Federal Air Surgeon’s Medical Bulletin · 2 The Federal Air Surgeon's Medical Bulletin • Winter 2002 By Jon L. Jordan, MD, JD The Federal Air Surgeon’s Column ... (cyclobenzaprine

02-4Winter 2002

U.S. Department of TransportationFederal Aviation Administration

Federal Air Surgeon’sMedical Bulletin

Aviation Safety Through Aerospace MedicineFor FAA Aviation Medical Examiners, Office of Aerospace Medicine

Personnel, Flight Standards Inspectors, and Other Aviation Professionals.

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Best Practices

A Dean Among DoctorsBy Mark GradyGeneral Aviation News

This article launches Best Practices, a new series ofprofiles highlighting the shared wisdom of the mostsenior of our senior aviation medical examiners.Written by one of Dr. Moore’s pilot medicalcertification applicants, this article appeared inthe November 22, 2002, issue of General Avia-tion News. —Ed.DOCTOR W. DONALD MOORE of

Coats, N.C., knows a lot of pilots— many quite intimately. After

all, as an Federal Administra-tion Aviation Administration-approved medical examiner,he’s poked and prodded quitea few of them during his morethan 40 years of making surethey meet the FAA’s physicalrequirements for flying.

He also knows what it’s liketo fly, because he flew for 40years.

Moore began giving FAAphysicals in 1960, the sameyear he learned to fly. Now83 years old, he is not as active at hismedical clinic as he once was, but he stillventures in for an hour or two each

morning just to give medicalexams for pilots in the area.He estimates he’s given morethan 12,000 flight physicalsover the past 41 years.

“I’ve given an average of300 flight physicals a year since1960,” he says, noting thoseexams have been in additionto running a busy generalmedical and obstetricspractice.

While he majored in Greekand English at Wake Forest,

Moore was always interested in the sci-ences. He couldn’t escape an interest in

Quick FixBy Richard F. Jones, MD, MPH

PROBLEMStudent pilots are sometimes receiving an FAA Form 8500-9, Medical Certifi-

cate, instead of an FAA Form 8420-2, Medical Certificate and Student PilotCertificate, at the time of their FAA medical examination.

Another part of this problem is where an applicant has requested a combinedMedical and Student Pilot Certificate in block 1 on the 8500-8 form, but theaviation medical examiner (AME) indicates in block 62 of the form that only aMedical Certificate has been issued.

RESULTIf only a Medical Certificate is issued, student pilots are flying without valid

certificates and are subject to disciplinary action when caught. These studentpilots are often very hostile toward the AME who failed to issue the appropriatecertificate.

Dr. Moore, shown in hisCoats, N.C., office

2 Editorial: Researchand Aviation Safety

3 Certification Issuesand Answers

6 BariatricSurgery:How Longto Wait?

7 Checklist forPilotPhysical

8 Palinopsia CaseReport

9 Factors in HumanError

11 Hydrocephalus CaseReport

12 AAM News13 AME Seminars14 Health of

Pilots:YourHeart &Exercise

16 Index of2002 Stories

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2 T h e F e d e r a l A i r S u r g e o n ' s M e d i c a l B u l l e t i n • Winter 2002

By Jon L. Jordan, MD, JD

The Federal AirSurgeon’s Column

Federal Air Surgeon’sMedical Bulletin

Secretary of TransportationNorman Y. Mineta

FAA AdministratorMarion C. Blakey

Federal Air SurgeonJon L. Jordan, MD, JD

EditorMichael E. Wayda

The Federal Air Surgeon’s Medical Bulletinis published quarterly for aviation medicalexaminers and others interested in aviationsafety and aviation medicine. The Bulletin isprepared by the FAA’s Civil Aerospace Medi-cal Institute, with policy guidance and supportfrom the Office of Aerospace Medicine. AnInternet on-line version of the Bulletin isavailable at: http://www.cami.jccbi.gov/AAM-400A/fasmb.html

Authors may submit articles and photos forpublication in the Bulletin directly to:

Editor, FASMBFAA Civil Aerospace Medical InstituteAAM-400P.O. Box 25082Oklahoma City, OK 73125e-mail: [email protected]

Aerospace Medical Research: Making Air Travel Safer

is accomplished quietly and without agreat deal of fanfare. I can assure you,however, that the contributions theseorganizations make to system safetyprovides a big “bang” for the relativelysmall expenditure of dollars that go totheir support.

Human Resources. Research psy-chologists and supporting staff com-prise the Human Resources ResearchDivision. Their goal is to improve aero-space safety and workforce performancethrough human factors research. Inplain language, these folks play a majorrole in identifying environmental andother factors that impact pilot and airtraffic controller performance and causeor contribute to accidents. Among oth-ers things, the research includes humanperformance under various conditionsof impairment, human error analysisand impact of advanced automationsystems on personnel performance.

Medical Research. The other divi-sion, the Aerospace Medical ResearchDivision, is composed of a more het-erogeneous group of scientists. Amongothers, included are re-search physicians, chem-ists, and engineers. Toname just a few, thesefolks engage in accidentinvestigation from themedical perspective,look for ways to improveoccupant protection andsurvival in the event ofan accident or other life-threatening event, andidentify physiological,psychological, and per-formance factors that threaten safety.

It is impossible to cover in this col-umn all the important aviation safetycontributions being made by our tworesearch organizations. I feel compelled,however, to mention at least one. Thisis the wide-body environmental researchfacility that was completed in 2001.

The wide-body research facility wasdeveloped through refurbishing the hullof a scrap Boeing 747 aircraft. Throughingenuity in securing funds and a lot of

hard work by the staff at CAMI, whatbegan as a cast-off hunk of metal hasbecome a unique, multi-purpose, highlysophisticated, research facility.

Thus far, the facility has been usedfor a number of research tasks. In-cluded among these is the training ofaircraft accident investigators as well assecurity personnel for dealing with hi-jackers and unruly passengers. The fa-cility is equipped to investigate cabinairflow that will define molecular, par-ticulate, and microorganism dispersionand aid in studies of contamination ofcabin and cockpit air from a variety ofpotential sources, including possible

acts of terrorism. Mostrecently, the facility wasused to determine thetime required to secure apassenger cabin follow-ing a warning of air tur-bulence. This researchwas in support of NASAfor the development ofan early-warning systemfor air turbulence. Fu-ture potential uses forthe facility are virtuallylimitless.

Those of you who have had theopportunity to visit CAMI recently arefamiliar with the current high level ofsophisticated research going on there.For others who have never been there orhave only a dim recollection of ourresearch activities, I simply wanted tolet you know or remind you of thededicated and highly professional staffthat— in many ways— is working tomake air travel as safe as it can be.

JLJ

TO MANY PERSONS outside the Fed-eral Aviation Administration

(FAA), the Office of AerospaceMedicine’s greatest visibility relates toour administration of the airman medi-cal certification system. There is goodreason for this since ensuring that air-men meet sound medical criteria andare free of drugs and alcohol have longbeen considered our highest priorities.Sometimes overlooked are the signifi-cant contributions and support our re-search organizations provide, not onlyto the certification process but also tothe overall safety of the national air-space system.

The FAA is blessed with having two“World Class” research organizationsat the Civil Aerospace Medical Insti-tute (CAMI). Much of the work carriedout by these two research organizations

Wide-Body ResearchFacility at CAMI

T h e F e d e r a l A i r S u r g e o n ' s M e d i c a l B u l l e t i n • Winter 2002 3

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1Certification

Issues and

Answers

Dr. Silberman manages the Civil Aero-space Medical Institute’s Aerospace Medi-cal Certification Division. Continued, answers on page 4...

One of our hard-working med-ical review physicians, LarryF. Wilson, MD, is in the Okla-

homa Army National Guard and hasbeen mobilized for at least one-year [seestory, page 12]. This has resulted inquite a strain on our other physicians,and we pray for his safe return.

I am requesting that you aviationmedical examiners who regularly callthe Aerospace Medical CertificationDivision to speak with one of ourphysicians to be patient and to utilizeour Physician of the Week (POW) forall questions relating to medical cer-tification. When phoning intoAMCD to speak to the physician andthat line is busy, the operator will askyou for a good phone number wherewe can reach you. Should you have anairman in the office and want ourverbal authorization for a special is-suance, you may want to tell the air-man you will be in touch afterspeaking with us. We want to keepthe phone calls to physicians who arenot manning the phone left alone sothey can perform their case reviews.The POW will return your call.

You need to also be aware thatyou may phone your RegionalMedical Office for medical certifi-cation questions.

Now, I am going to continue withour questions and answers, all ofwhich are referenced to the 1999Guide for Aviation Medical Examin-ers. The appropriate page numbersare in parenthesis after each answer.

A 22-y/o airman has a single epi-sode of spontaneous pneumothorax andapplies for a 1st-class medical certifi-cate. What do you need to provide theAMCD? Can you grant medical certi-fication?

