Abnormal ECG for Category 1 Medical

[taro]

Hi all,


I recently bugged TC for the status on my medical, and they finally got back to me yesterday. They are requesting some more information (24 hour Holter monitor, echocardiogram, all cardio medical records) because I may have "right branch bundle block (RBBB)" and they want to rule out heart diseases.

The AME I went a few months ago, I was told about this abnormality when I did the ECG, and the nurses and AME all said it was pretty common in young, skinny men like myself and it's nothing to fear. Otherwise, I am young and healthy and I don't feel anything wrong. But I'm still worried because this dream I've been trying to accomplish for so long and all I've done to make it come true can all crumble down in a heartbeat (pun intended)...

If anyone has any experience with RBBB I'd love to hear your story and would appreciate your advice. Is this a disqualifying thing? Am I screwed before I even started?


Thank you.

[DanWEC]

As far as a BB goes, by the books a Right block isn't disqualifying, so that's good, (Left is structurally more serious.) it only requires further assessment to insure it isn't correlated with ischemic heart disease. Sometimes it's very good to find these things out early! A long healthy life is more important than just one job.

I can't speak any further specifically to the RBBB, but since this is your first foray into TCM, you should be aware that unlike what you've experienced so far with the medical community, it seems that TCM is not there to help and support anyone. You have to strongly advocate for yourself and push them for results.

My first Cat 1 medical revealed what they called a reverse P wave. Took 6 months of delays while I still trained, stress test, etc before it was issued. It was a one time anomaly, yet
every year for 10 years I had my perfectly fine ECGs scrutinized, until I moved to a new CAME, who said "Oh, yeah that happens if they reverse 2 leads", which was my original suspicion that wasn't given any regard at the time, and had it erased from my file. Yup.

Now, 15 years later I'm in yet another pointless fight, and the list of colleagues being taken offline is growing as well. I don't know what's going on over there.... and neither does anyone else. The clerks try to be helpful, and seem to be a frustrated as we are, but the issues lie upstream with the bureaucrat physicians.

Not trying to freak you out, just letting you know they're an organization of which an increasing number of people seem to have to fight instead of working with, so be prepared.

Most importantly, don't think it's all over if they just come back with one bad answer. There are avenues. But, sometimes we have to just play with the cards we're dealt.

Good luck!

[taro]

Thank you for your thoughful reply Dan (I assume that's your name). I just started my flight training much like you did when you got your first medical - but I've gotten my Cat. 4 declaration (not the actual medical) and my instructor said he can accept that so I can at least get beyond the first solo.

May I ask if you have any advice for choosing a CAME? I heard the ones with nurses may not be as good, and indeed, when I did the ECG the nurse told me she put the pads in the wrong place the first time, and got it right the second time. But both indicated the RBBB apparently.

And do you know where I can find the reference for the RBBB in the TCM books? Just very confusing to find TC published stuff. Thank you.

[Ash Ketchum]

I had this issue on some past ECGs. Apparently it could happen to tall, athletic young men. It only showed up when they took the ECG in certain positions but not in others. I ended up going through an echo and stress test and was cleared without issues.

[North Shore]

I've held a medical for over 30 years with an RBBB present. I didn't have to do any other tests back in the day, though? No-one at Transport has questioned it since (touch wood!) I used to carry a copy of my initial ECG around with me as during my early career I did a medical at a Dr who didnt know my history, and didn't want to issue me a Cat 1 due to the RBBB showing up. Once I showed him that it was pre-existing, he was happy with it.
I do make a point of telling people giving me an ECG that I have a low (<50) resting rate and the RBBB, though, as the combination can set off alarm bells.

You should be fine. Just go through the process.

[DanWEC]

Well there ya go! Those testimonials should bouy your spirits a bit.

