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The Work of the Aviation Medical Examiner

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  1. The Work of the Aviation Medical Examiner Dr. Martin F Hudson MBBS, MRCP(UK), FRCP Edin. Immediate Past Chairman of the Association of Aviation Medical Examiners Authorised Medical Examiner for UK CAA, EASA, FAA (USA), CASA (Australia),Transport Canada Company Medical Adviser Thomas Cook Airlines June 2011

  2. The Main Priorities • To assess the physical and psychological fitness of Aircrew and Air Traffic Control Officers to fulfil safely their role in aviation • To comply with the requirements of the regulations of the relevant licensing authority

  3. Who do we examine? • Class 1 Commercial Pilots - Renewals, Re-validations. NB All initial Class 1 performed at AMS, i.e. CAA Gatwick • Class 2 Private Pilots - Initial, renewals and Re-validations • European Class 3 ATCO • UK Class 1 Flight Engineers, Flight Navigators, Flight Information Service Officers, Aerodrome Control Officers, Commercial Balloon Pilots,Commercial Airship Pilots,Class 2 Private Balloon Pilots

  4. Who are the examiners? • Aviation Medicine Specialists • Occupational Health Physicians • General Practitioners • Private Practitioners • Consultants • Military Medical Officers

  5. Availability • Commercial pilots: Available to all air-lines and aviation commercial organisations • Pilot’s freedom of choice • Private Pilots • Information not advertising • Web-sites: information and on-line booking • e-mail

  6. Appointment as an Authorised Medical Examiner • Appointed by the CAA or relevant authority • Guaranteed appointment if suitably qualified • No upper retirement age • No waiting lists • Initially appointed for Class 2 only then up-graded to Class 1 after a period of time and on completion of further training and examinations

  7. Accreditation as an AME • Interest and experience in Aviation Medicine/Armed Forces • Basic Certificate in Aviation Medicine (minimum of 60 hours) Class 2 • Advanced Aviation Medicine Certificate (minimum of 120 hours) Class 1 • Diploma in Aviation Medicine • Flying experience, CPL, ATPL, PPL, NPPL

  8. Appointment as an AME • Class 1 requires minimum 6 points • Class 2 requires minimum 4 points • 3 points for completion of higher training • 2 points for Dip. Av. Med. • 1 point for 1 year work in aviation medicine practice • ICAO PPL or NPPL 1 point • ICAO CPL or IR 2 points

  9. History of AME Training Courses • General Aviation Course (Farnborough) GAM: 5 days started 1973 • Initially linked with Aviation Medicine Course for Armed Forces MOs. • 1984 expanded to 10 days • 1998 IAM Farnborough closed • 1998 Kings College, London - Advanced and Basic Courses. • Diploma in Aviation Medicine

  10. Other Aviation Authorities • EASA (European Aviation Safety Agency) • FAA (American) • CASA ( Australian) • Canadian • Singapore • Others: e.g. China, Hong Kong, New Zealand, UAE, South Africa, Middle East • ? Global harmonisation

  11. The Medical Examination • Appointments • Consulting room(s) • Lighting • Administration/secretarial/financial • Nursing assistant • Computerisation - Internet - e-mail • On-line transmission of medical examination

  12. Equipment • Basic examination instruments • Couch • Stethoscope • Auroscope + speculae • ? (Aural syringe) NB Medico-legal • Ophthalmic equipment • Torch

  13. Equipment • Height measure and weighing scales • Sphygmomanometer ?Mercury,Aneroid,Automatic (NB validation and calibration) • Audiometer (NB annual calibration) • 12 lead ECG with computerised interpretation (? + modem capability) • Haemoglobinometer (calibration) • Urine testing kit (Hema-combistix) • Venepuncture (laboratory facilities) • Peak flow meter

  14. Ophthalmic Equipment • Snellen Charts; 6 metres and 1 metre (use of mirror is permitted to achieve distance) • RAF Near Point Rule • Ishihara plates (24): 15 to be read correctly • Maddox rod/wing (phoria testing) + light • Ophthalmoscope • Eye mask/cover and Pin Hole disc • Vision tester e.g. Titmus

  15. The Examination • The History • The Clinical Examination • Investigation

  16. The Medical History • Initial: All previous medical/surgical/psychological • Revalidation/Renewals: Recent events (since last examination) • Recreational drugs - alcohol, tobacco,others • Medications - OTC, Prescribed • Check pilot’s entries and accuracy on application form. N.B.’tickitis’!!! • NB Thoroughness, deliberate omissions, non deliberate omissions, life-time not just recent for initial examinations

  17. Physical/psychological fitness • Exercise • Diet • Hobbies • Commuting • Family • Sleep • Fatigue

  18. Psychological History • Stress - work and domestic ? Second jobs • Anxiety • Sleep history, Fatigue, Epworth sleep scale, sleep apnoea • Depression; ? use of depression scoring questionnaires • Alcohol problems / use of CAGE questioning • Drug dependency • ‘Gut-reaction’

