AINsight: Explain the Symptoms

When a pilot experiences symptoms that lead to an emergent evaluation, the FAA often will not determine that pilot’s aeromedical eligibility based on a single test result.

The FAA will expect that not only are test results favorable, but that the pilot’s symptoms have abated and are not likely to return. In other words, the pilot is safe to return to the cockpit.

How is that determination made?

For example, a pilot sought emergent evaluation at a hospital twice in one year for symptoms of chest pain. This is quite concerning, as significant chest pain can be incapacitating.

Further, if the diagnosis turns out to be heart disease requiring formal treatment, the pilot has then found themself in the special issuance process. Then that pilot would need a formal authorization for special issuance of a medical certificate to continue to fly, given that heart disease requiring treatment is a specifically disqualifying medical condition as per the FARs.

Now that I have already terrified you, rest assured that the majority of pilots who have had cardiac interventions will ultimately return to active flight status.

That said, sometimes the decision tree is not all that clear-cut. What do we do to move forward in the FAA medical process? More importantly, what do we do moving forward to protect the pilot’s health and future?

Continuing with the example from above, once a pilot has sought urgent medical care for chest pain, a full cardiology evaluation will certainly follow. This evaluation may include everything from blood testing to exercise stress test evaluations (with and/or without formal imaging such as either by nuclear isotope injection or stress echocardiography) to possibly a formal cardiac catheterization/angiogram to more specifically image the individual cardiac vessels themselves.

Suppose then that all of these tests turn out benign. The pilot does not need intervention for atherosclerotic coronary artery disease. That is a relief and is certainly excellent news.

Is the pilot good to go? Not so fast.

While it is reassuring that the pilot will not require intervention such as a cardiac stent or coronary artery bypass surgery, their symptoms have not yet been explained. After all, it was the symptoms that brought the pilot to the emergency room in the first place.

All we have done so far is confirm a result that did not bring the pilot to the emergency room in the first place. Reassuring as the result is, the picture remains entirely incomplete.

The symptoms must not only be explained, but the FAA will expect that, if any formal treatments are needed, they have been initiated and demonstrated to have improved the pilot’s medical condition. The FAA loves the word “stable” when referring to medical treatments that have been initiated.

Let me also state something obvious: Pilots are, as I was during my professional aviating years, loath to go for urgent medical evaluations. At the same time they are wondering if they will survive, they are equally concerned about what happens to their flight privileges. If a pilot presents to the emergency room, they are quite concerned about the severity of a medical situation.

Hence, urgent medical evaluations, while critically important, lead to an earnest desire by the FAA to figure out what exactly did take place. If a pilot presented to the emergency room, it must be determined whether future risks have been mitigated.

If it turns out that the pilot had, coincidentally, two episodes of trauma in the same year—such as falling off a mountain bicycle and hitting their chest on a rock—then, assuming the remainder of the evaluation was negative, the symptoms have been adequately explained. No additional treatment would then be required, other than counseling the pilot that perhaps a less dangerous sport might be a good idea.

Chest pain can also be caused by other conditions, such as a significant arrhythmia (irregular heartbeat), severe gastrointestinal upset, and a wide assortment of other medical conditions. 

If a pilot had similar symptoms after two food-related illnesses, a few considerations are in play. Perhaps the pilot should just be more careful when eating out, for example. However, many people get “food poisoning” yet do not wind up in the emergency department. What did an evaluation find? Are additional tests warranted?

A trial of gastrointestinal prophylactic medications may reduce that pilot’s risk while at the same time keeping the pilot on FAA-approved medications if long-term use is considered. It must be determined why the symptoms were severe enough to cause the pilot to go to the emergency room. 

Returning to the arrhythmia consideration, this is a significant concern. An arrhythmia can not only cause chest pain but can also lead to sudden incapacitation. On a long-term basis, repeated arrhythmias can lead to congestive heart failure, heart attack, or stroke, along with the annoying symptoms themselves.  

If there is any suspicion that an arrhythmia might be causative, then formal rhythm monitoring is indicated.

If an arrhythmia is found, the FAA will want to know what is causing it and if anything can be done about it. Does the pilot actually have undiagnosed sleep apnea, which may very well cause arrhythmias such as atrial fibrillation? Does the pilot have an aberrant cardiac conduction pathway that might be controlled with either medication or a formal ablation procedure (electrical current applied directly to the inside of the heart to obliterate the offending abnormal conduction)?

Were the symptoms due to a hypertensive crisis (extremely high blood pressure) that may be alleviated through medication?

In this case, so far all we know is that the pilot went to the emergency room twice and it was determined, fortunately, that bypass surgery or stent placement was not required. And, of course, changing hobbies or restaurants might simplify the follow-up.

Before returning the pilot to flying, the FAA will want to know if anything was “fixed.” Simply stating that cardiac intervention was not indicated still leaves questions. Will the symptoms recur, and what are the risks should they next be experienced in flight?

Therefore, research must continue until a probable cause is identified and proper steps are being taken to reduce the risk of recurrence and to hopefully reduce the severity of any unexpected symptoms should they arise again.

Once symptoms are explained and potentially treated, and the pilot is determined to be at low risk for an incapacitating event, the pilot will likely be released back to flight status. As can be surmised, this may not happen overnight.  

Remember, the results of a single medical test, no matter how favorable, may not be enough to satisfy the FAA. Safety is paramount, and the FAA must determine that the pilot is stable from an aeromedical standpoint.

I fully understand that this can become a complicated situation. Would the best course of action be for a pilot to simply avoid an emergent evaluation? Obviously, that is a rhetorical question.

No different than for mechanical systems, the sooner that medical problems are diagnosed and treated, the more likely it is that the pilot will continue to fly and live a healthy life—even if they were temporarily grounded along the way.

As for the AME (aviation medical examiner) and the FAA, it is easier to keep a pilot flying if they are still alive. Therefore, it is always best to find the root cause of significant medical symptoms before relying solely on a test result that, while favorable, may not explain the entire picture and, in and of itself, is doing little to determine or alleviate future risks.

Find the problems before they find you yet again!