Medically Speaking: A second chance

<BR cmid="Article:Two Deck"><SPAN class=twodeck cmid="Article:Two Deck">From the August 2008 issue of <EM>AOPA Pilot</SPAN></EM>

July 17, 2008

Forty-seven-year-old Malvern “Skip” Monaghan Jr. had logged around 630 hours by August 2001. The last time he went up was when he flew the Cessna 182 from St. Simons Island, Georgia, back home to Suwanee, Georgia, three weeks before he visited the doctor. Lately his throat had been getting tight, but he wrote it off to exercise-induced asthma.

Although he was a little overweight—230 pounds on a 5-foot, 10-inch frame, he worked out regularly with a trainer, lifting weights and running on the treadmill. He’d always exercised. But now Monaghan had grown tired of being winded, so he went to the doctor and asked for an antihistamine or an inhaler.

Instead the doctor hooked him up to an EKG and found trouble. He wanted Monaghan to stay in the hospital for the weekend—it was Friday—but Monaghan said he felt fine and went home.

On Monday the doc performed an angio-gram and discovered several blockages. “We’ve got to do a bypass pretty quick,” the doctor said. Monaghan had the surgery the following morning. And he died on the operating table.

How AOPA can help

Skip Monaghan initially contacted the AOPA medical certification specialists in early 2002, a year prior to his transplant. At that point, the FAA was not considering heart transplant recipients for medical certification. However, the AOPA medical staff stayed on top of the issue and knew that the policy was under review while the FAA continued to gather risk assessment data. After Monaghan underwent his surgery, he continued to stay in touch with the medical certification staff, and, when AOPA learned in mid-2006 that an FAA policy change was imminent, he was quickly in line with his medical records to apply for a special issuance.

AOPA has a full-time medical certification staff of four who specialize in understanding the complexities of the FAA regulatory medical process. In addition to more than 40 years of combined staff experience, AOPA offers members a library of online medical certification reference information, including a comprehensive database of medications that are both allowed and disallowed by the FAA, and an interactive online medical application planning tool, TurboMedical®, to assist in preparing for the FAA physical exam.

The most effective way to handle a pending medical certification challenge is to become educated about your individual medical condition and the process by which the FAA will handle your case. The medical certification staff can answer your questions and provide you with the expert guidance you need. The staff is available 8:30 a.m. to 6 p.m. Eastern time by calling the Pilot Information Center at 800-872-2672.— Gary Crump, AOPA medical certification specialist

Staying alive

The surgeon revived him and then told Monaghan’s wife, Jeanine, he didn’t know if her husband would make it through the night. But Monaghan did, then spent seven days in intensive care. After his bypass he still didn’t have his former energy. He still couldn’t breathe. And he kept returning to the hospital. After a year passed his doctor performed another angiogram, and all the grafts but one were totally blocked. That one acted as the superhighway, or the only road in town. It kept him alive.

He got in line on the University of Alabama’s transplant list. A year later he was still waiting; in November 2002 his condition had deteriorated so much that he was forced to live in the hospital. When he wasn’t trying to walk a mile and a half around the nurses’ station, he built model airplanes—B-17s, F/A-18s, P-51s—the kind he used to build in his early teens. He gave away some to the doctors and some to the nurses. For one nurse he even built a special helicopter, a Cobra gunship, like the one her husband was flying around in Afghanistan that very moment. A lot of the models he hung from his ceiling with fishing line.

Still, modeling didn’t always keep him optimistic. Monaghan knew that a high percentage of all transplant patients die before they get a heart. “You go through periods of anger,” he said, “then you become hopeful, and sometimes you resign to your fate.” Three of the classic five stages of death.

But in January 2003, a 17-year-old from Alabama, a clean-living kid who played on the high-school football team, swerved to avoid hitting a deer. He was declared dead at the scene and a LifeFlight crew flew him to the University of Alabama at Birmingham Hospital, and Monaghan was prepped for surgery.

With a new heart

A nurse who observed the transplant procedure said Monaghan’s old heart nearly disintegrated in the surgeon’s hands. The following day, with the new heart beating in his chest, Monaghan got out of bed and walked around the nurses’ station. On the fifth day he was walking outdoors. That same day he was discharged—to an apartment about a block from the hospital. Within a week he was walking two miles a day. A scar ran from his collarbone to about four inches above his navel, and his chest was extremely painful, but he felt better each day. Every two days he had to check back in at the hospital’s transplant clinic. Finally, four months after receiving the new heart, his doctor released him. Monaghan was free to go home and return to his normal life.

