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									                 Federal Air Surgeon’s
                 Medical Bulletin
                              Aviation Safety Through Aerospace Medicine
Vol. 49, No. 1     For FAA Aviation Medical Examiners, Office of Aerospace Medicine Personnel,         U.S. Department of Transportation
2011-1                    Flight Standards Inspectors, and Other Aviation Professionals.               Federal Aviation Administration

                                             X-Ray Backscatter Security
                                             Scanners at U.S. Airports:
                                             How Safe Are They?
                                             By Brian Pinkston, MD
  2 EDITORIAL: MOST UNDERUTILIZED
    ‘APP’ OF OUR TIME REVEALED

  3 CERTIFICATION UPDATE:
    MEDICATIONS, PART III
                                             R     ecent questions from aviation
                                                   medical examiners about the use
                                             of the new x-ray Backscatter Scanners
                                             at airports have prompted the Civil
  5 AME UPDATES: VALIDATION                  Aerospace Medical Institute’s Radio-
    INFORMATION, WEB-BASED                   biology Research Team members Dr.                 Photo courtesy Transportation Security Admin.
    TRAINING NEWS                            Wallace Friedberg and Kyle Copeland                  This technology is being utilized
                                             to publish a risk analysis for our readers.       in U.S. airports by the Transportation
  5 IS THIS THE FINAL PRINTED BULLETIN          Controversy about this technology              Security Administration (TSA) as an
    FOR AWHILE?
                                             from the public is primarily based on             alternative means to a physical search to
                                             two issues: First, a potential loss of pri-       determine if a person is carrying harm-
  5 AVIATION MEDICAL EXAMINER                vacy due to the ability for the technology        ful or contraband materials on his or
    SEMINAR SCHEDULE
                                             to “see through clothing” and provide a           her body. Although identifying features
                                             detailed view of a subject’s anatomy; and         and parts of anatomy are distorted to the
  6 DECOMPRESSION SICKNESS
                                             second, the risk associated with being
    WITH PERMANENT NEUROLOGIC
    IMPAIRMENT (CASE REPORT)                 exposed to ionizing radiation.                                           Continued on page 4

                                             Coming Your Way: AME Site Visits
  8 BRIEF PSYCHOTIC DISORDER (CASE
    REPORT)                                  By Harriet Lester, MD
                                             Dr. Lester has been working with the Aerospace Medical Education Division and the Regional
  9 NEW LASER HAZARDS BROCHURE               Flight Surgeon’s Working Group to devise innovative strategies to best accomplish site visits. We
    PUBLISHED                                appreciate this regional perspective.—Ed


  9 WEB SITE SHORTCUTS
    IMPLEMENTED
                                             I  n 2008, the FAA Office of Aerospace
                                                Medicine developed the AME Sur-
                                             veillance Program, which formalized
                                                                                               offices and added other quality assur-
                                                                                               ance oversight features. This surveillance
                                                                                               program was a natural outgrowth of
                                             site visits to aviation medical examiner          several national initiatives already in
  10 TWO NEW FACES IN AEROSPACE
     MEDICINE
                                                                                               progress, including ISO9001 multisite
                                                                                               certification in 2006 and the congres-
                                                                                               sionally sponsored Safe Pilot Program.
  10 REFRESHER TRAINING SOFTWARE
     UPGRADED                                                                                     Those of you who have attended AME
                                                                                               seminars in recent years have heard us
  11 LETTERS TO THE EDITOR
                                                                                               discuss the AME Surveillance Program.
                                                                                               Many of you have already been visited
                                                                                               by regional office Surveillance Program
  12 INDEX OF ARTICLES PUBLISHED IN
     THE BULLETIN DURING 2010
                                                                                               analysts. Some of you have not yet had
                                                                                               this opportunity.
                                                                                                                      Continued on page 4
Most Underutilized ‘App’ of                                                                                The reason I am talking to you, our
                                                                                                       AMEs, about MedXPress is that I am
Our Time Revealed                                                                                      very disappointed by the low utilization
                                                                                                       of the system. In 2010, only 21 percent

H      ello everyone. I hope that 2010
       treated you well, that you had
a nice holiday season, and that 2011
                                                                                                       of our examinees used MedXPress. We
                                                                                                       have advertised in safety meetings, in
                                                                                                       safety publications, and at our AME
is even better than 2010. With that                                                                    seminars.
in mind, I would like to spend a few                                                                       I just returned from the seminar that
minutes talking about FAAMedXPress                                                                     we held in Jacksonville, Fla. One AME
(MedXPress).                                                                                           approached me and told me he did not
    You may recall that we introduced                                                                  use the system or intend to encourage
MedXPress with announcements that it                                      By Fred Tilton, MD           his pilots to use the system because he
was only available to airmen on the West                                                               only did 30 or 40 exams a year. He
Coast. In truth, the system was available                     It took me a while to convince him       said that it would be too much bother
across the whole country. However, we                      that he could use the system because        to learn how to use a new system for
were trying to limit the number of users                   of our East Coast location, but I kept      so few exams.
so that we could wring out any problems                    insisting that I knew what I was talk-          I then proceeded to tell him how
that we might have missed in our beta                      ing about, and he finally, begrudgingly,    misguided he was. That’s because with
tests. At that time, I was due my annual                   agreed to make the attempt.                 a paper system, someone on his staff has
Class II examination, so I entered all of                                                              to enter the data from the 8500-8. This
my information into the database, and                            ‘The next year, when                  takes time and frequently introduces
I asked my AME to give it a try.                               I called to schedule                    errors. With MedXPress, all he would
                                                               my appointment, his                     have to do is take the confirmation
                                                                                                       number that the pilot gives him, enter
        Federal Air Surgeon’s                                assistant told me that he                 it into AMCS, and bring up the exam.
          Medical Bulletin                                   would not see me for my                       Many doctors walk around with
         Library of Congress ISSN 1545-1518
                                                             FAA exam unless I used                    laptops or PDAs as they examine their
 Secretary of Transportation                                                                           patients. If an AME wishes, he or she
 Ray LaHood                                                         MedXPress.’
                                                                                                       could review the history, perform the
 FAA Administrator                                                                                     exam, enter the exam data, and print
 J. Randolph Babbitt                                          From my perspective as an examinee,      the medical certificate—while the
 Federal Air Surgeon                                       the process worked quite well, but over     pilot is in the exam room. Obviously,
 Fred Tilton, MD                                           the next few weeks, he experienced          the process would not be so simple if
 Editor                                                    several technical issues, and he was        the airman had issues that required
 Michael E. Wayda                                          not bashful about calling me to let me      additional testing or deferral, but time
 The Federal Air Surgeon’s Medical Bul-                    know about them. I assured him I was        would still be saved and errors reduced
 letin is published quarterly for aviation                 grateful for the calls because we needed    by using MedXPress.
 medical examiners and others interested                   the feedback to help us fix the system.         If you do not use or encourage the
 in aviation safety and aviation medicine.                    The next year, when I called to          use of MedXPress, please think about
 The Bulletin is prepared by the FAA’s Civil               schedule my appointment, his assistant      doing so. As a pilot, I think it is infi-
 Aerospace Medical Institute, with policy
 guidance and support from the Office of
                                                           told me that he would not see me for        nitely better than the paper system. I
 Aerospace Medicine. An Internet on-line                   my FAA exam unless I used MedXPress.        am convinced that once you start using
 version of the Bulletin is available at: www.                That was three years ago, and I now      it and benefit from the efficiencies it
 faa.gov/library/reports/medical/fasmb/                    consistently get positive feedback from     provides that you will not go back to
 Authors may submit articles and photos                    AMEs and pilots who use the system.         the paper system.
 for publication in the Bulletin directly to:              Pilots can fill out the electronic 8500-8       Again, I hope 2011 is a great year for
 Editor, FASMB
                                                           in the privacy of their own home. Once      you, and thanks again for all you do for
 FAA Civil Aerospace Medical Institute                     a pilot has used the system, it populates   the Office of Aerospace Medicine and
 AAM-400                                                   his or her demographics in successive       your pilots.
 P.O. Box 25082                                            years, and we are considering changes
 Oklahoma City, OK 73125
                                                           that will “remember” the rest of the                                       —Fred
 E-mail: Mike.Wayda@faa.gov
                                                           historical information as well.

