Flight Physicals- FAA Senior Aviation Medical Examiner

Airplane Cockpit and PilotsAbout 20 years ago I was invited by the Federal Aviation Administration (“FAA”) to travel to Oklahoma City and take the one week course to become a certified Aviation Medical Examiner. During the course I was asked to perform tasks members of a flight crew are routinely asked to perform so that I could understand what they went through. I was placed in a decompression chamber and the pressure was dropped to simulate high altitude loss of pressure conditions. I learned to recognize the first signs of low pressure and reach for the oxygen mask and place it over my face. I sat in a commercial airliner fuselage with 100 other participants and we had to exit the plane rapidly as the plane filled up with smoke from a fire limiting your visibility to less than an inch in front of your face. I experienced the Vertigon machine which simulated a slow death spin dive – the type of accident that claimed the life of the late John F. Kennedy, Jr.

There was considerable class room instruction and then a test of your competency. Since then I have been performing Class I, Class II and Class III aviation medical exams on civilian pilots, commercial pilots and students hoping to become pilots. Every other year I am required to participate in a refresher training exercise and this year I will be traveling to Tampa, Florida in January for a weekend cardiology seminar. As new data and medical safety information becomes available, the FAA incorporates it into their agenda to improve safety and modernize for the future.

Aviation Medical Candidates (pilots) can now enter their health information in advance of a visit over a computerized network that I retrieve and review with the pilot candidates before their exam. The results of the exam are now transmitted electronically by computer to the FAA in Oklahoma City rather than by mail. If there are questions or concerns about a pilot’s health and safety I can confer with the Regional Flight Surgeon in Atlanta or call the experienced staff in Oklahoma City.

The goal of the FAA is to encourage civilian flight and to find a safe and healthy way to keep existing pilots flying. While the FAA rules and regulations are strict and developed for the pilot and public’s safety, they do not regulate the fees that Aviation Medical Examiners are permitted to charge for the exam. Different offices still charge different amounts for the same examination.

If you are interested in a FAA Flight Physical give my practice a call. We love seeing pilots and pilots in training.

Is Aspirin Resistance A True Entity?

Aspirin

Aspirin has been a recognized agent to inhibit platelet function and prevent clotting.  We use it to prevent heart attacks and strokes. It’s used in individuals who have a transient ischemic attack or mini-stroke to prevent a future major stroke. It’s also used as a component of the therapy in patients who have stents put in arteries to relieve arterial blockages.

Despite the use of the aspirin, either alone or in concert with other medications, a certain percentage of patients do have the heart attack or stroke we are hoping to avoid. Scientists have postulated that a number of these patients have a condition called aspirin resistance. They believe aspirin may not work in them due to genetic factors that affect the way aspirin works. The belief is so strong that certain labs now offer genetic assays to assess whether you are a patient with aspirin resistance.

Garret A. FitzGerald, MD, and associates from the University of Pennsylvania published their research in the online section of Circulation: Journal of the American Heart Association which questions the existence of aspirin resistance at all. They recruited 400 healthy non-smoking participants between the ages of 18- 55 to measure the response to the ingestion of a traditional 325 mg regular aspirin or an enteric coated version.  They were able to use several different well accepted measures of aspirins anti-platelet effects to divide the group into aspirin responders and non-responders. They basically found that the non-responders were primarily individuals who received enteric coated aspirin. When you tested their blood in the laboratory with regular non-coated aspirin, or tested them with non-coated aspirin, they suddenly became responders.  FitzGerald and colleagues concluded that “pseudo resistance is caused by delayed and reduced absorption of coated aspirins.”

Doctors and pharmacists have encouraged the use of “coated” aspirin to offset aspirin’s tendency to irritate the lining of the stomach and duodenum and initiate gastrointestinal bleeding. Based on this paper it seems reasonable to suggest to patients that they use regular uncoated aspirin to achieve the desired anti-platelet effect if the patient is not high risk for intestinal bleeding.

 

Inflammation and Vascular Disease

Heart, stethescopeI was privileged to hear Bradley Bale, MD and Amy Doneen, MSN, ARNP talk about the development of coronary artery disease and cerebrovascular disease in patients with low or few cardiac risk factors.  They cited American Heart Association studies looking at groups of men and women between ages 45 and 65 who have their first heart attack or stroke despite being in compliance with suggested lipid and blood pressure guidelines. They pointed out that the first Myocardial Infarct or Stroke occurred in 88% of women who met lipid guidelines and 66 % of men.  These are people who do not smoke, do not have untreated or uncontrolled lipid levels, are not diabetics and who lead an active life style.  They asked “why”?

