The Work of the Aviation Medical Examiner Dr

The Work of the Aviation Medical Examiner Dr. Martin F Hudson MBBS, MRCP(UK), FRCP Edin. Immediate Past Chairman of the Association of Aviation Medical Examiners Authorised Medical Examiner for UK CAA, EASA, FAA (USA), CASA (Australia), Transport Canada Company Medical Adviser Thomas Cook Airlines June 2011

The Main Priorities • To assess the physical and psychological fitness of Aircrew and Air Traffic Control Officers to fulfil safely their role in aviation • To comply with the requirements of the regulations of the relevant licensing authority

Who do we examine? • Class 1 Commercial Pilots - Renewals, Revalidations. NB All initial Class 1 performed at AMS, i. e. CAA Gatwick • Class 2 Private Pilots - Initial, renewals and Revalidations • European Class 3 ATCO • UK Class 1 Flight Engineers, Flight Navigators, Flight Information Service Officers, Aerodrome Control Officers, Commercial Balloon Pilots, Commercial Airship Pilots, Class 2 Private Balloon Pilots

Who are the examiners? • • • Aviation Medicine Specialists Occupational Health Physicians General Practitioners Private Practitioners Consultants Military Medical Officers

Availability • Commercial pilots: Available to all air-lines and aviation commercial organisations • Pilot’s freedom of choice • Private Pilots • Information not advertising • Web-sites: information and on-line booking • e-mail

Appointment as an Authorised Medical Examiner • • • Appointed by the CAA or relevant authority Guaranteed appointment if suitably qualified No upper retirement age No waiting lists Initially appointed for Class 2 only then up-graded to Class 1 after a period of time and on completion of further training and examinations

Accreditation as an AME • Interest and experience in Aviation Medicine/Armed Forces • Basic Certificate in Aviation Medicine (minimum of 60 hours) Class 2 • Advanced Aviation Medicine Certificate (minimum of 120 hours) Class 1 • Diploma in Aviation Medicine • Flying experience, CPL, ATPL, PPL, NPPL

Appointment as an AME • • • Class 1 requires minimum 6 points Class 2 requires minimum 4 points 3 points for completion of higher training 2 points for Dip. Av. Med. 1 point for 1 year work in aviation medicine practice • ICAO PPL or NPPL 1 point • ICAO CPL or IR 2 points

History of AME Training Courses • General Aviation Course (Farnborough) GAM: 5 days started 1973 • Initially linked with Aviation Medicine Course for Armed Forces MOs. • 1984 expanded to 10 days • 1998 IAM Farnborough closed • 1998 Kings College, London - Advanced and Basic Courses. • Diploma in Aviation Medicine

Other Aviation Authorities • • • EASA (European Aviation Safety Agency) FAA (American) CASA ( Australian) Canadian Singapore Others: e. g. China, Hong Kong, New Zealand, UAE, South Africa, Middle East • ? Global harmonisation

The Medical Examination • • Appointments Consulting room(s) Lighting Administration/secretarial/financial Nursing assistant Computerisation - Internet - e-mail On-line transmission of medical examination

Equipment • • Basic examination instruments Couch Stethoscope Auroscope + speculae ? (Aural syringe) NB Medico-legal Ophthalmic equipment Torch

Equipment • Height measure and weighing scales • Sphygmomanometer ? Mercury, Aneroid, Automatic (NB validation and calibration) • Audiometer (NB annual calibration) • 12 lead ECG with computerised interpretation (? + modem capability) • Haemoglobinometer (calibration) • Urine testing kit (Hema-combistix) • Venepuncture (laboratory facilities) • Peak flow meter

Ophthalmic Equipment • Snellen Charts; 6 metres and 1 metre (use of mirror is permitted to achieve distance) • RAF Near Point Rule • Ishihara plates (24): 15 to be read correctly • Maddox rod/wing (phoria testing) + light • Ophthalmoscope • Eye mask/cover and Pin Hole disc • Vision tester e. g. Titmus

The Examination • The History • The Clinical Examination • Investigation

The Medical History • Initial: All previous medical/surgical/psychological • Revalidation/Renewals: Recent events (since last examination) • Recreational drugs - alcohol, tobacco, others • Medications - OTC, Prescribed • Check pilot’s entries and accuracy on application form. N. B. ’tickitis’!!! • NB Thoroughness, deliberate omissions, non deliberate omissions, life-time not just recent for initial examinations

Physical/psychological fitness • Exercise • Diet • Hobbies • Commuting • Family • Sleep • Fatigue

