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CASA Avmed – In my opinion, a biased, intellectually dishonest regulator

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CASA Avmed – In my opinion, a biased, intellectually dishonest regulator

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Old 8th Dec 2018, 03:52
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True.

I was trying to make a broader point: You’ll also be sharing the skies with pilots who might never have been near a DAME and might never have held a medical certificate.
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Old 8th Dec 2018, 04:43
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I appreciate the passion and effort you're putting into your case, as you and others have said, you are entitled to administrative fairness and should be able to clearly understand the basis of a decision for which you disagree with and challenge it if it is incorrect. I don't want to engage in a giant point by point internet forum battle over your process, just give you some commentary from someone who has some general knowledge of an element of your problems.

To clarify on a small number of your points. All post fellowship doctors are specialists. Fellows of any specialist college and some senior trainees can undergo aviation medical training. Of that cohort some can go on to further post graduate qualifications and experience in the aerospace industry- generally, through the military and in the US or UK. There are some avenues for distance education and new courses in the Aus/NZ space recently. Australia has its own aerospace medical fellowship as well, the post nominals FACASM indicate that, earned after a number of years of study and assessment. There are very few surgeons with that dual qualification (I would say less than 10 in Aus, most of them eye, ortho and general surgery).

So when we play the game of "my opinion is better than yours" some of the weight will come from that specific expertise and as I said before, expert opinion alone is the lowest level of 'evidence' to support a decision. If there's no well designed study into your condition (and even better, a meta-analysis), in the aviation environment as well, then making a defensible decision will be hard, hence defaulting to a the general decision pathway for brain surgery/injury/interventions which does have this top level of evidence. There are even more complications when expertise on the condition, the environment and the safety system need to overlap, no one doctor is expert in all of them.

Using examples from non aviation contexts i.e. "I can drive a car so what if X" have not much relevance. The regulator is protecting the public from direct harm from aircraft crashes, protecting the industry with a perception of assisting rigorous safety management systems and setting a standard which is 'acceptable' to government, the public, industry and aircrew (in that order) Your car crashing into a pole vs shutting down an airfield or crashing into a house in western Sydney are obviously different levels of consequence (reductio ad absurdum on buses full of school children don't help you) and form part of the basis for differing standards to drive a car vs flying. Endless argument can be had over how automation and support systems have now altered what critical phases of flight is and the burden of the aviation environment on the body is little in recreational flying. Perhaps the standards will lower in the future, and they have already arguably with the introduction of the basic Class 2.

Undoubtably an unfair, or perception of an unfair, regulator will lead to lowered rates of compliance to 'protect' a privilege or avoid censure. This is not unique to aviation and applies to safety management universally. Processes and cultural changes need to be in place to avoid this as much as possible but again, universally, these do not tend to happen until after some critical failure and it is a thorny problem.

I felt I should put the previous and this here to assist the community in understanding some of the why/how in these kinds of cases, that do tend to appear each year or so. Being told you can no longer do something when you believe that it is the wrong decision is hard, it is distressing but it is not out of some systemic malice or malfeasance. It's a difficult decision (because there is no high quality evidence to support, because there are conflicting opinions from relevant subject experts and because it is in a population not flying Class 1- with the employment and industry pressures that may assist in gathering support) and no one would argue it is a perfect process.
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Old 8th Dec 2018, 04:57
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The behaviour of Avmed appears to encourage non reporting because there is a perception that Avmed will always act in its own interests at the expense of the pilot. This encourages what the ICAO safety management manual terms latent violations of safety principles. These are things that are loose in the environment that may one day result in an accident if other defences are overcome. As such it appears that Avmed is making us less safe.