2 T h e F e d e r a l A i r Su r g e o n ' s M e d i c a l B u l l e t i n • Vol. 49, No. 1 •
Medications, Part III                              CERTIFICATION UPDATE                                                 UPDATE NOTICE
                                                  Information About Current Issues
   The following is a continuation of certi-                                                            Our Medical Certification physicians
fication issues that pertain to medications.                                                            wanted me to remind you all of an

A     ntianginals. You should all be able
      to guess this one! Recall that with
any use of medications, it is the medical
                                                                                                        innovation that came out some time
                                                                                                        ago that you may not be aware of: You
                                                                                                        can print a medical certificate from
condition—not the medication—that                                                                       the Aerospace Medical Certification
                                                                                                        Subsystem (AMCS). You now can
should be your guide. In this case,
                                                                                                        also print a medical certificate if the
angina is a specifically disqualifying
                                                                                                        airman has an AASI (AME Assisted
medical condition, so an airman of any                                                                  Authorization for Special Issuance).
class may not be granted certification                                                                  When we developed this program, I
(without a waiver) for angina. These            By Warren S. Silberman, DO, MPH                         made sure that we could keep track
medications mask the symptoms,                                                                          of airmen that have one of 20 allow-
meaning they decrease the likelihood           a muscarinic receptor antagonist, also                   able medical conditions (see “Revised
of someone having angina under exer-           requires a 30-day observation period                     Policy Announced on Special Issu-
tion. We do not accept these medica-           and mention of any side effects.                         ance Procedures,” FASMB, Spring
                                                                                                        2002, p. 1).
tions under any circumstance, even if
the medication is being used to treat
esophageal spasm. This includes Ranexa
                                               G     astrointestinal medications. This
                                                     is a huge grouping of GI medica-
                                               tions covering anything from gastro-
                                                                                                        To print a medical certificate for a
                                                                                                        third-class airman with one of these
(ranolazine), a newer medication used          esophageal reflux to colitis to peptic                   conditions, go into the AMCS and
for chronic angina. Should an airman           ulcer disease. Once again, it depends                    search for the airman’s record. When
be taking one of the many antianginal          first on the medical condition being                     you pull it up, you will find an icon or
medications and presents for certifica-        treated. Histamine H2 receptor an-                       radio button all the way to the right of
                                                                                                        the airman’s name that says “AASI.”
tion with the results of a stress test, you    tagonists such as Zantac (ranitidine) are
                                                                                                        Click on it and a medical certificate
may not accept the test results unless         acceptable with no observation period.                   will come up, allowing you to change
the airman had discontinued the use of         Reglan (metoclopramide), a medication                    the expiration date. We built in the
the medication at least 48 hours prior         that assists with the forward motility of                capability that won’t allow you to have
to taking the test.                            the bowel, is unacceptable. All of the                   a date of expiration past the date of

B    ladder medications. These are a
     group of medications that are gener-
ally used to relieve urinary difficulties,
                                               antispasmodic medications are unac-
                                               ceptable. For example, Bentyl (dicy-
                                               clomine), Librax (chlordiazepoxide and
                                                                                                        the current medical examination. This
                                                                                                        function now makes it so you don’t
                                                                                                        have to use a typewriter any longer!
including frequent urination and the           clidinium), Levsin (hyoscyamine), and
inability to control urination. Ditropan       Lomotil (diphenoxylate and atropine).
(oxybutynin) is one of the medications         Imodium (loperamide), an over-the-
we frequently see that aviation medical        counter medication in the USA, is used                  a “neurology summit” in March 2010
examiners mistakenly grant certifica-          for diarrheal illnesses. It is acceptable               and discussed many medical conditions,
tion for. Performance testing performed        providing the airman is not taking more                 including migraine. Accordingly, some
with patients on this medication found         than two tablets per day. Again, the                    policy changes will occur as a result of
that it causes sedation, especially in         issue here is why the airman is taking                  this summit. One change is that we
the elderly, for whom it is commonly           the medication.                                         are only going to allow an airman to
prescribed. It is unacceptable. Some
of the medications that are acceptable
are Detrol and Detrol LA (tolterodine)
                                               M       igraine treatments. This is anoth-
                                                       er condition (as most are) where
                                               it is the medical history that should
                                                                                                       have one migraine headache per month
                                                                                                       and that we are encouraging airmen
                                                                                                       with migraines to be on a prophylactic
and Uroxatrol (alfuzosin). Enablex             initially determine whether we grant                    medication, rather than waiting until
(darifenacin) can prolong the QT               medical certification. This condition                   having a headache to take an abortive
interval but is allowed with a 30-day          will usually require an authorization for               medication. An exception would be if
pre-observation period, requiring the          special issuance. For this article, I am                the headaches occur very rarely and are
AME to get a statement concerning side         not going to get into the many presen-                  dissipated by sumatriptan derivatives,
effects and any evidence of unfavorable        tations of migraine headaches but keep                  which are all allowed. However, air-
ECG findings. Vesicare (solifenacin),          to the discussion of treatments. We had                 men are required to ground themselves

Dr. Silberman manages the Aerospace Medical Certification Division.                                                              Continued on page 4


