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The Work of the Aviation Medical Examiner

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The Work of the Aviation Medical Examiner. Dr. Martin F Hudson MBBS, MRCP(UK), FRCP Edin. Immediate Past Chairman of the Association of Aviation Medical Examiners Authorised Medical Examiner for UK CAA, EASA, FAA (USA), CASA (Australia),Transport Canada - PowerPoint PPT Presentation
  • The Work of the Aviation Medical ExaminerDr. Martin F HudsonMBBS, MRCP(UK), FRCP Edin.Immediate Past Chairman of the Association of Aviation Medical Examiners

    Authorised Medical Examiner for UK CAA, EASA, FAA (USA), CASA (Australia),Transport Canada

    Company Medical Adviser Thomas Cook Airlines

    June 2011

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

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

  • Who are the examiners?Aviation Medicine SpecialistsOccupational Health PhysiciansGeneral PractitionersPrivate PractitionersConsultantsMilitary Medical Officers

  • AvailabilityCommercial pilots: Available to all air-lines and aviation commercial organisationsPilots freedom of choicePrivate PilotsInformation not advertisingWeb-sites: information and on-line bookinge-mail

  • Appointment as an Authorised Medical ExaminerAppointed by the CAA or relevant authorityGuaranteed appointment if suitably qualifiedNo upper retirement age No waiting listsInitially appointed for Class 2 only then up-graded to Class 1 after a period of time and on completion of further training and examinations

  • Accreditation as an AMEInterest and experience in Aviation Medicine/Armed ForcesBasic Certificate in Aviation Medicine (minimum of 60 hours) Class 2Advanced Aviation Medicine Certificate (minimum of 120 hours) Class 1Diploma in Aviation Medicine Flying experience, CPL, ATPL, PPL, NPPL

  • Appointment as an AMEClass 1 requires minimum 6 pointsClass 2 requires minimum 4 points3 points for completion of higher training2 points for Dip. Av. Med.1 point for 1 year work in aviation medicine practiceICAO PPL or NPPL 1 pointICAO CPL or IR 2 points

  • History of AME Training CoursesGeneral Aviation Course (Farnborough) GAM: 5 days started 1973Initially linked with Aviation Medicine Course for Armed Forces MOs.1984 expanded to 10 days1998 IAM Farnborough closed1998 Kings College, London - Advanced and Basic Courses.Diploma in Aviation Medicine

  • Other Aviation AuthoritiesEASA (European Aviation Safety Agency)FAA (American)CASA ( Australian)CanadianSingaporeOthers: e.g. China, Hong Kong, New Zealand, UAE, South Africa, Middle East? Global harmonisation

  • The Medical ExaminationAppointmentsConsulting room(s)LightingAdministration/secretarial/financialNursing assistantComputerisation - Internet - e-mailOn-line transmission of medical examination

  • EquipmentBasic examination instrumentsCouch StethoscopeAuroscope + speculae? (Aural syringe) NB Medico-legalOphthalmic equipmentTorch

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

  • Ophthalmic EquipmentSnellen Charts; 6 metres and 1 metre (use of mirror is permitted to achieve distance)RAF Near Point RuleIshihara plates (24): 15 to be read correctlyMaddox rod/wing (phoria testing) + lightOphthalmoscopeEye mask/cover and Pin Hole discVision tester e.g. Titmus

  • The Examination

    The History

    The Clinical Examination


  • The Medical HistoryInitial: All previous medical/surgical/psychologicalRevalidation/Renewals: Recent events (since last examination)Recreational drugs - alcohol, tobacco,othersMedications - OTC, PrescribedCheck pilots entries and accuracy on application form. N.B.tickitis!!!NB Thoroughness, deliberate omissions, non deliberate omissions, life-time not just recent for initial examinations

  • Physical/psychological fitness


  • Psychological HistoryStress - work and domestic ? Second jobsAnxietySleep history, Fatigue, Epworth sleep scale, sleep apnoeaDepression; ? use of depression scoring questionnairesAlcohol problems / use of CAGE questioningDrug dependencyGut-reaction

