No slapping – or – How I passed the Maintenance of Wakefulness Test for Apnea

Mike with many electrodes

This is how you will look for most tests

(updated)

Recently the FAA proposed a new rule making that would require pilots with a body mass index (BMI) of 40 and a neck size larger than 17 to be screened for Obstructive Sleep Apnea (OSA) before being considered for a medical certificate. Pilots and pilot associations are wildly panning this proposal given the high test costs and the perceived precedent it sets for requiring a test based solely on risk factors. As a pilot with apnea I thought it time to share my experiences and weigh in on the long-term FAA requirements that come from an apnea diagnosis. I’m against this proposal, but not for the reasons you might think… and I have a proposal of my own.

Risk Factors

I know many folks are up in arms over the precedent of requiring a test based solely on risk factors. I also know I’ll get some negativity for the fact I don’t consider it a precedent. Thinking of the tests we go through at each exam, I see them all as a reaction to risk factors. I’ve been getting medical exams since before I was 20 and the doctors do much more poking a probing now that I’m on the back half of my 40s. For example, based solely on my increasing age, I get to look forward to my first rectal exam on my next FAA Medical exam. Am I disclosing anything on the questionnaire that makes the doctor think the test is needed? Nothing but my birthday. So, a rectal exam comes from a single risk factor: age. The proposed apnea tests use the same logic. Are you a male over 45? You need a rectal exam. Have a high BMI and large next size? You need to be tested for apnea.

I’m still not sure what they might find up there during a rectal exam that will impair my ability to fly later that day, but don’t get me wrong… guys need that particular test. Similarly, the proposed rule addresses a group that have a very high incidence of having apnea and who are likely already impaired in the cockpit. To me, the big difference between the tests is cost. Most of the exams performed by the AME take no time at all and are performed during the medical exam process. Tests for apnea, however, are expensive and time consuming. Further, if a person has apnea, the ongoing treatment leads to ongoing tests to prove the treatment is effective. I’ve seen it get easier over the years, but pilots who are suddenly facing an apnea diagnosis need to understand this will stay with them for the rest of their flying career.

Other Factors

Given the cost and hassle, I have to wonder where this new requirement is coming from. According to AOPA and EAA, the FAA is citing the need for apnea tests on only one incident that had no crash and no injuries… the pilots fell asleep and overshot their destination before landing safely. I’m not minimizing this incident. Those pilots made a huge mistake that put lives in danger. That said, I can’t help but wonder if apnea might have had a bit of help from fatigue brought about from the crew’s schedule. Flight crews often fly fatigued and I think incidents like this could happen to many folks with or without apnea being involved. The FAA points to other aviation data where pilots had apnea or sleeping disorders at the time of the incident, but I really think the FAA’s apnea concern comes from the Department of Transportation’s current focus on fatigue in over-the-road truck drivers rather than from the pilot community. I sure hope that engineer in New York who recently fell asleep in the cab and derailed the overspeed train didn’t have apnea or it will add fuel to the DOT’s position. Unfortunately, the proposal doesn’t seem to be following normal procedure that allows for transparency and feedback, so we don’t know if the DOT is considering the dangers from fatigue brought by stressful, demanding, corporate-driven schedules… I really think that is a bigger risk than apnea, but the FAA isn’t touching the real problem.

My Apnea Journey

So, how did I come to have opinions on apnea? Long ago, my wife encouraged me get tested for apnea since I wasn’t sleeping well and snoring loudly. So, I scheduled a sleep study with the Northwest Community Hospital sleep lab in the shadow of O’Hare airport. I spent the night there with lots of wires all over and a camera watching me. The result was an apnea diagnosis and the chance to buy my own CPAP machine. I continue to use a machine and it’s mask every night to keep me breathing well…. and it works very well. I sleep so much better with that thing on. I fall asleep right away. I sleep deeply. I don’t wake my wife up. I wake up fully rested. It’s been good for my life even if it’s somewhat a pain to take with me everywhere I travel. I like the results so much that I strongly encourage people who might have apnea to get tested and to get a CPAP since it will improve their lives. Really. It works.

