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NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N.W. (202) 234-4433 WASHINGTON, D.C. 20005-3701 www.nealrgross.com

UNITED STATES COAST GUARD + + + + + 11TH MEETING OF THE MERCHANT MARINER MEDICAL ADVISORY COMMITTEE Day I + + + + + TUESDAY April 4, 2017 + + + + +

The Committee met at the National

Maritime Center, 100 Forbes Drive, Martinsburg,

West Virginia, at 8:00 a.m., Captain Margaret

Reasoner, Chair, presiding.

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PRESENT CAPTAIN MARGARET REASONER, MEDMAC Chairperson LESLEY KARENTZ, MEDMAC Vice Chairperson, RN, Medical Professional DR. BRIAN BOURGEOIS, Medical Professional LOUISE BROCK, RN, Medical Professional DANIELLE CAMENZULI, PA-C, SUNY Maritime College CAPTAIN ELIZABETH CHRISTMAN, Professional Mariner JEFF LANTZ, Director of Commercial Regulations and Standards MAYTE MEDINA, Chief, Office of Merchant Mariner Credentialing, DFO DR. JOSEPH MIGNOGNA, Medical Professional BROOKE RUSSELL, OHN, Kirby Marine Transportation DR. ERIC SCHAUB, Medical Professional DR. RAGHU UPENDER, Medical Professional ALSO PRESENT DR. ADRIENNE BUGGS, ADFO LTJG JAMES FORTIN, CG-MMC-2, ADFO LUKE HARDIN, CG-MMC-1, ADFO DR. TIMOTHY BERGAN, Force Medical Officer, Military Sealift Command KAREN W. COHEN, RHIA, Corporate Health Resources, Inc. CLAY DIAMOND, American Pilots Association DR. DEBORAH EICHELBERGER, MD, National Maritime Center IKE EISENTROUT, Deputy Director, National Maritime Center JERALD JERVI, USCG, NMC6 KIMBERLY KAPSIAK, Kirby Corporation MARK KELLY, Anderson-Kelly Associates, Inc. CAPT KIRSTEN MARTIN, USCG, NMC Commanding Officer KAI NEANDER, GWU, Maritime Medical Access Program MIRIAM NESHEWAT, Anderson-Kelly Associates, Inc. EDWARD O=BRIEN, Vice President, NACO JJ PLUNKETT, Houston Pilots

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ALSO PRESENT (CONTINUED) ROBERT QUIGLEY, Keystone HEATHER SAWAGID, Anderson-Kelly Associates, Inc. ROBERT SHEARON, Houston Pilots TRACI SILAS, DHS CMO/FACA CDR MICHAEL SIMBULAN, CG-INV-2 JUSTIN STEPHANY, Anderson-Kelly Associates, Inc. DR. LAURA TORRES-REYES, Medical Evaluations Division Chief, National Maritime Center CONNIE TURNER, Corporate Health Resources, Inc. DAVID VAN NEVEL, Attorney Advisor to the Office of Merchant Mariner Credentialing ANNE WEHDE, MARAD, Office of Labor and Training AUTUMN WELCH, USCG, NMC6 RICHARD WELLS, Vice President, OMSA

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TABLE OF CONTENTS Call to Order and Opening Remarks 6 Opening Remarks from the Coast 10 Guard Leadership

Captain Kirsten Martin Administrative Issues 12

LTJG James Fortin Opening Remarks from the Coast 14 Guard Leadership (Continued) Introductions 21 Task Statements from Previous Meeting 28

LTJG James Fortin Task Statement 25, Medical Manual 32

Dr. Adrienne Buggs Questions and Comments 45 New Committee Members Sworn-In 44 Introductions of New Members 49 Laws and Regulations Applicable to 52 the Medical Certificate

David Van Nevel Questions and Comments 69

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TABLE OF CONTENTS (CONTINUED) The 719K

Dr. Laura Torres-Reyes 74 Autumn Welch 77

Questions and Comments 83 Opportunity for Public Comment 129 Introductions 138 Motion on New Task Assignment, to Take 139 the Culmination of Some Work and Review It at the Medical Manual (Motion passed) Assignment to Tasks 140 Preparation for Breakout Working Groups 143

Traci Silas Working Group Summaries Medical Manual 149 Health Risk Analysis 150 Appropriate Diets and Wellness 151

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P-R-O-C-E-E-D-I-N-G-S 1

8:25 a.m. 2

MS. MEDINA: Good morning, everyone, 3

and welcome to the MEDMAC meeting. 4

First of all, I would like to thank 5

Captain Martin and the National Maritime Center for 6

allowing us to the 11th MEDMAC meeting here at the 7

NMC. It seems only fitting that MEDMAC would be 8

meeting here. Last time we were here was in 2011. 9

I'm Mayte Medina, and I'm the 10

Designated Federal Officer for this meeting. Mr. 11

Luke Hardin, Dr. Adrienne Buggs, and Lieutenant JG 12

James Fortin are the Alternate Designated Federal 13

Officers for this meeting. 14

First of all, I would like to start by 15

saying that our appointments were signed yesterday 16

afternoon by the Department of Homeland Security. 17

And yesterday morning we didn't have a Chairman and 18

Vice Chairman. I'm happy to report that we have 19

a new Chair, Captain Margaret Reasoner, and a new 20

Vice Chair, Lesley Karentz. So, congratulations 21

on your new appointments. 22

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(Applause.) 1

I was very saddened by the news that 2

Captain Mahoney had resigned and Captain Bob 3

Bourgeois decided not to reapply for his 4

appointment. 5

We have two reappointments that were 6

made, and this was Lesley Karentz and Dr. Brian 7

Bourgeois, the reappointments. And we will have 8

five new appointments for the next meeting. Emily 9

Reiblen, Brooke Russell, Danielle Camenzuli, Dr. 10

Rafael Lefkowitz, and Captain Joy Manthey are the 11

new appointments. As you will know, we were not 12

able to get them here since we only received those 13

yesterday afternoon. 14

I would like to also mention that this 15

meeting was advertised in The Federal Register on 16

Thursday, March 2, 2017. There have been no public 17

comments posted through the dockets as of March 18

31st, 2017. To date, MEDMAC has held 10 full 19

Committee meetings and two intersessional 20

meetings. 21

As stated in the agenda of this meeting, 22

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we will be reviewing the following tasks: provide 1

review of the Merchant Marine Medical Manual; 2

provide recommendations on appropriate diets and 3

wellness for mariners who are onboard merchant 4

vessels; conduct and provide Mariner Occupational 5

Health Risk Study Analysis; provide 6

recommendations on revisions of NVIC 04-08. 7

I would like to remind you that, if you, 8

an immediate family member, an organization for 9

whom you serve an officer, director, trustee, 10

partner, employee, a prospective employee of this 11

particular matter, you must disqualify yourself 12

from participating in this discussion, 13

deliberations, and voting on the issue. 14

However, note that an exemption to this 15

rule allows for the participation of the members 16

whose financial interest is in the members' 17

non-federal employee if the matter will not have 18

a special or distinct effect on the employer, other 19

than a member of the employer's industry. 20

As I said, we do have these four task 21

statements. I would now like to take the 22

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microphone back for my remarks. 1

Our staff was very impressed at the last 2

meeting working with the doctors and the members 3

of the Committee. There is a wealth of knowledge 4

that you have that is very important for the Coast 5

Guard. 6

I know that you are a relatively-new 7

Committee when we compare with the other 8

committees, but I can tell you that your expertise 9

is actually helping us. And you will be hearing 10

today and tomorrow already, the recommendations 11

that you have made, where have they gone? That is 12

the first question that anybody that provides help 13

to the Coast Guard asks, which is you volunteer your 14

time, and the least we can do is to make sure that 15

we let you know where that information went. 16

With that, I would like to ask now 17

Commanding Officer of the National Maritime 18

Center, Captain Kirsten Martin, for a few words. 19

CAPTAIN MARTIN: Good morning, 20

everyone. Welcome to this Committee and new 21

Committee members to the National Maritime Center. 22

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We are very happy and honored to be your host for 1

this next two days in the public meeting here. 2

I think James will cover some other 3

admin stuff, but, first and foremost, facilities 4

and safety. I think everyone knows that the 5

restrooms are right here. You go out, make a 6

right, and then, take your first left, and you will 7

see the men's and women's restrooms. Those are the 8

facilities. There's a small galley there as well, 9

soda machines, fridge, water available there. 10

If there was some type of emergency, you 11

would follow your Coast Guard personnel out to our 12

muster station which would be right in the parking 13

lot, pretty much directly in front of the building 14

in the far right corner. So, knock on wood, we 15

won't be evacuating. I already heard some of you 16

had to evacuate the hotel this morning. So, we've 17

checked every toaster on the property to make sure 18

there's no bagels that are going to burst into 19

flames. 20

But I look forward to you all 21

participating in a very productive session here. 22

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I know we have key members of our NMC-6 staff ready 1

and available to help you. Dr. Laura 2

Torres-Reyes, who you all met at the last meeting, 3

is here, and her staff has really taken the lion's 4

share of organizing this event. 5

So, if you have any questions, please 6

don't hesitate to ask Doc TR; also, Ike Eisentrout, 7

our Deputy Director, is here as well. And we will 8

be in the meetings as much as we can. 9

We have our Regional Exam Center 10

Chiefs' meeting these couple of days as well as the 11

first deck. So, we're kind of splitting our time 12

between those two groups, between you and, then, 13

our Regional Exam Center Chiefs, who we need to meet 14

with more often than we do, but we were able to get 15

them all together. It just so happened it was all 16

at the same time. 17

So, again, thank you very much, and 18

please let us know, as your host, if there is 19

anything we can do to make this meeting a little 20

bit more productive. We will check on the speaker 21

issue, see if we can get that working a little bit 22

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better. But we are here really to serve you and 1

serve the Committee over the next couple of days. 2

Thank you. 3

MS. MEDINA: Thank you very much, 4

Captain. 5

Lieutenant JG James Fortin, on 6

administrative issues. 7

LTJG FORTIN: Thank you. 8

Good morning. My name is Lieutenant JG 9

Fortin. 10

Thank you, Captain Martin, and thank 11

you to the NMC staff. They have been great so far 12

helping us get this set up. 13

I just had a couple of admin issues that 14

I wanted to go over. First of all, we've got 15

coffee, water, some snacks, and then, some fruit 16

and vegetable trays in the back. So, please help 17

yourself to any of that. 18

As Captain Martin stated, the restrooms 19

are straight down the hall and to the left. 20

Your visitor badges, if anybody intends 21

on just staying today and departing afterwards, 22

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please make sure we get your visitor badge back 1

today. If not, we will be collecting them 2

tomorrow. 3

If anybody has their phone or laptop or 4

tablet, we've got a guest WiFi set up for 5

everybody's personal use. 6

And that's about all that I have. Oh, 7

and so, as far as the NMC building goes, please keep 8

in mind that, as Captain Martin stated, we still 9

have staff here who are working throughout the 10

building today. And so, please be mindful to just 11

stay in the conference room, the restrooms down the 12

hall, and then, down on floor one as you exit the 13

building. So, offlimits, only one and three. And 14

for assistance with anything, please let myself or 15

one of the NMC staff know and we will be happy to 16

help you with it. 17

Yes, Captain? 18

CAPTAIN MARTIN: Sorry, I have one more 19

comment. I didn't point out Jen Vankirk in the 20

back. She works with Doc TR. She also has been 21

working closely with James on setting this meeting 22

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up. So, another good point of contact for 1

logistics. 2

And we are offering two flexi-tours 3

over today or tomorrow. I am not sure who has been 4

to the NMC before versus who has not, but it is a 5

unique place. It is the only place, obviously, 6

where we are doing this kind of work for the U.S. 7

merchant mariner, and we will offer some building 8

tours, but we're trying to work that into the 9

schedule of the work groups and the Committee work 10

that needs to occur. 11

So, the only thing we would point out 12

is that our credential printers kind of shut down 13

at 1500 each day. So, if you wanted to see those 14

in action, knock on wood, that they're actually 15

working. 16

Then, just in terms of when you would 17

want to schedule the tour portion of the building? 18

LTJG FORTIN: Thank you, Captain. 19

We had Ms. Traci Silas from the 20

Department of Homeland Security scheduled next, 21

but I have not seen her. 22

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So, we will just go next to introduce 1

Mr. Jeffrey Lantz. He is the Director of 2

Commercial Regulations and Standards at Coast 3

Guard Headquarters. 4

MS. MEDINA: Before we do that, I just 5

want, Captain Reasoner, the meeting is yours. 6

CAPTAIN REASONER: So, that means you 7

want to make welcoming remarks? Well, maybe I'll 8

start with some welcoming remarks and just thank 9

everyone for being here. 10

MR. LANTZ: Sure. 11

CAPTAIN REASONER: And thank you, 12

Captain, for hosting us. It is nice to get back 13

to the National Maritime Center. Pretty much the 14

thing we are most concerned about is mariners' 15

health. That gets evaluated here. 16

So, I'm excited to take over. I have 17

been attending these meetings now pretty much since 18

the inception. I deal with a lot of mariners. So, 19

this is an issue near and dear to my heart, and for 20

the safety and health of our mariners. 21

So, I am looking forward to it. I will 22

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probably make some mistakes. This is the first 1

time as the Chair at this level. 2

This meeting is also, when I compare it 3

to some of the other Coast Guard advisory meetings, 4

we are a little young. I think those that are used 5

to advisory meetings will say that. Having 6

attended others, I think we are young. So, I hope 7

we can improve just our formatting and how we 8

operate the meetings. I think we have been very 9

productive to point. Hopefully, our area of 10

responsibility and advisory to the Coast Guard when 11

it comes to health issues will expand and that we 12

can continue to be effective and providing good 13

advice to the Coast Guard. 14

Anyway, with that, I will turn it over 15

to you. 16

MR. LANTZ: Thank you, Madam Chair. 17

We always have this issue. How do we 18

address chairmen when they are women? So, I can 19

tell you that at IOM they have come to the term 20

"Chair". So, you're Chair. So, if this was in 21

French or Spanish, I think -- in it 22

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Spanish? -- French for sure, if you say "Chair," 1

you're actually referring to a piece of furniture. 2

It's the way the language works out. So, we prefer 3

not to refer to people as a piece of furniture. 4

Anyway, I would like to say thank you 5

and welcome everybody to the National Maritime 6

Center. It's always great to have the meetings up 7

here. And I thank Captain Martin for allowing us 8

to intrude. I know that she is busy. 9

But I would recommend, if anybody can 10

take advantage of the tour of the building and to 11

see it in action, I would highly recommend that. 12

I certainly welcome all the members of 13

MEDMAC who make it and come here, but a special 14

thanks to Captain Reasoner to take over as the 15

Chair, the Chairperson, and also Lesley Karentz for 16

agreeing to be the Vice Chair. We really do thank 17

you for agreeing to take this on. 18

I think last meeting -- this is my 19

second meeting here at MEDMAC, and this is all as 20

the result of the organizational change we had at 21

Headquarters. And we talked a little bit about 22

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that, where we consolidated all of the policy 1

credentialing at Headquarters, and it now resides 2

with me, which I am very happy and honored to have. 3

But I think the one issue we hadn't 4

discussed or we hadn't pointed out last time 5

because it was new in the reorganization was that 6

Mayte Medina is actually now officially the Office 7

Chief. So, everything falls on her. So, if the 8

coffee is no good, okay, if the organizations are 9

no good, any complaints, just let me know about her 10

performance. I would be appreciative of that. 11

While preparing for this meeting -- and 12

like all the advisory committee meetings that we 13

have, it's always a great gratitude to see the work 14

by the members and the work of the Committee that 15

it does, and how much value that it provides to the 16

Coast Guard. As has been mentioned -- Mayte 17

mentioned it -- your expertise is very valuable and 18

we certainly take advantage of that. 19

A couple of things. You know, the 20

Coast Guard is well on its way to revising the 21

Merchant Mariner Medical Certificate, which you 22

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have had a great deal of input on, which we are 1

