DAME Newsletter - October 1999

Distribution
Notification of address changes (including e-mail address)
CASA's new Medical Records System (MRS) developments
Request for notification of deaths
ICAO-driven amendments to medical examination / reports and certificates
ECG Reports
DAME ARNs
DAME addresses
Simple (but important) clinical matters to remember
Applicants with diabetes mellitus
1999 AMSANZ Meeting
DAME fees
Feedback from Newsletter recipients

Distribution

Please read and digest this Newsletter yourself, retain it for future reference, and make it available to any members of your staff who have dealings with CASA.

Notification of address changes (including e-mail address)

In preparing for distribution of this Newsletter, test transmissions were sent to a number of DAMEs' / DAOs' nominated e-mail addresses. No doubt because of the frequency and ease with which some internet users change ISPs, a number of these transmissions "bounced" from no-longer-current electronic addresses.

Recipients are requested to ensure that CASA is notified immediately they change e-mail addresses of where they wish CASA to contact them.

CASA's new Medical Records System (MRS) developments

The contractors are well advanced with development of the revised MRS. Staff from Aviation Medicine Section have regular input to the process and have suggested a number of improvements. Availability of the system to DAMEs / DAOs has been delayed because of unresolved legal questions over security of medical information transfers and positive identification of DAMEs / DAOs logging onto the system. Consequently, full deployment of the new MRS is now not anticipated to occur until early 2000. Feedback on it and suggestions for further improvements to it will be welcomed. CASA has identified the need to provide funding for maintenance of and regular updates to the system, so the MRS initially deployed should be thought of only as its Mark 1 incarnation.

Meanwhile, Phase 1 of the new MRS will proceed as anticipated by the end of November 1999. This involves the transfer of all OCR-captured data from the existing system to the new system's database, where it will be more readily accessible to CASA staff (and ultimately to DAMEs / DAOs). For the first few months of its operation, until the legal questions already referred to have been settled, CASA will continue manual scanning of the existing medical forms into the new system. Staff from CASA's Aviation Medicine Section will be called on increasingly to assist the contractors in perfecting the final design and operation of the new MRS over coming months. Some delays in routine processing of medical examinations and reports will be inevitable during this period: forbearance of DAMEs / DAOs will be appreciated.

One casualty of the new MRS will be any DAMEs whose practices rely for computing on Mac systems rather than PCs. CASA's specification for MRS did not include any requirement for Mac-driven access to it. System requirements for communication with CASA, as already advised in the Newsletter for August 1999, are:

PC running Windows 95, Windows 98 or NT;
Internet Explorer 4 or 5 or equivalent web browser;
modem connection and Internet access; and
flat bed document scanner.

Remember that examinees will absolutely require an Aviation Reference Number (ARN) prior to any medical examination undertaken once the new, interactive MRS is fully functional. For existing licencees / medical certificate holders, the ARN appears on each licence / medical certificate. CASA will shortly publicise the means by which first-time applicants can obtain an ARN prior to undergoing an initial medical examination. Additionally, all examinees will be required to nominate names, addresses and practice telephone numbers for their usual GPs and dentists at every medical examination under the new MRS. Applicants for renewals MUST bring their existing medical certificates with them for revalidation by DAMEs. In short, additional planning by applicants and DAMEs' staffs will be required prior to every medical examination if applicants are to avoid delays and inconvenience in the issue of their medical certificates under the programmatic rules of the new MRS.

Ideally, applicants should undergo any required additional testing or have additional assessments made (ECG, biochemistry, audiogram, consultants' reports, etc) well before the medical examination, so that results are available at the time of examination and these can be transmitted with the electronic medical examination report.

DAMEs should note that, for applicants required to submit serum lipid results, a figure for ldl WILL BE REQUIRED. CASA realises that many / most pathology laboratories do not supply ldl results in the presence of a normal cholesterol estimation. This is entirely due to Medicare funding arrangements, which are irrelevant for purposes of CASA-required medical examinations. Accordingly, DAMEs should endorse request forms with advice that the examination is OCCUPATIONALLY REQUIRED FOR SCREENING PURPOSES AND IS NOT MEDICARE REBATABLE. Pathology laboratories have little objection to performing the estimation when they are able to bill for it privately. (Obviously, this endorsement applies only to asymptomatic examinees with no relevant history. Where clinical indications for the estimation exist, it should attract usual HIC benefits).