                                                              T h e F e d e r a l A i r Su r g e o n ' s M e d i c a l B u l l e t i n • Vol. 49, No. 1 •   3
DRUGS from page 3                                          SCANNERS from page 1                             SITE VISITS from page 1
for 24 hours after using sumatriptan                       viewing TSA agents, to maintain their
derivatives. Most migraine preventive                      privacy, some travelers have expressed
medications are acceptable. Medica-                        concerns about a violation of their rights.
tions such as the ergotamine deriva-                          A more commonly expressed concern
tives, nonsteroidal anti-inflammatory                      by our airmen to our AMEs, however,
medications, and beta blockers are all                     involves the increased risk associated
acceptable. An airman who relied on                        with radiation from x-rays. Air-carrier
the use of narcotic analgesics would not                   crewmembers are occupationally ex-
be approved. One of the more common                        posed to higher doses of ionizing
medications that are used is Midrin                        radiation than normally received by
(isometheptene, dichloralphenazone,                        members of the general population due
and acetaminophen). This medication                        to their volume of flights in a year. The
is unacceptable. Our FAA neurology                         backscatter technology does increase
consultants “liked” the use of calcium                     this risk, but only minimally. This
channel medications such as verapamil                      technology uses soft (low-energy) x-rays
(Calan, Covera, Isoptin, and Verelan                                                                         AME site visits are mandated
                                                           that bounce back from the body and
                                                                                                         by our ISO9001 process; however,
PM) as prophylactic medications, all                       nearby objects to form images useful          performing site visits serves many
of which are acceptable.                                   for body screening.                           functions in addition to keeping us
P    arkinson’s disease. With parkin-
     sonism, the fundamental issue to
be aware of is that the FAA has only
                                                              Utilizing information from one
                                                           device used by the TSA (Rapiscan
                                                           Secure 1000 by Rapiscan Systems),
                                                                                                         all in compliance with our ISO9001
                                                                                                         quality assurance system. A site visit
                                                                                                         is always scheduled in advance with
allowed medical certification with an                      the CAMI researchers found that               your office by regional office person-
authorization for special issuance in                      from the manufacturer’s worst-case            nel, and it includes a discussion with
only the mildest of cases. However,                        scenario of exposure to radiation per         you and your staff and a tour of your
look for some future modifications of                      scan, an individual could be scanned          facilities.
the required workup for this condition.                    2,500 times per year and not exceed the           We review your equipment, and
About the only medication allowed in                       Health Physics Society’s recommenda-          both you and the FAA analyst fill
this condition is Levodopa with the                                                                      out some paperwork. Photographs
                                                           tions for maximum radiation dose for
                                                                                                         are usually taken. It is an opportunity
carbidopa combination Sinemet. The                         security screening. Interestingly, the        for us to get to know you better and
COMT (catechol-O-methyltransferase)                        average effective dose of ionizing radia-     for you to tell us your concerns and
inhibitors entacapone, entacapone,                         tion in 2006 to an average member of          ask questions.
tolcapone, and Stalevo (combination of                     the U.S. population from non-medical              Essential components of any type
entacapone, levodopa, and carbidopa)                       sources was equal to the dose of 32,000       of site visit are communication and
are not acceptable because of side ef-                     “manufacturer’s worst scans.”                 verification. As our designees, we trust
fects like syncope, dizziness, fatigue,                       In summary, the additional dose of         you to represent the FAA to the pilot
and hallucinations. Also unacceptable                      radiation from being scanned does not         community, and we are obligated to
are dopamine antagonists pramipexole                       significantly impact radiation safety for     make sure that we are all on the same
(Mirapex), ropinerole (Requip), and                        most crewmembers. However, a preg-            page. Site visits and the overall AME
bromocriptine (Parlodel) because,                          nant crewmember should be aware that          Surveillance Program are “works in
without warning, they can cause fall-                                                                    progress,” so we welcome your sug-
                                                           being scanned increases the dose to her
                                                                                                         gestions as we all strive for the safest
ing asleep. Pergolide (Permax) can also                    unborn baby and may reduce the total          possible national airspace system.
result in sudden falling asleep and is thus                number of future flights she can work             Remote site visits are being ex-
unacceptable. Amantadine (Symmetrel)                       during her pregnancy, to not exceed the       plored as a future direction to comple-
is used to treat influenza infections and                  recommended radiation limits.                 ment and supplement “live” site visits.
is acceptable for short-term use in air-                      To read the CAMI Radiobiology              The “virtual site visit” adapts the
men, but it is unacceptable for treating                   Research Team’s full report, please see:      standard site visit format, utilizing
parkinson’s. Benztropine (Cogentin), an                    www.faa.gov/library/reports/medical/          video and a “real-time” telephone
atropine-like medication, is unaccept-                     fasmb/media/backscatter_research.pdf          interview.
able, as are trihexyphenidyl (Artane)
and deprenyl (Eldepryl).                                                                                Dr. Lester is the Eastern Regional Flight
                                                           Dr. Pinkston manages the Aerospace Medical    Surgeon.
                                                          Education Division.

 4 T h e F e d e r a l A i r Su r g e o n ' s M e d i c a l B u l l e t i n • Vol. 49, No. 1 •
AME Updates                                        LAST HARD COPY—FOR A WHILE                             Important note: Your account will
Web-based training revised                         The federal government has                          be frozen if you fail to log in and validate
                                                recently been hit by funding cut-                      your staff at least every 90 days, and it
By Brian Pinkston, MD                           backs in many areas, including                         will require a call to the AMCS help
                                                printing. Therefore, we will not be
H      appy New Year! The Aerospace
       Medical Education Division
comes bearing gifts in the form of
                                                able to provide printed copies of
                                                the Bulletin beyond this issue and
                                                                                                       desk to re-activate your account.
                                                                                                          Military AMEs have an additional
                                                                                                       requirement coming up with the New
                                                will curtail all commercial printing
a new Multimedia AME Refresher                                                                         Year: training currency. Yes, as we
                                                for the near future. We will, how-
Course, which was made possible by              ever, continue to provide quarterly                    discussed last year, the grace period for
huge teamwork from the Regional                 electronic copies of the Bulletin on                   military AMEs to catch up on currency
Flight Surgeons, Mike Monroney                  the FAA Web site and will notify                       training through seminars is now over.
Aeronautical Center staff, and our own          you via E-mail when a newsletter                       Leah Olson and I (the International,
division. We are now diligently work-           is available and how to retrieve it.                   Military, and Federal Region Program
ing to provide you with other updated                                                                  Analyst and Regional Flight Surgeon,
educational products in 2011 that will     Inspector General’s Office mandates                         respectively) are sending out termina-
be completely Web-based.                   that we ensure that AMEs are perform-                       tion letters to all military AMEs out of
   For more information on the new         ing and certifying examinations entered                     compliance. If you receive this letter,
MAMERC revision, see “Refresher            into the AMCS.                                              you will no longer be able to perform
Training Software Upgraded” on                 Part of that requirement is to validate                 examinations. However, if you work
page 10.                                   that all AME staff members who have                         with us to get your training current,
   In that spirit, I want to reemphasize   access to AMCS are still authorized to                      we will consider reinstatement.
the importance that the Aerospace Med-     do so. This means that an AME must                             If you have any questions, write Leah
ical Certification Subsystem (AMCS)        personally sign into AMCS at least every                    Olson at Leah.Olson@faa.gov or me at
plays in both airman exam transmission,    90 days to validate staff members. One                      Brian.Pinkston@faa.gov.
as well as a communication tool for        by-product of this requirement is that                         Thanks for all your hard work, and
updates to policy and administrative       AMEs are also alerted with updates of all                   we look forward to serving you in the
information. For example, a recent         new policy changes in the AME Guide                         upcoming year!
requirement placed upon us from the        through the AMCS messaging system.
Dr. Pinkston is the Aerospace Medical Education Division manager.                                                               

                                Aviation Medical Examiner Seminar Schedule
                                                               2011
    February 28–March 4                             Oklahoma City, Oklahoma                                             Basic (1)
    March 25–27                                     Providence, Rhode Island                                            OOE (2)
    May 9–12                                        Anchorage, Alaska                                                   AsMA (3)
    June 13–17                                      Oklahoma City, Oklahoma                                             Basic (1)
    August 26–28                                    Washington, District of Columbia                                    CAR (2)
    October 6–8                                     Tucson, Arizona                                                     CAMA (4)
    October 31–November 4                           Oklahoma City, Oklahoma                                             Basic (1)
    November 17–19                                  Portland, Oregon                                                    NPN (2)
CODES
CAR Cardiology Theme
NPN Neurology/Neuro-Psychology/Psychiatry Theme
OOE Ophthalmology-Otolaryngology-Endocrinology Theme
(1) A 4½-day basic AME seminar focused on preparing physicians to be designated as aviation medical examiners. Call your Regional
    Flight Surgeon.
(2) A 2½-day theme AME seminar consisting of aviation medical examiner-specific subjects plus subjects related to a designated theme.
    Registration must be made through the Oklahoma City AME Programs staff, (405) 954-4831 or -4803.
(3) A 3½-day theme AME seminar held in conjunction with the Aerospace Medical Association (AsMA). This seminar is a new Medical
    Certification theme, with 9 aeromedical certification lectures presented by FAA medical review officers, in addition to other medical
    specialty topics. Registration must be made through AsMA at (703) 739-2240. A registration fee will be charged by AsMA to cover
    their overhead costs. Registrants have full access to the AsMA meeting. CME credit for the FAA seminar is free.
(4) This seminar is being sponsored by the Civil Aviation Medical Association (CAMA) and is sanctioned by the FAA as fulfilling the FAA
    recertification training requirement. Registration will be through the CAMA Web site: www.civilavmed.com.
                 The Civil Aerospace Medical Institute is accredited by the Accreditation Council for Continuing Medical
                                    Education to provide continuing medical education for physicians.