grateful, and we thank you for that. 2

Last year in April we published the 3

change to the Medical NVIC. That Medical NVIC, 4

right after I got the job I am in now, I think the 5

first version of the Medical NVIC landed on my desk, 6

and it was, let's just say it wasn't well-received. 7

And so, at that point in time, I said we needed to 8

get MERPAC input on it and get the industry input 9

on it. And I think that has happened. And so, 10

again, my thanks to you for the input you had on 11

that particular revision of the NVIC. 12

But I think, in your wisdom, you kind 13

of kept that whole thing open, that task statement, 14

because we are now coming up to the Merchant Medical 15

Manual, which is, I think, in the final stages and 16

we are going to be having a task statement on that, 17

which will kind of, as I understand, take over for 18

the NVIC. So, again, we are looking for your input 19

on that. Yes. 20

So, again, I would like to thank all the 21

attendees and say it is an honor to be here. 22

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We mentioned about mariner safety, how 1

critical that is, and I couldn't agree more. As 2

I have told Captain Martin and all those in the 3

credentialing program, within the broader context 4

of the Maritime Safety Program, you know, and 5

preventing things from happening, a lot of the work 6

we do, we will go out and we inspect ships. We say, 7

you know, you need to do this; you need to do that. 8

We are actually impacting the actions of a company 9

or an organization, where it is money they have to 10

spend. 11

But, when it comes to credentialing and 12

the medical, you know, the impact, while it does 13

have an impact on safety, it impacts the individual 14

mariner, you know, their way of life, how they earn 15

a living, how they provide for their dependents, 16

all those kinds of things. So, this is really, 17

really critical. 18

This is really touching a personal 19

point within the whole Marine Safety Program and 20

the Shipping Program. So, I don't think we should 21

lose sight of that. I think, again, it just raises 22

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the stakes on how valuable the input that we get 1

from MEDMAC as we go forward on this. 2

Again, I realize that MEDMAC probably 3

is not your full-time job, and your agreeing to take 4

time out of your full-time job to participate in 5

this, it is just all the more to, again, thank you 6

from the Coast Guard. 7

With that, I will hand it over to you. 8

CAPTAIN REASONER: At this time, we 9

want to do introductions. So, we can start around 10

the table here and, then, those who have come to 11

the meeting, introduce yourself. 12

CAPTAIN CHRISTMAN: Good morning, 13

everybody. Beth Christman. I'm a Maryland 14

pilot. 15

I have been attending these meetings 16

probably about two years in. So, I am not 17

quite -- I'm a little green, but not quite as green 18

as some others. 19

DR. MIGNOGNA: Good morning. Dr. Joe 20

Mignogna. 21

I've been attending these meetings, I 22

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think, since 2012. So, I have really enjoyed the 1

interactions. 2

One comment that Jim made, you know, I 3

think our input I'm hoping has more impact than just 4

check off a box on a physical exam to help with the 5

mariners. It impacts not only themselves 6

personally, but the businesses they work for and 7

just the general population at sea. So, I hope we 8

have a bigger impact than just keeping our blinders 9

on. 10

Thank you. 11

DR. SCHAUB: Dr. Eric Schaub. I've 12

been attending these for about the same timeframe, 13

I think about two-three years now. 14

I am a physician, Medical Director for 15

Seafarers Health and Benefits Plan, which is kind 16

of a combination between the employers and 17

Seafarers International Union. 18

DR. BOURGEOIS: My name is Dr. Brian 19

Bourgeois. I am in New Orleans, Louisiana. I am 20

in private practice, occupational medicine, highly 21

involved in, let's say, offshore oil, gas, 22

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shipping, et cetera. 1

And I have been coming like this since 2

2011. It has been a while, and I have enjoyed it. 3

It has been interesting. 4

MS. KARENTZ: Good morning. Lesley 5

Karentz with the STAR Center, AMO Maritime 6

Officers. And I have been on the Committee since 7

2011. 8

MS. BROCK: Good morning. Louise 9

Brock. I'm a Registered Nurse with ConocoPhillips 10

and am responsible for the health of the mariners 11

and, also, the drug and alcohol testing, and I think 12

three years. I think we are at three years. 13

DR. UPENDER: I'm Raghu Upender. I'm 14

a neurologist and a sleep medicine doctor at 15

Vanderbilt University in Nashville. And I have 16

been attending these meetings since 2012 and been 17

on the Committee for about two years. I'm involved 18

with inland waterway, providing sleep services to 19

inland waterway companies. 20

LTJG FORTIN: I'll pass this around. 21

If you just want to state your name and affiliation? 22

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MS. COHEN: Karen Cohen, President of 1

Corporate Health Resources. 2

MS. KAPSIAK: Kimberly Kapsiak. I'm 3

the Medical Records Administrator for Kirby. 4

MS. RUSSELL: Brooke Russell, 5

Occupational Health Nurse for Kirby Marine 6

Transportation. 7

MR. EISENTROUT: Ike Eisentrout, 8

Deputy Director here at the National Maritime 9

Center. 10

DR. BUGGS: Adrienne Buggs, Office of 11

Merchant Mariner Credentialing. 12

DR. TORRES-REYES: Dr. Laura 13

Torres-Reyes, the Division Chief for Medical here 14

at NMC. 15

MS. CAMENZULI: Good morning. 16

Danielle Camenzuli, a SUNY Maritime College 17

Physician Assistant and Director of Health 18

Services. 19

DR. BERGAN: Good morning. Dr. Tim 20

Bergan, Force Medical Officer, Military Sealift 21

Command. 22

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MR. O'BRIEN: Ed O'Brien, Vice 1

President of the National Charterboat Association. 2

MR. WELLS: Good morning. Richard 3

Wells, Vice President of the Offshore Marine 4

Service Association. 5

CAPTAIN MARTIN: Kirsten Martin, 6

National Maritime Center. 7

MS. WEHDE: Good morning. Ann Wehde 8

with the Maritime Administration Office of Labor 9

and Training. 10

DR. EICHELBERGER: Dr. Deborah 11

Eichelberger, occ. med. doc here at National 12

Maritime Center. 13

MR. PLUNKETT: JJ Plunkett. I'm with 14

Houston Pilots. 15

MR. NEANDER: Kai Neander. I'm with 16

the George Washington University Maritime Medical 17

Access Program. 18

MR. VAN NEVEL: David Ven Nevel, Coast 19

Guard Office of Maritime and International Law. 20

MR. HARDIN: Luke Hardin, ADFO for 21

MEDMAC. 22

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MR. DIAMOND: Clay Diamond. I'm with 1

the American Pilots Association. 2

CAPTAIN SHEARON: I'm Captain Robert 3

Shearon. I'm the presiding officer of the Houston 4

Pilots. 5

MS. TURNER: Connie Turner with 6

Corporate Health Resources. 7

CAPTAIN REASONER: Thank you, 8

everybody, for the introductions. 9

I believe there's a couple that, 10

hopefully, will be on the Committee formally. Can 11

you raise your hands. 12

(Hands raised.) 13

We are going to see maybe if we could 14

get that going while we are actually in the meeting. 15

DR. SCHAUB: Last meeting we had our 16

ethics training, and they discussed the FACA 17

database and you could look at the FACA database 18

and see who is on. I actually went to the FACA 19

database -- and this is from last night -- there 20

are three members on the Committee according to the 21

FACA database. So, they may want to update that. 22

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CAPTAIN REASONER: Well, I'm glad 1

there's more of us here today. 2

DR. SCHAUB: You're one of them. 3

You're one of the three. 4

(Laughter.) 5

CAPTAIN REASONER: Oh, good. Who 6

else? 7

DR. SCHAUB: Joe is and Raghu. That's 8

the three. 9

CAPTAIN REASONER: Okay. We have a 10

quorum then? 11

DR. SCHAUB: Yes, so we do have a 12

quorum. 13

CAPTAIN REASONER: All right. Well, 14

we can address that and get that going. 15

Thank you, everybody. Thanks for the 16

introductions. I think we have a good group and 17

a lot of expertise in the room. So, that is good 18

for our purposes. 19

The next portion of the agenda is to 20

move forward and review the last meeting's minutes 21

and the tasks. 22

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LTJG FORTIN: Thank you. 1

Real quickly, I just want to go over the 2

task statements from last meeting. The following 3

task statements were opened, reviewed, and closed 4

at MEDMAC meeting 11 in St. Louis: 5

Task Statement 21, Doctors of 6

Chiropractic and Merchant Mariner Medical 7

Examination. 8

Task Statement 22, Medical Marijuana 9

and the Merchant Mariner Medical Evaluation. 10

Task Statement 23, Mariner Medical 11

Education Prevention and Over-the-Counter 12

Medications. 13

The following task statements are still 14

currently open: 15

We have Task Statement 11-01. This is 16

the NVIC 04-08 revision. This task statement is 17

going to be replaced by Task Statement 17- -- it 18

will become Task Statement 25, if accepted into the 19

minutes, which will be the Medical Manual that Dr. 20

Buggs will be presenting on later. 21

Task Statement 15-13, Health Risk 22

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Analysis. This is currently unassigned and will 1

be assigned later in the meeting. 2

And then, we have Task Statement 16-24, 3

Appropriate Diets and Wellness. And currently, 4

Captain Margaret Reasoner is the Chairperson for 5

this Committee. 6

Thank you. I turn it back over to you, 7

Chairman. 8

CAPTAIN REASONER: Okay. I'm 9

learning the administrative side here. 10

On the open task statements that we 11

have, just kind of to reiterate and for the 12

committees, the NVIC 04-08 is going to be closed 13

and opened as a Medical Manual to address the 14

Medical Manual and revise that, look at that, 15

review that. 16

The Health Risk Analysis Task 17

Statement, we are going to need someone to chair 18

that. Any volunteers? 19

(Laughter.) 20

Okay. Dr. Joe, and I would like to get 21

someone on the seafaring side. Yes. Okay, yes, 22

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because we also have to -- I would like to get, since 1