What I didn’t know at the time of the sleep study was that apnea is considered by the FAA to be a disqualifying medical condition which means the FAA wouldn’t issue a medical certificate without ongoing proof that my apnea was under control. So, the next time I went to get my FAA medical, I didn’t know that by disclosing my condition, I was ending the ability to easily get my medical. I didn’t know I was setting myself up for annual tests. I had no idea it would make it so hard to fly.

What is a FAA Medical Certificate?

For the non-aviators out there, most pilots need two documents to fly: 1) a non-expiring pilot certificate and 2) a medical certificate that gets renewed every six to sixty months. I said “most” since there are some pilots exempted from having a medical certificate at all. Some pilots who fly balloons, gliders, and certain small, sport planes need only to self certify their medical condition is appropriate for their flight. To them, this rule making wouldn’t apply and they can fly at will.

For those that haven’t applied for a medical certificate, it involves a visit to a FAA designated aeromedical examiner (AME). Essentially, an AME is a doctor with special training who runs through various tests which are increasingly stringent with the type of flying involved. Airline pilots, for instance, hold a 1st Class medical certificate which needs renewal every six months or every year for those not yet 40 years old. Pilots like me who fly non-commercially usually only need a 3rd class medical which needs renewal every two years for those of us over 40. Younger pilots need only renew their medical every five years.

What isn’t obvious even to most pilots is that the terms of their medical certificate are only this long if the medical examiner doesn’t find any health concerns. If there are concerns, then all the rules change and the expiration dates can come much sooner and the pilot may only get their medical through Special Issuance certificate where the exact restrictions are decided on in a case by case basis.

Old Medical Reviews: testing a patient’s patience

When I mentioned I had apnea, my AME didn’t know what information I needed to show to the FAA. At the time, the AME couldn’t issue medicals with special issuances like they can today. At the time, all I could do was wait. In the meantime, my existing medical expired… and still I waited. After a month, I enlisted AOPA to help and they did what they could by contacting the FAA on my behalf to find out the obvious: it was still “in process.” I asked them for help again another six weeks later (now 10 months since the exam and 9 months since my medical expired). This time, they said a decision was made an I should expect a letter soon. Two weeks after that, I got a letter asking me to repeat my sleep study and submit the results for review. Not what I, AOPA or my AME expected. Confused, I again called the folks at AOPA and they suggested I contact my AME and cancel my application and reapply in about a year since it was their view that my application would be denied if I continued. They expected that if I waited a year to reapply, there was a good chance my application would be handled by a different inspector. So, I called my AME, pulled the plug, and started my wait. Why cancel and wait? Because they had seen other applications handled by this particular inspector and, apparently, any time he asked for repeat tests, the applicant was handed a denial… and a denial is the worst fate of all.

The Catch 22 of Denials

Why didn’t I want a denial? Remember when I mentioned that ballon, glider, and sport pilots don’t need a medical certificate? Well, it’s true that they generally don’t ever need a medical. Unfortunately, not having a certificate is much different than having been denied a medical. If a pilot applies for a medical and it is denied, they are specifically excluded from the right to self-certify their wellbeing. It’s well known that a denial effectively means your days of flying anything are over until you can clear a medical exam. No planes. No balloons. No gliders.

The result of this is simple. Pilots don’t want denial, so they are inherently conservative when it comes to interacting with medical professionals. Pilots around the country routinely refuse to go to doctors, refuse most medicines, and pay more for their visits to avoid using medical insurance. No, I don’t recall seeing an official study to back this up, but I’ve been talking to and instructing pilots for 20+ years and it’s a common point of discussion. To most pilots, the equation is simple: If they don’t see a doctor, they can’t be diagnosed with anything that might one-day lead to the denial of a medical. I know several pilots who’s only doctor visits are to their AME every couple of years. Even when they do visit a doctor, most pilots are exceedingly prescription-adverse since so many medicines are banned when flying and would need to be reported at their next medical exam. I also know pilots who pay out of pocket for any medical visit so that it doesn’t hit their insurance provider who will require a diagnosis code in order to pay the doctor. These pilots have a perception that any diagnosis other than “well care visit” or “pregnancy” has the potential of having long-term risks when visiting an AME, so they don’t use insurance and, therefore, avoid official diagnosis. Most pilots will do anything they can to keep flying and avoiding doctors is a simple way to mitigate the risk of a denial.

