant concerns. And here we look very carefully at the medicines that we would not certificate, particularly antipsychotics or anxiolytics. And these adjustment disorders are only granted once we've been convinced that the adjustment disorder has been resolved and they're all psychotropic medications. Case 45 talks about anemia. and our disposition. Something that has popped up on multiple tests is the requirement for an airman not flying or putting themselves down after donating blood, 24 hours. The FAA requires 24 hours. Here, we move on to an airman with allergic rhinitis, a very common issue in all of aviation as well as typical clinical practice. Here on this slide, we talk about the aeromedical concerns and the aeromedical disposition of airmen that have allergic rhinitis. Case 47 is an airman that has an anxiety disorder. So we talk about the clinical issues, our concerns, and our disposition. And these cases are certainly challenging cases that require a very specific psychiatric workup, so we look closely to make sure that an airman that has had any of these anxiety issues is now safe and off of all psychotropic medication. Here's our airman with asthma, our clinical issues regarding airmen with asthma. Moving on to our concerns and our dispositions. And once again, asthma is a condition that we have been able to put in as one of our 22 CACI conditions, and if an airman meets all the criteria, they can be given a regular issuance. Here, we move on to an airman with ulcerative colitis, a discussion of the clinical issues. Here, you'll see the concerns and the disposition. And of course, ulcerative colitis, like colon cancer, is one of our CACI conditions. And as you can see here, we allow corticosteroids, we allow sulfosalazine, and the newer drugs for ulcerative colitis that you see there. Here again, atrial fib is something we frequently see, and you should indeed have aeromedical concerns with AFib. So, we discussed the clinical issues, and here, we talk about our concerns. We have lots of airmen that have been diagnosed with AFib. Here, we talk about disposition, what the FAA allows. And typically, what we're seeing these days is the catheter ablation procedures, and those are very those are very safe and effective. And typically, after a wait of six months, we are able to safely certificate these airmen. Case 51, an airman with migraine headaches. So, we're going to talk about the clinical issues regarding migraines and concerns. Certainly, we would expect a severe headache to be worked up to make sure it's not one of the more rare causes of headache. And certainly, medications are a concern with migraine headaches, because use of narcotics and other medications are not allowable. More on the aeromedical disposition. And typically, we allow airmen to have up to three headaches per month. And this, of course, depends on the characteristics of the headache. And here's where we frequently cite the Federal Aviation Regulation 6153, telling an airman of the necessity to ground themselves and report any changes. Typically, those patients that have an aura with classic migraine have a sufficient warning to ground themselves and are frequently certificated based on that warning. Here we have an airman with mitral valve prolapse. Do you have concerns? Do you have concerns? And certainly, there are concerns with mitral valve prolapse. I talk about those concerns here. And I talk about the disposition of mitral valve prolapse. And what we would expect the airman to get in terms of follow-up testing. And frequently, with mitral valve prolapse, once there's evidence of chamber enlargement, airmen are denied certification until they have their mitral valve repaired or replaced. I move on to sinusitis, something that is a real challenge in aviation. So there's a number of slides that discuss the sinusitis issue and what our concerns are. And our disposition and route for certification. Sometimes, these patients that have been treated with the endoscopic surgery end up being put through an altitude chamber to see if they have symptoms. And certainly, this is something that we would expect our AMEs to defer to the FAA. We allow the use of oxymetazoline in the FAA, as well as nasal steroids. And now we move on to our next to last case, an airman with a seizure disorder. Do you have paramedical concerns? Well, yes, I should certainly hope so. Seizures are certainly typically a condition that would render flying an aircraft impossible. So we follow these cases quite closely. We do allow cases of seizures where the history indicates that they may have been febrile seizures as children, but here I talk about the clinical issues regarding those seizures and why they're a concern. Here, the slide talks about the paramedical disposition of those that have been diagnosed with a seizure disorder. And