we are closing 04-08, 11-01 task statement, and 2

moving it to the medical, maybe I can have you on 3

the Medical Manual. 4

MS. MEDINA: Sure. I'll chair. 5

CAPTAIN REASONER: And then, Lesley, 6

could you go into the Health Risk 7

MS. KARENTZ: Sure. 8

CAPTAIN REASONER: Okay for Dr. Bob, 9

Lesley. 10

And for the other task statement, which 11

is the Appropriate Diets and Wellness, I won't be 12

the Chair of that Committee anymore. So, I'm going 13

to need someone to take over that. 14

All right. So, since we are going to 15

try and get you ladies sworn in, we will wait for 16

who I assign or who volunteers for that Committee. 17

Some of you ladies were in the meeting 18

last time on some of the progress we made with the 19

appropriate diets. Were you in there? Who 20

attended that section while we were in St. Louis? 21

It would be nice if we had some continuity there. 22

31


Okay, we'll hold that one. 1

And then, we would also need to get a 2

Chairperson and Assistant Chair for the Medical 3

Manual. So, Beth? 4

CAPTAIN CHRISTMAN: Yes. 5

CAPTAIN REASONER: Yes. And do I have 6

a doctor, Dr. Brian? I think you're going to end 7

up with the other one. Okay. 8

And, Dr. Buggs, would you please 9

introduce that task statement for the Medical 10

Manual? 11

DR. BUGGS: Can you all hear me? All 12

right. 13

So, while James is bringing that up, I 14

just want to thank you all. I know this has been 15

a long, long road, especially those of you who 16

started locally and Brian back in 2011, when we 17

first started with some of the tasks related to 18

this. So, this is kind of the culmination of that. 19

Okay, the other one, the task, yes. 20

Okay. Good. Let's go ahead and go to the first 21

slide. 22

32


So, remember, we have the medical and 1

physical standards included in Title 46, CFR, Part 2

10, Subpart C. Our policy, medical policy, is 3

contained in actually various places, NVIC 04-08, 4

NVIC 01-14, as well as the Marine Safety Manual. 5

We currently, then, now are working 6

through the Draft Merchant Mariner Medical Manual, 7

which will, then, provide a single source for all 8

of our medical guidance, put current Coast Guard 9

practices into written, so that, then, we can be 10

transparent, but also have consistency in 11

application, make sure mariners, the medical 12

community understand what it is we are looking for, 13

how we are evaluating the medical applications. 14

Next slide. 15

So, as we said, remember, our standard, 16

which is what sets the standard for what your 17

physical condition has to be, is set in 46 CFR, Part 18

10, Subpart C. That's the regulation. 19

The parts of that or the requirements 20

from the regulation are that the mariner has to have 21

a general medical exam, and that exam should ensure 22

33


that there are no conditions that pose a 1

significant risk of sudden incapacitation or 2

debilitating complication. And it is also 3

supposed to identify medications that pose a risk 4

of impaired judgment, cognitive ability, or 5

reaction time. It also requires certain physical 6

abilities that are listed in the table. 7

Next slide, James. 8

A hearing standard and a vision 9

standard. But what it does not provide, right, are 10

specific conditions or medications that would lead 11

us, you know, automatically just to disqualify 12

someone. And it doesn't really include a physical 13

fitness standard other than the few items listed 14

in the physical abilities. 15

Next slide. 16

So, our policy documents, NVIC 04-08, 17

which everyone is familiar with, as well as NVCI 18

01-14, which came about when we began using the 19

medical certificate, and then, the Marine Safety 20

Manual, Volume III, also has a good deal of 21

information, which probably predated NVIC 04-08, 22

34


but has some additional information that was not 1

contained in 04-08. 2

Remember, our policy documents, the 3

guidance documents, don't set regulation and they 4

don't set standard, right? All that they can do 5

is provide guidance to the regulated community on 6

the best methods or suggested methods for 7

demonstrating that they are able to meet the 8

requirements of the regulation. 9

The audience, as we said, is the 10

regulated community, it's the medical 11

practitioners, Coast Guard personnel, so that 12

everyone has the same information, is working from 13

the same sheet of music, so to speak. 14

It lists currently NVIC 04-08 with 15

conditions that are subject to further review and 16

also lists some recommended evaluation data that 17

mariners, you know, it may be helpful for them to 18

submit to show the status of their medical 19

condition. 20

Next slide. 21

So, remember, for those of you who were 22

35


back here at our inaugural meeting back in 2011, 1

back when this all started, we were going through 2

a period of challenging times. We had a surge in 3

denials and in medical appeals back in 2011. A lot 4

of that or probably the bulk of that denial increase 5

was due to incomplete information. So, even 6

though we had a lot of tests listed in the NVIC, 7

it wasn't always clear to individual mariners or 8

other providers which tests needed to be submitted 9

for which conditions or when. 10

So, the National Maritime Center often 11

spent a good deal of time trying to track down 12

information or chase down mariners. It finally 13

kind of got to the point, with limited resources, 14

that they needed to just make a decision based on 15

the information that they had. Eventually, that 16

ended up resulting in a large number of denials, 17

which, then, ended up on my desk as appeals. 18

We knew then we really needed to get 19

some more detailed guidance in our guidance 20

document, which included information, better 21

information, about the medical evaluation process; 22

36


specifically, when a condition might lead to 1

disqualification; criteria for granting medical 2

waivers; really describing what happens during the 3

individualized assessment or the medical 4

evaluation process. 5

The aim of our policy revision, then, 6

is going to be reduce confusion, increase 7

specificity, reduce the incidence of processing 8

delays caused by having to go back and forth looking 9

for information, but, then, also, to ensure that 10

we were consistent in how we applied the evaluation 11

process to all mariner applicants. 12

Next slide. 13

And that slide here is just kind of 14

demonstrating that jump that we had. You see in 15

2009, 2010, in terms of medical appeals, less than 16

40, and then, year 2011 we had a sharp spike, which 17

generated a lot of industry concern, a lot of 18

congressional interest. And really, that far side 19

where you see that begin to trend down is really 20

the result of a lot of the work of this Committee 21

over that time period. Even though you didn't see 22

37


a big, giant document be published, remember, we 1

saw some changes that were published to NVIC 04-08, 2

as well as just getting information out. 3

So, next slide. 4

So, to revise the medical policy, we 5

started off consulting with this Committee, right? 6

We had five tasks related to revision of the medical 7

policy over the years: Task 11-01, NVIC 04-08; 8

Task 11-02, which looked at top medical conditions, 9

and those were both assigned at the same meeting. 10

We also had Task 14-09, which looked at medications 11

and how those should be evaluated, which ones might 12

be generally disqualifying and which might need 13

further review. Color vision, we had asked for 14

some input in terms of kind of a practical 15

demonstration or what kind of practical tests we 16

could use to demonstrate color vision. 17

And then, Task 15-11, if you recall, was 18

the general medical exam, trying to get some input 19

on how we could describe the Journal of Medical Exam 20

so it wasn't just a checkbox. You know, so the 21

doctors aren't just going through or providers 22

38


aren't just going through checking boxes. Are 1

they really looking to solicit the information that 2

they need to tell us for sure that the mariner is 3

unlikely to have a condition that poses a 4

significant risk? 5

Next slide. 6

So, during this process, we also 7

solicited public comment on matters of medical 8

policy. You remember, most recently, in February 9

2015, we had a Federal Register notice seeking 10

input on diabetes, cardiomyopathy, sleep 11

disorders; then, another one on medications 12

earlier that year in 2013. And actually, the one 13

on medications eventually led to Change 2, to NVIC 14

04-08. 15

We also had Federal Register notices on 16

seizures and implantable cardioverter 17

defibrillators. And the information kind of 18

gleaned from that resulted in the initial Change 19

1 to NVIC 04-08. 20

And then, we also had public 21

participation at MEDMAC meetings. 22

39


Next slide. 1

So, Change 1, published in June of 2013, 2

as we said, covered implantable cardiodeverter 3

defibrillators and seizure disorders. Really, 4

what those were, then, describing -- because, 5

remember, we said back before, our standard, the 6

regulation does not list any disqualifying 7

conditions. So, we don't have anything that we can 8

just flat-out prohibit. Everybody is 9

required -- or sorry -- everybody is allowed to have 10

an individualized assessment. And so, with Change 11

1, we wanted to describe what that individualized 12

assessment looked like for these conditions that 13

we consider generally disqualifying, but we can't 14

really describe them as flat-out disqualifying. 15

NVIC 01-14, which was published in 16

January 2014, after we began the process of issuing 17

medical certificates, and then, Change 2, which 18

discussed medications subject to further review, 19

but, additionally, added further guidance on 20

medications that we considered generally 21

disqualifying. Once again, we can't prohibit 22

40


medications because it is not prohibited in the 1

regulation, but we can describe them as generally 2

disqualifying and, then, describe the 3

individualized assessment that we will go through 4

in looking at an application. Okay? 5

So, the Draft Merchant Mariner Medical 6

Manual, then, incorporated the comments from 7

MEDMAC recommendations. Remember, on Task 01-14, 8

although the task was left open, you provided 9

recommendations in the form of a draft NVIC. We 10

also considered public comment, consolidated 11

guidance from the other NVICs, from the Marine 12

Safety Manual, and reorganized all this into a 13

manual format. 14

Now part of the reason for choosing a 15

manual format is that the number won't change every 16

time we revise. As many of you recall, with NVIC 17

04-08, the NVIC before that was a completely 18

different number, right? It was 02-98. So, every 19

time you revise a NVIC, you come up with a 20

completely different number. With the manual, the 21

number will stay the same. So, it will update 22

41


maybe like a little sub-something on there, so you 1

know if it is an update, but you won't change the 2

entire number. 3

Next slide. 4

So, one of the things that we had to deal 5

with, we talked earlier about all the different 6

audiences that we address, and in the Draft NVIC, 7

the task response from MEDMAC, you know, you all 8

touched on that a bit. Some information was kind 9

of for the mariners, some for the doctor, some maybe 10

even for the person actually performing the exam. 11

So, we tried to pull that out, then, and separate, 12

so it would be clear which audience we were talking 13

to when and in which instance. 14

We reorganized and clarified one of the 15

things you all had put in the Draft NVIC. You 16

organized it by systems and, then, put kind of a 17

complete set of information under each topic, like 18

if it was cardiomyopathy, so that someone wouldn't 19

have to flip back and forth to the beginning of the 20

book to get part of the information and, then, back 21

to the cardiomyopathy section. 22

42


So, you wanted that kind of organized 1

all under a particular topic. And so, we listened 2

to that and continued that. And actually, you will 3

see a lot of the language is lifted directly from 4

the Draft NVIC, even though it may look slightly 5

different because we had to meet the manual format. 6

The other thing to remember, the Staff 7

Mariner Medical Manual doesn't establish new 8

policy. It really is just reformatting and 9

clarifying, bringing together stuff that came from 10

Change 1, Change 2, the NVIC, the MSN, et cetera. 11

Now there is some discussion in there 12

really for information purposes and for 13

consideration during the pilot program, where we 14

talked about maybe what things they will or will 15

not be able to do or what they should refer to the 16

Coast Guard and which things they can make 17

decisions about. And that also came, actually, 18

from other MEDMAC tasks and your recommendations 19

from those tasks as well. 20

So, next slide. 21

So, with all that background, the 22

43


description of the task is to review the Draft 1

Merchant Mariner Medical Manual and provide 2

recommendations to the Coast Guard with respect to 3

the following: 4

Substantive errors. Please identify 5

any of those errors in the document and provide 6

recommended corrections. 7

Clarity. We really want to try to make 8

sure we can be clear in this document, so people 9

understand and they know what they need to submit; 10

the regulated community understands, providers 11

understand what we are looking for. 12

If there are sections in the document 13

which you find to be unclear, please identify and 14

provide recommended language or recommended action 15

to clarify. 16

And then, ease of use. Please evaluate 17

the document for ease of use and provide 18

recommendations to improve usability. 19

Please provide recommendations to the 20

Coast Guard by the close of the spring 2018 meeting. 21

All right. Any questions on the task? 22

44


CAPTAIN REASONER: Thank you. 1

DR. BOURGEOIS: I have two questions. 2

One is, so the 719KE, none of the medical 3

credentials or Medical Manual would apply to that, 4

correct? That would still be outside of the 719KE? 5

DR. BUGGS: Yes and no, because we want 6

to make sure that we are explaining the stuff that 7

we are asking in the manual, to make sure we are 8

explaining what we are, then, asking on the K and 9

the KE. This probably more pertains to really what 10

is on the K. 11

DR. BOURGEOIS: Because there is no 12

medical criteria on the KE. So, okay. 13

DR. BUGGS: This is one is more, you're 14

right, speaking to the K. 15

DR. BOURGEOIS: Okay. 16

DR. BUGGS: And other than maybe the 17

physical ability section -- 18

DR. BOURGEOIS: Okay. And then, let's 19

see, the second question is, under the 04-08, NVIC 20

04-08, there are a number of the disorders that are 21

listed. When someone has one of those disorders, 22

45


do the mariners get any waiver, do they not get a 1

waiver, and how is that decided currently? 2

DR. BUGGS: So, currently, and 3

actually in the introduction to the NVIC, that 4

introduction section, it describes that some of the 5

conditions on there may require a waiver; some may 6

not. It really is an individualized assessment 7

and related to their risk of sudden incapacitation. 8

If, from the information that is 9

presented -- and Doc TR can touch on this a little 10

bit more -- if there is no information presented 11

that gives the indication that the mariner is at 12

risk of sudden incapacitation, then they wouldn't 13

need to have a waiver. Generally, the waiver is 14

if there is some concern; there is something about 15

that condition that says there could be a concern, 16

but, from our individualized assessment, it looks 17

like you're stable. Your doctor says you're using 18

your meds, whatever. You know, you haven't had any 19

problems over the last few years. Therefore, we 20

are going to grant you a waiver. So, really, we'll 21

still be individualized. 22

46


And that language, by the way, is kind 1

of, I guess it's mandatory language. So, it is in 2

the old NVIC. It will be in the new Draft Medical 3

Manual. That language continues. 4

CAPTAIN REASONER: So, for clarity, 5

the NVIC 04-08, that will retire and any policy or 6

any information-seeking for a medical condition 7

will just be held in the Medical Manual? 8

DR. BUGGS: Correct, correct. 9

MS. MEDINA: The idea is to have one 10

place where everything medical would be in it, 11

whether it is policy, even if we have to talk about 12

what the application would be; also, about the 13

document that you will fill. It would be one 14

place. And that way, you can go back and forth. 15

It is not looking at, okay, what did this one say; 16

what did the other one say? It is one place. So, 17

it makes it easier for everyone and makes it a 18

reference document for usability purposes. We 19

thought that would be. 20

So, I think there is going to be a 21

presentation a little bit later from Dr. TR, and 22

47


I think some of the question that were asked will 1

be answered during that. 2

CAPTAIN REASONER: Are there any more 3

questions? 4

(No response.) 5

Dr. Buggs, thank you. I appreciate the 6

background that goes with this to bring it forward. 7

Because one of those things we, as a Committee, have 8

done a lot of work here and work here, work here. 9

It is nice to see that there is going to be the 10

consolidated effort, at least where many of the 11

recommendations will be housed, and that you have 12

laid that out, our history. 13

Thank you. 14

DR. BUGGS: You're welcome. 15

CAPTAIN REASONER: At this point, we 16

are going to divert from our agenda and add 17

something. We are going to do the swearing-in of 18

our new Committee members. We have two that are 19

here that we can swear-in today. 20

Brooke Russell and Danielle Camenzuli. 21

I hope I got that right. Camenzuli? Okay. 22

48


MR. LANTZ: Are you ready? Okay. 1

Please raise your right hand and repeat after me. 2

(New Committee members sworn.) 3

MR. LANTZ: Thank you very much. 4

(Applause.) 5

CAPTAIN REASONER: Yes, we kept a 6

couple of those working groups open for you. 7

(Laughter.) 8

And congratulations. 9

At this time, we're going to take a 10

short break. It's 9:15. 9:30. 11

(Whereupon, the foregoing matter went off the record at 12

9:15 a.m. and went back on the record at 9:38 a.m.) 13

CAPTAIN REASONER: Okay. I come from a 14

family of five, so I have a voice that carries. And working on the back 15

deck of a tugboat with engines, I've always had a voice that carries. 16

