Caring for pilots is not as easy as it seems.
It was once said to me “Medicine is the natural enemy of aviation”. That was a comment from an Army Warrant Officer and he wasn’t kidding. Pilots hate going to the doctor. The fact is that every pilot who is legally flying a powered airplane, with a couple of very infrequent exceptions and the newly emerging class of pilots known as “Sport Pilots”, will need to see a flight doctor at some point.
Now I referenced some exceptions. You might be interested to know that sailplane pilots do not have to see a physician. Nor do self-launching sailplane pilots. I have always found that interesting. It is entirely legal for a rated Sailplane pilot to buy a Grob 109B or a Stemme S-10 and just never turn the motor off. He could fly it from coast to coast and because it is considered a sailplane, that happens to self-launch, and not an Airplane Single engine Land, well let’s just say that before sport pilot this was the insurance in the bank for many pilots who considered the possibility of losing their medical.
Balloonists do not need to see doctors to fly. Now this perplexes me. Of all the flying machines in the world, balloons are the least controllable and if they can be controlled it is only by the hands of a seasoned and conscious aeronaut who understands winds and how to manipulate the burner to take advantage of where those winds might be. An aeronaut who is comatose at the bottom of the basket after a seizure isn’t going to do the hapless passengers who are rapidly approaching high-tension lines any good. Be that as it may, you can have all manner of otherwise disqualifying problems and still fly a big bag of gas. That, and a sailplane with a cruise speed of 140 knots at 10,000 feet, a service ceiling of 30,000 feet, retractable gear, feathering prop (folding in the Stemme) oh and did I mention a gross weight of 1874 pounds? Doesn’t quite match light sport aircraft does it?
This leads me to Sport Pilots. Sport pilots can become certified to fly aircraft with substantially less performance than a Stemme S-10 with just a driver’s license, unless of course they have previously held a medical and been rejected in which case they must first get wavered back to class III medical standards before reverting back to the ‘driver’s license’ self-certification of the sport pilot provision. In the Sport pilot case you are better off never having held a medical because should you ever fail your medical you have to get wavered before being legal to fly again under Sport Pilot. If you never had a medical in the first place, it is moot.
Now there are specific reasons why all of this is the way it is. As an aviation advocacy agency the FAA certainly had it in its interests to try and get more pilots in the air. Frankly there are a lot of old pilots who simply are done with their Barons and King Airs and just want to fly a Cub and don’t want the hassle of a medical exam. More on that later. And there is the reality that general aviation has dichotomized into two very distinct entities.
These two groups are easily described as; The I don’t care how much money it costs because I have more money than I will ever need and so all I need is a machine that turns gas into noise, preferably a lot of noise; AND, the rest of us. Well that is unfair; there is a third group, actually a sub group of “the rest of us”. They are the experimental pilots. Most of those cats, including myself, are the ones who are sick of the cost and antiquated nature of production airplanes and realize that the sanest method for us to take the air is to build it ourselves.
And all of this is really a sad turn of events because the days of cheap Cubs populating flight schools around the country are gone and not likely to return in the future. The real issue is not making a pilot’s license easier to get, it is creating a landscape where good airplanes don’t cost a lot to fly. But that is not the nature of business and there are a lot of people out there who have no problem plopping a bunch of dough on the table for new Cirrus, or $85,000 for what is essentially a new J-3.
Where am I going with this? Actually I am going back to medicals.
Unbeknownst to most pilots, every year, several times a year, many of those of us who are flight surgeons and Aero Medical Examiners treck off to one or more seminars on how to properly care for pilots. In fact, the picture you see below was taken just today in the meeting hall prior to a lecture by one of the chief heart doctors in this country. His talk was specifically oriented toward how we as flight docs can safely get pilots who are sick, well enough to be able to fly again. That is the essence of what we focus on; getting otherwise bad risks, better enough to be a risk worth betting on.
That is important to understand.
You might not realize it but there are several hundred-airline pilots flying right now who have had heart attacks. There are a few who have had brain tumors. In fact, unless we are talking about flat out psychosis or seizures there are likely pilots flying who have just about every conceivable medical condition. They fly because they have taken the time and their flight doctors have expended the effort to carefully document their problem, their treatment and how well that therapy has worked. If it has worked well and the pilot can function normally, they are likely to fly.
Hardly the enemy of aviation.
In any endeavor that is not easily understood, the likely human response is one of stereotyping. Medicine is no different. Medicine is an arcane profession. The internet notwithstanding, the information that physicians possess is something that lay people do not have access too unless they choose to spend the better part of their young productive years learning the art of medicine. Because of this there is considerable fear borne from not understanding just what flight doctors are up too.
