The Civil Aviation Medical Examiner and You
- ISSUE 4/2006
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Mandatory Reporting of Unfit Pilots, Air Traffic Controllers and Flight Engineers
Did you know that, by law, all physicians in Canada must inform a Regional Aviation Medical Officer (RAMO) of any pilot, air traffic controller or flight engineer who has a medical condition that could adversely affect flight safety? (Note-for purpose of this article the term "medical certificate (MC) holder" will be used to apply equally to pilots, air traffic controllers and flight engineers, unless otherwise stated.)
Subsection 6.5(2) of the Aeronautics Act requires that:
The holder of a Canadian aviation document that imposes standards of medical or optometric fitness shall, prior to any medical or optometric examination of his or her person by a physician or optometrist, advise the physician or optometrist that he is the holder of such a document.
Therefore, as a MC holder you must inform any physician-not just your Civil Aviation Medical Examiner (CAME)-of your status before each examination or treatment. Your physician must consider whether your condition or treatment would constitute a hazard to aviation safety, and if this is likely, inform a medical adviser designated by the Minister (the RAMO) of that opinion and the reasons behind it.
If uncertain whether a hazard exists, your physician can discuss your case with the RAMO hypothetically- without revealing your identity-until it appears necessary that a flying restriction may be necessary. This does not necessarily mean that your medical certificate will be suspended; however, the RAMO will make inquiries to confirm whether you remain medically fit. If the condition or treatment is self-limited, you would be advised not to fly until after recovery.
You should also remember that under Canadian Aviation Regulation (CAR) 404.06, Prohibition Regarding Exercise of Privileges, MC holders who know, or are informed, that they have a condition (or are prescribed treatment) that might make it unsafe to perform their duties, must"ground" themselves temporarily.
In some cases, a physician may choose to report a suspected unfit MC holder confidentially-without informing the individual. This is more likely to occur where no on-going relationship exists between the physician and MC holder, for example during or after an emergency room visit.
Once a report under section 6.5 of the Aeronautics Act has been made, it is the RAMO's responsibility to take further action. Although Transport Canada may use the reported information as necessary to ensure aviation safety, the report itself is privileged and cannot be used as evidence in any legal, disciplinary or other proceedings. When you sign the "Statement of Applicant" on a Medical Examination Report, this is considered as your consent for giving information to a medical adviser designated by the Minister when required under the Act.
If your name and condition were reported confidentially, you would likely receive a registered letter from the RAMO requesting further clinical reports to assess your condition. You would also be reminded of your obligation not to fly (CAR 404.06) pending a decision in your case.
Canadian physicians are currently being reminded of their responsibilities for reporting, and given some guidance on the types of medical problems that might warrant restrictions. Here are some of the symptoms and conditions to be considered, listed by system (abridged list):
Conditions where visual impairment is temporary or vision is temporarily affected by the use of medications need not be reported. The MC holder should be warned not to fly until normal vision has returned.
- Diplopia (double vision); monocularity; altered visual fields; eye injuries or retinal detachment; cataract surgery; surgical correction of myopia, including radial keratotomy (RK), photorefractive keratectomy (PRK), laser-assisted in-situ keratomileusis (LASIK) or other refractive eye surgery.
Ear, nose and throat
Significant deterioration in hearing must be reported. Any condition affecting balance or spatial orientation must be reported.
- Sudden loss of hearing, or conditions significantly affecting hearing; middle-ear conditions; damage to the tympanic membranes (ear drum) or the Eustachian tubes; any condition affecting or impinging upon the inner ear or the vestibular (balance) organs; stapedectomy and other ear surgery; surgery affecting the nasal passages, sinuses or Eustachian tubes; conditions leading to voice distortion or inaudibility.
The appearance of cardiovascular signs or symptoms is of great concern and must be discussed with the RAMO. Even benign cardiac rhythm disturbance can cause distraction that, during critical phases of flight, may cause an incident or accident. Medications to treat blood pressure with side effects of fainting/postural hypotension, arrhythmias or effects on the central nervous system are unacceptable.
- Cardiac inflammation and infection; acute ischemic syndromes (heart attack, angina); revascularization surgery (bypass or angioplasty, including stent insertion); initial treatment of hypertension with medication; symptoms of low blood pressure; new heart murmurs; significant heart disease; repair or replacement of heart valves; premature contractions; tachyarrhythmias (fast heart rhythms); bradycardia (slow rates) with symptoms; fibrillation; heart block and bundle branch blocks; pacemakers.
