Saturday, June 6, 2015

Special

A Little Bit Special

"You are ineligible for medical certification under Title 14, Code of Federal Regulations (CFRs) revised part 61; specifically under paragraph(s) or section(s) 113 (b) (c), 213 (b) (c) and 313 (b) (c)."

Words to chill the soul of any aviator, inscribed in a letter dispatched to me many years ago from the FAA's Aerospace Medical Certification Division in Oklahoma City, OK. These words were profoundly difficult to read and absorb, but were softened by the fact that the situation was resolved before I ever received them. The letter went on to say:

"I have determined, however, that you may be granted an Authorization for special issuance of the enclosed third-class airman medical certificate as provided for in Title 14 of the CFRs, Section 67.401."

In brief, a "special issuance" indicates that, despite a disqualifying medical condition, the FAA has determined that the disorder is sufficiently managed to restore medical certification. No one wants to be "special" in the eyes of the FAA, myself included. Nevertheless, I would continue to fly for many years after this letter arrived. In many ways, I was better off than before, though my improvement in quality of life came with a annual commitment to interface with the bureaucracy of the Aerospace Medical Certification Division.

Pathological Exhaustion

My wife was the first to mention the phrase in the early 2000s: sleep apnea. She observed that I occasionally stopped breathing in the middle of the night. Sleep apnea? I certainly did not fit the profile. Though stouter than I was as a teenager or twenty-something graduate student, I was still relatively scrawny and my BMI has always been in the normal range.

But there was no mistaking that I was tired; a lot. Not with a simple weariness of the sort that dulls the edge after a night of inadequate rest. This was a deeply rooted fatigue that blurred the mind, derailed concentration, and disconnected my consciousness from the real world as though it were wrapped in a thick, suffocating blanket. I was well beyond tired, I was experiencing pathological exhaustion.

As a student pilot, I learned that such fatigue turned the mind to stone making it impermeable to learning. A flying lesson taken thus impaired was an exercise in maddening futility. In such a state, I was sometimes able to perform adequately on tasks already mastered, but there was no improvement and no hope of learning anything new. Once I realized this, I cancelled lessons on bad days. Before each flight, every pilot should critically review his or her condition and "self-certify" as suggested by the well-known IMSAFE mnemonic (illness, medication, stress, alcohol, fatigue, eating). This need to carefully assess my fatigue state concretely established this essential preflight concept for me long before I earned my private pilot certificate. Fatigue was responsible for many cancelled flights over the years, opportunities to fly necessarily surrendered. The greatest disappointments came on those clear, calm, glorious days that seem tailor made for an aviator's pleasure.

Was Kristy's proffered diagnosis correct? If so, how would it impact my flying? 

Resistance Is Futile

The conundrum with disqualifying medical conditions is that diagnosis and disclosure may jeopardize an airman's medical certificate. It is tempting to allow the condition to remain undiagnosed, but this is obviously unwise; genuine health issues will not disappear when ignored. I explained the fatigue to my doctor, dreading the final diagnosis that the process might uncover.

I was scheduled for a sleep study at Bronson Hospital in downtown Kalamazoo. When I arrived at the sleep center, I was promptly wired up with electrodes and other sensors meant to measure limb movements, eye movements, breathing, brain activity, heart rate, and blood oxygen content. The various wires from every sensor were brought together into a single umbilical connecting me to a device that recorded all the data.

"We are the Borg. Resistance is futile," I thought, contemplating the braid of wires extending from my body.

This was not a good experience. Mostly, I remember lying awake that night, frustrated, incapable of sleep. I stared at a red LED light across the room, the only sign of life on an infrared camera that impassively returned my gaze. I became lost in the head game of the situation. I desperately wanted to fall asleep so that we would collect useful data and, the more I wanted it, the more it eluded me. I perceived that I was awake all night. This was not actually the case; I dozed periodically and was simply fooled by the subjective nature of time's passage while on the brink of sleep. Still, the evening was not remotely representative of a typical night's rest. I was so exhausted the next day that I could not function at work and left early to take a nap.

"Well, you don't have sleep apnea. You did wake up up about 8 times an hour, but we're not sure why," explained the doctor holding the report her hand. All that effort for nothing? Based on my memories of the night, I suspected prevailing circumstances made for a lousy, non-representative test (I still do).

I returned to managing as best as I could, foregoing flights in Warrior 481 on days when I was clearly dulled by fatigue. Before any additional follow-up on the sleep study could occur, however, there was a "minor" distraction. My work site was shut down and there was a scramble to find a new job that culminated in a move from Kalamazoo, MI to Rochester, NY.

The Machine

A couple of years passed. We relocated, started new jobs, and The Bear was born. I was still fatigued and began the process all over again, this time with the Strong Sleep Disorders Center at the University of Rochester Medical Center. Knowing what to expect from my previous experience, I calmly submitted myself to be wired back up for observation. I did not sleep well, but it was enough.

"You have moderate sleep apnea," my new doctor explained during our follow-up, reviewing the data with me methodically and thoroughly. I like my sleep doctor; he talks to me like I'm an intelligent adult. "I am going to write you a prescription for CPAP," he continued. For the unfamiliar, CPAP stands for continuous positive airway pressure. This is a machine that delivers pressurized air through a mask to prevent apenas by keeping the airway open.

Though I was pleased to know what was wrong with me, I was also thoroughly dismayed by the undeniable reality of the data. I was now diagnosed with a disqualifying medical condition in the eyes of the FAA. Moreover, I would be dependent on a machine to breathe adequately in my sleep. I was consumed with loathing at the very thought.