Flight doctors, almost without exception, are very interested in seeing pilots fly. If a flight doc grounds every pilot, the flight doctor will soon find himself without any pilots to care for. A military flight surgeon has the added pressure of a commander who really prefers that his millions of dollars worth of aircraft actually do more than serve as easily accessible practice material for his ground maintenance personnel. More importantly, most flight doctors truly love aviation and do what they do for the simple reason that they know how much pilots love to fly.
I personally spend several hundred hours a year just working on waivers for pilots who have specific medical problems that need certain unique treatments to be safe. Safe is very important. Remember those pilots I mentioned that have had heart attacks? You would probably agree that keeping a close eye on them is probably a good idea if our desire is to prevent the commercial airliners that they are flying from smashing into the ground.
And this is where science, another arcane practice, comes into play.
Unlike many human endeavors (the use of a beer bong for example) when you are dealing with the heart of the person who drives all 870,000 pounds of a 747-400 it is preferable to exercise precision. The dedicated agency responsible for American pilots is called CAMI or the Civil Aero Medical Institute. It is located in Oklahoma City, Oklahoma and is part of the FAA. There are seven physicians who are the central core of CAMI. It is those seven, and really ultimately just one (because the others are his deputies), who have to take real science and apply it precisely to the guy who moves the stick on the 747. There is little room for error.
It would be appropriate at this time to interject some observations. Since I am now on my way home and I was not afforded the opportunity to fly Southwest (in spite of it costing the government less than this Delta ticket that I am using) I must tell you that Orlando, MCO, has a terrific airport in all respects save for one; Gate 60. Gate 60 is the closest thing to some third world hellhole that you can imagine. All of Delta’s partners flying those Jungle Jet Embraers seem to board through here. It is a low ceiling room filled wall to wall with people and unlike the E gates at PIT, there is no residual room. Flat out the only thing that differentiates this place from say the middle of Nigeria is the lack of smell. They have the smell under control.
The take home is this; Delta is dying. You can tell by the conditions that they force their pax through. Best pay a few extra bucks and fly Southwest. Trust me on this one.
Back to our 747 driver.
There are many pilots, including the editor of a popular flying magazine, that I have spoken too over the years, who think that the entire medical requirement is ridiculous. Their argument usually goes like this, “I self-certify every time that I fly, you see me for just one day and even then you are not perfect, so why am I forced to get this medical in the first place?”
I have another friend, a very wise one, who says this, “It is very foolish for a man to try and work outside of his trade.”
I suppose that when your job involves writing stories about airplanes that 99% of all pilots will never be able to afford and you have a constant parade of manufacturers installing the priciest equipment in your airplane just so you can play with it and write more stories read by people who will never be able to have the same toys, it is tempting to start believing that ‘You da man’ and as such, a re invincible.
Don’t work outside of your trade.
Here is what a medical is not: A medical is not an omniscient overview of all that is you. None of us have Superman vision. Heaven knows that I wish that I did have it. None of us can tell you the day you will have your MI; those of us who are smart leave that to God. A medical is not even a guarantee that you are healthy the day of the exam.
Here is what a medical is: A medical is an exercise in risk management. A medical is your opportunity to sit down with a skilled medical professional, preferably one who is also an experienced pilot, and evaluate the relative risk of you flying your airplane in a safe and healthy fashion for the period of your medical. Your AME or flight surgeon is a person who has crammed a boatload of data into their brain-housing group. When we see you, as we are freaking you out with the various, “hmmms, okays, whoas and uh-ohs” that come out of all of our mouths when we are examining a pilot, what is actually happening is a complex computational exercise that crunches what you report, what you say, what we find and what the regulations require into a risk management profile.
The end product is a medical certificate, but what that paper really is, is a statement of relative risk. It is an assertion by a person like me that says that I have examined all the variables and I feel based upon a lot of science and data that you are a good health risk to be flying for the next 6 months, 1-year or even 3 years. It is not a simple or amateur process and while certain detractors can launch their aircraft and pop on the autopilot and then sit back smugly making comments about the inadequacy of our work, I assure you that most of us take it very seriously.
I would mention Scott Crossfield. I do not intend nor portend to have any knowledge of why Crossfield is now dead. All I think I can say with assurance is that he flew a 210 into a level 6 cell and it ended up in pieces (Scott Crossfield, by the way, was one of my aviation heroes and has been for years, long before most people had heard his name for the first time in the various obituaries). But what is unique about Crossfield is his age. Scott was in his 80s, flying a 210 in weather. Chuck Yeager only recently gave up flying F-15s and still flies regularly. Now is it just me or do any of you wonder about the health of an 80 year old flying a Mach 2+ capable fighter plane?
