[Peetwo]

CASA AVMED: Case for the case against?

Last Friday week I did the op check, and "passed" with flying colours. It took the docs at AVMED just over a week to give me a choice.....either come up with some clinical evidence proving I won't have a repeat episode, or accept restrictions on both my class 1 and 2 medicals. Basically I won't be able to fly without a safety pilot.
On August 27 2015, I had a mild stroke. I was in hospital for 3 days, and discharged with no medication requred, and no rehab necessary. I was a bit tired for the next two weeks, but I was back at work as soon as I got home from the hospital....working from home made it easier. I didn't really even surrender my drivers licence, although I didn't drive for a month.
Two neurologists and my gp reckon I had a once-off event. My blood pressure is excellent, and I've never been hypertensive. I've made some changes since I got out of hospital....quitting smoking, watching what I eat, and exercising.
So....back onto the clinical evidence....does anyone know of any other pilots who've had a stroke and gotten back into flying with no restrictions, or am I pissing into the wind?

Cap'n Wannabe thought I'd bring your QON up to the sexual life of the camel, because in light of some recent discussion (especially from Sandy.. ) and the AOPA petition/proposal (along with SAAA) to CASA on changes to the Class 2 pilot medical requirements, then it is probably about time we opened up the debate...

To kick it off and very relevant to your QON CW, I am not sure if you have seen this latest AAT 'setting aside' of a CASA decision to reject a class 2 medical - Courtney and  Civil Aviation Safety Authority  [2016] AATA 755 (28 September 2016) - IMO it is definitely worth a full read. But for those time constrained amongst us (or simply too lazy), here is a brief summary (paragraphs 46-54) of the case for & against, plus the final decision (para: 55-72)...    

  

SUBMISSIONS

Mr Courtney

46.Mr Courtney in his submissions relied on Doctors Habersberger and Keighley, who had found his chances of having a cerebrovascular accident or an episode of myocardial ischaemia while flying was extremely low. Although neither of them was able to place a percentage on the risk, they intimated it was less than one per cent.

47.Mr Courtney submitted that as CASA focuses on times and percentages in relation to risk, on his estimations he was in the air flying his aircraft for 1.1 per cent of total time in a year and 23 per cent of that 1.1 per cent was flying in or around a settled area being Moorabbin airport. The majority of his flying was in the outback, where the chances of hitting a member of the public on the ground were very remote.

48.Based on the overall evidence from 2012 onwards, Mr Courtney contended that despite having no symptoms he had undergone various forms of treatment which reduce any risk he might be to himself, his passengers, other aircraft and the public in general. He contended that no abnormality had been demonstrated on radio nuclear myocardial scanning in January 2014. The scan in February 2015, (performed using a different technique and reported on by a different cardiologist) had revealed an area of left ventricular apical ischaemia despite normal left ventricular function. This apical defect was the subject of disagreement in terms of its relevance and when the scan was repeated 10 months later there was no further change. Mr Courtney submitted that if there had been any change it occurred between January 2014 and February 2015 and had not advanced thereafter.

49.Mr Courtney sought to have the condition of only flying with a safety pilot removed. He also sought that the requirement for a CT coronary angiogram, if regarded as necessary, should be delayed until his next application for licence renewal.

Mr Carter for CASA

50.Mr Carter reiterated the opinion of CASA authorities that Mr Courtney did not meet the requirements for a class 2 licence. Based on the authority of Re Window and  Civil Aviation Safety Authority  [1999] AATA 525; (1999) 56 ALD 316, the test to be adopted was whether the risk was real and not remote.

51.Mr Carter addressed Mr Courtney’s long history of cardiac problems - with the necessity for coronary grafting and various medication, insertion of a pacemaker and a persistence of an elevated cholesterol as he was not able to take statins. Mr Carter pointed to the CHADS VASc score calculated at 3.2 per cent and also Mr Courtney’s age of 77 which alone carried according to the ABS 3.6 per cent risk of death. While Mr Courtney had stated in his evidence that he was not afraid to die, the Act required CASA to consider the pilot’s safety as well as that of passengers, other aircraft and the public in general.

52.Mr Carter contended that we were essentially dealing with unknowns. While the evidence was that each particular condition from which Mr Courtney suffered carried with it a very low risk of a sudden debilitating event, in totality concern was raised. Further considerations were that Mr Courtney always flew with his partner Megan and while she had had flying lessons she was not a licenced pilot despite her belief that she could land a plane. Mr Courtney had also said he would like to take his grandchildren on flights.

