First Medical and Deferral

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DenverDave

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Hi everyone, this is my first post here.

I had my first medical today (3rd class) and it got deferred. This AME said in a consultation 2 month ago that he wouldn't need to defer it but I guess times change.

The AME only plans to submit the doctor's note for the condition, although I have lots of medical records that corroborate "I'm fine." I thought you were supposed to submit all relevant information?
 
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What makes you think what you have is relevant?

It's going to be hard (even for our resident AMEs here) to make any suggestions without knowing just what the AME decided needed deferring. What you can do is expect a long wait now.
Third class medicals for non-working pilots are the lowest priority.
 
Damn hard to provide comment on your case if we don't know what the condition was or why it needed to be deferred.

And yes to all relevant info, but certain conditions may be an auto deferral. Did you read the Guide for Aviation Medical Examiners before going in for the live exam?

To paraphrase a key FAR...

§91.103 Preflightexam action.
Each pilot in command of his medical shall, before beginning an flightexam, become familiar with all available information concerning that flightexam.​
 
Yes, read through it all. As far as the AME and I can tell the FAA has never published anything in specific regard to this condition (liver disease called PSC)

They certainly have published stuff on possible symptoms of PSC that I do not have.

I'm 100% asymptomatic so my bloodwork is normal, no transplant, MRIs are normal, etc. It's like it disappeared.

Blood liver enzymes are a major part in how this and other liver diseases are detected and evaluated. For example the CACI for hepatitis c uses blood liver enzymes, 1 unit over on 1 of 4 tests and it's deferral for hep c so they obviously care about real numbers in liver cases

The doctors note was written with the expectation that it would be accompanied by relevant documents like recent blood work and radiology results if needed for examination so it doesn't have any solid numbers. At a minimum I'm concerned that not including an extra few pages of stuff will significantly push this farther back...
 
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Yup... deferrals will add weeks of time to the approval process... could be 3-4 before the reviewers get to your submission, read it, decide what action and I do is needed, and then mail you a letter to that effect. Then you will have a short window to respond with the requested data. Then it's back to the bottom of the heap to await your turn for the reviewers to read the updated info, make a decision on your case, and either issue or send another letter asking for more info.

Welcome to Deferral Hell

As F'Ron indicates, 3rd class reviews are done as workload permits. And it's well known amongst the members here that the reviewers are overwhelmed with submissions. We have heard it can be 12 to 16 weeks for some special issuances to be decided on. I would expect 3-6 weeks (maybe more) before you receive a letter from OKC.

Does your AME show any interest in acting as your advocate and making calls to the OKC docs on your behalf to shorten the wait?
 
AggieMike88 said:
Yup... deferrals will add weeks of time to the approval process... could be 3-4 before the reviewers get to your submission, read it, decide what action and I do is needed, and then mail you a letter to that effect. Then you will have a short window to respond with the requested data. Then it's back to the bottom of the heap to await your turn for the reviewers to read the updated info, make a decision on your case, and either issue or send another letter asking for more info.

Welcome to Deferral Hell

As F'Ron indicates, 3rd class reviews are done as workload permits. And it's well known amongst the members here that the reviewers are overwhelmed with submissions. We have heard it can be 12 to 16 weeks for some special issuances to be decided on. I would expect 3-6 weeks (maybe more) before you receive a letter from OKC.

Does your AME show any interest in acting as your advocate and making calls to the OKC docs on your behalf to shorten the wait?
Click to expand...

His website has info on special issuances and previously he implied that OKC would not even need to be involved and that he could just issue a 3rd class medical.

He told me to start flying because he could do any class (obviously contingent on actual exam results outside the medical history scope) once 2 doctors notes come in. So now I could solo tomorrow morning if I had the medical in hand.

Unless the interface with OKC goes bad I dont see how they'd flat out deny a SI, I read a journal article about an ATP who was basically dying after already getting a liver transplant and they gave him a SI.
 
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PSC always gets worse and so is always a special issuance. Even If the liver functions ate still normal ( unlikely as the disease is detected “by the numbers”—>biopsy) the crucial part is “rate of progression.....
 
bbchien said:
PSC always gets worse and so is always a special issuance. Even If the liver functions ate still normal ( unlikely as the disease is detected “by the numbers”—>biopsy) the crucial part is “rate of progression.....
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Thanks for the input, I don't disagree with the decision to defer or anything of that nature. It was just surprising considering how he had previously said it wouldn't be an issue.

No liver biopsy has ever been performed or recommended by any gastroenterogist, hepatologist, interventional radiologist or other medical professional I've ever talked to.

