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Diabetes case-based scenario
Sweet outcome for remote cattle grazier
"I had no idea I was ill until I started getting leg cramps, suffering fatigue in flight, and noticed my vision occasionally blurring,” says Roger, a 65 year old cattle grazier. “When they told me I had type 2 diabetes, I thought for a while my flying days were done. Luckily for me, a few simple lifestyle changes soon had me flying again."
Roger has been running cattle on his 300,000 hectare station in the remote Kimberley Ranges of Western Australia for more than 30 years. Keen to enlarge his holdings, he is currently negotiating the purchase of a neighbouring property so he can expand his herd and his access to Asian markets.
Roger has two aircraft: a helicopter mostly used for muster by senior station managers, and a fixed wing, four seat single engine aircraft he uses for his regular business commutes south to Perth and north to Darwin. He regularly flies to a number of regional airports, including Broome International.
Roger has held a Private Pilot's Licence (PPL) for 25 years with a Class 2 medical certificate. He visits his Broome-based Designated Aviation Medical Examiner (DAME) every two years to renew his medical certificate.
Several members of Roger's family have type 2 diabetes, a condition where the insulin the pancreas produces is insufficient to meet the body's needs and does not work effectively. Since type 2 is the most common form of diabetes, and has a strong hereditary component, Roger has always been at risk of developing the condition himself.
Managing a large cattle station in a remote area of the country has certainly not helped. The risk of contracting type 2 diabetes is greatly increased when associated with lifestyle factors like high blood pressure, overweight or obesity, insufficient physical activity, poor diet and the classic ‘apple shape' body where extra weight is carried around the waist.
"As the years passed and my business grew, I'm afraid my waistline grew too," Roger says wryly. "I was trying hard to look after my diet, but I was steadily gaining weight."
In between scheduled visit to his DAME, Roger noticed some changes in his wellbeing which he initially put down to stress, his increasingly busy lifestyle and his advancing years.
"I started feeling ever more tired and lethargic; I was passing urine more frequently, and I was constantly thirsty. I put it all – even the blurred vision and leg cramps – down to the pressure of running a multi-million dollar business," he says.
Eventually, at the urgings of his family, Roger sought the advice of his general practitioner (GP) who examined him and ordered a series of tests.
The tests showed that Roger had a fasting blood sugar level in the diabetes range. A repeat blood sugar test later in the week also showed elevated levels, confirming a diagnosis of type 2 diabetes.
The GP referred Roger to a diabetes educator at Broome Community Health Services. The diabetes educator helped Roger to understand the condition and its' management, directed him to community support services and taught him how to use a glucometer.
The GP recommended Roger modify his lifestyle and start monitoring his blood glucose levels.
Visit to DAME
Roger contacted his DAME and told him of this new diagnosis. The DAME in turn contacted CASA, which notified the Aviation Medicine (Av Med) branch of a change in medical condition in accordance with their obligations under the Civil Aviation Safety Regulations. The DAME advised Roger not to fly until he received a clearance from CASA or from the DAME himself.
The DAME forwarded copies of the GP reports and the diabetes educator report to AvMed with the notification email. AvMed reviewed the supplied information. Because heart disease can already be present at diagnosis of diabetes, CASA asked Roger to do an exercise stress test. Since his DAME had already referred him to such a test based on the clinical practice guidelines published on the CASA website, Roger was ahead of the game.
"I already had my test booked by the time CASA told me I needed it, and I'm delighted to say I passed the test with flying colours," he says.
Since his doctors had advised him he only need to adopt lifestyle changes to manage his diabetes, and could find no sign of organ damage, CASA assessed his risk of having an acute episode in the next 12 months as low (less than one per cent probability). As a result CASA found no need to apply operational restrictions to Roger's medical certificate.
The information on the CASA website helped his DAME to work with Roger to minimise the length of time he was grounded; he was flying again within a fortnight of the notification to CASA.
Because Roger was assessed as a ‘low risk diabetic', CASA required minimal additional reports at the next medical. Roger was required to provide a report from his GP describing the management of his diabetes. CASA also requested that Roger's DAME assess the cardiovascular risk score at the next medical, making allowance for the diabetes diagnosis, and to repeat the exercise stress test if the score was elevated.
The risk of complications of diabetes increases with time since diagnosis. As a result CASA required annual review. This requirement parallels the best practice care recommendations for people with diabetes, so these routine checks can all be timed to coincide with information needed for a medical certificate application. Sometimes diabetes improves, sometimes complications occur. Information requirements will reflect this and CASA will continue to require regular baseline data on Roger's condition.
Roger was reminded to notify his DAME or CASA about any changes to his condition or treatment, especially being prescribed diabetes tablets or insulin. diabetes treatments work by lowering the amount of sugar in the blood. Unfortunately, if they are too effective, they can lower the blood sugar to unsafe levels. This is dangerous as it can occur without the person affected knowing or recognising it. A person can suffer impaired thinking or even lose consciousness. These are called hypoglycaemic episodes or "hypos." For this reason, CASA will require close surveillance of pilots and controllers on these medications.
The cumulative effect of having excess sugar circulating in the blood stream can lead to damage to blood vessels, nerves, eyes and kidneys. As the disease progresses AvMed requirements may increase to include specialist review as well. The specialists that may be involved include endocrinologist (hormone specialist), cardiologist (heart), ophthalmologist (eye) and nephrologist (kidney).
"Look, having diabetes is quite frankly a bit of a pain," Roger says. "Under the circumstances, though, I consider myself extremely fortunate, as I can still fly and hope to be able to continue to do so for many years to come."