The Medical Exodus - by Dr Robert Liddell

[poteroo]

Ref: 'Australian Pilot' AOPA Dec-Jan 2015

 

 

AOPA members will have already read this article by Dr Liddell, who was head of CASA Avmed from 1988-1997. Dr Liddell has real life aviation experience as ATPL on jet RPT, and as medical director of RFDS WA. He is well placed to comment upon the industry wide concerns with CASA Avmeds' recent approach to medical renewals for 'recreational' pilots. I have taken the liberty to quote his last 2 paragraphs:

 

 

 

 

'The micromanagement of every recreational pilot with type 2 diabetes has driven many of them out of the industry, increased the costs of regulation with extra staff and resources to pore over the submitted daily blood sugar results,(which have already been checked by the DAME), and achieved nothing for aviation safety.

 

Like the rest of the population who trust their doctors, CASA needs to trust its' medical examiners, and stop wasting funds on over-regulation of private pilots. If they diverted the savings into teaching pilots about airmanship and sound decision making, only then might there be a positive effect on aviation safety'

 

Now I agree with all of what he wrote, and more. If you don't think this applies to you - then think again. If you seek a RPL at anytime - it will. If you cannot meet the DL medical, (and many, many older pilots will not), - then you go straight to Class 2 - and that's when the fun begins. And so too does the cost of your ,(by now, annual), medicals. I'm sure that it's only 'medicals' which is creating such an increase in enquiries about converting from GA to RAAus.

 

 

 

happy days,

 

 

[frank marriott]

I'm sure that it's only 'medicals' which is creating such an increase in enquiries about converting from GA to RAAus.

 

Poteroo

 

Whilst I have no doubt that medicals may have a part, in 'my' experience the major reason is the affordibility of owning and maintaining a what some would call a "useable" aircraft [for travelling distances] is the main force.

 

By way of explanation - in my immediate area there are 6 RAA owner/operator/pilots all converted to RAA certificates from various levels of CASA licences and all still hold Class 2 or Class 1 medicals.

 

This may well change with the current CASA proposed restictions as they all own Jabiru aircraft. Another 6 RAA pilots who purchased and operate their aircraft [also Jabirus] based on observations of what we were enjoying. Although I appreciate the operators of 60/70kt machines, and their enjoyment of flying their chosen aircraft, it is not of interest to everyone.

 

 

[Yenn]

At my age CASA say that if you exceed a certain number of points you have to have a stress test. Age is one of the things that allot points and at 78 I have to get zero for all the other things that can add to the point score. Such as weight, smoker or not and a load of other questions. I am fitter than a lot of people 20 years younger, but according to CASA I am close to being dangerous.

 

 

[frank marriott]

Yen,

 

I can only hope I am still flying in another 18 years. My comment was not that the medical issue was a non event, but more about the the major issue with GA to RAA conversions. Potreroo's statement well may be correct across the board, I just thought I would mention that it doesn't appear to be the case locally. I may well be a candidate at any time, having just passed the 60 point - hears hoping I continue good health as you have.

 

 

[facthunter]

If you don't get the medical you don't get the chance to have the other problems with Aviation.

 

Rob Liddell should be listened to. I would suggest HE was the best we ever had in the Job. (Avmed) by a country mile. Nev

 

 

[BoxFat]

Just been through the class 2 medical renewal and been forced to delve into the inner workings of the cardiac risk score, type 2 diabetes (incipient in my case) and the role of the exercise ECG stress test. It seem the goal is to keep the risk of an incapacitating CV event within the licence renewal period to under 1%. This is at any time during that period, not the risk while actually flying.

 

As Yenn said, the cardiac risk score increases with age and by the time you are in your late 50s you can cross the 1% with only a minor increase in blood pressure (for example). At that point, and at any point after age 60, your class 2 will only be renewed for 12 months and may require other tests such as the exercise ECG. The good thing about the latter test is that it is a very reliable indicator of cardiac health and is about 80% successful in predicting no CV event within 12 months (hence the annual renewal required). Note that this independent of my blood sugar, which only has health relevance here in respect of the risk of a suddenly incapacitating cardiac event - it is not insulin dependent and so does not require micromanagement for me to be safe to fly.

 

I have no problem with any of the above because if I can sit wired up on a bike every 12 months and thereby convince CASA and myself that my heart is good for another 12 months I'm happy to pay the ~ $350 to do it. I do have two issues with the current process though:

 

1. The 1% target applies equally to me flying 50 hours a year and Joe Bloggs flying 1000 hours a year. That doesn't make sense. My risk of a CV while flying is .05 of Joes risk but we both have to do the ECG stress test. I think there should some common sense applied here. And yes I suddenly might start flying 1000 hours a year (I wish !) but as in everything else I am responsible for my daily flight decisions between annual medicals, not CASA so this is no different

 

2. I cannot get specialist referrals without going to my DAME first so I have to anticipate what CASA will require, ask for those referrals, send in my DAME report, wait for CASA to say specialist reports are/are not needed, arrange appointments, send in specialist reports and wait to see if further tests are required by CASA. If so, I then may need to back to the DAME to get more referrals and repeat. At the end of this process, as it panned out this time, three months have passed, I have spent more than $1000 and my Class 2 certificate is issued - but valid from the date of the first DAME visit so due for renewal in 9 months !

