AINsight: Aviation Medicine in the Pandemic, Part 2

 - June 12, 2020, 12:41 PM

In my last blog, I talked about your aircraft and the aviation system in general entering a holding pattern of unknown duration due to the Covid-19 pandemic. The current situation is along the lines of: “Expect one or two more turns in the holding pattern, then clearance back on course.”

Just how much has changed since last month? Some, lots, and probably not enough. There is gradually a small amount of optimism emerging, but we must remain vigilant and exercise caution.

More and more aspects of society are opening back up, albeit painfully slowly. That said, if things open up too quickly, some experts warn that the dreaded “second wave” of virus-related hospitalizations will again threaten to swamp the healthcare system.

We are in a global health crisis that is clearly one of the most significant since the Spanish Flu pandemic over a century ago. There are billions more people living on our overly stressed planet now, with rapid worldwide travel available at our fingertips. The rate that contagion can spread these days is mind-boggling.

There are both believers and naysayers in this discussion. I am not supporting either cause, but as we all know there are very strong opinions regarding all ends of the spectrum.

Some voices argue to just open everything up now, and we’ll just take things as they develop. This is about freedom, not medicine, they say.

Others voice tremendous caution, all while understanding full well the economy is suffering dramatically as a result of the social distancing and executive orders to close businesses.

Whether you agree with one side or another, everyone has valid concerns, and I support the freedom to voice any and all opinions on the subject. This is a stressful and challenging time for everyone, and we must respect that we all have individualized concerns and agendas.

I wish there was an easy answer and fix to the problems that the novel coronavirus has caused worldwide. Everyone's wishes for the world to recover is one of the rare situations where most have at least some semblance of agreement.

Last month, I discussed in some detail the medical exemptions issued by the FAA in response to the early concerns about the coronavirus. There were both good and bad aspects to these orders. However, one important aspect is that the exemptions did provide options for pilots to continue flying for a few additional months if they were unable to update an expiring medical certificate. 

The FAA did state, however, that “we continue to encourage” pilots to update their medical certificates on their usual schedules if at all possible. That recommendation remains posted on the FAA website.

To my knowledge, there have been no new medical expiration date extension (exemption) orders issued by the FAA in the past month, which implies that a sufficient number of pilots have indeed been able to keep their medical certificates current to support the existing—significantly reduced, but finally increasing again—airline flight schedules.

Some pilots, specifically those required to provide additional medical data for special issuance authorizations—pilots with heart conditions, diabetes, sleep apnea, or in follow-up for drug/alcohol issues, for example—were somewhat stymied, as it has been difficult to obtain required medical data when so many physicians were operating at minimum capacity and often for emergencies only.

At first, the FAA was not providing any relief, even on a temporary basis, for these pilots. Fortunately, more recently the FAA is now permitting one-time exemptions, on a case by case basis, for pilots unable to provide required data by the time of their FAA medical exam.

Later the same day that my May blog was published, the Federal Air Surgeon issued an urgent plea to AMEs to respond to a brief survey. The FAA was trying to determine how many AMEs were still available and if they plan to continue to provide AME services in the future.

This research was prompted by the fact that many AMEs are “an aging lot” (with myself reluctantly included in that generalization) and are therefore in a high-risk demographic medically. Some have elected to shut down their offices permanently as a result of the coronavirus, as they might have been nearing retirement anyway. The survey was urgent enough that the FAA reissued it to AMEs just a week or so later, still attempting to get a bead on future AME availability.

I have not yet been able to obtain the results of the AME survey. When I have those results, I will present them in a future submission.

Covid or otherwise, AME availability has been steadily declining in the years since I became an AME in 1993. I will not speculate on the reason for this trend but am hoping that enough young physicians become AMEs and pick up the slack when we older AMEs inevitably must leave the industry behind.

Pilots have been asking physicians to prescribe prophylactic (and as of yet medically unproven in the setting of Covid-19) prescriptions to ward off the virus. This behavior is entirely understandable, of course, as pilots (along with other cabin crewmembers) are putting themselves at high exposure risk by simply going to work. The situation is, without question, rather concerning to aviation workers.

