Medical Waivers 101 “There will be a quiz”

1. Medical Waivers 101“There will be a quiz” CDR L.K. GRUBB, MC, USN Director, Physical Qualification And Review

2. Martha Stewart Calls my wife for advice on domestic matters

3. A Fit and Ready Force We are in an era of increased operational demands on a military that is decreased in size The Applicant pool has markedly decreased in size and quality It’s the economy (Bill Clinton) It’s the family (Dan Quayle)

4. OVERVIEW • What exactly does BUMED do, besides make your life more difficult? • Current DoD and BUMED Policies • List of top 15 Disqualifying Conditions • Issues of Concern • Eye • Asthma • ADHD • Knees

5. What the heck is a waiver? • DoDD 6130.3 (look on the WWW) lists all of the physical conditions that are physically disqualifying for enlistment, induction or commissioning. A medical waiver allows someone with a physically disqualifying condition to still serve in the military. CNET’s medical waiver review office (that’s me) is located at BUMED in Washington, D.C.

6. Medical Waiver Criteria • Not Progressive • Won’t be Aggravated by service • No interference with training or Full Duty-- Worldwide deployability, not assignability • No danger to self or shipmates • Functional capability NOT anatomical correctness

7. Disqualifying Conditions • Vision (myopia, hyperopia, astigmatism) • Limitation of motion of foot or hand • Asthma • Abnormal Hearing (speech is in the 500-2000 range) • Knee Ligament Injury and Repair (ACL, Meniscus) • Heart Disease (valvular & dysrhythmia) • Hypertension (uncontrolled)

8. Disqualifying Conditions • Scars & Deformities of fingers or hands • Retained Orthopedic Hardware (location, location, location) • Pes Planus (flat feet) if symptomatic • Substance Abuse or Dependency • Allergic Manifestations: bees/buoys • Somnambulism (sleep walking) • Academic Skills Defect (ADHD, etc) • Seizure disorders

9. Disqualifying Conditions (complexity) • 1995-1996: the avg. waiver package had 1-2 disqualifying conditions. • Mid 1996 to present, the avg. waiver package has 3 or more disqualifying conditions. The complexity of the disqualifying conditions has increased dramatically for all services. • We won’t see the case if DoDMERB or MEPS approves the physical.

10. VISION: PARTS OF EYE

11. VISION

12. RADIAL KERATOTOMY(RK)

13. PHOTOREFRACTIVE KERATECTOMY(PRK)

14. LASER IN-SITU KERATOMILEUSIS(LASIK) “Flap and Zap”

15. REFRACTIVE SURGERY • We waive PRK or LASIK for initial accession. We do not waive RK • Three months post surgery with stable refraction • Less than 8.0 diopters of refractive error prior to surgery • Aviation/Undersea/Surface warfare have their own standards!!!! • PRK/LASIK is elective surgery and requires command approval.

16. ASTHMA • Asthma is one of the most common disqualifying condition for enlistment and USNA/NROTC applicants. • DoDD 6130.3 says that “…asthma, reliably diagnosed at any age, is disqualifying…”, but how diagnosed? • Asthma is over-diagnosed (as is ADHD) by family practice and pediatric specialists. It’s true.

17. Asthma • Utilize bronchoprovocation tests, e.g., methocholine or histamine challenge tests when records are not complete. • “The Gold Standard” is not really gold. • When they are not available, an exercise provocation test may be utilized. • REMAIN: We are waiving mild asthmatics at RTCGL in the near future and follow them for two years.

18. Academic Skills Defects (ADHD) • DoDD and MANMED both allow for DQ of individuals requiring medication or special adaptations for learning. • DQ for Academic Skills Defects, such as ADHD requiring medication, generates a lot of interest and communications.