I underwent a follow-up sleep study to determine the appropriate pressure for the CPAP machine, received my personal machine set to the prescribed pressure, and proceeded to fight with the damn thing nightly for many weeks.

Truce

Statistics on the matter vary widely, but CPAP compliance among first time patients is generally poor. In those early weeks, I completely understood why. An ill fitting mask means a leak, which not only reduces the effectiveness of the treatment, but also creates an obnoxious hissing sound loud enough to wake the sleeper. The first mask type that I tried fit over my nose. The bridge of my nose is narrow (actually, this is part of the problem - my nasal passages are extremely narrow) and, whenever the mask shifted in the night, a cold jet of air would squirt directly into my eye. That will wake you up in a hurry. I went through phases of alternately tightening the straps more, then wearing them more loosely. The sensitive skin on the bridge of my nose reacted poorly to the mask material and an open sore developed there.

But I stayed with it, trying different mask geometries and different ways of tensioning the straps. It seemed like no matter what I did, I frequently woke in the middle of the night and, as frustration set in, I often needed to suppress violent urges to throw The Machine through a window. We fought for roughly six weeks, The Machine and I, before finally coming to terms.

That truce was brokered, serendipitously, by a trip to Europe. I was invited to present at a scientific conference. As I contemplated the logistics of the trip, I was not eager to lug The Machine along, particularly through airport security. It was expensive, its fragility unknown, and, frankly, I was embarrassed at the thought of having to remove it for screening and display my infirmity in a public place. To my mind, all I ever did was fight with The Machine anyway, so I left it behind.

I had a wonderful trip on many levels, but getting good sleep was not one of them. I found myself struggling to breathe at night. To my absolute shock, I realized that The Machine had already started to improve my quality of life. In that moment, I made my peace with it. When I returned home, I embraced The Machine (mentally and physically). I began sleeping through the night and waking up absolutely refreshed.

I still despise the thought of being dependent on The Machine, but I cannot deny the positive impact it has made on my quality of life. For years, I awoke with a headache every morning. Thanks to The Machine, the headaches are gone. I used to wake up every morning with phlegm in my throat and a stuffy nose. I used to suffer through multiple sinus infections each year. All gone, fringe benefits of an open airway that no longer serves as a collection point for glop and bacteria. Best of all, I am no longer exhausted and my thoughts are often crisp and clear - exactly what a pilot needs when making command decisions at the helm of an airplane, no matter how small or slow.

However, there remained the small matter of my disqualifying condition. Fortunately, my diagnosis came in November and my self-grounding was facilitated by dreadful weather. I dropped the matter in the lap of my AME (aviation medical examiner) and developed a plan with him.

My AME is a cool guy. He served as a flight surgeon for the Space Shuttle program for many years and his office is decorated with photographs of NASA spacecraft autographed by the men and women who flew them. He believes in general aviation and is committed to keeping as many pilots flying safely as he can. I am grateful for his help.

Validation

We decided that the best, most rapid path back to medical certification would be to conduct a maintenance of wakefulness test (MWT). It is one thing to be diagnosed and prescribed CPAP treatment. It is quite another to demonstrate that the treatment is actually working. That is where the MWT helps.

For the MWT, I spent the day in a dimly lit, comfortably warm room at the Strong Sleep Center. The MWT is administered in four, forty minute intervals throughout the day where the subject (in this case, me) has to sit quietly without dozing off during each test interval. Reading, watching TV, moving, talking, singing out loud, and any other activity that might stave off sleep are strictly prohibited. I would have never passed this test before CPAP, particularly during the afternoon intervals. However, I easily aced the test, a testament to the effectiveness of my treatment.

With test results in hand, my AME called everything in to Oklahoma City and received authorization over the phone to issue my medical. I was back in the air! The paperwork containing my special issuance, as described earlier, arrived within weeks. Annually, I need a report from my sleep doctor demonstrating my CPAP compliance (no worries there) and lack of symptoms. He submits this directly to my AME who then issues my medical (under the AME Assisted Special Issuance program, AASI). The best part is that I keep flying.

Current Events

There is some mild irony in the fact that, with treatment, I am a safer pilot than I was before the diagnosis, but I am now subject to far more FAA scrutiny than before.

In 2013, FAA Federal Air Surgeon Dr. Fred Tilton incurred the wrath of pilots and the aeronautically-oriented alphabet associations by suggesting that any pilot with a BMI over 40 needed an assessment for sleep apnea (usually in the form of a sleep study). Editorials blared pithy headlines like "Are You Too Fat To Fly?" and "FAA Targets Fat Pilots". While I agree -- from deep experience -- that sleep apnea is something that needs to be managed, I concur with this outrage because I am not convinced that BMI is truly predictive on its own. After all, BMI would have never flagged my condition. Perhaps I am an outlier. Regardless, it seems a poor practice to demand that a pilot undergo an expensive sleep study on the basis of a single metric when there are so many other corroborating symptoms to assess.

After retreating on the issue for a time, the FAA issued new guidelines in March 2015 with an improved, risk-based approach that allows an AME to evaluate several signs and symptoms beyond just BMI (though it remains one of several risk factors for the AME to consider). I think this is a much better approach. Then again, who am I to say? It's a moot point for me.

Despite the annual inconvenience of being "special", I went down the right path. In seeking to understand the cause of my fatigue and receiving adequate treatment for it, the disruption to my flying was minimal and my life is decidedly better in just about every way.

Except for dealing with The Machine (now on its second incarnation) at TSA checkpoints when flying commercial. That still sucks.

Fly safe, everyone.

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