A 45 y/o airman develops a boutof paroxysmal supraventricular tachy-cardia. Can you issue a 3rd class medicalcertificate for this?

Does the AMCD grant medicalcertification after an airman suffers apulmonary embolus? What if the air-man is still on Coumadin®?

An airman comes to your officefor an initial flying examination. Onexamination, you note that he has ascar from childhood that goes acrosshis orbit, and the cicatrix essentiallyresulted in a profound ptosis of theeyelid. You wonder if he has adequatefield of vision in that eye. Should youissue the medical certificate?

A pregnant airman, just initiat-ing her third trimester, applies for a 2nd-class medical certificate. What shouldyou do?

Airman Bubba Ray Beauregardapplies for a 1st-class medical certifi-cate. Three months ago, he passed acalcium oxalate stone. He provides anote from his treating urologist statingthat Bubba has retained a 4mm stonein the upper pole of the right kidneyand that if he drinks plenty of fluids, hemay not pass the stone. What shouldyou do?

An airman in chronic renal fail-ure on hemodialysis three times perweek requests a 3rd-class medical cer-tificate. He demonstrates stable elec-trolytes, BUN, and creatinine. Heappears to be alert and oriented. He hassome hypertension, which is adequatelytreated. Since he “looks great,” theAME issues an unrestricted medicalcertificate. Was she right?

An applicant for student pilot 1st-class medical certificate has had anamputation above the right elbow. Hewears a prosthesis, but the extremity ispretty much nonfunctional. The re-mainder of his flight exam is benign.What should you do?

An airman who last had an FAAmedical certificate in 1992 has a historyof chronic tension headaches. He writesin Block 17 that he takes Ultram®

(tramadol hydrochloride) and Flexeril®

(cyclobenzaprine HCL) for the head-aches. He has been averaging four head-aches per month, and they seem tooccur when his boss “gets on his case”about things. The headaches are linkedwith nausea and photophobia. Noisesseem to make them worse. He must getto a dark room and try to rest when hegets one of them. He claimed that heonly takes the Flexeril® when he has to,but the Ultram® works quite well. Youissue an unlimited medical certificate.Were you right?

What are the five mental health-related specifically disqualifyingillnesses?

What criteria do the FAA con-sider in making the diagnosis of sub-stance dependence?

An individual who had an Au-thorization for Special Issuance for sub-stance dependence came in for anexamination and informed you thatshe only had about four glasses of wineafter work each day. Would you giveher a medical certificate?

Airman Potawanamie Pauly, 35,presents for a 1st-class medical certifi-cate and gives the following history. Heanswered “yes” to question 18 w., whichasks applicants to list their history ofnontraffic convictions (misdemeanorsor felonies). When he was 16, Paulyreceived five tickets for speeding, andthe police came to his home and ar-rested him for nonpayment of the fines.At age 18, he was arrested for stealingacne cream from a local drugstore. At20, and while a student in politicalscience at Yale, he was arrested for therape of a freshman law student, but thecharges were ultimately dropped. Hewas arrested for cocaine possession atage 27 and spent two years in a Federalprison. It seems that his friend askedhim to drive his car to pick up someother guys at a not so good part of town.He really didn’t know that in the trunkof the car was a kilo of cocaine, so whenthe police stopped the car for having an

By Warren S. Silberman, DO, MPH


Issues & Answers from page 3

out-of-date license plate, well, youknow what happened from there!Pauly now tells you that all theseevents were due to a lack of maturity,and he has seen the error of his ways,and wants to become an airline trans-port pilot. Should you issue the medi-cal certificate? Does this story soundright to you?

ANSWERS TO THE QUIZQUESTIONS

1: To make a decision, we need tohave the hospital and/or emergencyroom admission and discharge notesthat describe the event. We need toknow the treatment provided andsome proof that it was successful. Ifyou could provide some statementfrom the treating physician of thelikelihood of recurrence, this wouldalso be helpful. If the airman has acompletely expanded lung and therehas been no recurrence, you may grantmedical certification. You MUSTprovide AMCD with all the informa-tion (AME Guide, page 45).

2: No, you cannot! An AMEshould provide the medical recordsthat describe the event and surround-ing circumstances. We will need acurrent status report that mentionsthe workup that was accomplished.The workup should have includedthyroid function studies, 2 Dechocardiogram, and 24 hour HolterMonitor. If there are increased car-diac risk factors, then a maximal BruceProtocol Stress test should be per-formed (page 46).

3: An airman who suffers a pulmo-nary embolus can gain medical certi-fication. We usually would like toknow that all potential etiologies havebeen evaluated to include hyperco-agulable states. An airman who istaking an anticoagulant can also be

medically certified. The airmanshould be stabil ized on theCoumadin® for at least one monthand all the International NormalizedRatio values should be provided, allof which should be within the thera-peutic range. This will result in anAuthorization for Special Issuance(page 49).

4: No. You should obtain an eyeevaluation with field of vision andforward the case report to the AMCD(page 53).

5: Perform the exam and, if she isotherwise normal, you may issue anunlimited medical certificate. I wouldcaution the airman about the risk ofinjury secondary to the aircraft re-straint systems, but pregnancy is not,in itself, disqualifying (pages 55-6).

6: Defer to the AMCD. We wouldlike to see some type of imaging pro-cedure to note the exact site and sizeof the stone. Unless this stone wasembedded in the kidney cortex, he willlikely get a denial (page 55).

7: No, she wasn’t! We do not grantmedical certification to any airmanfor any class when they are on hemo-dialysis. We have granted medicalcertification to airmen who are stablereceiving peritoneal dialysis. Recallthat patients who are in chronic renalfailure on dialysis are in a precariousmetabolic situation requiring strictdiet control and fluid balance. Wewill grant medical certification afterthey receive a renal transplant anddemonstrate 6 months of stability.We do accept most of the antirejectionmedications (page 55).

8: The applicant will require aStatement of Demonstrated Ability(SODA). You should defer the caseto the AMCD, but also have the ap-plicant provide a letter requesting theSODA. This request will also resultin the FAA administering a medicalflight test in the aircraft that theapplicant is familiar with. If the

applicant needs some modificationof the aircraft, this will be noted. Theapplicant will also receive a notationon his airman certificate that his fly-ing is limited to the particular aircraftin which the test was taken (page 57).

9: No, you were not! Both Ultram®

and Flexeril® are unacceptable for fly-ing duties. Both of these medicationscause sedation. The other significantissue is the headaches, themselves.The airman appears to be having toomany of them to allow medical certi-fication at this time. Perhaps theAMCD would allow certification ifthe airman would try some non-sedating medications or biofeedback,and the headaches were less frequentand debilitating (page 63).

10: 1) psychosis, 2) bipolar disorder,3) personality disorder manifested byovert acts, 4) substance dependence, 5)substance abuse (page 3).

11: 1) increased tolerance; 2) mani-festation of withdrawal symptoms; 3)impaired control of use; or 4) contin-ued use despite damage to physicalhealth or impairment of social, per-sonal, or occupational functioning(page 67).

12: No, I surely hope not! Note inPart 67 that the FAA does not grantmedical certification to an airmanwith a known diagnosis of substancedependence until the airman can dem-onstrate total abstinence. This totalabstinence also becomes a require-ment of any future medical certifica-tion and is written into theirauthorization letters (page 66).

13: Fellow AMEs, what part of thisstory sounds right to you? Do yourecall the specifically disqualifyingcondition, personality disorder mani-fested by overt acts? Do you think thisdiagnosis fits this case? It certainly does.Issuing a medical certificate is not ap-propriate in cases such as this.

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medicine and what he believes was acalling to become a medical mission-ary. He accomplished that goal by serv-ing in a 100-bed, Baptist-run hospitalin southern China for two years in thelate 1940s. The missionary hospitaltreated patients who would not haveaccess to or been able to afford decentmedical care. The Communist-runChinese government eventually ranMoore and other missionaries out ofthe country. He returned to the stateson a different type of mission.

“When the doors closed in China, Ifelt I needed to be in a small commu-nity where the need was the greatest,”he said.

Coats, a small town in the heart ofNorth Carolina, became his new mis-sion field. He set up practice there in1949. Today, pilots and other patientsstill make their way to Coats MedicalClinic, which features two other doc-tors, including his daughter, Dr. LindaRobinson. She added the AME desig-nation to her list of medical credentialsa few years ago. She performs the flightphysicals her father’s reduced schedulecan’t fit in.

Moore says he was always fascinatedwith aviation, but his interest peakedduring World War II while serving as aphysician in the Philippines. Talkingwith Navy pilots fueled his interest inflight, as did some of the flights he tookwith those Naval aviators.

Eventually, 10 years after setting uphis practice, he decided it was time tolearn to fly. He called on another long-time Harnett County resident and avia-tor for help.

“I talked to Gene Stewart, whotaught flying during the war,” Moorerecalled. “I told him, ‘I think I wantyou to teach me to fly.’ He had stoppedteaching for a while, but he got backinto it and continued to teach for quitea while.”