So, anyway, where we want to pick up, just to restart, 17

we have two new Committee members, and I would like them to 18

introduce themselves now and give, as the rest of us did, how long 19

you've been affiliated with the Committee, and introduce yourself as a 20

member. 21

MS. RUSSELL: Thank you so much. 22

49


Good morning, everyone. 1

My name is Danielle Camenzuli. I'm a 2

physician assistant with SUNY Maritime College in 3

the Bronx, and I'm also Director of Health 4

Services. And I have been attending the meetings 5

for about two years now. So, I am real excited to 6

be a part of this Committee and team. 7

One of my big things is kind of, like 8

we were just discussing, you know, cadets coming 9

into the schools and making sure that they are 10

medically cleared and sound and fit for duty to 11

complete their four years and be licensed upon 12

graduation. 13

So, thank you very much. 14

MS. CAMENZULI: Good morning. 15

I'm Brooke Russell, Occupational 16

Health Nurse with Kirby Marine Transportation, 17

Inland and Offshore. I've been attending the 18

meeting since fall of 2013, the first one in 19

Nashville, Tennessee, one to remember. 20

And thank you for having us. 21

MS. MEDINA: Okay. Next on the agenda 22

50


we have a presentation of the laws and regulations 1

that are applicable to the medical certificate. 2

David Van Nevel. 3

LTJG FORTIN: Real quick, Chairman, if 4

I could just mention one thing? We have got a 5

public comment period scheduled after the 6

presentations. So, for members of the public who 7

wish to speak during that period, if you could just 8

please sign up? I am going to pass this sheet 9

around. 10

MR. VAN NEVEL: Good morning. 11

My name is Dave Van Nevel. I'm from the 12

Office of Maritime and International Law at Coast 13

Guard Headquarters. I'm embedded in the Merchant 14

Mariner Credentialing Program. Basically, what 15

that means, they are my only client. All I do all 16

day every day is merchant mariner credentialing. 17

But I like it, thankfully. I have to say that 18

because Mr. Lantz is here. 19

(Laughter.) 20

So, I am going to go over very quickly 21

on the legal authorities. I don't want to go into 22

51


depth. You don't need to be experts on this, but 1

you just have to understand the background and some 2

of the constraints we face as a federal agency with 3

your recommendations. You may wonder why you made 4

a recommendation and why we didn't adopt it. It 5

may be related to some of the things I'm going to 6

just touch on very briefly here. 7

Next slide. 8

I'm going to start with NVICs. Most 9

people will start with the statutes and work down 10

to the policies. But, since Dr. Buggs has already 11

talked about NVICs, and specifically NVIC 04-08, 12

basically, NVIC stands for Navigation and Vessel 13

Inspection Circulars. These were informal 14

guidance to the industry on various matters. In 15

years past it generally pertained to technical 16

inspection issues. I checked the website, the 17

oldest one that is still active is from 1956 and 18

it is still a valid guidance. 19

So, they are around. We have used them 20

more in recent years than we did in years past. The 21

important point here -- and Dr. Buggs mentioned 22

52


it -- they don't have the force of law by 1

themselves. There has to be a legal underpinning 2

to them in order to make this whole system work. 3

Next slide. 4

So, NVIC 04-08, Dr. Buggs already 5

talked about this. So, I won't go into this in 6

detail, but that is the main NVIC right now. 7

When I am talking about the Medical 8

Manual, it basically applies. Legally, there 9

isn't a major difference between the two. It is 10

mainly a throwback to when manuals were published 11

in paper and we had to mail out changes. If you 12

weren't on the distribution list, you didn't get 13

any changes. 14

Well, now with electronic publishing, 15

from a practical effect, there really isn't a 16

difference. There's a lot of differences internal 17

to the Coast Guard, but not to the public at large. 18

The Medical Manual will still not on its own have 19

legal effect. 20

Next slide. 21

So, this is what goes into NVIC 04-08. 22

53


That is what that document is there on the right. 1

And you see there's basically three ingredients, 2

so to speak. There's STCW. There is the Code of 3

Federal Regulations, Title 46, Part 10, Subpart C, 4

that we have already talked about. And then, the 5

bottom is a line of books from the United States 6

Code. The United States Code is really the 7

underpinning of it all. I am going to start with 8

STCW, then go to the Code, and save the regulations 9

for last because I want to talk a little bit about 10

how those are developed. 11

So, STCW is the Standards Training 12

Certification and Watchkeeping for Seafarers. 13

They have some regulations in there that basically 14

states the administration is to set medical 15

standards. And then, they also started the 16

two-year medical certificate regime, the separate 17

document. And then, in Section A-1/9, they have 18

some basic medical requirements. 19

So, they are similar. The language is 20

a little bit different. But, as you can see, they 21

are very general requirements, and so, a lot of this 22

54


still needs to be explained. 1

The last bullet is the key bullet. An 2

international convention can have a force of law 3

and be equal to U.S. law if it is a self-executing 4

instrument. STCW is not. So, STCW puts the 5

burden on the flag state to adopt their own national 6

provisions. 7

So, the STCW alone, almost like a policy 8

letter, doesn't have independent legal authority. 9

Now, if we were to do something to depart from STCW, 10

it would be a violation of the treaty, but it 11

wouldn't be a violation of U.S. law unless there 12

was a separate stated requirement in the Code. 13

So, the statutory bases are fairly 14

simple and fairly light. You will see the first 15

part is in Code 7101(c). That is licenses. It 16

talks about masters, mates, engineers, pilots, 17

operators, and radio officers to be physically fit. 18

Pilots get a little extra. They have the annual 19

physical and a few more heightened requirements. 20

The key point is there are no 21

requirements for Certificates of Registry, you 22

55


know, pursers, doctors, professional nurses. So, 1

there's no fitness requirement there in the 2

statute. 3

The one thing to point out is you will 4

see the words "physically fit". Some people could 5

term that like a physical fitness test. That is 6

obviously not what we do, and I will discuss a 7

little bit in our regulations how that 8

interpretation, that the general medical 9

requirements actually fit under that. 10

The second bullet there is about for 11

able seamen and, then, qualified members of the 12

engine department. Basically, all they say is 13

qualified as to sight, hearing, and physical 14

condition. Everything else is left for the regs 15

and the Coast Guard to fill in the blanks about what 16

that means. 17

The key things to point out here, 18

there's nothing for Certificate of Registry, 19

entry-level, deck, or engine. And I should have 20

mentioned it because it is a recent change; it used 21

to be cadets either. A recent National Defense 22

56


Authorization Act changed that. So, that is going 1

to change, but, as you know, that created a problem. 2

Cadets could go through a program, face graduation, 3

and then, couldn't get their credential. So, that 4

has been fixed. It will take a little bit to 5

implement that, but cadets would no longer be on 6

here. 7

So, another key point. That was 8

basically our organic statute in Title 46. That 9

is our authority for doing all of this. It doesn't 10

really say a whole lot. 11

There are some other statutes and key 12

items of interest. First is the Americans with 13

Disabilities Act. I am sure everybody has heard 14

of that. It does not apply to the Coast Guard as 15

a regulator. We're not an employer. We're not a 16

public accommodation, and we're not a training 17

provider. 18

There is the Rehabilitation Act that 19

applies to federal programs. It is very similar. 20

There are some minor differences. But, basically, 21

you cannot deny someone in a federal program solely 22

57


because of their condition. The keyword there is 1

"otherwise qualified". If they can't do the job, 2

you can deny them, but you have to make it very 3

job-related. You just can't come out and say, "You 4

have epilepsy. You're denied." You have to show 5

that it creates a significant risk of sudden 6

impairment and, then, you're not otherwise 7

qualified. 8

This has not been a major issue, but it 9

is just we sometimes get appeals where people will 10

say, you know, the Americans with Disabilities Act, 11

and the answer is it doesn't apply. 12

Another issue is HIPAA. That doesn't 13

apply, but, of course, we're dealing with medical 14

doctors all the time. So, it does apply, 15

practically speaking because, for people to share 16

information with us, they need to make sure that 17

the requirements are met. 18

The Privacy Act is big. That's ours 19

where you can get your own record and protect your 20

protect. 21

The Paperwork Reduction Act comes in a 22

58


lot when we are doing the forms. I know there has 1

been a lot of recommendations about changing the 2

forms. It seems like a form should be a simple 3

thing to do. It's not. 4

And then, finally, the last and the 5

biggest one is the Administrative Procedures Act. 6

That is from 1948, with the rise of the regulatory 7

state. That's the biggest. It governs our 8

appeals. It governs basically everything we do. 9

And most importantly, it governs the rulemaking 10

process, which is how we go from the Code, the 11

United States Code, the statutes, to the 12

regulations and, then, from the regulations to the 13

policies. 14

So, here, as has been mentioned before, 15

Title 46, Part 10, Subpart C, that is where our 16

substantive regs are. And now, I am going to talk 17

very quickly on how we get there. 18

So, what happens, when we publish a 19

Federal Register notice or a proposed rule, it gets 20

published in The Federal Register. The Federal 21

Register is printed every day, every business day. 22

59


I don't remember the last time I saw a paper one. 1

I know they used to exist. 2

And then, once the rule is adopted, it 3

gets put in the appropriate subject area in the Code 4

of Federal Regulations, such as Part 10 of Title 5

46. So, that is how it works. 6

So, the Administrative Procedures Act 7

has four basic requirements for informal 8

rulemaking. Now the amazing part of all this is 9

this big, long rulemaking process that we go 10

through, that is considered informal. I mean, the 11

formal rulemaking is when you have hearings on the 12

record and take testimony. Nobody does it 13

anymore. I don't want to say "nobody," but it is 14

rare because it is so burdensome. 15

So, there are four steps. Issue a 16

Notice of Proposed Rulemaking. You provide an 17

opportunity for public comments. You issue the 18

final rule. And then, you make the rule effective 19

not less than 30 days. The more complex the rule, 20

generally, the more time we give. 21

So, basically, all of administrative 22

60


law comes out to: tell people what you are going 1

to do and, then, do what you said you were going 2

to do. So, that is basically what it comes down 3

to. 4

So, there are some other non-APA 5

authority controlling rulemaking. You have DHS 6

Directives. You have other statutes, and you have 7

Executive Orders. 8

I am just going to breeze through these. 9

These don't matter. 10

Next. 11

I just want to show you that it is 12

complex. And I didn't even update this list 13

because you don't need to know it. But the point 14

is, there's a lot of stuff that we have to look at 15

before we can put out a rule. 16

I bolded the bottom one because that is 17

the agency authorizing or the organic statute. 18

That is Title 46, U.S. Code, what we talked about 19

before. So, that is where it ties into the 20

rulemaking process. 21

Next slide. 22

61


And then, here's some Executive Orders. 1

The same thing, I did not bother updating these 2

because we don't need to get into the weeds. But 3

I did update the last one because that was one that 4

was signed last week. The sole point of that is 5

just to show that these do change and there's a lot 6

of them. 7

And so, you would ask like, if the 8

policy doesn't have the force of law, why not put 9

everything in the regs? Well, here's why: it's 10

not easy. 11

James, next. 12

Okay. So, once we have done the policy 13

and we have put it in the regs, the final backstop 14

is your judicial review of our agency action. It 15

almost never happens because of the resources it 16

takes to fight the government, but it does happen 17

occasionally. 18

In the merchant mariner medical field, 19

there actually have been three, I'll say, recent 20

cases within the last five years where they 21

actually upheld the use of NVIC 04-08 to deny a 22

62


mariner's credential. 1

And what the court looked at was the 2

fact we followed the rulemaking process. The NVIC 3

wasn't a rule, but we did public notice. We took 4

comments from the public. We incorporated them. 5

We provided notice to the industry and, then, we 6

consistently applied NVIC 04-08. And so, the 7

court basically said, "No, Coast Guard, you did it 8

right." 9

Because the particular condition the 10

mariner had was not listed in the regulation. And 11

so, what the court was determining was that, yes, 12

the regulation didn't say -- I think it was 13

cardiac -- it didn't say cardiac, but NVIC 04-08 14

is a reasonable interpretation of that regulation. 15

And the Coast Guard deferred to our decision 16

because of its reasonableness, how it was 17

developed. 18

The other factors the court looked at 19

were that we provided the mariner ample opportunity 20

to submit extra documents to support his case and, 21

then, we wrote a thorough, well-thought-out appeal 22

63


letter that explained our decision. 1

So, the backdrop of everything is the 2

judicial review. And then, although we say there 3

is no legal basis in the policy documents, they are 4

not by themselves enforceable. If we do it 5

properly, the courts will accept our 6

interpretation of our regs. And that works from 7

the statute down. 8

The Code only talked about being 9

qualified as to physical fitness. Then, we wrote 10

Part 10, Subpart C, of Title 46. That is our 11

interpretation of what the statute said. And 12

then, NVIC 04-08 or the Merchant Mariner Medical 13

Manual, if we end up issuing that, will be our 14

interpretation of the regulations. 15

So, that is how it all fits together. 16

And so, although the policy document does not 17

legally on its own have legal authority, or STCW 18

doesn't have its own independent legal authority, 19

there is a chain that relates back. And as long 20

as we can follow that chain, that works. 21

Now, with respect to your 22

64


recommendations specifically, one of the biggest 1

problems with the rulemaking is every time you make 2

a recommendation and we impose a burden, we have 3

to do an economic analysis of the benefits versus 4

the cost of complying with that recommendation. 5

And that is one of the things that really will get 6

us a lot of times, because, you know, the benefits, 7

although very real, the actual amount of them can 8

be speculative because we are preventing accidents 9

from happening. So, we don't know the exact 10

benefit. And then, the costs are very real, and 11

it is really hard to weigh and justify speculative 12

benefits against real costs. And so, that is one 13

of the areas we struggle with and why sometimes 14

things that are very sensible don't make it into 15

the rules. 16

So, here's just some of the -- when I 17

was talking the court case, this is basically some 18

of the legal standards for reasonableness. And 19

the big thing is, you notice, disclosure of data. 20

I bolded "data". That is one of our things that 21

gets us every time. 22

65


And then, the explanation for any 1

change in position, and it is not that one position 2

is necessarily better. But, if we change a policy, 3

we have to explain why. 4

So, why does it all matter? Well, it 5

is complex. It takes long. Any rule or policy is 6

subject to compromise, based on the competing 7

interests. 8

I don't know if any of you were at MERPAC 9

recently. Some people stood up and said the 10

medical standards were too easy; some people stood 11

up and said they were too strict. So, you know, 12

as an agency, with your advice, we have to balance 13

those competing interests. 14

And then, the other issue is we can't 15

deal with every possible situation. It's 16

impossible even in a policy document to list every 17

single condition or situation. So, necessarily, 18

we are writing to basically the lowest common 19

denominator, the minimum standard that applies 20

industrywide. 21

Now we do make exceptions in certain 22

66


areas, but every time you do that it complicates 1

things. And so, that is where you get the 2

employers saying our standards are too lax, because 3

they have a higher standard because they need it 4

because their job is demanding. And that is where 5

I think some of the comments were coming from. 6

And so, you have to recognize that we 7

are not the employer and we are writing 8

qualifications for certification. There may be a 9

particular job that you are not 10

medically-qualified, but that is really up to the 11

employer under the ADA to make that requirement. 12

The other area where this comes up is 13

in educational institutions because they are 14

subject to the ADA in providing those sort of 15

reasonable accommodations. And there is some 16

tension there. So, you just have to keep in mind 17

that our role isn't the employer; it isn't the 18

treating physician, and it is the union or any other 19

industry group. We are kind of in the middle of 20

all that, and we are trying to balance all those 21

competing interests. 22

67


And that's all I have. If anyone wants 1

more detail, I can provide it, but I don't think 2

it is necessary. 3

Any questions? 4

CAPTAIN REASONER: I have a question. 5

Because you bring up some things that we have 6

recommended. And actually, I appreciate the full 7

presentation because I know we work very hard, and 8

why isn't this done; why didn't anything change? 9

So, it helps all of us when we make recommendations 10

