Medical reform and type 1 diabetes

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onwards

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onwards
As someone who has been going through the intricate annual special issuance medical process for a number of years now, I am very interested in this topic.

But I can't find an answer. Since insulin dependent diabetes is pretty much the number one "you don't fly" condition that requires special issuance... Is it reasonable to expect that it will be part of the reform?

Oh, how I would love some relief from the current process!
 
Well, you know it's not one of the listed conditions. So in theory, you should be able to fly under the exemption if you can get a doctor to sign you off. "As presently treated..."

In practice, of course, we'll have to see what the final rules look like.
 
onwards said:
As someone who has been going through the intricate annual special issuance medical process for a number of years now, I am very interested in this topic.

But I can't find an answer. Since insulin dependent diabetes is pretty much the number one "you don't fly" condition that requires special issuance... Is it reasonable to expect that it will be part of the reform?

Oh, how I would love some relief from the current process!
Click to expand...
I didn't know that you could get a SI for Type 1. Is it based on a certain history of A1Cs? What type of requirements are there, CGM etc.?
 
Cooter143 said:
I didn't know that you could get a SI for Type 1. Is it based on a certain history of A1Cs? What type of requirements are there, CGM etc.?
Click to expand...

It's one of the few special issuance conditions that you can only get a third class for, but there is a protocol for getting an SI for insulin-dependent diabetes (Type 1 or Type 2). Yes, it is based on A1C values, among other things, and there is a required exam every three months and a rather detailed set of things you need to do for every flight:

https://www.faa.gov/about/office_or...guide/dec_cons/disease_prot/diabetes_insulin/

My read of the statute is that, as long as you meet all of the requirements to qualify under the exemption (medical sometime since 2006, not revoked, have a driver's license, medical exam and sign-off, etc.), there are no special requirements that a Type 1 diabetic needs to satisfy.
 
Yes, you can (obviously, I'm testament to that).

It's a royal PITA though, so while I'm not complaining - I get to fly! - making it a bit simpler would be very welcome, especially considering my diabetes has been rock stable for decades.
 
STOP!!!
BEFORE YOU START!!!

Talk to Dr. Bruce, who is on this forum, offline. He will make sure that you can pass the requirements before you get started, and things get worse (from a getting your Class 3 perspective)

If you really want to fly, don't go in to the "Hotel California" of the FAA until you talk to Dr. Bruce. You can still do Sport Pilot without the Class 3. You can also transfer to PPL from SP.

Once you start the Class 3 Medical process, you will either be issued a Class 3, or be denied a Class 3 medical. It's one or the other.
If you are denied, you are out of the new rules per Section 2307, a.4
In General.—Not later than 180 days after the date of enactment of this Act, the Administrator of the Federal Aviation Administration shall issue or revise regulations to ensure that an individual may operate as pilot in command of a covered aircraft if
(4) the most recent application for airman medical certification submitted to the Federal Aviation Administration by the individual cannot have been completed and denied;
See https://www.congress.gov/bill/114th-congress/house-bill/636/text
​
The exact requirements are found at:
http://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/media/guide.pdf Page 229
Also search in there for any other conditions you may have (Sleep Apnea, Blood pressure, high cholesterol, whatever...)

A little about me:
I am a T1D for 44 years, and I started the "You have to get a medical" path that my local flight school told me. "Go to Dr. xxxxx and he'll get you set up". What they should have told me is, "If you're a Type 1 Diabetic, read up on what you need, talk to an AME that has gotten these done, and DO NOT PUT ANYTHING IN MEDXPRESS until you are ready to pass."
 
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As a T1D having had a 3rd class medical since August of 1997. I can say that Jeffythequick is absolutely right.
To be clear;
If you do not want to be restricted to SP types of aircraft and you have never had a medical before you will need to get a 3rd class medical certificate at least once. You do not want to fail this medical. If you do however it will be for some reason that the FAA medical branch specifies. And then you will have to work through that issue. I have had my 3rd class denied any number of times due to some unexpected issue where they wanted another exam. For example my eye specialist at one time wrote in his report that I was suspect for Glaucoma even though later eye docs said that I am no more suspect for Glaucoma than the rest of the population. That generated a form being sent to me by the FAA that I then had to have an ophthalmologist examine my eyes to determine I do not have Glaucoma. That has now continued every year since. Trying to get my yearly diabetic eye exam and all of the other things that FAA wants my eyes to be checked for in one visit to the "Eye Specialist" FAA's terminology is difficult. But it can be worked through. Mostly no matter how much I try to get the Eye clinic to be prepared for what my requirements will be during my visit they are never quite prepared to provide all of the exams in one visit. I have tried multiple clinics and currently have a Dr. who is prepared to work with me.
Jim
 
Definitely hire dr Bruce while he's still willing to offer his services if you are embarking on this path.

