AME Guide Grand Rounds February 2026 Session

Hello everybody. Good evening. Welcome to AME Grand Rounds. I'm Dr. Brett Warrick. I'm the Deputy Federal Air Surgeon. I have the privilege of working for Dr. Susan Northrup who cannot, who sends her regrets she cannot be here today. But I want to thank all of you for coming and participating tonight. I see a lot of my former military colleagues and also we have many FAA employees on here tonight. The reason being I keep them busy in their day jobs and they can't attend the afternoon session of Grand Rounds so they're on tonight. And also a special welcome to Dr. Tim Sprott who is joining us from New Zealand, head of the medical branch of the New Zealand Civil Aviation Authority. Welcome, Tim. And with that, we've got an exciting, we've got a very exciting presentation for you today. I think you're going to find it interesting and I also think you're going to find it useful for what you do for the FAA. And with that, let me give you back over to Christy Risley for our housekeeping announcements and how, most importantly, how to access your continuing medical education certificates for this event tonight. Christy, take it away. Oh, I think I was muted. Thank you, Dr. Warrick. Next slide, please. I'll echo Dr. Warrick. Hello, good evening, good afternoon, wherever you are from that you're joining us. First and foremost, the session is being recorded like all of our sessions. No participants will be shown and the recording will be made available later on our YouTube channel. The best way to find that is just to open up your favorite internet browser, go up in the search bar, type in FAA AME Grand Rounds, hit enter, and you should be taken to our YouTube channel. It can take us up to a couple of weeks to get those recordings loaded for you, but they should, the recording from today should be there within a week or so. Next slide, please. Some rules of engagement. First off, we do lock the room after the first 10 minutes. What this means to you is that once you are in the Zoom and we lock that room, if you drop out of Zoom, you won't be able to rejoin. Your chat, your cameras, those are all disabled. We do that because we want to capture any questions using that Q&A button that is at the bottom of your Zoom screen. If you're new to Zoom or you haven't been in Zoom in a while, if you'll take a minute, look at your screen, locate that Q&A button, and that is where you're actually going to go in and enter your questions for the session. We do ask that you would please keep your questions to the topics being discussed. We know you may have a lot of questions and they may be really good questions that aren't related, but we do want to try to stay on schedule by keeping your questions to the topics at hand. Also, as part of our accreditation, which allows us to grant you one hour of CME every month, we do have to tell you if any of our speakers have any disclosures, and this is the statement for the session, that no speakers have any prohibited relationships to disclose. Okay, what you're here for. Here are our objectives for the evening. We have two parts to this evening. The first one is we're going to talk about the requirements for the AME to use DMS, and that is guided and directed by FAA Order 8000.95D. Leah Olson is going to be talking about that and what the impact is if you have staff members logging into DMS as the AME, and also how to correct that if it occurs. And then Dr. Charles Mathers is going to talk about the AME guide updates that were released today. We have some new GI conditions. We have a new GI conditions index, a MASLD, NAFLD, or MASHNASH, and a new CACI worksheet that goes along with that. We have updated disposition tables for cirrhosis, esophageal varices, liver transplant, and an update to the ulcerative colitis CACI. And in addition, we have a new disposition table for alpha-gal syndrome. So without anything further, I'm going to go ahead and turn this over to Leah Olson. Leah? Thank you, Christy. I just have a little bit to talk about how to log in to DMS through login.gov and what not to do. Next slide, please. Okay. So as you know, the order that governs your AME designation is the 8000.95, and it's version D now. Under the responsibilities and obligations of the designee, it states what is expected of you. Part of that is to take care of your DMS account and not your staff. Next slide, please. So we've had a little bit of an influx with the staff logging into the AME's DMS account but using their own login.gov account, and that is a big no-no. The staff should not be accessing your DMS account for you at all. It should be only you as the AME. So that includes all your DMS actions, your annual requests every year that you have to submit to renew your AME designation. Anything that you need to do in DMS needs to be done by you, the AME. Next slide. So what happens when the staff member logs in with their personal login.gov account and logs into the DMS account of the AME, it automatically updates the name of the AME to the staff member. And so the end result of that is when you do exams and you go to print out certificates, your staff member's name is being printed out on those medical certificates instead of the AME's name. There is a way to correct that, but the main thing is always make sure it's you, the AME, and not your staff member. Next slide. So if this happens, first thing you need to do is immediately stop doing medical exams. Second thing you need to do is contact your managing specialist. If you don't know who