Julian Hensey

An interesting article

The widow of a man killed in a plane crash has criticised air authorities for allowing a pilot’s severe heart disease to go undetected. As a pilot for Ryanair Tony Corr flew thousands of people around the world and helped to train young pilots for the company. The 54-year-old was able to fly Boeing 737s for the budget airline after passing a full medical, including an ECHG test.

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Widow criticises air authorities after pilot's heart disease goes undetected (From Witney Gazette)

Loose rivets

I assume there is still some training done in the real aircraft, and it doesn't leave much to the imagination when considering what might have happened.

One man and a boy operations banned? Well, we had to ride shotgun during line training. It was a PITA, but one can see the importance. Having said this, the Pappa Alpha disaster, was not helped by the number of crew.

Throughout my flying career, there have been stories of people suddenly finding they have severer heart conditions having passed their medicals with ease. 20+ years ago, someone died just after passing the 5 year medical at CME. They were 'on the steps of the building.'

Sadly, CAT scans involve X-rays, and MRIs are limited because of the cost/availability. Considering the seriousness of the issue, there may be a case for a 5 year MRI for pilots. Sadly, to give appropriate coverage, they would have to start at age c40.

There is quite a lot on the net about this procedure, but a lot of it is trying to sell a service, and I haven't seen a serious paper on the subject - though I'm sure there will be.

Detecting a few obvious ones still doesn't preclude sudden heart failure. The development of the sonic camera ( inserted in an incision in the groin and looking sideways at the walls of heart vessels ) showed the possibility of an embedded brew of cholesterol and the by-products of inflammation, in pockets in the walls of the critical vessels. This scenario means that even an apparently fit person might have the potential for a sudden heart attack. It is the very process of reacting to the foreign material that causes the blob of matter to be released.

Viewing from outside is difficult, since these vitally important vessels are surprisingly small, and the detection would need highly focused attention to the critical areas, and indeed, very detailed examination of the results. By no means a routine procedure.

I'm not sure we can sit back and say, "It's too difficult - we'll just have to rely on statistics." The potential for another crash on the scale of P.A.is real, and containing a flailing colleague at a critical moment - behind a locked flight-deck door, damned near impossible.

AnthonyGA

I don't understand why this clueless widow doesn't go after government motor-vehicle authorities for allowing the pilot to drive a car. The principle is the same, and you're just as dead after hitting a tree in a car as you'd be after hitting the ground in an airplane.

The fact is that almost no automobile drivers are incapacitated by sudden cardiovascular incidents, even though they are not screened for cardiovascular health before being given a license. And conversely, there are still pilots who have sudden strokes and heart attacks, despite a more rigorous screening for pilot medicals. Which in turn implies that (1) medical incapacitation is extremely rare even in the general, unscreened population, and (2) screening people for heart disease won't necessarily reduce the already low incidence of incapacitation. The tests that might actually be able to verify if someone is at risk of incapacitation, at least in the case of cardiovascular disease, are extremely expensive and invasive, and thus not really practical. And the tests actually being used aren't really very reliable for isolating who will or will not be incapacitated.

HEATHROW DIRECTOR

AnthonyGA.. That's a pretty despicable comment about a woman who has suddenly become a widow. I know the quacks can't do much, but she has every reason in the world to ask why.

EuroPPL

(1) The obvious difference is that a car driver can easily and quickly stop the car and phone for help.
(2) It is possible to measure the diameter of arteries non-invasively, so this condition would have been detectable with a more complete test.

Julian Hensey

HD,

Speaking to an aviation doctor it is very difficult to detect this problem - in fact there does not seem to be (unless a medic out there corrects me) a very conclusive test to find this defect even with the best will in the world. I think the issue here is that the widow has "criticised" the medical examination and the authorities without asking the question whether there was anything that could have been done. Fine if there was a test that cost £10 and could detect it, but there isn't. Going to the press before understanding the issue is not helpful and I would always ask the question whether the person who had died as a result of something would want the person left alive acting in the way they did by talking to the press while maybe not knowing the full picture.

J

Broomstick

Julian,

I'm not an AME, but I am a doctor, and you are absolutely correct. One of the main reasons for asking about family history, performing blood tests for lipids, measuring blood pressure, asking about smoking and calculating BMI is to build a picture of cardiovascular risk. There are very few clinical signs on examination which will alert a clinician to the presence of coronary disease, and in many cases there will be none. In the absence of a history of symptoms (angina, pains in the legs after exertion etc), adverse risk factors or a positive family history, it would be difficult to justify more invasive investigations. These may include formal angiography, which carries a complication risk, or coronary CT, which is associated with radiation exposure. Therefore in someone who is otherwise low risk, the risk-benefit ratio would not be in favour of performing further investigations.