It's a different question for me though: clearly, I have successfully obtained a class 3 for a number of years in a row. I will continue to do so, but if the process can be made simpler and just focus on what actually matters medically - as this bill seems designed to do - then I'm all for it. For example, if my diabetes is rock solid stable, it seems silly to have the FAA special issuance division have to waste resources and time on validating that every year. My endo is probably even more conservative than they are, and if she thinks nothing has changed, she should be able to assert so.
 
onwards said:
Definitely hire dr Bruce while he's still willing to offer his services if you are embarking on this path.

It's a different question for me though: clearly, I have successfully obtained a class 3 for a number of years in a row. I will continue to do so, but if the process can be made simpler and just focus on what actually matters medically - as this bill seems designed to do - then I'm all for it. For example, if my diabetes is rock solid stable, it seems silly to have the FAA special issuance division have to waste resources and time on validating that every year. My endo is probably even more conservative than they are, and if she thinks nothing has changed, she should be able to assert so.
Click to expand...
I know what you mean... Having to have the same rules for a Commercial Drivers License for an airplane is a bit much. The T1D rules are appropriate for a Class 2 or 1, but for a Class 3, IMO, too much. And this is from a diabetic that is in good control. There is also some logical issues with the requirements. Someone that has just gone on insulin has to wait 6 months, and the rule for the "assisted hypoglycemic events" applies only to those that have been on insulin longer than 6 months, mainly because those T2D that go on insulin aren't going on it because their blood sugar is too low, but because it's too high.
My favorite rule on that is the "if you're low, eat something, and carry on, but if you're too high, STOP EVERYTHING! LAND! LAND! LAND! CANCEL FLIGHT!" (The odds are that you'll have to go to the bathroom anyways if you're over 300 mg/dl).
Other things are the little non-sequitur at the end: "Insulin Pumps are acceptable" No where in the preceding protocol does it even mention insulin delivery methods, but there you go... if you're on a pump, that won't block you from flying.

Things I wish the protocol had:
  1. Protocol for flying with a Continuous Glucose Monitor (CGM). Things like "if you are at 80 mg/dl, and your blood sugar is steady or increasing, proceed" and "if you're at 300, and the blood sugar is coming down, monitor every 5 minutes, and react appropriately."
  2. Protocol for having blood sugar lower than 100 mg/dl as your "normal". Muggles (non-diabetic folk) typically have blood sugar from 70-80, and if their fasting is above 100 mg/dl, then they're "pre-diabetic" Well, if we're in control, and can manage blood sugar to the non-diabetic levels, why not?
  3. Well, since I can only get glucose tablets in 4g increments, why not have the "if you're low, or can't measure within an hour, take 3 glucose pills" (a minor point)
  4. Having your endocrinologist look at the "in flight" part of the protocol and talk with you on those requirements, and make adjustments, as necessary, or better yet, have you make a protocol, and see if s/he agrees to it. Something like,
    "Prior to flight, ensure blood sugar is >= 80mg/dl using a blood checker. Ensure that CGM is calibrated to the current blood sugar reading. Ensure that blood sugar is not rising or falling without explanation. Do not fly within 1 hour of eating or exercising, unless your blood sugar is stable. In flight, carry enough supplies for twice the anticipated flight length. Ensure that you have at least 20 glucose tablets readily available. If your blood sugar rises or drops without explanation, land at the nearest airport, and correct the situation (i.e. Infusion set has come out, too much excitement in flight). Check CGM every 15 minutes in flight. Fly safely."
As for the bill, I'd rather keep my health between me and my doctor. It's interesting how the protocols have come about, and they look general in nature.

