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ACS Internal Medicine keeping pilots flying, improves research

Staff Sgt. Jonathon Lee, pulmonary technician with the Aeromedical Consultation Service Internal Medicine Branch, conducts a demonstration of a pulmonary function test for forced vital capacity as Staff Sgt. Sean O’Neill sits in a pressurized cabin awaiting the command to exhale. The branch reviews around 700 requests for waiver recommendation cases annually concerning pilots, navigators and other aircrew, with 90 percent of them receiving waiver recommendations. (U.S. Air Force photo/John Harrington)

Staff Sgt. Jonathon Lee, pulmonary technician with the Aeromedical Consultation Service Internal Medicine branch, conducts a demonstration of a pulmonary function test for forced vital capacity as Staff Sgt. Sean O’Neill sits in a pressurized cabin awaiting the command to exhale. The branch reviews aproximatley 700 requests for waiver recommendation cases annually concerning pilots, navigators and other aircrew, with 90 percent of them receiving waiver recommendations. (U.S. Air Force photo by John Harrington)

WRIGHT-PATTERSON AIR FORCE BASE, Ohio (AFNS) -- EDITORS NOTE: This is the second part of a four-part series on the Aeromedical Consultation Service at Wright-Patterson Air Force Base. Part three will delve into how the ACS' Neuropsychiatry branch keeps aviators in the fight. Part one was an overview of the ACS.

The Aeromedical Consultation Service here at Wright-Patterson Air Force Base reviews more than 2,000 waiver recommendation requests for Air Force pilots, navigators and other air crew annually. A staff of approximately 80 Airmen at the ACS ensures aviators get back in the sky as soon as possible.

“You know, these guys just want to fly,” said Lt. Col. Eddie Davenport, ACS Internal Medicine chief cardiologist. “Even after potentially life-threatening cardiac disease, these aviators push to get back in the cockpit - no excuses, no balking at deployments. Our hopeful goal is to safely get them back flying.”

Internal Medicine staff do that by diagnosing a wide range of health issues in cardiology, pulmonology, endocrinology, gastrointestinal and others, and determining the risk of those issues to safety of flight for air crews. A team of four general internists, two cardiologists, one pulmonologist and five technicians review studies such as echocardiograms, stress tests, and holter monitors in dealing with everything from asthma, arthritis and obstructive sleep apnea to diabetes, coronary disease and cancer.

The ACS publishes waiver guides that let waiver authorities, generally major commands, make informed decisions on what medical conditions can and cannot be waived, but there are always times when things turn grey.

“In cases that are confusing or unusual, they’re very likely to ask our opinion,” said Maj. Kevin Alford, ACS Internal Medicine branch deputy chief and staff internist.

That equates to about 700 annual case reviews with more than 150 in-person evaluations for the Internal Medicine branch. The bar to receiving a waiver recommendation from Internal Medicine is high.

“We have a one percent rule,” Davenport said. “If there’s over a one percent chance of them suddenly having incapacitation while they’re flying, we don’t let them fly.”

But, ACS staff ensure aviators are given the best chance possible to receive a waiver recommendation through not only a very detailed review of their medical data, but tests that may go above and beyond the norm.

“We’re very thorough,” said Lt. Col. Dara Regn, ACS Internal Medicine branch chief and staff pulmonologist. “We do additional tests that they may not do in the civilian world just to make sure that we are being thorough because this is a tremendous investment. It costs over $5 million to train someone to fly a heavy (aircraft) and $3 million for a high-performance fighter. They’re a person and an investment, so we do everything we can to keep them healthy and keep them flying.”

Remarkably, over 90 percent of cases reviewed ultimately receive a recommendation for waiver from the Internal Medicine branch, with the waiver authority making the final decision to return them to flight. It’s a number that’s been climbing over the years.

