Features Procedures Safety & Training
Fit to Fly

Have you ever heard of a pilot hiding or masking medical conditions from his aero medical doctor? Have you done it yourself? All pilots want to keep their medical status intact, but some pilots want to keep it so badly they will mask medical issues they have been developing for some time. They justify that they are still OK to fly and will ground themselves when their condition has deteriorated enough to be dangerous. Well, as one very popular book puts it, “Let ye without guilt cast the first boulder . . .”

Many pilots feel conflicted about reporting medical issues, but fitness to fly is of paramount importance to you and your passengers.

Unfortunately, most of us are not good judges of our true medical condition because we tend to overlook deterioration with age and figure we are “normal.” In many cases we are simply unable to diagnose symptoms accurately or judge the importance of losses in cognition. (Could it be a lack of mental alertness that precludes us from seeing this loss of mental cognition?)

Perhaps the true story of a professional pilot who drove a twin turboprop into the ground will serve as an example of the tendency for pilots to tenaciously hold on to their medical validations. The captain flew below minimums during a non-precision IFR approach and then below minimums for the circling approach during a rainstorm with weather as low as 300 feet and 2.5 miles in fog. He levelled off marginally above the terrain but failed to apply power in the level off and repeatedly ignored stall warnings. As a result, the aircraft stalled and plunged into the ground and the six people on board died. 

Toxicology tests determined the pilot possessed several medical issues that would have grounded him – had they been divulged. The testing detected sertraline in the pilot’s kidney and liver. Sertraline is a prescription antidepressant medication used for anxiety, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder and social phobia. The records also documented a diagnosis of diabetes without any indication of medications for the condition, and noted three episodes of kidney stones, the most recent case (two years prior to the accident) when the pilot experienced “severe and profound discomfort” from a kidney stone while flying. None of these conditions or medications was noted by the pilot on his medical application forms; each would have precluded him from holding a pilot’s licence.

Putting it into Perspective
COPA (Canadian Owners and Pilots Association) members who attended the COPA AGM in Summerside, P.E.I., last June had the great pleasure of attending a seminar by flight surgeon Dr. Trevor Jain entitled: Stay Fit – Stay Flying. It was humorous, entertaining and packed with information about medical conditions – many of which our aging pilot population encounter through time. He started by explaining the position of the aero medical doctor and his need to protect the flying public, the general public and pilots – in that order.

Many pilots feel conflicted about reporting medical issues, but really, your fitness to fly is of paramount importance to you and your passengers. What do you think about the twin turbine pilot who killed – no, murdered – six people? None of us would knowingly risk our passengers’ lives – would we?

Pilots with medical questions relating to the Canadian Aviation Regulations (CARs) should refer to CAR 424.17 (4). However, this article will attempt to address most of the go/no go issues in the CARs. Dr. Jain puts forward a simple question that most of us could answer without hesitation: “Would I allow my family to fly with a pilot who has this medical condition or is taking this medication?”

GROUNDING Medical conditions
A medical evaluation tries to cover all the bases, including eyes, ears, nose, throat, respiratory system, digestive system, risk factors for strokes and heart attacks, malignancy, psychiatry, MSK (musculoskeletal), genitourinary system, HIV/AIDS and diabetes. Now, in some detail . . .