Request for notification of deaths

Acquisition of the new MRS will enable CASA to undertake statistical analyses of Australia's aviation medical certificate holders and applicants in a way which has never before been possible. As a courtesy, DAMEs are requested to notify CASA Aviation Medicine Section whenever they become aware of the death of a medical certificate holder or previous holder. Full name, cause of death and ARN (if possible) are the only details needed. Possession of these data will enable CASA, for the first time, to determine the longitudinal health outcomes for many subjects who have been granted waivers etc.

ICAO-driven amendments to medical examination / reports and certificates

In 1999, ICAO began a series of audits of contracting States under its Safety Oversight Program. It intends regularly to audit all contracting States to ensure their conformance and compliance with ICAO's Standards and Recommended Practices (SARPs) contained in Annexes to the Chicago Convention. During August, a team from ICAO visited Australia and, amongst other things, made a number of suggestions for changes to the present, long-established system for medicals and reports. Most of these are of a relatively minor nature, requiring only the inclusion of additional specific questions in the applicant history section (particularly in respect of a history of syphilis or of lymphatic diseases). The creation of the new electronic medical examination and report will be used to add these extra questions.

Additionally, there will be introduced a specific requirement for females with all classes of medical certificates to obtain clearance from a DAME prior to resuming aviation related duties following confinement, caesarean section or termination of pregnancy. This and other administrative changes will be detailed in forthcoming amendments to the electronic DAME Handbook.

A number of long-standing differences from ICAO SARPs, previously notified by CASA to ICAO, have implications for licensees' legal exercise of privileges in states other than Australia. CASA will publicise these matters widely to licence holders and applicants in coming months. Relevant details will also be included in materials included with new-style medical certificates which are to be introduced shortly.

CASA has redesigned all aviation licences and accompanying certificates, including medical certificates. The intention is for all these documents to be kept together in a dedicated A6 size folder. The new medical certificates will be user-useful, with provision for advice of the dates of most recent required examinations. This should assist applicants and their DAMEs to determine more readily when further examinations / tests are due.

ECG Reports

A number of DAMEs have questioned the need for routine ECGs to be read by a specialist physician or cardiologist, pointing out their own considerable experience and expertise in the task. CASA acknowledges that many GP DAMEs are very able interpreters of ECGs, but also recognises that some others are not. CASA does not have medical staff available to review all ECGS received, so many years ago introduced a policy where all ECGS which do not originate from a self-reporting machine or which have not been reported by a cardiologist or specialist physician should be sent for confirmatory reporting by a cardiologist in Canberra. Staffing reductions which will accompany introduction of the new MRS will mean that CASA will no longer have the spare clerical capacity required to continue this practice. Moreover, as a matter of policy, the cost of ECG interpretation should be borne by the applicant rather than by CASA.

Once the new MRS is operational, therefore, ECGs will only be accepted if they are derived from a self-reporting machine or have been reported by a cardiologist, specialist physician or other specialist individually approved by the Director of Aviation Medicine. If ECGs which do not meet these criteria are submitted, the medical assessment will be delayed until the matter is rectified. CASA emphasises that this procedure is not really new, but its implementation is more explicit than previously.

DAME ARNs

DAMEs who have applied for but not yet received an ARN are advised that these will be supplied to them well in advance of their requirement for use with Phase 2 of the new MRS. DAMEs who do not have an ARN and who have not yet requested one are advised to do so immediately as interactive communication with the new MRS will absolutely require DAMEs to have ARNs. To obtain an application form, visit the CASA homepage <www.casa.gov.au>. Once there serially click on 'forms and manuals', 'CASA forms', 'form no 759'. Print this form, complete the required details and mail it to CASA Aviation Medicine Section. (For legal reasons, an original signed hard copy is required). An ARN will then be issued in due course.

DAME addresses

DAMEs are reminded that their designation is routinely granted for a single address only and that it is not automatically transferable to any other location. In certain circumstances, it may be permissible for DAMES to perform medicals at a number of locations other than their normal rooms (eg RFDS doctors visiting remote outback locations, or DAMEs who occasionally fly to remote locations for clinics etc). However, it is NOT possible for DAMEs' names to appear on the DAME list in more than one location.

CASA will include DAMEs' e-mail contact details on the DAME list only on specific request from the DAMEs concerned. Anyone who wants an e-mail contact to appear on the list should so advise the DAME Liaison Officer, Ms Margaret Urban, at <urban_ma@casa.gov.au>. As earlier mentioned, PLEASE ensure that any e-mail address so notified is kept current by early notification to CASA of any change.