                                                              T h e F e d e r a l A i r Su r g e o n ' s M e d i c a l B u l l e t i n • Vol. 49, No. 1 •   5
Medical Certification Following Decompression                                                                     DECOMPRESSION SICKNESS
Sickness With Permanent Neurologic Impairment                                                              Decompression sickness results
Case Report by John D. Swanson, IV, MD, MPH                                                                when there is a reduction in ambi-
                                                                                                           ent pressure relative to the partial
Neurologic decompression sickness (AKA Type II DCS) can have devastating con-                              pressure of dissolved inert gasses
sequences even if appropriately recognized, especially when definitive treatment is                        in the tissues. In the human body,
not immediately available. It can occur as a result of exposure to hypobaric envi-                         ambient partial pressure of nitrogen
ronments such as unpressurized flight at altitude; however, the more serious cases                         stabilizes dissolved nitrogen in the
                                                                                                           tissues such that a state of equilib-
commonly result from decompression following hyperbaric exposure (8, 9). This
                                                                                                           rium is established. When the rate
case report outlines the sequence of events as they pertain to an airman who devel-                        of decrease in ambient atmospheric
oped neurologic DCS while scuba diving in a remote location and the aeromedical                            pressure exceeds a critical threshold,
considerations required in ultimately returning him to the cockpit.                                        nitrogen in the tissues becomes
                                                                                                           supersaturated relative to ambient
                  History
                                                                                                           atmospheric pressure, and dissolved

W       ithin ten minutes of surfacing
        from a recreational scuba dive,
an otherwise healthy 42-year-old male
                                                          T-12 (ASIA D) paraplegia, neurogenic
                                                          bladder, and neurogenic bowel. The
                                                          ASIA Impairment Scale (American
                                                                                                           nitrogen in the tissues comes out of
                                                                                                           solution to re-establish equilibrium.
                                                                                                           The result is bubble formation within
airman with 5,800 hours of flight                         Spinal Injury Association) defines Type
                                                                                                           the tissues, which can then embo-
time began to experience shortness of                     D paraplegia as incomplete, where motor
                                                                                                           lize in the blood stream, causing
                                                          function is preserved below the neuro-
breath, visual disturbances, and bilateral                                                                 ischemic damage to highly sensitive
                                                          logic level and most key muscles have
lower-extremity paresthesias. Within                                                                       tissues such as those of the central
                                                          a muscle grade greater than or equal to
one hour, the airman’s symptoms had                                                                        nervous system. Recompression
                                                          3/5 (1, 15).
progressed to near-complete blindness                                                                      with hyperbaric oxygen therapy
                                                             At 24 days post-injury, he returned
and frank paraplegia. Prior to this event,                                                                 reverses this gradient and reduces
                                                          to the United States, where he contin-
                                                                                                           bubble size, effectively reducing
his airman duties included functioning                    ued with outpatient rehabilitation and
                                                                                                           the state of critical nitrogen super-
as an airline transport pilot for a major                 management of his urinary retention
                                                                                                           saturation within the body tissues.
airline, as well as piloting the F-15 Eagle               with indwelling catheterization (5, 6).
                                                                                                           This allows re-equilibration to occur
for the Air National Guard.                                  This airman experienced substantial
                                                                                                           at a rate whereby ongoing bubble
   Because immediate recompression                        neurologic insult as a result of DCS,
                                                                                                           formation is unlikely to occur.
was not available, the airman under-                      and although his condition improved
went in-water recompression on 100%                       with HBOT and spinal rehabilitation,
oxygen (10, 14), during which time his                    a thorough evaluation of the affected
symptoms almost completely resolved.                      organ systems was warranted prior
Within one hour of resurfacing, how-                      to reconsideration for airman duties.
ever, he again developed dyspnea, pares-                  Based on Title 14 of the Code of Fed-           Although he initially experienced near-
thesias, and ultimately complete bilateral                eral Regulations (CFR) Part 67.213              complete blindness on the day of injury,
lower-extremity paraplegia. He was hos-                   (b), he was ineligible for a second-class       this fortunately resolved with immedi-
pitalized at the nearest appropriate                      airman medical certificate following            ate in-water recompression and did not
medical facility in the Solomon Islands,                  this event (2).                                 recur (5, 6, 7).
where he underwent hyperbaric oxygen                         Upon his return to the U.S., the                The airman faithfully participated in
therapy (HBOT), consisting of Table 6                     airman began outpatient treatment at a          outpatient rehabilitation for six months
treatment daily for four days and Table                   spinal cord injury rehabilitation facility,     post-injury, during which time he was
5 treatment daily for two days (14). He                   at which time his motor function on the         noted to be a highly motivated patient
was then transferred (12) to Sydney via                   left was noted to have improved to 4/5          and no longer required the use of gabap-
MEDEVAC Jet pressurized to 1 ATM,                         below L-4. However, he had persistent           entin. His only residual sensory deficits
where he underwent daily recompression                    sensory deficits as high as the T-9 level, as   included mild diminished sensation in
therapy for an additional five days. Upon                 well as multiple foci of cutaneous hyper-       the bilateral lower extremities, most
completion of this therapy, his bilateral                 esthesia and neuropathic pain, requiring        notable at L-3 on the left, where he
lower-extremity function improved such                    treatment with gabapentin (Neurontin),          failed to regain sensation (left medial
that he was able to ambulate with the                     a disqualifying medication (3).                 femoral condyle). His motor function
aid of axillary crutches and participate                     At two months post-injury, the in-           returned to 5/5 at all levels except S-1
in outpatient physical therapy.                           dwelling catheter was removed, he was           on the left, where his plantar flexion
   At 16 days post-injury, he was dis-                    voiding spontaneously, and no longer            (soleus, gastrocnemius) was still noted
charged from the spinal rehabilitation                    required oxybutynin (Ditropan). His             to be slightly diminished at 4/5. The
unit with the diagnosis of incomplete                     neurogenic bowel had also resolved.                                      Continued


