US Army Aeromedical Waiver Guide, 1998Dr. Yi-Chang Wu, MD, Phd

US Army Aeromedical Waiver Guide, 1998Dr. Yi-Chang Wu, MD, PhD

US ARMY

AEROMEDICAL POLICY LETTERS

AR 40-501

COMPILED VERSION 98A,Win.95

15 January, 1998

Compiled by

Colonel Richard L. Broyles

*This compiled version of the US Army Aeromedical Policy Letters, Technical Bulletins, AR 40-501, and AR 40-8 has been produced primarily for use in the Flight Surgeons Office. This version completely replaces all previous versions of APLs and ATBs. It was compiled using the help compiler HelpBreeze produced by SolutionSoft. The compiled help file will work on Windows 95 as a 32 bit program.

Please report any errors in the operation of the program or in the actual text to Director, Aeromedical Activity, ATTN: MCXY-AER, Fort Rucker, AL, 36362-5333, DSM 558-7430 pr COMM (334)-255-7430.

2. Authority. The Commander, USAAMC, is authorized to issue aeromedical technical bulletins and policy letters to provide flight surgeons guidance in regards to examinations and procedures to determine the fitness for flying duties, and the interim aeromedical disposition of disqualifying conditions, IAW para 6-5 b, AR 40-501.

3. Implementation. Policy letters and technical bulletins remain in effect from the date of publication until rescinded or superseded by the Commander, USAAMC, or a higher authority.

4. Purpose.

Policy letters recommend Army-wide standardization of aeromedical evaluation, treatment, and disposition for a variety of common clinical problems. They provide continuity of aeromedical care for flight surgeons and aircrew members world-wide and ensure the optimum quality of care. They ensure the safe return of countless aviators to flying duties once effective treatment has been achieved.
Technical bulletins recommend Army-wide standardization of aeromedical testing and administration. They ensure the proper use of testing equipment and testing procedures throughout the Army Medical System.
Policy letters and technical bulletins, while not regulations or orders, are a statement of policy by the Commander, USAAMC, as derived from the recommendation of the Aeromedical Consultant Advisory Panel's (ACAP) review of data from the Aeromedical Epidemiology Data Register, consultation with numerous specialists, and review of medical literature. The policy letters also recommend medical evaluations which are required to make a final recommendation for flying duties, thus avoiding the delays resulting from incomplete aeromedical summaries.
Policy letters and technical bulletins are designed to be updated as the standards of aeromedical care and knowledge change. Flight surgeons are encouraged to submit recommendations for changes to DSN 558-7430 or COMM (334) 255-7430.

INSTRUCTIONS

Navigating through this document should not be very difficult for you, since it works exactly the same as a Windows Help file. The buttons at the top of the screen labeled ATBs, AR 40-501, APLs, Instruction, or Contents will jump you to the appropriate section of the help file. The Contents button will take you to the Table of Contents. These buttons stay active anywhere within the help file so you may return to or jump to these areas at anytime. Any word or string of words that is underlined, green, and turns the mouse cursor to a hand will take you to another topic when you place the pointer on the word or string and click with the left mouse button. Once within the main contents the arrow keys will be active (indicated by turning black). This will allow you to browse through the files much like turning the pages of a book. Finally, you will also find similar jump spots located throughout the text of a help topic. This jump spot will also be underlined and if clicked upon will automatically jump to the reference being referred.

The greatest advantage of this help files is its search capability. Type in a keyword for the topic you are looking. This should take you to your topic without having to work your way through the Table of Contents. Once you are finished with a topic all you have to do is to click on the Back button at the top of the screen or press the letter B on your keyboard and you will be returned to the opening Table of Contents. This version of the help files also has the ability to do word searches just click on Search and the Find Tab or click on the Find button. Occasionally you will come upon a graphic symbol, e.g., within the text which will jump you to a topic or bring up another window with additional information.

You can print any topic you need to have hard-copy reference to simply by clicking on the print button or by clicking on the File and Print commands from the menu bar. With the File – Printcommand you may also highlight a portion of the topic file and print only that selected portion. The Option button quickly accesses many of the commands from the menu bar.

You can also copy the full topic by selecting the Copy button and then later paste it to another windows file. This is great for extracting information you may need in another document. Note: This may not appear to work since it gives no indication it has worked. Just wait, exit or minimize the help file and paste it into your active Window's program. You can perform the same actions by selecting Edit then Copy commands

Other functions exist which are common to all help files.