My own DAME tells me his job is to keep me flying as long as possible.
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Old 8th Dec 2018, 05:50
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It’s an acceptable risk for me to continue to drive a car that weighs more than my aircraft and carries more people than my aircraft, on the road shared by buses full of school children a mere couple of metres away, day and night in all weather, when I’m apparently an ongoing potential neuro-circulatory time bomb.
I would be careful going down that track. The Austroads medical standards say for vascular malformations of the brain treated surgically a person should not drive for 6 months - private or 12 months - commercial. Advisory only, but if I understand your description of your condition, Austroads do in fact say you should not drive.

Certainly you share the roads a lot more closely than the sky, but the obvious difference is that if you suddenly get a splitting headache in the car you don't need to do much more than hit the brakes (pulling over to the side of the road is desirable but not essential). In an aircraft, you need to continue to perform complex tasks for at least a few minutes, possibly even 30 minutes or more.

I have been through the process with Avmed myself and have some sympathy. I agree that their standards don't always match the risk. But in this case I think perhaps you are underestimating the seriousness of your condition and of the surgery. The plumbing in your head is pretty serious stuff. The reality is that medicine is not like mechanical repairs, and they can't usually make things as good as new - more often it's patch things together and hope it holds. Any scan now will show what is happening at that instant, but can't guarantee it will be the same in 6 months.

Avmed are the bad guys because they ground people, but sometimes medical conditions are real.
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Old 8th Dec 2018, 05:55
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Originally Posted by andrewr View Post
But in this case I think perhaps you are underestimating the seriousness of your condition and of the surgery. .
Did you miss the point that the specialist has stated he is fit to fly?
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Old 8th Dec 2018, 06:33
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Originally Posted by Cloudee View Post
Did you miss the point that the specialist has stated he is fit to fly?
That's the other half of the problem. Avmed want to know what is the risk of incapacitation, they reserve the right to make the "fit to fly" judgement themselves based on that information.

Avmed asked what is the risk of incapacitation. The specialist said he doesn't meet the class 1 medical standard - which implies there is some risk of incapacitation but doesn't quantify it. The specialist said he considers him fit to fly day VFR. Unfortunately that is not a medical standard, and the further implication is that the specialist believes he also doesn't meet the class 2 medical standard.

So the advice from the specialist is in fact:
  • He does not meet the class 1 medical standard
  • He does not meet the class 2 medical standard (which allows night, IFR etc)
  • He is fit to fly day VFR. That might be closest to the basic class 2 standard which Clinton has said he does not want.
Avmed want some definite statement from the specialist saying e.g. the risk of incapacitation is less than x%, so that if an accident occurs in the future they can point to it and say we were acting on this advice. Stating or implying that he does not meet various standards but is fit for day VFR isn't much help. However specialists, in general, don't want to be pinned down to that sort of statement.

Without a less equivocal statement from the specialist, the best Avmed can do is a time based test - if nothing bad happens in 12 months, the probability of something happening in the future is acceptably low.
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Old 8th Dec 2018, 10:03
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Might be worth you reading through the thread, Andrewr.
Avmed asked what is the risk of incapacitation. The specialist said he doesn't meet the class 1 medical standard - which implies there is some risk of incapacitation but doesn't quantify it.
If you refer to earlier posts in this thread, you will see that specialist’s letter said, among other things:
My professional opinion is that I do not consider you a risk of incapacitation now that the lesion has been treated.
Is that not a statement of the risk of incapacitation? That was before the dynamic CTA and then DSA confirming ongoing success of the procedure.

But let’s ignore that for the time being.

The AATs decision on the question whether to ‘stay’ the decision to suspend my certificate said, among things (with my bolding):
... CASA has pointed out that Dr Mews has said that Mr McKenzie would not meet the standard for a class 1 licence. That is so, but it is not relevant to whether he meets a class 2 standard. It is to be expected that there will be a subset of class 2 licence holders who would not meet the class 1 standard.
The above is, of course, a selective quotation and emphasis. Kinda like what CASA does.
I would be careful going down that track. The Austroads medical standards say for vascular malformations of the brain treated surgically a person should not drive for 6 months - private or 12 months - commercial. Advisory only, but if I understand your description of your condition, Austroads do in fact say you should not drive.
Gosh, Andrew. Are my specialists incompetent? None of them has advised that I should neither drive nor fly.