Psychological History • Stress - work and domestic ? Second jobs • Anxiety • Sleep history, Fatigue, Epworth sleep scale, sleep apnoea • Depression; ? use of depression scoring questionnaires • Alcohol problems / use of CAGE questioning • Drug dependency • ‘Gut-reaction’

Epworth Sleepiness Scale • How likely are you to doze off in the following situations in comparison to feeling just tired? • 0 = never; 1 = slight chance; 2 = moderate chance; 3 = high chance • Sitting and reading • Watching TV • Sitting inactive at a meeting • Passenger in a car for an hour with no break • Lying down to rest in the afternoon • Sitting and talking to someone • Sitting quietly after a lunch without alcohol • In a car, while stopped for a few minutes in traffic

The Physical Examination • Careful full routine clinical examination • Use examination to prompt more history from pilot. i. e. palpation of liver/auscultation of chest • Ophthalmic: uncorrected and corrected, contact lenses and spectacles • ENT ? Valsalva maneoeuvre • Other examinations as clinically indicated • ? Rectal • ? Breasts and genitalia • NB Chaperone strongly recommended. GMC/CAA consider this is essential

Ophthalmic standards • Myopia for initial Class 1: +5 to – 6 • Myopia for renewal/revalidation; no limits • Astigmatism (irregular shape of the cornea)/Anisometropia (unequal refractive power of the eyes) initial Class 1: 2 dioptres • Astigmatism/Anisometropia no limits for Class 2 and for Class 1 renewal/revalidation • Esophoria Class 1 limits now 8 prism dioptres • Amblyopia V/A in non amblyopic eye must be 6/6 corrected or uncorrected

Comprehensive Ophthalmic Examination for pilots with high degree of refractive error (RE) • Not required for RE up to +3 to – 3 • Required every five years for Class 1 pilots with RE +3 to +5 or – 3 to – 6 • Required every 2 years for Class 1 pilots with RE >-6 • Anisometropia and/or astigmatism of 3 D requires 2 yearly ophthalmic review • CAA Optometrist’s Excel calculator available online for checking exact requirements

Comprehensive Ophthalmic Examination for pilots with high degree of refractive error • • Performed by any Optometrist Includes refraction, slit lamp, Tonometry IOP (> 40 years of age) *Colour vision (Ishihara 24/15 plates), phoria, visual fields, fundoscopy • * Initial examination only for CAA but each medical for FAA, Canadian, CASA

Comprehensive Ophthalmic Examination for ATCO’s, Flight engineers, navigators • Required at initial examination • Colour perception • Phorias

European Class 3 (ATCO) Periodic Requirements • Comprehensive ophthalmic examination every two or five years depending on refraction level • Tonometry every 2 years • Haemoglobin every 2 years

JAA Class 1 or Class 2 Visual Limitations Endorsements • 2 VDL; Vision Distance Limitation (shall wear corrective lenses and carry a spare set of spectacles) [myopia] • 3 VNL; Vision Near Limitation (shall have available corrective lenses) [presbyopia] • 4 VCL; Flights only within JAA airspace. VFR flights by day only (colour vision defects) Class 2 PPL only.

Spectacles/contact lenses requirements • 3 VNL for presbyopia look over or varifocal with no upper lens correction + back up • 2 VDL with no presbyopia correcting spectacles or contact lenses + back up spectacles. NB Not back up contacts lenses • 2 VDL + VNL; varifocals, bifocals, trifocals or contact lenses + look over half rim

Limitations for European Class 3 ATCO • APC Standard proximity condition • ATL Valid only while wearing correcting spectacles for ATCO licence (distance vision) • AUD Annual audiogram required • CLL Valid only while wearing contact lenses with alternative spectacles available • RLL refer to limitations on licence • IGR Issued under ‘grandfather rights’ • VSA Valid only when corrective spectacles available (near vision requirement)

Spectacles/contact lenses requirements • No photochromic lenses. Tinted lenses OK • No varifocal or near vision contact lenses or mixed contact lenses • Check vision uncorrected and with both contact lenses and spectacles • Back up MUST be same prescription. Not ’old’ pair of spectacles • Annual or bi-annual check with optometrist advised even if not CAA requirement especially over 40 years of age, NB Tonometry advised

Refractive surgery • • • Generally not recommended for pilots 3 month flying ban post operation Detailed ophthalmic reports required Class 1 pre-op limit – 6 Class 2 pre-op limit – 8 Post operation complications may occur , glare, distortion, pain, corneal complications

ENT examination • • • Visualise Tympanic membrane ? Removal of wax Valsalva and patency of Eustachian tubes Nasal airway assessment Sinuses 2 metre conversational voice test each ear separately