to understand why some of it makes it and we see 11

process improvement or changes. 12

But you made a comment about the 13

speculative benefits and database. How do we get 14

that established, especially when, I think as this 15

Committee, we have recommended some database 16

tracking? 17

MR. VAN NEVEL: Well, we have started 18

with that. I note Dr. Buggs reached out to the 19

office that does investigations for the Coast 20

Guard, and they worked on and developed a 21

checksheet for whenever there is an accident and 22

68


human factors are involved, to go through -- not 1

to make the ultimate decision, but just to kind of 2

highlight that the investigator should be looking 3

at medical as a possible cause, a medical -- you 4

know, an undiagnosed or even a diagnosed medical 5

condition. 6

Surprisingly, there hasn't been a lot. 7

I mean, industrywide there's a lot of accidents. 8

But, when you start breaking it out, there is not 9

a lot of accidents that the investigators have 10

attributed to medical. 11

The problem is we don't know if that's 12

because they are not using the checklist or whether 13

that's -- you know, it is very hard, unless we were 14

to have the staff to go through every accident 15

report and, then, dig and, then, kind of do our own 16

independent follow-on investigation. 17

So, we have a database. It is in MISLE. 18

I think it is probably more of a training to get 19

the investigators who don't work for us to 20

recognize that medical -- you know, human factors 21

we know is one of the biggest issues, but to 22

69


recognize medical as a potential issue anytime 1

there is an accident. 2

CAPTAIN REASONER: Thank you. 3

DR. SCHAUB: You touched briefly on, 4

very well on the issue between credentialing versus 5

actually being fit for duty, so that those are 6

actually two different things. 7

MR. VAN NEVEL: It is subtle. I like 8

to use I wake up today and I have a killer flu. I'm 9

not fit for duty. But, obviously, the 10

credentialing program doesn't care. I mean, we 11

can't react that quickly. 12

But it is there is a lot of gray area 13

in between the obvious case and the case where it 14

is a judgment call. You know, employers -- and I 15

don't blame them; as a lawyer, I understand what 16

they are dealing with. It is much easier if we deny 17

someone a credential because, then, the employer 18

doesn't really have to worry about being sued. But 19

it is really not the same. 20

I will use an example. When I was on 21

active duty, we escorted a converted sealer up into 22

70


the Arctic. It was research scientists. And so, 1

they were basically going to be left in the ice over 2

the winter, just left there, and, essentially, 3

isolated. 4

So, that is a situation where maybe 5

everyone on that boat was a qualified mariner and 6

met the regular medical standards, but there was 7

a bona fide reason that in that situation the 8

standard should have been higher. 9

And I am trying to think of a good 10

industry example, but, of course, I am drawing a 11

blank at the moment. 12

DR. SCHAUB: But, then, it gets into 13

ADA where the employer could be sued under the EEOC 14

for denial of employment when you actually have a 15

valid credential for this job. 16

MR. VAN NEVEL: And that is, basically, 17

the issue that was raised at MERPAC, the exact 18

issue. And that is also the point of saying we set 19

the minimum standards. If an employer needs a 20

higher standard, they need to establish that within 21

their own corporate policies, just through their 22

71


usual HR processes. 1

Probably the best employer, maybe MSC 2

is probably the best example of that, where they 3

have fairly high employment standards. I am sorry 4

to put you on the spot, but, also, that is a federal 5

government agency. So, that isn't an ideal 6

comparison, but -- 7

MS. MEDINA: I think the MSC just 8

lowered their standards for CONMARs. They just 9

said that contract mariners have to meet the Coast 10

Guard standard. 11

MR. VAN NEVEL: Yes, we did that, but 12

we also added some additional things that have to 13

be done to bring it back up, but a little less 14

burdensome on contract operators. 15

MS. MEDINA: Any other questions? 16

(No response.) 17

Thank you. That was a good 18

presentation. 19

DR. TORRES-REYES: Good morning, 20

everyone. 21

I'm Dr. Laura Torres-Reyes. I am the 22

72


Division Chief of the Medical Evaluation Division 1

here at the NMC. I am very fortunate to be in 2

charge of a group of about 36 individuals who are 3

responsible for taking care of the 719K from start 4

to finish in terms of determining the fitness of 5

the mariner. 6

I know there is a lot of concern about 7

what it is we look at. And so, I am going to spend 8

a little bit of time today going -- one of our 9

wonderful, talented physician assistants is going 10

to walk you through what they see when a 719K comes 11

in the door. 12

I think the most important thing -- and 13

it has been hit on several times -- this is a 14

fitness for certification. It is not a fitness for 15

duty. 16

And so, I think, Dr. Schaub, we had an 17

example just recently where the information that 18

we got with the 719K and the note from the 19

ophthalmologist basically said that 20

regulatory-wise they were fit for certification. 21

So, all of the checks for "Are they certified?" were 22

73


yes. 1

However, Dr. Schaub informed me that, 2

based on what the mariner does, that they were going 3

to have to make some accommodations because of 4

his -- he has a field-of-vision deficit from his 5

coronary artery disease. He had a stroke. And 6

so, he said, based on his daily job, he was going 7

to have some accommodations because this mariner, 8

there were some things he could not do. You know, 9

looking at the 719K and the note from the 10

ophthalmologist, he was good to go from our 11

perspective. So, again, fitness for 12

certification is different than fitness for duty. 13

The other example I give is, you know, 14

we certify people for five, two, one year. So, 15

think about this. So, we are saying this person 16

is reasonably good to go for five years without risk 17

of sudden incapacitation. 18

As we all know, life happens. So, 19

let's say, for example, I was a trainer for The 20

Biggest Loser. Sound familiar? You know, 21

looking good, doing everything right, perfectly 22

74


healthy, training people. And then, in the blink 1

of an eye, something happens where you have a major 2

heart attack. Do you think that we here at the NMC 3

see that? Well, we should, but, more likely than 4

not, we do not. 5

So, we always make it clear that it is 6

the mariner's responsibility, if there is a change 7

in condition, to notify us because, obviously, we 8

are not clairvoyant. So, we only can do what we 9

know with what we have. 10

So, we are going to start by going 11

through a mariner. This is a pretend mariner. 12

So, don't worry, there's no personal information 13

here. 14

So, we are going to have Autumn come up. 15

She is going to have some screenshots, because a 16

lot of what we do has to do with what is called the 17

MMLD database. And so, it is a database that has 18

a lot of information. The evaluator can actually 19

go back and see what the previous certificates were 20

and if they had previous waivers. 21

It is amazing and you're not surprised 22

75


how many times a perfectly clean physical -- oh, 1

look, this guy is perfect. If you go into the 2

database, oh, oh, wait a minute. You know, he had 3

a waiver five years ago for coronary artery disease 4

and, oh, yes, sleep apnea, and now he's magically 5

cured. 6

Well, our evaluators are very 7

meticulous at being able to go back into the 8

database, seeing what their previous waivers are, 9

previous conditions. They get information from 10

the physicians. And it makes it very thorough, 11

that they get as much information as possible. 12

Okay. Autumn, take it away. 13

MS. WELCH: Good morning. 14

My name is Autumn Welch. I'm a 15

physician assistant here at the NMC. I have been 16

here about 10 years. I have been here a long time. 17

Jim, I am going to have you, if you can, 18

just scoot through the first couple of slides. 19

Basically, just our mission, until you get down to 20

the MMLD screenshot. The next. All right, right 21

there 22

76


So, this is MMLD. This is our database 1

that we use for every mariner. MMLD is Merchant 2

Mariner Licensing and Documentation. Like Doc TR 3

said, we are just going to walk through a case. 4

So, MMLD allows us to generate AI 5

letters, which are the letters that request 6

additional information from the mariner. We 7

generate the medical certificates from here as 8

well. Basically, this is where we document 9

everything on the mariner. 10

Next. 11

So, like I said, just an example case. 12

This is page 1 of the 719K. In this particular 13

mariner, you can see there is a "yes" response for 14

Item No. 16 with obstructive sleep apnea 15

underlined. So, this mariner has OSA. No other 16

conditions identified. 17

Next. 18

And unfortunately, a lot of times this 19

is all we get on the 719K: OSA, diagnosed rather 20

recently, December 2016; treated with CPAP. 21

You know, sometimes you will have 22

77


mariners that have supplemental information with 1

their application, but sometimes you don't get 2

that. In those cases, like in this one, we would 3

have to generate that additional information 4

letter to request further information on the 5

mariner's condition. 6

Next. 7

So, this is page 3. Obviously, the 8

vision, the hearing, and the color vision. So, 9

10.305 gives us the vision standard. So, in this 10

case the mariner's uncorrected visual acuity is 11

20/100, corrected down to 20/40. So, this mariner 12

would actually require an operational limitation 13

for corrective lenses on the medical certificate. 14

Next. 15

So, this is the application-tracking 16

tab of MMLD. This is where we actually input the 17

information that we are going to need back from the 18

mariner. So, in this case, like I said, he 19

obviously has the OSA. So, we generated the AI 20

letter from here. 21

Next. 22

78


And the mariner has 90 days to submit 1

that information back to us. Once they do submit 2

that information back to us, it comes back to the 3

medical evaluator and, then, we make our 4

determination off of that information. 5

If we feel the mariner is too high of 6

a risk and we would recommend denial, those are all 7

reviewed with and approved by Dr. TR, as our 8

Division Chief. 9

In this case, we are actually going to 10

approve this mariner. So, the mariner medical 11

form, part of the medical record in MMLD, is where 12

we document. 13

Next. 14

So, this is actually like the template 15

that we use. Basically, just saying the vision. 16

He, like I said, has the operational limitation for 17

the corrective lenses. And then, my information 18

that I got back on the OSA. 19

So, because this mariner was a rather 20

new diagnosis, like I said, December 2016, but the 21

CPAP log showed excellent compliance, we 22

79


recommended a waiver with a two-year limited 1

search. And that just shows the two-year cert 2

there. 3

The next slide, this one is going to be 4

where we actually do the medical certificate. 5

Like I said, we generate them from MMLD. And if 6

you can see -- it is probably really difficult to 7

see -- but the STCW and pilot and domestic all have 8

the two years. So, it is the two, two, two. 9

Certainly, if someone had OSA for 10 years and 10

they're well-controlled and it is effective 11

treatment, they would be okay for a two, two, five, 12

meaning STCW and pilot would be two, but domestic 13

would be a full five years. 14

And then, on the bottom -- sorry, Jim, 15

if you could just go back? -- on the bottom shows 16

the operational limitations. You have the 17

corrective lenses as the last one there and, then, 18

the waiver for the OSA. 19

This is just an example of how all of 20

our evaluator templates look. You have the top, 21

which is in that first box, and then, that bottom 22

80


that just shows the condition they are actually 1

waiving. 2

And for those of you who haven't seen 3

these, this is a copy of a waiver letter. In this 4

case, like I said, it is the OSA and was a two-year 5

time-limited cert. 6

Just helpful links on the NMC website. 7

Obviously, it has the copies of the 719K there. It 8

has guidance for medical providers. It is a very 9

useful site for mariners and their providers. 10

And then, it also has a whole page -- you 11

can hit, Jim -- it also has a whole page for the 12

medical certificate. You know, it talks all about 13

what the medical certificate is and how it works, 14

and just very useful information there. 15

And that's it. Any questions for me or 16

Doc TR? 17

DR. SCHAUB: Question. When you have 18

a condition, coronary artery disease, is it 19

automatically a two-year? Does it ever become a 20

one-year? How do you decide that? 21

DR. TORRES-REYES: The answer to that 22

81


is it depends, because every case is truly unique. 1

So, it depends on what other conditions the 2

individual has. It depends on how recently that 3

was diagnosed. It depends on how severe the 4

condition is. It depends on what kind of note we 5

get from the treating provider, because the AI, the 6

amplifying information, we really look at is the 7

treating provider saying, "You know, I am fairly 8

confident that there is a low risk or probability 9

of sudden incapacitation in the next five years." 10

And some say, "You know what? I can't vouch for 11

more than two." Some say, "You know what? 12

Outside of a year, I'm not going to say it's more 13

than a year." So, there is a lot of information 14

that goes into. So, the answer is it depends. 15

Yes? 16

DR. BOURGEOIS: What standards are you 17

using to make those decisions? Do they change or 18

are they the same? 19

DR. TORRES-REYES: The only standards 20

we have that are regulations are the CFR. 21

Everything else is guidance. 22

82


DR. BOURGEOIS: So, when we see someone 1

that has been approved outside of CFR, how does that 2

happen? 3

DR. TORRES-REYES: So, he asked if 4

there was somebody who was approved -- oh, go ahead. 5

DR. BOURGEOIS: So, my point is, I see 6

people that are approved outside of standards that 7

are written in CFR that, let's say something maybe 8

I even had worked on. Once again, occasionally and 9

on occasion, I have seen people who are approved 10

for a medical certification outside of standards, 11

in my terminology; CFR, in your terminology. And 12

I'm wondering how that decision is made. Who makes 13

the decision? My original question was, what 14

standards do you use? And she responded with CFR. 15

So, I said, when I see somebody who is approved 16

outside of CFR, how does that happen? 17

DR. TORRES-REYES: So, you're kind 18

of talking about waiver. 19

DR. BOURGEOIS: Well, you know, we had 20

this discussion a long time ago. I thought we were 21

getting rid of waivers. Either the people were 22

83


cleared or not cleared, recognizing they had a 1

medical condition. 2

Because, well, but prior to your being 3

here, there was a big discussion of waiver being 4

a bad term, and we were going to get rid of waivers. 5

That's why we were going to this medical 6

certificate. And so, I mean, there's no doubt. 7

We have had discussion, a lot of discussion. 8

I have seen people who are overtly 9

approved outside of CFR standards. And I am 10

wondering why -- well, not necessarily why. Where 11

does that come from? 12

DR. TORRES-REYES: The answer to that 13

is, as of 1 July, it comes from me. 14

DR. BOURGEOIS: Yes. 15

DR. TORRES-REYES: So, anytime you see 16

one of those, because the buck stops 17

here -- everyone knows that; I'm the final say in 18

any decision -- when you see those, I would like 19

for you to contact me, and I can look into the case 20

and see what it is you're speaking of. So, I can't 21

speak to it unless you -- so, I would say that in 22

84


the future give me a call. Dr. Schaub is very good 1

at calling me. Let's talk and we'll see what the 2

decision was and why it was made, and we can discuss 3

it. 4

DR. BOURGEOIS: Okay. Sometimes we 5

don't always see that. The mariner gets a 6

credential. He goes off somewhere else. We may 7

see it years down the road or we see it from a 8

company. And so, you know, we don't always see it. 9

That's unfortunate. Once they leave our place, 10

they don't necessarily come back. 11

DR. TORRES-REYES: Yes, so, obviously, 12

I can only address when I see the data and the 13

information that you provided. 14

DR. BOURGEOIS: And so, my point is 15

that -- this is a yes-or-no answer. 16

DR. TORRES-REYES: Okay. 17

DR. BOURGEOIS: Are the CFR standards 18

concrete or are they not concrete? 19

DR. BUGGS: I think he is addressing 20

more the issue of waiver where we say our choice, 21

your waiver, right? The problem that you were 22

85


referring to with waivers was when we were giving 1

waivers to anybody, even if they didn't need a 2

waiver. Because a waiver is supposed to apply to 3

an individual that does not meet the standard. 4

However, I think we put extenuating circumstances 5

exist that show that they are not a significant 6

risk. And that wording is also in the CFR, as to 7

when we give a waiver. 8

Our problem before was we were giving 9

a waiver to anybody who had any type of medical 10

condition and they were being overused. And Clay 11

called us out on it quite a bit. 12

But now, part of what we wanted, part 13

of that original NVIC task and, then, also, in the 14

tasks or in The Federal Register notices we started 15

pulling out some of our more problematic conditions 16

to start to, then, identify what would be the 17

criteria for issuance of a waiver for people who 18

had conditions that don't meet the standard. So, 19

what will we look at? 20

And that gave more information, then, 21

to the providing doctor, but also the mariner. I 22

86


mean, a lot of times now when those mariners are 1

denied at the NMC, they don't even come to us on 2

appeal. They can see in writing what the issue 3

was. They understand what the criteria was. 4

Their doctor looks and says, "Hey, they have some 5

set criteria here. You don't meet them." And 6

often, then, it is dropped at that point. It 7

doesn't even go beyond that. 8

So, that's where you all's help has been 9

very, very helpful. 10

DR. MIGNOGNA: That's helpful. So, 11

you have an internal process to differentiate 12