The fact that you, too, may have received the Avmed ‘treatment’ is not evidence that it’s necessary.

And I have to say that the concept of Avmed expressing opinions about objective risks of sudden incapacity is laughable. I’m sure Avmed does it, but the chances of those opinions being ballpark accurate are vanishingly small.

Last edited by Clinton McKenzie; 8th Dec 2018 at 10:42.
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Old 8th Dec 2018, 10:16
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I wonder what qualifications the AVMED doctors are required to have. Do they have qualifications in aviation medicine? Are they also pilots? Or are they GPs who no longer want to see patients face to face and just act as an interface between DAMEs, specialists and their own lawyers?
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Old 8th Dec 2018, 11:48
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Originally Posted by Clinton McKenzie View Post
Might be worth you reading through the thread, Andrewr.If you refer to earlier posts in this thread, you will see that specialist’s letter said, among other things: My professional opinion is that I do not consider you a risk of incapacitation now that the lesion has been treated. Is that not a statement of the risk of incapacitation?

That is definitely a statement of the risk of incapacitation. However, it is undone a bit by the additional opinions that you don't meet the standards for class 1 (Why not, if you are not at risk of incapacitation?) and the suggestion that you are fit for day VFR (again, why not a normal class 2 if you are not at risk of incapacitation?).

This is why people recommend giving Avmed what they ask for, but don't volunteer extra information. Extra information confuses things and in this case throws doubt on the statement on incapacitation that Avmed were looking for.
Originally Posted by Clinton McKenzie View Post
Gosh, Andrew. Are my specialists incompetent? None of them has advised that I should neither drive nor fly.
Probably every doctor in Australia has patients that technically, legally, shouldn't be driving, but they judge that the risk is too low to be worth the inconvenience to the patient in our car-dependent society so it is never discussed. Basically a case of don't ask, don't tell. If you did ask, they might be obliged to refer to the Austroads standards, and advise that you should not be driving. (I suspect you are also qualified to make a distinction between should not and must not.)

Originally Posted by Clinton McKenzie View Post
And I have to say that the concept of Avmed expressing opinions about objective risks of sudden incapacity is laughable. I’m sure Avmed does it, but the chances of those opinions being ballpark accurate are vanishingly small.
I'm sure that is true in many cases, but that is their job and that is the system we need to work in. Surgery involving the blood supply to the brain probably does have a real, relatively high risk of sudden incapacitation compared to many of the areas where people have trouble with Avmed.

You dismissed Nowluke's post because it was a first post, but to me it looks like an expert evaluation of your situation. I think a careful re-reading would help you to understand your situation WRT Avmed, and help you understand your potential path forward.

(Although I think Nowluke's suggestion of a basic class 2 might be a non-starter, because it appears to me (as a layperson) that you also would not meet the unconditional commercial driving standards.)

Legal challenges to Avmed are likely to be counterproductive, because it locks them into a position and forces them to put together a case to show why they should NOT grant a medical. It means any additional information needs to be much stronger before they will change their position.
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Old 8th Dec 2018, 19:34
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Surgery involving the blood supply to the brain probably does have a real, relatively high risk of sudden incapacitation compared to many of the areas where people have trouble with Avmed.
I’m guessing that’s true, but I’m not an expert.

Fortunately, I didn’t undergo surgery involving the blood supply to the brain.

This is part of the problem with non-experts, like Avmed, wading in with their 2 cents’ worth.

I didn’t “dismiss” nowlukes post. I responded to it. Others can judge whether it answered any of the points made.


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Old 8th Dec 2018, 20:44
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Legal challenges to Avmed are likely to be counterproductive, because it locks them into a position and forces them to put together a case to show why they should NOT grant a medical. It means any additional information needs to be much stronger before they will change their position.
And that’s another fundamental flaw in the system.