 

So here are my suggestions to all Class 2 holders approaching 60:

 

1. Get your DAME to do a referral for an exercise ECG stress test regardless - it almost certainly will be needed

 

2. Go get it done and ask for digital copies of the report and ALL the charts to be emailed to you

 

3. Ask the DAME not to hit the button to send your report to CASA until you are ready to email them the ECG results.

 

4. Don't worry about cholesterol etc reports unless specifically requested by CASA - the exercise ECG should supersede the need for any other CV risk indicators.

 

CASA does indicate what tests they require at next renewal but that doesn't help because they can and do require extra ones dependent on the results. Back to the DAME for more referrals...

 

All of this is just my interpretation of the situation re the cardiac risk aspect and there maybe broader health matters of course. But in 9 months time I am going to attempt to save time and money by following steps 1 to 4. I should say that individual CASA Avmed staff were very helpful, they are just stuck in the same messy process as I am.

 

Cheers

 

BF

 

 

[pmccarthy]

Is the class 2 as hard as all that? I am 62, 126kg, on blood pressure pills, and I got a 2 year renewal without any special tests. My DAME is on the DAME review panel, whatever it is called, so he is meticulous.

 

I would describe my self as fat as a Mallee bull.

 

 

[BoxFat]

Is the class 2 as hard as all that? I am 62, 126kg, on blood pressure pills, and I got a 2 year renewal without any special tests. My DAME is on the DAME review panel, whatever it is called, so he is meticulous.I would describe my self as fat as a Mallee bull.

If it stays with a sensible DAME, no, apparently not. But if for some reason it goes for CASA audit ONCE, then you have come to attention and the rules, IF they are applied consistently, would see you off to have a stress ECG. I had one impaired fasting tolerance sugar test some years ago (which was not repeated), that triggered a glucose tolerance test which showed minor impairment (not diabetes but a warning to watch it). That then triggered an exercise ECG requirement, then (despite that being fine) a cardiologists report etc etc. I don't smoke, weigh less than 80 kg and am otherwise healthy.

 

Go figure.

 

 

[old man emu]

I'm like PMccarthy - 62, just the wrong side of 12o kg on blood pressure pills. I went for a heavy vehicle driver's licence and my doctor noted a heart murmur. So off I went for a session wired up and on a treadmill. The cardiologist reported back that my blood pressure was good (124/78), Pulse 58 but there was a T-wave inversion. Result for flying: Cardiac change, sit on the ground. I had a bit of a Google about the T-wave inversion and it seems that if the patient is not showing any cardiac problems, then the T-wave inversion could be put down to a genotype difference. In other words, there may be a small part of the human population who natrually have a T-wave inversion and it causes no harm. The improvement in the ability of new cardiac test equipment might even be throwing light on this previously unidentified group.

 

However, I can't get a CASA licence until I jump through the hoops at the behest of the Aviation Medical section, and the first step is a session with a DAME at more expense.

 

I reckon I'll just keep operating in ground effect.

 

OME

 

 

[BoxFat]

For clarification: burrowing down into CASA.gov.au /operations/individuals/medical certification/medical information for pilots/coronary risk index etc. says that the CRI is not routinely required for class 2 but can be on a case by case basis. If it is, then the rules for class 1 and 3 apply and these make it automatic after age 60.

 

BF

 

 

[facthunter]

You mention an exercise bike. I've always done it on a treadmill. Stress ECG Bruce's protocol. Nev

 

 

[poteroo]

The improvement in the ability of new cardiac test equipment might even be throwing light on this previously unidentified group

Yes, new diagnostic technology will continue to raise the bar for any type of medical. Fact of life. Stress ECG's now involve a lot more than even 5 years ago.

 

After doing Class 1 renewals since age 60, (14 years), I've found that there's a need to be well organised with your 'extra' specialist tests and visits. Get referrals from your DAME and begin these tests up to 3 months prior to your medical expiry date. This should allow your DAME to have everything on his desk at time of medical, allowing for the whole bundle to be forwarded electronically along with the medical review and...............most importantly - your credit card details so that CASA can extract their fee for service before the service is provided.

 

happy days,

 

 

[BoxFat]

You mention an exercise bike. I've always done it on a treadmill. Stress ECG Bruce's protocol. Nev

Yeah I believe it can be either bike or treadmill. Depends on the provider but the target heart rates are the same.

 

 

[BoxFat]

Yes, new diagnostic technology will continue to raise the bar for any type of medical. Fact of life. Stress ECG's now involve a lot more than even 5 years ago.After doing Class 1 renewals since age 60, (14 years), I've found that there's a need to be well organised with your 'extra' specialist tests and visits. Get referrals from your DAME and begin these tests up to 3 months prior to your medical expiry date. This should allow your DAME to have everything on his desk at time of medical, allowing for the whole bundle to be forwarded electronically along with the medical review and...............most importantly - your credit card details so that CASA can extract their fee for service before the service is provided.

