Pilot Protection Services November Medical Mailbag

QUESTION: I came across a prior AOPA article about AAA and this hit home after losing one family member to this quiet but deadly problem, but your article did not seem to cover the whole area of concern. You talk about EVAR, but I have been told it only works if the aneurysm is in your belly, or, as it was described to me, a descending aortic aneurysm. You mention nothing about the other kind, an ascending aortic aneurysm. I have also been told that the size, as well as the location, of the aneurysm varies in the need for surgery, being upper or lower. Can you give us some more information regarding the ascending aortic aneurysm? What the surgeon says seems to differ greatly from what the FAA says.

ANSWER: Thanks for your email and I am sorry for your loss. The term “AAA” is medical shorthand for abdominal aortic aneurysm, a ballooning of the main blood vessel in the back of the belly. “EVAR” (endovascular aneurysm repair) refers to a technique of replacing the diseased artery from within using a minimally invasive approach.

You are correct that there are other forms of aneurysm and it is my plan to cover aortic dissections, ascending aortic aneurysms, cerebral aneurysms, and other vascular problems in future articles. The information you were given about the approach depending on location and size is correct; additionally, the specific disease process may impact what needs to be done. Most aneurysms are not caused by inherited disease but in those cases where they are, family members may need to be screened. As for the FAA's position, it may differ from what is done in clinical practice. The FAA, like most large government bureaucracies, cannot move as fast as clinical practice changes but they and AOPA do speak with some frequency about such matters.


QUESTION: I imagine most aviators get their prescription drugs from doctors who may or may not recognize that some medications are not allowed if you are a pilot. It is also very interesting that the FAA has no official “list” of drugs that is available to the public. Almost alarmingly so.

I think it would be an excellent idea to inform pilots that not all medications are approved for use while flying. Some medications have “Black Box” warnings which warn of serious side effects. A good explanation of what a “Black Box” warning entails would be very helpful.

I view this as a serious safety issue and we need to inform all pilots on the possible dangers of some prescription drugs.

ANSWER: We absolutely concur, and given that non-allowed medication usage is a reason for medical certification denial, and is noted in accident investigation reports with regrettable frequency, it is a major concern. For this reason, we have tackled the topic repeatedly in the pages of AOPA Pilot magazine, online articles, videos, and public presentations. One of us (JMS) also presented this to an NTSB Panel focused on improving aviation safety. AOPA does have a comprehensive online medications database that indicates which drugs are allowed or not. There is also an information sheet dealing with the FAA policy on meds that can be referenced here. However, pilots need to take a greater responsibility for taking medications, knowing what the side effects are, if there is a Black Box warning, or if they are allowed to be used while flying. A black box warning is the strictest warning put in the labeling of prescription drugs or drug products by the Food and Drug Administration (FDA) when there is reasonable evidence of an association of a serious hazard with the drug.

While this is still a problem we shall continue to address it via all communication channels.


QUESTION: Can you tell me about Special issuance for a patient having undergone a heart transplant with no issues during the year following transplantation?

ANSWER: It is astonishing to look back at how revolutionary this technique was when first performed by Dr. Christiaan Barnard of Cape Town, South Africa, in December 1967. Now, roughly 40 such operations are carried out every week in the USA alone!

For heart transplants, there is a one-year recovery period post-operatively before one can do any testing for special issuance consideration. The FAA will be looking for a detailed report from the treating cardiologist regarding your current status, records of the pre- and post-op testing, comments regarding functional capacity, cardiovascular risk factors, and prognosis for incapacitation. You will also need current lab work, a coronary angiogram to identify any evident coronary artery disease, a stress test and stress echocardiogram, and a 24-hour Holter monitor. The FAA will also review any records about rejection history, any infectious process, and malignancies. All transplant cases are presented to the Federal Air Surgeon’s Cardiology Panel for consideration for Third Class special issuance. Right now, the number of heart transplant recipients with special issuance is small, but just one pilot flying means that it is possible! Good luck to you!


QUESTION: As we age, some of us begin to lose the ability to hear well. At what point will this affect one’s ability to obtain an FAA medical, either second class or third class? Is the need for hearing aids a reportable event?

 ANSWER: Hearing loss is, as you mention, one of the unwanted “gifts” of the aging process. Often, the damage begins when we are still young, especially from prolonged exposure to high decibels, like working around a flight line with lots of loud airplanes. FAA hearing standards for all medical classes requires that we be able to hear a conversational voice at six feet with our backs turned to the examiner. That’s a bit subjective standard and has a number of variables to consider, but if that standard isn’t met, additional clinical testing can be employed to identify the extent of hearing loss and in what frequency range the loss is present. The FAA can request a Medical Flight Test, if indicated, to allow the issuance of a Statement of Demonstrated Ability (SODA), depending upon the circumstances, but if hearing aids are required to meet the hearing standard, your aviation medical examiner can issue a medical certificate at the time of the exam with the limitation “Must wear hearing amplification.” That doesn’t mean you have to wear your hearing aids while flying, though. If you can comfortably fly with a high-quality noise-canceling headset, that will meet the hearing amplification requirement. 

: Hello, I went in for my First Class Medical about two weeks ago. When I went in I took my hypertension worksheet (three blood pressure readings, and details from my doctor about my prescriptions). I also took in my latest biopsy for my prostate along with a letter from my urologist explaining my treatment for my prostate cancer.
I have been taking in my worksheet and urologist report along with blood work report for years. BP under control with meds as detailed in hypertension worksheet. Prostate cancer is active surveillance for now.

Doctor put me on extra BP medication along with what I am currently on. My AME had to defer for the extra meds, or, I guess, crossing the threshold of meds one can take. My application is in Oklahoma City for review and hopefully issuance of SI.
Is this is a problem or just a protocol that the FAA requires for review? I called this past Thursday and the application is in the queue. Any idea how long it might take? They did ask me for a fax number to fax my medical when and if ready. I also briefed my doctor that he might have to write a detailed letter about my visits and meds to the FAA for further explanation.
Thanks for your insight, Pat

ANSWER: Patrick, the FAA allows for an office issuance for hypertension under the CACI program if you are on no more than three blood pressure medications.  If you require more than three meds, the FAA will probably grant you a special issuance authorization instead of the CACI if the additional meds get your pressure under the 155/95 certification limit.  Unfortunately, deferrals are taking about 90 days plus before airmen are receiving their certificates, so just be patient and don’t let your blood pressure spike while you’re waiting!  For your prostate cancer, you will need a current report from your urologist summarizing your history and how it’s being treated.  Also, you will need a current PSA report.  If the status report is favorable and your PSA isn’t significantly elevated, the AME could issue your medical to you in the office under the CACI program except that you’re on more than three blood pressure meds which requires the special issuance.

Portrait of Gary Crump, AOPA's director of medical certification with a Cessna 182 Skylane at the National Aviation Community Center.
Frederick, MD USA
Gary Crump
Gary is the Director of AOPA’s Pilot Information Center Medical Certification Section and has spent the last 32 years assisting AOPA members. He is also a former Operating Room Technician, Professional Firefighter/Emergency Medical Technician, and has been a pilot since 1973.

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