• The Eyes Have It: Myopia – pilots can hold a Class 1, 2 or 3 medical certificate if their visual acuity (VA) is equal to or less than 6/60 (20/200) but is correctable with prescription lenses. In the case of cataracts, the medical licence is suspended when the cataract impedes the vision such that the minimum vision standard is not attainable during testing.  Intraocular lenses are not permitted; however, the pilot is suspended from flying for six weeks after surgery. If a colour deficiency is noted, the pilot may fly with a restricted medical permit, but must fly daylight only and when operating from a controlled airport with two-way radio communication. Contact lenses are now approved for all categories.
• Listen to the Details: If a pilot fails an audiogram test, he may still be able to fly after further testing. Minor, dry (no discharge) perforation of the eardrum is acceptable; however, wet discharge showing infection will result in grounding until cleared up. Otitus and sinusitis conditions will also require grounding until overcome. Meniere’s disease revokes the medical certificate until an ENT doctor says otherwise, and labyrinthitis requires grounding while the infection is acute.
• Better Breathe Well: Wanna fly? Give up smoking before it’s too late. To determine the risk of licence continuation, a pulmonary function test may be required to ensure adequate oxygenation as well as an arterial blood gas test. For those who think wearing a pulse oximeter should suffice to gauge oxygenation, Dr. Jain was adamant they are unsuitable as the sole device to rely upon for oxygenation. Also, a person must be fully cured from pneumonia before resuming flying operations; COPD/emphysema are usually grounding if active treatment is required.
• Asthma: There are so many fitness and medical concerns associated with asthma that it becomes a complex issue to assess. Those with the disease know there are many causal factors to be avoided, but can you fly with asthma? Your doctor will look at many considerations in the fly/no fly decision to determine the flying risk including: length of time the applicant has had the disease, severity, number of ER visits and hospitalizations in the past five years. If the symptoms are mild and well controlled, an applicant may be able to hold Cat 1-4 medicals. Pilots with moderate cases may be able to fly on a restricted category licence; however, severe, poorly regulated cases will preclude flying.
• Gastrointestinal Diseases: Dyspepsia or esophagitis treated with antacids are OK if there are no side effects present. But gastric duodenal ulcers are disqualifying while the ulcers are present and under treatment. (An exception occurs when long-term treatment results in no side-effects).
• Hernias: Significant hernias require temporary grounding until they are repaired. If there is any question about the severity of a hernia, a medical consult is necessary.
• Gall Bladder: With cholelithiasis (the presence of gall stones in the bladder), minor incidental stones with easy passage may not become a grounding issue. However, symptomatic, recurring stones will require grounding. Essentially, the issue here is the immense pain and incapacitation that occurs during stone passage.
• Genitourinary Disease: Kidney stones (Renal Calculi) can result in grounding with repeated occurrences; however, the single passage of a stone may be OK as long as imaging shows negative results for additional stones. I believe the non-medical term here would be a quarry Cancer of the prostate may be acceptable for licence continuation after a report from the surgeon or oncologist.
• Metabolic Disorders: Thyroid issues may be acceptable after an internist or endocrinologist indicates the condition has stabilized and there is an acceptable degree of risk. Diabetes mellitus, (DM) on the other hand, is complex in terms of medical validation. Applicants who can control their blood glucose with diet alone are fit to hold all medical categories – provided they have no cardiovascular, neurological, ophthalmological or renal complications that could result in a subtle incapacitation while flying. An applicant on oral hypoglycemics must meet the conditions above and will also need to show the medicine and dosage they are taking provides stable blood sugars without any intervention (medical issues) for a period of six months in order to obtain a medical validation. Because of the incapacitating nature of DM, additional tests will be required, making the acquisition of medical fitness assessment an uphill battle.
• Musculoskeletal Diseases: Locomotor dysfunction such as all amputations, malformations, arthritis and other losses of function will be individually assessed by the medical practitioner. In some instances, a flight test will be required.
• Psychiatric Diseases: Watch this one! Pilots with anxiety disorders that require active treatment, those with substance abuse/dependence or those under treatment for ongoing depression are typically grounded. In many cases, the U.S. FAA allows pilots to fly even if using certain antidepressants. Transport Canada is currently looking at the issue. 
• Malignancy: No flying is permitted while a pilot is undergoing chemotherapy. Pilots are assessed on an individual basis when the doctor receives pathological and oncology reports that include staging treatment, prognosis and followup.
• HIV/AIDS: The major concern in this situation is the potential development of psychiatric and/or neurological complications; CD-4 count and viral load measurements are taken into account for the medical practitioner to say yea or nay.
• Have Some Heart: Be aware, chest pain is grounding until the cause is determined. Acute coronary syndrome possibilities are multifaceted and full-blown ischemic heart disease will result in at least six months’ grounding. Medical science can predict the likelihood of a potential heart attack by considering just seven items: high blood pressure, being of the male persuasion, diabetes, high body mass, smoking, high (bad) cholesterol and advancing age. The good news is you can modify your lifestyle and potential for heart attack or stroke by losing weight, exercising, stopping smoking and adopting healthy eating. The choice is yours.
• Strokes: Strokes (TIAs) are commonly misdiagnosed during emergencies and lead to a loss of licence. However, a clear CT scan, normal neck Doppler and normal echo helps get the pilot back into the air. Pilots who have had TIAs are often able to fly again in three years with no repeat attacks. Unfortunately, pilots with cerebral vascular events are normally not permitted to fly.

THE Cognitive Conclusion
The aero medical doctor is there to protect the flying public, the general public and pilots. Being aware of your medical limitations and expected recuperation time after being sick will go a long way to help you fly safely and obtain your fit-to-fly endorsement. Attempting to mislead your aero medical doctor is not only foolhardy and counter-productive, it can also be deadly.

Special thanks to Dr. T.N.M. Jain, MSM, CD, MD, Flight Surgeon, Emergency Specialist, Dive Medicine Consultant.