If CASA were, in fact, an objective evidence-based and objective risk-based regulator, it would inexorably follow that a challenge in the AAT to a decision to suspend a person’s medical certificate should make zero difference to CASA’s subsequent assessment of the person. That’s because, as a matter of objective fact, there is no causal connection between a person’s compliance or otherwise with a medical standard and the existence or otherwise of an AAT challenge to Avmed’s decision that the person does not comply with the standard.

It means any additional information needs to be much stronger before they will change their position.” That’s not being objective.

Avmed is emotionally engaged in the ‘defence’ of these decisions. That’s why they emphasise some things and downplay others, and selectively quote and interpret, in their statements and requests for “independent” opinions. That’s why the AAT in the Bolton matter disregarded the opinion of Avmed’s Principal Medical Officer.

My view is CASA should not be the contradictor - the other ‘side’ - in these AAT matters in the first place.
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Old 8th Dec 2018, 23:49
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To clarify, a specialist is a post graduate fellowship in a relevant discipline. Aerospace medicine specialists are denoted by the post nominals FACASM in Australia, the lesser post graduate qualification being a diploma in aerospace medicine, generally from the UK and generally held by (ex) military doctors; NZ also has a program and some Aus universities have started up equivalents to a lower post grad level. It also generally a secondary speciality after general practice, general surgery etc. There would be 10 or fewer surgeons in Aus with the qualification. It, like all specialties, takes several years and has an examination process. The other end of the scale has a number of 6-12 week courses to become a DAME, this is the minimum amount of training to provide some occupational context for clinical advice to be placed in alongside regular professional development. I don't know what mix of these differing skillsets CASA has.

It's obvious you feel strongly about your issues but you do yourself a disservice and practice the same alleged selective use of facts in how you're going about engaging on this. Repeatedly you choose very limited aspects that support your narrative to the cost of your credability here.

As previous, the absolute gold standard for your condition would a meta-analysis of a number of long term follow up studies in aircrew to determine your risks. The opinion of a "specialist" is the lowest evidentiary weight in clinical decision making. Brandishing your supporting narrative and and then claiming that it 'proves' you're cured and thus now at baseline risk is meaningless in the context of the decision being made. All it does is demonstrate, at a single time point that you remain at the baseline risk of your clinical cohort- not back to the standard. You may indeed be theoretically 'fit to fly' on that day and the next but nowhere has it been addressed, in what you put forward, in a comprehensive way, with clear clinical research based evidence.

It is churlish to suggest you have not undergone surgery in the broader sense, an endovascular procedure is of the same nature as keyhole surgery or imaging guided interventions. Generally, they have more positive results (quicker recovery, less infections etc), hence the trend towards them. However, just because no one has opened your skull and put a scalpel in does not mean you no longer fall under the post operative precautions and physiological changes that are universal to all physical interventions to anatomical structures. A change was made and hopefully you are now at lower risk of an event but it is not a stochastic on/off; yes/no change with an absolute outcome.

You again attempt to shape your narrative around “it wasn’t my/in my brain” therefore the rules don’t apply. It’s the circulation to the sac your brain sits in, both are dependant on blood from your neck and spine and the same endovascular access techniques are used. A poor outcome to your treatment will absolutely affect the function of your brain.

The high value you continue to place on your limited ‘specialist’ opinions on fitness to fly has not been situated anywhere up the clinical evidentiary scale. It remains the very lowest evidentiary (in the clinical, not legal) basis to assess your risk. There is large body of work on neurovascular, neuro-malignancy and head trauma that underlies the position for having a post incident/intervention 12 month assessment period. I devalue them even further when the absolute statements along the lines of “no risk of incapacity” and “100% success” are made by your treating doctors. They have misspoken grossly and not provided an accurate assessment of your risks; at best a statement of short term resolution can be drawn from them and some further extension into the medium term from your imaging. Again, it forms a foundation for long term success and risk reduction but it does not allow you to then infer this off into 1-2 years into the future.