You may select Edit then Annotate selected help topics with your own notes. This is helpful in adding your own personal comments, thoughts on further investigation or clarification, additional research, and questions which need to be addressed in the future.
You may select Bookmark when you are in a selected file and automatically recall this location at some later time, even after exiting the help program.
Selecting History will show you the last 40 topics you have visited within the help file. You may jump back to any of these topics by simply double clicking on the selected topic.

TABLE OF CONTENTS

SUBJECTS PAGE

INTRODUCTION………………………………………………………………. 6
CARDIOVASCULAR WAIVERS……………………………………………... 41
DERMATOLOGY WAIVERS…………………………………………….….. 109
ENDOCRINOLOGY WAIVERS…………………………………………...… 117
GASTROENTEROLOGY WAIVERS……………………………………….. 127
HEMATOLOGY WAIVERS………………………………………………….. 147
INFECTIOUS DISEASE WAIVERS……………………………………...….. 157
MALIGNANCY AND TUMOR WAIVERS…………………………………. 171
MEDICATION WAIVERS…………………………………………………..... 212
MISCELLANEOUS WAIVERS…………………………………….………... 228
NEUROLOGY WAIVERS…………………………………………..………... 255
OBSTETRICS AND GYNECOLOGY WAIVERS………………….………. 281
OPHTHALMOLOGY WAIVERS……………………………………………. 294
ORTHOPEDIC WAIVERS…………………………………………..………. 331
OTORHINOLARYNGOLOGY WAIVERS………………………...………. 350
PSYCHIATRIC WAIVERS………………………………………………..…. 366
PULMONARY WAIVERS………………………………………….……..…. 400
UROLOGY WAIVERS…………………………………………………....….. 409
REFERENCES…………………………………………………………....…... 416

INTRODUCTION

Commander's Forward……………………………………………..….. 7

Acknowledgements……………………………………………………… 9

The Waiver Process……………………………………………………. 10

Waiver Authorities…………………………………………………….. 12

Waiver Criteria………………………………………………………… 14

Aeromedical Summary – Template…………………………………... 16

Aeromedical Summary - Guide to Completion……………………… 18

Abbreviated Aeromedical Summary

Glossary………………………………………………………………… 21

Regional Flight Surgeon Program……………………………………. 26

Directory of Regional Flight Surgeons ………………………………. 28

Aeromedical Consultants Advisory Panel …………………………… 29

Aeromedical Consultation Service…………………………………… 31

Magic List of Aeromedical Consultants……………………………… 33

COMMANDER'S FORWARD

There are times when it is difficult to see that we have come far since the times of Dr. Theodore Lyster and his colleagues when they first set up criteria for selection and retention of military aviators. Dealing with the disappointment of sincere and dedicated men and women who have been found disqualified from entering or continuing in aviation careers is a painful task for most of us. The foundation of our inner strength in dealing with them is a solid, well-considered rationale and process for determining their suitability for flying status. This collection of policy letters is a positive force in that arena, and a clear demonstration of our progress to date. The fact that these policies are being distributed for the first time as electronic files on diskette is additional evidence of our commitment to optimal support of all aircrew members, including ourselves.

We have borrowed from and even coordinated with the other military services to arrive at a consistent, up-to-date guide to the aerospace medicine approach for the majority of conditions which we see in our aircrew-patients. We can all use them to guide our approach to patients requiring waiver or disqualification actions. Our counsel to affected individuals can be consistent and supportable. These are living documents, not tablets of stone. We will continue to use our accumulated experience and advances in medical knowledge to improve our ability to predict conditions which may be inconsistent with flying safety and mission completion. New versions of these policies will be forthcoming as required; hopefully, the electronic revolution will facilitate their timely distribution (including annual distribution) and ease of use.

Use this consistently formatted set of documents to:

(1)Counsel your patients and their commanders about their conditions and the likely outcome of waiver or exception-to-policy requests;

(2)Plan your work-up for potential waiver so that a complete package can be submitted the first time;

(3)Counsel your patients on likely follow-up requirements for conditions which are waivered;

(4)Review as a text on practical applications of aviation medicine by disease category; and

(5)Submit any comments, noted errors, or potential changes and updates to USAAMA for improvement of the next edition.