The whole diagnosis as explained to me is on one bad MRCP in conjunction with high liver enzymes at the time. 6 month after that MRCP liver enzymes had decreased dramatically and intrahepatic biliary duct dilation in segment 5 had gone down from 13mm to 9mm. As of last December "Previously noted segment 5 bile duct irregularity and dilation which measured up to 13mm are not appreciated on this exam."
GGT (ref 5-80) 178 in 2015, 40 in 08/2018
Alkaline Phosphatate (ref 40-129) 208 in 2015, 99 in 08/2018

So as I understand there's a negative rate of progression.

Going back to the original topic, the AME wasn't interested in collecting any of the documentation for this in the deferral. He doesn't even have any numbers or a timeline.
 
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DenverDave said:
Going back to the original topic, the AME wasn't interested in collecting any of the documentation for this in the deferral. He doesn't even have any numbers or a timeline.
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Doesn't sound like the best AME to use in the future.

If you are in Denver, maybe @murphey or one of the other Denver folk can recommend an AME who would be a better choice for you.
 
Welcome to POA and sorry to hear about the deferral. The guy I used, pretty well known for handling hard medicals in the area is no longer taking new patients. I switched to BasicMed, so no longer have to follow that route. Irrelevant to your situation - just explains why I don't see him any longer. So, sadly, I don't have any helpful information to add - just wanted to say "welcome" and "good luck".
 
John Harris, just north of KAPA. Does consults, too. Will review & consult your situation. Not overly expensive, either.
 
The words "not appreciated" doesn't mean the condition is not there, just that the current test isn't a way to test for it

The problem is he's already deferred. Nothing happens now until the 12 week or longer initial queue passes and the thing lands on someone's desk who then decides what the FAA wants to see next.
Doing the "concerned airman" dodge may help things slightly.

Once he gets the first "you appear to not meet the stanards" letter back he can see a possible new AME (and in my case talking to the RFS and her pilot advocate) can make sure the next step is done properly.
 
DenverDave said:
Thanks for the input, I don't disagree with the decision to defer or anything of that nature. It was just surprising considering how he had previously said it wouldn't be an issue.

No liver biopsy has ever been performed or recommended by any gastroenterogist, hepatologist, interventional radiologist or other medical professional I've ever talked to.

The whole diagnosis as explained to me is on one bad MRCP in conjunction with high liver enzymes at the time. 6 month after that MRCP liver enzymes had decreased dramatically and intrahepatic biliary duct dilation in segment 5 had gone down from 13mm to 9mm. As of last December "Previously noted segment 5 bile duct irregularity and dilation which measured up to 13mm are not appreciated on this exam."
GGT (ref 5-80) 178 in 2015, 40 in 08/2018
Alkaline Phosphatate (ref 40-129) 208 in 2015, 99 in 08/2018

So as I understand there's a negative rate of progression.

Going back to the original topic, the AME wasn't interested in collecting any of the documentation for this in the deferral. He doesn't even have any numbers or a timeline.
Click to expand...

Dr. Chien is correct, PSC progresses. The fibrosis does not reverse, however the dilation and enzymes might vary at any one time, I would guess based on my limited knowledge. (Bile drainage might be better one day than another.)

The diagnostic criteria you list is valid ONLY if other causes of the sclerosing cholangitis have been ruled out. You've consulted a gastroenterologist and a heptologist but you seem a bit uncertain the diagnosis is correct. Nothing wrong with finding a second heptologist with extensive experience in this particular disorder and getting a second opinion. A liver biopsy (mentioned by Dr. Chien) will confirm and stage your PSC.

None of this will help your deferral situation at this point. I'm appalled your AME told you this could be issued in the office.

Were I you, I would demand better explanations from the doctors than what they've given you for the confusing results to date.

Best of luck!
 
Rushie said:
Dr. Chien is correct, PSC progresses. The fibrosis does not reverse, however the dilation and enzymes might vary at any one time, I would guess based on my limited knowledge. (Bile drainage might be better one day than another.)

The diagnostic criteria you list is valid ONLY if other causes of the sclerosing cholangitis have been ruled out. You've consulted a gastroenterologist and a heptologist but you seem a bit uncertain the diagnosis is correct. Nothing wrong with finding a second heptologist with extensive experience in this particular disorder and getting a second opinion. A liver biopsy (mentioned by Dr. Chien) will confirm and stage your PSC.

None of this will help your deferral situation at this point. I'm appalled your AME told you this could be issued in the office.

Were I you, I would demand better explanations from the doctors than what they've given you for the confusing results to date.

Best of luck!
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I'm uncertain because every GI and hepatologist I've talked to has said some version or another of 'it's not really PSC but I don't know what to call it.' long story short bile duct/gallbladder removed at age 16, stand in bile duct to liver joint was inflamed and constricted when I had active UC. Since being medicated and in remission for the UC the inflammation at that joint has stopped and liver function has returned to normal. The treating doctor for the liver at the time of the backed up liver said it's cleared up, he doesn't need to see me anymore and to get a liver panel done once a year to keep an eye on it.