6 T h e F e d e r a l A i r Su r g e o n ' s M e d i c a l B u l l e t i n • Vol. 49, No. 1 •
airman was able to ambulate with sym-                        Outcome                                 7. Fitzpatrick, D. T. (1994). Visual Mani-
metrical steps and normal cadence and            At seven months post-injury, the                       festations of Neurologic Decompres-
was maintaining a rigorous exercise          airman was evaluated by the U.S. Air                       sion Sickness. Aviat Space Environ Med
program on his own.                          Force in the F-15C Eagle simulator, at                     Vol. 65, No. 8, 736-8.
         Aeromedical Concerns                which time his performance was noted                    8. Francis, J. (2002). Decompression sick-
   As specified in 14 CFR part 67.401,       to be exceptional and without noted                        ness. Emerg Med. 14, 358–36.
an airman with a neurologic condition        deficiencies. Thereafter, he submitted                  9. Francis, J.T., Mitchell, S.J.; Pathophysi-
may be considered for special issuance       all necessary documentation to the FAA                     ology of Decompression Sickness. In:
of a medical certificate if the person can   requesting reconsideration for second-                     Bove, A.A.; Davis, J.C., eds. Diving
demonstrate an ability to execute airman     class privileges.                                          Medicine, 4th ed. Philadelphia, PA:
duties without endangering public safety         His complete medical file was re-                      Saunders; 2004: 165-84.
(4). Submission of all treatment records     viewed, and the airman was authorized
                                                                                                     10. Hawes, J. and Massey, W.E. (2008).
as well as a current status report from a    to perform a medical flight test in the                     Neurologic Injuries From Scuba Div-
qualified neurologist or neurosurgeon is     Airbus A-320 simulator, which he suc-                       ing, Neurol Clin 26, 297–308.
required. It is the airman’s responsibil-    cessfully completed. No limitations were
ity to provide documentation that the        deemed necessary, and a Statement of                    11. Kirshblum, S.; Millis, S; McKinley, W.
condition is stable and does not interfere   Demonstrated Ability (SODA) was is-                         and Tulsky, D. (2004). Late Neurologic
                                             sued (4). He was also given a corrected                     Recovery After Traumatic Spinal Cord
with cognitive or physical requirements                                                                  Injury. Arch Phys Med Rehabil 85 (11),
necessary to safely pilot an aircraft.       (time-limited) medical certificate, at                      1811-7.
   Because this airman experienced           which time he was cleared to return to
a transient episode of blindness, eye        the cockpit.                                            12. MacDonald, R.D.; O’Donnell, C.;
evaluation (including completion of the          Under 14 CFR §67.401, an Authori-                       Allan, G.M.; et al. (2006). Interfacility
FAA Form 8500-7) was undertaken,             zation for Special Issuance was granted.                    Transport of Patients with Decompres-
                                             An updated current status report from                       sion Illness: Literature Review and
and no abnormalities were identified.                                                                    Consensus Statement. Prehosp Emerg
In addition, an MRI/MRA of the brain         his neurologist was favorable, revealing                    Care 10 (4), 482-7.
was unremarkable, and an electrocardio-      no adverse changes in his condition,
graphic workup was negative for patent       and at one year post-injury, the airman                 13. Marino, R.J. (2005). Neurological and
foramen ovale (4, 7).                        was once again recertified by his desig-                    Functional Outcomes in Spinal Cord
                                             nated AME for a second-class medical                        Injury: Review and Recommenda-
            Role of the AME                                                                              tions. Top Spinal Cord Inj Rehabil 10
   The presence of neurogenic bladder        certificate.
                                                                                                         (3), 51–64.
and neurogenic bowel requires thought-                      References
ful consideration by the AME, particu-       1. American Spinal Injury Association/                  14. Moon, R.E. Treatment of Decompres-
larly due to the potential for autonomic        International Medical Society of                         sion Illness. In: Bove, A.A.; Davis, J.C.,
dysreflexia and resultant cardiovascular        Paraplegia. International Standards for                  eds. Diving Medicine, 4th ed. Philadel-
                                                Neurological and Functional Classifica-                  phia, PA: Saunders; 2004: 195-224.
instability. In addition, attention should
                                                tion of Spinal Cord Injury Patients.
be directed at the degree to which these                                                             15. Waring, W.P.; Biering-Sorensen, F.;
                                                Chicago, IL: American Spinal Injury
conditions may distract the airman                                                                       Burns, S.; et al. (2010). 2009 Review
                                                Association; 2002.
from cockpit duties. Fortunately for                                                                     and Revisions of the International
                                             2. Code of Federal Regulations, Title 14,                   Standards for the Neurological Classi-
him, both conditions resolved without
                                                Part 67, 67.213(b). Washington DC:                       fication of Spinal Cord Injury. J Spinal
complication.                                   U.S. Government Printing Office,                         Cord Med 33 (4), 346-52.
   The most obvious concern in this             [Dec 8, 2009].
airman is the degree to which his re-                                                                16. Weisher, D.D. (2008). Resolution of
                                             3. CFR, Title 14, Part 67, 67.213(c).                       Neurological DCI after Long Treat-
sidual motor and sensory deficits could         Washington DC: U.S. GPO, [Dec 8,
interfere with the physical demands                                                                      ment Delay. Undersea Hyperb Med 35
                                                2009].                                                   (3), 159-61.
required to safely pilot an aircraft (11,
                                             4. CFR, Title 14, Part 67, 67.401(a).
13, 16). His sensory deficits were partial
                                                Washington DC: U.S. GPO, [Dec 8,
in all dermatomes except L-3 on the left,       2009].
a region that is unlikely to affect avia-                                                                          About the Author
tion. With respect to his motor deficits,    5. Consortium for Spinal Cord Medicine.
                                                (2006). Bladder Management for Adults                Dr. John D. Swanson completed a residency at
however, careful assessment is warranted        with Spinal Cord Injury: A Clinical                  Wright State University in Dayton, Ohio, and
to evaluate his functional ability at the       Practice Guideline for Health-Care                   is now board certified in Aerospace Medicine.
S-1 level on the left. Adequate plantar         Providers. J Spinal Cord Med 29 (5),                 He wrote this report while rotating at the
flexion strength is essential for satis-        527-73.                                              Aerospace Medical Certification Division of
factory operation of the rudder pedals       6. Elliott, D.S.; Mutchnik, S.; Boone, T.B.
                                                                                                     the FAA Civil Aerospace Medical Institute.
and braking apparatus in unmodified
aircraft.
                                                (2001). The “Bends” and Neurogenic                                            
                                                Bladder Dysfunction. Urol 57 (2) pps.
                                                365i-365ii.

                                                            T h e F e d e r a l A i r Su r g e o n ' s M e d i c a l B u l l e t i n • Vol. 49, No. 1 •   7
Brief Psychotic Disorder                                                                                   Brief Psychotic Disorder
Case Report, by J.D. Haines, MD, MPH                                                                  Brief psychotic disorder is a short-
                                                                                                      term illness with psychotic symptoms.
                                                                                                      The symptoms often come on sud-
Brief psychotic disorder is a short-term illness with psychotic symptoms. The symp-                   denly but last for less than 1 month,
toms often come on suddenly but last for less than one month. The illness may oc-                     after which time the patient recovers
cur with or without a stressor or in the postpartum period. The condition responds                    completely.
favorably to a wide variety of anti-psychotic medications. Although the psychiatric                   DSM-IV-TR diagnostic criteria
literature provides a favorable prognosis for some, the aeromedical context requires                  Presence of 1 (or more) of the follow-
a more guarded prognosis.                                                                             ing symptoms:
                                                                                                      • Delusions, hallucinations, disorga-
                  History                                 feelings regarding the deposition. He       nized speech (e.g., frequent derailment
                                                                                                      or incoherence), grossly disorganized