GLENN W. MITCHELL

COL, MC, SFS

Commanding

ACKNOWLEDGEMENTS

The total revision of these policy letters has been the resulting work of countless hours and numerous personnel and designed to reflect the most current medical literature available and better align the US Army aeromedical policy with the aeromedical policies of both the US Navy and the US Air Force. To this end, specialists in every field of medicine were consulted and either authored or edited these policy letters; members of the Aeromedical Consultants Advisory Panel (ACAP) were constantly tasked to review and approve these policy letters, often repeatedly due to numerous additional revisions; and finally, US Army Aeromedical Activity staff members were involved in the constant editing, typing, and organizing. As chief editor and sometimes author of this endeavor, I would like to express my personal thanks and appreciation for all the work of these contributors to an endeavor which I hope will greatly assist the flight surgeon in his understanding of aeromedical policy. The following list of personnel deserve special recognition for a job well done: COLs John Blough, Gary B. Broadnax, Myron Harasym, Jerry W. Hope, Elwood Hopkins, James W. Ralph, Gregory D. Parrish, Frank S. Pettyjohn, Craig L.Urbauer, LTCs Leo Conger, Walter J. Hubickey, Robert L. Johnson, Jr., Kelley Kofford, Ricky D. Latham, Deogracia Quinones, MAJs John V. Albano, Scot Callahan, Monica Gorbandt, Eugene H. Ryan, Franklin E. Schewbert, Wallace J. Seay, Mark J. Tedesco, CPTs Lawrence A. Edwards, Lawrence A. Edwards, Mark J. Ivey, Dexel V. Peters, Andrew R. Wiesen, Erin V. Wilkinson, CW5 James R. Kale, Dr. Jenifer L. Reichle, Mr. Jim Field, Mmes Lannie B. Hutcheson, Barbara A. Kelley, Patricia L. O'Saile, Beverly Urech.

RICHARD L. BROYLES

COL, MC, MFS

Director, US Army Aeromedical Activity

Editor-in-Chief

THE WAIVER PROCESS

GENERAL: The waiver process has been developed to ensure the consistent and proper management of disqualified aviation personnel. This process has been responsible for the safe return of countless aviators to flying duties once effective treatment has been achieved. It also has been responsible for clearly identifying those individuals with medical conditions incompatible with continued safe flying or their continued good health. It allows for consistent health care management of individuals who routinely receive their health care from many different health-care providers. With proper utilization of senior health-care consultants, it ensures the highest level of health care and provides quality assurance. Most importantly, it ensures the maintenance of a readily mobile effective fighting force.

WAIVER AUTHORITY: Waivers are granted by PERSCOM; Chief, National Guard Bureau; and by the local Commanding Officer, depending upon the status of the aircrew member. (See Waiver Authority) USAAMA, much like the local flight surgeon, only recommends a course of action. The needs of the Army may occasionally supersede these medical recommendations.

THE PROCESS: The entire waiver process normally starts at the local flight surgeon's office at the time of the discovery of a disqualifying medical condition. Local evaluations and consultations must be obtained which support or fail to support waiver activity. Once this packet is forwarded to USAAMA, it can take several different routes depending on the nature of the disqualification. Most waiver requests are considered routine waivers (those that have clear policy established) and require little more than review and endorsement, and then are forwarded with recommendations for appropriate follow-up or restrictions to the waiver authority. Occasionally waiver requests are forwarded for review to the designated Army medical consultant (See Medical Consultants) or to NAMI, Pensacola, FL, or AMCS, Brooks AFB, TX. Cases which are unusual, potentially precedent setting, involve flight or other operational limitations, and all Class 1 Exceptions to Policy are presented to the Aeromedical Consultants Advisory Panel (ACAP). The decision of the ACAP is reviewed and approved/disapproved by Commander, USAAMC and forwarded to the appropriate waiver authority. The waiver authority will then take appropriate action, normally producing a formal letter of waiver/termination notification.

