THE ROLE OF AEROMEDICAL EXPERTS IN THE SCREENING OF

ATYPICAL MEDICO-PSYCHOLOGICAL SITUATIONS

5TH EUROPEAN CONGRESS OF AVIATION MEDICINE

OSLO - SEPTEMBER 15 - 18, 2016

MANEN O, MD, Pr MONIN J, HORNEZ AP, HUIBAN N, GUIU G,

DUBOURDIEU D, OLIVIEZ JF, DEROCHE J, BERTRAN PE, AUXEMERY Y, COLAS MD, PERRIER E

Percy Military Hospital, Clamart, France Aeromedical Center Cardiology and Aviation Medicine Department

French Military Health Service

Academy

5TH EUROPEAN CONGRESS OF AVIATION MEDICINE

OSLO - SEPTEMBER 15 - 18, 2016

DISCLOSURE INFORMATION

MANEN Olivier

I have no financial relationships to disclose

The opinions or assertions expressed here in are the private views of the authors

and are not to be considered as official or as reflecting the views of

the French Military Health Service, or .

French Military Health Service

Academy

Percy Military Hospital, Clamart, France Aeromedical Center Cardiology and Aviation Medicine Department

Recent aviation events Role of the mental health in public aviation safety EASA working group : new regulations in process Ideally : Trust between AME and pilots Psychological pb recognized by the pilot & confessed to the AME Adapted aeromedical decision Common situations : No trust, dissimulation Subclinical problem, denial High risk

BACKGROUND

IR and AMC MED.B.055 Psychiatry - MED.B.060 Psychology Present : Details of decision in case of a well-kown and confirmed diagnosis of a mental disease : Aeromedical Authority Future : Recommendations to take into account about the screening of mental health problems during aeromedical examinations The Pilot/AME meeting during initial and periodical visits : a crucial moment When should AME get worried ?

BACKGROUND

AeMC of Percy Military Hospital, Clamart (PARIS) 14,000 annual initial/periodical visits for civilian/military applicants/aircrews 10 MD specialized in aviation medicine (6-year training) Individual think about atypical situations List of mental health warning signs (Alcohol and drug data excluded) Dialogue to share the clinical findings Organization into categories (no real hierarchy)

METHODS

8 categories : 1. Context of the consultation 2. Career path 3. Past medical history 4. Personal life 5. Professional situation 6. Past event during flight 7. Aspecific symptoms 8. Physical exam

RESULTS

« Intermediate » examination after a sick-leave Motive ? Duration ? « fatigue », « need to take a break », « no need for medical certificate » No real diagnosis, poor details Long duration of a sick-leave Form analysis Warning boxes : checked ? Explanations written ? 28. Medication 128. Medical consultation

1. CONTEXT OF THE CONSULTATION

Examination in a different location (AME/AeMC) Motive ? Previous AME/AeMC ? Medical records ? Aeromedical wandering Denunciation / Notification Strange behaviour on board or on the ground Conjugal, family or professional conflict ? What is true ?

1. CONTEXT OF THE CONSULTATION

Initial applicant Study with no aviation connection No minimum flying activity Strange motivation : family (parents), money « he/she looks for a way » « liking taking risks » Paradoxal motion sickness Confirmed pilot A very long time to qualify Job with no aviation connection & no real search for a flying job Frequent change of job / society / company

2. CAREER PATH

Personal or family past psychological history Rarely completed : 118. Psychological troubles 120. Suicide May be interesting : 126. Hospitalization 127. Other disease 132. Unfitness for national service Anamnesis : Initial applicant with a previous « reactive » depression past follow-up by a child psychiatrist previous use of psychoactive substance Family history of depression, suicide, psychosis, alcohol abuse

3. PAST MEDICAL HISTORY

Personal history of somatic disease Severe With social impact With unfitness consequences Exemples : road accident head trauma major surgery incompatible drug therapy… Risk of psychological consequences

3. PAST MEDICAL HISTORY

Conjugal problems Break-up, long period of divorce, difficulties with children, geographic single life Family problems Death, inheritance conflict, critical health, end of life assistance, strained relationship Sudden events A life which is « insistently described » or « unusually hidden » while consultation Talking with emotion « Nothing is all right in my life »

4. PERSONAL LIFE

Declining working conditions Overworking Overinvestment with « low » salary Expatriation with unequal On/Off periods Difficult period for the society or airline company with a redundancy risk Changing working hours (day / night) Long period of unemployment Multiple failure during flight simulator or captain stage Major conflict with colleagues or hierarchy Legal procedure against the employer Cause for concern ?

5. PROFESSIONAL SITUATION

Technical event Very bad weather conditions (Engine) failure Emergency braking or landing In-flight fire Crash Human event Death of passenger Bad experience in cockpit (conflict) Medical incapacitation in command (or of the copilot) Which management ? Return to fly ? Refusal of a flight ? Talking with emotion ?

6. PAST EVENT DURING FLIGHT

Fatigue Back pain (with normal back condition) Vertigo (with no ENT cause) Sleep disorders (new hypnotic consumption) Loss of motivation Symptoms with unclear description, atypical association Changing complaints Symptoms on board only (« in-flight malaise ») Begining when personal/professional problems Out of proportion anxiety Insistence during consultation

7. ASPECIFIC SYMPTOMS

Clothing and physical presentation Inappropriate cloths for the function or the context Atypical style Hat, cap, sunglasses (not removed) Not very clean person Strange tattoo Strange body piercing Scar suggestive of deliberate self-harm Useful inspection during physical exam

8. PHYSICAL EXAM

Strange attitude Very few words, long time to answer, introverted, sadness Inappropriate stress or emotionalism A few tears Looking as requiring help Inadequate answers, curious questions to the AME Too relaxed (casual), logorrhoea, too laughing mood Unusual friendly attitude Refusal or abnormal duration to get undressed

8. PHYSICAL EXAM

The warning signs A not exhaustive list If positive : thorough evaluation which may need a psychological or psychiatric consultation Advantages of AeMC : screening & training Secretaries, nurses, orthoptists, MED/OPH/ENT practitioners taking part in the decision-making process Main activity : the more you see pilots, the more you get experience ! Feedback of colleagues « How would you have done in that case… » Specialists of the Psychology Department Applied to Aeronautics

DISCUSSION

How to improve trust between pilots and AME ? Ideally all examinations of a pilot in a same place (AME/AeMC) First step : efficiency in managing somatic problems Key messages : « Past medical history does not mean permanent unfitness » « We are at the service of aircrews » « Safety is our common objective » Years are required…

DISCUSSION

Major role of aeromedical examiners To incite pilots to declare and to detect those who will not… Probably the most difficult part of the aeromedical assessment Little place for evidence-based medicine here ! « Is there something strange » (subjective)

CONCLUSION

NORMAL

ABNORMAL

Psychiatrist ?

Contact: olivier.manen@intradef.gouv.fr