Transport doesn't publish the standards behind the scenes, only the CAME guidelines, which are in TP 13312 here:
https://tc.canada.ca/en/aviation/public ... s-tp-13312

You can glean further information from the UK and FAA guidelines which Canada is generally aligned with, though there is some variation in criteria.
https://www.faa.gov/ame_guide
Pdf download:
https://www.google.com/url?sa=t&source= ... i=89978449

Uk civil Aviation guidebook PDF:
https://www.google.com/url?sa=t&source= ... i=89978449

Cheers

[taro]

Thank you everyone for your replies. I'm glad to hear I'm not the only one with RBBB, especially when I could barely find any information about this online or on this forum. I'm going to my GP today so she can refer me to a cardiologist, so hopefully I can get the tests done soon.

I just know I'll have to keep bugging TC again and again so my medical doesn't take like another 4 months to get here! I'll keep this thread updated.

[tsgarp]

Went through something similar (paroxysmal a.fib). My CAME was very supportive; we got the extra tests from the specialist and the specialist wrote a short letter saying I was a no greater risk of sudden incapacitation than any other 47 year old. We sent the package off to TC and TC renewed my medical. This was pre COVID so it was all pretty quick.

[Bede]

Went through something similar (paroxysmal a.fib). My CAME was very supportive; we got the extra tests from the specialist and the specialist wrote a short letter saying I was a no greater risk of sudden incapacitation than any other 47 year old. We sent the package off to TC and TC renewed my medical. This was pre COVID so it was all pretty quick.

The magic number is an incapacitation risk of less than 2%/year for the specified condition. When your doc sends a letter to the RAMO, make sure that they include the probability of incapacitation. It will make the RAMO's job much easier.

[taro]

Update - I've gone to my GP and I was referred to see a cardiologist at a heart centre later today. Although the letter from TC only asked for a Holter monitor and an echocardiogram, they are insisting that I do a stress echocardiogram as well. Any know if I need an echocardiogram specifically as per TC, or will a stress echocardiogram be acceptable?

And I think I'll have to ask them to forward the report to me or my doctor so we can then forward it to the CAME who'll then forward it to TC.

[taro]

Update 2

I've just finished the testing required. I am now wearing a Holter monitor and will be until tomorrow afternoon. When I went to the heart centre, they first measured my blood pressure. They then put an IV in my arm and some saline. I then did the "stress test," where the doctor sandpapered me (yes, he took some sandpaper and rubbed my chest), and then put some leads on.

I walked then ran on a treadmill for about 15 minutes - light work. Every 5 or so minutes, the doctor took my blood pressure and printed out some ECGs. When I reached my maximum heart rate, they stopped the test and gave me a minute to catch my breath, and took off some of the leads. The nurse proceeded to get me to lay on my left side and took an ultrasound of my heart (echocardiogram). She put some contrast in my IV and did another ultrasound pass. She told me she took about 120 pictures and videos total.

After that, she took off the rest of the leads on me and removed the IV. I wiped the ultrasound gel off and the nurse attached a Holter monitor to me, which I will need to return tomorrow. I will be seeing the cardiologist to discuss results next Friday, but I am going to try for an apppointment sooner. Gotta say the most painful part was trying not to think about the IV and contrast moving inside my veins.... I felt really grossed out the whole time and was repeating to myself what I learned about geostrophic winds in ground school to distract myself!

Anyways, I hope if anyone else in the future comes by this thread with the same circumstances as I, you'll leave this thread more comfortable and informed about the process. I will update again once anything new happens. Thank you.

[DanWEC]

If the cardio wants to do the stress echo according to their expertise and recommendation, then by all means, it's for your health. However I would separate their procedures and TCM's, and absolutely insist that the letter and report prepared specifically for TC only includes the holter and echo, unless the cardio believes that the stress echo results unequivocally support your fitness without debate.