that is, you can send me an email and I can tell you who your managing specialist is. We also sent out an email last week and you also got a message in DMS with an instruction sheet on how to fix this issue if it should happen. Just make sure that you're not doing any exams after this has happened, because again, your name's not going to be printed on it, so the medical's not going to be valid. If you have questions or need help with it, we do have our DMS help desk. It's 9-AVS-DMS-AME at FAA.gov. Thank you, Leah. Hey, Dr. Matthew, or Mather, sorry. Would you like to go ahead and continue with the second part? We'll do all the Q&A at the end of the evening. Absolutely. Good afternoon, or good evening, everybody. Welcome to the evening session of AME Grand Rounds. We're happy to have you here. Today, we're going to be going over several AME guide updates. This is Gastroenterology Month, so you're going to hear about a bunch of GI-related conditions. I also have an announcement to make. You may have heard of a system called OneGuide that we use internally at the FAA. This is a system primarily used by our medical officers and regional flight surgeons to review cases, make air medical dispositions. We are going to be releasing that to the public in phases starting tomorrow. It was supposed to release today. It's going to be released tomorrow. The message for the AMEs is that we primarily still want you to use the AME guide. That's going to be your source material. However, if you're curious about the system that we use, OneGuide, that will be available to you starting tomorrow. So, it will be released in phases. You're first going to have access to the neurology section, and then periodically after you'll get some new sections. So, that was the one announcement I wanted to make before I got started. Okay. So, in keeping with this being GI Month, item 38, abdomen and viscera. We have updated this section in the AME guide. There's now a condition index with links so that you can more easily find these conditions. There's several new disposition tables. So, we hope that this format makes it easier to work with and easier to find conditions in the AME guide that are GI related. Okay. The first condition is MASLD slash NAFLD. This is metabolic dysfunction associated steatotic liver disease or MASLD, formerly known as NAFLD, non-alcoholic fatty liver disease. So, this is fatty liver. MASLD is the newer term. Non-alcoholic fatty liver disease is the older term. We listed both of those just because they're probably still in use. This is overall, as you know, pretty low error medical risk, pretty commonly seen out there. If you see a pilot with fatty liver disease and you can determine the conditions under control, those symptoms that would interfere with flight or safety related duties, you can go ahead and issue and we won't ask for any information about that. This is a low risk error medical condition. Now, the next one is MASH, NASH. We actually got this as a request from an AME. They reached out to us and said, you know, we're seeing more and more of this and there are some phases of MASH, NASH that are a little more concerning from an error medical perspective and we really don't have any guidance on it. So, we took that for action and we came up with some guidance. Most of the time, MASH or metabolic dysfunction associated steatohepatitis, formerly known as non-alcoholic steatohepatitis, most of the time this is going to be of low error medical risk, but there are going to be scenarios where the fibrosis has progressed to a point where we do want to take a closer look. Because most of these cases are lower medical risk, we decided to make this into a CACI. So, I'll show you that CACI here in just a minute. So, this is what the CACI for MASH and NASH is going to look like. We're going to ask for a current detailed clinical progress note. It can be from a treating physician or a specialist. We want to verify that the condition is under control. If there's any insulin resistance present, we want to make sure that's adequately treated and no symptoms. So, sometimes MASH can cause fatigue and malaise. We just want to make sure that there are no symptoms that would interfere with flight or safety-related duties. Insulin resistance is very common with this. So, if the pilot has pre-diabetes, we have a CACI for that. If they're treated with weight loss medications, such as one of the GLP-1s, there's a CACI for that. So, as long as they meet CACI criteria, you can continue to issue under CACI qualification. The second one is any clinical evidence or diagnosis of cirrhosis. This is a condition that can progress to cirrhosis. So, we want to make sure that it has not progressed yet to that phase. The fibrosis score from a lab or imaging performed no more than 90 days ago. We want none of these values exceeded. A question we got this morning, which we will clarify in a later update, is you'll notice that we've listed several tests here that you can use. The first is the FIB4 index. That's just a lab test. I'll go over that more in a second. The second is ultrasound-based vibration-controlled transient elastography, and the second is magnetic resonance elastography. These are all non-invasive tests that are used to evaluate MESH. We don't need all three. We just need one. So, if the FIB4 index is the easiest one for you to get, that is acceptable. The FIB4 index is calculated using age, platelet count, AST, and ALT. There's a bunch of online calculators that you can use, and the FIB4 index just has to be less than 