[Cap'n Wannabe]

A rather long and detailed reply to CM by Nowluke:

Leaving aside the details of your concerns with the application of administrative process and the roles of a regulator/accrediting body. I have no skin in the game or knowledge on that front, I have no CASA connection and empathise with your frustrations. It looks like you've not had a pleasant experience.

Nevertheless, you had a flight safety relevant condition which was treated using novel (i.e. new techniques) for which a significant body of long term evidence has not been generated. Your specialist opinions did not address the specific questions required in order to make a sound risk based decision. You then further complicated the process by acting as your own medical advocate with the avmed unit. Where was your DAME or GP in this process? Further complicating this you sought out 'tests' to provide secondary proof against a negative, which can't really logically ever be done i.e. "prove it won't happen"

There's an element of fixation around 12 months being 'required' to make a decision. Without diving into a large amount of academic papers, generally, any instrumentation of your brain, its vascular sctructures and the cavity it sits in has a significant risk of generating a (new) source of future seizures (i.e. risk) and causing damage/infection/bleeding. This risk is generally realised within the first 12 months if it is to occur and the corollary is that if its occurrence rate is less than once/year then it should generally be acceptable under most aviation contexts (or have mitigations applied to make it so).

There is no evidence that can be provided in the intervening time period as there is no clinical/investigatory test able to stratify the cohort- there is generally only evidence/results of higher risk i.e. a bleed/neurological symptoms/infection etc. or immediate short term 'treatment' success. That you have normal post intervention tests is reassuring you are not at a higher risk than baseline however the condition has risks of recurrence/treatment failure/complication that no test other than the passage of time exists to prove non-occurrence. A 12 month period is somewhat arbitrary but it is the objective statistical risk standard/threshold for decision making and there is some evidence for that period roughly correlating with a period of recovery healing/rehab and then physiological stabilisation (more towards the 6-12month time period). Much argument can be had over the 1% rule and its origins/assumptions but it is what is used and sets part of the standard.

The phrasing/process in the corro out of CASA, from your position, would not be compliant with admin process law or some similar position. It doesn't strike me as particularly troublesome in providing an independent opinion. Very specific hypothesis/questions/risk scenarios/assumptions need to be addressed with rigour. Provision of a supporting or dissenting opinion (with academic clinical research/analysis to support) against these is critical in coming to a reasonable decision against a risk framework (Meta-analysis, single quality study, other cohort research and then expert opinion form the hierarchy with most weighting to the former). The absence of an opinion (against not just "fit to fly today" but time based risk and long term consequences with quality research to back it up), as would appear to have occurred with your earlier reports has led to the ambiguity/lack of probabilistic statements against the risks. I would be very surprised if any reasonable person would then afford you the 'benefit of the doubt' rather than take the conservative position.

I'd likely consider you recommendable to be fit to fly Class 2 with restrictions after 12 months from your narrative but can't offer an opinion on an incomplete picture. The other question I would ask is that why not fly under an RPL or Basic Class 2 - if you VFR day fly only for your own pleasure? The emotional effort and time to 'fight' for a principle or against perceived slights is not going to be healthy for you in the long term.

And CM's response..

Nevertheless, you had a flight safety relevant condition which was treated using novel (i.e. new techniques) for which a significant body of long term evidence has not been generated.

Thanks for your opinion. I am not aware of what expertise and experience you have.

That said, I agree, based on the advice of specialists whose opinions I respect, that I did have a safety relevant condition. But note: I left out “flight”, because part of the problem with the Avmed paradigm is its self-interested insistence that aviation is ‘special’ with unique risks.

In fact, apart from the activities engaged in by fighter pilots and aerobatic pilots, there’s very little in aviation that entails some special demands on pilots, resulting in an objective justification for a special medical standard (even though pilots, wearing their own-worst-enemy hats, like to think otherwise).

Specialists with relevant, current experience disagree with your opinion that the treatment continues to be “novel” as you have defined it.

It’s an acceptable risk for me to continue to drive a car that weighs more than my aircraft and carries more people than my aircraft, on the road shared by buses full of school children a mere couple of metres away, day and night in all weather, when I’m apparently an ongoing potential neuro-circulatory time bomb. Were I to instead get into a vehicle of less weight with fewer passengers, usually kilometres from the nearest other people, apparently the risk of sudden incapacitation increases or the consequences become more catastrophic if there happens to be an air gap between the vehicle and the ground. That seems to me to be a nonsensical incongruity. However, I know why it exists - more on this later.

Your specialist opinions did not address the specific questions required in order to make a sound risk based decision.