Once the results are in, if your specialist believes you're fine, make sure they clearly attest to that in the letter, specifically that you have no more risk of sudden incapacitation than if you didn't have the block. That's the part that TCM is laser-focused on.
I'd also ask your CAME for guidance as well on what to say and relay that to your specialist. I'm no expert, I have barely a whiff of medical background but I'm only relaying experience from myself and others.

Good luck!

[taro]

Thank you Dan, I will make sure to request that report be made specifically to TC's requirements and for a letter to be included stating I'm at no greater risk of sudden incapacitation. I did call my CAME last week and the nurse said that once I get the report from cardio, tell them and they'll get me to upload it to SecureDocs and they'll send it off to TC.

Again, will update this when I get to see my results next Friday. Thanks!

[taro]

Update 3

I went to my cardiologist yesterday, and good news - he told me everything is normal, as I expected. He said I have a straight back, common in skinny people like me, meaning my chest doesn't protrude outward as much as normal, making me appear "thin." So, my chest cavity would be smaller so my heart is more compressed and thus I have an enlarged right ventricle - but he says that is totally normal and nothing to be worried about since I was born like this. We went over the stress test and Holter results and turns out I have a resting heartrate of only 39 BPM and a max of 196 under exercise, which means I'm very healthy - also good to hear that my hiking and biking is doing me good!!

Anyways, I digress. The cardiologist proceeded to tell me that he'll write up a letter (including the fact that I'm at no greater risk of sudden incapacitation) and send it to the TC doctor who deferred my medical (?), my CAME, and my family doctor (?). Not sure why he is sending it to everyone, but I guess the more people know the better maybe? Perhaps it will make the doctors up at TC more aware of my situation instead of just my CAME. But I'm not sure if I need to send it to my CAME myself anymore, since the cardiologist will be doing it for me. If anyone has experience on this please chime in!

So I guess next steps for me is to keep calling everyone.
1) Call the cardiologist to make sure he wrote the letter (with no greater risk etc. etc.)
2) Call the CAME to make sure he received the documents and that he's going to forward them to TC for me.
3) Call TC to make sure they get the documents.

Sooooo how does this sound? Am I missing anything? Should I ask anything else in specific?

Again, I hope this will be of help to others in the future and of course, I'll keep y'all updated.

[taro]

Update 4

I asked my CAME's office if they got the reports directly from the cardiologist and they didn't. So I have retrieved the reports from my family doctor. She was in a rush to leave so she forgot to give me the last few pages, so I had to go back the next day and get them back. Included in this report were all the Transport Canada requests, in addition to a stress test report and a copy of my ECG.

Because TC specifically asked for the investigation, Holter, and echo reports only, I then asked my CAME if I should be including the stress test and ECG reports with the submission to TC. Just wondering in cause that would slow down the process or make TC fussy. They told me it wouldn't hurt. I guess it supports my case.

I have now given the reports to the CAME's office, who would then send them off to TC by the end of the week. Will be calling TC to confirm this.

And when I called about a week ago, the gentleman on the TC phone also told me I should have my medical issued "only a week or two" after they receive my reports, provided that everything is okay.

Thanks for reading!

[taro]

Well guys, it looks like my medical has been approved today! I am beyond delighted.

"Flexibility has been applied to the CARs medical standards, and you have been assessed as Fit Unrestricted for Category 1 Medical Certificate."

I'm very grateful I didn't have to wait years to get it. It's been seven weeks since my additional tests were submitted to TC and twenty weeks since I did the medical exam, so I guess I got lucky here.

Thank you everyone for your encouraging words along the way, and I'll see y'all in the skies!

[DanWEC]

Excellent news! That's the exact same verbiage I received last month after I was originally told last year that I'd either never hold a medical again or at best it would be restricted.
Pretty hard to argue with tests saying I'm at the 96th percentile of fitness... surprising because my subsistence is beer and club house dawgs.


Very happy for you man.

[taro]

Thanks man! Congrats on your good news too. Can't wait to start flying again.

I appreciate everyone's advice here, it's been really useful. XD