THE PACKAGE: An Aeromedical Summary (AMS) is required for any action which requires waiver, permanent medical disqualification (permanent termination from flying), termination of permanent termination from flying, and request for aeromedical consultation. The information needed to process a waiver is quite variable. Normally a complete AMS (See Aeromedical Summary) is required. An abbreviated AMS (See Abbreviated Aeromedical Summary) may be used in certain minor actions, i.e., hearing loss, pregnancy, seasonal allergic rhinitis (SAR) when submitted with a SAR Worksheet, hypertension controlled by diet or waiverable medications, and any other uncomplicated condition. The submitted information will usually need to include any available supportive consultations; reports of all operations; tissue examinations; and path/lab reports; actual tracings, x-rays, pictures, films, or tapes of all procedures (ECG, AGXT, Holter, ECHO, cardiac scans and catheterization); hospital summaries; past medical documents (e.g., hospital summaries, X-rays, ECGs); reports of any proceedings (tumor board, MEB, PEB, FEB); and any letters of recommendation. Required documents include: SF 513 - Consultation Sheet, SF 520 - Mounted ECGs, DA Form 759 - Individual Flight Record, and ORB - Officer Record Brief. An FDME is not always required since the AMS contains significant history or physical findings. Your recommendations should include any restrictions, follow-up, date of incapacitation, or request for consultations which you feel are appropriate. Legibility is a key. Altered (white out, erased, blocked out, etc.) records are not accepted.

TIMELINESS: Yes, it takes time to process a waiver. At USAAMA the waiver package must pass through 9-11 essential work-stations and at PERSCOM 5-7. Bottlenecks are inevitable. Complicated cases or cases which have no precedent often take additional time due to the need for specialty consultation or medical research. Remember, most routine waivers may be granted temporary clearance pending waiver (See Temporary Clearance Pending Waiver), and telephonic approval is often available for the uncertain cases. If you need a rush disposition, you may send the waiver packet via overnight mail or Federal Express. Please ensure the package is complete. FAX copies are generally not accepted due to their poor quality and the ease with which they may be altered.

WAIVER AUTHORITIES

ACTIVE ARMY OR USAR ACTIVE ARMY OR USAR ACTIVE ARMY OR USAR

CLASSES 1/1A AND CLASS 2 CLASSES 2F & ETC * CLASSES 2S/4 & CLASS 3 (FOR

THRU THRU DRUG ALCOHOL ONLY)**

Commander, Commander, THRU

USAAMC, USAAMC, Commander,

ATTN: MCXY-AER, ATTN: MCXY-AER, USAAMC,

Fort Rucker, AL 36362-5333 Fort Rucker, AL 36362-5333 ATTN: MCXY-AER,

FOR FOR Fort Rucker, AL 36362-5333

Commander, Commander, FOR

PERSCOM, PERSCOM, Commander,

ATTN: TAPC-PLA, Health Services Division, PERSCOM,

200 Stovall Street, ATTN: TAPC-OPH-MC, ATTN: TAPC-EPL-T

Hoffman Building, Room 3N25 200 Stovall Street, 2461 Eisenhower Ave

Alexandria, VA 22331-0413 Hoffman Building, Room 9N68, Alexandria, VA 22331-0453

Alexandria, VA 22331-0413

ARNG Contract Civilians DAC

CLASSES 1/1A/2//2F/2S/4, All CLASSES ALL CLASSES

AND CLASS 3 (DRUG AND THRU THRU

ALCOHOL ONLY)** Commander, Commander,

THRU USAAMC, USAAMC,

Commander, ATTN: MCXY-AER, ATTN: MCXY-AER,

USAAMC, Fort Rucker, AL 36362-5333Fort Rucker, AL 36362-5333

ATTN: MCXY-AER, THRU THRU

Fort Rucker, AL 36362-5333Contracting Representative OfficerAviation Unit Commander

FOR FOR FOR

Chief, Commanding General, or Commanding General,

National Guard Bureau, his Designated Waiver or his designated waiver authority

Authority

ATTN: NGB-AVN-OP (i.e., air field commander or(air field commander or

command aviation officer) command aviation officer).

111 South George Mason Drive, Send final copy to Send final copy to

Arlington, VA 22204-1382Contracting Office & Firm. local civilian personnel office.

* - Includes aviation audiologists, dentists, optometrists, and psychologists.

** - Class 3: Several other conditions require submission to USAAMA for final review and disposition to include:

Alcohol and Drug abuse or dependence as above.

Type II decompression sickness.

Coronary disease, suspected or proven.

HIV seropositivity. (Civilian employees are not disqualified based solely on the presence of the HIV virus.)

Any other condition for which the FS or local aviation commander requests consultation.

- Waivers for other than drug and alcohol abuse/dependence and the above conditions are submitted through the local FS, for the local aviation unit commander. (See Class 3 Aircrew Members APL)

WAIVER CRITERIA

INTRODUCTION: Factors commonly used in the consideration of granting a waiver include feasibility, in-flight safety, impacts on mission and deployability, progressive nature of the illness, requirement for treatment or medication which will not readily be available during mobilization and ultimately the needs of the Army.