Investigations • • • Measurement of the blood pressure (seated) ECG with computerised interpretation Audiometry (250 - 8000 Hz) Urine - protein, blood, glucose Blood testing – haemoglobin at each medical, cholesterol (once only at age 40) • Peak Flow Rate, initial Class 1 only unless clinically indicated • Other investigation as clinically indicated

ECG interpretation • • Computer reading Certain ‘abnormalities’ accepted as normal Read rhythm strips not read by computer Select appropriate computer code NB different codes for Pilots and for ATCOs • Seek local opinion from cardiologist for abnormal Class 2 ECGs. • Keep ECG reading skills up-to-date

Disposition • Calculate and include all expiry dates i. e. for single/double pilot/private pilot(Class 2) Automatic if done ‘on-line’ • Include dates of last ECG and Audiogram • Stamp with appropriate limitations • Issue medical certificate - signed in presence of the AME by the applicant and witnessed and signed by AME with name under signature • Remind pilots to read back of their medical certificate which lists extract from regulations and a pilot’s responsibilities • Defer for further assessment

Operational Safety Endorsements • 5 OML: Valid only as or with qualified co-pilot ( NB 2 OMLs can now fly together) This endorsement applies to Class 1 pilots. Probably not going to be permitted under EASA rules • 7 OSL: Valid only with safety pilot and in aircraft with dual controls. This endorsement applies to Class 2 (Private Pilots) • SSL: Special safety limitations e. g. annual audio • FHA: functional hearing assessment (completed by training pilot, captain, qualified instructor)

Deferred assessments • • • Inform and explain to the pilot the process Work up case as much as possible GP/Hospital liaison Pilot’s consent for information CAA Algorithms for guidance Liaison with CAA

Current Validity of JAA medical certificates • Class 1: 12 months <60: 6 months > 60 for multipilot operations • Class 1: 12 months <40: 6 months > 40 for singlepilot operations • Class 2 : 60 months < 40 • Class 2 : 24 months 40 - 49 • Class 2 : 12 months > 50 • NB The 45 days pre expiry date rule • For renewals new date of expiry is anniversary of date of issue

Validity of European Class 3, UK Class 1 and NPPL certificates • • • ATCO: < 40 24 months ATCO: > 40 12 months 45 days rule now applies for ATCOs’ as for Pilots Flight engineers, navigators: 12 months NPPL Initial valid to age 45 then up to 65 years of age: 60 months. > 65: 12 months

European Class 3 ATCOs and periodicity of ECGs • Less than 30 • 30 - 39 • 40 and over 48 months 24 months 12 months

Flight Eng. & Flight Nav. periodicity of ECGs • < 30 • 30 - 39 • > 40 60 months 24 months 12 months

European Class 3 ATCOs and periodicity of Audiograms • < 40 Every 48 months • > 40 Every 24 months

European Class 3 ATCO’s other clinical requirements • Comprehensive ophthalmology examination; at initial then refraction within +5 and – 6 D: 5 yearly, more than – 6 D: 2 yearly • Tonometry; at initial then 40 +: 2 yearly • Haemoglobin estimation under 40: 4 yearly • 40+: 2 yearly • Other tests i. e. Respiratory, CXR, EEG only if clinically indicated

Flight Engineers & Flight Navigators: periodicity of Audiograms • < 40 60 months • > 40 36 months

Audiometry for JAA Medical Class 1 and 2 Certificates • Class 1; at initial then under 40, 60 months, 40 and over 24 months • Class 2; Instrument rating only at initial then under 40: 60 months, 40 and over 24 months

ECG Requirements for JAA Class 1 and 2 • Class 1 initial ( CAA Gatwick) • Class 1 renewal; < 30: 60 months: 30 - 39 24 months: 40 – 59: 12 months: 50 and over 6 months • Class 2 at initial (all ages): 40 – 49: 24 months: 50 and over 12 months

ECG coding • Class 1; 55 normal 56 abnormal • Class 2; 70 normal 71 abnormal • European Class 3 (ATCOs) 58 normal 59 abnormal • Only the ECGs coded abnormal are seen by CAA cardiologists • ECG computer coding diagnosis must comply with CAA guidelines.