Modern Special Issuance

Eventually my medically induced hiatus came to an end. After the initial 10 months of waiting for my application and after another 12 months of a self-imposed no-fly, I decided it was time to try again. This time, I expected it to go more smoothly since I was better prepared. Fortunately, the FAA had used my time off to create new rules allowing the AMEs more authority to issue medicals to those with certain disqualifying conditions including apnea. To support this, the FAA started publishing guidance as to what data the medical examiner will need to re-issue a medical certificate. They’ve even published an Apnea FAQ.

With those details, I asked my regular doctor for a statement verifying my ongoing CPAP treatment. Of course, my doctor wouldn’t sign off on a letter like that without the sleep study, so back to the sleep lab I went for another expensive overnight visit. As an aside, I’m glad that I brought my CPAP to that lab visit because the staff also read the history stored on the device and could see that I had been using it and that it was effective. Their report was enough for my doctor who signed the letter. So, I finally had all the data I needed and I took all of this back to my AME and hoped for the best. After a standard test and after verifying criteria with the FAA website, my AME issued my 3rd Class medical on the spot… and it good for the next few years! Phew! I could fly again!

A few weeks after getting my medical from my AME, I got an envelope from the FAA with another 3rd class medical and a Special Issuance letter. What I didn’t expect was that the medical wasn’t valid for use after a date less than six months away. The medical didn’t expire in six months, but it was useless in six months. Fortunately, the letter clearly outlined what I needed to provide to my AME to get my medical reissued. So when I returned, I would need another letter from my physician along with results from a Maintenance of Wakefulness Test (MWT). Essentially, the FAA wanted to see that my CPAP was working at night (via the data I provided from the sleep study) as well as see that I was rested enough to stay awake during the day. Makes sense to me even it mean more testing.

No slapping – or - How I passed the Maintenance of Wakefulness Test

While the MWT is provided by a sleep lab, it is the opposite of a sleep study. It’s goal is to make sure you don’t fall asleep during the day. No problem. I could do that! So, I scheduled it and when the day arrived, I started about 7am with a blood draw and a very expensive screen for stimulants including caffeine. Yup. 7am hospital visit with no morning coffee. Then I went to the sleep lab who’s staff said I could sit and work, make calls, whatever I wanted as long as I stayed awake until we finished about 3pm. One catch… three times during the day, I would be required to sit in a chair for 45 minutes with the lights darkened and the shades drawn. Not much light. No sound. No TV. I remember the nurse’s summary: “No talking, singing, or slapping to stay awake.” I could do nothing but sit and face forward while they watched via an infrared camera to see if I would fall asleep.

Ask yourself… could you do that? Forget apnea. Is your life calm enough that you can skip your morning coffee or tea and then spend three different fourth-five minute periods in a dark room without falling asleep? If that would be a problem, then the MWT might not be much fun.

Fortunately, my test was fine and my doctor agreed with the lab. So, my AME issued me another third-class medical good for five years (since I was under 40 years old). As expected, I got another letter from the FAA a few weeks later with another Special Issuance letter and another third-class medical. (If you are keeping track, that’s four third-class medicals in one year) The interesting part to me was that the medical was good for five years but using it was limited to a year unless I renewed it under the conditions outlined in the Special Issuance which had it’s own expiration date six years away. Confusing.

The practical outcome was that I had medical I could use for a year. I also could renew the medical every year for five years without a full medical exam. I merely needed to provide a letter from my treating physician that my apnea treatment continued to work. Of course, I needed my doctor to help with this and that was a struggle until I was finally able to convince him to sign off on the annual letter based on reports recorded by my CPAP. I repeated this annual process several times without a full FAA medical exam, but after a few years, my doctor wanted another MOW test or sleep study before he would sign off again. Doctors deal with liability by requiring more tests, so I did another MOW test. the bonus was that when I did provide updated test results, the FAA sent out an updated Special Issuance good for another six years. Eventually, my medical expired and I needed a full medical exam, but I still had a Special Issuance letter so it was an almost trivial process.

