October 1, 1993
Dr. H. Stacy Vereen
When you're a medical examiner, the questions come up over and over again. Can I take this medicine and fly? Is the medication approved by the Federal Aviation Administration? Is this antibiotic on the FAA's "Okay List"? Well, the FAA has no list per se. Oh sure, there are many medicines that the FAA routinely approves and some that are most certainly disqualifying, but most are considered on a case-by-case basis. In most instances of short-term therapy, the FAA relies on the aviation medical examiner to advise the airman on medication usage, side effects, and flying status.
Before a decision can be reached on whether a pilot who is taking a certain medication can fly or not, many factors must be considered. One of the most important is the underlying illness. Sometimes the medication is fine, but the pilot needs to be home in bed, not in the cockpit.
Strep throat is a good example. It is usually treated with penicillin and aspirin or Tylenol. Under favorable circumstances, usually it is safe to fly while taking these medications. But strep throat can be accompanied by a fever high enough to cause delirium and throat pain severe enough to be very annoying. So in spite of the relatively benign side-effect profile of both aspirin/Tylenol and penicillin, flying would not be wise.
In other cases, it's the medication rather than the condition that compels a physician to ground the pilot. Other than pain and soreness, there would be no reason a pilot could not fly after having an ingrown toenail removed. But in the 24 to 48 hours after undergoing this minor surgical procedure, the discomfort can require a narcotic pain reliever. Of course, the side effects of this class of medication preclude any cockpit duties whatsoever.
Between these two extremes lie hundreds of illnesses and hundreds of medications in an almost endless array of circumstances. Which affect a pilot's performance, and which do not? Sometimes complex situations cannot be distilled down into a yes or no answer. In these cases, we must err on the side of safety.
But what about self-treatment of minor ailments with over-the- counter medications (referred to in the trade as OTC meds)? Some basic differences between OTC meds and prescription drugs are worth considering. First, because an OTC med is simply a medication that you can buy without a prescription, you usually have no opportunity to discuss your illness or the medication with a doctor. You decide what ails you, what kind of medication to take, and, ultimately, if it is safe to fly.
Another big difference is that most OTC meds are intended to relieve symptoms and not to cure illnesses. There are a few exceptions to this, but most of the time when you take an OTC med, you are masking an illness rather than curing it. This can be especially insidious if the illness you are masking is getting worse.
People do not want to feel bad or be sick, and pilots hate to cancel flights, so it is understandable that we would take an occasional OTC med to treat ourselves. However, before you decide to take an OTC med and fly, you should ask yourself four questions:
First, how bad do you feel? Be honest with yourself. Over and over, I have seen pilots in the clinic with the same request: "Give me something to get me through, Doc, I've got an important flight." Some of these intrepid airmen were treated and returned to flight status, but many of them obviously were too sick to fly under any circumstances — medication or no medication. When I point this out to them, there is usually an audible sigh of relief. Someone else telling them they were too sick to fly forced them to consider how bad they really felt.
If you decide to treat yourself, then you must stop for a minute and take an objective look at how you really feel. This is the most important thing to do when making a go/no-go decision. Unfortunately, it is also the easiest step to skip. When our mind-set is "I must fly," it is amazing how much we rationalize about how we feel. This can be a very insidious process as our skills degrade and our judgment goes down the tubes.
Another part of this question is, what sort of symptoms do you have? Instead of looking at how bad you feel, turn your attention to how you feel bad. Some symptoms should obviously preclude flight, no matter how mild they might be. Dizziness, blurred or double vision, persistent chest pain, and shortness of breath all belong in this category.
Your medical history also should be part of the equation. For example, if you have a history of kidney stones, then even the mildest flank pain (lower back and side pain — frequently experienced with a kidney stone) should tell you not to fly until you get it checked out. A mild headache in an airman who gets an occasional tension headache might be okay, but this same headache in an airman with high blood pressure should be a no-go symptom, at least until it is checked out.