Blood tests • Class 1 Haemoglobin every medical • Class 1 Cholesterol (fasting Lipids) at age 40 • European Class 3; Haemoglobin every 4 years under 40 and every 2 years over 40. • Class 2 Haemoglobin at initial plus any other tests as clinically indicated. • Class 2 Cholesterol if more than two coronary risk factors identified at initial (at any age) or if 40 years of age or older for renewal/revalidations. • Other tests as clinically indicated • No blood tests required for UK Class 1

Pitfalls • • Poor history taking Hurried examinations ‘Tickitis’!! Deniers - pilots want to pass the examination! • Bogus applicants - NB photo identification • Too low index of suspicion

Administration • Records/medical files/computer/CAA on-line • Booking appointments • *Forms: application (can be printed from on-line system), medical, ophthalmic, ENT * only needed for back up if on-line system fails or for non CAA/JAA applicants i. e. Ireland • Medical Certificates • Renewals/reminders/on-line booking systems • Computerisation/ Web sites/ E-mail

Administration - finance • • • Charges Debit or credit cards/cheques/cash Accounts – book keeping Income tax!! Expenses VAT

Continuing medical education • During the period of authorisation (3 years) an AME must complete a minimum of 20 hours refresher training. • Scientific meetings, AAME, As. MA, ICASM • Flight deck experience/simulator (NB: Post September 11 th problems for flight deck visits) • Revalidation/Annual appraisal (GMC re-licensing of doctors) N. B. AAME Appraisal service • CAA Annual audit

Appraisal requirements • • • Annual appraisal Mission statement Complaints policy Security of records and offices Customer satisfaction survey (see AAME website) • Staff training and confidentiality

Suspension/withdrawal of CAA approval • • Suspension by GMC Failure to participate in CME Poor record keeping Poor clinical assessment Unsatisfactory clinic arrangements Failure to follow and apply regulations Informal then written then final warnings

CAA Good Medical Practice Guidelines • • • Publication of guidelines document Annual audit Appraisal and 5 year GMC re-license Role of AAME in appraisal CAA Algorithms (keep in a file) CAA web-site for updates

CAA Good medical practice for AMEs • Section 1 Providing good medical practice • Section 2 Maintaining good medical practice • Section 3 Teaching, training, appraising and supervising • Section 4 Relationships with applicants • Section 5 Working with colleagues • Section 6 Probity and health • Section 7 Practice facilities

Current political issues • European Aviation Safety Agency (EASA) • European Society of Aerospace Medicine (ESAM) • European Class 3 ATCO medical certificate now in place • New European Leisure Pilots Licence (LAPL) • Cabin crew medical examinations • Retirement age of Pilots, age discrimination issues • ICAO recommendations Class 1 under 40 years of age

ICAO • Frequency of Class 1 medicals for pilots age <40 • Seen annually but medical examination every 2 years • Visual check and emphasis on health education and behavioural issues, depression, drugs, alcohol etc. every alternate year • Additional physical examination and investigation as clinically required

ICAO recommendations • Less emphasis on gynaecological issues, i. e. menstruation questions • Pilot’s obligation to report illness/accident etc. to be based more on the condition and not on the number of days off sick

CAA new developments • • New Colour Assessment Diagnosis (CAD) test Pilots with Insulin dependent Diabetes Depression and SSRIs ? Pilots with positive HIV no longer to be classed as permanently unfit • Emphasis on early diagnosis and treatment • Certification of pilots on anti retroviral medication • Brughada Syndrome new algorithm

Current medical issues • Pilots’ fatigue and proposed EASA increase in flying hours limitations. 900 to 1000 hours per annum. • Security checks at airports • ? Flight deck/cabin air contamination • Cosmic radiation (? Need for monitoring) • Hypoxia awareness and training • Flight deck noise (use of noise attenuating headsets) • Breast cancer and night work • H 1 N 1 virus infection

Other current medical issues • Possibility of grading periodicity to risk and level of fitness • Retirement ages and age discrimination • Disability discrimination and the disabled pilot • Drugs, booze and flying!

The Railways and Transport Safety Act 2003 • • • Breath alcohol limit 9 mcg/100 ml Blood alcohol limit 20 mcg/100 ml Urine alcohol 27 mgms/100 ml Extends to Flight Deck and Cabin Crew Engineers limits are 35 mcg (breath): 80 mcg (blood) & 107 mgms (urine)!! • Powers of police to test and arrest • No random tests. Must be reasonable grounds • Tests following accident

Drugs, Booze and Flying The UK CAA role • Pilot referred to CAA, alcohol questionnaire • Seen and examined • Blood tests, MCV, GGT, Carbohydrate Deficient Transferrin test (CDT) • Testing of hair for drugs • Treatment, Acamprosate and CBT • AA, Alanon etc. • Rehabilitation not discipline

The Association of Aviation Medical Examiners • Provides sufficient CPD through Annual Scientific Meeting • Appraisal and re-validation service • Web-site www. aame. co. uk • Liaison with colleagues and European scene • Free first year membership • Link to UK for overseas members • Non political and not a trade union

The Work of an Authorised Aviation Medical Examiner • Any Questions?