1.3. We've provided values also for the VCTE and the magnetic resonance elastography. Again, we only need one of these. So, if you're able to check one of these, you're good to go. Medications for the condition, any combination of either none, vitamin E, or if they're treated with weight loss medication, you'll want to see that page and ensure that they're CACI qualified. So, that's the MASH-NASH CACI. We hope that is helpful to you all in the field. Now, of course, if they have MASH that's higher risk, you're going to want to defer. There is a typo on this page I wanted to point out. So, it says here FIB4 index greater than 1.45. That is a typo. Sorry about that. We'll get that fixed as soon as we can. You're going to want to follow the CACI guidance for this, and if it's over 1.3 for the FIB4 index, that's going to meet deferral criteria. So, we will get that fixed. Now, of course, if they're symptomatic, if they have a fibrosis score of F2 or greater, or the liver biopsy if they had one, definitively shows cirrhosis, you're going to want to go to that page. In this case of a higher risk MASH, we're going to want a DCPN from a hepatologist or a treating physician is okay. Labs to include liver function testing, CBC, results of any imaging studies performed, and then liver biopsy if performed. Okay, so that covers MASH and NASH. Moving down the progression in liver disease, now we're going to talk about cirrhosis. So, for those of you who treat cirrhosis, you know this is a serious medical condition that involves the, you know, typically an end stage, end stages of liver disease. There is a spectrum of it, and there are some pilots out there who have mild disease that we might be able to get to a yes to, but this is a serious condition. Now, row A for cirrhosis is going to be just an incidental finding on radiology only. So, as you know, sometimes a radiologist will call a study and say, hey, this looks like cirrhosis. If a note from the treating physician documents that actually they don't have cirrhosis, that was just an imaging call, you can go ahead and issue in that instance. Now, of course, if they have any of these other things that are identified, or if they actually have cirrhosis, you're going to want to move on and go to row B. So, this is row B. This is non-alcoholic cirrhosis. We have a separate row for alcoholic cirrhosis. There's going to be a bunch of stuff that we ask for here. There has been a link to cirrhosis in the AME guide previously. It didn't contain a lot of information, though, and so we're going to try to give you guys some info so that you know what we're going to expect. So, in this instance, we're going to want a DCPN from a hepatologist or a gastroenterologist. This is going to require a specialist. We want to know things like how the condition was diagnosed, the etiology, if there were any hospitalizations, and then, of course, if there are any complications, such as a history of hepatic encephalopathy, ascites, or varices. We would like a calculation of the Child-Pugh score. There's also MELD scoring out there. We have found the Child-Pugh score works better for us from a prognostication standpoint, and it helps us to assign aeromedical risk. Some labs are going to be needed, typical liver stuff, CBC, CMP, GGT, etc. If there were any imaging studies, we're going to want to see those. Important to submit the most recent upper endoscopy because varices are a known complication of cirrhosis, and they can be suddenly incapacitating if they rupture, and so that's very important to assess in these patients. Biopsy results, if they're performed. So, this is the big one that I want to spend a little time on. So, we are going to ask for an initial cog screen with a new diagnosis or a new presentation of cirrhosis. Now, the reason why we're going to ask for a cog screen. So, I'm an internist, and when I used to treat these patients, we used to think of this as kind of like an on and off switch. So, a patient would come into the hospital with a history of cirrhosis. They would be acutely encephalopathic. We would treat it, and they would get better, and their mental status would clear. What's been learned since then, there's lots of evidence to back this up, is that the encephalopathy exists on a spectrum, and so typically, these patients, if you test them even at their baseline, they're not neurocognitively normal in many cases. There's even a concept called minimal hepatic encephalopathy, which is basically like even at baseline, you have this minimal sort of encephalopathy going on. So, it's really important for cirrhosis to get a baseline assessment of the neurocognitive function, so we're going to ask for that. The other important thing to know is that this is going to be a recurring requirement. Because cirrhosis is typically a progressive disease, and because the metabolic function can fluctuate, we're going to want to see this on the follow-up evaluations as well. There may be some one-off or some specific cases where we may not have to do that recurrently, and we're going to evaluate that case-by-case basis, but for the most part, we're going to be requesting this on each exam. So, the only other thing we're going to ask for is any other testing deemed appropriate by the treating physician. So, again, cirrhosis is a serious aeromedical condition, requires a bunch of information, and we've given this information for you all here. Row C is going to be alcoholic cirrhosis, so alcohol is still a very common cause of cirrhosis. If they have a history of abuse or