Aeromedical Deliberations in the Germanwings Tragedy

Germanwings crash 4U 9525

Germanwings crash 4U 9525

The Germanwings tragedy this week brought to the forefront the mental health assessment for commercial airmen.  There are reports that the copilot had another serious health issue with his vision.   I would like to raise the possibility that there is a connection between the suicide, mental health issues, change in vision, and perhaps a brain tumor that was not detected.

Flight surgeons and aviation authorities will seek to avert another tragedy if airmen with serious mental health issues continue to fly.   My expertise as a senior aviation medical examiner over the last 27 years with thousands of commercial airmen gives me some perspective on the screening process in the United States. I have also attended European aviation conferences some of which were sponsored by the Lufthansa aeromedical service.

Commercial airline pilots have both physical and mental examination to maintain their medical certification every six months after the age of forty and younger airmen are examined every year.

The basic examination is straightforward. The pilot completes an online medical application containing a detailed health questionnaire that includes medications, doctors’ visits, and arrests or legal infractions. The airmen are also expected to self-report if there any mental health issues by answering if they have had any visits with psychologist or psychiatrist we’re taking any medication.  These questions are answered every six months and are often one of the tripwires to detecting a pilot with alcohol or drug problems. Airmen are required by law to answer truthfully. There is an exchange between the FAA database and government registries for serious driving offenses such as DWI and DUI infractions.

The physical examination is comprehensive particularly involving vision.  There is a urine analysis but it is not a toxicology screen or drug screen.  The FAA monitors the online questionnaire and the medical examination so that all medical certifications are confirmed by their medical staff in both the federal medical division in Oklahoma City and by the regional flight surgeons.

My ability to detect emotional or psychological instability is fundamentally based in detecting any aberration in their well-being. Many airmen come twice a year, often for the duration of their professional career. While there is no specific mental status examination that is a routine part of the examination, I do engage the pilot in conversation asking their schedule and days off. I look for eye contact, facial expressions, and in particular, the facial muscles will reveal their state of mind. Simple questions such as when they last flew and their next trip gives me some indication of stress or fatigue.  I like to ask about family, kids, and vacations.  Sometimes this leads to news of divorce or an illness in the family. Sometimes I find out through there are financial problems or a need to relocate.

At times airmen are based in another city from where they live. This requires them to commute to an airport far from home. This situation contributed to the Colgan Air Flight 3407 in February 2009 in Buffalo, NY. The extra travel can make their workday extremely long and stressful. New duty rules adopted after the Colgan Air mishap addressed some of these concerns but airmen are often have non-restorative sleep by traveling through many time zones without proper acclimation.  Commercial airline pilots may be away from home for several days at a time while some airmen flying a corporate jet maybe away for 2 to 3 weeks.

I am intrigued by the constellation of symptoms of altered personality, depression, and some vision disturbance that may affect his ability to continue as a professional pilot.  Why would a commercial airline pilot intentionally committed suicide and murdered 149 other souls. Is there a common medical causation to explain these findings?  We should have a high index of suspicion when there is a new illness and subtle neurologic changes are currently in an individual who was otherwise asymptomatic.

There are three health issues currently being mentioned in the news: mental illness, personality disorder, and vision difficulty.  Each of them occurs sporadically in the general population. However some conditions are more likely in his mid-20s age group. One of the most common conditions is the onset of schizophrenia. While there may have been significant mental health issues previously, we don’t have enough detail to know if he fits the criteria for new onset schizophrenia. However the manifestations of schizophrenia include auditory or visual hallucinations. Features of paranoia are also well-known.

The personality disorder has features which may correspond to the disrupted social relations that a young adult would experience at the onset of schizophrenia. It is difficult to maintain personal relationships and there is often an element of paranoia or a tendency to distrust a close friend or family.  Hence reports in the media of his girlfriends’ ending relationships.

The incidence of mood disorders is also compatible with news reports and are a common mental health issue in this age group. Frequently this takes the form of an anxiety or panic disorder. They may self-medicate either self-medicate with alcohol or through a prescription that is not revealed to authorities such anxiolytic drugs such as Xanax or Valium.