  • Epworth Sleepiness ScaleHow likely are you to doze off in the following situations in comparison to feeling just tired?0 = never; 1 = slight chance; 2 = moderate chance; 3 = high chanceSitting and readingWatching TVSitting inactive at a meetingPassenger in a car for an hour with no breakLying down to rest in the afternoon Sitting and talking to someoneSitting quietly after a lunch without alcoholIn a car, while stopped for a few minutes in traffic

  • The Physical ExaminationCareful full routine clinical examinationUse examination to prompt more history from pilot. i.e. palpation of liver/auscultation of chestOphthalmic: uncorrected and corrected, contact lenses and spectaclesENT ? Valsalva maneoeuvreOther examinations as clinically indicated? Rectal? Breasts and genitaliaNB Chaperone strongly recommended. GMC/CAA consider this is essential

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

  • Comprehensive Ophthalmic Examination for pilots with high degree of refractive error (RE)

    Not required for RE up to +3 to 3Required every five years for Class 1 pilots with RE +3 to +5 or 3 to 6 Required every 2 years for Class 1 pilots with RE > - 6Anisometropia and/or astigmatism of 3D requires 2 yearly ophthalmic reviewCAA Optometrists Excel calculator available on-line for checking exact requirements

  • Comprehensive Ophthalmic Examination for pilots with high degree of refractive error

    Performed by any OptometristIncludes refraction, slit lamp, Tonometry IOP (> 40 years of age)*Colour vision (Ishihara 24/15 plates), phoria,visual fields, fundoscopy* Initial examination only for CAA but each medical for FAA, Canadian, CASA

  • Comprehensive Ophthalmic Examination for ATCOs, Flight engineers, navigatorsRequired at initial examinationColour perceptionPhorias

  • European Class 3 (ATCO)Periodic RequirementsComprehensive ophthalmic examination every two or five years depending on refraction levelTonometry every 2 yearsHaemoglobin every 2 years

  • JAA Class 1 or Class 2 Visual Limitations Endorsements2 VDL; Vision Distance Limitation (shall wear corrective lenses and carry a spare set of spectacles) [myopia]3 VNL; Vision Near Limitation (shall have available corrective lenses) [presbyopia]4 VCL; Flights only within JAA airspace. VFR flights by day only (colour vision defects) Class 2 PPL only.

  • Spectacles/contact lenses requirements3 VNL for presbyopia look over or varifocal with no upper lens correction + back up2 VDL with no presbyopia correcting spectacles or contact lenses + back up spectacles. NB Not back up contacts lenses2 VDL + VNL; varifocals,bifocals,trifocals or contact lenses + look over half rim

  • Limitations for European Class 3 ATCOAPC Standard proximity conditionATL Valid only while wearing correcting spectacles for ATCO licence (distance vision)AUD Annual audiogram requiredCLL Valid only while wearing contact lenses with alternative spectacles availableRLL refer to limitations on licenceIGR Issued under grandfather rightsVSA Valid only when corrective spectacles available (near vision requirement)

  • Spectacles/contact lenses requirementsNo photochromic lenses. Tinted lenses OKNo varifocal or near vision contact lenses or mixed contact lensesCheck vision uncorrected and with both contact lenses and spectaclesBack up MUST be same prescription. Not old pair of spectaclesAnnual or bi-annual check with optometrist advised even if not CAA requirement especially over 40 years of age, NB Tonometry advised

  • Refractive surgeryGenerally not recommended for pilots3 month flying ban post operationDetailed ophthalmic reports requiredClass 1 pre-op limit 6Class 2 pre-op limit 8Post operation complications may occur , glare, distortion, pain, corneal complications

  • ENT examinationVisualise Tympanic membrane? Removal of waxValsalva and patency of Eustachian tubesNasal airway assessmentSinuses2 metre conversational voice test each ear separately

  • InvestigationsMeasurement of the blood pressure (seated)ECG with computerised interpretationAudiometry (250 - 8000 Hz)Urine - protein, blood, glucoseBlood testing haemoglobin at each medical, cholesterol (once only at age 40)Peak Flow Rate, initial Class 1 only unless clinically indicatedOther investigation as clinically indicated