Stewart taught Moore to fly in aSuper Cub. He soloed that plane at the

BEST PRACTICES

DR. MOORE’S SUGGESTIONS FOR A SUCCESSFUL AVIATION MEDICINE PRACTICE

1. Pilot area. Have a separate place for pilots (especially if the practicehas patients other than pilot applicants) for FAA materials to bedisplayed and organized. It could be located in the waiting area; itis a place for pilots to read, work on forms, and not be interrupted.

2. Office assistant. Have a very knowledgeable assistant. Our nurse,who schedules work for us, has doing it long enough to be able toanswer all technical questions about forms, procedures, and so on.She was trained at the FAA seminar, which was very helpful.

3. Regional Flight Surgeon. Contact with the regional office is alwaysvery helpful. We enjoy our contacts with the regional office becausethey are knowledgeable and easy to talk with. You can discuss anyquestions that affect the certification outcome with them.

4. Pilot status. I recommend that all AMEs be pilots because they canbetter understand various situations as they arise. While I lost myown medical and am no longer eligible to fly solo, I still enjoy flyingwith others.

5. Be engaged in the aviation community. Speak at safety seminars, getinvolved in some of the seminar discussions, get to know the pilotsin your area. Perspectives vary and you can promote aviation safetywhile in the health care business. I feel a great sense of responsibilityfor my pilots’ safety.

Harnett County Airport near Erwin,N.C. He bought a Tri-Pacer after get-ting his private pilot’s license in 1960.

During the same year he earned hislicense and bought his first plane, hedecided to meet the FAA requirementsto give pilot physicals. Eventually, hebecame the only doctor between thelarge cities of Fayetteville and Raleighcertified by the FAA to issue all classesof medicals. He says it’s only naturalfor a doctor who flies to want to pro-vide the service of flight physicals.

The Tri-Pacer was sold during themid 1960s and Moore upgraded to aMooney. It’s obviously a plane he wasvery fond of. A picture of that Mooneystill hangs inside the office where heperforms his examinations on pilots.He actively flew until a few years ago.

One of the pleasures of giving flightphysicals is in getting to know thepilots and some of the “characters” inaviation, Moore says. But being a doc-tor for pilots isn’t always rosy. Moore

has always found it difficult to informa pilot that he or she no longer meetsthe FAA medical requirements.

“I’m always reluctant to have to tellthem,” he says. “But, I think they un-derstand you just can’t get around someof the very specific requirements.”

Moore has seen a great deal of changein both planes and pilots the past 41years. When it comes to aircraft, henotes the biggest change is in naviga-tion. “By far, the biggest change hasbeen in the electronics. When I started,everything was based on homing in ona station, using ADF. Today, every-thing is so advanced and easier,” hesaid, noting how he finds today’s sys-tems, such as GPS, fascinating.

When it comes to pilots, the changeMoore notes should come as good newsfor those of us who hope to fly for a longtime. “Some of the health problems areabout the same, but for the most partpilots are healthier today,” he said. ��

The next issue of the Bulletin will featureDr. James E. Moore, a Stamford, Conn.,aviation medical examiner who will observehis 56th year in aviation medicine on March1, 2003. —Ed.

Doctors’ Dean from page 1

This article is reprinted with the permission of: General Aviation News, P.O. Box 39099,Lakewood, WA 98439. To contact the editorial staff, their E-mail address is:[email protected]


The well documented prevalence of obesity in the United

States has led to an increase in bariatric surgery. It is

incumbent upon the AME to understand complications

and prognosis associated with the various bariatric surger-

ies, so that the aviator is properly certified post operatively.

The most serious complications associated with bariatric

surgery occur within 30 days of operation and represent the

greatest risk for sudden incapacitation. Accordingly, the

author recommends waiting this period post-operatively,

prior to medical certification.

ACCORDING TO THE FEDERAL Cen-ters for Disease Control andPrevention statistics, from

1999 to 2000, the number of over-weight adults rose from 56% to 65%of the United States population. Giventhe prevalence of obesity in the generalpopulation, it behooves the aviationmedical examiner to become familiarwith surgical procedures that pilots mayopt for in their “battle of the bulge.”

Admittedly, obesity is not an auto-matically disqualifying condition (1)and is not queried as part of themedical history (Box 18 on FAA8500-8). However, the mortality as-sociated with obesity is well known,i.e., a two fold mortality rate for men50% above average weight. This isattributable to an increased preva-lence of cardiovascular risk factor suchas hypertension, diabetes mellitus,hypertriglyceridemia, and low levelsof high-density lipoprotein choles-terol. In addition, the prevention ofsecondary complications of morbidobesity is an important goal of man-agement, with data from theFramingham study to support theestimate that a 10% reduction in bodyweight corresponds with a 20% re-duction in the risk of developing coro-nary heart disease.

As with smoking cessation, theaviation medical examiner shouldhave an interest in providing dietaryand exercise counseling for the pilot,since we all play a role in preventingsudden incapacitating events. How-ever, when diet modification hasfailed, and morbidity and mortalitybecome a significant risk, thenbariatric surgery may be the only vi-able option.

The option of surgical treatmentshould be reserved to patients whoare morbidly obese, well-informed,motivated, and willing to accept theoperative risk. In addition, the pa-tient should be able to participate intreatment and long-term follow-up.Surgical treatment of morbid obesityfocuses on a body mass index of over40kg per meter squared, or with be-ing 100 pounds overweight.

Bariatric surgery is a recognizedsub-interest in the field of generalsurgery and has been endorsed by theNational Institutes of Health Con-sensus Conference of 1992. Surgerygenerally involves a reduction in sizeof the gastric reservoir, with or with-out a degree of associated malabsorp-tion. Subsequently, eating behaviorimproves dramatically and reducescaloric intake; thereby ensuring thatthe patient practices behavior modi-fication by eating small amounts andchewing each mouthful well.

The AME should realize that op-erations vary according to an indi-vidual surgeon’s recommendation,patient choice, and availability. Com-plex operations combine gastric re-striction and gastric bypass, whereassimple procedures are purely gastricrestriction. The percentage of com-plex procedures has increased steadilyfrom 1991, with 97% of the proce-dures performed in the year 2000categorized as being complex; com-pared with 11% in 1986. Overall,79% of operations submitted to theInternational Bariatric SurgeryRegistry’s pooled report were indi-cated as being complex.

The mean percentage excess weightloss at five years ranges from 48-74%after gastric bypass and from 50-60%after vertical banding gastroplasty. Ina ten-year follow-up series from theUniversity of Virginia, weight losswas reported as 60% of excess weightat 5 years and as 96% of excess weightat 14 years. This weight reduction ina pilot would certainly improve sev-eral co-morbid conditions —glucoseintolerance, diabetes mellitus, sleepapnea, and obesity-associatedhypoventilation, hypertension, andserum lipid abnormalities.

Despite its benefits, the pilot whowishes to undergo such treatment

Dr. Borrillo is the Medical Director of Occupational and Hyperbaric Medicine, The Toledo Hospital, ProMedica Health System. He is also asenior aviation medical examiner, an attorney, and a pilot with a Commercial rating.

Continued �


must assess the risk of surgical treat-ment, which includes the operative,peri-operative, and long-term com-plications. Specifically, the obese pi-lot has an increase in morbidity in theearly post-operative period fromwound infection, gastric or anasta-mosis leaks from staple breakdown,stenosis, marginal ulcers, various pul-monary problems, and deep throm-bophlebitis, which may be more than10%. Splenectomy is necessary in0.3% of patients to control operativebleeding, and the risk of the mostserious complications of gastrointes-tinal leak and deep vein thrombosis isless than 1%. Such conditions wouldobviously require grounding and de-ferral upon medical certification.

The current trend toward decreasedlength of post-operative hospital stayhas increased the importance of theAME when examining or screeningfor medical events within 30 days ofthe operation. Indeed, some compli-cations may not be recognized until

after hospital discharge, with approxi-mately 0.1% of the patients requiringa re-operation within 30 days of theprimary operation and death occur-ring in 0.3% of the patients.

The most common complicationsreported within 30 days of operationfor severe obesity are respiratory (2%);minor complications (atelectasis, hy-perventilation, plural effusion pluritis,and pneumonitis) represented thegreater part; and major respiratorycomplications (pulmonary embolismand respiratory failure) only 0.3% ofall complications.

Bowel obstruction and gastric leaksof the digestive juices into the ab-dominal cavity require immediate at-tention and occur approximately0.3% of the time. As a general group-ing, when staple breakdown, perito-nitis, and sub-hepatic abscess werecombined with the percentage of GIleaks, the incidence rose to 0.45%.Thirty percent of all 30-day deathsare associated with a GI leak.