Dr. Bale and Ms. Doneen work with the well respected cardiovascular Center of Excellence at the Cleveland Clinic program in Ohio, and believe that inflammation is the root of the problem.  They believe that soft plaque composed of lipids and other cells lurks beneath the endothelial cells lining blood vessels. In the presence of inflammatory stimulants, this soft plaque ruptures suddenly through the endothelial level into the blood stream. When it comes in contact with the blood flowing through the vessels the body believes we are bleeding and cut and chemical mediators are released that initiate the formation of a clot. When this clot occurs in a small coronary artery we have a heart attack or myocardial infarction or precipitate a lethal irregular heartbeat. When this clot occurs in the blood vessels of the brain, we have an acute stroke or cerebrovascular accident.

The key to prevention in the so called low risk patient is to detect the inflammation in advance, and treat it. They are firm believers in performing B Mode Duplex ultrasounds of the carotid arteries in the neck to look for the presence of soft plaque beneath the endothelial cell lining. This soft plaque is distinctly different from the safe but calcified plaque we can see on CT scans used for cardiac scoring studies.  They couple this imaging study with a series of complex blood tests which identify inflammation. These include a myeloperoxidase level, the Lp-PLA2 level, the urine microalbumen to creatinine ratio, a F2-IsoPs level and the cardiac specific CRP level.

These tests and studies in combination with a traditional history and exam, sugar and lipid levels and EKG can help us identify those “low risk” patients who actually are high risk for a heart attack or stroke. The cause of the inflammation is often difficult to spot and may be in your mouth with dental or periodontal disease or in your joints with inflammatory arthritis.  Patients with excellent dental hygiene and normal appearing gums may harbor specific inflammatory bacteria that put them at risk. While this seems a bit forward thinking, remember we once questioned the research that showed that bacteria (H Pylori) caused gastric ulcers and intestinal bleeding.

I have begun instituting the inflammatory blood marker panels in my practice. Labs are sent to the Cleveland HeartLab for this purpose. I will be initiating periodic carotid ultrasound studies for the appropriate patients in the coming year.

It is often difficult for clinicians to distinguish snake oil sold for profit from cutting edge science. I have tried to spare my patients from worthless but profit driven products. I am convinced the Cleveland Clinic is just ahead of the rest of us in offering these services and I will make them available to the appropriate patients and will do it in a financially structured manner that does not add out of pocket cost to the patient. It’s not about adding another profitable income stream to the practice. It’s about identifying individuals who shouldn’t have a heart attack or stroke before they do.

Remote Care for the Elderly, Choosing the Right Care Team

Senior Couple At HomeMy elderly and infirm parents live 15 minutes south of my home in an assisted living facility.  They moved there after it became apparent that they could not manage their affairs in their own home, have some degree of independence and socialization with friends and receive the care and supervision they needed to stay out of the hospital.  Their cognitive impairment and dementia made it necessary for me to be in contact with their personal physician and to be able to reach him if he is needed.

It would be far more difficult if I did not live close by.  What would I look for in a physician for my elderly parents if they did not live close by? I would want the physician to have some experience in geriatric medicine. That would include being fellowship trained in geriatric medicine or having some training and certification from the American Geriatrics Society.  A board certified internist or family practitioner with experience in caring for the elderly could do fine as well. The doctor would need to be available by phone for questions and available to see my parents on the same day that they develop a medical problem needing the doctor’s attention.  That physician should have hospital privileges at a local facility where my parents might be taken to by ambulance in an emergency so that he could follow them into an acute care hospital if necessary.

I also would prefer a doctor that had a professional relationship with a rehabilitation or skilled nursing facility so that they could be treated as they recover from an acute hospital stay in a rehab setting.  I love physicians who make house calls if the situation calls for it. While much more can be accomplished during most office visits than a home visit, sometimes the illness dictates the location where the care is provided.

The doctor should be a compassionate individual who is a great listener and who relishes the responsibility of being an advocate and champion for his patients.  It’s commonplace for the elderly to languish waiting for evaluation in the emergency department or to be put off when trying to make an appointment for a test or specialty visit.  Patients need a doctor with a staff who will help them through this process.

To find such a doctor I suggest you start by asking at the local hospital medical staff office. They know who does what and who is accepting new patients. Word of mouth is the best advertising so a testimonial from a friend familiar with the doctor and the practice is priceless.

While Internet rating services provide some information they are less valuable than a personal reference. Local and County Medical Societies are another great starting place in the search for a physician.  If you are looking for a direct pay or concierge type practice, I suggest you perform a thorough Internet search and interview any physician you are considering.