Simple (but important) clinical matters to remember

If you do not consider an applicant is clearly fit for medical certification, please do not issue the interim medical certificate or revalidate an existing medical certificate. (This still happens with depressing regularity).

Do not use vague descriptive terms in reports / clinical comments sections. Expressions such as 'brief', 'infrequent', 'mild', 'some', and similar convey no meaningful information. Instead, use Sweeney's '6-W mnemonic':

WHAT 1: What happened? (signs and symptoms that led to consultation?)
WHAT 2: What were the sequelae?
WHEN: Dates and frequency
WHERE: What body part - left or right, upper arm / forearm, etc.
WHY: Why was a procedure performed?
WHO: Who was involved, who carried out a procedure / made an assessment / is following up the case, etc.

Applicants with diabetes mellitus

DAMEs Chris Jambor and Hal Leaver read an interesting paper to the recent AMSANZ meeting in Cairns: the insulin dependent diabetic pilot - an inflight test of the US FAA protocol - is it safe? Their conclusion: for well-controlled and motivated pilots, it may be. They plan an early follow-on repetition of their study, using the same subject and control.

The experimenters are willing to make their test protocol available to other DAMEs who may be interested in duplicating the experiment with insulin dependent applicants of their own. CASA encourages such practices as an appropriate and objective means of gauging the safety of any potential relaxation of Australia's medical standards. Any other DAMEs considering in-flight tests for insulin dependent diabetic applicants are invited to contact the Acting Director, Aviation Medicine to discuss the matter.

1999 AMSANZ Meeting

The Cairns meeting was of high quality and attendees appeared to enjoy both its educational and social aspects. CASA DAME sessions were held at which CASA's experience with HIV positive applicants and with pregnant medical certificate holders were reviewed and at which the audience had an opportunity question existing CASA practices and impending changes accompanying the new MRS. Items of particular interest to DAMEs included:

legal liability under additional delegations (CASA will ensure that DAMEs remain covered by CARs, as at present).
practicalities of compliance with ICAO Standards and Recommended
Procedures (with minor exceptions, intended changes to CASA's rules will affect only licence holders who wish to operate in other states' airspace).
cost of computerisation / additional equipment required to permit commerce with new MRS (obviously a commercial decision for each DAME / DAO to make individually).
"New" ECG reporting requirements (as earlier explained in this Newsletter, the requirements are long-standing but will be more explicit under new MRS, when additional charges will affect applicants).
GP-conducted stress ECGs (these will be dealt with identically to other ECGs - that is, cardiologist / physician interpretation will be required).

DAME fees

DAMEs frequently approach CASA Aviation Medicine Section for advice re "appropriate" or "usual" fees for aviation medicine examinations, investigations, reports etc. CASA has never specified or recommended fees, except in a very general sense. Indeed, the ACCC nowadays takes a very dim view of any such recommendations as a supposed instance of collusive price fixing.

Perhaps a useful pointer as to fees for DAMEs is CASA's own recent acceptance of a recommendation from the Acting Director of Aviation Medicine that payments for specific investigations required by its own licensed staff (fees for which CASA is liable) should be made at the levels recommended in the List of medical services and fees produced and updated each year by the Australian Medical Association. These fees are more economically realistic than the politically driven fees prescribed in the Medicare Schedule, previously used as the comparator. Presumably, CASA's recognition of AMA recommended fees as appropriate for its staff members who require aeromedical certification could be interpreted as de facto acceptance that those fee levels should be more generally applied throughout the aviation industry.

Feedback from Newsletter recipients

To say the least, the first e-mailed Newsletter (for August 1999) had its problems, particularly with formatting. As a result, this edition is being sent as a Word attachment to overcome that difficulty. DAMEs / DAOs are encouraged to contact Aviation Medicine with suggestions for further improvements or to discuss any other aeromedical matters of concern to them. The next Newsletter should be posted on the CASA website within one month. Shortly thereafter, legal advice permitting and all else being well, it will be showtime! for the new (and greatly improved) MRS. Meanwhile, its Phase 1 use within CASA Aviation Medicine Section should allow elimination of at least some of any initial problems with its use. As explained earlier, DAMEs and DAOs will have to wait a little longer for access its benefits.

Peter Wilkins
Acting Director, Aviation Medicine

Aviation medicals