Designated Aviation Medicine Examiner/Designated Aviation Ophthalmologist 1Designated Aviation Medicine Examiner/Designated Aviation Ophthalmologist

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IN THIS EDIT ION•Onlinemedicalsubmissionpages

•CASApolicyforaeromedicalcertificationofapplicantswithADHD

EvENTS fOr yOur DIaryaSaMThe2011AnnualScientificMeetingwillbeheldatNewcastle’sCrownePlazaHotelfrom6-9 October 2011.

aviation Medicine NSW Sunday 27 March 2011, MiltonParkCountryHouseHotel,Bowral

Saturday & Sunday 12-13 November,SydneyHarbourMarriottHotel,CircularQuay,Sydney

aMSvIC4-5, March 2011,AirshowDownundermeeting.

ICaSMBucharest,Romania September 11-15, 2011

Melbourne,Australia September 16 - 20, 2012

rDaQ Cairns10-12 June

asMaThe82ndAnnualScientificMeetingoftheAerospaceMedical Association May 8-12, 2011,HiltonandCapt.CookHotelsinAnchorage,AK

Furtherdetailswillbeprovidedonthewebsiteandfuturenewslettersasavailable.

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DaMEnewsletter

PMO’s COLuMN

The new forms ThenewformsarereadyandwehavestoppedissuingtheolderformssincemidSeptember.WewillcontinuetoaccepttheolderformsuntiltheendoftheJanuary.Thisisnotjustaquestionofmovingfromonetotheotherforms.Whentheformsarereceivedbyus,theygetscannedusingascannerwhichhasasetoftemplates.Currently,anduntil01February2011,wehavedividedthescannersinawaythatweareabletoscanbothtypesofforms.However,thisisaproblem,becauseitreducestheefficiencyofoursystem,andincreasesthetimethatittakesforthepaperworktobescannedon.Obviously,itisessentialtoallowforaperiodoftransition,andthatiswhywewillscanbothtypesuntiltheendofJanuary.Ourintention,isthatanyoldformsthatwereceiveafter1February2011willhavetogobacktotheconcernedmedicalexaminer,foreitherbeingredoneonthenewforms,orincaseofanurgentneed,byanonlinesubmission.

Hopefullythiswillnotbeaproblemforanyone,aswehaveflaggedthelikelihoodofthechangingformsforthelastcoupleofnewsletters.Pleaseunderstand,after01February,allthescannerswillbeconvertedsoastousethenewforms,anditwillnotbeacaseofCASAbeingdifficult,itwilljustnotbepossibletoscantheolderformsafterthatdate.

The creation of ARNs Wehavecontinuedtohavedifficultieswithnewapplicantswhodonothaveaviationreferencenumbers,andwishtoapplyforamedicalcertificate.Inthepast,wehaveacceptedsuchformsandputtheminafloatfilependingthearrivaloftheARN.This,initselfhasbecomealargeandtime-consumingprocess,andonewhichhasoftenresultedinthelossofforms,delaysinprocessingetc.Wehavehadaconversationwiththeteamwhichissuesaviationreferencenumbers,andweareadvisedthatifthedocumentationis

complete,anARNcanbeissuedveryquickly.Therefore,infuture,pleaseensurethatallnewapplicationsaresubmittedaftertheindividualhasreceivedanaviationreferencenumber.WewillnotbeacceptingapplicationswithoutanARNafter31January2010.

The old online system. ThenewMRSonlinesystemisnowworkingwell.Wearecollectingfeedbacksothatwecanmakeafewchangesafterwehavegotareasonablenumberofpeopleusingit.Atthemoment,wehavesomeDAME’susingtheoldonlinesystemandsomeusingthenewonlinesystem.Thismakesforallsortsofconfusionanddelaysinprocessingattheback-end.CometheendofJanuary,wewillbeswitchingofftheoldonlinesystem.Wehopethatthisgiveseverybodywhowasusingtheoldonlinesystemenoughtimetogetusedtothenewonlinesystemandtransitioningoodtime.