   T     he applicant, a 50-year-old first-
         class airman, was employed as a
test pilot for an aircraft manufacturer.
                                                          became fearful that he could be arrested
                                                          if his answers during the deposition were
                                                          not found to be completely accurate,
                                                                                                      or catatonic behavior (note: do not
                                                                                                      include a symptom if it is a culturally
                                                                                                      sanctioned response pattern).
The airman was involved in an aircraft                    even though he recognized that this was     • Duration of an episode of the distur-
                                                                                                      bance is at least one day but less than
crash investigation in which several                      illogical. He experienced no hallucina-     one month, with eventual full return to
people were killed. His employer was                      tions, disorganized speech, or grossly      premorbid level of functioning.
sued, and he was required to give a legal                 disorganized behavior.                      • The disturbance is not better ac-
deposition in court.                                          The airman had a remote history of      counted for by a mood disorder with
                                                                                                      psychotic features, schizoaffective
   He had never given a deposition                        “heavy drinking” in college but reported    disorder, or schizophrenia and is not
before and was subjected to what he                       that he now drinks only socially. There     due to the direct physiological effects
called a seven-hour “nightmare.” He                       was no history of drug abuse. He had        of a substance (e.g., a drug of abuse,
                                                                                                      a medication) or a general medical
described the attorneys’ questioning                      received psychological counseling sev-      condition (1).
as “relentless.” When he requested that                   eral years ago for “anger management,”      This illness manifests itself in 1 of 3
certain questions be reframed or be                       but otherwise denied any psychiatric        forms:
given more time to consider his answers,                  history, hospitalizations, or psychiatric   • Brief psychotic disorder with obvi-
they became even more aggressive. He                      medications. He had no known family         ous stressors—occurs in response to
                                                                                                      trauma, stress, disasters.
described the situation as being very                     history of psychiatric illness, and there
                                                                                                      • Brief psychotic disorder without
stressful and noted that he had quickly                   was no evidence of malingering or facti-    obvious stressor—no trauma or stress
become “overwhelmed.”                                     tious illness.                              triggers.
   Following the deposition, the airman                       The airman subsequently developed       • Brief psychotic disorder with post-
described feeling fearful that he had not                 increasing agitation and was referred to    partum onset—within 4 weeks of
                                                                                                      delivery (2, 3).
responded to all the attorneys’ questions                 a psychiatrist who diagnosed a brief psy-
                                                                                                      The cause of brief psychotic disor-
to the best of his ability. Efforts to con-               chotic disorder and prescribed risperi-     der is unknown. It is an uncommon
sole him were unsuccessful. He became                     done (Risperdal). Although the patient      disorder that usually first appears in
preoccupied with paranoid thoughts and                    was concerned about taking an anti-         young adults in their 20s and 30s and
                                                                                                      is more common in females. People
believed he was being “monitored.” He                     psychotic medication, he finally agreed     with personality disorders seem to be
became suspicious of a repair truck in                    and experienced rapid improvement of        more prone (4).
his neighborhood, reported odd phone                      his symptoms. Two weeks following           The work-up for brief psychotic dis-
calls, and believed he heard strange                      initiation of risperidone, the airman       order includes a complete history
noises in his home.                                       was noted to have no further intrusive      and physical, laboratory studies, and
                                                                                                      a complete psychiatric/psychological
   The airman’s wife convinced him to                     thoughts or paranoid ideation and was       evaluation. Treatment involves psy-
seek medical help, so he consulted his                    sleeping normally without nightmares.       chotherapy, hospitalization (in severe
family physician, who prescribed ser-                         The risperidone was subsequently        cases), and psychopharmacology.
                                                                                                      Medications used include Risperdal,
traline (Zoloft) and lorazepam (Ativan)                   discontinued, as was the sertraline after   Clozaril, Seroquel, Geodon, and Zy-
for sleep and anxiety. He also sought                     he had completed a three-month course       prexa. Tranquilizers may be useful for
care with a psychologist for increasing                   of therapy. The airman was discharged       symptoms of anxiety and insomnia.
anxiety and despondency.                                  from psychiatric and psychological care     A recent review of the literature shows
                                                                                                      the recurrence of psychotic symptoms
   The psychologist diagnosed him                         with an excellent prognosis.                or emergence of other psychiatric ill-
with adjustment disorder with mixed                                  Aeromedical Issues               ness is sufficiently high and unpredict-
anxiety and depressed mood. He was                            The primary aeromedical concern         able to make brief psychotic disorder
                                                                                                      unacceptable without an individual-
not found to be suicidal and was fully                    following a confirmed diagnosis of a        ized, detailed specific case review.
oriented, although he had paranoid                        brief psychotic episode is the airman’s
                                                                                                                              Continued
8 T h e F e d e r a l A i r Su r g e o n ' s M e d i c a l B u l l e t i n • Vol. 49, No. 1 •
complete recovery, and the predictable       2. Chaudron L, Pies RW. The relationship                 Web Site Shortcuts
risk of recurrence. Title 14 CFR Part        between postpartum psychosis and bipolar
                                             disorder: A review. J Clin Psychiatry Nov                Implemented
67 states that an airman may not have                                                                 Use them to reduce clicks
                                             2003;64(11):1284-92 [Medline].
an “established diagnosis of a psychosis
in which the individual has manifested       3. Valdismarsdottir U, Hultman CM,
delusion, hallucination, grossly bizarre
or disorganized behavior or other
                                             Harlow B. Psychiatric illness in first-time
                                             mothers with no previous psychiatric hospi-              M     any users of the Federal Avia-
                                                                                                            tion Administration’s Internet
                                                                                                      services have commented regarding
                                             talizations: A population-based study. PLoS
commonly accepted symptoms of this           Med 2009 Feb; 10;6(2):e13. [Medline].                    the excessive length of URLs (Uniform
condition” or may be expected to have                                                                 Resource Locator) required when navi-
                                             4. Susser E, Wanderling J. Epidemiology                  gating to frequently accessed content.
such in the future.                          of nonaffective acute remitting psychosis                We are pleased to announce the recent
   This airman has a specifically            vs. schizophrenia. Arch Gen Psychiatry 1994              implementation of several abbreviated
disqualifying condition normal func-         Apr;51(4):294-301 [Medline].                             URLs.
tioning off medication. If the airman        5. Kulhara P, Chakrabarti S. Culture                             AMCS Support Page
requests reconsideration, then the           and schizophrenia and other psychotic                        www.faa.gov/go/amcssupport
                                             disorders. Psychiatr Clin North Am 2001                                AME Guide
case requires review by the FAA Chief        Sep;24:449-64.
Psychiatrist (AAM-202) following a                                                                          www.faa.gov/go/ameguide
complete psychiatric and psychological                                                                       AME Seminar Schedule
                                                 About the Author. J.D. Haines, MD,                       www.faa.gov/go/ameseminars
evaluation.                                  MPH, is a board-certified family physician
   After a specific, individualized case                                                                   AME Training Information
                                             with 23 years’ civilian experience in family,                 www.faa.gov/go/ametraining
review, as well as an extensive literature   emergency, and sports medicine. He currently
                                                                                                            Content specific to AMEs
review, the Federal Air Surgeon issued       serves on active duty in the U.S. Navy as Wing
                                                                                                               www.faa.gov/go/ame
a final denial in this case.                 Surgeon, 2nd Marine Air Wing (Fwd) at Camp
                                             Leatherneck, Afghanistan. He completed a                    Aerospace Medicine Technical
                                             residency in Aerospace Medicine in January                               Reports
               References                    2010 and wrote this report while rotating as a              www.faa.gov/go/oamtechreports
1. American Psychiatric Association. Di-     Resident in Aerospace Medicine at the FAA’s                 We hope the shortened URLs will help
agnostic and statistical manual of mental    Civil Aerospace Medical Institute.                       you when navigating to these commonly
disorders (DSM-IV-TR). 4th ed. Washing-
                                                                                                      accessed services.
ton, DC: American Psychiatric Press; 2000.                                                           Information provided by David Nelms,
                                                                                                      Program Analyst and CAMI Web Content
                                                                                                      Administrator, Aerospace Medical Certifica-
AME Resources                                                                                         tion Division.
New Laser Hazards Brochure Published                                                                                           
By Mike Wayda

A    LTHOUGH L A SER S H AV E       many
     legitimate outdoor uses, such as
in astronomical research, deep-space
                                             documented more than
                                             3,000 reports of aircraft
                                             laser illumination events
                                                                                                                         responsible for the appre-
                                                                                                                         hension and prosecution
                                                                                                                         of violators.
communications, orbital satellite imag-      that had occurred over a                                                       Another byproduct of
ing, and outdoor displays to attract and     20-year period.                                                             the research program is a
entertain the public, the misuse of laser       In 2005, responding                                                      new brochure, Laser Haz-
devices poses a serious threat to aviation   to the rapid increase                                                       ards in Navigable Airspace,
safety. Aviators are particularly vulner-    in the number of laser                                                      which is now available on
                                                                                                                         w
able to laser illuminations during low-      illuminations of air-                                                       the FAA Web site and in
level flight operations at night, when       craft, the Department                                                       print form.
the irresponsible use of laser devices       of Transportation pub-                                                         Online: www.faa.gov/
can threaten the lives of flight crews       lished Advisory Circular                                                    pilots/safety/pilotsafety-
and passengers.                              70-2 entitled “Reporting                                                    brochures/
   The increasing number of incidents        of Laser Illumination of                                                       Print version: http://
involving pilots being blinded by lasers     Aircraft.” This provides                                                    ame.cami.jccbi.gov/form_
prompted the FAA Civil Aerospace             an off icial reporting                                                      and_brochure/Brochure-
Medical Institute to research the laser      mechanism and coor-                                                         OrderForm.asp
hazards issue and publish information        dinates efforts between
to document these events and establish       local and federal law
                                                                                                                                         