ANOTHER CHECKLIST FOR THE FLIGHT PHYSICAL

Dr. Robert Gordon and Dr. Donald Ross presented a useful list of reminders for pilots about toundergo a flight physical in the last issue of the Bulletin (A Checklist for Pilots Approaching the FlightPhysical, fall FASMB, p. 7). Here is a compressed list of these reminders that was prepared by Dr. GuyBaldwin, a Tulsa, Okla., senior aviation medical examiner, who advises pilots that this list “is niceto keep on hand when you are approaching your medical examination.”

1. If you wear glasses or contacts, do not forget them. Make sure you have a recent eye examand have updated your lenses accordingly, especially if your near/far vision has changed.

2. Bring all required medical records from your personal physician regarding any chronicmedical conditions such as hypertension or asthma.

3. If you have been issued a Special Issuance letter from the Federal Aviation Administration, besure to bring it with you to the examination, along with all medical information specified inthe letter.

4. If you have borderline high blood pressure, see your personal physician for evaluation andtreatment prior to the medical examination. Avoid coffee, decongestants, cigarettes, or anyother stimulants prior to your exam. These may all raise your blood pressure.

5. If you have diabetes mellitus, avoid large amounts of sugar prior to the exam , as this can causethe urinalysis to show positive for sugar. If you have a family history of diabetes mellitus orother familial diseases, consult your personal physician for periodic checks prior to medicalexamination.

In summary, the three most seri-ous major complications associatedwith bariatric operations for severeobesity are pulmonary embolism, res-piratory failure, and gastrointestinalleaks. Eighty percent of all deathsoccur within 30 days of the opera-tion; therefore, when confronted withan airman who presents post-operativefrom bariatric surgery, the AMEshould keep in mind these complica-tions and defer medical certification,until at least 30 days post operatively.In addition, a search for complica-tions associated with bariatric sur-gery by review of systems should beconducted.

Reference1. Pursuant to FAR part 67.113/213/313,

obesity would fall under a “generalmedical condition” and would be dis-qualifying if it rendered the airmanunable to safely perform duties.

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Palinopsia Secondary to a Motor Vehicle AccidentCase Report, by Ahmet Akin, MD

Palinopsia is a rare but ominous symptom of cerebral dysfunction and canbe associated with brain lesions, some medications, physical brain trauma,or illicit drug use. This is a case study of a 44-year-old female airline pilotwho experienced palinopsia after a car accident. Since her symptoms disap-peared and there was no other associated pathologic etiology, the AerospaceMedical Certification Division granted 1st class medical certification (withrestrictions) after reviewing her file and obtaining a neurology consult.

Continued �Dr. Akin is an international exchange physician from Manisa, Turkey, and he wrote this casestudy while at the Civil Aerospace Medical Institute.

In February of 2001, a 44-year-oldfemale airline pilot received a severecervical whiplash injury and prob-able closed-head injury when thestopped car in which she was seatedwas struck from behind, forcing hercar into the vehicle in front. Theairbags did not deploy. When hervehicle was first struck, she wassnapped backward, then thrown for-ward. When her vehicle struck thevehicle in front, her head and bodycontinued forward, possibly strikingthe dash or the windshield and thensnapping backwards again, with herhead hitting the seat’s headrest. Herseatbelt had been fastened during theaccident.

She was taken to a hospital whereshe complained of neck pain. A CTscan disclosed degenerative changesat C5-C6 and C6-C7 with foramenalnarrowing bilaterally at C5-C6, worseon the right, with reverse lordosis atC5-C6. No fractures or evidence oftraumatic injury was seen. She wasdischarged to home after about fourhours. An MRI in March 2001showed no evidence of brain damageor collection.

Shortly thereafter, the pilot notedvision changes and a decrease in tastesensation; her sense of smell was un-affected. Visual symptoms consistedof an after-image of a “grayish/whit-ish glow” around objects that waspresent whether she was stationary ormoving and followed when the ob-ject moved. There was no “frank”diplopia, no associated eye pain or

loss of consciousness with the acci-dent. The visual sensations werepresent bilaterally, with or withoutone eye covered, but more markedwith both eyes open. She noted acutevisual blurring that lasted about sixhours and then resolved completelyin April 2001. Sometimes she no-ticed a “kaleidoscopic effect” of hervision bilaterally when things “ap-peared to become fragmented periph-erally.” This first occurred four timesa week but had decreased to abouttwice a week later and then subsided.She denied seeing flashing or zigzag-ging lights. She was treated withZanaflex®, Vicoprofen®, and Pro-poxyphene®. All medications werediscontinued in June 2001.

Visual field studies in May 2001revealed a “nonspecific” small superiordeficit in the right eye and a “question”of superior nasal step in the left eye.Evaluation in the electrophysiologylaboratory in June 2001 disclosed ab-normal bilateral electrooculogram andsuspicious ECG, suggesting photopsiasdue to early retinal degeneration. Elec-troretinography in July 2001 was unre-markable.

She had 50 sessions of physiotherapyfrom February to September 2001. Itcan be summarized as somewhat lim-ited progress in the successful treat-ment of her cervical pain. The MRI ofOctober 2001 showed entirely normalcervico-cephalic vasculature with noevidence of stenosis or aneurysm.

PalinopsiaPalinopsia, occasionally

spelled palinopia, refers to thereappearance of an image aftersome time when the originalexternal stimulus is no longeravailable. Palinopsia may oc-cur soon after the object hasbeen viewed or hours later. Theother terms used to describepalinopsia are “after image,”“visual perseveration,” and“trails.”

The neural basis of palinopsiais unknown but many pal-inopsia patients have some pa-rietal, occipital, or temporallobe lesions. Lesions in the non-dominant hemisphere haveoutnumbered dominant hemi-sphere lesions. In the formerinstance, palinopsia is usuallyassociated with homonymoushemianopia, hemiparesis, and/or psychic disturbances.Palinopsia may also be in-duced by physical braintrauma or a variety of medica-tions, such as clomiphene ci-trate, trazadone, nefazodone,and mitrazapine (1).

Palinopsia can occur afteracute ingestion of lysergic aciddiethylamide (2). According tothe Diagnostic and StatisticalMethod of Mental Disorders (4th

Edition), palinopsia followinghallucinogen use is a commonsymptom of a broader categorycalled hallucinogen persistingperception disorder (3).

Cases are also reportedwhere there is no direct causeknown. Palinopsia and relatedvisual symptoms can occur inotherwise healthy individualsand in patients with diseaseapparently confined to the eyeor the optic nerve (4).


OutcomeThe pilot in this case applied for

reconsideration about one year afterthe accident. She has been off flightstatus since the time of her accident.Her most recent visual examination,documented on the FAA Form 8500-7, was entirely normal with stable vi-sion and visual fields. Her treatingophthalmologist approved returningher to normal activity without occupa-tional restrictions.

In July 2002, an FAA neurologistconsultant reviewed her case and ap-proved 1st class medical certification.However, he recommended that shesubmit annual neurologic and/orneuro-ophthalmologic follow-ups for2 years to ensure her continuing sta-bility. He also advised her to submitan EEG obtained within the upcom-ing year for the same reason. An Au-thorization for Special Issuance wasissued in August 2002 with the re-striction “Valid for 12 months fol-lowing the month examined” andrequesting the above-mentionedevaluations.

References1. Fournier AV. Palinopsia: A case re-

port and review of the literature. CanJ Ophthalmol 2000;35:154-7.

2. Kawasaki A, and Purvin V. Persistentpalinopsia following ingestion of ly-sergic acid diethylamide (LSD). ArchOphthalmol 1996;114:47-50.

3. American Psychiatric Association.Diagnostic and Statistical Method ofMental Disorders, Fourth Ed. Wash-ington, DC: 1994.

4. Pomeranz HD, and Lessel l S.Palinopsia and polyopia in the ab-sence of drugs or cerebral disease.Neurology 2000;54:855-9.

�

Factors in Human ErrorThe NTSB’s accident archives are a treasured history— atestament to human frailty and to lessons learned the hard wayBy Parvez Dara, MD, FACP

The evolution of decision-makingrests on the signatures of past

experience. This premise brings tomind two accidents that illustrate thedomineering effect of the humanmind, which overrides the clues ofimpending disaster. The NationalTransportation Safety Board’s ar-chives are a treasured history, both asa testament to human frailty and tolessons learned. There is no gain inadding to that ink and much value inlearning from those unfortunateenough to have required it.

On a clear Friday afternoon, a manchose to fly from New Jersey to

Texas. A mathematician, by profes-sion, he had been drawn to aviationsince childhood. A teller of tall flyingstories, he embellished them with theraw power of numbers and made every-thing seem so real. His trips, mostlylogged in the Northeast, covered 200-300 miles, all impeccably detailed inhis logbook.

On this spring afternoon, he planneda solo flight from New Jersey to Texas,with a fuel stopover in Nashville, Tenn.Based on the distance and prevailingconditions at various flight levels, hedecided on an uneventful VFR passage.In play were a receding “high” perchedover Boston and a weak trough with adeveloping “low” angling its way overIndiana. This system promised scat-tered cloud layers above 8000 feet forthe three-hour duration of the initialleg of his flight.