Being a pilot with apnea became very manageable once the FAA eased the rules and once I found a bit of data my doctor would accept. Unfortunately, life isn’t always manageable and I’m again between medicals: new job, I lost my dad, another new job, etc… It all combined to slowed me down and I let my medical and my Special Issuance expire. So, I’m starting over, but now I know what the system expects. Now I just need time to see my doctor to get a prescription for a MOW test, schedule and take the MOW, return to my doctor to have them sign the letter to the FAA, schedule my FAA exam, and then onto the biannual. Nothing to it as long as the doctors don’t find something new to worry about.

Unfair Burden

If some of you are reading this thinking “that’s a lot of work to keep flying,” I’d agree. It’s too much work. Especially when you consider how much more of a burden it is compared to other areas of federal regulations. I also own and operate an RV.. no, not an homebuilt RV-8 aircraft… a recreational vehicle. Our RV, @HomeSweetRaod (yes, it has a twitter account), is almost 40 feet long and fills the width of the lane, yet I didn’t need anything special to operate. No new license and certainly no medical. Interesting considering it weighs three times what my club’s Cessna 182 weighs. To be fair, if I wanted to drive it commercially, I’d need a state Commercial Driver’s License (CDL) much like bus drivers and over the road truckers need. How many commercial trucks are on the federal highway system? All of them are driven by people with CDLs that prove they have specific knowledge to handle the increased difficulties of a large truck. But how many of those truck drivers need medical exams from a federally authorized doctor? The answer is “none.” There is no governmental medical requirement unless they are interstate drivers (thanks Kent for the clarification). I’m told that some insurance carriers and trucking companies require medicals. Regardless, trucks are all over federal highways and are involved in fatal accidents far too often, yet they have a much lower set of medical testing requirements than what pilots face.

A Proposal

Given the federal government doesn’t require a medical to use federal roads nor does it require special licenses for non-commercial use of “smaller” vehicles including RVs, why isn’t there a similar differentiation in the air? I have a commercial pilot certificate but I don’t make my living flying commercially. In fact, it’s been more than a decade since I needed the commercial license. Same goes for my instrument rating which hasn’t been current since before the turn of the century. At this point, all I want to do if fly on nice days to get back into flying. Unfortunately, I need the same medical exam that needs to make sure I can handle long, monotonous night-time flights where anyone has trouble staying awake. How about a “nice-day” medical certificate? How about letting me self-certify that I’m ok to fly on a nice, low-risk day just like the sport, glider, and ballon pilots do? I humbly propose that a pilot should be able to self-certify their medical condition if they:

  • have a commercial license with instrument privileges
  • have at least 200 hours total time,
  • are flying legs no more than 100 nm.
  • are flying a an aircraft for which they are rated weighing less that 12,500 lbs,
  • are flying non-commercially
  • are flying between civil sunrise and sunset,
  • are flying when the weather has at least 6 miles visibility and affords at least 1000 ft cloud clearance
  • have a valid driver’s license,

Do I really need the same medical exam for these conditions as I did when I was flying commercially? Is my apnea really a medical risk on short, activity filled flights? Do I really need to spend thousands of dollars in medical tests every few years to be able to fly in these conditions? In my case, all I want to do is go around the pattern and to the practice area so I can remind myself of why I love to fly.

Why is that so hard?

-Mike

(Updated medical requirements based on Kent’s comment and some private feedback)

Links:

(1) AOPA Post on a bill to slow the FAA down: http://www.aopa.org/News-and-Video/All-News/2013/December/05/bill-to-stop-new-sleep-apnea-policy-moves-forward.aspx

(2) EAA post urging pilots to contact their congressman: http://www.eaa.org/news/2013/2013-12-04_eaa-urges-support-for-bill-on-sleep-apnea-policy.asp

(3) Disqualifying Conditions: http://www.faa.gov/licenses_certificates/medical_certification/faq/response6/

(4) FAA Apnea FAQ: http://www.faa.gov/news/fact_sheets/news_story.cfm?newsId=15474

(5) Guide for Aviation Medical Examiners – Apnea: http://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/special_iss/all_classes/sleep_apnea/

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8 Responses to No slapping – or – How I passed the Maintenance of Wakefulness Test for Apnea

  1. Kent Shook says:

    Hey Mike,

    Great post, and a much-needed dose of reality given the current discussion on this issue. Just one correction – Commercial drivers engaged in interstate commerce *are* required to have a medical exam and carry a medical card – See 49 CFR 391.41. However, you are correct in that they aren’t required to be given by “federally authorized” doctors – Pretty much any MD, DO, PA, LPN or even chiropractor will do. (49 CFR 390.103(a)(1)). That’s soon to change, though, in a few months they’re going to have to be on a list of docs with the DOT and have a little training. They’re still going to be a lot easier to find than AME’s, though, and there will be no special issuances or any of the hoops that pilots have to jump through – The docs merely have various standards for shortening the length of time that the “FedMed card” is good for, no SI’s necessary. The FAA could take some lessons here.