exposure limits. The research team           enforcement agencies

                                                             T h e F e d e r a l A i r Su r g e o n ' s M e d i c a l B u l l e t i n • Vol. 49, No. 1 •   9
                     New Faces in Aerospace Medicine                                                   Refresher Training
      David Schall Great Lakes                                        New Deputy in
                                                                                                       Software Upgraded
                                                                                                       Users welcoming revisions
      Regional Flight Surgeon                                       Certification Division
                                                                                                       By Susan E. Buriak, MS, MPH, PMP
    David Schall, MD,                                         Courtney Scott,
                                                          DO, MPH, is a new
was recently selected
to become the Great
Lakes Regional Flight
                                                          physician on the Aero-
                                                          space Medical Cer-
                                                                                                       A     n updated version of the
                                                                                                             Aviation Medical Examiner
                                                                                                       Refresher Course (MAMERC, ver.
                                                          tif ication Division
Surgeon. He will man-                                                                                  2.0) was launched on December 22,
                                                          (AMCD) staff. His
age the region’s medi-                                    responsibilities are to:                     2010, to replace obsolete software
cal programs, budget,                                         • Serve as Deputy                        and content deficiencies that we
and personnel matters,                                           to Dr. Warren Silberman, Chief        could not repair.
while also providing medical advice. A                           of AMCD.                                 The final exam (60 items) was
Chief Flight Surgeon in the U.S. Air                          • Manage the AMCD physicians
                                                                                                       also updated. Additionally, two
Force with more than 1,600 hours’                                and some of the staff.
flight time, Dr. Schall was a military                        Dr. Scott served in the U.S. Air Force   Regional Flight Surgeons and two
flight surgeon for 30-plus years.                         for 22 years and held top-level medical      Civil Aerospace Medical Institute
    He graduated from the University                      positions, including Commander and           physicians verified and validated
of Missouri-Kansas City School of                         Dean of the U.S. Air Force School of         the changes.
Medicine and completed an Air Force                       Aerospace Medicine. His final USAF              The Aerospace Medical Educa-
                                                          assignment was in a joint position as
residency in Aerospace Medicine with                                                                   tion Division worked closely with
                                                          commander of the tri-service Defense
a master of public health degree from                     Medical Readiness Training Institute,        Medical Certification subject mat-
Johns Hopkins University. Dr. Schall                      the group that teaches the prestigious       ter experts to align course content
completed his residency in otolaryn-                      Combat Casualty Care Course, or C4           with the Guide for AMEs and per-
gology head and neck surgery at the                       as it is known. He retired in 2008 with      tinent federal regulations.
University of Nebraska, followed by a                     the rank of colonel.                            The “Depression” video was
fellowship in otology-neurotology skull                       Prior to joining the AMCD, Dr.
                                                                                                       updated to reflect recent allowable
base surgery at the Ear Foundation in                     Scott specialized in international af-
                                                          fairs and global health security for the     medication changes. Four addi-
Nashville, Tenn.
    Dr. Schall held a variety of senior                   Department of Homeland Security in           tional videos will be updated and
positions in the Air Force, including                     Washington, D.C. He worked with              re-released in version 2.1, slated for
Vice Commander of Wilford Hall                            international infectious disease experts     completion during the third quarter
                                                          to study the complex and globally con-       of this year.
Medical Center in San Antonio, Texas;
                                                          nected issues of emerging pandemic
Major Command Surgeon, Pacific Air                                                                        So far, 41 users have completed
                                                          threats in the context of protecting the
Forces; and, most recently, Combatant                     American people.                             their refresher training using the
Command Surgeon for the European                              When he was presented the prospect       new software, and 103 have just
Command in Stuttgart, Germany. He                         of working in aerospace medicine, Dr.        begun training. Overall, users were
has coordinated international medical                     Scott said he was quick to respond and       “very satisfied” with the revised
engagements worldwide. He served as                       again become involved in the mission of      courseware.
consultant to the Air Force Surgeon                       aviation safety: “When the opportunity
                                                                                                          You may register and enroll in
General in otolaryngology head and                        came to return to my roots in aerospace
                                                          medicine with the FAA, I could not           MAMERC training on the FAA
neck surgery with areas of interest in
                                                          resist. I have longstanding relationships    Web site:
spatial disorientation and management
of the dizzy flier. A prolific writer, he                 with many people in the Federal Air
                                                          Surgeon’s office, in the Regional Flight       www.faa.gov/go/ametraining
has authored in more than a dozen
                                                          Surgeons’ offices, and in the Civil Aero-
journals.                                                 space Medical Institute. I am honored        Ms. Buriak is the Aerospace Medical
    Dr. Schall replaces Dr. Nestor                        to once again be able to work with these     Education Division’s program manager
Kowalski, who retired in August 2010.                     outstanding public servants. We have a       for curriculum development and qual-
                                                          great mission and vision here, and it is a   ity assurance. Her E-mail address is
Information for this article provided by AVS                                                           Susan.E.Buriak@faa.gov.
                                                          privilege to work with this team!”
Flyer.
                                                                                   
                        

10 T h e F e d e r a l A i r Su r g e o n ' s M e d i c a l B u l l e t i n • Vol. 49, No. 1 •
         Color Vision Testing                                                                         such conditions must provide a medical
                                                                                                      report satisfactory to the FAA. Normally,
    Dear Editor,                                                                                      this report would include a baseline
    I just read the latest Medical Bulletin                                                           polysomnogram, treatment regimen, etc.
(AME Alert: Color Vision Testing; Vol.                                                                If appropriate, these airmen are granted
48, no. 4, p. 4)…about color vision                                                                   a special issuance for aviation.
testing. I just bought a new Titmus                 Baldness and Finasteride                             Courtney D. Scott, Jr., MD
vision machine in June [2010]. The                                                                    Aerospace Medical Certification Division
manufacturer no longer uses the same              Dear Editor,
designations used in the past. My new             Dr. Silberman’s article [Federal Air                      ECG Question, Night Vision
machine is a V2 model. That model is          Surgeon’s Medical Bulletin, Vol. 48, no.,                             Goggles
not listed in your alert. I assume that       p. 3] on baldness meds: finasteride, 1mg
it is okay since this is a new machine,       daily is an oral med for male pattern                      Dear Editor,
but I wanted to check.                        baldness. At this dose, it is relatively                   1) Dr. Tilton’s column mentions
                  Thanks,                     free of side effects, and I wonder if any               EKGs transmitted to them indicate the
       Randy Martin, MD                       treating doc needs to clear [its use with               person tested should have been sent to
          Montgomery, Texas                   the FAA]. The foam or lotion also used                  ICU—what provision is the FAA taking
                                              is 5% Minoxidil. This is also very safe.                to notify these patients or the physicians
    Dear Dr. Martin,                          In larger doses it is an antihypertensive,              ordering the tests? My EKGs transmit-
    Any commercially available vision         and would need a comment.                               ted from Odessa [Texas] are done in
tester in the U.S. can be used to screen                       Thanks,                                the hospital, and I get a copy later. In
for acuities and phorias, so the Titmus V2           Howard Keller, MD                                our little hospital in Iraan, Texas, all
would be OK for those. However, at this                    Kailua, Hawaii                             activity is put on “hold” in lab, X-ray,
time, the Titmus V2 is not FAA-approved                                                               EKG, and clinic departments while I
for color vision screening of pilots. New        Dear Dr. Keller,                                     check the EKG before it is transmitted.
versions, or “designations,” of vision           The medication Finasteride is an ac-
                                              ceptable medication for prostate enlarge-
                                                                                                         Appropriate transmission of emer-
testers do not necessarily use the same                                                               gency information should partly be
                                              ment and thus would also be acceptable
light source or the same test plates for      for this alternate use. The AME should                  assumed by the FAA if the emergency
color vision as earlier versions from the     inform the FAA in Block 60 at a mini-                   merits immediate ICU referral.
same manufacturer. Consequently, the          mum that the medication is being used                      2) In previous edition [Night Vision
test results may not meet FAA require-        for this particular indication, versus the              Goggles: The Basics for AMEs; Vol. 48,
ments. For this reason, only the color        one it is usually used for—otherwise, we                no. 2, p.6] two special courses in OKC
vision testers, exactly as listed in the      will probably request more information                  were mentioned. Can you send me sched-
AME Guide, can be used for color vision       from the airman.                                        ules concerning night vision [classes]?
testing of airmen.                                 Warren Silberman, DO                                       Edwin Rathbun, MD
    The acceptable color vision testers                                                                                  Iraan, Texas
listed in the Guide have been tested by                      Sleep Apnea
vision researchers in the Human Factors           Dear Editor,                                           Dear Dr. Rathbun,
Division at CAMI—all have been vali-              Do aviation medical examiners spe-                     (1) The AME is responsible for grant-
dated as meeting our aviation-specific        cifically test all pilots for sleep apnea?              ing certification to the airman. You should
requirements for both chromaticity and                   Martin Long                                  provide the performing lab with the list of
the pass-fail criteria (note: our pass-fail    Sleep Medicine Center, Chicago, Ill.                   “normal variants” that the FAA accepts.
criteria may be different than the manu-                                                              Tell the lab that if the ECG performed
facturers’). We contacted the manufac-           Dear Mr. Long,                                       shows anything other than what is on
turer for documentation of the light             To supplement the medical standards                  the list you provided, they should fax the
source and testing plates for the Titmus      contained in Part 67 (Under Title 14 of                 ECG to your office immediately.
V2. To date, they have not provided the       the Code of Federal Regulations, Part 67),                   Warren Silberman, DO
documentation we need to determine if         the Office of Aerospace Medicine provides
this version is acceptable for FAA exams.     substantial guidance material created                      (2) There is not a schedule of course
     Arleen M. Saenger, MD                    specifically for use by designated avia-                offerings yet. The final details are be-
        Manager, Aeromedical                  tion medical examiners. This Guide for                  ing completed, and a schedule will be
     Standards and Policy Branch              Aviation Medical Examiners is available                 published soon—perhaps by the time
                                              on-line, and specifies pertinent medical                you read this.
                                              information is required for history of                           G.J. Salazar, MD
                                              obstructive sleep apnea and periodic limb                 Southwest Regional Flight Surgeon
                                              movement disorder. Pilots suspected by                                            
                                              the AME or the personal physician to have