Designated Aviation Medicine Examiner/Designated Aviation Ophthalmologist2

Errors in forms Untilnow,whenaDAMEforgottoentersomedataontheformwewouldsendbackaletteraskingforthattobecorrectedandsentback.Werecentlyhadthise-mailconversationwitha DAME.

“Looks like the f*** up is mine. I obviously omitted to put on the form your **** dose, assuming that the specialist’s report was adequate. Call me tomorrow and remind me to fax the details to those bureaucrats at CASA. I can only apologise. I didn’t think CASA were that petty”. (senttoCASAbymistake)

IwrotetotheDAMEsaying,“ ….. I am happy to discuss how we can make the system more friendly. I am very conscious that our DAMEs are a very important resource, and I would certainly like us all to operate from the same song sheet. I have had recent feedback about our becoming more human, which is good, but I need to explore the specific issue you raise, to see whether there is any legal room to move. If you have any other issues, I am always open to listening. I can only promise that I will engage, not that I will necessarily agree, but I am sure that is a step in the right direction. So if you have suggestions, do drop me a line, and we can then argue about them!”

TheresponseIgotis“I’d like to suggest that if any further information is needed (ie, that’s been accidentally missed) from a DAME form, that the DAME receives either a fax or a phone call, requesting the information. This information could then be given verbally and recorded by you - for legal purposes. The information is then faxed to you by the DAME - who stamps the fax with the DAME stamp. This should satisfy all normal legal requirements and would be just as secure as any other method. (Lawyers use faxes for multi million dollar contracts, Telstra ad banks accept verbal authorizations, having established that the person they are speaking to is the authorized account holder) CASA won’t accept a verbal confirmation of a pulse rate! More than that, you send a letter to the doctor and patient, that is almost like a schoolboy’s parents receiving notification that the pupil has been a naughty boy. Things have to be right, because aviation safety is no small matter but surely, the present system is too authoritarian, too bureaucratic and too inefficient in certain instances.”

Formysins,IamcurrentlyundergoinganMBAtrainingprogramme.Doingthiscourse,oneofthethingswhichwelearnedisthatwhensomeonecomplains,thatisthemomentoftruth.Becausehowthatcomplaintisdealt

with,says,muchlouderthanwords,howwethinkaboutthepersonwhomadethecomplaint.

So,withimmediateeffect(thisone’snotwaitinguntilthe31stJanuary)ifsomebodydetectsanerrorontheform,wewillringupandleaveamessagewiththeDAME’sofficeexplainingwhatisneeded.Wewouldthenrequestafaxedcorrection,whichwewillscanonthefile.(Obviously,ifwedonotreceiveafaxedcorrection,wewillnotproceedfurther).Thatway,thedictatesoflegalcorrectness,andthatofconveniencewillbemet.

International Academy of aviation and space medicine TwoCASAmedicalofficersattendedtheInternationalAcademyofaviationandspacemedicineinSingapore,on10-14September.Wepresentedontheerrormedicalissuessurroundingkidneystones,andonthepatternofmorbidityinaircrewinAustralasia.Bothpresentationswerewellreceivedandgeneratedconsiderablefeedback anddiscussion.

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INTrODuCINg Dr IaN CHENg, ParT-TIME avIaTION MEDICaL OffICEr, CaSa

Ian will be responsible for medical examinations for pilots whose arN ends with a 2 or 3.Ian’searlycareerwasthatofaprofessionalstudent,pursuingundergraduatedegreesreflectingachildhoodfascinationofaeroplanesbybuildingAirfixWWIIeramodel aeroplanes, teenage interest in buildingTamiyaFormula1racingcarsandadolescentinterestinhumananatomyandphysiology!AftercompletionofBachelorofEngineeringandBachelorofMedicinedegrees,Ianspent14yearsatWestmeadHospital,workingthelast12yearspart-timeintheEmergencyDepartmentandpart-timeinthefamilybusiness.

