Pilot Protection Services Medical Mailbag - January Q&A

December 22, 2013

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Jonathan Sackier
Jonathan Sackier

  • Surgeon, Clinical Professor 
  • 30 years of healthcare experience 
  • Author of the “Fly Well” column in AOPA PILOT 
  • Flying since 15 years old, owns a Columbia 400 
Warren Silberman

Warren Silberman

  • Former Manager, FAA Aerospace Medical Certification 
  • Doctor of Osteopathic Medicine 
  • Expert in Aerospace/Preventive Medicine 
  • Pilot since 1986

QUESTION: I am a healthy student pilot but have been taking Zoloft for 19 years which works well with no side effects. I am due to see an HIMS AME and would appreciate any advice. I am surprised to find that SSRIs are such a big issue for the FAA. Can you help me understand the concern? Do they think that anyone taking an SSRI is likely to become suicidal in midair and crash his aircraft? Or, is it a concern that the medication will impair the person’s senses and/or judgment?  What kinds of evidence will most effectively convince the AME that I do not have a problem?  I feel like Gary Cooper in Mr. Deeds Goes to Town, walking in to have my sanity adjudicated without really understanding the process. I appreciate any advice you can offer.

ANSWER: Thanks for writing - many pilots have similar questions. The topic of depression, and especially anti-depressant use, has its roots in US Military medical certification. Until the Selective Serotonin Reuptake Inhibtor class of drug (SSRI) came along, they would never allow a person who was actively being treated for depression to fly.  On top of the depression symptoms, side effects from medications, amytriptylline derivatives, were a cause for concern. It was a bold act, quite frankly, to allow airmen to fly while being treated and it was the Australians who first certified pilots to fly while receiving antidepressants and this propelled the USA to consider granting issuance after years of discussion and FAA refining the protocol.

FAA allows airmen with depression to be considered for certification if the are taking one of four SSRI medications, including the one you are taking, Zoloft (sertraline), as well as Prozac (fluoxetine), Celexa (citalopram) and Lexapro (escitalopram).  One must be on the same dose for 12 months and the case will require review. To obtain guidance on navigating clearance to fly while taking an SSRI I recommend reviewing the following web address: http://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/dec_cons/disease_prot/ssri/ 

QUESTION:  I have two issues pertaining to surgery that I would welcome answers to. I have undergone emergency operations for small bowel obstruction as well as cataract surgery

What do I need for my next second class medical certification? Will my application be deferred?

ANSWER: The numerous feet of small bowel transmits food from stomach to colon and is where most nutrients are absorbed. If it becomes kinked inside a hernia, from adhesive scar tissue or blocked by something inside the tube or in the wall, food cannot continue downstream and the patient experiences abdominal distention, vomiting, constipation and pain. In order to manage the aviation aspects, once recovered, at your next exam provide your AME with the operative report and discharge summaries as well as a letter from your treating surgeon. It would be prudent to have Pilot Protection Services review everything first, though.

For cataracts, ask your eye surgeon to complete the FAA Eye Exam form 8500-7. If you had intraocular lenses inserted and they are of the "mulitfocal" type, you are grounded for 3 months.   

QUESTION: I have a special issuance authorization for hemochromatosis  and hypertension. Hemochromatosis treatment requires me to have four phlebotomies per year. Can I use the blood pressures taken during these treatments for the required periodic blood pressure readings necessary for my hypertension monitoring?  Can I use the blood pressures I take at home which is recorded on an Omron BP Monitor and uploaded to Microsoft Health Vault? I have a problem with white coat hypertension.

ANSWER: It is lovely to get some challenging questions and this one has some complexities! Hypertension, or high blood pressure is rampant and merits careful investigation to exclude hidden causes, therapy and monitoring. Many people have "white coat hypertension" - the doctor or nurse walk in and your BP goes up! Waiting 15 - 20 minutes is often all that is needed to see it come back to normal levels. Hemochromatosis is a condition where the body absorbs too much iron and can be simply treated by removing some blood at regular intervals (phlebotomies). BP readings taken at these treatment sessions can be used as can those uploaded to the web. If a reading taken in the doctor's office is greater than or equal to 155/95 that may lead to a deferral.  

QUESTION: I have finally committed to following my dream to become a pilot. However, one of the questions on the medical application has me concerned. "History of (1) any arrest(s) and/or conviction(s) involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug; or (2) history of any arrest(s), and/or conviction(s), and/or administrative action(s) involving an offense(s) which resulted in the denial, suspension, cancellation, or revocation of driving privileges or which resulted in attendance at an educational or a rehabilitation program. Yes/no." 

I was arrested but not convicted of "driving a vehicle in an intoxicated manner" in 2006 when I was 21. Through the court proceedings I received a suspended imposition of sentence if certain criteria were met. I had complete everything within the necessary time frames and the offense does not show on my record. I do have proof and documentation of everything. How do I answer the question? I want to be open and honest but not over disclose if it is not recommended. I do not have a substance dependency problem. It was one instance of poor judgment while I was in college. 

ANSWER: This is a great question!  You MUST answer that you had the "arrest" even though it was ultimately expunged. You should provide proof that it occurred back in 2006.  As a student, and this event occurred over 5 years prior to application, then you will not be required to provide any further evaluations.

QUESTION: Earlier this year I had Aortic valve replacement and three coronary arteries bypassed. As an aerial application pilot I require a Class II Medical and because of my history a coronary angiography is required. This is quite expensive and not covered by my insurance.

If I were to apply for a limited second class with "Second Class Privileges Limited to Aerial Application" would the angiography still be required? 

ANSWER: The aortic valve exists to ensure unidirectional blood flow out of the left ventricle of the heart and into the aorta, thence around the body. If the valve becomes 'stenotic' or tight, blood flow is limited and if it becomes incompetent, blood washes back and forth. In either circumstance, replacement may be necessary either with a mechanical or biologic valve. Coronary artery disease is the biggest killer in the USA and if it has progressed far enough then bypass graft surgery, CABG, is required.

If you wish to request a Limited Second-class medical certificate for Aerial application Only/Full third-class, you must do so in writing and would not need to obtain a repeat heart catheterization. However, you must provide:

1. Hospital admission and discharge summaries, the original cardiac catheterization report, surgical operative report and the pathology report on the valve.

2. You must  remain grounded for 6 months following the procedure

3. Provide a current status report that lists all medications and side effects. This should note how you have done in regard to your valve surgery and chest pain  since the procedures.

4. A 2-D echocardiogram at the 6 month point together with any tests to evaluate the dysfunctional valve.

5. The results of a maximal nuclear stress test to at least 9 minutes and as close to 100% of maximal heart rate as possible. You must also provide the FAA with all the 12 lead electrocardiograms from the test and copies of the nuclear scan films.

6. If you received a mechanical heart valve, you will be taking medications such as Coumadin to prevent blood clotting and as such will be having regular 'INR' blood tests to measure whether the dose of medication is correct. You must provide all the INR levels and  80% of these levels must be within 2.5 to 3.5 range (which is what your treating physician would want anyway).

7. The results of a current Lipid panel and blood panel

Fly Well! Jonathan and Warren