Having the Heart to Fly

Getting my ticket back after heart surgery

August 1, 2004

Sometime between Thanksgiving and Christmas 2002, I began to notice that something wasn't quite right. I'd get a pain in my left arm that radiated into my chest whenever I'd begin to exercise. By the New Year it was noticeably worse. The pain could come from just climbing the one flight of stairs to my office or walking briskly down the hall.

Like many American men in their early to mid-40s, I was slightly overweight and definitely out of shape, but I thought I'd been taking pretty good care of myself. I have high blood pressure and a family history of heart problems, so I've been watching what I eat for years.

Given that family history, I had a pretty good idea of what was causing my pain. I went to see my family doctor, who did an electrocardiogram (ECG). It was normal, but knowing my history, he decided to send me to a cardiologist for an evaluation and treadmill stress test.

The cardiologist agreed that a stress test with perfusion scan would be the best way to figure out what was going on inside of me, so a week later I presented myself at the diagnostic center for a thallium stress test.

But even before the test, I dropped in to see Gary Crump, director of AOPA Medical Certification Services, to discuss the probable diagnosis and what it meant to my medical certificate. (That's one of the advantages of being an AOPA employee — I can drop in — but members get exactly the same service by calling 800/USA-AOPA, or 800/872-2672.) As I feared, my medical certificate would become invalid. In fact, under FAR 61.53, it was already invalid because I "[knew] or had reason to know of any medical condition that would make the person unable to meet the requirements for medical certification." But the good news was that it's a relatively simple, although time-consuming, process for many cardiac patients to get a special-issuance medical certificate.

Back to the stress test. It involves two injections of thallium, a radioisotope that, when carried through the bloodstream, allows a "nuclear" camera to see how well the blood is flowing to the heart. The first dose was used to check my resting blood flow. After the injection, I waited about 20 minutes, and then lay down on the platform of the nuclear camera for the 10 minutes it takes to collect all the images.

Then came the stress test itself. The second dose of thallium was to be injected once my heart rate reached a certain level. I was hooked up to a host of chest sensors for the ECG, and the treadmill started moving at a slow walk. Three minutes later, the speed picked up and the angle of the treadmill steepened. Almost immediately, the pain began in my arm. The physician's assistant (PA) administering the test quickly decided not to push me to 100 percent of my expected heart rate. Instead, when my pulse reached 150, they gave me the second dose of thallium and let me walk for one more minute to give it time to circulate.

As I was cooling down, the PA said there was "definitely something there" in my ECG, and that I should expect a call to schedule a follow-up visit. Then it was back to the nuclear camera for another 10 minutes before heading home.

After looking at the stress-test results, my cardiologist wanted to do a heart catheterization test, or angiogram, the gold standard for determining the extent of circulation problems in the heart. So two weeks later I was again lying on a table, this time waiting for them to slither a tube up through my arteries to my heart. Both the doctor and I expected that he'd have to do angioplasty, using a small balloon at the end of the tube to widen my artery, and put in a stent, a wire-mesh device that holds the widened artery open. So I was shocked when he said, "I recommend a heart bypass." It seems the type of blockage I had made me a bad candidate for the stent, and angioplasty by itself was not likely to last. So that left two options: heart attack or heart surgery. And since one was totally unacceptable, that really left me with no option at all.

The surgery itself caused surprisingly little pain. It just left me with very little energy. I spent the next nine weeks at home, recuperating enough to return to work. During that time, I walked and walked and nearly wore out the carpet. Just as I was ready to start venturing outside, the worst snowstorm in years slammed into the area, trapping me in the house.

Returning to work began what was probably the hardest part of getting my medical certificate back: sitting out the mandatory six-month recuperation period. Even though I still had the piece of paper saying I have a third-class medical, it was no good. I was essentially in the same boat as a presolo student. But remember — presolo students are allowed to fly.