The one medication that I will specifically address is hydroxychloroquine, which is also marketed under the brand name Plaquenil. This medication has been used for many years, quite successfully, in treating arthritic illnesses refractory to other medication options. It is approved by the FAA under special issuance for pilots with rheumatic diseases. However, this medication is also known to have potential cardiovascular and ophthalmological side effects, sometimes quite serious.

Given that Covid-19 is a disease that has caused both pulmonary and cardiovascular compromise, it is not yet well established whether hydroxychloroquine is safe and effective in the setting of the coronavirus. This is being studied as rapidly as is ethically feasible, of course, and there might indeed be some promise in its use.

In the meantime, however, given the frequent requests by pilots to use hydroxychloroquine in the hope of proactively preventing side effects from the coronavirus, the FAA felt compelled to act in opposition to this practice. This response was due to the potential cardiovascular risks, and since pharmacies were receiving multiple requests for new prescriptions, the medication’s availability for existing rheumatic patients was being depleted.

The FAA has issued a blanket statement that the use of hydroxychloroquine as a prophylactic medication against coronavirus is not approved in pilots. Whether it becomes approvable for such use in the future is not yet known.

That said, if a pilot is seriously ill as a result of coronavirus, during the urgent treatment phase any and all medications and medical modalities can (and should) be utilized. Once a pilot has fully recovered from either known or suspected Covid-19 illness—and the treating physician agrees that the risk of contagion to others has resolved—the pilot can usually return to work. No formal pre-approval is required by either the FAA or the pilot’s AME.

This is a circumstance covered under FAR 61.53, “Prohibition on operations during medical deficiency.” Under this FAR, for the most part pilots can use their own judgment to determine when they are safe to return to the flight deck. It would be prudent, of course, for the pilot to consult with their physician and AME to get a medical opinion first, after any serious illness.

Should there have been significant pulmonary or cardiovascular compromise from a Covid infection, then the pilot would likely have to provide data demonstrating adequate recovery to assure aeromedical safety. This would fall under basic reporting requirements, and even with supportive data, the AME may have to “defer” issuance of the next medical certificate, leaving the final disposition to the FAA.

In general, however, if a pilot contracted Covid-19, did not have severe medical compromise that will be ongoing, and is feeling well and past the time of any potential risks to others, then that pilot may resume flight duties. 

There is still plenty to be learned about how the virus came into existence, how it has spread, what level of contagion and severity of disease we can expect in time, and, obviously important to all of us, what treatment and mitigation strategies might be available to help us both now and in the future.

Hopefully, the increased availability of testing—both for the virus directly and for post-infection antibodies—will provide the epidemiologists and other infectious disease experts with additional tools that may be useful in the long run. I also hope that the development of vaccines and their contribution to “herd immunity” might lessen the impact of the coronavirus, given some time.

Many questions remain unanswered. As fast as the scientists can do their research, it will simply take a bit more time to understand enough about the virus to provide effective strategies and recommendations. Unfortunately, for the time being, some dreaded “guessing” is still in play.

What will the expected second wave bring? Nobody knows for sure. It is expected, of course, that as more retail, dining, and recreational businesses are permitted to open, that some increase in cases is inevitable.

The protests in response to the tragic death of George Floyd last month has also brought thousands of people together in close proximity. While that may bring about some unanticipated challenges in reducing the impact of any second wave, the right to protest is an inviolable aspect of freedom of speech, bringing an important voice to our country at a time of urgency. I am a strong supporter of freedom of speech rights.

For now, as individuals, all we can do is our very best to follow recommended strategies—with the understanding that Covid-related executive orders are, in essence, law—as tedious, frustrating, and maddening as they might be at times. I empathize and appreciate the ongoing frustrations that society is experiencing as a result of all aspects of the pandemic and its many devious tentacles. 

Let’s hope that the aviation industry demonstrates the same versatility that helped it bounce back after other economic and terrorist-related setbacks over the past few decades. Let’s also hope that the disease itself can be brought under control, so that the economy can get rolling again, including travel and international tourism.

Wouldn’t it also be nice to eventually be able to see people’s faces, finally again out from hiding under their face masks?

Along the way, I will continue to update you with protocol updates as they pertain to FAA medical certificates and special issuance authorizations. Maybe you will finally get your aircraft out of the holding pattern after all.