A severe form of a mood disorder may be major depression. This condition likely to affect somebody attempting suicide.  These individuals typically have dysfunctional social interactions and would have a great deal of difficulty maintaining an uninterrupted work schedule.

News reports indicate that he appeared physically healthy. He also had an eye disorder.  If he was to self-report visual disturbances, the most common would be blurred vision, double vision, or loss of peripheral vision. Proper examination by a medical doctor or ophthalmologist could reveal the disorder. Some reports have said that he had a problem with his lens. This condition may have been floppy lens has been associated with Marfan’s syndrome. This condition has been associated rarely with familial mental disorders such as schizophrenia and personality disorders.

If we consider structural abnormalities of the brain or organic brain lesions we should consider the ideology as emanating from cerebrovascular injuries, demyelinating conditions, inflammatory, infectious, or miscellaneous causes.

My synthesis of the mental and psychiatric conditions brings me to consider an underlying brain lesion. In clinical practice, any patient presenting with new psychiatric illness over the age of 40 would merit referral for brain imaging such as an MRI. This would include older individuals at risk for Alzheimer’s. However in this case of a young adult, we are considering a neurologically silent organic brain lesion manifesting it’s presence with mental illness.

There are a number of common features to organic brain lesions occurring in a specific part of the brain. Lesions of the temporal lobe commonly cause depression. Temporolimbic lesions may present as auditory and visual hallucinations, panic or anxiety disorders.

So in reviewing the preliminary reports about the airman fitness to fly, I find the symptoms and history to be intriguing.  Was there a common denominator to his illness?  Can we learn from this tragedy?

We are all asking ourselves why a doctor would write a note to keep him from flying but not notify the airline or authorities.  Is it reasonable to expect a pilot to self-report his mental problem to his employer?  Did the doctor not know that the copilot was still continuing to fly after the previous warnings and notes went unheeded and unused?  Why wasn’t there a holistic approach to this pilot’s wellbeing that might bring together other health issues such as his vision disturbance and personality changes?

The accident investigation is also a criminal investigation now. For the flight surgeons and aviation medical examiners, we should pay very close attention.



I have enjoyed scuba diving for many years. As a physician, I am fascinated with the physiology of barometric pressure and offloading gases within the body.  I did advanced hyperbaric training through Divers Alert Network and through New York Medical College where I am a Clinical Assistant Professor of Medicine.

Decompression sickness is the medical condition arising from dissolved gases coming out of the bloodstream and producing bubbles within the body. This condition is also known as the Bends.

These bubbles can migrate within the body and cause joint pain, paralysis and even death. The most common symptom is local joint pain. Pain in the arms is twice as frequent as pain in the legs. Almost all of the decompression sickness occurs within the first eight hours.

There are various forms of decompression sickness including arterial gas embolism and barotrauma. Some of the most severe conditions arise when air bubbles form in the central nervous system, spinal cord, or brain.  There are so many manifestations of decompression sickness that almost any symptoms occurring after diving could be explained as a consequence.

We typically think of decompression sickness is occurring in scuba divers. However, this also occurs to astronauts when they perform a spacewalk and the pressure in the spacesuit is lower than the pressure in the spacecraft.

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Obstructive Sleep Apnea (OSA) – Pilot – FAA Medical Exam


Pilots are concerned about a new medical standard for Obstructive Sleep Apnea (OSA) by the Obstructive Sleep Apnea (OSA). The concern is that pilots with a serious weight problem will be adversely affected in their recertification. I would like to present my perspective as a senior AME. My thoughts are my own and not necessarily shared by the powers that be.

Obstructive sleep apnea may cause functional impairment for safe aircraft operations. OSA literally means that someone stops breathing during sleep or effectively loses the ability to oxygenate the blood stream. This is because the upper airway is partially or completely blocked during sleep. Therefore the chest muscles and diaphragm must work much harder to open the airway and maintain respiration.