 

happy days,

Is your DAME happy to provide the referrals without visiting him/ her prior to the main exam or does it require two (at least) separate visits and fees ?

 

 

[facthunter]

BF where there are difficulties with legs etc It can be done with an injection of adrenalin, I'm told. It isn't without it's risks, in any case.. It's more effective diagnostically,if followed by an ultrascan immediately. Nev

 

 

[poteroo]

Is your DAME happy to provide the referrals without visiting him/ her prior to the main exam or does it require two (at least) separate visits and fees ?

Short answer is YES.

 

 

[Kyle Communications]

Well I had a stress test on a treadmill and it all showed clear no issues. 6 months later I had a angiogram and was found to have all 3 arteries 90% blocked and told not to do anything stressful until 3 days later when I was on the table for a quad bypass....so stress tests like that are a crock of you know what.

 

Just because you do the treadmill for 15 or 20 mins doesn't mean your heart is ok

 

 

[Yenn]

When you have done all the tests and are found OK for a licence, there is still no way thay the medics can predict or rule out a heart attack. A friend of mine died from a massive heart attack 2 months after getting his medical as commercial pilot. I quiried our DAME and he said he could not predict either way. So basicly the testing is only a way to weed out those you do not want.

 

 

[Kyle Communications]

This is the stupid part about this. I can understand a very stringent medical for someone in commercial ops like flying a jet with 800 pax etc...but I can drive a B-double weighing 65 tonne at 100 kph or a bus or a train carrying 500 pax...yet I can not pass the CASA version of the Ausroads medical let alone a class 2 with all the crap. I just want to fly with 2 people total in any aircraft up to 1500kg I don't want to fly in CTA at all I have no interest in it. I am sure there are many pilots in the same boat.

 

 

[BoxFat]

Well I had a stress test on a treadmill and it all showed clear no issues. 6 months later I had a angiogram and was found to have all 3 arteries 90% blocked and told not to do anything stressful until 3 days later when I was on the table for a quad bypass....so stress tests like that are a crock of you know what.Just because you do the treadmill for 15 or 20 mins doesn't mean your heart is ok

Strewth Kyle ! Well I am glad you are still with us.

 

That's the problem with Internet forums - just when you think you have something figured out, along comes the contrary example. I saw one of the best known cardiologists in my city and he not only told me but also told CASA that a normal stress ECG was significant and sufficient evidence that I was not in the above 1% risk category for an event in the next 12 months. Doing a bit of my own research not just on the web but in the medical literature (just because I am a nerd and do stuff like that) I learnt that the rate of false negatives was less than 20% for diagnosis of significant coronary artery disease, that being defined as 70% blockage or more across the arteries. So...either you are one of the 1 in 5 false negatives or the rate is higher than 1 in 5.

 

I went ahead and got a heart risk scan (artery CAT scan) anyway as I am about to start exercising more but don't have the results yet. That will give ME peace of mind (until someone posts about that like yours about the stress test) but CASA Avmed peace of mind is satisfied by the stress ECG (I think).

 

Cheers

 

BF

 

 

[Kyle Communications]

I just finished another round of tests recently..in the last 6 months which had a heart 3D angio catscan probably what you just had then a cardio perfusion test where they inject radioactive stuff into you and then measure how well your heart chambers pump and how big they are and also of course a cardiac echo. The report from the cardiologist after all these said I had had a good outcome from the bypasses done 2 years ago. My issue was diabetes got me. long term diabetic that was not under good control is what caused the blockages. I still have this issue with the diabetes but early next year I think that will hopefully be fixed and if all goes well after a operation and I will no longer be a diabetic. If I continue the way I am my bypasses may last 5 or 6 years not the roughly 15 they usually last for. You only ever get done twice and you run out of spare parts after the second set of bypasses

 

 

[Kyle Communications]

This is what the perfusion tests look like

 

 

 

 

[paulh]

Kyle, all this doesn't sound as good as it could be, gotta look after your health man

 

 

[Kyle Communications]

This is why the govt and health mobs are pounding the diabetes issue...I have to admit I certainly was guilty of taking it too lightly many years ago....now after the horse has bolted it is very much in the forethought of everything I do

 

 

[facthunter]

The Stress ECG combined with an ultrascan is one of the most valid of tests. An angiogram may be a bit more specific but It can have more risks. About a 2% risk of a problem incl death.

 

CT scans involve a fair bit of radioactive substances and not too good for you. Don't have them unless really necessary

 

You can have your arteries scanned with ultra sound at no real risk.

 

Stroke (2 kinds) are a big risk not mentioned so far. If the blood flow through your heart is turbulent you are at a much greater risk of stroke from clots. If you have irregular heartbeat you are at risk of sudden heart failure. Nev