  19. Epworth Sleepiness Scale • How likely are you to doze off in the following situations in comparison to feeling just tired? • 0 = never; 1 = slight chance; 2 = moderate chance; 3 = high chance • Sitting and reading • Watching TV • Sitting inactive at a meeting • Passenger in a car for an hour with no break • Lying down to rest in the afternoon • Sitting and talking to someone • Sitting quietly after a lunch without alcohol • In a car, while stopped for a few minutes in traffic

  20. The Physical Examination • Careful full routine clinical examination • Use examination to prompt more history from pilot. i.e. palpation of liver/auscultation of chest • Ophthalmic: uncorrected and corrected, contact lenses and spectacles • ENT ? Valsalva maneoeuvre • Other examinations as clinically indicated • ? Rectal • ? Breasts and genitalia • NB Chaperone strongly recommended. GMC/CAA consider this is essential

  21. Ophthalmic standards • Myopia for initial Class 1: +5 to – 6 • Myopia for renewal/revalidation; no limits • Astigmatism (irregular shape of the cornea)/Anisometropia (unequal refractive power of the eyes) initial Class 1: 2 dioptres • Astigmatism/Anisometropia no limits for Class 2 and for Class 1 renewal/revalidation • Esophoria Class 1 limits now 8 prism dioptres • Amblyopia V/A in non amblyopic eye must be 6/6 corrected or uncorrected

  22. Comprehensive Ophthalmic Examination for pilots with high degree of refractive error (RE) • Not required for RE up to +3 to – 3 • Required every five years for Class 1 pilots with RE +3 to +5 or –3 to –6 • Required every 2 years for Class 1 pilots with RE > - 6 • Anisometropia and/or astigmatism of 3D requires 2 yearly ophthalmic review • CAA Optometrist’s Excel calculator available on-line for checking exact requirements

  23. Comprehensive Ophthalmic Examination for pilots with high degree of refractive error • Performed by any Optometrist • Includes refraction, slit lamp, • Tonometry IOP (> 40 years of age) • *Colour vision (Ishihara 24/15 plates), phoria,visual fields, fundoscopy • * Initial examination only for CAA but each medical for FAA, Canadian, CASA

  24. Comprehensive Ophthalmic Examination for ATCO’s, Flight engineers, navigators • Required at initial examination • Colour perception • Phorias

  25. European Class 3 (ATCO)Periodic Requirements • Comprehensive ophthalmic examination every two or five years depending on refraction level • Tonometry every 2 years • Haemoglobin every 2 years

  26. JAA Class 1 or Class 2 Visual Limitations Endorsements • 2 VDL; Vision Distance Limitation (shall wear corrective lenses and carry a spare set of spectacles) [myopia] • 3 VNL; Vision Near Limitation (shall have available corrective lenses) [presbyopia] • 4 VCL; Flights only within JAA airspace. VFR flights by day only (colour vision defects) Class 2 PPL only.

  27. Spectacles/contact lenses requirements • 3 VNL for presbyopia look over or varifocal with no upper lens correction + back up • 2 VDL with no presbyopia correcting spectacles or contact lenses + back up spectacles. NB Not back up contacts lenses • 2 VDL + VNL; varifocals,bifocals,trifocals or contact lenses + look over half rim

  28. Limitations for European Class 3 ATCO • APC Standard proximity condition • ATL Valid only while wearing correcting spectacles for ATCO licence (distance vision) • AUD Annual audiogram required • CLL Valid only while wearing contact lenses with alternative spectacles available • RLL refer to limitations on licence • IGR Issued under ‘grandfather rights’ • VSA Valid only when corrective spectacles available (near vision requirement)

  29. Spectacles/contact lenses requirements • No photochromic lenses. Tinted lenses OK • No varifocal or near vision contact lenses or mixed contact lenses • Check vision uncorrected and with both contact lenses and spectacles • Back up MUST be same prescription. Not ’old’ pair of spectacles • Annual or bi-annual check with optometrist advised even if not CAA requirement especially over 40 years of age, NB Tonometry advised

  30. Refractive surgery • Generally not recommended for pilots • 3 month flying ban post operation • Detailed ophthalmic reports required • Class 1 pre-op limit – 6 • Class 2 pre-op limit – 8 • Post operation complications may occur , glare, distortion, pain, corneal complications

  31. ENT examination • Visualise Tympanic membrane • ? Removal of wax • Valsalva and patency of Eustachian tubes • Nasal airway assessment • Sinuses • 2 metre conversational voice test each ear separately

  32. Investigations • Measurement of the blood pressure (seated) • ECG with computerised interpretation • Audiometry (250 - 8000 Hz) • Urine - protein, blood, glucose • Blood testing – haemoglobin at each medical, cholesterol (once only at age 40) • Peak Flow Rate, initial Class 1 only unless clinically indicated • Other investigation as clinically indicated

