Flight Med Frequent Flyerasmameeting.org/asma2013_mp/pdfs/asma2013_present_544.pdf · Distribution...

Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2164, 6 May 2013 1

Michael “Jethro” Jacobson, DO, MPH

Col, USAF, MC, SFS

Sanjay “Swipe” Gogate, DO, MPH

Lt Col, USAF, MC, SFS

USAF School of Aerospace Medicine

WPAFB, OH

RAM 2013

Flight Med Frequent FlyerFlight Med Frequent Flyer


Disclosure InformationDisclosure Information84th Annual Scientific Meeting84th Annual Scientific Meeting

Drs. Sanjay Gogate and Michael JacobsonDrs. Sanjay Gogate and Michael Jacobson

We have no financial relationships to disclose.

We will not discuss off-label use and/or investigational use in our presentation.


• Chief Complaint: “I feel tired all the time”

• History: 31-yr-old F-16 Viper pilot just arrived 1st assignment states that for the past 3 mo he has noticed an increase in daytime drowsiness and doesn't feel rested after sleeping.

• He is worried that he may get in the jet and be “unsafe”; he has only flown 4 sorties at this base over 1 mo.

• He feels this way daily and does not feel more rested after sleeping in on weekends.

• Member previously flew in KC-135s as a navigator for 5 yr without symptoms

Case PresentationCase Presentation


• HPI cont.: Daily sleep ranges from 6-8 h/night. Pt denies any known exacerbating/alleviating factors. Pt did not have these symptoms at his previous base (Fighter Pilot School) or assignments (KC-135 NAV).

• ROS: Pt denies fatigue, nausea, vomiting, bowel changes, shortness of breath, excess alcohol intake/snoring/allergies.

• + Occasional daytime headache• + Daytime drowsiness• + His 3rd sortie was a self-declared in-flight emergency for

hypoxia symptoms just after take-off, FL 7,000 ft. He denies any residual symptoms from that incident.

HPI/ROSHPI/ROS


• Medical: Tonsillectomy at 5 yr old; bilateral tympanic myringotomy @ 6 yr old

• Surgical: No other surgery• Allergy: NKDA• Meds: None• Family: Father – alive/healthy, prior USAF X 7 yr;

Mother – alive/healthy; 1 Sister – 28 yr old, alive, healthy, USAF officer (non-aviation)

Past HistoryPast History


• Vitals: Stable• Gen: Alert, oriented, lean, 5’ 8", 150 lb, BMI-23, appears younger

than stated age (31)• HEENT: Normal eyes, ears, eardrums; slight decreased

posterior pharyngeal space, tonsils absent, no significant deviated septum, no nasal erythema/edema

• Neck: Supple, no goiter• Psych: Slight anxious mood/affect• Rest of physical exam unremarkable: chest/lung; abdomen;

extremities; neurological

Physical ExamPhysical Exam


• Insomnia-transient• Obstructive sleep apnea (OSA)• Anxiety • Fear of flying/non-phobic manifestation of

apprehension

Differential DiagnosisDifferential Diagnosis


• Member’s sleep study shows mild OSA, Apnea-Hypopnea Index=5 (plus symptoms) treated and controlled with oral device

• OSA severity is defined as mild for Respiratory Distress Index ≥ 5 and < 15, moderate for RDI ≥ 15 and ≤ 30, severe RDI > 30/h (Consensus AASM-Adult OSA Task Force 2009)

Obstructive Sleep Apnea – OSAObstructive Sleep Apnea – OSA


A Return to FlightA Return to Flight

• As part of OSA work-up, member sees clinical psychologist and states he is feeling overwhelmed by amount of studying required, his feelings of finally meeting his goal of flying the F-16 as being somewhat anticlimactic, lack of enjoyment for flying. No psych diagnosis was made at this time.

• Disposition: The pilot gets a waiver to return to fly for OSA after being cleared by USAF Aeromedical Consultation Service (ACS). Member was also given diagnosis of “occupational problem,” not disqualifying.