Let me fix that for you: Apparently the specialist opinions do not address the specific questions that, in Avmed’s opinion, are required in order for Avmed to make what is, in Avmed’s opinion, a sound risk based decision by Avmed.

Were it the case that:

1. any of the medical professionals with whom I’m dealing were prepared to speak in glowing terms of Avmed’s expertise and decisions, and

2. I could find any correspondence or statement in this matter that is not replete with what I consider to be biased and intellectually dishonest spin by CASA, and

3. my specialists were unwilling to express any opinion as to my current fitness to fly,

then I might take Avmed’s opinions seriously and allocate weight to them compared with specialists with first hand knowledge of my circumstances.

What I find baffling is that when my specialists express the opinion that the procedure was a success, that I am not a risk of incapacitation and meet the standard for day VFR, it seems Avmed (and you) think those opinions were expressed just for shits and giggles, or perhaps based on disembowelling a goat and reading the entrails or by consulting an astrologer.

The objective fact is that there is no causal connection between Avmed’s opinions and levels of knowledge or ignorance on the one had and my compliance or otherwise with the medical standard on the other. Or do I have that wrong?

You then further complicated the process by acting as your own medical advocate with the avmed unit. Where was your DAME or GP in this process? Further complicating this you sought out 'tests' to provide secondary proof against a negative, which can't really logically ever be done i.e. "prove it won't happen"

Bit hard to know where to start with that...

I haven’t “sought” any tests. I hate doctors (not on a personal basis), I hate hospitals (but love their work), I hate needles and I hate holes being punched in my groin so that tubes and contrast chemicals can be fed through my circulatory system.

I’ve undergone the kinds of scans that my specialists recommended I undertake, at the points in time my specialists recommended that I undertake them, in what they say is the ordinary course of follow-up tests in cases like mine. (And let me make this very clear: If it were otherwise, I would be taking action if my specialists have been ‘ordering’ scans in circumstances in which they would not ordinarily recommend them. However, I’m very confident that my specialists know what they’re doing, in my particular circumstances.)

I have no idea what you mean by “acting as [my] own medical advocate with the avmed unit”. I asked my GP and specialist to forward to Avmed whatever stuff that may be relevant to my case. My first post-procedure correspondence with Avmed was me forwarding to Avmed my GP’s letter to Avmed that I requested my GP to send Avmed, just to make sure Avmed had received it and I couldn’t be accused of withholding information from Avmed. My GP didn’t generate that letter as a consequence of sensing a disturbance in ‘the force’.

I visited my GP after the procedure. I had a follow-up visit with the specialist a few weeks after the procedure. Are you or Avmed worried that my GP and specialist failed to notice that half my face was paralysed, drool was running down my chin and I was in a wheelchair being led by a guide dog?

As to a DAME, what possible ‘value add’ could a DAME’s opinion currently be? Are you seriously suggesting that, having disregarded the specialists’ opinions, Avmed is going to do anything other than disregard the opinions of the non-specialist GP and DAME? (This was one of the fascinating things that CASA brought up at the stay hearing.)

I have repeatedly requested that the delegate confirm, in writing, that the results of scans carried out during the 12 month period post-procedure will be assessed by and potentially change the delegate’s position during the 12 month period. That request has repeatedly been denied. There’s been some sophistry in correspondence from a CASA lawyer, but the lawyer isn’t the delegate and the lawyer’s opinion does not determine the delegate’s position. For CASA to keep raising the issue of GPs and DAMEs in those circumstances is, in my view, simply disingenuous. CASA will ignore their opinions (unless, of course, they are against my interests) and GPs and DAMEs will defer to the opinions of treating specialists in any event.

There's an element of fixation around 12 months being 'required' to make a decision. Without diving into a large amount of academic papers, generally, any instrumentation of your brain, its vascular sctructures and the cavity it sits in has a significant risk of generating a (new) source of future seizures (i.e. risk) and causing damage/infection/bleeding. This risk is generally realised within the first 12 months if it is to occur and the corollary is that if its occurrence rate is less than once/year then it should generally be acceptable under most aviation contexts (or have mitigations applied to make it so).

In your opinion.

And what, in your opinion, is the percentage risk of a recurrence of or new vascular abnormality, multiplied by the the percentage risk of that causing sudden incapacitation? Or is this one of the circumstances in which it’s just OK to use words like “significant” or “high”, rather than specific numbers like 1% or 2% that apparently have some magical consequence. The insistence on specificity is selective. That selective insistence is, in my view, biased and intellectually dishonest.