After a three-hour unexpected workdelay, he was “wheels up” at 11 AM andon his way. The ride was smooth and hekept busy with changing frequencies asone controller handed him over to thenext. His trusty E6B on the passengerseat was kept busy revealing secrets ofthe wind condition and the fuel flowdata. All calculations indicated he wouldreach his destination within the legalVFR reserve limit.

As the low exerted its pressure andthe ground speed slowly diminished,the E6B use increased. The right wingfuel light flickered and then began toburn continuously. He continued on,eventually switching to the other tank.He could see the faint lines of theapproaching clearing that suggested theNashville airport. Below him, the out-line of a single runway airport slowlydisappeared. “I wonder if I should…”No! The calculations showed he couldmake it to Nashville— only now withlesser reserves. Midway between thepassed airport and the view of his des-tination, the engine sputtered and died.

The E6B flew out of his hand as thewhoosh from the slipstream got hisattention. He flew the plane onto afield of freshly harvested corn. Afterthe aluminum met the brown earth ina twisted sort of way— but damagedbeyond repair— the mathematicianemerged shaken but able to fly an-other day.

Implicit in this story is human arro-gance. A good pilot is careful in plan-ning but cognizant about variability.Weather change not only relates toclouds, obscuration, rain, hail, sleet,freezing rain, or ice, it also relates toincreasing winds. A mind so fixated onprocessing information is reluctant tosee all that effort wasted, like a writerwho falls in love with his words, un-willing to edit and adapt. Flying thesesometimes unfriendly skies, we mustunderstand the limits of our capacities.

What monster of the mind kills arehearsed discipline with suchimpunity?

The same monster was at work onthis bright summer’s day, as the

next story about a practicing ophthal-mologist illustrates. An optimist, hesaw the silver lining in every cloud or agood retina behind every cataract. He

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nformation

With

Your Staff and

Patients

Continued on page 10...


believed there was always a blue skyabove every storm cloud, and who couldargue with his logic?

The chariot of his desire— a BeechBonanza— loved, polished, and keptimmaculate in a hanger, was the envy ofall the local aviators. Even though heflew infrequently, he still stayed withinthe confines of legal currency. His sparetime was sparse. So, never a refreshercourse was logged in his books, nor anemployment of an instructor to honehis skills. Oh, but he loved to fly, forthat there is no question.

So, on that fateful Friday afternoon,across a span of 300 nautical milesbetween the neighboring states of Penn-sylvania and New Jersey, he and a com-panion were comfortably settled on theleathered seats of the Bonanza, moni-toring things as “Jeeves” (the autopilot)flew. The sky, marred only by the con-trails of a passing jet, presented a perfectforeground for a smooth VFR flight.

All of this suddenly ended, as thepassenger who limped away from thefatal accident scene related:

“He kept saying, ‘We can make it!’”Holding back an imaginary yoke inboth his clenched fists, he mimickedthe aviator. “He kept counting downthe distance to the airport. I mean theengine had quit 4 miles out at 5000feet. We were gliding.” He broke for abreath. “Caught my attention when

the checklist, mumbled to himself ashis eyes darted to every knob and dialfor confirmation.

I asked him if he was concernedabout the safety of the flight.

“Every time,” he laughed, “Youknow, there are no gas stations in thesky.”

These events, albeit isolated, are nev-ertheless tethered to each other in thesimple reality of human nature. Thelogical mathematician sticks doggedlyto his numbers while giving no cre-dence to the need for flexibility and agenerous allowance for the ever-chang-ing weather. An optimist rides the shim-mering waves of desire, only to throwthe caution of aerodynamic laws to thewind. So what, if any, lessons can onelearn from this?1. Keep an open mind, gather the whole

picture.2. Practice simulated emergencies –

enhance your positive experience.3. Always have a way out.4. Adapt to changes.5. Obey the rules – follow established

procedures. The laws of physics areunyielding.

6. Err on the side of safety.7. Respect nature, where change is a

constant.8. Understand your capabilities and

your aircraft’s limits.9. Remember, it could happen to you.

�

the damned thing sputtered, and thena quarter-mile from the airport the planekind of shuddered and then took anosedive. All I could see was the groundcoming at me, and I remember saying,‘This is it!’” His face twisted for apensive moment, “I wish he had pulleda little harder at the yoke, maybe hewould still be alive.”

As the events of his last 20 minutesof life unfolded, one would have toagree with the NTSB, who ruled it aspilot error — both for starving theengine (one tank was still half-full) andfor exceeding the angle of attack. Be-yond the critical angle of attack pale laythe arrogance of an undisciplined opti-mist, all twisted into shards of alumi-num and human remains. This was atestimony to observe the law of rules.

These tragedies, inextricably linkedlike the DNA helix, carry the urgings ofpast experience, casting a historical lineinto the present for us to draw upon.To develop good habits, it is importantto keep an open and engaged mind likemy newly minted instrument student.

“Is it okay to get butterflies everytime you go up?” This was a questionfrom this 21-year-old, private pilotflying a Piper Warrior from the leftseat. “My hands get cold and sweatyevery time I go flying.” His eyes werewide, as beads of sweat irrigated thelines of concern on his forehead. Butthrough it all, he methodicallychecked line by line, every item on

Human Error from page 9

Dr. Dara is an aviation medical examiner who specializes in hematology and oncology in Toms River, N.J.; he is also a pilot with the ratingsof Airline Transport Pilot, Certified Flight Instrument Instructor, and Multi-Engine Instrument with more than 2,400 hours in the air. Heis a director of the Mooney Aircraft Pilot Association and a frequent speaker at ground and flight safety seminars.

In the case where the AME issuesa combined Medical and StudentPilot Certificate but erroneously in-dicates in the block 62 of the Form8500-8 that only a Medical Certifi-cate was issued, no record is estab-lished that the applicant is a student.This means that the student pilotdoes not receive critical safety infor-mation mailings from the FAA orfrom various pilot organizations.

SOLUTIONAMEs must pay more attention to

which certificate is issued to studentpilot examinees and recognize thatthe student pilot may not know whichcertificate he or she should be issued.To prevent errors from occurring, itwould be helpful to have your recep-tion staff remove and void the certifi-cates (Forms 8500-9 or 8420-4) theapplicant is not applying for from theForm 8500-8 at the time the exam-inee checks in and indicates whichtype of certificate is being sought.

Hopefully, this will avoid issuance ofthe wrong certificate.

Please double check for consistencythe selection the applicant makes inblock 1 and your selection in block 62of the Form 8500-8 when transmittingand sending the paper application tothe AMCD. This will assure that thecorrect records are created and avail-able when needed.

Dr. Jones is the manager of the Civil Aero-space Medical Institute’s Aerospace MedicalEducation Division.

Quick Fix from page 1


An Unexpected Finding of Hydrocephalus in an ApplicantCase Report, by Paul L. Blanchard, MD

With our increasing use of CT and MRI technologies, an airman willoccasionally be found to have unexpected pathology that is unrelated tohis symptoms. This applicant was found to have an asymptomaticarachnoid cyst and hydrocephalus. Now that this unexpected finding hasappeared, what should the aviation medical examiner do?

This case involves a 20-year-old gentleman who desires tobegin flight training. He pre-

sented to an aviation medical exam-iner in April 2000 requesting issuanceof a 1st-class medical and student pi-lot certificate.

History. On review of his history,the applicant reported hay fever thatwas not currently symptomatic andrequired no medications. Additionalhistory disclosed that he had beeninvolved in a traffic accident in Octo-ber 1999, when he was struck frombehind while riding his bicycle. Hesuffered a broken left wrist and alaceration above his right eye thatrequired sutures. He was alert andoriented when he arrived at the localemergency room and, according tothe treating physician’s note, thisgentleman had a normal neurologicalexam. However, he had no recollec-tion of the accident. Therefore, theattending physician felt it would beprudent to obtain a CT scan of thebrain to assess possible intracranialpathology.

The CT scan showed some extracra-nial swelling above the right eye. Noorbital fracture or intracranial he-matoma was identified. There was,however, an interesting incidental find-ing. This gentleman had a congenitalarachnoid cyst located at the superiorcerebellar cistern. Because of the masseffect from the cyst, hydrocephalus withprominent lateral and third ventricles wasseen. The radiologist recommended anMRI to further study the arachnoid cyst.

The MRI showed the arachnoid cystto measure 6.5 centimeters AP diam-eter by 5 centimeters transverse diam-eter by 5.2 centimeters craniocaudaldiameter. The cyst exerted a significantmass effect on the cerebellar vermis andthe dorsal brainstem. There was nar-rowing of the cerebral aqueduct result-ing in hydrocephalus of the lateral andthird ventricles.

This gentleman was sent for a neu-rosurgical opinion. The neurosurgeonadvised following him with serial MRIstudies since he had no symptoms, andhis neurological examination was com-pletely normal. Follow-up MRI studiesin January and May of 2000 showed nosignificant interval change.