AchangeincareerdirectionledIantowardsoccupationalmedicinetrainingwithattainmentoftheAustralianCertificateinCivilAviationMedicine,aGraduateDiplomainOccupational&EnvironmentalHealth,a Diploma in Aviation Medicine and a MasterofPublicHealthalongtheway.IanattainedhisfellowshipinOccupationalandEnvironmentalMedicinein2003.

Ianhasbeenpart-timeStaffSpecialistOccupationalPhysicianatRoyalNorthShoreHospitalsince2003andalsoconductsaprivatepracticeinaviationandoccupationalmedicine.Ianwaspart-timemedicalofficeratQantasAviationMedical

Servicesfrom2002to2009andmorerecentlyhadafractionalappointmentasanOccupationalPhysicianatIBM.Allthesepart-timejobsinvolvemorehours,butnotnecessarilymoremoneythanonefull-timejob,however,workisdiverseandinteresting.

IanhasbeenaDAMEsince2001andanelectedcommitteememberofASAMsince2005.Duringthisperiod,IanhasbeenastrongadvocateforongoingDAMEeducationandrecognitionoftheirsignificantroleinaviationmedicineandflightsafety.Ian’spreviousandcurrentrolesfrequentlyinvolvehimliaisingwithfellowDAMEsthatheattemptstoperforminaninformed,collaborativeandprofessionalmanner,thesameapproachhewillcontinuewithfrom the“otherside”,aspartofCASA’sOffice ofAviationMedicine.

Designated Aviation Medicine Examiner/Designated Aviation Ophthalmologist4

DAME Liaison ReportNEW fOrMSOLDformswillbeprocessedupuntil1Feb2011.Thenewformnumberforbothinitialandrenewalmedicalsis011.Thisformwill besuppliedautomaticallywhenorderingR orOforms.PleasereadthePMOcolumn forfurtherinformation.

rESuLTS fOr LIPIDS aND gLuCOSEIfyouhavetranscribedtheresultsonto the medical there is no need to send the hardcopyalso.

DuPLICaTE DOCSIfyouhavesentadocumentbyfax;pleasedonotalsosendbymail.Thisisahugewasteoftimeforyourstaff,extracostforyouandextraworkforus;leadingtodelaysinprocessingofmedicalsfortheapplicants.

Thisisespeciallytruewhenitcomestopaymentforms.

COMPLETION Of MEDICaL EXaMINaTION fOrMSWecontinuetohaverealproblemswiththereceiptofformsmissingtheinformationfromthetopoftheform;noDAMEnameandidentifier,nodateofexamination.PleaseensurethatthesedetailsarecompletedonallformsthatyousendtoCASA.

MuLTIPLE BLOOD PrESSurES WrITTEN ON THE fOrMIfyoutakemultiplebloodpressurereadingsonanapplicantforsomereason,pleasenoteonlyoneoftheseintheBPsectionoftheform.Pleaseusethecommentssectionifthereissomethingaboutthereadingsthatyouwishustonote.

aDDrESSES ON MEDICaLSAsfromthe1February2011,AviationMedicinewillnotbeingupdatingourdatabasewiththeaddressfromthemedical.Wehavefoundovertimethatweareupdatingnewaddressestooldaddressesresultinginmedicalcertificatesbeingsenttoincorrectaddresses.

Applicantswhohaveanaddresschangetomakeshouldgotohttps://portal.casa.gov.au/casaforms/addrchange.htm.ThiswilltakethemtoachangeofaddressformthatwillensurethatthischangeismadecorrectlyintothemainCASAdatabase.

MrS ONLINE HINTWhereapilotshouldbereferredforfollow-uporfurthertestsMRSgivesyoureferrallettersthatyoucanprintoutandgivetotheapplicantatthetimeoftheconsultation.Thisisagreattimesavingfeatureforbothyouandtheapplicant.

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Online medical submission pages

1: DELaySThesearedelaysthataregoingtoshowwhenthe assessor goes in to assess the medical. Thereisnoneedforyoutodoanythingregarding this

2: DOCuMENTSThesearelettersthatyoumayprintoutforyouruseortogivetotheapplicant.