This case is tragic, and the natural response of anyone grieving for this man will be to ask questions. The class 1 medicals are quite prescriptive and standardised, so it is difficult to see how anything could have been handled differently, or how this sad outcome prevented.

Broomstick

gingernut

It'd probably be wrong to comment on this specific case, but I'm making the assumption that this man had no symptoms prior to his death.

If that is the case, we are into the realm of screening for asymptomatic disease-the fact that he was a pilot is mostly irrelevant. The purpose of the dept is to protect the public, not the pilot.
One would have thought that the main purpose of the aviation medical is to reduce the risk of sudden incapacitation. Unfortunately medicine isn't that refined. The best we can do at the moment is managing the odds. Perhaps there may be a role for better tests, (eg exercise ecgs), but I'm not sure if the criteria below are fulfilled.

A rather dated criteria for screening is

Wilson

An old adage, but probably as relevant today.

My sympathy with the grieving families. Heart disease is a scourge.

AnthonyGA

Accusing the aviation industry of negligence in the press is pretty despicable, too. I'm sorry for her loss, but she needs to wait a year or so before drawing any conclusions on who or what might have been responsible for her loss. Right now she is emotional, and she should deal with her emotions in private rather than wailing to the press. Decisions made in haste are usually poor decisions.

No more so than a pilot. Cardiac arrest or PE will produce unconsciousness in seconds. The driver of a car in this case will crash and die just as surely as a pilot, or more so (since there are two pilots in many aircraft).

Which arteries? Clots and plaques can come from anywhere, and it's not practical to look at everything, even non-invasively. Additional, things like sudden cardiac arrest may be completely unpredictable. Athletes in perfect condition occasionally drop dead from sudden cardiac death for no identifiable reason; they may have some occult cardiovascular issues, but nothing that could have been screened for in advance. And most pilots, while they are generally in good health, are not as healthy as athletes.

Overall, I think the risk of sudden incapacitation is dramatically overestimated by aviation authorities, and the methods they use to screen for it are dramatically inadequate, anyway (and only cause problems for people who may not be at risk of incapacitation at all). A more useful test might be one that checks how much sleep a pilot has been getting, but I don't think any such test exists.

robin

The question remains though.

If the £150 pa medical doesn't pick up the likelihood of a cardiac problem, why are we doing it?

Peter Saundy has been speaking about this for years.

Landflap

Quite right Robin. Why the hell are we doing it. The medical profession are completely incapable of predicting our demise. Bunch of Quacks. Self perpetuating, self interested, incapable idiots. Look, a mate of mine ws subjected to "enhanced medical tests" in order to succeed in gaining a "Over age 60" contract from Gulfair, He passed. A week later, he was in intensive care with double kidney failure!He died a short time later. Another mate, was diagnosed with Diabetis type 2. Placed on extreme doseage he started pissing blood, suffered exteme kidney pain, and palpatations. He threw the medication down the toilet and has never felt fitter. I started my careeer in aviation in the Crew Records Dept of a major Airline. I caused mayhem when rebooking all medicals at the CME ! Guys called in stating that they had a "friendly " quack who offered a glass of Sherry, quick cough & bollock test & away we go !! Another job I had was as a Medical Rep for a major pharmaceutical company (sorry, no spell check.it looks right), I wa authorised to spend loadsa dosh on inducing, er "doctors" to sign up, only, to our products. Of course they did. I won a major bonus for paying one GP his annual subscription to a famous Northern golf club. So, boys & galls, no respect. Even me, I was anorexic. Went from 11 stone to 8 stone six. After a warning from my , er, "Doctor", i gained to 9st 7. At my annual medical, I was told by the quack to watch out, as I was gaining weight !! We are stuck with it ! Finally, when renewing my Dutch Licence, some years ago, the Head of the Medical Board, looking like an Aids Victim, puffing on his 90th untipped woodbine, remarked on my pearshape and rapidly developing manboobs. I told him I was there for Medical renewal & not insults. He stamped my approval & I have not stopped flying since. I am a fat bastard, exceed these stupid bodymass index criteria, shag endlessley, drink until I fall over or get badly hit in a drunken bar brawl but, gees, I ove aviation, but hate the quacks with a vengeance !

henry crun

robin: You ask "If the £150 pa medical doesn't pick up the likelihood of a cardiac problem, why are we doing it?".

I have not seen any statistics on the subject, but I suggest the number of cases of incipient cardiac problems that the Docs find on annual medicals, vastly outweighs the very small number of unpredictable heart failures on the flight deck.

gingernut

Crickey, I thought I was cynical.


I would have thought the purpose of the aviation medical is (or should be)

1. To predict sudden demise
2. To detect acute and chronic disease
3. To promote health

Apart from "barn door" cases, and there will be some anecdotal evidence, I wouldn't have thought that it's much good at 1 or 2, and actually, there are other routes for this anyway. The prediction of 1 and 2, mostly relies on measures designed to assess risk of a population.