MC holders who show any evidence of memory loss, poor concentration or diminished alertness must be reported.
- Transient ischemic attack (TIA) or cerebral artery stenosis that has led to confusion, disturbance of vision, attacks of vertigo or loss of consciousness; stroke or any other cerebrovascular accident.
Other vascular disorders
- Aortic aneurysms; surgical repair of an aneurysm; deep venous thrombosis.
Disorders of the central nervous system can be a potent source of occult incapacitation. Lapses of consciousness or memory in the aviation environment can be fatal.
- Syncope (fainting); unexplained loss of consciousness, whatever the cause; seizure disorders; any significant head injury, unconsciousness or post-traumatic amnesia; sleep disorders of any type; migraine with aura; severe or prolonged headaches; disorders of coordination and muscular control.
Gradual deterioration of the respiratory system over the years may not be obvious, particularly if the pilot does not complain, or is using bronchodilator medications. Physicians treating MC holders must remain alert to the risk of hypoxia and trapped gas expansion (e.g. pneumothorax) when deciding upon treatment.
- Spontaneous pneumothorax, lung cysts or other conditions that may lead to problems with expansion (this may be of less significance in air traffic controllers); chronic obstructive pulmonary disease; significant decreases in pulmonary function or oxygen saturation; asthma-increasing requirements for inhaled bronchodilators or steroids; pulmonary embolism; sarcoidosis.
- Diabetes mellitus-type 1 diabetes (insulindependent) when first diagnosed (pilots and air traffic controllers requiring insulin are considered on an individual basis); type 2 diabetes (non-insulindependent) on first requirement for hypoglycemic drugs, changes in type or dose of medication or hypoglycemic attacks requiring treatment; initial diagnosis or significant changes in treatment of thyroid and parathyroid disease; pituitary or adrenal disease.
- Renal colic (kidney or bladder stones); renal failure; renal transplantation.
- Recent amputation of a limb or part of a limb; arthritis treated with second- or third-stage medications (e.g. Gold, azathioprine).
The level of tolerance for mental disorders or disease is small. Even when symptoms are effectively treated, the side effects of psychoactive drugs, such as selective serotonin reuptake inhibitors (SSRI) are usually unacceptable.
- Cognitive disorders; dementia; psychosis; bipolar affective disorder (manic-depressive); emotional disorders that require drug therapy or may interfere with judgment, decision making or reaction time.
- Any tumour that limits the ability of a MC holder to perform safely; tumours that may metastasize to the brain.
- Positive test for HIV; diagnosis of AIDS.
- MC holders who abuse or are addicted to alcohol or other chemical substances.
Physicians should discuss in detail the side effects of any medication that is prescribed or recommended to pilots. Minor side effects, for example, on visual accommodation,
muscular coordination, the gastrointestinal tract, or tolerance to acceleration, may be more serious when they occur in flight. If in doubt, the physician should discuss the medication with the RAMO.
Generally, MC holders are advised to avoid taking any medication within 12 hr (or, if longer-acting, within about five half-lives) before a flight if pharmacological effects may affect flying. Although there are exceptions to this rule, caution is advised.
There is no general rule about how long a MC holder should be grounded after receiving a general anesthetic. It depends on the type of surgery, premedication, and the anesthetic agent. Physicians should be aware that the effect of some anesthetics may take days to wear off, and caution is recommended.
Adverse reactions to local anesthetic are uncommon after the effect of the anesthetic has worn off, but in cases where they have been used for extensive procedures, such as the removal of several teeth, flying should be restricted for a minimum of 24 hr. One must be aware that dental surgeons sometimes prescribe long-acting tranquillizing agents before surgery, as well as narcotic pain-killers for post-operative discomfort.
If you have any questions regarding your personal medical fitness, they should be directed to either your CAME or RAMO. Toll-free numbers for the regional medical offices are printed on the tear-off bottom section of your medical certificate, as well as published on our Web site (under Contacts) at www.tc.gc.ca/eng/civilaviation/publications/tp13312-2-menu-2331.htm#contacts.
The following references are available online:
The Aeronautics Act.
Canadian Aviation Regulation (CAR) 404.06, Prohibition Regarding Exercise of Privileges.
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