I checked with Rob Hackman, then manager of aviation technical services for AOPA, who confirmed that I could fly with another pilot or instructor. I was just not permitted to "exercise the privileges of pilot in command." However, I could log PIC time (more on that later).

In fact, Hackman told me that while it's not written anywhere in the regulations, the last thing the FAA wants is for a pilot who's been sitting idle for six months or more to jump back into the cockpit with all that accumulated rust. Better to stay current with a fellow pilot along for the ride.

So I began my instrument training during this period, since an instructor has to be on board for that. As for logging the time, FAR 61.51(e)(1)(i) says, "A recreational, private, or commercial pilot may log pilot-in-command time only for that flight time during which that person is the sole manipulator of the controls of an aircraft for which the pilot is rated."

In a letter of interpretation requested by AOPA the FAA said, "There is a distinction between acting as pilot in command and logging pilot-in-command time. In order to act [emphasis added] as pilot in command, the pilot who has final authority and responsibility for the operation and safety of the flight, a person must be properly rated in the aircraft and be properly rated and authorized [as in valid medical, which counts me out] to conduct the flight. In order to log pilot-in-command time, a person who is the sole manipulator of the controls only needs to be properly rated [single-engine land, that's me] in the aircraft."

Six months to the day after my surgery, I went in for my follow-up stress test. This time everything went well. The doctor administering the test seemed very pleased with the results.

Now, from this point forward, I'd have to suggest you do as I say, not as I did.

The best way to expedite a special-issuance medical is to send all the necessary documentation in one nice, neat packet to the FAA Aeromedical Certification Division in Oklahoma City. Essentially, you need to provide the FAA with a request signed by you asking for a special-issuance medical under FAR 67.401 (it can be as short as one sentence — just be sure to sign it and include your social security number), the stress-test results, a status letter on the doctor's letterhead stating that you've recovered, and all relevant hospital records. AOPA's Medical Certification staff has prepared a medical subject report on what the packet needs to contain. It's available online to AOPA members ( www.aopa.org/members/files/medical/cardio.html).

It's vital that you be very specific with your doctor's office about what documents you need and the deadline for submitting them.

Unfortunately, that's not what I did. Although I requested the necessary report and documentation immediately after my stress test, I did not make clear enough the time constraints involved. The FAA requires that the stress-test results be in its possession within 60 days of the test being administered. That means not only that the documents have arrived in Oklahoma City, but that they have been logged into their system as well. I wasted a lot of my 60 days by not being clear enough and not making follow-up phone calls often enough.

Once my doctor's office had assembled the results, in an effort to be helpful, they mailed them directly to the FAA. Don't let your doctor's office do that. You are your own best advocate, and you need to see the information they've put together to make sure it's everything you're going to need. Specifically request that the results be sent to you.

At the same time you make that request, ask if your doctor's office has all the hospital records from your procedure. In all likelihood, it will not. In that case, you'll need to contact the medical records office at the hospital where your surgery took place. Do this early in the process. It can take two to three weeks for the records to be pulled, copied, and sent to you. (Knowing what I know now, if I had to do it over, I'd submit the request for the hospital records as soon as I was released from surgical care — usually a few weeks after surgery.)

Because of a recent federal law protecting a patient's medical records, you will have to submit either a signed form or a letter requesting release of the information. The medical records office can tell you what they require. Also, expect to pay a per-page fee for copying the records.

Once the records are assembled, the next step is to call AOPA's Medical Certification office. Seriously.

"There are a lot of pieces to this puzzle, and we can help make sure you've got them all," said AOPA's Crump. "That can really cut down on the time it takes to get your medical back. Every time the FAA has to ask you for more information it's just time lost before you get your special issuance.

"We'll help you assemble the packet in the way that will present your medical history in the best possible light. And we can help track the progress of your special-issuance request once it reaches the FAA."