mariner A with sleep apnea and compliance and this 13

level of sleep disturbance versus mariner B who 14

might get a one-year or a three-year. I mean, how 15

does that work internally? What kind of process 16

or algorithms do you use? 17

DR. TORRES-REYES: Okay. So, 18

internally, we have discussions on a weekly basis. 19

I meet with all the evaluators. We discuss 20

particular cases. We have general guidance about 21

what severity means, and it is not like written in 22

87


stone, but we have some aids that help us, reference 1

aids. 2

Every case is discussed with me. So, 3

that is part of job, is on a daily basis, if there 4

are conditions that are of question or complicated, 5

my staff will come and talk to me. Again, I have 6

been here since July of 2016, and it has been really 7

encouraging, because I do QA of decisions. And 8

then, there are no wrong or right decisions. It 9

is a matter of the variety and where we are on 10

consensus. 11

So, I have seen that in the last nine 12

months we have definitely started to come closer 13

to the centerline of decisions. And I have always 14

made it clear, you know, our staff are 15

professionals. They are allowed, they are getting 16

paid to make decisions. And so, my job as the 17

Division Chief, which they haven't had for three 18

years, is to kind of get into that consensus and 19

talk. And they know where I'm coming from. As a 20

group, we talk about it and develop a consensus of 21

what we are feeling. 22

88


The beauty, not the beauty, but, you 1

know, this is a challenging job in that there is 2

variety. And every single case, no kidding, is 3

different. So, you are not going to have a cookie 4

cutter of saying this is this way and this is not. 5

It depends. 6

And that's why, really, my word is "it 7

depends." And in the end, hopefully, we come to 8

a general consensus that is fair and that is safe 9

for the industries, fair to the mariner. 10

DR. SCHAUB: So, they have a 11

certificate which we have heard doesn't mean that 12

they are necessarily fit for duty. So, they have 13

the certificate. They may or may not have a 14

waiver, depending on the condition. So, really, 15

it is, then, incumbent upon the employer to make 16

sure that they are actually fit for that particular 17

job? 18

DR. TORRES-REYES: Absolutely. On a 19

daily basis, you know, I mean any given day in the 20

commission of occupational medicine -- you know, 21

your job is industry occupational medicine -- it 22

89


is to make sure that they are fit for duty on a daily 1

basis. 2

We are certifying for five years, two 3

years, or one year. Anything in between that, we 4

depend on hearing from the mariner, change of 5

condition. You know, you could have a mariner who 6

breaks a leg. That is an industry issue. We won't 7

hear about that at the NMC. Now, hopefully, we 8

will; they will report it. But, again, it doesn't 9

necessarily change their certification on that 10

yearly five-year, two-year basis. 11

DR. SCHAUB: I have a question. You 12

know, mentioning change of condition -- 13

DR. TORRES-REYES: Uh-hum. 14

DR. SCHAUB: -- I saw something on the 15

website that said it's the mariner's 16

responsibility within 30 days to report a change 17

in condition. But, then, we have also been told 18

at meetings that there is no requirement to have 19

a report of change of condition. 20

So, I have coronary artery disease. I 21

have a new stent placed. Do I have to notify the 22

90


Coast Guard? Do I not have to notify the Coast 1

Guard? It's up to the mariner? 2

DR. TORRES-REYES: Yes. I mean, 3

again, probably it is a legal issue to talk to, but 4

it is like highly recommended -- 5

MR. VAN NEVEL: If you have a waiver, 6

one of the conditions of waivers -- I'm sorry -- if 7

you have a waiver, we put that on a waiver. One 8

of the conditions of the waiver is you notify us 9

for a material change in condition. 10

This stems back to the conversation 11

about the overuse of waivers. A number of years 12

ago, we tried to put in the regulations an authority 13

to require mariners to report changes of condition, 14

which I think everyone would probably agree in 15

principle is a good idea. You know, defining what 16

has to be reported and what doesn't is more 17

difficult. And basically, OMB said, no, because 18

you don't have any data. 19

When I was talking about the benefits 20

versus -- I was actually thinking about that 21

specific issue. So, in general, there's no legal 22

91


requirement. We can't force you. We can't take 1

S&R against you just because you didn't report a 2

changing condition. 3

So, what was happening is, under prior 4

Administrations here, they thought, oh, we can get 5

around that; we'll issue a waiver. So, if someone 6

is qualified, but we think their condition might 7

change in the next five years, we would give a 8

medical -- well, it was before medical 9

certificates. And then, we would issue a waiver 10

and, then, require them to tell us every year. 11

And that is some of the things that Clay 12

and some of the other members of industries 13

complained about because people were trying 14

to -- you know, "I have a cold today. Do I need 15

to report that to the Coast Guard?" Obviously not. 16

And so, that's where it comes out. So, 17

in waivers there will -- I don't want to say 18

"always"; I always hate to say that -- but I would 19

still say it. A waiver will always have you must 20

report a change in condition related to the 21

waiverable condition. 22

92


But, for a general mariner, if I get my 1

certificate and the next month I come down with a 2

condition that could be disqualifying, there is 3

actually no legal requirement for him or her to 4

report that. 5

And it is something we are working and 6

we are hoping to fix and, then, limit it to the cases 7

that we really care about, so it isn't a burden. 8

But it is always difficult to draw those lines and 9

get to that point. 10

So, does that answer, I hope? 11

DR. TORRES-REYES: Yes? 12

DR. BOURGEOIS: Okay. So, following 13

this line of thinking, the NVIC and let's say the 14

approval of such or approval of an individual with 15

it is a fitness for certification, not a fitness 16

for duty. You made the statement that "We're not 17

issuing fitness for duty. It is incumbent upon the 18

physician. That's who determines the fitness for 19

duty." 20

Bluntly put, what is the point of even 21

doing a merchant mariner physical exam? It offers 22

93


no backstop in either the determination of fitness 1

or the denial of fitness of the physician who is 2

doing thousands of these a year and who has 3

literally a week ago sat in a deposition on this 4

exact point. 5

When someone has a positive outcome of 6

the process, meaning they have a physical that is 7

cleared, they get their credentials, et cetera, 8

what does that actually offer them other than, I 9

guess, a license as a merchant mariner? Because 10

it doesn't offer them a fitness for duty. I guess 11

it offers them a certification that they can work 12

in that industry. True or not true? 13

DR. TORRES-REYES: That's true. 14

DR. BOURGEOIS: But it doesn't offer 15

them -- they can't say, "I am cleared for duty."? 16

DR. TORRES-REYES: They can say that 17

they have a medical certificate that allows them 18

to sail under that credential for the time period 19

of that -- 20

DR. BOURGEOIS: No, but they cannot say 21

that, "I am fit for duty."? 22

94


DR. TORRES-REYES: Well, you probably 1

could if you are. I mean -- 2

DR. BOURGEOIS: No, no, I understand. 3

I'm just saying, because let's say if I determine 4

that they are not fit for duty -- we could take both 5

instances -- they come back and say, "Oh, oh, look, 6

the Coast Guard says I'm fit for duty, so I should 7

be fit for duty." I said, "You're not fit for duty. 8

That's a fitness for certification." And they 9

say, "Well, I'm certified to do duty under the 10

auspices of the U.S. Coast Guard. Doesn't that 11

mean I'm fit for duty?" And I said, "No, you're 12

not fit for duty. That means you're fit to be 13

certified to do that." 14

Likewise, if I say someone is fit for 15

duty, based on the Coast Guard regulations or based 16

on this, right, that they are fit for duty, if my 17

fitness-for-duty determination is questioned in 18

the future, I cannot say, "Oh, well, I relied on 19

the U.S. Coast Guard guidelines," because, in 20

reality, that is not a fitness-for-duty standard. 21

It is a fitness for certification. 22

95


Do you see my point is that the U.S. 1

Coast Guard standards have in the past been a 2

backstop for fitness for duty at a certain level. 3

Granted, it's the lowest bar, but it has been a 4

backstop. But, right now, with that terminology, 5

the backstop has been removed. 6

DR. TORRES-REYES: Okay, I'm sorry, I 7

can't -- 8

DR. BOURGEOIS: Okay. 9

DR. TORRES-REYES: I just don't have 10

any answers because I'm not sure what you are 11

saying. 12

DR. BOURGEOIS: We all understand. We 13

all understand. 14

MS. BROCK: If I could just ask a 15

different question? 16


MS. BROCK: In terms of discussing 18

cases with you -- 19

DR. TORRES-REYES: It's not on 20

(referring to microphone). I'm right here; we can 21

talk. Let's go. 22

96


MS. BROCK: Okay, sorry. All right. 1

In terms of discussing cases with the Coast Guard, 2

in what cases would you need a release from the 3

applicant or employee, or whatever? And if you do, 4

how would we go about getting that? What kind of 5

release? Do you have releases -- 6

DR. TORRES-REYES: So, we get the 7

information from the mariner and their provider. 8

So, we have that information. So, if you, as the 9

employer, were going to ask me and say, "Hey, I have 10

this case. What can you tell me about this case?", 11

basically, as I did with Dr. Schaub, I can tell you, 12

just like any other occupational medicine, I can 13

tell you whether they are fit for certification or 14

not. 15

If you don't have the information that 16

I have from the physician, I can't give it to you, 17

especially as the employer. And so, it goes down 18

to the fact that, actually, as the employer, you 19

can ask the employee for the information because 20

that's your right under occupational medicine, 21

right? You have that right to -- 22

97


MS. BROCK: I guess my concern in some 1

of the cases is, do you have the information that 2

we have? And because there's no waivers, we don't 3

know if you've actually received the 4

information -- 5


MS. BROCK: We may have received it and 7

not forwarded it, but we have it. 8

DR. TORRES-REYES: Well, so I could 9

tell you that I have their 719K. I could tell you 10

that I have a note from Dr. Jones. I could tell 11

you that I have the cardiologist report from Dr. 12

Smith. I could tell you what documents we do have. 13

Yes. So, yes, okay, I look forward to that. Yes, 14

okay. 15

But, again, I'm saying you're 16

absolutely right. So, we have information you may 17

not have or you might have information that we don't 18

have. So, yes, that discussion. 19

But, again, if the mariner hasn't 20

provided it, I don't think there is any legal way 21

for me to say, "Hey, Employer, you have this. Can 22

98


you send it to us?" I mean, that is going to be 1

a violation. 2

MS. BROCK: And we would say you two 3

need to talk. 4

DR. TORRES-REYES: Right, yes. 5

DR. SCHAUB: I've actually asked you 6

that because I have had people that have been on 7

controlled medicines, and I'm like, did they really 8

disclose to the Coast Guard? 9

DR. TORRES-REYES: So, that was 10

case -- and that most recently -- so, Dr. Schaub 11

had a case where we gave a disposition -- that Dr. 12

Schaub asked, "Well, did you know he was on this 13

certain medication?" But we had received a 14

doctor's note, subsequent to what he knew about it 15

on the 719K, and I told him, I said, "No, he is no 16

longer on that medication." And I was able to say 17

that. And he said, "Oh, okay." 18

So, you know, that was a case where they 19

had sent in information that you -- it was a great 20

question because it was concerning and there are 21

issues. So, I was able to release that 22

99


information. 1

DR. MIGNOGNA: So, you were able to 2

release the private medical information -- 3

DR. TORRES-REYES: No, I was able to 4

confirm to him that, yes, we were aware of the 5

previous medication. However, we had received 6

information since from his treating provider; that 7

that's why our wonderful evaluator said, "No, he's 8

good to go." And he was no longer under the waiver. 9

DR. MIGNOGNA: Yes, and just very 10

quickly, the whole issue of the certification 11

versus fitness for duty, I mean, all the agencies 12

deal with this. FAA has got their special issuance 13

and -- 14

DR. TORRES-REYES: Right, exactly. 15

DR. MIGNOGNA: -- DOT has got their 16

exemptions and waivers. So, we do all that 17

hundreds of times a day. 18

DR. SCHAUB: You understand my point 19

about there is a big change; there is a sea change. 20

MS. MEDINA: Let me try to make sure 21

that I think Dr. Mignogna just brought a good point, 22

100


which is every agency does that, but every agency 1

has a different system on how they do the medical. 2

I mean, the FAA, they do have the DME, so they see 3

them periodically. 4

The system that we have is not perfect, 5

but, as you know, we have the 719K. Let's not even 6

talk about the 719KE. 7

And we heard from Dave Van Nevel, 8

meaning our authority is in law. They start from 9

there very specifically. The authority is in the 10

law. So, that is one of the areas that we have been 11

struggle and we will continue to struggle. We are 12

trying to fix it, but the fix doesn't come quick 13

enough. 14

We do have the form. We rely on the 15

mariner to fill parts of the form and, then, we rely 16

on physicians, meaning if I don't like, in some 17

cases if I don't like the answer I get from one 18

doctor, I go to another doctor. And that's why we 19

are hoping that the DME would solve part of that 20

problem. I mean that would be, uh-hum. 21

But one thing that is very 22

101


important -- and we had a meeting last year with 1

SIU and Dr. Schaub came with that and a particular 2

company, and they brought this up to us. One of 3

the issues that we have, too, is that the Coast 4

Guard does not have data, meaning unless we hear 5

about it and unless we can enter, we can get the 6

data, we don't know what the result. So, that is 7

the issue that we need to improve. 8

And your bringing that, meaning Dr. TR 9

talking to Dr. Schaub all the time, that's the only 10

way we can resolve the issue. It is not a perfect 11

system by any extent of the imagination. And I can 12

be good today, and tomorrow I may have 13

incapacitation. I mean, that is how the system 14

works. Unfortunately, that is how the system 15

works and we have to rely on the certification and 16

the fitness for duty. 17

And this is the venue and I am glad 18

that -- I mean, that is why we wanted to have that 19

presentation, is to bring out more questions and 20

more issues and to see if we can get -- and I 21

guarantee that we will go back to you individually 22

102


also, because we heard certain things, to be able 1

to get back more information. 2

DR. SCHAUB: So, it sounds like the 3

liability for anything that would happen would rest 4

with the employer. So, if you have a mariner that 5

comes onboard, he's got his med cert, but, then, 6

that mariner accidentally doesn't see something 7

because of a medical condition, runs into a bridge, 8

takes out an interstate, that's on the employer. 9

That is not on the Coast Guard, correct? 10

MS. MEDINA: Not necessarily because, 11

when there's an investigation, they will go back 12

all the way to how they got certified, what did we 13

receive, and all that. I mean, as Dr. Torres 14

mentioned, we make mistakes, too. The system that 15

we had before was relying on giving waivers and all 16

that, and then, it came, so many investigations and 17

things that should have been done. 18

So, it will go back to the Coast Guard, 19

find out what we did, how did we certify the person. 20

What did they submit? Did they hide anything on 21

the stuff that they submitted? I mean, that is 22

103


where the investigation comes and, then, it goes 1

to the company. So, there's a whole investigation 2

of due diligence to be able to get there and how 3

that will be done. 4

But, no, we're not home-free, meaning 5

you will start with us first. 6

DR. SCHAUB: Say I deal with employers, 7

but the Coast Guard will also be -- 8

MS. MEDINA: He would, they would come 9

to us, exactly. It means how the investigation or 10

how does it work, yes. 11

MS. CAMENZULI: I have a three-part 12

question. 13


MS. CAMENZULI: How long has this 15

database system been in place? Like how many years 16

have been documented in your system for the 17

mariners? 18

DR. TORRES-REYES: In the MMLD? 19

MS. CAMENZULI: Yes. 20

DR. TORRES-REYES: 2008? Yes, 2008. 21

MS. CAMENZULI: 2008? Okay. 22

104


DR. TORRES-REYES: Uh-hum. 1

MS. CAMENZULI: And so, are you able to 2

pull metrics such as this person that is a mariner 3

has diabetes and things like that, so just so we 4

know where we can focus health and wellness 5

efforts? 6

DR. TORRES-REYES: Unfortunately not. 7

MS. CAMENZULI: Okay. 8

DR. TORRES-REYES: The database is 9

archaic. I will be giving a presentation tomorrow 10

that shows you the type of data that we can pull. 11

So, basically, we can capture and query how many 12

denials, how many certificates worked through. In 13

terms of linking a mariner number to a diagnosis 14

and the outcome, it doesn't do that. 15

So, part of the DME, the future, is that 16

we are looking at investing in a database that has 17

ability to query true data, like I said, risk and 18

outcomes. What are the conditions that are 19

diagnosed. 20

So, again, I will show you the 21

information tomorrow about what we can see. So, 22

105


we get numbers of how many diabetics were denied -- 1


DR. TORRES-REYES: -- how many 3

coronary artery disease were denied, how many were 4

appealed. So, that kind of basic numbers. But, 5

in terms of the outcomes of conditions, we don't 6

really have that. 7

MS. CAMENZULI: That would kind of be 8

where your top 10 conditions that were -- 9

DR. TORRES-REYES: Right. So, I can 10

tell you. Yes, I can tell you that, you know, from 11

2015 to 2016 the No. 1 condition was lack of AI, 12

which it is. It is huge. So, missing information 13

is one of the No. 1 reasons for denial, and from 14