And yes, it is possible to do more damage with an 80,000 lb truck at 80mph than it is with a 3500 lb aircraft at 250 KIAS.
 
Jeffythequick said:
The T1D rules are appropriate for a Class 2 or 1, but for a Class 3, IMO, too much.
Click to expand...

No kidding. I mean, I am grateful that I get to fly, but the amount fo validation I have to go through is almost like an ATP... at least let me get a class 2 if you're gonna make me do that :)

Jeffythequick said:
My favorite rule on that is the "if you're low, eat something, and carry on, but if you're too high, STOP EVERYTHING! LAND! LAND! LAND! CANCEL FLIGHT!"
Click to expand...

Yeah, no kidding again. That is the one I have always considered the stupidest as well. It makes zero sense in the T1 world.

Jeffythequick said:
"Insulin Pumps are acceptable"
Click to expand...

I use a pump and a CGM (the Medtronic 530G/Enlite). I stated that in every annual class-3 medical application since I started using it, and also stated that I use that instead of pricking my finger every thirty minutes or hour. They asked me to explain it, and have since accepted that every time, so it seems like there is some sort of internal understanding of the advantages of using a CGM/Pump over the normal protocol.
 
onwards said:
No kidding. I mean, I am grateful that I get to fly, but the amount fo validation I have to go through is almost like an ATP... at least let me get a class 2 if you're gonna make me do that :)



Yeah, no kidding again. That is the one I have always considered the stupidest as well. It makes zero sense in the T1 world.



I use a pump and a CGM (the Medtronic 530G/Enlite). I stated that in every annual class-3 medical application since I started using it, and also stated that I use that instead of pricking my finger every thirty minutes or hour. They asked me to explain it, and have since accepted that every time, so it seems like there is some sort of internal understanding of the advantages of using a CGM/Pump over the normal protocol.
Click to expand...
It'll be interesting to see what the update is in 2045 (yes, that's sarcasm...) to the announcement yesterday by Minimed...
http://www.cbsnews.com/news/fda-app...creas-type-1-diabetes-medtronic-minimed-670g/

I'm an Animas/Dexcom guy, especially after trying out Minimed's harpoon CGM in 2008-9.
I'm in the pump market now, and may consider this, but Dexcom and Tandem may have an answer back to this announcement with the Tandem X2.
 
For medicals, I would not expect the standard to change much. My expectation is that the FAA will instruct doctors on how to judge things. You won't suddenly get released from a disqualifying condition just because you don't have to go to a AME anymore. Anything that is disqualifying today will still be disqualifying.

The major difference we're getting is that you'll have to talk with your doctor about when you're fit to overcome the condition rather than Oklahoma City. Essentially, your doctor will issue your "SI" although we won't call it that.
 
bflynn said:
For medicals, I would not expect the standard to change much. My expectation is that the FAA will instruct doctors on how to judge things. You won't suddenly get released from a disqualifying condition just because you don't have to go to a AME anymore. Anything that is disqualifying today will still be disqualifying.

The major difference we're getting is that you'll have to talk with your doctor about when you're fit to overcome the condition rather than Oklahoma City. Essentially, your doctor will issue your "SI" although we won't call it that.
Click to expand...

Depending how it goes, it may be a good thing for younger pilots who had informal diagnoses of ADD. We still have to wait to see how the FAA will view that when they write the final rules.
 
midcap said:
Depending how it goes, it may be a good thing for younger pilots who had informal diagnoses of ADD. We still have to wait to see how the FAA will view that when they write the final rules.
Click to expand...
Doubtful this would change anything for them PERIOD. While you might skate with an adult-onset condition you got after your first medical, these kids likely never were eligible for a medical to begin with and hence will not have one now. Congress hasn't left the FAA leeway to give them a pass yet.
 
flyingron said:
Doubtful this would change anything for them PERIOD. While you might skate with an adult-onset condition you got after your first medical, these kids likely never were eligible for a medical to begin with and hence will not have one now. Congress hasn't left the FAA leeway to give them a pass yet.
Click to expand...

you are probably right. as it stands, it's not complicated but it's not cheap to get through the 3rd class for it.
 
Here it is in the FAR (14 CFR):
§67.113 General medical condition.
The general medical standards for a first-class airman medical certificate are:

(a) No established medical history or clinical diagnosis of diabetes mellitus that requires insulin or any other hypoglycemic drug for control.