                                                            T h e F e d e r a l A i r Su r g e o n ' s M e d i c a l B u l l e t i n • Vol. 49, No. 1 •   11
Index of Articles Published in the Bulletin During 2010
                                    HEADLINE                                                           AUTHOR             ISSUE    PAGE
A Note From “The New Doc”                                                                        Brian Pinkston, MD       2010-3    12
Acceleration in Aviation: New Pilot Safety Brochures in Works                                    Mike Wayda               2010-1    15
Alpha-1-Antitrypsin Deficiency (Case Report)                                                     Kevin Brown, MD          2010-4    10
Antidepressants: Understanding New Policy (Federal Air Surgeon’s Editorial)                      Fred Tilton, MD          2010-2     2
Antuñano, Salazar, Silberman: 3 AAM Staff Receive Industry Awards                                AVS Flyer                2010-3     4
Aviation Medical Examiner Population                                                             Staff                    2010-1    14
CAMI Video Wins Telly Award                                                                      AVS Flyer                2010-3     4
Certification Process: Working Together to Improve (Federal Air Surgeon’s Editorial)             Fred Tilton, MD          2010-4     2
Certification Update: ECG Guidance                                                               Warren Silberman, DO     2010-2     3
Color Vision Testing (AME Alert)                                                                 Brian Pinkston, MD       2010-4     4
Cystic Fibrosis (Case Report)                                                                    Raymond Clydesdale, DO   2010-3     6
Distribution of AMEs by Medical Specialty                                                        Staff                    2010-2    12
Diverticulitis (Case Report)                                                                     Christopher Hudson, MD   2010-1    10
Driving While Intoxicated (Letter to the Editor)                                                 George Higgins, MD       2010-1     5
EAA AirVenture: 2010 Oshkosh Report                                                              Matthew Dumstorf, MD     2010-4     7
ECG Normal Variant List                                                                          Warren Silberman, DO     2010-1     5
ECG Normal Variant List                                                                          Warren Silberman, DO     2010-2     3
Forms and Supplies: Ordering Made Easy                                                           Gary Sprouse             2010-3    12
Index of Articles Published in the Bulletin During 2009                                          Mike Wayda               2010-1    16
International AME Seminar to Be Held in Wiesbaden, Germany                                       Melchor Antuñano, MD     2010-2     5
Introducing the FAA’s Aviation Safety Partnership                                                Harriet Lester, MD       2010-4     1
Kowalsky, Dr. Nestor: Retires                                                                    Matthew Dumstorf, MD     2010-4     7
Letter to the Editor: Visual Acuity                                                              Brian Turrisi, MD        2010-4     5
Lyme Carditis and Atrial Fibrillation (Case Report)                                              Joseph LaVan, MD         2010-2     8
Medical Certificate and Privacy Concerns (Federal Air Surgeon’s Editorial)                       Fred Tilton, MD          2010-1     2
Medications and Flying Brochure Revised                                                          Mike Wayda               2010-3     8
Medications List Needed (Letters to the Editor)                                                  Gary Swann, DO           2010-3     5
Medications, Part II (Certification Update)                                                      Warren Silberman, DO     2010-4     3
New Theme Seminar Débuts at AsMA                                                                 Richard Carter, DO       2010-4    11
Night Vision Goggles: The Basics for AMEs                                                        G.J. Salazar, MD         2010-2     6
Optic Neuritis (Case Report)                                                                     Anthony Waldroup, MD     2010-3     9
Papillary Thyroid Cancer (Case Report)                                                           Mary Brueggemeyer, MD    2010-4     8
Phakic Intraocular Lenses for Myopia (Case Report)                                               Mark Jacques, MD         2010-1     6
Pinkston, Dr. Brian: AMED Manager Selected                                                       Melchor Antuñano, MD     2010-2     1
Pituitary Adenomas: A Cause for Pause for Medical Certification? (Case Report)                   Alfred Shwayhat, DO      2010-2    10
Policies & Unacceptable Medications (Certification Update)                                       Warren Silberman, DO     2010-3    3
Privacy Problems Arise With Customs Inspection (Certification Update)                            Warren Silberman, DO     2010-1    3
Pseudo Social Security Number (Letter to the Editor)                                             Harry Wander, MD         2010-1    5
Quality Standards for Designees (AME Updates)                                                    Brian Pinkston, MD       2010-4    4
Sleep Apnea Brochure Published                                                                   Mike Wayda               2010-3   8
Smith, Dr. Margaret: In Memoriam                                                                 Harriet Lester, MD       2010-3   1
SSRI: New Certification Policy Guidelines in Place                                               Michael Berry, MD        2010-2    1
Sublingual Immunotherapy for Allergic Rhinitis (Case Report)                                     Steven Gaydos, MD        2010-1    8
Suicide Attempt (Case Report)                                                                    David Hardy, DO          2010-1   12
Tiger Team Pounces on Backlog                                                                    Richard Carter, DO       2010-1    1
Tilton, LaHood, Silberman, Dumstorf: Aerospace Medicine Teams Up at Oshkosh (caption)            Mike Wayda               2010-4    1
Transient Global Amnesia in an Airline Pilot (Case Report)                                       Lloyd Sloan, MD          2010-3   10
Vision Standards (Letters to the Editor)                                                         Joseph Kearns, MD        2010-3    5
Wake UP! (Federal Air Surgeon’s Editorial)                                                       Fred Tilton, MD          2010-3    1
Western Pacific Medical Certification: The Need for Speed                                        Richard Carter, DO       2010-2    7
Who’s Who in Aerospace Medical Education                                                         Janet Wright             2010-4    6


12 T h e F e d e r a l A i r Su r g e o n ' s M e d i c a l B u l l e t i n • Vol. 49, No. 1 •

								
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