“But wait!” You say, that’s Crossfield, Yeager and for equanimity let’s throw in Bob Hoover; they are the masters of the wing. They can fly by merely willing the airplane into the air. Oh, but were that true. The sad fact of reality is that the only unique thing about these three men is that they were blessed with very good genes and as a consequence long lives. Their aviation skill is unquestioned, but it is not in the god-realm. They just flew a great deal and learned a great deal. I am certain that BG Yeager could tell us all of many “great sticks” that died over France or in a smoking hole at Muroc. They were just in the wrong place at the wrong time.
The real issue is that all three men, and I theorize Crossfield, are at ages where most of their peers are dead or in nursing home with significant cognitive decline. I am forced to wonder whether or not Crossfield’s cognitive ability played any role in his judgments on the day of his death. That is an issue that all flight surgeons have to look at. I know that I do and as a circle back to my notion on risk management, I have told more than a handful of over 70 aviators that they ought to consider selling their Bonanzas and buying a good Champ or a Cub. Why? Because life moves a lot faster at 165 knots than it does at 60 knots and 70+ year-old minds don’t continue to work as fast as they did at 40. Risk management.
It is the same situation when I sit down and ask about a person’s heart history and their family history and their blood pressure and mentally calculate what the potential issues are that if left unchecked might lead to a pile of wreckage in the middle of a school yard with a corpse in the middle of all of it.
Witness British European Airways Flight 548 and Captain Stanley Keys. In this unfortunate accident a BEA Trident with Captain Keys in command crashed into a wooded area near an expressway. 118 people died. During autopsy it was found that Keys had evidence of a past heart attack as well as a presumed coronary artery aneurysm. While nobody knows exactly why the airplane crashed the forensic evidence weighs heavily on at least a partial incapacitation of Keys and in the environment of poor crew resource management and the departure stage of the flight the end result was catastrophic.
Ever wonder how many general aviation accidents are actually the result of the sole pilot experiencing a heart attack or seizure or perhaps a stroke? Read through the report below
http://www.ntsb.gov/ntsb/brief2.asp?ev_id=20040824X01278&ntsbno=ANC04LA093&akey=1
What is important to note are two things, well actually, three. The first is that this pilot never mentioned on his medical that he had diabetes. Why? Fear of losing his medical? Forgot? Perhaps he felt it was under control so he no longer had it (I see this all the time with people when asked if they have high blood pressure. They take medication, their blood pressure is normal, and so they no longer have high blood pressure). We will never know because he is dead. The second thing to note is that he has over 5000 mg per deciliter of glucose in his urine. I assure you that this is not an example of well-controlled diabetes. It certainly is not an example of “militant” control. In fact he has so much sugar in his urine that when I treat patients like this I like to say that they are, “Pissing cotton candy.” It is also noted that the pilot had several hypoglycemia, or low blood sugar, episodes. Not good.
The third thing that warrants mention is that diabetes is waiverable condition for third class medical when treated according to the standards set forth by the FAA/CAMI. Did the pilot know this? Did he know it and just didn’t want to go through the hoops, thinking he could do it better himself? Did the pilot’s AME know this? I see many pilots who come to me because their AME frankly doesn’t know what he or she is doing and either denies a medical or tells the pilot that they cannot fly with a condition that is clearly waiverable with a little work.
The point here is this; what we do as flight surgeons is an exercise in risk management. We are after all the pilot’s advocates. I could show you many letters that I have written, all of which say something to the effect that “I recommend waivering this pilot for class “x” privileges”. I have never written a letter recommending permanent disqualification and like I have said, I have diabetic pilots, asthmatic pilots, brain tumor pilots, heart attack pilots and all of them currently hold valid, FAA bonafide, medicals. It is what I do.
So here is the rub. Only about 43% of all AMEs are pilots. Now it is the case that just because a doctor is a pilot doesn’t make him an aerospace medicine expert and just because he is not a pilot does not mean that they are not an expert. But in general it is a good idea to go to the best-prepared AME you can find. Remember, it is about risk management, for your sake. You wouldn’t purposely find the crappiest A & P to do your annual; I mean it’s your life right? Well regardless of your health problems you would be well served to find the most inquisitive and eager AME as well. They might just save your personal “airframe and powerplant” from catastrophic failure.
Reality is that with a little cooperation and patience I can get almost any pilot wavered. It sometimes takes a few months and sometimes it is frustrating for the pilot, but that is what I do. I do it because I love flying so much that I cannot imagine what it would be like to be told that I could no longer do it and so I want to make sure that I help those pilots who are facing that possibility get their privileges back. It is after all what THEY do and I am glad to help.
Fly safe.