airmen that have had a seizure disorder do have a route back to the cockpit. But as you can see here, they have to be off any medication for the most recent two years, following four years from the time of their seizure. So we look at these cases quite closely and often it's a tincture of time before we're willing to certificate these airmen that have had a seizure. So here before I run out of voice is our final case. An airman with a BMI of 40 and a neck circumference of 19 reports to your medical clinic and request a third class medical. His wife also reports that he will frequently appear to stop breathing and partially awake gasping for air. Do you have air medical concerns? Well, I certainly hope so. So once again, with an aging population, we are seeing more and more obstructive sleep apnea and are well aware that this is a significant cause for fatigue in airmen. Here I talk about the fact that the initial literature indicated the prevalence of OSA at 2% for women and 4% for men. But more recent data shows it's really much higher, 4% for women, 9% for men. And that prevalence increases with age. So here we talk about the clinical issues. Most particularly, the airmen that have the higher BMI's have a significant concern for OSA. And that relates to one of the more recent adventures that I was able to experience at the FAA. My predecessor back in 2013 in the Federal Air Surgeons Medical Bulletin basically talked about the safety concerns with obstructive sleep apnea and the Federal Air Surgeons medical bulletin. Sleep apnea and the fact that it was a major cause of fatigue and fatigue was often cited as a contributing factor in multiple, multiple mishaps. Also the fact that obstructive sleep apnea is also associated with other refractory issues that you can see before you. So due to the fact that OSA had a significant impact on the safety, the FAA was going to begin to require AMEs to calculate the BMI of airmen. And for those airmen that had a BMI of 40 or greater, we were going to require that they be referred to a sleep specialist for evaluation and CPAP therapy until their obstructive sleep apnea was shown to be stable. So immediately after announcing this, the medical, the advocacy organizations for airmen and air traffic controllers immediately went on the warpath. And in particular, I can remember looking at the blog page for one advocacy organization whereby the FAA was accused of exceeding their constitutional authority. And we were called Nazis, communists and agents of Obamacare. Basically, typically this organization, the airline organization, the Pilots Association present in every state and every county immediately wrote their congressmen and Congress got involved and basically told us that we were not allowed to implement this strategy. So we went back to the drawing board. We worked with these advocacy organizations and typically came up with a policy whereby no airman was allowed to be disqualified on BMI alone. We went strictly by the American Academy of Sleep Medicine guidelines in terms of the diagnosis of OSA and had our AMEs apply these guidelines. AMEs apply these guidelines. We allowed these airmen to see either their primary care providers or their AMEs for an evaluation. We did not require sleep studies unless the evaluating physician determined that the airmen needed these studies. All that being said, once an airman was found to need CPAP, it's actually an easy condition to certificate with a special issuance. Basically an airman is required to use a CPAP for at least six hours per night. And if they have the use of a CPAP machine, they can submit the results of the recording device and we are allowed to renew their special issuance based on our acceptance of their CPAP readings. So it's been a successful program to date. The number of airmen that have been certificated with CPAP are now airmen that approximate the prevalence of known obstructive sleep apnea in the civilian population. So we feel like we have been able to mitigate this significant safety risk. At the same time, we have helped airmen avoid the more serious consequences, not only of fatigue, but cardiac arrhythmias, MI, sudden cardiac death, et cetera. So I will end my presentation with that success story. And I look forward to our opportunity for questions that we have following the airing of this presentation in the near future. So until then, this is Dr. Frazier. I look forward to your questions and I appreciate this opportunity to be able to talk to you about clinical aerospace medicine.

Aerospace Medicine

FAA Guidelines

Dr. James Frazier

Allied Pilots Association

Medical Certification

Coronary Artery Disease

Epilepsy

Bipolar Disorder

Psychotropic Restrictions

Anticonvulsants

HIMSS Program

SSRIs Allowance

Type 2 Diabetes

Obstructive Sleep Apnea

Aeromedical Challenges