Complex Aeromedical Assessment

Transcription

1 Complex Aeromedical Assessment Robert Haddon, MD, MS Mayo Clinic, Rochester Division of Preventive, Occupational and Aerospace Medicine Civil Aviation Medical Association September 16, MFMER slide-1

2 Disclosures Dr. Haddon has no commercial relationships to disclose. He works as a Consultant at Mayo Clinic, Rochester He formerly served as a flight surgeon for both USAFR and NASA. He is a Senior AME 2015 MFMER slide-2

3 2015 MFMER slide-3

4 Lost Dog 2015 MFMER slide-4

5 Three legs Lost Dog 2015 MFMER slide-5

6 Three legs One eye Lost Dog 2015 MFMER slide-6

7 Three legs One eye Ear torn Lost Dog 2015 MFMER slide-7

8 Three legs One eye Ear torn Tail bent Lost Dog 2015 MFMER slide-8

9 Lost Dog Three legs One eye Ear torn Tail bent Mange & Fleas 2015 MFMER slide-9

10 Lost Dog answers to Lucky 2015 MFMER slide-10

11 Background Events: 9/10/ yo M pilot w 1 st Class FAA Medical Walking, developed abrupt numbness of left face, hand, leg and foot. Leg dragging. Symptoms peaked at one hour, gradually resolved. Evaluation showed R thalamic lacunar infarct, airman placed on clopidogrel SI issued for First Class Certificate with annual MRI and Neuro Follow up 2015 MFMER slide-11

12 Exercise Sestamibi Normal Perfusion LVEF 55% MRI shows old CVA Neuro eval normal Action/Development 9/1/ MFMER slide-12

13 MRI Head Action/Development 10/15/2013 L Perifalcine Meningioma R Thalamic chronic infarct 2015 MFMER slide-13

14 MRI Head Action/Development 10/29/2014 L Perifalcine Meningioma Slight growth Small chronic infarct R Thalamus 2015 MFMER slide-14

15 60 yo Pilot w FAA 1 st Class Certificate Situation: Fall 2014 Active Problems Stable or resolved R Thalamic CVA SI Meningioma HTN Hyperlipidemia Elevated BMI FH MI 2015 MFMER slide-15

16 Action/Development 11/14/2014 Special Issuance for one year for: Right Thalamic Lacunar Infarct Perifalcine Meningioma Requires: Note from Neuro + MRI Authorization Expires 10/31/ MFMER slide-16

17 Action/Development 10/29/2015 Class I sixth month exam some things have been happening 2015 MFMER slide-17

18 Action/Development Summer 2015 Airman has develops chronic cough, he attributes to sinus drainage. This gets progressively worse MFMER slide-18

19 Action/Development September 2015 Airman grounds self after progressive cough symptoms for several months leads to discovery of 8 centimeter Left lung mass with mediastinal lymph nodes. CXR PET Scan with CT Head to Femurs Video Assisted Thoracotomy 10/5/ MFMER slide-19

20 You are here 2015 MFMER slide-20

21 Action/Development September 2015 Video Assisted Thoracotomy 10/5/15 Biopsy shows: 2015 MFMER slide-21

22 Action/Development September 2015 Histoplasmosis 2015 MFMER slide-22

23 Histoplasmosis Soil fungus common in Ohio/Mississippi Valley Associated with bird droppings Potentially Fatal Treat with Itraconazole 2015 MFMER slide-23

24 Histoplasmosis 2015 MFMER slide-24

25 Histoplasmosis May affect these organs: Lung,Brain,Eye,Kidney, Bone marrow, Skin, Lymphatics I.e., pretty much anything with a vascular bed 2015 MFMER slide-25

26 Histoplasmosis Most cases are sub-clinical, give rise to incidental findings of small pulmonary nodules later MFMER slide-26

27 Itraconazole May prolong QT Interval May cause hepatotoxicity Prolonged course of IV treatment Monitor Levels 2015 MFMER slide-27