Thereferrallettercanbesenttoensurethatthe applicant has a head start on getting tests donethatareneeded.Wewillalsosendthislettertotheapplicanttobesurethattheyhave it.

ThePaymentformcanbeprintedout,completedandsent,eitherbyfaxORmailtoouroffice.Thiscannotbeuploadedwiththemedical.

Examinersummaryisacopyofthewholequestionnairethatyoucanprintandkeepforyourrecordsorsavetotheapplicantsfile.

ApplicantdeclarationmustbeprintedandsignedbyboththeDAMEandtheapplicantanduploadedwiththemedical;oritmaybefaxedORmailed.

Applicantsummaryisacopyofalltheinformationontheexaminationformthathasbeenprovidedbytheapplicant.Thiscanbeprintedandgiventothemfortheirowninformation.

Reportsrequiredatnextexamcanbeprintedandgiventotheapplicantsotheyknowwhattheyneedtohavedoneinordertohavetheirmedical assessed at the next examination.

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1: Thesenotationsinbluequestionsorsectionsofthequestionnairethathavenotbeenfullycompleted.Youcangobacktothesebyclickingonthewords.

2: Thedeclarationformcanbeprintedfromhere(ifnotalreadyattendedto)byclickingontheblue“here”.

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3: Applicantsummarymaybeprintedfromhere(ifnotalreadyattendedto)byclickingontheblue“here”.

4: ExaminerDeclaration.Alloftheseitemsneedtobecompletedandtheboxestickedbeforeattemptingtosubmittheexam.

Designated Aviation Medicine Examiner/Designated Aviation Ophthalmologist6

CASA policy for aeromedical certification of applicants with ADHDAsaresultofaworkshoplastyearregardingADHDandaviation,CASAhasrecentlydevelopednewguidelinesregardingcertificationofapplicantswhohaveadiagnosisofADHD.ThefollowinginformationisprovidedforyoureducationastoCASA’spositionandfortoadviseapplicantsaccordingly:

1. BaCkgrOuND

attention and aviationAviationisadynamicenvironment–itisoftennecessarytoshareattentionbetweenseveralinformationsourcessuchas:

– Makeandrespondtoradiotransmissionsonmultiplefrequencies(area/aerodrome)

– Controllingtheattitudeandflightpathoftheaircraft

– Navigating

– Dealingwithemergencies

– Checklists

– Weather

– Trafficavoidance

– Fuelcontrol

– Flyinginstrumentapproaches

Aninabilitytofullyconcentratemayleadtoalackofsituationalawareness–whichhasbeendefinedasacontributingfactorinmanyaccidents and incidents

Nature of aDHDADHDisadisordercharacterisedbymaladaptivelyhighlevelsofimpulsivity,hyperactivityandinattention.

– ‘impulsivity’signifiesprematureandthoughtlessactions;

– ‘hyperactivity’arestlessandshiftingexcessofmovement;and

– ‘inattention’isadisorganisedstylepreventingsustainedeffort

ADHDisdistinguishedfromthenormalrangebythenumberandseverityofsymptomsandtheirassociationwithsignificantlevelsofimpairment.

AreasofneuropsychologicaldeficitsinADHDinclude:

– Planning

– Vigilance

– Verbalandspatialworkingmemory

– Moment-to-momentvariabilityandinconsistencyinperformance

– Selectiveattention(focusedattention,integrationofsensoryinformation)

– Impairedcontinuousperformancetasks

– Distractability

– Memory

– Reaction time

– Informationprocessingspeed

– Flexibility

– Motor speed

– Visuomotorability

Co-morbidordifferentialpsychiatricdiagnosesarecommonandmayinclude:

– depression

– anxiety

– conductdisorder

– oppositionaldefiantdisorder

– personalitydisorders

– bipolardisorder

AutomobileaccidentsaremorecommonamongthosewithADHD,andmaybeassociatedwithahigherrateoffatality

YoungdriverswithADHDare:

– twotofourtimesmorelikelytohavetrafficaccidents

– threetimesaslikelytohaveinjuries

– fourtimesaslikelytobeatfault

– sixtoeighttimesmorelikelytohavetheirlicensesuspended

Diagnostic CriteriaInAustralia,diagnosisisbasedonDSM-IVcriteriawhichlist18symptoms-9inattentive,6hyperactive,3impulsive,ofwhich6inattentiveand/or6hyperactive/impulsivesymptomsarerequiredfordiagnosis.Thesymptomsmusthavepersistedforatleast6months to a degree that is maladaptive and inconsistentwithdevelopmentallevel,andsomehyperactive-impulsiveorinattentivesymptomsthatcausedimpairmentwerepresentbeforeage7years.Someimpairmentfromthesymptomsmustbepresentintwoormoresettings(e.g.,atschool[orwork]andathome),andtheremustbeclearevidenceofclinicallysignificantimpairmentinsocial,academic,oroccupationalfunctioning.

Therearevariousratingscalesavailablewhichmaybeusefulindiagnosisandmonitoring,howevertheyshouldnotbeusedsolelytomakeadiagnosis.

StudiesontheuseofquantitativeEEG(QEEG)havesuggestedsomeabnormalitiesthatcorrelatewiththediagnosisofADHD,butagainthesetestsdonotreplaceathoroughassessmentagainstDSM-IV.

StudiesofneuropsychologicaltestinginADHDshowthattreatedpatientsperformbetterthanuntreatedpatients,andpatientsimproveontestsaftertheyaretreated,howevertreatedpatientsarestillsignificantlyimpairedcomparedwithnormalcontrols.However,thereisdebateastotheapplicabilityofneuropsychologicaltestinginthenaturalenvironment.

aDHD in adultsThereisevidencefromfollow-upstudiesthatADHDpersistsintoadulthoodinaround30%ofcases.Ingeneral,symptomintensitydecreases,hyperactivitybecomeslessapparentbutthedifficultieswithimpulsivityandattentionarepersistent.AssuchmostadultswiththeconditionwillnotmeetthefullcrtiteriaunderDSM-IV,eventhoughimpairingsymptomsmaypersist.

Markers of remission of aDHDTherearefewstudiesorrecommendationsregardingthedeterminationofremission.Itisgenerallyrecommendedthatpharmacological

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thecontextofandnotingtheimplicationstoboththenormaldaytodaylifeandtheconductofaviation.

– Copiesofacademicrecordsandemploymenthistory

– Copiesoftrafficinfringementsandcriminalrecords

– CopiesofanyspecialinvestigationsperformedsuchasQEEGorneuropsychologicaltesting

TheinformationprovidedwillbeconsideredbyCASA,andifnecessary,byanindependentpsychiatrist.

requirements for applicants taking aDHD medicationsApplicantswillnotbeconsideredforcertificationunlesstheyhaveceasedpharmacologicaltreatmentforaminimumof 6months.Thisisbecause:

– DSM-IVcriteriarequireatimeframeofatleast6monthsofsymptomsbeforeadiagnosiscanbemade–itisthereforereasonablethataperiodof6monthswithoutsymptomsisrequiredtobesatisfiedthat the condition is no longer active

– Themeasurementofimpairmentinoccupationalandpsychosocialdomainswouldnotbeevidentimmediatelyonceasing medication. For example, decreaseinacademicachievementorworkperformancewouldtakesometimetobemademanifest.

Attheendofthattime,thereportsasprescribedabovewillneedtobesubmittedtoCASAforevaluation.

Ongoing certificationOngoingcertificationmaybesubjecttoannualreviewbyatreatingspecialistonacasebycasebasis.

treatmentbeepisodicallyhaltedduringchildhood and adolescence to assess the clinical condition. Most treatment is tapered offinearlyadulthoodorlateadolescence,oftenrelatedtothecessationofhighschooleducation.Ongoingtreatmentmaybenecessaryinsome.Inothers,ADHDsufferersmaygravitatetowardsoccupationslessdemandingonfocusandattention.Inadditionthereisgenerallypoorhandoverfromchildhoodtoadultservices.