  33. ECG interpretation • Computer reading • Certain ‘abnormalities’ accepted as normal • Read rhythm strips not read by computer • Select appropriate computer code NB different codes for Pilots and for ATCOs • Seek local opinion from cardiologist for abnormal Class 2 ECGs. • Keep ECG reading skills up-to-date

  34. Disposition • Calculate and include all expiry dates i.e. for single/double pilot/private pilot(Class 2) Automatic if done ‘on-line’ • Include dates of last ECG and Audiogram • Stamp with appropriate limitations • Issue medical certificate - signed in presence of the AME by the applicant and witnessed and signed by AME with name under signature • Remind pilots to read back of their medical certificate which lists extract from regulations and a pilot’s responsibilities • Defer for further assessment • Deny

  35. Operational Safety Endorsements • 5 OML: Valid only as or with qualified co-pilot ( NB 2 OMLs can now fly together) This endorsement applies to Class 1 pilots. Probably not going to be permitted under EASA rules • 7 OSL: Valid only with safety pilot and in aircraft with dual controls. This endorsement applies to Class 2 (Private Pilots) • SSL: Special safety limitations e.g.annual audio • FHA: functional hearing assessment (completed by training pilot, captain, qualified instructor)

  36. Deferred assessments • Inform and explain to the pilot the process • Work up case as much as possible • GP/Hospital liaison • Pilot’s consent for information • CAA Algorithms for guidance • Liaison with CAA

  37. Current Validity of JAA medical certificates • Class 1: 12 months <60: 6 months > 60 for multi-pilot operations • Class 1: 12 months <40: 6 months > 40 for single-pilot operations • Class 2 : 60 months < 40 • Class 2 : 24 months 40 - 49 • Class 2 : 12 months > 50 • NB The 45 days pre expiry date rule • For renewals new date of expiry is anniversary of date of issue

  38. Validity of European Class 3, UK Class 1 and NPPL certificates • ATCO: < 40 24 months • ATCO: > 40 12 months • 45 days rule now applies for ATCOs’ as for Pilots • Flight engineers, navigators:12 months • NPPL Initial valid to age 45 then up to 65 years of age: 60 months. > 65: 12 months

  39. European Class 3 ATCOs and periodicity of ECGs • Less than 30 48 months • 30 - 39 24 months • 40 and over 12 months

  40. Flight Eng. & Flight Nav. periodicity of ECGs • < 30 60 months • 30 - 39 24 months • > 40 12 months

  41. European Class 3 ATCOs and periodicity of Audiograms • < 40 Every 48 months • > 40 Every 24 months

  42. European Class 3 ATCO’s other clinical requirements • Comprehensive ophthalmology examination; at initial then refraction within +5 and – 6D: 5 yearly, more than –6D: 2 yearly • Tonometry; at initial then 40 +: 2 yearly • Haemoglobin estimation under 40: 4 yearly • 40+: 2 yearly • Other tests i.e. Respiratory, CXR, EEG only if clinically indicated

  43. Flight Engineers & Flight Navigators: periodicity of Audiograms • < 40 60 months • > 40 36 months

  44. Audiometry for JAA Medical Class 1 and 2 Certificates • Class 1; at initial then under 40, 60 months, 40 and over 24 months • Class 2; Instrument rating only at initial then under 40: 60 months, 40 and over 24 months

  45. ECG Requirements for JAA Class 1 and 2 • Class 1 initial ( CAA Gatwick) • Class 1 renewal; < 30: 60 months: 30 - 39 24 months: 40 – 59: 12 months: 50 and over 6 months • Class 2 at initial (all ages): 40 – 49: 24 months: 50 and over 12 months

  46. ECG coding • Class 1; 55 normal 56 abnormal • Class 2; 70 normal 71 abnormal • European Class 3 (ATCOs) 58 normal 59 abnormal • Only the ECGs coded abnormal are seen by CAA cardiologists • ECG computer coding diagnosis must comply with CAA guidelines.

  47. Blood tests • Class 1 Haemoglobin every medical • Class 1 Cholesterol (fasting Lipids) at age 40 • European Class 3; Haemoglobin every 4 years under 40 and every 2 years over 40. • Class 2 Haemoglobin at initial plus any other tests as clinically indicated. • Class 2 Cholesterol if more than two coronary risk factors identified at initial (at any age) or if 40 years of age or older for renewal/revalidations. • Other tests as clinically indicated • No blood tests required for UK Class 1

  48. Pitfalls • Poor history taking • Hurried examinations • ‘Tickitis’!! • Deniers - pilots want to pass the examination! • Bogus applicants - NB photo identification • Too low index of suspicion

  49. Administration • Records/medical files/computer/CAA on-line • Booking appointments • *Forms: application (can be printed from on-line system), medical, ophthalmic, ENT * only needed for back up if on-line system fails or for non CAA/JAA applicants i.e. Ireland • Medical Certificates • Renewals/reminders/on-line booking systems • Computerisation/ Web sites/ E-mail

  50. Administration - finance • Charges • Debit or credit cards/cheques/cash • Accounts – book keeping • Income tax!! • Expenses • VAT