Disposition. As previously stated,the applicant had presented to a localAME in April requesting airman medi-cal certification. On review of his FAAForm 8500-8, the applicant had nocomplaints or concerns that day, andthe AME recorded a normal physicalexamination. However, because of theabnormal CT and MRI studies, a medi-cal certificate was not issued, and thecase was deferred for review to the FAAAerospace Medical Certification Divi-sion (AMCD) in Oklahoma City.

In September 2000, the AMCD de-nied the application for medical certifi-cation due to the “disqualifying generalmedical condition of arachnoid cystwith mild hydrocephalus.” The rel-evant regulations are 14 CFR Part67.113(b), .213(b), and .313(b).

The following month, the applicantfiled an appeal for reconsideration ofthe denial. The CT and MRI studies

were submitted for review, and the casewas forwarded to an independent neu-rologist for his opinion as to theapplicant’s suitability for medical certi-fication. After reviewing the scans, theneurologist felt that the hydrocephaluswas even more advanced and severethan had been reported. He also be-lieved that the cyst would continue toexpand over time and eventually oc-clude the fourth ventricle. Should thishappen, both intraventricular and in-tracranial pressure would increase, andthis could possibly lead to sudden inca-pacitation.

The applicant’s neurosurgeon be-lieved that piloting would be a safeactivity, given the current stability ofthe arachnoid cyst and the absence ofsymptoms. The neurological consult-ant disagreed and recommended that“this airman be denied all classes in-definitely into the future.”

The current recommendation fortreatment depends on the person’ssymptoms. Asymptomatic cysts can befollowed with serial exams and imagingstudies. Surgical intervention becomesnecessary if one develops symptoms ofincreased intracranial pressure, seizures,neurologic deficits, or cognitive im-pairment. Needle aspiration only pro-vides temporary benefit and is not along-term treatment option. At present,this applicant is denied medical certifi-cation because the transition from anasymptomatic to symptomatic arach-noid cyst is unpredictable, which posesan unacceptable risk to aviation safety.

If the applicant were to elect to un-dergo surgical treatment, he might beplaced on anticonvulsants as a prophy-lactic measure after his procedure. Ifthat were the case, he would need tohave a seizure-free period for an appro-priate observation period (determinedon a case-by-case basis) following dis-continuation of any prophylacticanticonvulsants before he could be re-considered for issuance of a studentpilot medical certificate.

Based on the neurological con-sultant’s opinion, the original denial ofSeptember 2000 was sustained.

Dr. Blanchard was a Wright State University resident in Aerospace Medicine when he wrotethis case report at the Civil Aerospace Medical Institute. Continued on page 13...


Chinese Official Visits CAMI

Mr. Joseph Chu-Chen Tien, Secre-tary General of the Taiwanese CivilAviation Authority, visited the CivilAerospace Medical Institute (CAMI)on November 19, 2002. Mr. Tien wasinterested in CAMI’s medical certifica-tion and aviation medical examinerprograms. He also visited the FAA Acad-emy and the air traffic control towersimulator. Pictured are (L-R) BillTraylor (FAA Academy Superinten-dent), Secretary General Tien, LindyRitz (Mike Monroney AeronauticalCenter director), and Dr. Warren Sil-berman (Aerospace Medical Certifica-tion Division manager).

Office of Aerospace Medicine NEWSInternational ExchangePhysician Completes Tour

Major AhmetAkin, MD, a na-tive of Manisa,Turkey, completeda year-long tour inDecember 2002 asa participant in theInternational Ex-

change Visitor program at the CivilAerospace Medical Institute.

Dr. Akin is an assistant professorin the Department of AerospaceMedicine at Gulhane Military Medi-cal Academy in Eskisehir, Turkey.During his year at CAMI, Major Akinrotated through the research, educa-tion, and certification divisions, andhe also co-authored a major researchpaper and a case report (seePalinopsia, page 8).

Dr. Melchor Antuñano, CAMIDirector, said that Dr. Akin “workedhard and contributed much” duringhis rotation at the Institute. “We arepleased with his efforts and wish himevery success in his future endeav-ors,” he concluded. Dr. Akin is thesecond physician from Turkey toparticipate in the exchange program.

While he says he “really enjoyed” hisyear at the Oklahoma City, Okla., In-stitute, Dr. Akin said he was also look-ing forward to returning to Turkey to“get reacquainted with my friends, fam-ily, and professional associates.”

The International Exchange Visi-tor program allows qualified foreignspecialists to enter the US for up totwo years to conduct studies and ex-change information at FAA facilities.

The Office of Aerospace Medicinesupports all international programs thatpromote interaction between aviationmedicine professionals, enable the ex-change of scientific information, andpromote the FAA’s prominence in civilaerospace medicine.

Dr. Akin

FAA RemembersJim Spanyers

James (Jim) P.Spanyers, an avia-tion physiology in-structor with theCivil AerospaceMedical Institute’sAirman Education Program staff, passedaway on October 18, 2002, after aterminal illness. Jim had worked atCAMI for seven years and was wellknown in the aviation community asan expert at demonstrating survival skillsand as a lecturer. His talents were rec-ognized by the U.S. Air Force, where heworked in a similar capacity during a26-year career. At the Institute, he dis-tinguished himself by teaching pilotsvaluable survival skills and physiologi-cal aspects of safe flight.

In addition to working in Okla-homa City, Jim and his fellow instruc-tors traveled to many locations in theU.S. and abroad to teach aviation safetyshort courses to pilots and others. Hehad been recognized for his efforts bytwo major awards by the FAA andreceived numerous letters of apprecia-tion from those he served.

Mr. Spanyers

Review Physician Called toActive Duty

Larry F. Wilson, MD,a medical review phy-sician in the AerospaceMedical CertificationDivision, is in theOklahoma Army Na-tional Guard and hasbeen mobilized for at least one year. Heexpects to be stationed in Bosnia. Priorto working at the AMCD, Dr. Wilsonwas a flight surgeon in the SouthernRegion.

Dr. Wilson

Librarian 2002 Employee ofthe Year

If the adage knowl-edge is power is accu-rate, then librarianKatherine Wade is apower broker. Ms.Wade was chosen asthe 2002 Civil Aero-space Medical Institute’s Employee ofthe Year by her co-workers at the Insti-tute in recognition of her “professionalexpertise” and “in-depth ability” tofind facts and figures. She was recog-nized as one who is keenly knowledge-able of vast resources of informationavailable to researchers or anyone with“a need to know.”

Ms. Wade

L-R: Mr. Traylor, Mr. Tien, Ms. Ritz,and Dr. Silberman

Continued �


Aviation Medical ExaminerSeminar Schedule

2003

March 10-14 ----------- Oklahoma City, Okla. -------------- Basic (1)April 25-27 ------------- Atlanta, Ga. --------------------------- OOE (2)May 5-8 ----------------- San Antonio, Texas --------------- N/NP/P (3)June 9-13 --------------- Oklahoma City, Okla. -------------- Basic (1)July 18 - 20 ------------ Chicago, Ill. --------------------------AP/HF (2)August 15 - 17 -------- Washington, D.C./Mclean, Va. --- CAR (2)September 15 - 19 --- Oklahoma City, Okla. -------------- Basic (1)October 3 - 5 ---------- Salt Lake City, Utah ----------------- OOE (2)November 3 - 7 ------- Oklahoma City, Okla. -------------- Basic (1)

CODES

AP/HF Aviation Physiology/Human Factors ThemeCAR Cardiology ThemeOOE Ophthalmology - Otolaryngology - Endocrinology ThemeN/NP/P Neurology/Neuro-Psychology/Psychiatry Theme(1) A 4½-day basic AME seminar focused on preparing physicians to bedesignated as aviation medical examiners. Call your regional flight surgeon.

(2) A 2½-day theme AME seminar consisting of 12 hours of aviation medicalexaminer-specific subjects plus 8 hours of subjects related to a designatedtheme. Registration must be made through the Oklahoma City AME Programsstaff, (405) 954-4830, or -4258.

(3) A 3½-day theme AME seminar held in conjunction with the AerospaceMedical Association (AsMA). Registration must be made through AsMA at(703) 739-2240. A registration fee will be charged by AsMA to cover theiroverhead costs. Registrants have full access to the AsMA meeting. CME creditfor the FAA seminar is free.

The Civil Aerospace Medical Institute is accredited by the AccreditationCouncil for Continuing Medical Education to sponsor continuing medicaleducation for physicians.

DOT Secretary’s Award. Patricia Calvert(center), is shown accepting the Secretary’sAward from Department of TransportationSecretary Norman Y. Mineta, as FAAAdministrator Marion C. Blakey looks on.Ms. Calvert works at the Civil AerospaceMedical Institute’s Protection and SurvivalLaboratory.

