because of the science, the politics, the bureaucracy (not the most favorite part of the job by any means!), the aviation component, and, most important, the people: AOPA members, our staff here at AOPA, the AMEs I have met over the years, and the staff of the FAA Office of Aerospace Medicine. Coming into the job with a BS in Aviation Management, a long early career as a Surgical Technologist and professional firefighter/EMT provided me with just enough background to be dangerous, but the journey of learning has been great fun that I enjoy to this day. Having worked with the FAA for so many years, I’ve seen many changes in medical certification policy and practice, and there are more on the horizon, hopefully all good!
Even though many parts of the FAA medical certification regulatory process are routine, things do change from time to time, and that’s a good thing, if the changes are for the better! At one of the last meetings I attended in 2019 before the pandemic shut us down, I learned more than I understand about a group of immunotherapies now being used to treat aggressive cancers known as “immune checkpoint inhibitors.”
Immune checkpoints kick into action when certain proteins on the surface of immune T-cells identify with and bind to proteins on other cells, such as certain tumor cells. Our immune systems that help us fight illnesses contain checkpoint proteins that throttle back our natural immune response to prevent destruction of healthy cells in addition to the diseased ones. Big Pharma has introduced a number of these meds over the last few years, with more coming on the market, that are used to treat a variety of cancers such as breast, cervical, colon, head and neck, liver, lung and stomach. Obviously, a broad spectrum!
The FAA has been looking closely at these medications, but current long-standing policy doesn’t allow for medical certification while treatment is ongoing. As with all medications, the side effect profile is always a front and center consideration for flying, and some of the side effects of these treatments can be pretty nasty, including lung inflammation, gastrointestinal inflammation, diabetes, hepatitis, myocarditis, nervous system symptoms such as muscle weakness, numbness, and the list just goes on.
However, once treatment has been completed for at least 90 days and the patient is stable, the FAA will review the medical history and may be able to special issue on a case by case basis.
Atrial fibrillation, AFIB, is the most common heart arrhythmia, and well-controlled AFIB is not too difficult a special issuance to get. The evaluation requires a stress test, Holter monitor, and echocardiogram as the basic reports. One important concern with AFIB that isn’t properly treated is the risk for thrombus, or blood clots, that can form in a small pouch of the upper chamber of the heart, the left atrium, called the left atrial appendage (LAA). The LAA is like our appendix; it’s there, but we don’t really know what function it has, other than to be a pool that collects blood that can clot and cause strokes. An LAA closure procedure known as WATCHMAN is gaining some popularity among patients with AFIB who are on anticoagulants. The FAA is now considering the procedure after a six-month recovery period. In some cases, having the closure device deployed may allow discontinuation of anticoagulants after the implant has been in place for several weeks.
Over the last few years, the FAA has been working on ways to more efficiently notify airmen about what records are needed for review. Remember, they are the regulatory bureaucracy, and thorough medical record review is in their DNA! In the past, the list of reports and evaluations was included in an often-lengthy letter sent out to the pilot. The letter was and is often confusing and inconsistent. Now, in the true spirit of flying, “checklists” or worksheets have been created for many medical conditions including Insulin Treated Diabetes Mellitus, Pacemaker, Atrial Fibrillation, Heart Valve Replacement, and Chronic Kidney Disease. There will be more of these coming, and that’s a good thing. This change should make it easier for pilots and their treating physicians to better understand what the FAA needs for medical certificate issuance. The online Guide for Aviation Medical Examiners is available for you to do some homework prior to your next FAA physical. It does take some patience to navigate if you’re not familiar with it, but you can start with Aerospace Medical Dispositions, CACI Worksheets, and Disease Protocols. Of course, you can always contact us here in the Pilot Information Center as well!
Take your masks off (outside at least!) and stay well!