“We have a lot of examples of where, if you looked 10 years ago at what we were doing from a waiver standpoint, we were a lot more restrictive,” Alford said. “We’ve been able to move to a waiver policy that allows more aviators to get back to doing their job by finding ways to do that safely. Part of that is advances in medicine but part of that is the work of people here and at other organizations to find those safe ways to monitor and maintain our aviators in their positions.”

Some of the things ACS Internal Medicine allows are unheard of in other nations.

“Conditions like bicuspid aortic valve or mitral valve prolapse, a lot of other countries in the world do not let those folks fly, which is largely based on expert opinion, but we do,” Davenport said. “The reason we do is because we used published data, as well as our own, to support their safety and then we watch them very closely. We get an echocardiogram or (some other) testing every year just to make sure they’re OK. If anything changes, then we take care of it before anything happens.”

This intense dedication to aviators is often appreciated by the waiver authorities.

“ACS is very important to Air Force Materiel Command,” said Daniel J. Huber, AFMC Aerospace Medicine Programs and Standards manager, who’s responsible for approximately 1,000 aircrew and air traffic controllers throughout seven bases. “The staff at the ACS is remarkable. AFMC’s aeromedical case manager Jeannette Remy, is always responsive to requests whether it be to expedite an appointment for someone deploying to checking on the status of an evaluation in progress. The physicians are readily available and responsive to the needs of the aeromedical community.”

ACS is part of the U.S. Air Force School of Aerospace Medicine, which itself is part of the 711th Human Performance Wing. The Internal Medicine branch staff have made efforts to work closely with the 711th HPW such as in a recent study on the effect of aircraft ejections on aviators with osteoporosis, according to Davenport. In addition, the branch has recently worked with Naval Medical Research Unit Dayton and the U.S. Army on the pulmonary impacts of aviation, such as when rotary aircraft kick up dust in a deployed environment, according to Regn.

“This is something that we’ve really worked on for the last year or two, finding ways that we can collaborate with them to try and help them and also for them to help us to create research that helps us answer the challenging questions that we have,” Alford said.

In fact, the Internal Medicine branch is shifting more focus to research as its huge repository of information will allow for policy to be guided more by specific statistics vice expert opinion.

“We have 1.2 million (electrocardiograms) on about 300,000 aircrew over 70 year’s time frame,” Davenport said. “We have every cardiac study done on every aviator since the inception of the Air Force, whether normal or abnormal. We follow every member from accession through retirement and use data to make policy. Right now, we’re combining databases and putting it into a more meaningful format for higher order analysis.”

Davenport began digitizing the studies when he first arrived at the ACS in 2009. Since then, he’s traveled the world discussing his early findings and the database’s importance. In 2010, he presented some data on a trip to Germany during a European flight surgeon’s course. He met with doctors from several other countries and proposed standing up a NATO cardiology working group. Today, he co-chairs that group.

“I get e-mails from all over the world every day because we have the data to support every aeromedical cardiac recommendation,” Davenport said.

While the extent of the database’s impact is yet to be known, it’s already being felt.

“The continued research has definitely enhanced the capabilities of the aeromedical community and provided up-to-date treatment regimens for a wide variety of conditions,” Huber said. “Their work allows us to support our flying personnel with the overall goal to keep them flying safely and effectively.”

From ensuring capable pilots are able to climb back into cockpits to being a world leader in aeromedical internal medicine, the staff at the ACS Internal Medicine branch enjoy the opportunity to impact the Air Force mission of “fly, fight, win.”

“It’s very rewarding because we do it not only on an individual patient level but also dealing with the major commands, dealing with headquarters and now on an international level to a lot of other countries who look to us and our opinions on how we care for our aviators,” Regn said. “That feels very impactful and rewarding.”

Regn, herself a co-chair on NATO working groups on pulmonology and sleep, says it’s the people of the ACS that makes the difference.

“I truly think that the people you work with make the work environment,” Regn said. “This group of people are super intelligent, very motivated and very mission-oriented. They truly exemplify the core values of service before self.”

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