Unfortunately, my position is somewhere approaching the objective one. If there is no higher research on your risks then it does become a case of trumps. Until you (or your supportive specialists) start dropping things like :

Link, M. J., Coffey, R. J., Nichols, D. A., & Gorman, D. A. (1996). The role of radiosurgery and particulate embolization in the treatment of dural arteriovenous fistulas. Journal of neurosurgery, 84(5), 804-809.

and quoting out the long term risks and rates, you’re not even on the playing field (note this is not applicable to you, just a very proximal cohort using a different process). That they have not done this is a big issue in any serious consideration of your concerns.

The position you’re in of apparently insurmountable standards is just that, insurmountable, you logically cannot provide proof of a negative prospectively. You no longer met the standard, the current gold standard relevant clinical research defines the guidelines and no amount of single point in time imaging will change the fundamental hazard that underlies the ‘waiting period’ - esp. when your question of fitness to fly is in it’s full context - i.e. the 1/2 year licence period.

To its extreme, it will end up the case that at day 364 you remain not fit and then the next day, through administrative magic, you then are. Unless you can create the body of knowledge to change the gold standard position i.e. a number of longitudinal clinical studies on endovascular repair of AVM of your type in aircrew using your technique and compound then you’re going nowhere fast, no amount of letters from a procedural specialist will change that. There is a vast difference in your apparent clinical ‘fix’ and returning, with evidence, to the standard.

As andrewr said it may even be the case you no longer meet basic class 2 as well. Vis Austroads the non-driving for intracranial procedures is advisory only; non-driving periods may be varied by the neurosurgeon - this may be applicable to the basic class 2 but I would say CASA may/may not align with this.

You've taken repeated umbrage and described it as dishonest when terms like significant and high etc are used. It is a shorthand for the rate of unacceptability at which the hazard is realised when an appreciation of the condition in the environment is made with respect to the standards acceptable within the safety management system. This rate is whatever is set by the regulator and it is the best that can be made with the scientific, not single expert, knowledge available and it will change over time. And people will disagree with it.

I don’t want to engage in some giant internet forum battle over this. I only responded initially as you were very vocal along a narrative that was fundamentally incorrect from a (my) clinical aeromedicine view. I don’t care about your CASA dealings or the administrative parts as the root cause has been the failures of communication with you by your treatment team and the lack of understanding of aeromedicine. My position may even be incorrect as in the future the evidence I spoke about will come into being, it could even exist now. Although you would not be in this position were that the case.

Last edited by Nowluke; 9th Dec 2018 at 04:44. Reason: Grammar
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Old 9th Dec 2018, 01:54
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I wonder what qualifications the AVMED doctors are required to have. Do they have qualifications in aviation medicine
Can't answer your question directly, but going back a couple of decades my understanding of the process was Avmed had a meeting once a month with a panel of medicos, drawn from where I know not. It was from this panel that a yes/no would be forthcoming. In one particular case the Avmed director went into bat for the applicant and pressured a recalcitrant medico specialist to make a decision that he could take to the monthly board. So even specialists at times are reluctant to give a yes/no, a sign of our litigious society I guess. In the case mentioned the applicant was given a thumbs up.
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Old 9th Dec 2018, 07:42
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Originally Posted by Nowluke View Post
Feel free, first post as I haven’t had much to contribute. As you can check though, I have been a member for a while. I’m offering a perspective from a different part of the aviation community; take whatever value you wish, discard it if you want. As I said, it’s a shame you’re not flying, it’s doubly so that communication issues have compounded your distress.
Mr. Nowluke,

Are you a pilot, or hold any type of pilot's license, whether it's a ppl/cpl/atpl?