  • ECG interpretationComputer readingCertain abnormalities accepted as normalRead rhythm strips not read by computerSelect appropriate computer code NB different codes for Pilots and for ATCOsSeek local opinion from cardiologist for abnormal Class 2 ECGs.Keep ECG reading skills up-to-date

  • DispositionCalculate and include all expiry dates i.e. for single/double pilot/private pilot(Class 2) Automatic if done on-lineInclude dates of last ECG and AudiogramStamp with appropriate limitationsIssue medical certificate - signed in presence of the AME by the applicant and witnessed and signed by AME with name under signatureRemind pilots to read back of their medical certificate which lists extract from regulations and a pilots responsibilities Defer for further assessmentDeny

  • Operational Safety Endorsements5 OML: Valid only as or with qualified co-pilot ( NB 2 OMLs can now fly together) This endorsement applies to Class 1 pilots. Probably not going to be permitted under EASA rules7 OSL: Valid only with safety pilot and in aircraft with dual controls. This endorsement applies to Class 2 (Private Pilots)SSL: Special safety limitations e.g.annual audioFHA: functional hearing assessment (completed by training pilot, captain, qualified instructor)

  • Deferred assessmentsInform and explain to the pilot the processWork up case as much as possibleGP/Hospital liaisonPilots consent for informationCAA Algorithms for guidanceLiaison with CAA

  • Current Validity of JAA medical certificatesClass 1: 12 months 60 for multi-pilot operationsClass 1: 12 months 40 for single-pilot operationsClass 2 : 60 months < 40Class 2 : 24 months 40 - 49Class 2 : 12 months > 50 NB The 45 days pre expiry date ruleFor renewals new date of expiry is anniversary of date of issue

  • Validity of European Class 3, UK Class 1 and NPPL certificates

    ATCO: < 40 24 monthsATCO: > 40 12 months45 days rule now applies for ATCOs as for PilotsFlight engineers, navigators:12 monthsNPPL Initial valid to age 45 then up to 65 years of age: 60 months. > 65: 12 months

  • European Class 3 ATCOs and periodicity of ECGsLess than 3048 months 30 - 39 24 months 40 and over 12 months

  • Flight Eng. & Flight Nav. periodicity of ECGs

    < 3060 months30 - 3924 months> 4012 months

  • European Class 3 ATCOs and periodicity of Audiograms

    < 40Every 48 months

    > 40Every 24 months

  • European Class 3 ATCOs other clinical requirementsComprehensive ophthalmology examination; at initial then refraction within +5 and 6D: 5 yearly, more than 6D: 2 yearlyTonometry; at initial then 40 +: 2 yearlyHaemoglobin estimation under 40: 4 yearly40+: 2 yearlyOther tests i.e. Respiratory, CXR, EEG only if clinically indicated

  • Flight Engineers & Flight Navigators: periodicity of Audiograms

    < 40 60 months

    > 4036 months

  • Audiometry for JAA Medical Class 1 and 2 Certificates

    Class 1; at initial then under 40, 60 months, 40 and over 24 monthsClass 2; Instrument rating only at initial then under 40: 60 months, 40 and over 24 months

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

  • ECG codingClass 1; 55 normal 56 abnormalClass 2; 70 normal71 abnormalEuropean Class 3 (ATCOs) 58 normal 59 abnormalOnly the ECGs coded abnormal are seen by CAA cardiologistsECG computer coding diagnosis must comply with CAA guidelines.

  • Blood testsClass 1 Haemoglobin every medicalClass 1 Cholesterol (fasting Lipids) at age 40European Class 3; Haemoglobin every 4 years under 40 and every 2 years over 40.Class 2 Haemoglobin at initial plus any other tests as clinically indicated. Class 2 Cholesterol if more than two coronary risk factors identified at initial (at any age) or if 40 years of age or older for renewal/revalidations.Other tests as clinically indicatedNo blood tests required for UK Class 1

  • PitfallsPoor history takingHurried examinationsTickitis!!Deniers - pilots want to pass the examination!Bogus applicants - NB photo identificationToo low index of suspicion