there, it goes kind of like piecemeal to coronary 15

artery disease, obstructive sleep apnea, seizure 16

disorders, medications. So, again, I can show you 17

some printouts of what we can see. 18

MS. CAMENZULI: Okay. And then, the 19

last question. 20

DR. TORRES-REYES: Yes. 21

MS. CAMENZULI: How does the National 22

106


Maritime handle like non-disclosure issues? Say, 1

you've had a mariner. You have data since 2008 2

and, then, all of a sudden, they submit a Coast 3

Guard exam and they have been on a narcotic 4

medication they have never reported previously in 5

the past. 6

DR. TORRES-REYES: Right. So, since 7

I've come onboard, we get that quite a bit. 8


DR. TORRES-REYES: You know, people 10

say, "Well, that's fraud." Well, it is not fraud. 11

All we are here to do is to make sure that we get 12

as much information as possible. 13

So, what we will do is our evaluators 14

will come in and say, "Hey, Doc TR, this person was 15

on oxycodone in drug rehab five years ago. So now, 16

there is no mention of that." Because one of the 17

questions is, "Have you been treated?" 18

And so, what we do is we send an 19

amplifying information letter. We'll say, "Hey 20

Mariner Joe, we can see here that -- tell us the 21

recent status of your drug use." So, we just say, 22

107


well, we just assume that they forgot to give us 1

information, but we make it very clear that we know 2

that the information is in there. And sometimes 3

we have great responses; sometimes we don't hear 4

back. 5

And again, a lot of our denials are for 6

lack of daylight; people just don't get back to us. 7

So, that is where we put that, and we don't assume 8

fraud or intent. We just let the mariner know that 9

we need an update on this condition, on this waiver 10

that you had. "Hey, by the way, what's going on 11

with that? We didn't know from your private doctor 12

telling us what's going on with your current 13

condition," cardiac disease, obstructive sleep 14

apnea, diabetes. 15

MS. CAMENZULI: Even if they have never 16

reported it before, though? This is the first time 17

reporting it? 18

DR. TORRES-REYES: Well, okay, now so 19

that's another. So, if it is a first-time 20

reporting it, then we just assume it's a first-time 21

reporting. 22

108



DR. TORRES-REYES: I mean, you know, we 2

don't know. Sometimes it's amazing how, when we 3

look at the information that the doc -- you know, 4

they'll send in doctors' notes like doctor visits 5

from the last year and they will have a summary. 6

Many times the evaluator will say, 7

"Hey, on their medication list the doctor has that 8

they're on Codeine and it's a chronic use and they 9

get refills every five days." You know, that's 10

exaggerating it. 11

But, then, again, our evaluators send 12

a note saying, "Hey, Mr. Mariner, Mrs. Mariner, 13

please tell us about this condition, about this 14

medication. We need an update of where you are." 15


DR. TORRES-REYES: So, again, I have to 17

say our evaluators are very meticulous about the 18

information they get. And sometimes there's 19

volume of information, but they will spend the time 20

going piece by piece looking at every piece of 21

information to see if there is anything that we are 22

109


missing that is of interest and is a 1

safety/security issue. 2

MS. CAMENZULI: Okay. Wonderful. 3

Thank you. 4

DR. TORRES-REYES: Thank you. 5

Yes? 6

DR. MIGNOGNA: Just very quickly, to 7

take off on that, how is that information, if it 8

is, transmitted back to the examining physician 9

and/or employer as a heads-up? 10

DR. TORRES-REYES: Oh, that's 11

interesting. There is no connection back to the 12

examining physician. 13

DR. MIGNOGNA: So, if the mariner has 14

a potentially not-serious, not-fit-for-duty 15

condition, but otherwise has a credential, how does 16

that employer know to enact any restrictions or 17

accommodations, or et cetera? 18

DR. TORRES-REYES: Well, okay. When 19

we get the information, if there's a change of 20

condition of the medical certificate, we 21

change -- is that what you are talking about? 22

110


DR. MIGNOGNA: No, no. If the medical 1

certificate stands, but you learn of a new serious 2

health condition, otherwise meets the credentials, 3

but may impact their actual fitness for duty for 4

their job? How does that information get shared? 5

MS. MEDINA: He's asking, if we get 6

information that the mariner has a new condition, 7

how does the shipbuilder owner, how does the owner 8

know? Can we transmit that information? And I 9

think the answer is we cannot transmit that 10

information because -- 11

MR. VAN NEVEL: Can we transmit it to 12

the owner? No. 13

MS. MEDINA: We can't because of HIPAA. 14

MR. VAN NEVEL: Yes. Well, in our 15

case, it is privacy, because HIPAA -- we are not 16

a provider, an insurance exchange -- and I forget 17

what the three was. But the release of information 18

is protected by the Privacy Act and the procedures 19

there. It is not the same, but the same basic idea; 20

if you don't have a release, we can't release the 21

information to you. 22

111


The mariner, the interesting part of 1

the Privacy Act is the mariner can request his 2

record under the Privacy Act as part of fixing 3

erroneous records, but there are no provisions for 4

an employer. So, generally, if we found 5

information that we were concerned that the mariner 6

was not fit, we would take action against the 7

medical certificate and move to pull it, but there 8

is really no legal authority for us to go say, "Hey, 9

Employer, there's somebody working for you that's 10

unsafe." 11

DR. MIGNOGNA: Right. So, you can't 12

pull the medical certificate if they meet the 13

medical certificate standards. So, when we do 14

drug testing and we find somebody has a positive 15

drug test and they're on morphine, and they have 16

a prescription for it. The drug test is negative. 17

But it is our duty to advise the employer red flag, 18

something's up; we recommend a fitness-for-duty 19

exam. So, that doesn't happen coming from the 20

Coast Guard? 21

MR. VAN NEVEL: Well, if we were aware 22

112


of a condition, we would investigate, but we can 1

only use it for our own purposes. We can't as the 2

employer. I mean, it is not -- we have issues with 3

the drug testing in general because the way the 4

system is set up, it is the reports go to the 5

employer. And so, for a case where it is a 6

legitimate use, there would be no legal reason to 7

report that to the Coast Guard because of the legal 8

use. We only get the reports of illegal drug use. 9

DR. TORRES-REYES: Anything else? 10

Yes? 11

MS. RUSSELL: So, coming from, I guess, 12

the Academy perspective, you know, fitness for 13

certification versus fitness for duty, I had a case 14

last year. One of our cadets, you know, he was 15

ready to graduate, needed his last 90 days, you 16

know, summer sea term. Had a recent procedure. 17

Ends up with complications, pulmonary embolism. 18

You know, needed anticoagulation therapy. 19

The school, we went about it by applying 20

for his med cert, which he was granted with a 21

waiver. However, he was on daily Lovenox 22

113


injections. In my opinion, that was not -- he was 1

not fit for duty, ready to go on his summer sea term. 2

If he didn't go, he wasn't going to graduate in 3

September and he was going to miss the deadline to 4

sit for his license exam, and so forth. 5

So, we're not an employer. We're a 6

school. The students need to go on the ship within 7

a certain amount of time to get their credentials 8

met. 9

You know, it was a battle for me because 10

I said, no, I didn't think that he should be allowed 11

on that ship. The defense was, "Well, the Coast 12

Guard granted me a med cert." And his parents went 13

all the way to the top and he was allowed on the 14

ship. In my eyes, that was -- so, what would you 15

recommend in a situation like that? 16

I mean, we're coming up; May 8th the 17

ship leaves, and we have implemented new policy to 18

ensure that every cadet has an MMC, you know a cadet 19

MMC, but that doesn't guarantee that they are fit 20

for duty. 21

For example, a whole squad has ACL 22

114


injuries. They have their MMC, you know, their 1

cadet med cert. Should they be cleared fit for 2

duty to go on summer sea term? And that is kind 3

of the dilemma from our college we are 4

experiencing. And now, it is this battle of, well, 5

if they don't go on the ship, they don't graduate. 6

DR. SCHAUB: And what if he died on the 7

ship from bleeding out? 8

MS. RUSSELL: Exactly. Exactly. And 9

whose liability is that? You know, does that fall 10

under me, as the PA of the campus? You know, I know 11

all these students because we are relatively small 12

and I know them all. And then, the question comes 13

up for me, well, what is my duty? You know, I tell 14

the captain. It's his ship. They are our 15

students; they are our cadets. I mean, we are in 16

a working -- they need to be aware. 17

And then, there's a whole medical team 18

that goes on cruise with them, not necessarily 19

always me, and, you know, a proper transition of 20

medical care, you know, letting this new team know 21

of potential red-flag cadets who have an MMC, but 22

115


really aren't fit for duty. 1

So now, do we need to implement having 2

your cadet MMC is not enough to go on cruise? You actually need 3

to be cleared fit for duty? 4

DR. BOURGEOIS: Yes, yes. They internally need 5

to do what companies do. They need to say you also have to get a 6

fit-for-duty examination. 7

MS. RUSSELL: Right. 8

DR. TORRES-REYES: Yes, yes. Sorry. After all 9

that, yes; the answer is yes. 10

DR. BOURGEOIS: And that was my point, and I will 11

say this loudly. Trust me, I was not trying to be argumentative, but you 12

understand the sea change in this is because that terminology is a huge 13

change in the perception of what that form is. True? Okay, look, I'm 14

new to this, so I -- 15

DR. TORRES-REYES: I mean, yes. 16

DR. BOURGEOIS: But you see what it is for the 17

boots-on-the-ground people and, in fact, for the mariners, too, because I 18

know in the mariner's head, just from talking to them every day of my 19

life, they think if they get the U.S. Coast Guard checkoff for 20

certification, they're fit for duty. Okay? And everybody else does. 21

Like I'm saying, I had a five-hour deposition the other 22

116


day, arguing with an attorney that this does not mean he's fit for duty for 1

his job because his job was a way greater standard. 2

DR. TORRES-REYES: Right. 3

DR. BOURGEOIS: But my point being, it is 4

just a sea change in perception. 5

DR. TORRES-REYES: I understand. 6

DR. BOURGEOIS: I wanted to make it 7

clear amongst everybody here. 8

DR. TORRES-REYES: Thank you. 9

CAPTAIN REASONER: Well, I have to add, 10

because we went from five years to the two-year 11

medical cert, which was a good thing because those 12

employers that were doing it annually to make sure 13

that, when we get someone and they're going to sea 14

or a cruise once a year, that there is a more current 15

determination of their fitness. 16

DR. TORRES-REYES: Right. 17

CAPTAIN REASONER: Well, from an 18

employer, when you say it's just a certification, 19

that's just like he got a ticket. It is no more 20

an attestation of whether or not he is employable. 21

So, what you have just basically done -- I keep 22

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hearing this -- is like, oh, my gosh, now we're 1

going back to annual or periodic, 2

you're-getting-on-a-boat physicals because the 3

medical certificate isn't a safeguard anymore. It 4

doesn't say he can get on my ship; he can get on 5

my tugboat. It just says he's got a license again. 6

DR. TORRES-REYES: And so, based on our 7

evaluation, he is at low risk for sudden 8

incapacitation. You know, anything on a daily 9

basis, again, it is industry; you would need to make 10

sure that they are fit for duty. 11

I'm sorry. 12

DR. SCHAUB: I always think of it as it 13

is the difference between getting a college diploma 14

and getting a certificate that says, "I went to 15

every class, but I might not have passed every 16

test." 17

(Laughter.) 18

I mean, you're basically saying, "I 19

went to class, but, you know, can I design -- I went 20

to engineering class every day. Does that mean I'm 21

safe to design a bridge?" Probably not, but I went 22

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to class. So, we need to do it more as "I went to 1

class" rather than you actually have mastered the 2

material. 3

CAPTAIN REASONER: Are there any more 4

questions? 5

MS. KARENTZ: I just wanted to 6

add -- can you hear me? -- I just wanted to add that 7

I'm happy to hear that at least there is some 8

potential accumulation of data coming into 9

something that this Committee has been looking for 10

for many years, I think almost at the beginning, 11

since at least 2012, maybe even prior to that. 12

So, for this, I'm very happy to hear at 13

least some progress that we can at least start 14

looking at a matrix and matriculation of data. 15

DR. TORRES-REYES: Well, it hasn't 16

happened yet. The plan in the future is to have 17

a system that we can collect that, absolutely. 18

Yes, we're making strides in the right direction, 19

yes. 20

MR. DIAMOND: Clay Diamond with the 21

American Pilots. 22

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And since I was invoked in the 1

conversation, I thought I would comment. 2

(Laughter.) 3

And give a historical perspective 4

really on two things. This whole waiver issue, our 5

sole concern with it at the time -- this was in '12 6

or '13 -- was it was just being used incorrectly. 7

People would meet the medical standards, but were 8

being given waivers. And the common understanding 9

of a waiver is you don't meet the standards, but, 10

for mitigating reasons, we're going to waive that 11

particular standard and give you a certification. 12

So, that was our only thing. And ultimately, the 13

Coast Guard saw the light. 14

But the other historical perspective 15

that I think it is important to add to this current 16

conversation is, when the centralization here 17

first happened and the medical reviews were 18

happening here, there was a great deal of concern 19

from those of us from a different perspective that 20

the examining docs were getting zero deference. 21

There were many instances where we felt 22

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like the examining doc recommended certification, 1

or whatever we are going to call it now, and maybe 2

there was an issue. So, the mariner went to a 3

specialist, went through a number of very expensive 4

tests with a specialist in that particular field. 5

And that specialist also wrote a letter saying this 6

person is fit. 7

And again, from our perspective, 8

somebody sitting here who never even met or saw the 9

person was overruling several doctors who had gone 10

through extensive tests and, then, a specialist on 11

that particular condition. 12

So, while I understand and appreciate 13

the discussion here, I would just ask that we keep 14

the historical perspective in place, that we think 15

it is important that the examining medical 16

professional be given a certain amount of 17

deference. And I understand a DME will be given 18

even more deference. But the person that is 19

actually examining the mariner, with the 20

appropriate standards in place by the Coast Guard, 21

should be given a reasonable amount of deference. 22

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DR. SCHAUB: I would just say I would 1

agree with much of that. The one thing I would 2

disagree with is the specialist sees the mariner, 3

doesn't have any idea what the mariner does. The 4

one specialist, the one that we had discussed, the 5

neurologist actually wrote, "This mariner is able 6

to do this duty because I asked him and he says he's 7

able to do this duty." So, he has no idea what the 8

duty is. He just parroted it. And he actually put 9

it in writing. I'm like, wow, he actually put that 10

in writing. 11

(Laughter.) 12

But he actually parroted back what the 13

mariner told him as the reason why the mariner is 14

able to do that. It happens all the time, but they 15

usually don't put it in writing. 16

But, yes, that is the one concern, is 17

the specialist knows quite a bit, but if they say, 18

"Okay, this person is fine to ship, MSC, but they 19

just need to be seen every month," well, MSC is 20

Diego Garcia, and there's no way you're getting him 21

back every month from Diego Garcia. So, that's the 22

122


difference. 1

DR. TORRES-REYES: Yes, and we talk 2

about, you know, the value of the upcoming DME, the 3

Designated Medical Examiner Program. With our 4

waivers, though, we always were asking for more 5

information. We always say, "Please give this to 6

your treating provider." And it is the NVIC that 7

says what you're doing and the physical 8

requirements of being a mariner. So, ideally, we 9

would love them to see that. And you're right, it 10

doesn't usually happen. 11

But, with the Designated Medical 12

Examiner Program, these folks will be trained to 13

understand -- and most of you are already doing 14

that. I mean, you know the mariners; you know the 15

industry. So, in an ideal world, we will have more 16

quality physicals and understanding from 17

providers that really understand. 18

I just have to share this one. We had 19

an 82-year-old gentleman who, you know, 82 years 20

old, not age discrimination, but he had coronary 21

artery disease; he had COPD; he had diabetes. And 22

123


the provider said, "This guy is pretty good for an 1

82-year-old." Well, what does that mean? So, 2

like you said, they think that this is just an 3

82-year-old like working in an office, but he is 4

not. So, yes, that is an interesting story. 5

Okay, I have said enough. Anything 6

else? Anyone else? 7

(No response.) 8

CAPTAIN REASONER: Okay. Are there 9

any more questions on that one? 10

(No response.) 11

Thank you. 12


CAPTAIN REASONER: I think your 14

presentation brings up many of the questions we 15

have been dealing with since the inception. And 16

I think it raises some true issues that we maybe 17

we need to look at some tasking around this. 18

One that I heard clearly is the mariner 19

has no legal responsibility to notify the Coast 20

Guard that I've had a change. There's no 21

notification to the employer that there has been 22

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a notification of change or something substantive, 1