53.In his submissions Mr Carter raised the question of whether Mr Courtney had revealed his medical conditions to RAA who did require a declaration of any health matters. Mr Carter supported the idea of CT coronary angiography to assess whether there had been any progress of Mr Courtney’s coronary artery disease.

54.In response to Mr Carter’s question regarding RAA, Mr Courtney advised that he had completed the necessary declarations for RAA.

TRIBUNAL’S DELIBERATIONS

55.Mr Courtney has well documented but at all times asymptomatic coronary artery disease treated by off-pump coronary artery bypass grafting with the internal mammary artery. He has paroxysmal atrial flutter/fibrillation of 20 years duration requiring medication with Sotalol, and as a result of the development of bradycardia and sick sinus syndrome required the insertion of a pacemaker. Since ceasing the statin Crestor, his cholesterol level has become mildly elevated. On the basis of these medical conditions, his CHADs VASc score relating to the risk of a cerebrovascular accident was calculated at a 3.2 per cent annual stroke rate.

56.As already stated, Mr Courtney has always been free of symptoms relating to these medical conditions and they have in fact been diagnosed as a result of CASA’s requirements of annual cardiology assessments consequent upon his age and also because of his documented history of paroxysmal atrial arrhythmia since 1994/95. It was the Holter monitoring procedure requested by his DAME that revealed the presence of myocardial ischaemia presenting as ST depression on ECG. This of course led to a chain of events, including coronary angiography followed by bypass surgery.

57.It could be said that if Mr Courtney was not a pilot and as his cardiac coronary artery disease was asymptomatic, none of the investigations and treatment outlined above would have been indicated in normal clinical practice.

58.With each medical intervention or recommendation, Mr Courtney has followed the advice of his treating cardiologists. As a result of his coronary artery bypass surgery in June 2013, his left ventricular function as measured by left ventricular ejection fraction has been normal since the operation, the latest levels being 67-69 per cent (normal ejection fraction being 55 per cent or greater). The left ventricular ejection fraction increased marginally in the study of December 2015 despite the finding in both February and December 2015 of a small area of apical diminished profusion that had not changed in the intervening 10 months.

59.Dr Keighley has sent copies of all but two letters relating to Mr Courtney to CASA and these letters have been generated at three to six monthly intervals since 2012. Most of the letters have been addressed to Dr Drane who appears to have been a senior aviation medical officer, or to a Dr Clem, with only one being direction to Dr Seah. Every letter has been copied to Mr Courtney and the relevant DAME. Dr Clem was sent a summary of Mr Courtney’s progress in January 2016.

60.In mid-2013 CASA required further medical investigations and provision of results before reissuing Mr Courtney’s class 2 medical certificate. This was eventually issued on 6 March 2014. The expiry date of this certificate was 7 January 2015 but again delays relating to further requested testing and information resulted in Mr Courtney’s licence not being issued until 28 August 2015. It appears to the Tribunal that while these processes were extremely slow given that Dr Keighley rapidly responded and provided all investigation results, it was not until Mr Courtney saw his DAME to initiate the required investigations for reissue of his licence in January 2016 that a further reconsideration of his class 2 medical certificate and licence was initiated apparently by Dr Seah. The Tribunal presumes that Dr Keighly’s explanation that the abnormality in the radio-nuclear myocardial scan reported in February 2015 was an artefact and thus of no clinical significance, had been accepted.

61.In addition to the question of whether there was persisting myocardial ischaemia or, in the alternative, progression of the underlying disease, presumably in the right coronary artery as it is the dominant vessel, CASA’s medical section expressed concern regarding Mr Courtney's CHADS VASc score of 3.2 per cent per annum. In his reports Dr Keighley had made it clear that this figure of 3.2 per cent only applied in individuals who had frequent paroxysmal atrial arrhythmia or were in chronic atrial fibrillation and where not anticoagulated. He had advised that Mr Courtney did not fall into this group as his episodes of atrial arrhythmia were very infrequent and short-lived. As Mr Courtney has a pacemaker in situ, he is in the unusual position of being continuously monitored in terms of arrhythmias. There was thus irrefutable scientific evidence on which Dr Keighley based his opinion.

62.In June 2016 when Mr Courtney’s pacemaker check revealed that he had experienced a more prolonged episode of atrial flutter Dr Keighley commenced anticoagulation with an oral anticoagulant and this continues. While this was outside the period following the making of the decision it is relevant to this decision.