  • AdministrationRecords/medical files/computer/CAA on-lineBooking appointments*Forms: application (can be printed from on-line system), medical, ophthalmic, ENT* only needed for back up if on-line system fails or for non CAA/JAA applicants i.e. IrelandMedical Certificates Renewals/reminders/on-line booking systemsComputerisation/ Web sites/ E-mail

  • Administration - financeChargesDebit or credit cards/cheques/cashAccounts book keepingIncome tax!!ExpensesVAT

  • Continuing medical educationDuring the period of authorisation (3 years) an AME must complete a minimum of 20 hours refresher training.Scientific meetings, AAME, AsMA, ICASMFlight deck experience/simulator (NB: Post September 11th problems for flight deck visits)Revalidation/Annual appraisal (GMC re-licensing of doctors) N.B. AAME Appraisal serviceCAA Annual audit

  • Appraisal requirementsAnnual appraisalMission statementComplaints policySecurity of records and officesCustomer satisfaction survey (see AAME website)Staff training and confidentiality

  • Suspension/withdrawal of CAA approvalSuspension by GMCFailure to participate in CMEPoor record keepingPoor clinical assessmentUnsatisfactory clinic arrangementsFailure to follow and apply regulationsInformal then written then final warnings

  • CAA Good Medical Practice GuidelinesPublication of guidelines documentAnnual auditAppraisal and 5 year GMC re-licenseRole of AAME in appraisalCAA Algorithms (keep in a file)CAA web-site for updates

  • CAA Good medical practice for AMEsSection 1 Providing good medical practiceSection 2 Maintaining good medical practiceSection 3 Teaching,training,appraising and supervisingSection 4 Relationships with applicantsSection 5 Working with colleaguesSection 6 Probity and healthSection 7 Practice facilities

  • Current political issuesEuropean Aviation Safety Agency (EASA)European Society of Aerospace Medicine (ESAM)European Class 3 ATCO medical certificate now in placeNew European Leisure Pilots Licence (LAPL)Cabin crew medical examinationsRetirement age of Pilots, age discrimination issuesICAO recommendations Class 1 under 40 years of age

  • ICAOFrequency of Class 1 medicals for pilots age
  • ICAO recommendationsLess emphasis on gynaecological issues, i.e. menstruation questionsPilots obligation to report illness/accident etc. to be based more on the condition and not on the number of days off sick

  • CAA new developmentsNew Colour Assessment Diagnosis (CAD) testPilots with Insulin dependent DiabetesDepression and SSRIs? Pilots with positive HIV no longer to be classed as permanently unfitEmphasis on early diagnosis and treatmentCertification of pilots on anti retroviral medicationBrughada Syndrome new algorithm

  • Current medical issuesPilots fatigue and proposed EASA increase in flying hours limitations. 900 to 1000 hours per annum.Security checks at airports? Flight deck/cabin air contaminationCosmic radiation (? Need for monitoring)Hypoxia awareness and trainingFlight deck noise (use of noise attenuating headsets)Breast cancer and night workH1N1 virus infection

  • Other current medical issuesPossibility of grading periodicity to risk and level of fitnessRetirement ages and age discriminationDisability discrimination and the disabled pilotDrugs, booze and flying!

  • The Railways and Transport Safety Act 2003Breath alcohol limit 9 mcg/100mlBlood alcohol limit 20 mcg/100mlUrine alcohol 27 mgms/100mlExtends to Flight Deck and Cabin CrewEngineers limits are 35mcg (breath): 80mcg (blood) & 107mgms (urine)!!Powers of police to test and arrestNo random tests. Must be reasonable groundsTests following accident

  • Drugs, Booze and FlyingThe UK CAA rolePilot referred to CAA, alcohol questionnaireSeen and examinedBlood tests, MCV, GGT, Carbohydrate Deficient Transferrin test (CDT)Testing of hair for drugsTreatment, Acamprosate and CBTAA, Alanon etc.Rehabilitation not discipline

  • The Association of Aviation Medical ExaminersProvides sufficient CPD through Annual Scientific MeetingAppraisal and re-validation serviceWeb-site www.aame.co.ukLiaison with colleagues and European sceneFree first year membershipLink to UK for overseas membersNon political and not a trade union

  • The Work of an Authorised Aviation Medical Examiner

    Any Questions?

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