There is no evidence that can be provided in the intervening time period as there is no clinical/investigatory test able to stratify the cohort- there is generally only evidence/results of higher risk i.e. a bleed/neurological symptoms/infection etc. or immediate short term 'treatment' success. That you have normal post intervention tests is reassuring you are not at a higher risk than baseline however the condition has risks of recurrence/treatment failure/complication that no test other than the passage of time exists to prove non-occurrence. A 12 month period is somewhat arbitrary but it is the objective statistical risk standard/threshold for decision making and there is some evidence for that period roughly correlating with a period of recovery healing/rehab and then physiological stabilisation (more towards the 6-12month time period). Much argument can be had over the 1% rule and its origins/assumptions but it is what is used and sets part of the standard.

Interesting opinions.

“There is no evidence that can be provided in the intervening period as there is no clinical/investigatory test able to stratify the cohort”. Really? There are eminent specialists in medicine and statistics who have different opinions. Or is yours an objective truth?

“Somewhat arbitrary”. Is that like being “a little bit pregnant” or “slightly heavy-handed”?

The “1% rule” is not a rule. That’s why much argument can and should be had about it. I realise that it’s a number that’s nice and simple and, therefore, compellingly attractive and easy to use to convince the AAT and others of its safety relevance. But the objective fact is that it isn’t a “rule” and there is no safety magic in it.

The phrasing/process in the corro out of CASA, from your position, would not be compliant with admin process law or some similar position.

I have no idea what you meant by that.

It doesn't strike me as particularly troublesome in providing an independent opinion. Very specific hypothesis/questions/risk scenarios/assumptions need to be addressed with rigour. Provision of a supporting or dissenting opinion (with academic clinical research/analysis to support) against these is critical in coming to a reasonable decision against a risk framework (Meta-analysis, single quality study, other cohort research and then expert opinion form the hierarchy with most weighting to the former). The absence of an opinion (against not just "fit to fly today" but time based risk and long term consequences with quality research to back it up), as would appear to have occurred with your earlier reports has led to the ambiguity/lack of probabilistic statements against the risks. I would be very surprised if any reasonable person would then afford you the 'benefit of the doubt' rather than take the conservative position.

And there we have it, writ large: Not an objective assessment of the risks and consequences, but bias towards the worst-case scenario, based on an appeal to the “reasonable person”.

And we know what Ace CASA always has up its sleeve: the cognitive bias of the “reasonable person” contemplating an aviation catastrophe. You should read all the relevant studies on cognitive bias. Scaring the public pays the bills.

I'd likely consider you recommendable to be fit to fly Class 2 with restrictions after 12 months from your narrative but can't offer an opinion on an incomplete picture.

Not to worry: I have specialists who’ve already expressed an opinion.

The other question I would ask is that why not fly under an RPL or Basic Class 2 - if you VFR day fly only for your own pleasure?

Not that it’s any of your business, but the answer is: I don’t want to. I’m pretty sure I still have choices in these matters.

The emotional effort and time to 'fight' for a principle or against perceived slights is not going to be healthy for you in the long term.

And here we see another ghastly irony of the Avmed system, writ large.

Avmed made an administrative decision that affects my interests. I am entitled to seek review of that administrative decision, and have done so. That’s how it’s supposed to work in a representative democracy supposedly subject to the rule of law. Your dismissal of my concerns as “perceived slights” suggests to me that you might not understand how government accountability mechanisms are supposed to work, and why, (but also, coincidentally, confirms for me that you are in the medical industry).

The practical consequence of the way in which Avmed chooses to administer the medical certification system is that people can simply be ground into submission through not having the resources to fight or - and this is the ghastly irony - through the stress that is ultimately deleterious their health. What a great outcome! Caused by people who claim to be medical professionals.

Let’s see if I can summarise: We should all just cop whatever decisions Avmed makes, because to do otherwise will be bad for our health. (What’s the name of that organisation which says non-compliance with its demands could be bad for your health? The name escapes me for the moment...)

The “principle” that I am actually fighting for is aviation safety.

There are very simple ways for holders of class 1 and class 2 medical certificates to avoid all of what I’ve gone through as well as keep their medical certificates. Very simple ways.

The way in which Avmed currently chooses to administer the aviation medical certification regime encourages pilots to choose those ways. Pilots are increasingly choosing those ways.

That is bad for aviation safety because it’s bad for the health of those pilots.

That is why Avmed is now, in my view, a force inimical to aviation safety.

Think about that and your opinions, the next time you jump on a commercial aircraft. And remember: you’ll be sharing the sky with self-certified pilots.