Congratulations. Dr. Stephen L.Carpenter, a medical review officer inthe Aerospace Medical CertificationDivision, was recently certified in Aero-space Medicine by the American Boardof Preventive Medicine. Dr. Carpenterjoined the FAA in 1990, and he is anavid pilot and also serves as a flightsurgeon in the Oklahoma Air NationalGuard. �

Discussion. Arachnoid cysts accountfor 1% of intracranial mass lesions, andmost are congenital. Most of these cystsoccur in an area where the arachnoidmembrane becomes split or duplicated,and this allows CSF to collect betweenthe split in the membrane. As the cystincreases in volume, it may compressadjacent brain tissue and obstruct CSFflow. Arachnoid cysts can occur any-where in the nervous system wherearachnoid membrane is found.

As this case demonstrates, the num-ber of people found to have asymptom-atic arachnoid cysts is likely to risebecause of the increasing use of CT orMRI to assess unrelated problems.

ReferenceSamuels MA, and Feske S. Office

Practice of Neurology. ChurchillLivingstone, Inc., 1996.

�

Hydrocephalus from page 11

Be sure to or-

der enough Air-

man Medical

Certificate forms

(FAA Form

8500-8) to last one year. When

you deplete your supplies, order

another year’s supply.

STRESSAME

BUSTER

If you follow this

routine for restocking

your medical forms,

you should never be in

the stressful position

of having an airman arrive for an

FAA physical, only to find you are

out of medical examination forms!


By Glenn R. Stoutt, Jr., MD, SeniorFAA Aviation Medical Examiner

TOPICS AND ISSUES

Health of Pilots

J u s t f o r t h e

Dr. Stoutt is a partner in the Springs Pediatrics and Aviation Medicine Clinic, Louisville, Ky., and he has been an active AME since 1960. Nolonger an active pilot, he once held a commercial pilot’s license with instrument, multi-engine, and CFI ratings.

Continued �

SINCE THIS IS THE ISSUE for winterof 2002-2003, you can’t avoidthinking about flab. One way or

another, you have to survive the eat-ing (feasting) period that begins eachyear at Thanksgiving, goes throughthe religious holidays, and ends onthe almost-holy day of Super BowlSunday. Chances are good that youhave added a few unwanted poundsand have sworn to lose them.

For the past five years, this columnhas been dedicated to providing loadsof information (all you really everneed to know) in many articles aboutdiet and exercise. Fortunately, theyare all now available on the Web sitefor the FAA’s Federal Air Surgeon’sMedical Bulletin:www.cami.jccbi.gov/aam-400A/index.html

(If you can type all this addresscorrectly the first time you are trulyan amazing person—no one has everdone it before.) When you get to thesite, just key in the part listing thearticles of Just for the Health of Pilots.The articles on diet and exercise givea foolproof, medically sound methodfor losing the pounds of fat that youdon’t want.

The number of scientific and medi-cal journals is pushing the 10,000mark. Ideally, it would be nice to seethe best articles from the best jour-nals or even important articles fromimportant journals. I luckily found asmall jewel of an article in the Octo-ber 23/30, 2002, issue of the Journalof the American Medical Associationfrom researchers at the HarvardSchool of Public Health. The articlewas “Exercise Type and Intensity inRelation to Coronary Heart Diseasein Men.” No major breakthroughs inmedicine were revealed, but somesimple, solid, useful conclusions werereached.

Here is a summary of what I foundimportant in the article:

· Studies have shown that ex-ercise has a direct influence inreducing coronary heart diseasein men, but data on the typeand intensity of exercise havebeen sparse.· The group studied included44,452 US men (aged 40through 75 years) in varioushealth professions followedfrom 1986 to 1998 in a precise,well-controlled analysis of sub-sequent coronary heart disease(CHD) and levels of leisure-timephysical activity.· Men who ran for an hour ormore a week had a 42% riskreduction for coronary heartdisease.· Men who trained with weightsfor 30 minutes or more per weekhad a 23% risk reduction.· Rowing for 1 hour or moreper week was associated withan 18% risk reduction.· A half-hour per day or moreof brisk walking was associatedwith an 18% risk reduction.· Swimming and cycling werenot included in the study(though obviously excellent ex-ercise choices) because notenough were in the group to beof statistical significance.· Walking pace was associatedwith reduced CHD indepen-dent of the number of walkinghours.


The walking pace is a very impor-tant item in the analysis. Essentiallywhat was revealed was that brisk walk-ing for a short time has a greaterprotective effect than long periods of“strolling.” Walking pace was definedas casual (up to 2 mph), normal (2-3mph), brisk (3-4 mph), or striding (4or more mph). As a guide: a mile in30 minutes is 2 mph, in 20 minutes is3 mph, and 15 minutes is 4 mph. Aperson probably cannot walk fasterthan 8 mph unless he is “race walk-ing.” Most of us would probably besatisfied with a mile in 20 minutes.(Of course, a casual walk in the woodsor around beautiful scenery shouldn’tbe hurried. There is the psychologicaland healthful boost of “smelling theroses” on a stroll through nature.)

This study was one of the few thatshowed the advantage of resistance orweight training in reducing CHD.

In summary, the article stressed thatvigorous exercise was better than mod-erate-intensity exercise and that strengthtraining also had a direct effect in low-ering the incidence of CHD.

What is a measure of exercise inten-sity? At rest, the intensity is expressed as1 MET (metabolic equivalent task).This is the energy we spend entirely atrest, such as sleeping or sitting in achair. It is equivalent to l calorie perkilogram of body weight per hour. Asan example: One kilogram (kg) is equalto 2.2 pounds. So, a 220-pound manweighs 100 kg. He then needs 2400calories (100 kg times 24 hours) a dayjust to stay alive. To calculate yourown basal metabolic needs, just di-vide your body weight by 2.2 to getthe number of kilograms, and multi-ply by 24. Anything you do extra(walking, eating, standing, working,exercising) burns calories.

The article defines vigorous exerciseas 6 METs, or 6 times as much effort asyou expend sleeping or sitting still.This is really just brisk and intense—but not exhausting—exercise.

The take-home message from thestudy was stated at the beginning: Sed-entary individuals have almost twicethe risk of CHD as those performinghigh-intensity exercise.

Walking is the most common lei-sure activity among US men andwomen. As a rough measure, walking amile burns about 100 calories.

Current guidelines from the Na-tional Institutes for Health recommend30 minutes of moderate-intensityactivity on most, and preferably all,days of the week to prevent CHD andother chronic diseases.

Dr. Jesse Wright of the Universityof Louisville Department of Psychiatrysaid (in a lecture on depression) thatexercise was probably as good as theselective serotonin reuptake inhibitors(SSRIs such as Prozac®, Paxil®, andZoloft®) for treating depression. Headded that his running for the past 17years allowed him to avoid much of thestress of treating severe psychiatric prob-lems day after day.

Joggers and runners feel exhilara-tion from a surge of endorphins after aworkout. The release of muscle tensionof which we are unaware is also a sig-nificant benefit in promoting a feelingof calm. Exercise promotes more rest-ful sleep. As psychiatrists say, “Theanswer to anxiety is action.” The bodyloves the action of exercise. Can you bemad or anxious after a five-mile run?

Stress and tension lead to fatigue,the number-one cause of pilot error.Stay healthy, stay calm, stay cool. Putexercise into your daily plan—it is asnecessary as food and sleep for bothyour physical (especially heart) andmental health.

Yours for good health and safe flying,

Glenn Stoutt

Note: The views and recommendations made in this article are those of the author and notnecessarily those of the Federal Aviation Administration.

SOME HELPFUL FACTS, FACTOIDS,PEARLS, AND TIPS

♦ The Honolulu Heart Programfound that regular walking inolder men (two miles a day)was associated with significantyreduced mortality. They stud-ied 707 nonsmoking retiredmen, aged 61 to 81 years. Evenhalf a mile daily was beneficial.♦ Tomatoes contain the anti-oxidant lycopene, which canlower heart attack risk.♦ Potassium, high in fruits (es-pecially oranges and bananas)and vegetables, helps lowerblood pressure.♦ Deep breathing and walkingare great for control of anger.Counting to 10 is not muchhelp–you often blow up when10 is reached.♦ If you make your own ham-burgers or chili, use extra-leanbeef. Costs more, but has onlyabout 10 percent fat. (Still a lotof fat for steady use.)♦ Your heart weighs about onepound. It beats about 100,000times a day. Your body con-tains about 5 quarts of blood,and your heart has to pump(without rest) about 80 milliongallons of blood in a lifetime. Ifit stops for even five or six min-utes, you either get severe braindamage or enter the HardwoodHilton (“kick the oxygen habit”).So, take real good care of yourheart by developing a healthfullifestyle.♦ Monounsaturated fat (such asfound in canola oil and oliveoil) is said to cut the rate ofbreast cancer in half. Also helpsprevent heart disease.