63.Dr Keighley has given evidence before the Tribunal which essentially affirmed and expanded on his voluminous reports to CASA over the years. He reiterated his written opinion that the risk of a cerebrovascular accident occurring in Mr Courtney is very low and his risk of a cardiac event is less than one per cent. Dr Keighley negated the diagnosis of hypertension in Mr Courtney as episodic systolic hypertension had been ascribed to the so called white coat effect and Mr Courtney’s home monitoring of his blood pressure revealed normal readings.

64.Dr Habersberger is essentially of the same opinion as Dr Keighley. He estimated the risk of a cardiac event and cerebrovascular event as being extremely low and opined that it was impossible to give a meaningful percentage figure. Dr Habersberger said he would have treated Mr Courtney in exactly the same manner as Dr Keighley had done. However, he could not rule out the possibility of some progression of the underlying coronary artery atheroma process without further investigation. He did however respond to the Tribunal’s query as to why CT coronary angiography had not been employed, agreeing that this was very appropriate method of monitoring. He recommended that Mr Courtney undergo CT angiography annually.

65.Dr Seah was of the opinion that as Mr Courtney, based on his age alone, faced a 3.6 per cent annualised risk of death according to the ABS, this must be added to any heart or cerebrovascular accident risk and resulted in an unacceptable level of risk for a standard class 2 medical certificate. He did however agree that the risk of a cerebrovascular accident had been reduced by the prescribing of anticoagulants.

66.Clearly CASA is, by virtue of s 9(a) of the Civil Aviation Act 1988, required to consider the safety of air navigation in Australia above all else. This includes the ability of persons licenced as pilots to exercise the privileges conferred by the licence. The Regulations (CASR) provide in Table 65.155 the standard for a class 2 medical certificate as it applies to private pilots. CASA contends that Mr Courtney fails to meet a class 2 medical standard because of his coronary artery disease requiring bypass grafting, his radio nuclear scan evidence of reversible ischaemia, his sick sinus syndrome, paroxysmal atrial flutter, requirement for a pacemaker and hypercholesterolemia which it is argued elevate the risk of Mr Courtney having an acute coronary event or acute cerebrovascular event. For the same reasons he does not meet Item 2.9 as he clearly has a heart abnormality.

67.The Tribunal has heard the evidence of both Dr Keighley and Dr Habersberger, both of whom assessed the risk of a coronary artery event and an acute cerebrovascular event as being low; in Dr Keighley’s opinion less than the one per cent standard set by CASA.

68.The Tribunal was provided with the CASA evaluation graph (Exhibit R4) and, based on the evidence of Dr Keighley, Mr Courtney’s risk would be between insignificant and minor with the likeliness of an event occurring being low at either level. On Dr Habersberger’s evidence the risk would be minor and also unlikely and therefore low. According to the key at the bottom of this risk evaluation, persons classified as having a low level of risk are to be treated with routine procedures.

69.Based on the medical evidence before the Tribunal coupled with CASA’s own risk evaluation document, and particularly in view of the delays to which Mr Courtney has been submitted in the making of a decision regarding his medical certification the Tribunal determines that the decision under review be set aside and that Mr Courtney be issued with a class 2 medical certificate without the safety pilot condition. The certificate should be issued for a period of 12 months and in the interim, at Mr Courtney’s convenience, a CT coronary angiogram should be undertaken as both Dr Habersberger and the legal representative of CASA, Mr Carter, have agreed that this is an appropriate method of assessing the possibility of any progression of the underlying coronary artery disease.

70.Given Mr Courtney’s right coronary artery was said to be the dominant artery with only a 30 per cent stenosis it would seem unlikely that a critical degree of progression would have occurred in a period of three years.

71.The Tribunal has not addressed the question of Mr Courtney flying in an alternative manner through RAA approval, as he has stated he has no desire to be limited to the flying imposed by such licencing. Mr Courtney has been an impressive witness with an extraordinary grasp and understanding of his medical condition, and an acceptance of what has been good advice, which has led to an excellent clinical result. The Tribunal is not surprised to find that his Montreal Cognitive Assessment performed on 6 March 2015 resulted in a score of 30 out of 30.

72.The Tribunal sets aside the decision under review and substitutes its decision that Mr Courtney be issued with a class 2 licence without the condition that he can only fly with a safety pilot but that he undergo CT coronary angiography when convenient.




I certify that the preceding 72 (seventytwo) paragraphs are a true copy of the reasons for the decision herein of:
Miss E A Shanahan, Member

MTF...P2