You know what's strange, you have been a member for a while, as you have mentioned, but you have zero posts or opinions on other matters on aviation,
except, half page essays on aviation medicine.

So please tell me, have you got a pilot's license and have you passed a Class 1 medical?
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Old 9th Dec 2018, 08:26
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Seagull I believe your question as to Nowluke holding either a pilot licence and/or aviation medical is completely irrelevant to the medical issue being discussed.
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Old 9th Dec 2018, 08:57
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How about Nowluke, writes a half page essay, on other aviation topics, as discussed by others.

He has a speciality towards aviation medicine, but no opinion on other topics?

I don't buy that!
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Old 9th Dec 2018, 09:41
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Seagull why on earth would/should Nowluke write on other aviation topics where clearly aviation medicine is his forte. I believe he shows commendable wisdom and perhaps you could learn from this also.
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Old 9th Dec 2018, 16:25
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it’s called in debating the “appeal to authority” argument. luke is merely saying “show us the detailed long term follow up research on perhaps thousands of pilots who had your condition that proves you are not a risk to humankind” - and when this is not available as it never will be, that Clinton is an unacceptable risk. It (the argument) is dressed up because luke purports to be an aeromedical surgeon.

i say “never will be” since who is going to bother researching the outcomes in pilots? As for the general community, you would expect such studies in comparison with other available treatments.

His argument is specious because what matters is the risk associated with poor Clinton’s conditions compared to all the other risks of sudden incapacitation. A bad meal being top of the list.

But all that is irrelevant because there is no guarantee that Avmed will change its view in twelve months. if avmed were to state that a full certificate would be granted at the end of a year of good health , that would be different and perhaps justifiable.
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Old 9th Dec 2018, 20:26
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You refute things I haven’t said, and spin things, nowluke. A bit like Avmed.
Brandishing your supporting narrative and and then claiming that it 'proves' you're cured and thus now at baseline risk
”Brandishing”? That seems a rather emotive word to describe mere quoting.

I’m merely quoting the words of my specialists and the results of scans. I realise you simply dismiss those opinions and results (unless they are against my interests) because they’re from mere specialists, but all I have to rely on is their opinions and expertise.

And I haven’t said, anywhere, that this “proves” I’m “cured” and now at baseline risk. What I’ve pointed out is, among other things, the incongruity of my being allowed to continue to drive and pilots who self-certify being allowed to share the sky with RPT jets, and the patently biased approach to dealing with doubt. And who makes money out of that approach?
It is churlish to suggest you have not undergone surgery in the broader sense, an endovascular procedure is of the same nature as keyhole surgery or imaging guided interventions.
”Churlish” is another strange word to describe merely responding to andrewr’s implied statement that I had undone surgery involving the blood supply to the brain, when that is simply not true.

And you know that. Your response implicitly acknowledges it: “Surgery in the broader sense”. “Of the same nature”. Once again, selective specificity.

I realise it’s in Avmed’s interests to allow or encourage people to believe I’ve undergone “brain surgery”, but that’s not being objective.

Last edited by Clinton McKenzie; 9th Dec 2018 at 21:30.
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Old 9th Dec 2018, 21:51
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Originally Posted by Clinton McKenzie View Post
andrewr’s implied statement that I had undone surgery involving the blood supply to the brain, when that is simply not true.
I get the feeling that is the statement of a lawyer trying to find a loophole, rather than what doctors would view as involving the blood supply to the brain. You said it was the cranial blood supply, which in my understanding is the blood supply to (parts of) the brain. Are the vessels on the inside or outside of your skull? I don't think there are many major vessels inside the skull that are not somehow involved in blood supply to the brain. And just because it wasn't IN the brain doesn't mean it wasn't blood supply TO the brain.

You said the potential outcome if it was untreated could have been severe. How is that the case if it did not involve the blood supply to the brain? The severity of possible future complications probably correlates with the severity of outcomes if it was untreated, or complications during the surgery. The main question would seem to be the probability.
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