    • mike says:

      Kent,

      Thanks as always for great details. I see now that I shouldn’t have relied on the State of Illinois website for the medical information. I think the aviation world was in my head and I expected to see medical information next to licensure information… but it makes sense that it would only be for those that are interstate drivers.

      I appreciate the clarification and will update the post.

  2. James Carlson says:

    I’m in the same boat — snoring, wife complained, now on a BiPAP and an AASI with one year intervals. I agree it should be easier for non commercial part 91 flying, but I’m not so sure about the IFR exclusion. I don’t see how I’m a bigger problem as a trained, current, and proficient IFR pilot on a self-certified medical than as a VFR flib tooling around the edges of the local Class Bravo. I can see the public policy reasons to restrict for-hire operation or transport category, but what about private operators in light aircraft?

    • mike says:

      Thanks for the reply James and I’m sorry you are dealing with the same process.

      My thinking on the no-IFR is the idea of no-monotony. Clearly the MWT is testing the ability to stay awake during quiet times. So, my no-IFR is really about avoiding long, boring legs that would give the pilot time to doze off. Given that, what would be a better restriction?

      -Mike

  3. John Wesley says:

    You missed one or two really glaring pieces of information, Sleep apnea has serious side effects, I had 2 very good friends, that new for years that they had OSA, but did not want the hassle of going through the test and dealing with the FAA, Both are dead, one at 58, less than one hour after completing a flight in his employers MU2, the other at 61 walking from his house to his car on the way to the airport to fly his wife and family on a 300 mile trip.

    I got the test, dealt with the FAA and now have the piece of mind knowing that I do not have that worry hanging over my head. I fell better than I have in years. I fail to understand why anyone in their right mind would oppose a test for OSA.

    • mike says:

      Thanks for the comment John and I’m sorry to hear about your friends. All this attention on OSA must be a tough reminder of their passing.

      I hope you read that I’m in favor of people being tested if they think they have OSA as I know it made my health better… even if it made for trouble with the FAA. I’m certainly not an advocate of knowingly ignoring a disqualifying (and as you point out, dangerous) condition which you imply your friends may have done. That, unfortunately, supports my point that the current FAA medical process discourages pilots from getting the very treatment they need to improve and extend their lives.

      Unlike your friends, I didn’t know I had OSA when I got tested so the FAA’s response was a surprise. If the FAA goes through with mandatory testing, then more people will face the same surprise I did which is why I wrote the post. It’s a serious condition with serious and long lasting effects.

      Again, thanks for sharing

  4. Steve Ells says:

    Great post. I spent a number of years going from doctor to doctor (EENT, allergist, etc) trying to find out why I always woke up with a headache and a sore throat. I also had a what’s the use attitude and tired easily. Finally I was correctly diagnosed and started the CPAP treatment, which I still use.
    I have a special issuance out of the LA office and as long as I turn in an overnight blood/oxygen saturation test,which I do at home when hooked up to a finger clip pulse oximeter I borrow from my CPAP equipment supplier, I’m good to go. The LA office turns the application in about two weeks.
    The biggest problem I’ve had is when I go in to renew the 3rd class medical and the AME sends the results to OKE City, when they get side tracked.
    I’ve learned that have to make sure that the AME sends the results to my local special issuance office.
    Thanks
    Steve

    • mike says:

      Thanks Steve!

      Can you tell me more about the pulse/ox? Is it a standalone unit or does it connect to your CPAP? Who generates the results out of that unit? What I mean is, do you send the unit or a card or something to a doctor that makes a report or is the report generated by the machine itself?

      I’ve never heard of this and thing that might be an interesting option!

      thanks!

      -Mike

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