Pilot Protection Services Medical Mailbag- December Q&A

Pilot Protection Services Medical Mailbag- December Q&A

QUESTION: I am a private pilot working toward my instrument rating and spent 1.5 years corresponding with the FAA to get my Special Issuance Medical so I was very happy to hear about the CACI.

My primary care physician has been monitoring my liver for evidence of damage from Hepatitis C which have been stable for over 10 years since interferon treatment in 1995 and I have been living a healthy lifestyle. I feel great, but my doctor wanted me to talk with a specialist about the newer drug treatments. I did this and the liver specialist ordered a biopsy. The results were something like 9 out of 16 for inflammation and 5 out of 6 for scarring. He recommended that I take the treatment, but if I do, I can't fly. So I am putting it off. But I will need to have documentation for my next medical due August 2015. I don't want to have another biopsy nor do I want to risk the lengthy treatment that doesn't offer a cure, just a 60-80 % chance of the virus becoming undetectable.

So, my question is this: Do I have to have a biopsy every 2 years to get my medical? Isn't my blood work sufficient? If not, then what are the criteria that dictate I am too sick to fly? I feel great, eat a healthy diet, exercise regularly and work and play like anyone else. I am not, as far as I know, not going to 'fall apart' instantaneously. If my results were 6 out of 6 scarring, does that disqualify me from flying? I haven't been able to find a good resource for this information and my pilot buddy suggested to contact AOPA.

In closing, do you know of other pilots having Hepatitis C and how they are dealing with this. Please help me. I have waited 35 years to continue my flying and now it seems as though I have to give it up again.

Thank you!

ANSWER: Thanks for writing on this important issue. Hepatitis is a catch-all term that means inflammation of the liver, a very important organ. Hepatitis C refers to an infection with a virus that is transmitted sexually, from contaminated blood transfusions, intravenous drug use or some other ways. The problem with this disease – which is unfortunately very common – is that it tends to be silent until it does lasting damage, often causing damaging cirrhosis or scarring of the liver which might require a liver transplant. Sometimes the liver scarring causes veins in the gut to distend to the point that they rupture and these “esophageal varices” can be life-threatening. Additionally, chronic inflammation can lead to hepatoma, a nasty and often fatal liver cancer. So the first recommendation is to explore what specific risk you face of liver failure or cancer – it is not simply a matter of making the virus undetectable, it is about mitigating the risk of a fatal disease. Flying is important, but staying alive trumps that.

Chronic Hepatitis C infection is now under the category of CACI (Conditions AMEs Can Issue)

As soon as an airman is placed on a medication, such as the Interferon Alpha you took, they are disqualified until the treatment has been completed and any side effects have resolved.

As long as the airman is "stable," they can continue to fly and be "cleared" by their AME.

Stable means that they do not have cirrhosis of the liver (although if the cirrhosis is stable this might not preclude certification), esophageal varices or other serious sequelae. This would likely result in a special issuance. Once more complications of the cirrhosis occur, denial is likely.

After issuance, yearly follow up status reports and liver function tests from their treating physician are required but there are no requirements for "regular" biopsies; that is left entirely to the treating physician.

Hope this answers your concerns – you also might want to read an article in AOPA Pilot magazine entitled “Stealing Fire” from October 2011 that addressed this topic.

QUESTION: I have a second class medical that expires at the end of March. I have a umbilical hernia that I need to get repaired. Should I wait until I get a new medical or does it matter? Thank you.

ANSWER: A hernia is where the contents of a body cavity protrude through the membrane that is supposed to contain them and an umbilical hernia is where there is a gap in some of the layers of the abdominal wall such that a piece of gut (most commonly) can poke into the hole. This can cause discomfort, appear unsightly and does represent a small but real risk the knuckle of gut can get caught, swell up and even perforate. This is an easy problem for a surgeon to fix, usually with just a few stitches or sometimes a piece of reinforcing mesh.If you have decided to go ahead, it really makes no difference when you have the procedure. You must obtain the operative report and a note when the physician releases you back to full activities which is usually a few weeks after surgery. If you obtain this prior to the examination, you should hand carry the reports and the AME will be able to issue an unrestricted medical certificate providing you had no complications, although if you did, once these resolve you should be good to go. If you have decided to go ahead, it really makes no difference when you have the procedure. You must obtain the operative report and a note when the physician releases you back to full activities which is usually a few weeks after surgery. If you obtain this prior to the examination, you should hand carry the reports and the AME will be able to issue an unrestricted medical certificate providing you had no complications, although if you did, once these resolve you should be good to go.

QUESTION: I have Mitral and Aorta valve leaks. I had a TEE and this revealed that the Mitral Valve showed moderately severe regurgitation and is posteriorly directed, some of which goes into the left atrial appendage. The Aortic valve is tricuspid with moderate aortic insufficiency that is centrally directed, no evidence of stenosis. The left atrium is mildly enlarged.