Pharmacological treatment of aDHDThePathophysiologyofADHDisrelatedtodysregulationofdopamineandnoradrenalinecircuits,andmedicationsusedtotreatADHDincreasetheavailabilityoftheseneurotransmitters.

Dexamphetamineandmethylphenidatearebothstimulantsandareavailableinbothimmediateandmodifiedreleasepreparations.Ifdosesaremissed,therelativelyshortdurationofactionofthesemedicationsmeanthatrecurrenceofsymptomsandimpairmentisinevitable.InADHDpatientsthese medications help to settle associated symptoms.Innormalindividuals,stimulantsproduceeuphoriaandhyperarousalandimpairtheabilitytoperceiveandrecognisefatigue.

CharacteristicsofADHDthatareofsignificanceintheaviationenvironmentinclude:

– Theattentionaldeficitsthatmayimpairsituationalawareness

– Impairmentofdecisionmakingcapabilities

– Distractability

– Impairmentofprocessingspeed

aErOMEDICaL DISPOSITION IN aDHD

Classification of dispositionThedispositionofaircrewwithapastorcurrentdiagnosisofADHDisconsideredonacasebycasebasis,howeverasageneralrule:

– ThosewithacurrentdiagnosisandsymptomaticofADHDonnotreatmentareunlikelytobeeligibleforcertificationduetotheconcernaroundimpairment

– ThosewithacurrentdiagnosisandsymptomaticofADHDtakingpharmacologicaltreatmentareunlikelytobeeligibleforcertificationalsoduetotheconcernaroundimpairmentcombinedwiththeissuesaroundpharmacokineticsandpharmacodynamicsofthemedicationsused,andtheuseofmedicationasaproxymeasureofseverity.

– ThosewithADHDinremissiononnotreatmentarelikelytobeeligibleforcertificationprovidedthereisnoevidenceofongoingactivityofthecondition

– ThosewithadiagnosisofADHDbutwithnoobjectiveevidenceofcurrentsymptomsordysfunctionbutstillontreatmentareunlikelytobeeligibleforcertificationduetotheconcernsoftheadverseeffectofstimulantsonnon-impairedindividuals.

Information required for applicationToconsideranindividualwithahistoryofADHD,nolongertakingmedicationforcertification,thefollowinginformationisrequired:

– Copiesofmedicalrecordsfromdateofdiagnosis to the present

– CopiesofrecordsfromMedicaredetailingconsultationsandprescriptionofmedications

– Anuptodateassessmentbythetreatingpaediatricianorpsychiatristifavailabledetailing:

• Historyofcondition

• PreciseconfirmationofthediagnosiswithreferencetoDSM-IVcriteria

• Co-morbidities,includingdrugandalcoholuse

• Requirementandresponsetotreatment

• CurrentclinicalstatuswithrespecttoDSM-IVcriteria

• Currentfunctionalstatus,withreferencetocollateralinformationifavailablefromschool,family,workplaceetc.

– Completionbythepaediatrician/psychiatristandthechiefflyinginstructorofaquestionnaireregardingsymptomsin

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IMPOrTaNT INfOrMaTION aBOuT DaME rE-DESIgNaTION

RecentlyanauditoftheDAMEdatabasehasbeenperformed.ThereareanumberofdoctorswhosedesignationtoactasaDAME has expired.

PleasecheckyourDAMEcertificatefortheexpirydateofyourdesignationsothatyouarenotleftunabletoactinthiscapacity.

Ofcourse,ifyourdesignationhasexpired,youshouldnotperformanyfurthermedicalsuntilyouhavebeenredesignated.

LetterswillbesenttothoseDAMEwhosedesignationhasexpired.TheseDAME’saremarkedinactiveinthedatabase

andmedicalswillbereturnedtotheDAMEconcerned.

ItisimportanttosendacopyofyourcurrentregistrationandalsocompletethesectionoftheforminregardtoAviationMedicineCME.Applicationsforredesignationwithouttheseparticularscannotbeprocessed.

application forms can be found at:http://casa.gov.au/wcmswr/_assets/main/manuals/regulate/dame/form755.pdf