28 Action/Development October 2015 PET Scan with CT Head to Femurs mediastinal lymph node activity Video Assisted Thoracotomy 10/5/15 biopsy shows histoplasmosis Sees ID, starts Itraconazole QT interval is normal AST is 17 What do you want next? 2015 MFMER slide-28

29 Action/Development October-November 2015 Airman gets brain MRI and neuro eval as per SI, and we look at it specifically for histoplasmosis: No Sign of Histo, Same tumor (don t forget the brain tumor) Urine tests normal Ophthalmology shows normal retinae Spirometry small airway disease 2015 MFMER slide-29

30 Action/Development October-November 2015 Airman also gets on airplane as passenger with pulse oximeter, sats to the high 90 s So can he fly? 2015 MFMER slide-30

31 Action/Development AME Visit 10/29/2015 AME discusses with Great Lakes Region Gathers data and waits. Enters everything in box 60, including discussion with GLR Finally submits as a deferral on 11/12/15 The plan, with no surprises for anyone: Get follow up CT Monitor on Itraconazole Evaluate OSA Evaluate HTN on three meds 2015 MFMER slide-31

32 Action/Development 11/20/2015 FAA GLR sends 60 day letter requiring: Results of current chest CT OSA evaluation Spec sheet B (start by seeing a sleep specialist for OSA evaluation) HTN Report from treating physician 2015 MFMER slide-32

33 Action/Development November 2015 AME beginning to think about timing of resection of brain tumor MFMER slide-33

34 Active Problems Situation: Fall 2015 Stable or resolved Pulmonary Histoplasmosis Itraconazole Potential OSA (Not treated) R Thalamic CVA SI Meningioma SI HTN on metoprolol, olmesartan, HCTZ Hyperlipidemia on rosuvastatin BMI 40 FH MI 2015 MFMER slide-34

35 Action/Development January 2016 Progressive shortness of breath leads to discovery of bilateral pleural effusions and decreased LVEF, thought to be an effect of itraconazole. Effusions drained, itraconazole adjusted. Follow up echo 6/28/16 with LVEF of 65% and Aortic dilation of 41 mm mid-level 2015 MFMER slide-35

36 Action/Development 2/25/2016 FAA GLR sends denial letter as requested evaluations not yet completed. This was expected by everybody, and was taken in stride while we moved forward MFMER slide-36

37 Action/Development 3/1/2016 Meningioma excised with no complications, hospital discharge 2 days later. Itraconazole stopped after 6 months tx. ID confirms treatment complete Follow up CT shows regression of lesion, no further effusions 2015 MFMER slide-37

38 Action/Development 6/1/2016 CT chest shows shrinkage of LUL mass to 2 cm Incidental coronary artery calcifications 2015 MFMER slide-38

39 Action/Development Summer 2016 Stress echo negative for ischemia, shows mild ascending aortic artery dilation. Sleep study positive for OSA, starts CPAP and is well tolerated. Neuro follow up and post-op MRI all benign 2015 MFMER slide-39

40 Action/Development November Special Issuance First Class Certificate for: Resected meningioma OSA on CPAP Ascending aorta dilation Notation for any changes in: Melanoma in situ, reactive airway disease, GERD, posterior vitreous detachment, early catracts. Total grounded time 13 months MFMER slide-40

41 60 yo Pilot w FAA 1 st Class Certificate Situation: September 2017 Active Problems BMI 37 weight loss in work Stable or resolved HTN on HCTZ +Olmesartan Meningioma out R Thalamic CVA off SI OSA on CPAP and SI Aortic dilation h/o melanoma Hyperchol on statin Myopia/Presbyopia/Cataracts 2015 MFMER slide-41

42 General Conclusions Use the down time for medical housekeeping Parallel, not serial Plan ahead, i.e., prevent future seizure risk The pilot can get healthier and can be shown this 2015 MFMER slide-42

43 Still flying 2015 MFMER slide-43

44 Questions? 2015 MFMER slide-44

45 MFMER slide-45