Cardiac disease is an interesting one. The high tech stuff (the ecg) is not a reliable predictor. We can, however, make some idea of "risk" for an individual with some degree of accuracy.

If, for example, a 50 yr old bloke, who smokes 20 a day, has an elevated blood pressure, slightly raised cholesterol and who's dad died of a heart attack aged 45, then I could predict with some degree of accuracy, that he has a 30% risk of having a cardiac event in the next year.

If I had a hundred blokes with the same factors, then I know that 30 of them would topple in the next ten years - what I don't know is which 30 will, and which 70 won't.

So if I was the AME, do I ground all 100? And at what level of risk do I ground them?

More sophisticated measures (scanning the arteries) are no more better at predicting risk, and don't fulfil the requirements of screening that I've listed above.

The principles of managing risk can also be extended to other areas of health. The biggest cause of death in a 25 yr old ? - suicide.

Whilst your average 25 yr old may be livin g the dream on the day of his medical, there is nothing stopping him from dumping his airbus into the sea the day after, when his girlfriend has dumped him. No medical in the world would predict this, but if, say, he had a history of depresiion and attempted suicide, then he would be considered higher risk.

As for 3, health promotion, the stuff I've heard has,at the least, been questionable.

So, can the medical reliably predict risk at an individual level? Probably not. What it can do is help us juggle the odds.

Does medicine improve health? Not as much as Town Planners can.

Happy flying.

gingernut

Having said all that, the alternative is no medical, which, as a passenger, I probably wouldn't be too happy about either.

HEATHROW DIRECTOR

....and I hope to God I never have Landflap flying me!! When his time comes - which it surely will - for a quadruple by-pass I hope he makes it abundantly clear to the surgeon how much he hates doctors..... :-))

Loose rivets

ginge As with most of your posts, I read it very carefully and found it interesting. The bit about...

...had me wondering where medicine is going with this science.


CAT scans can be breathtakingly clear. I had an hour long demonstration from a teaching doctor/radiologist, who took a joy in showing me his new kit. Some of the functions were so space-aged I wondered if it was real. By total chance, I found a neighbor of mine had supplied the entire system, and was able to pick his brains for a while as well.

Skip for a moment to the vessel wall scenario I mentioned above. Much of the television program used graphics, but there was some film of the images from the tiny sideways looking sonic camera. They made a very convincing argument. I guess post-mortem research over a period of time confirmed the depth of the pockets which became inflamed and popped their gooey contents into the bloodstream.

What this is telling us is that there is no need for the vessel to be lined with the deadly product, it can be hidden in the walls of otherwise clear tubes.

Firstly, can CAT see these pockets? Given the images I saw were from a previous patient, a huge amount of information is stored. 'We' were not only taken to colour-coded vessels, but then progressed through walls that seemed to magically open as the 'focus depth' changed. I was shown the inner lining as clear as the artist's graphics in the program. I would have thought such pocketing would be crystal clear.


Okay, what's to be done? Putting a camera in is simply not acceptable. One can not subject crew to what is in effect, surgery with significant risk.

CAT uses X-rays. Low level, but for fairly long periods while the computer gathers enough data to achieve the tomography. This is okay in a search for something deadly, but not appropriate for routine checkups. Or is it?

When we consider what's at stake, then the middle aged captain - in command of an aircraft carrying hundreds of people - might well have such a check every five years. If he's going to take on that responsibility, they maybe he should accept the risk. I wanted chest X-rays to stop because of risk, but I would accept five-year CAT scans as I approached 50. The trouble is, they're not cheap, but there would perhaps be a significant advantage for the subject if lungs were looked at, at the same time.

gingernut

Thanks LR, it is indeed an interesting area. I've got some interest in this area as my patients are more likely to drop dead of heart disease more than anything else.

Doctors, especially radiogists, are very much like pilots. Slightly nurdy.

The trouble is, they sometimes get a little hooked on the process, rather than the outcome. We can have a fantastic process, but we need to be sure of the outcome. Drugs companies are very good at selling process, telling us what chemical blocks which receptor, but what I really need to know, is if intervention a makes a difference to outcome b. (Eg. will your pill stop a patient dying of heart disease, and if so, does it kill them of anything else?) Sounds a bit simplistic, but there have been some spectacular examples of late.

Gotta be honest, I'm not sure what the exact procedure is for the tests which look at calcium deposits. (I'm told that medical radiation sparks off about 200 cancers a year in the UK).

I'd need to be convinced that the test makes a difference to planes dropping out of the sky or prediction/prevention of an arterial event (and I'd agree, when performing a risk/benefit analysis, airline pilots are in a different category than Jo Average).

From the stuff I've seen, (big study at NEJM 2008:358:1336), the technology, unfortunately, isn't yet good enough.

However-watch this space.