or to the medical doctor who reviewed. 2

I don't believe companies are, "Hey, 3

Coast Guard, we repatriated him for this." So, we 4

haven't really kind of come full circle on how do 5

we assure that we've got a minimum bar now. 6

So, I think maybe we need to maybe 7

discuss some tasking in the future relative to this 8

whole question of how is that information 9

transferred for changes of conditions, and it may 10

be broader than that. But good dialog there. 11

Moving on, the next, we do have time for 12

public comment. Okay, we did have a public comment 13

that Eric would like to read. We did have a 14

Committee member who did want to read a statement. 15

So, we'll do that because we would like that on the 16

record. 17

And then, also, there may be an 18

opportunity, as we go out from this point, keeping 19

within our agenda, to do some tours. So, they will 20

be looking at that as an opportunity. And then, 21

next would be lunch. 22

125


DR. SCHAUB: Okay. This is a letter 1

that I was given. It was from Captain William 2

Mahoney, who a lot of you know, and Dr. Bob 3

Bourgeois. And it is an open letter to U.S. Coast 4

Guard MEDMAC. 5

"We have served on this Committee from 6

its inception and have decided to remove ourselves 7

from the Committee rather than to renew our 8

appointments. Our dedication to the health and 9

safety of U.S. mariners made service on this 10

Committee an important public service. 11

"However, the direction that NMC and 12

the U.S. Coast Guard have taken in the past three 13

years of dismantling most of the improvements to 14

the Mariner Medical Evaluation and 15

Fitness-for-Duty Program have become intolerable. 16

"The decision to continue to lower the 17

standards for U.S. mariners to," quote, "`improve 18

turnaround times,'" end quote, "for medical review 19

will prove to have fatal consequences in the 20

future. 21

"Prior to 02-98 NVIC, medical 22

126


examinations for mariners were the responsibility 1

of the seafarer's private or family physician. 2

Most of these medical professionals, not 3

understanding the particular requirements 4

inherent in the occupation, would not have examined 5

for specific conditions anomalous to mariner job 6

descriptions. 7

"A 2003 Andrew Berberis Elution 8

resulted in 11 fatalities. The issue of public 9

safety being tied to the physical health and 10

fitness for duty of a mariner was brought to the 11

attention of the U.S. Coast Guard by the NTSB. 12

"MERPAC, as part of the commitment to 13

improving the process for training and defining the 14

qualifications for mariners, created a new 719K and 15

crafted the NVIC 04-08 to improve the medical 16

guidelines for a seaman's fitness for duty. 17

"There was slow, but steady progress on 18

merchant mariner medical examination processes. 19

However, certain deficiencies in the system were 20

identified. Among the concepts, it was determined 21

that more transparency between mariner, examiner, 22

127


and NMC reviewer was necessary. Confusion as to 1

policies versus practice were epidemic. 2

"It was felt that fitness for duty would 3

be better founded if the status were determined 4

using occupational medicine/maritime medicine 5

principles: among other things, a more consistent 6

examination, review, and determination of fitness 7

were needed. 8

"MEDMAC, Merchant Mariner Medical 9

Advisory Committee, was formed to advise the U.S. 10

Coast Guard in merchant mariner medical issues. 11

Completed task statements included the top 10 12

medical conditions which were accepted and, then, 13

rolled into the NVIC 04-08 revision. Although 14

completed, they were never implemented," quote, 15

"`since NVIC revision not yet accepted by U.S. 16

Coast Guard.'" End quote. 17

"Seizure, ICD, added to the current 18

NVIC 04-08. NVIC was opposed by MEDMAC but 19

promulgated since the top 10 conditions was stuck 20

in the 04-08 revision. The revised 04-08, 21

although written and unanimously passed by the 22

128


MEDMAC as a whole, the revision still has not been 1

accepted. 2

"Revised medication guidelines to meet 3

the standard of public safety. Many 4

safety-sensitive medications are currently being 5

taken while onboard with NMC approval. 6

"719K form content was not approved by 7

MEDMAC" -- I'm sorry -- "form content not approved 8

by MEDMAC was changed or added after MEDMAC 9

approved the 719K. 10

"719KE recommended discontinuing as 11

unnecessarily redundant and because a generic 12

format would allow potentially substandard 13

personnel to enter the industry. Because of the 14

nature of the tasking aboard modern merchant 15

mariner entry-rate personnel share safety, 16

lifesaving, and emergency response duties along 17

with personnel with advanced endorsements. Their 18

medical fitness should be evaluated in a similar 19

fashion. 20

"Color vision still not being used as 21

per task statement or current NVIC 04-08 for a 22

129


medical waiver. Color discrimination has become 1

an important factor in the safety of a vessel, in 2

machinery spaces, as well as on deck." Quote: 3

"`See primary colors,'" unquote, "is not an 4

adequate color vision test. This statement 5

opposed by MEDMAC was still added to the 719K form 6

after MEDMAC approved the revision. 7

"Recommendations by MEDMAC concerning 8

restrictions on limiting duties or geographical 9

areas for working have been ignored. 10

"The damage, both present and future, 11

to public safety, other crew members, and the 12

environment, emergency response personnel, and 13

even health plans, company, individual, and union, 14

resulting from the approval of persons who are 15

either, one, incapable of performing the task 16

necessary for the safety of life, environment, and 17

vessel or, two, who become incapacitated because 18

of an existing condition while assigned or 19

contracted aboard a vessel are very real problems. 20

"NVIC 04-08 is the lowest bar for 21

merchant mariner medical fitness. Although 22

130


companies should use tougher guidelines for 1

certain positions, remote locations, and locations 2

where there's no tertiary health care readily 3

available, the EEOC routinely attempts to use the 4

U.S. Coast Guard Merchant Mariner Medical 5

Credential as a valid fitness-for-duty assessment. 6

"Companies and, indeed, unions have 7

potential legal issues rejecting the potential 8

crew members for apparent physical problems if 9

their MMC medical credential has no evidence of 10

conditions. The litigious nature of marine 11

employment creates an environment in which U.S. 12

Coast Guard acceptance of an individual as fit for 13

duty closes the door to the company, hiring agent, 14

or vessel for denial of employment to any 15

individual on the basis of physical condition. 16

"From a real-life standpoint, there may 17

be a few operators who would the concept of filling 18

a position with a warm body. Practical 19

considerations for crewing and manning regulations 20

and the high cost of post-sign-on care for those 21

crew members experiencing problems due to 22

131


preexisting conditions make this an untenable 1

position for the great majority of vessel owners, 2

operators, and maritime unions. 3

"Widespread development of in-house 4

wellness programs within unions and individual 5

companies is a reaction to the importance of health 6

in mariners capable of passing physicals during 7

their tenure as employees. 8

"The current NMC process focused on," 9

quote, "`positive,'" unquote, "numbers for passing 10

reviews regardless of an individuals condition 11

makes these wellness programs impotent. 12

"Current medical reviews can be very 13

superficial. It has been found that it is common 14

not to request appropriate documentation as per 15

04-08 NVIC. Denial rate of 0.11 percent is 16

dangerously and suspiciously low. 17

Fitness-for-duty evaluation principles are not 18

being applied. Fitness for duty is the basis for 19

medical certification, which is currently a major 20

qualifier for the merchant mariner credential. 21

The current inappropriate medical process is not 22

132


a sound fitness-for-duty assessment. 1

"Cardiac records documenting 2

successful completion of appropriate tests are not 3

be requested. Sleep apnea CPAP compliance logs 4

are not requested. Controlled drugs and impairing 5

medications have been approved for use while on 6

vessel or on watch. Abnormal color vision has been 7

approved without appropriate restrictions or any 8

restrictions. Very high BMIs with no sleep study, 9

no CPAP review, no physical abilities testing. 10

"Diabetic on insulin with poor 11

compliance and control had his gangrenous leg 12

amputated after his denial was reversed 13

inappropriately. The vessel was dockside. He 14

would have had a much worse outcome, probably 15

death, if the vessel had been at sea. 16

"The U.S. Coast Guard should 17

immediately apply the current NVIC or Task 18

Statement 11-01 MEDMAC revised NVIC to the medical 19

review process. The reviewer should apply 20

occupational medicine and maritime medicine 21

principles to the records review. 22

133


"If current lax processes remain in 1

place, there will be more accidents, injuries, and 2

loss of life. In the past three years, MEDMAC 3

members have protested the deterioration of the 4

medical review process. The MEDMAC did not 5

approve the ICD or seizures procedures. 6

Certainly, if the Commandant were aware of the 7

greatly increased risk that this flawed process 8

places on the U.S. Coast, the maritime industry, 9

the maritime unions, mariners, and the public 10

safety, he would have grave concerns." 11

And it was signed, "Sincerely, William 12

Mahoney, MEDMAC Acting Chairman from 2012 to 2017, 13

and Robert Bourgeois, MEDMAC member from 2012 to 14

2017". 15

MS. MEDINA: Thank you very much. We 16

are going to place that letter into the docket. 17

Meanwhile, there is a number of issues 18

that we will need to react that are in this letter. 19

We are not going to do that. And I think some of 20

those, a minority of those have been answered in 21

the discussions we have had this morning. 22

134


So, like I said, we are going this 1

letter into the docket to make sure everybody has 2

it. Okay? 3

Thank you. 4

CAPTAIN REASONER: Were we able to 5

arrange tours? 6

LTJG FORTIN: We can break. 7

CAPTAIN REASONER: So, a couple of more 8

things before we break and go on tour. 9

First, we had some new people come in. 10

I would like them to introduce themselves. 11

If you could get them a microphone, so 12

that they can add to the discussion and we can 13

welcome them? 14

MR. KELLY: Good morning. 15

My name is Mark Kelly. I'm the 16

President of Anderson-Kelly Associates. We 17

provide maritime occupational health services. 18

MS. SAWAGID: Hi. My name is Heather 19

Sawagid. I'm also from Anderson-Kelly 20

Associates. 21

MR. STEPHANY: Justin Stephany from 22

135


Anderson-Kelly, Client Development Manager. 1

MS. NESHEWAT: Morning, all. 2

Miriam Neshewat, also with 3

Anderson-Kelly. 4

CAPTAIN REASONER: Okay. Welcome. 5

All right. The other thing we need to 6

do as a Committee is we have been given a new task 7

assignment, which is to take the culmination of 8

some of our work and review it now at the Medical 9

Manual. 10

So, do I hear a motion to accept that 11

task? Pick one. Okay. It looks like that was 12

unanimous, but, Brian, you get the first. Beth, 13

you can have the second. And all in favor? Yes, 14

okay, so we will accept that task. 15

We had kind of, before we knew a whole 16

lot about it, we had designated Beth as the 17

Chairperson for that task assignment, with Dr. 18

Brian as the Co-Chair, just so that we have 19

everyone. 20

And then, Task 15-13, the Health Risk 21

Analysis, Dr. Bob and Lesley, you two are going 22

136


to -- oh, Joe, sorry -- Dr. Joe. I don't know why 1

I wrote -- yes, where is Bob? He's here in spirit. 2

Okay. 3

And then, we still need someone to take 4

over the Appropriate Diets and Wellness task. Do 5

I have any volunteers of our new Committee members? 6

You don't want me to assign you, do you? 7

(Laughter.) 8

Pick a number 1 through 5. 9

(Laughter.) 10

So, maybe both of you want to take on 11

the Chair? Who wants the lead? We'll give it to 12

Brooke. 13

Okay. Now to get an idea of where we 14

are going to come back and how many people are 15

interested in each task, we've got the Health Risk 16

Analysis. Just kind of to go back to that, MERPAC 17

actually worked on that a little bit. Do we have 18

MERPAC's input? Okay. All right. 19

So, how many people are working on the 20

Health Risk Analysis? And I'm asking the public, 21

too, so we can get an idea of where we are going 22

137


to put people. So, we have got Luke and our two 1

Chairs. That's it? Okay. So, we have a working 2

group of two people. Three. Okay. All right. 3

And then, how many people were 4

interested in doing the Appropriate Diets and 5

Wellness? Hopefully, that can be completed this 6

week in our two days. Okay. We have minimal 7

people there. 8

And we are working on the Merchant 9

Mariner Medical Manual. Everybody here wants to 10

be on that one. 11

(Laughter.) 12

Okay. All right. So, we will break 13

for the tours, those who want to do tours, and break 14

for lunch, to come back at 1300, and we'll come back 15

to this room and, then, from there, go to wherever 16

the breakout rooms will be. 17

(Whereupon, the foregoing matter went off the record 18

for lunch at 11:12 a.m. and went back on the record at 1:15 p.m.) 19

20

21

22

138


1

2

3

4

5

6

7

8

9

139


A-F-T-E-R-N-O-O-N S-E-S-S-I-O-N 1

1:15 p.m. 2

CAPTAIN REASONER: Hello, hello. 3

Okay. I hope everybody had a nice 4

lunch. We are ready to go back at it. 5

Where we would like to start after 6

lunch, Traci Silas is here, and we have her to thank 7

for getting our two appointments done today. And 8

she would like to have a few words. 9

MS. SILAS: Hello. Hi. 10

I'm Traci Silas. So, for those of you 11

who have not seen, I have changed my hair 5,000 12

times. 13

(Laughter.) 14

But I am the Director of Federal 15

Advisory Committees. This is one of the 28. Some 16

of you I have not seen since Galveston when we were 17

last there. I think that was last year. But some 18

of you I have seen in some other meetings. So, it 19

is good to see you again. 20

A few reminders. So, I know that we 21

break out in subcommittee sessions. The main key 22

140


is to please stay on the task that you are given. 1

It really is the most useful tool, as you are 2

generating recommendations that we can act upon. 3

All right. So, keep that in mind even when you go 4

to the subcommittees. 5

So, take in all of the information that 6

you get, even from our public attendees. They can 7

add quite a bit of value. Bring it back to the 8

table and have it ready for how to synthesize it 9

and to read out for tomorrow. 10

Another thing is, anytime you are 11

addressing any of the public inquiries, if you are 12

unclear as a member especially, please contact 13

someone from the Coast Guard, whether it be Mayte 14

or Luke or even myself if you have questions. 15

No individual member speaks for the 16

whole of the Committee. That is really important. 17

No individual member speaks for the whole of the 18

Committee. So, unless it is a recommendation that 19

has already gone forward, when you do your breakout 20

sessions, you know, don't speak on anything that 21

the Committee has not already deliberated and 22

141


passed on. Okay? You are not representing the 1

Committee, right? 2

I'll be here through tomorrow. So, if 3

you have any questions, I will put my cards -- my 4

information is public. So, you can find me with 5

or without a card. But I am happy to have any input 6

that I can. And I will be on the outskirts, so 7

don't get nervous. I am merely observing. Okay? 8

Any questions? 9

(No response.) 10

Okay. 11

CAPTAIN REASONER: Thank you, Traci. 12

And then, we skipped a very important 13

thing this morning. It is critical for this 14

evening. We did not decide where we might want to 15

go to dinner. 16

(Laughter.) 17

And just in case we needed to be making 18

reservations -- I think, James, you had some 19

suggestions or ideas? Or have you found a place? 20

LTJG FORTIN: I haven't decided on 21

anything. 22

142


DR. UPENDER: Casa Visone, where we 1

went to lunch. 2

CAPTAIN REASONER: Casa? 3

DR. UPENDER: Visone. 4

CAPTAIN REASONER: Visone? Is that 5

where we -- 6

DR. UPENDER: Yes, it's really good. 7

Local cooks, makes everything by hand. 8

CAPTAIN REASONER: Okay. 9

DR. UPENDER: Had a good espresso, 10

vital in life. 11

CAPTAIN REASONER: How do they spell 12

that? 13

DR. UPENDER: V-I-S-O-N-E. Right 14

down the main drag. 15

CAPTAIN REASONER: Okay. 16

DR. UPENDER: It's in the old part of 17

town. 18

CAPTAIN REASONER: Okay. Maybe later 19

could you check and see if we need a head count? 20

DR. UPENDER: I think we've got the 21

website. 22

143


CAPTAIN REASONER: Anybody who wants 1

to join, so we have a number to plan for them. 2

Thirty? Thirty-ish? 3

LTJG FORTIN: Well, 30-ish. I'm going 4

higher. It was 26. So, I am rounding and I can 5

see if they can fit us. 6

CAPTAIN REASONER: Okay. We'll 7

confirm that towards the end of the day. 8

And then, our next was to move into the 9

working groups. We've got our assigned 10

Chairperson for each group. 11

And I think, James, you were going to 12

say where the best location for each was. 13

LTJG FORTIN: So, the Medical Manual is 14

going to be here. The Health Risk Analysis will 15

be in the center. And then, for the Diets. 16

CAPTAIN REASONER: Let's go back to a 17

show of hands. I think the Medical Manual group was 18

larger than this section would do. How many 19

individuals were interested in sitting in on the 20

Medical Manual tasking? 21

(Show of hands.) 22

144


LTJG FORTIN: We're going to move 1

another table in here. 2

CAPTAIN REASONER: Okay. Now can I go 3

back to the Health Risk Analysis? Raise your hands 4

for that. 5

(Show of hands.) 6

Okay. And then, how many people, 7

again, for the Diet and Wellness recommendations? 8

(Show of hands.) 9

All right. So, Medical Manual here. 10

Then, the Health Risk Analysis in the second 11

portion, and in the far back will be those who are 12

working on diet and wellness. Okay? 13

Ready. Break. 14

So, just for purposes of direction, we 15

would expect that the groups work for a couple of 16

hours, take a short break, and then, come back. 17

We'll work through until about five o'clock and, 18

then, start separating, so that we can have closing 19

for the day. Okay? Back at 5:00. 20

(Whereupon, the foregoing matter went off the record at 21

1:21 p.m. to breakout working groups and went back on the record in 22

145


general session at 5:10 p.m.) 1

CAPTAIN REASONER: So, Beth, could you give us 2

a quick summation of what progress the Medical Manual Task Group 3

did? 4

CAPTAIN CHRISTMAN: Yes. We started 5

reviewing the 245-page document. We are happy to report we are on 6

page 27, over 10-percent done. 7

Going through line by line and just 8

checking as our task basically for making sure 9

there's no errors and making comments on ease of 10

use and those kinds of things. So, I think we are 11

making slow, but steady progress. 12

Is that good enough? 13

CAPTAIN REASONER: Perfect. For 14

tomorrow, you'll meet all day. 15

CAPTAIN CHRISTMAN: We'll need all day 16

and, then, some if we are making 25 pages -- well, 17

actually, maybe we will get 50 pages done if we have 18

morning and afternoon. No breaks. 19

CAPTAIN REASONER: Joe, you were the 20

Chair on the other one? I will pass this over to 21

you. If you could give us an update? 22

146


DR. MIGNOGNA: Thank you. 1

We have been talking about the Health 2

Risk Analysis. 3

CAPTAIN REASONER: It's not working 4

(referring to microphone). 5

DR. MIGNOGNA: I'm just going to 6

project. I will project. 7

Lesley and I chaired the committee 8

talking about health risk analysis. It took a 9

little while to figure out exactly what we were 10

supposed to be doing, but we tortured the task 11

request. 12

We are basically addressing the 13

opportunities to be a little bit more specific with 14

the physical ability testing recommendations as 15

they are tied to specific job requirements and 16

endorsements. So, we are working through that to 17

come up with some novel ideas from the examiner and 18

the mariner all the way up to how the National 19

Maritime Center can use the information. It is a 20

task in progress. 21

CAPTAIN REASONER: And then, can we get 22

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a report out from our task group on wellness and 1

diet? 2

MS. RUSSELL: Yes. We made some 3

progress today. We reviewed what the past working 4

groups had done and made some modifications on the 5

provisions for tobacco and, then, the work intake. 6

So, we are pretty much wrapping up, I think. I 7

think another hour or so tomorrow, yes, an 8

hour-and-a-half, two hours. 9

CAPTAIN REASONER: Okay. Great. 10

Very good. 11

All right. I don't really have any 12

closing remarks other than I thought we got a lot 13

done today, good progress here and almost finished 14

with another task. A great educational day as to 15

how our actual processes work and what we have 16

accomplished. 17

So, with that, unless you have 18

remarks -- 19

MS. MEDINA: Eight o'clock tomorrow 20

morning. 21

CAPTAIN REASONER: Then, eight o'clock 22

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tomorrow morning, start back up. 1

Thank you. 2

(Whereupon, at 5:13 p.m., the meeting 3

adjourned for the day, to reconvene the following 4

day, Wednesday, April 5, 2017, at 8:00 a.m.) 5

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