My Cardiologist recommended that I stop flying until I get this repaired/replaced. He feels my aorta will deteriorate to the point I need surgery in the next 6-12 months. I received a second opinion and this doctor thought I might be able to continue flying for a short period by submitting my test results to the FAA. I fly professionally but opted to self ground until after surgery in order to not lose my LSA option. My question is what are the differences between Class I,II,III for recertification after surgery and what is the wait time for a valve replacement vs. repair or two valves repaired?

ANSWER: The heart has four chambers, two atria, which are the smaller and less muscular and two ventricles which are the major pumps. Blood returns from around the body into the right atrium , passes through the a valve into the right ventricle, thence passing the pulmonary valve into the lungs through the pulmonary circulation. Oxygenated blood returns into the left atrium, through the mitral valve into the left ventricle and then the aorta, passing yet another valve and on around the body. These valves ensure blood goes the right way and does not wash back and forth as this would not be efficient. If a valve becomes “incompetent ” then heart performance can deteriorate and secondary damage ensues.The good news is that modern techniques of valve replacement can dramatically change the course of this disease and many folk are walking around – and flying – quite happily. The initial certification for valve replacement requires a 6 month observation period which may be lowered to 3 months. All first and second-class airmen must have their cases reviewed by the Federal Air Surgeon's Cardiology Consultant Panel. Double valve replacement is also reviewed by the Panel but in addition is also reviewed at the Federal Air Surgeon's office in Washington. Valve repair requires a 3 month period of grounding. Valve repair can be reviewed by the local FAA physicians. As for all serious conditions, put your health first and then deal with the flying issues.

QUESTION: What is the FAA's view on implants? Can a female, with breast implants, qualify for a 1st, 2nd, or 3rd class pilot medical? Likewise, can a male, with a testicular implant, qualify for the same?

ANSWER: For women, breast implants are used either to enhance the size and shape of the natural breast or to recapitulate this after surgery, most commonly for cancer. For men, one or both testicles might be removed as a result of a tumor, from torsion (twisting of the testicle that causes severe pain and the testicle to die) or in the event of incomplete descent and failure to form properly. Breast implants and testicular implants are acceptable to the FAA. The airman would need to provide the operative report from the procedure and a note as to how they have done post operatively.

QUESTION: I am in the process of re-obtaining my special issuance after a five year hiatus from flying. Back in 2009, I had my special issuance for a mild MI and the placement of one stent from back in 2005. I have obtained my 3rd Class Medical and my application is currently deferred until the FAA receives current labwork and a stress treadmill (Bruce protocol) test results from me.

My question for you is whether the Bruce protocol test standards have changed. The FAA sent me a specification sheet describing the “protocol for evaluation of coronary heart disease”. As I remember from before, this protocol describes the “maximal ECG treadmill stress test” achieving “100 percent of maximal predicted heart rate…”. But, nowhere on this specification does it refer to the 9-minutes any more. It does describe the following: “The blood pressure/pulse recordings at various stages and actual electrocardiographic tracings must be submitted. Tracings must include a rhythm strip, a full 12-lead ECG recorded at rest (supine and standing) and during hyperventilation while standing, one or more times during each stage of exercise, at the end of each stage, at peak exercise, and every minute during recovery for at least 5-minutes or until the tracings return to baseline level”.

I would hate to have my test run, as described above, and completed in 8 minutes…and have the FAA tell me that I did not do the test long enough.

Thoughts? I just want my cardiologist to order the right scenario for me so that I only have to do this once. I’m sure looking forward to getting back in the air!

Thank you!! I really enjoy the Mailbag!

ANSWER: Thanks for your note and we are glad you enjoy the mailbag. For the benefit of other readers, an “MI” is a “myocardial infarction” or heart attack where a section of heart muscle receives an insufficient blood supply and some muscle cells die off. This is often treated with a stent to hold an artery to the compromised area of the heart open. A stress test is where we ask a patient to exercise while monitoring how their heart responds. For those patients who cannot exercise for whatever reason, we can mimic exercise with a drug that stresses the hear

To answer your specific question, the stress test protocol for the FAA has not changed. They still expect a maximum exercise stress test to 100% of predicted maximum heart rate, or as close to that as you can get. The Bruce Protocol is three, 3 minute stages for a total of nine minutes. However, for pilots age 70 and over, the FAA allows completion of two stages of exercise, or six minutes, as long as at least 85% of predicted maximum heart rate is achieved. Maximum heart rate is determined by 220 - your age = maximum predicted rate, so if you are 60 years of age that number would be 220 – 60 – 160. Hope this helps. . . .

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