Some conditions that we usually think of as mild and not dangerous are of particular concern because of the environmental changes inherent in flight. Motion sickness is much more likely to occur when you start out with a queasy stomach. And any kind of stomach upset with cramping or gas probably will get worse at altitude. Even a common cold with nasal or sinus congestion can lead to incapacitating ear or sinus pain as cabin pressure rises on descent.
How well does the medication relieve your symptoms? Symptoms that are not relieved by OTC meds should be a signal to see your physician or flight surgeon. "Well," you say, "my symptoms aren't that bad. I have a mildly upset stomach, and a dose of Mylanta should fix me right up." This may indeed be true, but try it first — make sure. I once knew a pilot who occasionally took Tums for heartburn. One day, he barely was able to land his airplane before collapsing in the cockpit. He had to be transported by ambulance to the hospital, where, later that day, he underwent surgery for a perforated stomach ulcer. Later, he told me he had taken half of a bottle of Tums in the two hours preceding the flight, but this time, they didn't help. If you take a medicine that always works like a charm but suddenly it doesn't, something else may be wrong. Get it checked.
What else does the medication do to you? What are its side effects? Sometimes a side effect can be desirable or beneficial. Such is the case with an antihistamine taken at bedtime; the drowsiness might very well be of value to help you fall asleep. But most of the time when we use the term "side effect," we mean an undesirable effect. The thing to remember about side effects is that they are extremely variable and unpredictable. Different people will experience different side effects with the same medicine. The same person can even experience a different side effect from the same medication taken on two different occasions. Some side effects are more prevalent, and therefore more predictable, than others.
Antihistamines often cause drowsiness or sleepiness, while decongestants, as a group, are more likely to cause stimulation or nervousness. On the other hand, it is rare for Tylenol to cause an upset stomach, but it can happen. Medications come with labels describing potential side effects, but it is the individual who has the side effects, and these are as varied as individuals themselves. You are the unknown in this equation, and unfortunately, you do not come with a label. Read about the side effects, and respect the label, but don't rely on it completely. You could have an unexpected, rare side effect that is not even listed.
Because virtually all medications, OTC or prescription, have side effects, a good rule is to never take a medication for the first time and fly. If you fly while taking any medication, make sure you have experience with that specific medication and that you suffered no ill effects from it. Equally important before flying: Wait long enough after taking a dose to make sure you will have no side effects this time. The usual waiting period is about an hour. If you decide not to fly while taking a particular medication, how long should you wait before flying again? The general consensus is to wait twice as long as the usual dosing frequency. If a medicine is taken every four hours, then you would need to wait eight hours after the last dose before flying.
When taking an OTC med, you are the only one who can decide how you feel. Think back on previous illnesses when you felt really lousy, with high fever, vomiting, diarrhea, cramping, dizziness, weakness, and the like. If you have ever had any of these symptoms, you may recall that they came on slowly over the course of several hours. If you feel bad before going flying, consider how you are likely to feel later.
Are your symptoms likely to get worse? A beginning fever with the aching-all-over feeling is especially prone to becoming progressively more severe. Err on the side of safety.
Many other factors might make a difference in making a go/no-go decision when you're taking an OTC med or feeling not quite 100 percent. Anything that increases your work load, like single-pilot operations, solid IMC, and long cross-country flights, should be good reason to set your criteria higher. Again, err on the side of safety.
So on the one hand, you probably shouldn't fly if you feel bad enough to take a medication. On the other hand, mild symptoms treated with an appropriate medication without the presence of side effects might be acceptable. But the first and most critical step in deciding which situation applies is to evaluate your condition honestly and objectively.
Dr. H. Stacy Vereen, a senior aviation medical examiner in Atlanta, performs more than 1,000 flight physicals annually and is a medical review officer in the FAA's Drug Abatement program. He serves on the board of trustees of the Civil Aviation Medical Association and is an active speaker on the drug program and the aeromedical aspects of aviation safety. An avid aerobatic pilot and holder of an ATP certificate, he is currently building a Christen Eagle.
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