19. Academic Skills Defects • Recommend a medical waiver for individuals who have been off of medications required to aid learning for 6 months if in a school environment for 1 year if employed. • Recommend waiver if “mainstreamed” and don’t require special learning adaptations. • Start to waive recruits who need Ritalin (controlled substance)

20. Knees • Injuries to the Anterior Cruciate Ligament (ACL) are very common in a young, athletic population. We do waive these but….they need at least six months to heal (nine months is better) and for us to waive them they must have a recent comprehensive orthopedic evaluation and a documented good level of activity.

21. Impact of Waivers- Discussion • 1) ROTC units serve as “feeders” of members qualified for unrestricted line and worldwide assignments • 2) If we waive someone with special needs, can the operational unit support them medically, pharmaceutically and administratively?

22. MENTAL HEALTH DIAGNOSIS OR “Doc, do you think I’m crazy?”

23. The Five Axis • DSM-IV IS THE Reference • I: Clinical Disorders “The Big Ones” • II: Personality Disorders • III: General Medical Conditions • IV: Psychosocial and Environmental Problems • V: Global Assessment of Functioning (GAF)

24. The Big Diagnoses • Major Depression “I’ve got the greens” Kermit the Frog • Bipolar Disorder (Manic-Depressive DO) • Schizophrenia “what voices?” • Post Traumatic Stress Disorder (PTSD) • SEXUAL ABUSE; rape, war, accidents • Substance Abuse “what problem?” • Personality Disorders

25. MOOD AND ANXIETY DISORDERS (Hunter/Gatherers) • Depression • Major (single episode, recurrent), Dysthymic • Bipolar Disorders • Hypomanic, manic • Anxiety Disorders • Panic DO with/w/o agoraphobia • Social Phobia, Obsessive-Compulsive DO • PTSD, Generalized Anxiety

26. Personality Disorders • An enduring pattern of inner experience and behavior that deviates markedly from expectations of the individual’s culture. Pattern is inflexible, stable and of long duration. Onset in adolescence. • Hint: think of a general type for remembering these

27. Personality Disorders • Paranoid: “I’ll sue” • Schizoid: “I want to be alone” • Schizotypal: Dungeons and Dragons • Antisocial: The biker • Borderline: “fatal attraction” Good/Bad • Histrionic: Richard Simmons • Narcissistic: “that’s enough about me, what do you think about me?”

28. PD CONTINUED • Avoidant Personality Disorder: “I’d like to have a relationship but….” • Dependent Personality Disorder: “please don’t leave me” • Obsessive-Compulsive Disorder: “have I washed my hands enough?”

29. Adjustment Disorders • The development of emotional or behavioral symptoms in response to an identifiable stress within 3 months. Once the stress is gone, the symptoms do not persist more than 6 months. • Subsets: depressed mood; anxiety; mixed anxiety and depressed mood; disturbance of conduct, etc.

30. ADHD/ADD • A three year old is hyperactive! • There is no test for ADHD despite what the media says (ex. CPT). The diagnosis is made subjectively by symptoms. • Most diagnosis are made by pediatricians and family practice docs • MEDS: Ritalin, Dexadrine, Cylert • Bottom Line: look at school performance and parental reports.

31. Counseling • What the heck is counseling? • There are over 500 different modalities of treatment. Primal Scream is my favorite. • Who did the treatment? M.D., SW, Chap • What was treated? Big diagnosis? • Where was the treatment done? Inpt/outpt • Why treatment?

32. CONCLUSION • Call BUMED early when you find out about medical problems. • The biggest problem you will have for mental health is to get records from Student Mental Health. • Alcohol abuse is a major issue on campus. MIDN diagnosed with abuse/ dependence must be treated to be commissioned.

33. PHYSICAL QUALIFICATIONS & REVIEW DIVISION QUESTIONS ? Please come and visit when in D.C. CDR GRUBB (202) 762-0553 lkgrubb@us.med. navy.mil

34. POINTS OF CONTACT • LCDR Paul Seeman (202) 762-3468 • Deputy Director, Family Practice • LCDR Rob Lipsitz (202) 762-0200 • Board Certified Family Practice • LCDR Bert Coombs (202) 762-0174 • Physician Assistant