• 6 mo later, the next flight is scheduled, the pilot is nervous, not be able to “step” to the jet and returns to Flight Medicine. He says, “I just can’t do it, I don’t know why.”

• Member had flown KC-135 for 5 yr previously as a navigator.

Frequent FlyerFrequent Flyer


• Fear of flying• Anxiety • Anxious mood (AM)• Phobia• Adjustment reaction (AR)• Adjustment reaction with anxious mood

(ARAM)

What is the diagnosis?What is the diagnosis?


Aeromedical Considerations


Aeromedical ImpactAeromedical Impact

· “Adjustment disorder…one of… most common psychiatric diagnoses among aviators”

· Often associated with functional impairment due to· decreased concentration, …inattention · decreased working/short-term memory · insomnia, fatigue, temporary changes in social relationships,

and problems with decision making

· All incompatible with aviation duties


Aeromedical GuidanceAeromedical Guidance

· Flying Classes I/IA, II, III, IIU· AFI 48-123, 6.44.24.1.16. Adjustment disorders are DQ if

more than 60 days duration

· Air/Ground Traffic Control, Space/Missile Duty· Not specific DQ; however,…6.46.15.7. Any…mental condition

that may render the individual unable to safely perform controller duties

· “Unsuiting conditions” AFI 36-3208 5.11· If adjustment problems -> unsatisfactory duty performance· Fear of fly/controlling if lack DSM-IV criteria for disorder· =Administrative (i.e., not medical disability process)


Disposition GuidanceDisposition Guidance

· DNIF (duties not including flying) initially· If resolves within 60 days: return to flying

status (RTFS)· If exceeds 60 days: waiver required

· Mental health evaluation· Trained assets: no specific waiting period, but

sufficient to suggest no recurrence· Untrained assets: 1-yr waiting period after

resolution before waiver submission


Waiver ConsiderationsWaiver Considerations

· Must not pose a risk of sudden incapacitation· Must pose minimal potential for subtle performance

decrement, particularly with regard to the higher senses· Must be resolved, or be stable, and be expected to remain so

under the stresses of the aviation environment· If the possibility of progression or recurrence exists, the first

symptoms or signs must be easily detectable and not pose a risk to the individual or the safety of others

· Cannot require exotic tests, regular invasive procedures, or frequent absences to monitor for stability or progression

· Must be compatible with the performance of sustained flying operations


Waiver RequirementsWaiver Requirements

· Mental health consultation – · Must address criteria listed on previous slide· Comprehensive history (incl. medical, meds…)· Test results (lab, neuropsychological/cognitive)· Current mental status, diagnosis, motivation to fly· Prognosis, need for future treatment· Mental health records

· FS Aeromedical Summary: include job impact· Commander’s support letter


Aeromedical DispositionAeromedical Disposition

· RTFS: “fear of flying” – did not complete F-16 sortie· Waffled re: F-16 fly: wants to fly – refused 2 sorties· Cleared medically· Flying Evaluation Board: no loss of Flight wings, re-

assigned to E-8 Joint Surveillance Target Attack Radar System

· ARAM completely resolved; no further tx necessary· Successful career in KC/RC-135s since


SummarySummary

· Adjustment reactions – common· Adjustment disorder and/or fear of flying may

underlie initial complaints· Non-phobic fear of flying not considered

medical condition


BibliographyBibliography

· U.S. Army Aeromedical Activity. Flight surgeon’s aeromedical checklists. Aeromedical policy letters. Ft. Rucker, AL: U.S. Army Aeromedical Activity; 2008 Mar 31.

· U.S. Air Force School of Aerospace Medicine. Air Force waiver guide. Wright-Patterson AFB, OH: U.S. Air Force School of Aerospace Medicine; 2013 Jan 24.

· Naval Aerospace Medical Institute. Aeromedical reference and waiver guide. Pensacola, FL: Naval Aerospace Medical Institute. (n.d.).

· Federal Aviation Administration. Guide for aviation medical examiners. Washington, DC: Federal Aviation Administration; 2013.


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