§67.213 General medical condition.
The general medical standards for a second-class airman medical certificate are:

(a) No established medical history or clinical diagnosis of diabetes mellitus that requires insulin or any other hypoglycemic drug for control.

§67.313 General medical condition.
The general medical standards for a third-class airman medical certificate are:

(a) No established medical history or clinical diagnosis of diabetes mellitus that requires insulin or any other hypoglycemic drug for control.

That leaves it to the SI process...

§67.315 Discretionary issuance.
A person who does not meet the provisions of §§67.303 through 67.313 may apply for the discretionary issuance of a certificate under §67.401.

The same thing applies for 67.213 and 113 (Second and First Class).
 
This is fun...

From here (2015 study from the ADA):
http://pilotswithdiabetes.com/pdf/final_recommendations_package_pilots.pdf

Page 6:
The panel also considered the data from Canada’s experience certifying pilots with insulin treated diabetes to fly since 1992 as well as the data from the United States allowing pilots to fly with third class medical certification, including solo operations, since 1996. The twenty years of data from these two countries indicate that there has never been a diabetes- related accident or incident involving a pilot with insulin treated diabetes who has been granted certification to fly while using insulin. ​
 
Jeffythequick said:
This is fun...

From here (2015 study from the ADA):
http://pilotswithdiabetes.com/pdf/final_recommendations_package_pilots.pdf

Page 6:
The panel also considered the data from Canada’s experience certifying pilots with insulin treated diabetes to fly since 1992 as well as the data from the United States allowing pilots to fly with third class medical certification, including solo operations, since 1996. The twenty years of data from these two countries indicate that there has never been a diabetes- related accident or incident involving a pilot with insulin treated diabetes who has been granted certification to fly while using insulin. ​
Click to expand...
Not quite true. there was a Cape Air flight in which the Captain was incapacitated and the FO landed safely. 400 series Cessna. No, I don't have the cite. But I remember it pretty well.

I am working with another guy who the FAA thinks surreptitiously uses insulin and he passed out twice (part 121 F.O).
 
bbchien said:
Not quite true. there was a Cape Air flight in which the Captain was incapacitated and the FO landed safely. 400 series Cessna. No, I don't have the cite. But I remember it pretty well.

I am working with another guy who the FAA thinks surreptitiously uses insulin and he passed out twice (part 121 F.O).
Click to expand...
I trust you on this... You'd think that if you're taking insulin in secret, you'd take better care of yourself in the cockpit. (like run with higher blood sugar, and test in the lavatory before the flight)

However, the better tools that are available are prescribed by a doctor, like Continuous Glucose Monitors, Insulin Pumps, Lantus (I do miss UltraLente... same curve for me, and it mixes with other insulin - Lantus doesn't), so when someone hides their diabetes, they're keeping themselves from better management tools available. Looking at my Apple Watch for my blood sugar and popping some Skittles is a lot less conspicuous than puncturing my finger, bleeding onto a test strip, and flying an airplane.

To go the lawyer route, the stipulation was "granted certification to fly while using insulin." If they're hiding it, then there are other issues, like 'lying to the FAA' involved.

I did find something that you mentioned (For those following along, in 2002, CGM's weren't available to the public)...
http://www.straightdope.com/columns...ded-a-plane-after-the-pilot-was-incapacitated
In February 2002 a woman with just 48 hours of pilot training took the controls of a twin-engine Cessna over Cape Cod after the pilot became incoherent following an insulin reaction. Unable to reach anyone on the ground, she was able to safely crash-land the plane on the ground next to the runway, saving everyone aboard.​
I checked the NTSB database and couldn't find anything with 'Cape Air' in the full text search that had the Captain incapacitated. All of the Cape Air ones were weather or turkey buzzard related. I'll continue when I get home. Doing this on break is a bit rushed... The Straight Dope one I couldn't find either in NTSB, so it's probably my hurried search...
 