So this morning I gave the AME copies of every document I have on this and organized in the most logical way I could come up with. We'll see if any of that makes it to OKC. There's really nothing else to do except wait to see what happens.
 
DenverDave said:
I'm uncertain because every GI and hepatologist I've talked to has said some version or another of 'it's not really PSC but I don't know what to call it.' long story short bile duct/gallbladder removed at age 16, stand in bile duct to liver joint was inflamed and constricted when I had active UC. Since being medicated and in remission for the UC the inflammation at that joint has stopped and liver function has returned to normal. The treating doctor for the liver at the time of the backed up liver said it's cleared up, he doesn't need to see me anymore and to get a liver panel done once a year to keep an eye on it.

So this morning I gave the AME copies of every document I have on this and organized in the most logical way I could come up with. We'll see if any of that makes it to OKC. There's really nothing else to do except wait to see what happens.
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Ah! Also having UC lowers the bar for the PSC diagnosis (requires less stringent evidence) so looks like they're slapping PSC label on it even though it doesn't behave exactly like PSC is supposed to, because they're not sure what else to call it and it is a good code for your insurance. I'm just speculating you understand, I'm not a doctor and certainly not your doctors.

I think you did the right thing, I guess, if your AME knows what to do with it; the FAA will need to sort it out. So sorry this surprise was dropped on you. You tried to do the right thing scheduling a consult first, that's supposed to clear up this sort of mess but somehow the wires got crossed with your AME.
 
DenverDave said:
So this morning I gave the AME copies of every document I have on this and organized in the most logical way I could come up with. We'll see if any of that makes it to OKC. There's really nothing else to do except wait to see what happens.
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Handing all of that to the AME is one method. But you've already expressed disappointment in how he is handling your case. Should he be trusted to forward this critical information?

The better way is to "own your medical" by sending in the reports yourself to CAMI. Search this forum for the address.

Make sure to do the following:
  1. Send the packet in some manner that requires a signature. Certified Mail Return Receipt Requested is one of these ways.
  2. Make sure each page has your legal name, DOB, and any FAA Identifying numbers in the upper right corner. This helps the mail room keep things squared up and makes sure this new information is connected with your existing files in the databases.
 
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DenverDave said:
Going back to the original topic, the AME wasn't interested in collecting any of the documentation for this in the deferral. He doesn't even have any numbers or a timeline.
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This seems quite surprising. OTOH, I am not a physician. I'm not even a member of TV Doctors of America.

But I do have a liver disease.

I'm not really familiar with PSC. I have autoimmune hep (my own immune system is attacking my liver) and it's being treated with azathioprene, an immunosuppressant. Dr. Bruce Chien ( @bbchien ) handled my class 3 application recently, and most expertly IMHO. We submitted quite a stack of relevant paperwork including a letter from my gastro doc, biopsy results, blood work and other tests going back to disease onset, doctor's notes, etc.

90 days later I received an SI good for only one year from the date we submitted, therefore only useful for 9 months. But now I can go Basic Med and not hassle with it anymore. The FAA seems to want quite a bit of documentation about liver conditions and wants to keep close tabs, so I'm surprised your AME didn't submit thorough documentation.


The treating doctor for the liver at the time of the backed up liver said it's cleared up, he doesn't need to see me anymore and to get a liver panel done once a year to keep an eye on it.
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Great! Hope it stays good for you.

FWIW, I was completely asymptomatic. By sheer luck and the grace of God, I was being treated by my dermatologist for a rash and he ordered bloodwork which showed liver enzymes off the chart. They had been normal at my physical just six months prior. Went through a bunch of tests and then a biopsy that showed pretty advanced damage. The azathioprene has been effective and my numbers have been normal for years now, but had it not been for the rash and visit to the dermatologist, the liver damage would probably have only been found at my autopsy.

GOOD LUCK!
 
A simple doctor’s note that says “he is fine, dont worry” is almost never enough.

At this point wait and see what they ask for. They will have specific requirements and time lines for reports they want to see. Send them those and wait.

Once you have your medical, research basicmed as a renewal option for 2 years from now.
 
Yuh, you didn’t mention the ulcerative colitis before, which is how it always is on these boards....:(
 
bbchien said:
Yuh, you didn’t mention the ulcerative colitis before, which is how it always is on these boards....:(
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The UC got CACI ok'd

Again, this thread was not intended to be about every little detail on the medical application. All I came here asking was if it was strange that the AME didn't want any supporting documentation and should I push to get more documentation to OKC sooner rather than later. Mr. Farlow was able to connect the dots for me with his post about sending the records myself and I'm going to act on that suggestion.
 
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I get that. But not having the whole picture make it impossible for anyone to give you any meaningful help.

Sclerosing cholangitis is considered a complication of UC, really.....You case depends on showing current good function, lack of chemical liver impairment ( the liver function tests) and stability of liver function.
 
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