A Perfect World for Pilots
Joseph I. Sirven, M.D.
"A pilot lives in a world of perfection or not at all"
Richard S. Drury,
My Secret War
"You’ll be bothered from time to time by storms, fog, snow. When you are, think of those who went through it before you and say to yourself, what they could do, I can do."
Antoine de Saint-Exupéry,
Wind, Sand and Stars, 1939
Happy April to the readers and viewers of Epilepsy.com! As we begin this month, much is ongoing in the world of public policy relevant to the issue of epilepsy. From March 29th through March 31, 2010, the Federal Aviation Administration (FAA) convened a neurological and neurosurgical summit conference to address policies regarding traumatic brain injury, cerebrovascular disease, migraine headaches and seizures and epilepsy as it relates to pilot licensure in the United States (US). The object of this meeting was to determine whether the current policies governing pilots should be revised or updated to reflect the best evidence from current ongoing understanding and knowledge of these conditions.
Currently, the policy set forth by the FAA for a pilot’s license states that an applicant with a diagnosis of epilepsy must be seizure free for 10 years and off medication for at least 3 years before consideration can be given for an Airman Medical Certificate. After a 10-year seizure-free period and 3-year medication free period, a full neurological evaluation and a normal EEG is required for consideration for licensure.
There are a number of regulations regarding a single seizure and licensure. If an individual has had a single event and it was a documented febrile seizure between the ages of 3 months and 5 years, no further evaluation is required. If a single seizure is determined to be secondary to a known pathological condition and the cause has been corrected, an applicant may be considered for an Airman Medical Certificate with as little as a 1-year recovery. A neurological evaluation will be needed prior to the issuance of a medical certificate, but no follow-up is required. If a single seizure was unprovoked and there is no satisfactory medical explanation of the cause, the required seizure and medication free period is 4 years. At the end of the 4-years, the applicant must provide a current complete neurological evaluation to include a current EEG. CT or MRI scans of the brain may also be required. Tonic-clonic type activity that occurs during an episode of fainting or syncope but is not a seizure does not require additional neurological evaluation. The same applies to similar activity experienced with gravity-induced loss of consciousness.
In light of recent diagnostic and therapeutic improvements for epilepsy, a number of policy questions arise. Is the current 10-year seizure free and 4-year medication free policy appropriate? Is the current 4 year seizure free without medication policy appropriate for patients who have had single seizures but no epilepsy risk factors including no family history of febrile seizures? For acute symptomatic events? How should guidelines be set for a patient with an abnormal EEG but without clinical seizures or what should the policy be following successful epilepsy surgery?
These are the questions that experts, whether they are clinicians or legislators, must address in order to make logical and rational decisions for individuals who are in jobs that involve public safety. One of the hopes of epilepsy.com is to always find ways to help improve the quality of life of patients. But what happens if improving the quality of life for an individual patient has implications for public safety, an issue that often arises in the field of transportation or health. The role of the physician and other healthcare professionals is to help decide what is the healthy and reasonable balance point between allowing someone to have the best quality of life that they can have, whether it means flying or driving versus balancing the risks to the public for that individual to have that quality of life. This is a complex issue and one that does not always have a clear and obvious answer. It is only through sound reasoning yet heartfelt exploration of the issue and making tough calls that any appropriate decision can be made. Personally, I applaud the FAA for reviewing and potentially revising policies that emerge from such a summit. However, not everyone will be happy with the conclusions that have been reached. As both quotes at the beginning of this column illustrate, the public demands a perfect safety record from pilots and there is very little room for error. In essence, pilots must live in a perfect world.
We hope that you enjoy the content that is provided during the month of April on epilepsy.com. We are excited with the 2 Hallway Conversations that are planned for this month. On April 7th, Dr. Ruth Ottman from the Columbia University Comprehensive Epilepsy Center will join us to discuss common comorbidities of epilepsy. This is work that she is presenting at the upcoming American Academy of Neurology Meeting in Toronto, Canada, and we look forward to hearing more. On April 21, we look to the future with Dr. Ruben Kuzniecky from the New York University Comprehensive Epilepsy Center. He will sit down and discusses in Spanish the latest upcoming clinical trials and potential forthcoming therapies and approaches to the management of epilepsy. We hope that regardless of whether you speak English, Spanish or any other language that you find this material on the Hallway Conversations or any part of epilepsy.com useful for you and your patients and we hope that at the end we are able to help improve the quality of life of all of our patients who have epilepsy.
Joseph Sirven, M.D.
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