Sometimes a spouse or significant other will notice that during sleep an individual has difficulty maintaining normal respiration or, in fact, there are long pauses between breaths. Patient will come to the office with this clear witnessed account of sleep apnea and we request that a sleep study be done.  This involves going to a sleep lab and spending the night while being monitored.

However doctors also should be looking for symptoms of daytime sleepiness, excessive fatigue, non-restorative sleep, difficulty concentrating, forgetfulness, snoring, and inability to stay awake during common activities during the day.

Overwhelmingly the patients at risk for this are not aware of the condition. Therefore, prospective screening is the best way to diagnose and manage patients with OSA.  There are estimated to be more than 12 million people in the United States at this time with sleep apnea. More than half of those individuals are overweight. It tends to occur in middle-age man and older woman.  The risk factors for obstructive sleep apnea include obesity, thick or large next, and smokers.

The FAA’s concerned that OSHA will result in impaired pilot performance. The FAA has published the Guidelines indicating that mild to moderate obstructive sleep apnea can show performance degradation equivalent to 0.06 to  0.08% blood alcohol levels which is the measure of legal intoxication in most states.  There’s also the increasing risk of hypertension and atherosclerosis with the resulting increasing the risk of heart attack and stroke.  In fact 30 to 50% of patients with heart disease and 60% of patients suffering strokes are found to have obstructive sleep apnea.

The FAA medical guidelines indicate that OSA is present in almost all obese individuals with a body mass index over 40 and the next circumference greater than 17 inches.  Untreated obstructive sleep apnea is a disqualifying condition for airmen and air traffic control specialists.

The next steps in the process will be for the pilot to have a BMI and neck circumference measured during the medical examination. Those airman with high BMI above 40 and neck circumference greater than 17 will be asked to undergo specialized evaluation by a sleep disorder specialist.

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Duration of FAA Pilot medical certificates

Many pilots ask if we could recap the duration for their medical certificates. and the frequency for the EKG for the first class airmen.

  1. First Class Medical Certificate: A first class medical certificate is valid for the remainder of the month of issue; plus

o    6 calendar months for operations requiring a first class medical certificate if the airman is age 40 or over on or before the date of the examination, or

o    12-calendar months for operations requiring a first-class medical certificate if the airman has not reached age 40 on or before the date of examination, or

o    12 calendar months for operations requiring a second class medical certificate, or

o    24 calendar months for operations requiring a third class medical certificate if the airman is age 40 or over on or before the date of the examination, or

o    60 calendar months for operations requiring a third class medical certificate if the airman has not reached age 40 on or before the date of examination. *

EKG is first done on the first medical exam after the airman’s 35th birthday.

The next EKG is done on the first medical exam after the airman’s 40th birthday.

After that one EKG is done every 12 months.

Please note that having the EKG in proper sequence with the medical is vital to maintaining the first class certificate.

After 12 months, an airman who does not have a current EKG will lose the first class certificate as it reverts to a Second class automatically.

    2. Second Class Medical Certificate: A second class medical certificate is valid for the remainder of the month of issue; plus

o    12 calendar months for operations requiring a second class medical certificate, or

o    24 calendar months for operations requiring a third class medical certificate, if the airman is age 40 or over on or before the date of the examination, or

o    60 calendar months for operations requiring a third class medical certificate if the airman has not reached age 40 on or before the date of examination. *

     3. Third Class Medical Certificate: A third-class medical certificate is valid for the remainder of the month of issue; plus

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6th Annual International Aviation Medical Examiner Seminar – presenting cutting Edge Technology

Cool gadgets in Aviation! Check out the latest: X2 Biosystem (TBA) and Heart Rate & Pulse Oximeter Monitor – Cutting Edge Technology.

Once every 2 years, the FAA sponsors a medical education program in Europe for Senior Aviation Medical Examiners.  It is a terrific opportunity to learn directly from the top FAA medical leadership.  This year traveling to Munich from Oklahoma City and the FAA medical headquarters were 3 senior staff.  We learned about the new EKG transmission standards, CACI and special issuance rules, and discussed the future of aviation medicine with our colleagues from all parts of the world.