OK, here are some I found from NTSB:
ERA11FA258 - Pilot didn't report IDDM and probably had low blood sugar
http://ntsb.gov/_layouts/ntsb.aviat...-8294-4150-a8b0-55da42393a80&pgno=2&pgsize=50 - Pilot had low blood sugar and landed after damaging landing gear and pretty much wrecking the airplane

After reviewing about 30 of the 45 or so records with the word 'insulin' in them, I came up with one thing:
There is a lot of lying going on with diabetics and flying.
 
Jeffythequick said:
There is a lot of lying going on with diabetics and flying.
Click to expand...

I think that's part of the problem with a lot of SIs in general. Pilots lying to FAA or to themselves, or both. "I probably have xyz, but if I don't get a diagnosis then I don't have to report it" and "I know I have xyz, but I'll take my chances and not get a diagnosis or medication because then I have to report it". Those attitudes end up forcing FAA's hand and that can end up hurting the pilots that say. "I know I have xyz, I have a diagnosis, I know I have done abc to keep it controlled, and I reported it."

There are some conditions that affect judgement and in those cases there is enough reason to not trust the pilot's self assessment. That's a line that FAA, and understandably so, wants to stay clear of. It's interesting when I explain to non-pilots the medical requirements that even a weekend warrior has to meet.
 
Hey everyone,

I'm a new student pilot training for my PPL and I have had well controlled type 1 diabetes for 30 years. The FAA has issued a list of what I call "disqualifiers" for type 1 diabetics to receive their initial medical certificate (click here), which are (1) no recurrent history of severe hypoglycemia in the last 5 years, (2) no clinically significant eye disease, (3) two most recent A1c's, and, (4) ECG and cardiac stress test (for anyone >40 yrs of age). My physicians in Boston (Joslin Diabetes Center) have written letters for me confirming that (1) I have no history of severe hypoglycemia, (2) I do not have clinically significant eye disease (20/20 in right and 20/12.5 in left and healthy), and, (3) my last two A1c's are 6.6% and 6.3% (I wear a CGM and historically my A1c's have been between 6-7%). I have a cardiac stress test scheduled in a couple of weeks, which I should pass with no issues (still in good shape and healthy). Even with my solid history, I'm still a little nervous about my medical exam. If I meet all of the medical requirements listed by the FAA for Type 1 Diabetics, is there still a chance that the AME could deny me? I just want to make sure that I have all of my ducks in a row before scheduling my exam. I can't imagine not being allowed to fly. Thanks for any advice or tips.

Ryan
 
I'm a new student pilot training for my PPL and I have had well controlled type 1 diabetes for 30 years. The FAA has issued a list of what I call "disqualifiers" for type 1 diabetics to receive their initial medical certificate, which are (1) no recurrent history of severe hypoglycemia in the last 5 years, (2) no clinically significant eye disease, (3) two most recent A1c's, and, (4) ECG and cardiac stress test (for anyone >40 yrs of age). My physicians in Boston (Joslin Diabetes Center) have written letters for me confirming that (1) I have no history of severe hypoglycemia, (2) I do not have clinically significant eye disease (20/20 in right and 20/12.5 in left and healthy), and, (3) my last two A1c's are 6.6% and 6.3% (I wear a CGM and historically my A1c's have been between 6-7%). I have a cardiac stress test scheduled in a couple of weeks, which I should pass with no issues (still in good shape and healthy). Even with my solid history, I'm still a little nervous about my medical exam. If I meet all of the medical requirements listed by the FAA for Type 1 Diabetics, is there still a chance that the AME could deny me? I just want to make sure that I have all of my ducks in a row before scheduling my exam. I can't imagine not being allowed to fly. Thanks for any advice or tips.
 
@FlyingBliss - don't post here.

Go to http://www.aeromedicaldoc.com/ and consult with Dr Bruce.

The experience of others indicates that both the FORM and CONTENT of the letters from your healthcare providers can impact the outcome of your medical issuance.

He'll help you get it done as painlessly as possible.
 
Ravioli said:
@FlyingBliss - don't post here.

Go to http://www.aeromedicaldoc.com/ and consult with Dr Bruce.

The experience of others indicates that both the FORM and CONTENT of the letters from your healthcare providers can impact the outcome of your medical issuance.

He'll help you get it done as painlessly as possible.
Click to expand...

Thanks Rav. I just emailed Dr. Bruce. Hopefully he can help me work through this process expeditiously. Have a great day!
 
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