Before you stick all that paper in a giant envelope, copy every single page. You need to have a record for yourself in case anything happens to your paperwork during processing. And finally, put a label with your full name and social security number on every single page you send to the FAA. I used a sheet of blank return address labels and made a bunch of copies using my computer. Then send it all off to Oklahoma City and sit back and wait. At the time this article was being written, the Aeromedical Certification Division was taking about 60 or 70 days to process special issuances. But I'm not complaining! Not that long ago, the backlog was 90 to 120 days (three to four months!).

During that period, my previously issued medical certificate expired. Then in early December, 11 months after my medical certificate first became invalid, I got my special-issuance letter and passed my FAA medical exam a few days later. So now I'm legal again. From the time I submitted my first paperwork, it took about 70 days, as expected. But since I had to wait two weeks to get the missing hospital records, I probably could have reduced my wait to less than 60 days if I'd been able to send all of my records at once.

Treatment of coronary artery disease has come a long way in the past few decades, from a cutting-edge experiment to an almost-routine surgical procedure. And the FAA's come a long way, too. There are enough of us pilots out there who sport the "zipper" scar that the agency has a good understanding of the risks and recovery rates for bypass surgery as well as the less invasive treatments available. So while it may take a while to reach your destination of a valid medical, there's a clearly marked trail for both you and the FAA to follow. All you need is the heart to get through it.

Chris Dancy, AOPA 3389139, is the director of media information for the AOPA Communications Division.

It's All in the Details

As Chris Dancy's personal testimony confirms, there is light at the end of the tunnel for most pilots who experience a medical disqualification. That certainly doesn't suggest there won't be some frustration along the way, especially if you start out pointed in the wrong direction. The FAA's civil aviation medical standards are among the most progressive of any country in the world and the Federal Air Surgeon is willing to stretch the envelope of risk assessment to allow as many pilots and prospective pilots as possible to obtain a medical certificate. That certification flexibility comes with a price, however, and we're dealing with a federal bureaucracy that thrives on details. If the details are unattended to, it's a guaranteed long delay before a medical certificate shows up in your mailbox.

Among the most important things to keep in mind while preparing to apply for a medical certificate is to become as knowledgeable as you can about your medical condition. Most of us don't pay too much attention to the illnesses that could happen to us until we actually get one of them. That's stressful enough, but being a pilot adds a completely new dimension to the stress level. You're not only trying to learn as much as you can on your own and understand what your doctor is telling you about your disease and how to treat it, but you're also fretting about how all this is going to affect your flying privileges.

Once you have a handle on how your doctor is going to help you manage your condition, start learning about how the FAA is going to handle it. The first thing you want to do is get a fresh perspective on the FAA medical application that is central to the issuance of a medical. With a new medical history, you can no longer check "no" to all those questions about medical conditions that you "have now or have ever had in your life."

Be sure to visit AOPA's interactive medical application, TurboMedical ® ( https://www.aopa.org/members/medical/medform/) to make a "trial run" of the application. You can save your responses and print out the form to use as a guide when you complete the actual application in the medical examiner's office. "Yes" responses on the medical questionnaire will link you to detailed information reports on many of the most common medical conditions.

As Dancy suggested, proper documentation is absolutely crucial to the timely issuance of a medical certificate, and the time to have all that documentation rounded up is well before you first see your aviation medical examiner or submit records directly to the FAA.

The medical review process is very labor intensive, and the only way the FAA reviewers can accurately determine your medical status is by the reports you provide them. If incomplete information leaves any unanswered questions, the FAA has to come back to you with a request for more information, and that adds another two months to the time it takes to make a decision. When it comes to records, don't send anything until you can send everything that's asked for, nothing more, nothing less.

One final tip: Don't trust your health care provider's office staff to send the records to the FAA for you. Take charge of every aspect of getting your records and overnight them to the FAA yourself. And be sure to make copies of everything. The FAA's Aerospace Medical Certification Division receives thousands of pieces of mail every single workday and records can be misplaced. — Gary Crump, director of AOPA Medical Certification Services