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Lasik Correction for Pilot



From: Raymond Basri <xxxxxxxxxxxxxxxxx >
Date: June 24, 2014 11:03:41 AM EDT
To: <xxxxxxxxxxxxxxxxxxx>
Subject: Re:  LASIK

That is very good news indeed. I’m happy you are satisfied with the results. You should bring the report from the eye specialist as well as completing your Medxpress online application listing it as a surgical procedure.

I look forward to seeing you on your next visit and removing your vision restriction from your certificate.


On Jun 24, 2014, at 09:14 AM,  < xxxxxxxxxxxxxxxxxxx > wrote:

Hey Dr. Basri – how’s things?  Hope your summer is off to a good start.

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Coronary Artery Disease and Your Medical Certification



aymond Basri, MD, FACP



236 Crystal Run Rd, Ste. 2

Middletown, NY 10941

June 18, 2014


Coronary Artery Disease and Your Medical Certification

Pilots can have coronary artery disease and not be retired on disability. Here is a case where the pilot regained his Class 1 Medical Certificate exactly 6 months after having a mycardial infarction and coronary artery stent.

The FAA mandates a 6 month medical furlough after any cardiac incident or procedure including coronary artery bypass surgery (CABG). Although the 6 Months is a minimum, many airmen are never returned to duty sometimes becasue they did not seek out the proper medical advice.

In order to return to full duty with the least time off, pilots should work with their Senior AME to plan the testing and reporting needed to satisfy the FAA.

We are experienced with these issues and have successfully returned scores of airmen to work and recreational flying. Here is an example of how we approach the return to duty.

Ray Basri, MD, FACP

Senior Aviation Medical Examiner


Manager,  Aeromedical Certification Division

PO Box 26080

Oklahoma City, OK 73126


Dear Dr. XXXX at FAA,


I performed the cardiovascular exam as per protocol for the first request for Authorization for Special Issuance of a First Class Medical Certificate.

This airman has a history of MI in March 2013 followed by successful PTCA and stenting of the distal circumflex artery on March 28 using a Resolute drug eluting stent. He made an excellent recovery and underwent nuclear exercise stress testing on August 29 with normal exercise capacity (Bruce stage 4, 10 minutes) and normal scans. This airman also had transthoracic echocardiography done on the same date, which showed normal wall motion and LVEF.

Furthermore, after these tests were done and reported as normal, this pilot underwent another cardiac catheterization which showed normal flow through the stent and excellent perfusion to all areas of the myocardium.

I am pleased to report that his health continues to be good, free of cardiovascular symptoms of chest discomfort, shortness of breath, palpitations, dizziness, or side effects from his medications. He is currently taking Lisinopril 5 mg per day, Dexilant 60 mg per day, Crestor 10 mg per day, Plavix 75 mg per day and ASA 81 mg per day. His metoprolol was discontinued after the normal stress test and catherization. He has no side-effects from these medications. He does not use tobacco, family history is negative for CVD, and his weight has come down from 232 to 225 lbs. He runs a couple of miles daily.

This airman has normal blood pressure 120/80 in each arm on 3 separate visits, and physical exam shows:

HEENT- Anicteric, PERLA, EOMI, Fundi nl

Neck- supple, JVD neg , no bruits

Lungs- clear to A & P, well healed midline CABG scar

COR- RSR no murmurs, gallops or rubs, PMI is not displaced

Abd- soft, no organomegaly, no CVAT

Ext- no clubbing cyanosis or edema

Neuro- A & O X 3, Cr Nerves II-XII intact, Motor intact

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Revolutionary Virtual Medical Care via Skype Now

Our practice offers virtual One-on-One medical consultation via Skype now. If you do have any concerns about your health or medical issues, video conference is available prior scheduling your on-site office appointment.

Please use our Online Scheduling System to arrange the consultation or call to the listed numbers in our website.

Before your Consultation please fill out “Patient Forms” or be ready to have answers for these questions regarding with your medical history.



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