About 25 percent of patients who need transplants receive them, and 75 percent of those who get transplants live five years or more. There can be side effects, and Monaghan suffered through some minor ones. His hand shook a little, but that went away after his body acclimated to the anti-rejection drugs. Because a new heart is not wired to the brain with all the original nerves, it takes a moment for it to begin responding to exercise and stimulation. Before he’d work out, Monaghan walked up and down the driveway to get his pulse going. Still, within a year, no one could tell he’d had a transplant. He looked better, and he kept off the 50 pounds that he’d lost waiting for the heart.

In the air again

Two years passed before Monaghan flew an airplane again. On his fiftieth birthday, May 30, 2004, one of the partners in his Cessna 182, John Kimmons, bought him a couple of hours with an instructor. He started flying regularly, but always from the right seat with an experienced pilot in the left. His third class medical had expired, but he felt good about flying again and he really wanted it back.

“I started writing letters,” he says. “The FAA wrote me back saying I wasn’t allowed to fly alone, that they weren’t allowing heart transplants to be recertified, and that was pretty much it.”

Monaghan’s wasn’t the earliest instance that the FAA had considered certification for heart-transplant patients. Back in the late 1980s, the FAA had certified several patients who had undergone heart transplants. However, after only a few years, a change in FAA policy resulted in the withdrawal of those pilots’ special issuances. The reason: Some patients exhibited a tendency to develop a form of rejection called coronary artery vasculopathy, or transplant coronary artery disease, essentially a narrowing of the arteries that supply blood to the heart muscle. For many years, reliable technology to detect and monitor the disease wasn’t available, but recent developments in medical technology allowed the FAA to reconsider its anti-transplant stance.

Monaghan began pursuing recertification in 2004—coincidentally, around the same time that the FAA also began reassessing the risk and commissioned one of the world’s leading heart transplant centers to investigate. The FAA chose the University of Alabama at Birmingham—the same hospital, and the same doctors, that performed Monaghan’s transplant.

The study tracked data on almost 8,000 cardiac transplant patients. It helped the FAA develop a set of criteria for transplant pilots; if the pilot meets the criteria, they are determined to have a less than one percent chance of incapacitation.

That one-percent criterion is the same used by the FAA for airman medical certification. The required tests, however, are more stringent than reading an eye chart and having a pulse taken. Examinations must occur once a year. The transplant patient has to have been free from rejection of any kind for 12 months, free from any infection that would require treatment in a hospital, free from cancer and diabetes, and exhibit no signs of coronary artery disease. For 24 hours, the patient is required to wear a Holter monitor, which records any heartbeat abnormalities. He must list every drug he’s taking, and also submit a letter from his treating doctor assessing the prognosis and risk for sudden incapacitation.

The transplant patient must also undergo an exercise stress test, a stress echocardiogram, an angiogram, a cardiac biopsy, plus extensive blood testing, all of which must come back normal or better than normal. The FAA has zero tolerance for coronary artery blockages in transplanted hearts. On top of that, every two years patients must undergo physical examinations by aviation medical examiners.

“If you fly with me,” Monaghan said, “I have no greater chance of dropping dead at the yoke than you do.”

Once Washington analyzed the study and began compiling the new criteria, it became a matter of bouncing it off advisors, opening it up to public scrutiny, and otherwise drowning it in bureaucracy. “I had congressmen and senators writing letters,” Monaghan said. “I’d call the doctors in Washington and say, ‘What’s up?’ and they’d say ‘We’re still checking.’” Finally, in 2006, the study passed scrutiny and became part of FAA medical certification policy.

Monaghan applied in October 2006, and in July 2007 he became the first cardiac transplant patient to receive a third class medical certificate. Another pilot has been certified since, and a couple more are going through the process. “My opinion says we’re safer than other pilots who hold third-class medicals,” Monaghan says. His arteries are clean; theirs may well have some blockage.

Now that he’s legal to fly again, Monaghan has a new goal. He wants to take his three grandchildren for a ride. He’s also learned some valuable lessons. “I’ve learned to take better care of myself, keep the weight off, and reduce stress,” he said. “I’ve also learned persistence—that it pays off.”