Federal Air Surgeon’s Medical Bulletin Reference Index of Articles Published in 2002HEADLINE ISSUE PAGE

Akin, Dr. Ahmet: Exchange Physician Completes Year at CAMI ----------------------------------------------------------------------------- Winter ------ 12Alaska Capstone Program: Safety Through Technology, by Dr. Kevin Williams ----------------------------------------------------------- Spring --------- 6Alternative Color Vision Test a Winner, Letters to the Editor, by Mike Ruff --------------------------------------------------------------- Fall ---------- 12Antuñano, M.J: CAMI Director Attends Hispanic Summit ------------------------------------------------------------------------------------ Fall ---------- 13Bariatric Surgery, Medical Certification After, by Dr. Donato Borrillo ----------------------------------------------------------------------- Winter -------- 6Blakey, Marion Clifton: New FAA Administrator Sworn In ------------------------------------------------------------------------------------ Fall ------------ 1Calvert, Patricia: Receives DOT Secretary’s Award ---------------------------------------------------------------------------------------------- Winter ------ 13CAMI Website is Simmering, by Mike Wayda --------------------------------------------------------------------------------------------------- Spring --------- 7Carpenter, Steven: Receives New Rating ----------------------------------------------------------------------------------------------------------- Winter ------ 13Case Report: Alpha-1 Antitrypsin Deficiency, by Drs. L. Moreno & A. Wolbrink --------------------------------------------------------- Summer ---- 10Case Report: Hydrocephalus and Seizures, by Dr. Meire Gonzaga ---------------------------------------------------------------------------- Fall ------------ 9Case Report: Hydrocephalus, Unexpected Finding of, by Dr. Paul Blanchard -------------------------------------------------------------- Winter ------ 11Case Report: Meningiomas in an Airman, by Dr. P. Sheth ------------------------------------------------------------------------------------- Fall ---------- 11Case Report: Palinopsia Secondary to a Motor Vehicle Accident, by Dr. Ahmet Akin ---------------------------------------------------- Winter -------- 8Case Report: Vasovagal Syncope Episode in an Airman, by Dr. Katkovsky ------------------------------------------------------------------ Spring --------- 4Certification Issues and Answers, by Dr. Warren S. Silberman -------------------------------------------------------------------------------- Winter -------- 3Certification Issues and Answers, by Dr. Warren Silberman------------------------------------------------------------------------------------ Fall ------------ 3Certification Issues: Questions & Answers, by Dr. Warren Silberman ----------------------------------------------------------------------- Summer ------ 4Checklist for Pilot Flight Physical, by Drs. Robert Gordon, and Donald Ross -------------------------------------------------------------- Fall ------------ 7Checklist for the Flight Physical, by Dr. Guy Baldwin ------------------------------------------------------------------------------------------ Winter -------- 7Color Vision in Black & White, by Dr. Zimmer-Galler ---------------------------------------------------------------------------------------- Spring ------- 10Counterfeit Medications, by Dr. S. Goodman ---------------------------------------------------------------------------------------------------- Summer ------ 3Diabetic Pilot: Letter to the Editor by J. Gorder ------------------------------------------------------------------------------------------------- Summer ---- 12ECG Transmissions Reminder, Suspicious Airmen, Envelopes, by Dr. Warren Silberman ----------------------------------------------- Fall ------------ 8Editorial: Aerospace Medical Research: Making Air Travel Safer, by Dr. Jon L. Jordan --------------------------------------------------- Winter -------- 2Editorial: Alcohol Abuse, by Dr. Jon L. Jordan --------------------------------------------------------------------------------------------------- Fall ------------ 2Editorial: Doing Things Right, by Dr. Jon L. Jordan -------------------------------------------------------------------------------------------- Spring --------- 2Editorial: Security for American Aviation, by Dr. Jon L. Jordan ------------------------------------------------------------------------------- Summer ------ 2Environmental and Safety Issues Associated With PBDEs, by Dr. Arvind Chaturvedi ---------------------------------------------------- Spring --------- 4FAA Correspondence: Certification Applicants Be Aware of, by Dr. Charles Nicholson -------------------------------------------------- Fall ------------ 6Factors in Human Error, by Dr. Parvez Dara ----------------------------------------------------------------------------------------------------- Winter -------- 9FALANT: Letter to the Editor by Dr. R.T. Jennings -------------------------------------------------------------------------------------------- Summer ---- 12Fatigue and Desynchronosis in Aircrew, Letters to the Editor, by Larry Nazimek ---------------------------------------------------------- Fall ---------- 12Fatigue and Desynchronosis in Pilots, by Dr. Virgil Wooten ----------------------------------------------------------------------------------- Summer ------ 8Foreign Pilot Certification: FAA Changes, by FAA Aviation News --------------------------------------------------------------------------- Fall ------------ 1Gorrell, Dr. G., Friends for Life, AME Profile, by NW Mountain Region ------------------------------------------------------------------ Summer ------ 1Harlan, Dr. A: Visits Civil Aerospace Medical Institute ----------------------------------------------------------------------------------------- Fall ---------- 13Health Issues for Pilots: AMSIT: Scoring Points for Aviation Safety, by Dr. Glenn Stoutt ----------------------------------------------- Spring ------- 14Health Issues for Pilots: Living and Flying “Over Gross,” by Dr. Glenn Stoutt ------------------------------------------------------------- Summer ---- 14Health Issues for Pilots: Your Health: Who’s Really in Charge? by Dr. Glenn Stoutt ----------------------------------------------------- Fall ---------- 14Health Issues for Pilots: Your Heart and Exercise, by Dr. Glenn Stoutt ---------------------------------------------------------------------- Winter ------ 14Holmes, Dr. D., Friends for Life, AME Profile, by NW Mountain Region ----------------------------------------------------------------- Summer ------ 1Howard, Dr. M: AME Office Scores 100% on MAMERC ------------------------------------------------------------------------------------- Fall ---------- 13In-Flight Emergency, Letter to the Editor by Drs. Myers and Andrensen -------------------------------------------------------------------- Spring ------- 13In-Flight Medical Kits: Letter to the Editor by Dr. A.J. Parmet ------------------------------------------------------------------------------- Summer ---- 12Jones, Dr. R.F: CAMI Education Division Manager Named, by M. Wayda ---------------------------------------------------------------- Summer ---- 16Misuse of the AME Designation, by Dr. Richard F. Jones -------------------------------------------------------------------------------------- Fall ------------ 1Moore, Dr. Louis S: AME Profile ------------------------------------------------------------------------------------------------------------------- Spring --------- 5Moore, Dr. W. Donald: A Dean Among Doctors, by Mark Grady --------------------------------------------------------------------------- Winter -------- 1NASA-FAA Report Turbulence Aloft -------------------------------------------------------------------------------------------------------------- Fall ---------- 13Office of Aerospace Medicine Annual Awards, by M. Wayda ---------------------------------------------------------------------------------- Summer ------ 6Peripheral Vascular System: Beyond Deep Vein Thrombosis, by Dr. Donato Borrillo ---------------------------------------------------- Summer ------ 7Return Envelopes (Notice to AMEs), by Dr. M.J. Antuñano ---------------------------------------------------------------------------------- Summer ------ 1Revised Policy Announced on Special Issuance Procedures, by Dr. Warren Silberman ---------------------------------------------------- Spring --------- 1Sabatini, N.A: Visits Civil Aerospace Medical Institute ----------------------------------------------------------------------------------------- Fall ---------- 13Silberman, W.S: Receives CAMA Award, by M. Wayda ---------------------------------------------------------------------------------------- Fall ---------- 16Sleep Disorders in Pilots, by Dr. Virgil Wooten -------------------------------------------------------------------------------------------------- Spring --------- 8Sodhi, S., Lari-Castrillon, N., Rosser, M., New International AMEs ------------------------------------------------------------------------- Summer ---- 16Spanyers, James: FAA Remembers ------------------------------------------------------------------------------------------------------------------ Winter ------ 12Stoutt, Dr. G: AME Office Scores 100% on MAMERC ---------------------------------------------------------------------------------------- Fall ---------- 13Student Pilot Certificate Errors, by Dr. Richard Jones ------------------------------------------------------------------------------------------ Winter -------- 1Tapestry of Disaster: An Accident Story, by Dr. Parvez Dara ---------------------------------------------------------------------------------- Fall ------------ 4Tien, Joseph Chu-Chen: CAA Official Visits CAMI -------------------------------------------------------------------------------------------- Winter ------ 12Tox Lab Recertified, by M. Wayda ----------------------------------------------------------------------------------------------------------------- Spring ------- 16Wade, Kathy: 2002 Employee of the Year --------------------------------------------------------------------------------------------------------- Winter ------ 12Wilson, Dr. Larry: Review Physician Called to Active Duty ------------------------------------------------------------------------------------ Winter ------ 12

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Federal Air Surgeon’s Medical Bulletin · 2 The Federal Air Surgeon's Medical Bulletin • Winter 2002 By Jon L. Jordan, MD, JD The Federal Air Surgeon’s Column ... (cyclobenzaprine