Dr Claude Preitner. Senior Medical Officer Civil Aviation Authority of New Zealand
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1 Dr Claude Preitner Senior Medical Officer Civil Aviation Authority of New Zealand 16:30-17:25 WS #51: Essential Reporting and Prescribing For Pilots 17:35-18:30 WS #61: Essential Reporting and Prescribing For Pilots (Repeated)
2 Essential Reporting and Prescribing for Pilots? Dr Claude Preitner - Senior Medical Officer CAA FACASM, FRNZCGP
3 Disclaimer No financial or other conflicting interest in any of my presentations My own views not necessarily CAA s
4 So what if your patient happens to fly? Your patient is a pilot Your patient travels by air General principles Cases Doctors legal obligations General Principles In-flight emergencies
5 Pilots, not all subject to the same standards CAA medical certificate, by a designated & delegated Medical Examiner Class 1: Commercial Class 2: Private Class 3: Air traffic Controller (ATC) Non CAA medical certificate, by GP NZTA DL9 Cl 2 with passenger [P] endorsement Recreational pilot (RPL) Medical Declaration: Self regulating organisations e.g. gliders, microlights, hang gliders etc.
6 General principles Flying is foreign to the individual (3 D + time) Can t stop the aircraft! need for planning ahead, multitasking (piloting / navigation / radio communication). Must have good cognitive function & judgment Fatigue (workload - Jet lag - poor sleep e.g. due to sleep apnoea, pain, worries) Medication / drug and alcohol Mental Health, behaviour issues Aging
7 General principles Requires sufficient physical function for the task Vision Hearing Limb function Range of movements Power and coordination No distracting / incapacitating pain
8 General principles Must have low risk of incapacitation (sudden, subtle) Epilepsy, PTE CVA Migraine Vertigo Eustachian tube / sinus dysfunction Asthma (unstable or severe) / COPD Pneumothorax Coronary Artery Disease ACS Tachy / brady arrhythmia Hypotension & Vasovagal syncope Renal lithiasis Cholelithiasis DVT P. E etc
9 Case J Blogg, male - age 60 Flies twin engine aircraft for the local Air ambulance Total hip replacement on 1 July 2016 Reports to you that he is fine, wants to work seeking clearance certificate from you What do you do? What do you write?
10 Medical Certificate Typical certificate Mr J Blogg has been unable to work since 1st July He has recovered well and will be fit to work on 15 August Problem: CAA Medical certificate has been suspended CAA doctor or Aviation Medical Examiner needs to make a decision to clear him back to flying CAA Cannot make that decision without adequate medical information Can you make an aviation medicine decision or recommendation?
11 What would you want to know if you were in my place?
12 Cognitive: J Blogg Total hip replacement Sleep? Medication? Function? Range of movement Muscle power Incapacitation? Risk of dislocation DVT PE
13 Suitable certificate Medical Certificate Mr J Smith underwent left shoulder surgery on 1 July He has near full range of movement and full power, He is free of pain during the day, he sleeps well with the help of two Paracetamol tabs taken at night for some residual nocturnal pain. Or Copy of consultation notes
14 Agricultural pilot - mid 40s - Accident
15 Agricultural pilot - mid 40s S: patient seeks clearance to work as a Pilot. Aircraft accident one week ago. O: Moving well, no apparent pain, BP 136/74. chest and heart ok. Bruising only to leg and pelvis, abdomen ok. Chest X-ray reviewed, no finding. Plan: Copy notes to patient for aviation doctor.
16 GP notes - comments Notes quite detailed Considered chest injury No Pneumothorax! Did not give an opinion regarding flying clearance Not qualified to do so Avoids conflict Did not clearly indicate if head injury (CT scan?) Did not clearly address psychological status (PTSD?)
17 Treating / Prescribing to pilots Concern with conditions Seizure risk (head injury, history of seizure, cancer) Migraine Vertigo Ischaemic heart disease Rhythm disturbance i.e AF, tachyarrhythmia, heart block Renal stones Depression Drug / alcohol Etc. Concern with medication Psychoactive medication Medication that can lead to impairment - primary effect Antihypertensive (trial period), Warfarin, Dabigatran, Sulphonylurea Can lead to Impairment - side effects Alpha blockers, Steroids, Anticholinergics, Isotretinoin, Champix; etc
18 Case 3 Female Age 35 Jane Dow attends Poor sleep Anxiety Depressed mood, 1 month Not suicidal Relationship difficulties Mother just passed away Certification issues: Is condition likely to: Impair concentration? Impair judgment? Is the medication tolerated? CAA wants to know! Rx: Fluoxetine +/- CBT
19 Pilot obligation - s27c (paraphrased): If a licence holder is aware of or has reasonable grounds to believe any change in his / her medical condition that may interfere with safe flying, the licence holder must: Advise the Director of CAA May not exercise the privileges related to the certificate.
20 What are your obligations? S27C of the Civil Aviation act (paraphrased): If a medical practitioner is aware of or has reasonable grounds to believe that a person is a licence holder, and is aware, or has reasonable grounds to suspect that the licence holder has a medical condition that may interfere with safe exercise flying, the registered medical practitioner must, as soon as practicable:
21 What are your obligations? Inform the licence holder (your patient) that you will advise the Director of Civil Aviation Advise the Director of the condition Indemnified Act: Not subject to any civil or criminal liability.
22 CAA Action Require information Can impose conditions (e.g. Isotretinoin no night flying) Can suspend the medical certificate And after10 working days Can disqualify Can do all of the above
23 Cases of non reporting Case 1 Angina continued flying Case 2 Pulmonary embolism Near death Impaired LVF continued flying Case 3 Mental health issues (GermanWings Pilot > 150 deaths)
24 What needs to be reported? Most conditions General Direction lists exceptions to the need to report (under preparation)
25 Ethical Issues Ethical dilemma, choosing between: Best treatment, and Treatment that is acceptable for certification? e.g.: Not giving optimum treatment for diabetes, to avoid Sulphonylurea or Insulin Reporting to third parties: NZMC guidelines. No advocacy!
26 Take Home Message When treating, or when reporting Cognitive & Judgement (mental health, behaviour etc) Function Risk of incapacitation Obligations to report Conditions that may affect flight safety CAA docs available for advice:
27 Questions / Discussion? Medical med@caa.govt.nz or call us
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