dependence, you're going to want to follow the substance abuse or dependence criteria. They're going to still need all of the Row B information. Now, of course, for all you HIMSS AMEs out there, if they have substance dependence, they're going to fall within that category. They're going to be getting the full neuropsychological profile like they typically do. But the bottom line here is that if alcohol is involved, you're going to want to follow that process. And, of course, they have to be in stable recovery before we will consider them. Okay, moving on to our next topic, which is esophageal varices. Again, this is a known complication, very serious. If you've ever treated this in the ICU, you know it's a really scary thing to witness and to treat. So, Row A is going to be for individuals with small varices, and these are graded either 1 or F1 without red signs. So, red signs are indications that the varice has bled recently. So, we don't want to see any of those. Of course, if the underlying cause is identified, we're going to want to see that page. In many cases, this is going to be patients with cirrhosis. We're going to want to see a detailed clinical progress note from the gastroenterologist. It has to specifically include any bleeding events, treatment outcome, size, grade, location of the varices, and then, of course, any of these red signs. We're going to want to see a report from the most recent upper endoscopy study, labs to include CBC, anything else. All of these are going to be deferred because, again, esophageal varices is a serious condition that can cause sudden incapacitation. If they have had any history of bleeding esophageal varices, that requires a minimum of a six-month recovery period before we can consider them. Again, this is higher medical risk. We're going to need all information in row A after that six-month recovery period, and you're going to want to defer these cases. For row C, this is going to be everybody else. If they have enlarged or large varices, any with these red signs, any history of bleeding within the past six months or the disease process is inadequately controlled, this is probably going to be a no, but we're going to ask for some information just to kind of get an assessment, DCPN from a gastroenterologist, and then the most recent upper endoscopy. Okay, the next condition is liver transplant. So for the donor, this typically isn't a big deal. In fact, if it's been more than a year, you really don't have to do anything, just your usual AME exam, make sure they're doing fine, and you can go ahead and issue. The only thing we ask is if the donor surgery was within 12 months to just review a DCPN from the treating physician just to make sure there aren't any complications. This does not hold up certification. As long as you have that DCPN, it's good to go. If the surgery was within 12 months, you can still go ahead and issue. So overall, this is not typically a big deal aromatically. Now, of course, the liver transplant recipient is a big deal. So again, we're going to want to see six months post-surgery, three months of documented stability. We have updated this protocol and incorporated it into a DISPO table for you all. I'll go over this. There's a lot of information that we typically need for these cases. So we're going to want a DCPN from the transplant surgeon, transplant team physician, indication for transplant, any sequelae, any recent or expected change in the treatment plan, any rejection, grass versus host disease, any infections, hepatitis C, any malignancies, labs to include CBC, CMP, any imaging studies, MRI, CT, PET, specific results of the liver biopsy already performed. So again, quite a bit of information here, but we hope that by laying it out for you all, if you have any of these patients, that they have some good guidance for you all. Now, of course, if they have any combined transplants, such as liver or kidney, we're going to want to submit the required items for each individual organ transplanted. So if it involves the liver, you would use this page and then you would go to the other page for the other affected organ. Okay. I just have two more things. The last couple, the first one is just a quick update to the colitis CACI. We worked with one of our consultants and they wanted us to clarify what mild diarrhea meant. And as you can see here, less than four bowel movements a day is what is considered mild diarrhea. They also said that microscopic colitis could be added to the CACI. And so we have added the microscopic colitis to the CACI, as you can see right here. Okay. My last condition is alpha-gal syndrome. So some of you may have seen this or heard about it. This is thought of as a tick-borne illness that can lead to a meat allergy. And from an aeromedical standpoint, most of these cases shouldn't be too big a deal. The allergy tends to wane over time. And as long as you're avoiding the trigger, it shouldn't be an issue. So for row A, if they've just had some mild reactions or symptoms have resolved with dietary modification, we really don't need anything. Just make a note in block 60 and go ahead and issue. The only time we're going to ask for a deferral in this history is if there was a severe reaction, angioedema, anaphylaxis, syncope, that kind of thing, or if they're currently symptomatic. In that case, we'll accept a note from an allergist, a gastroenterologist, or a treating physician, give you guys a lot of options. Has to include the severity, frequency of the reactions. And then we also want to see results of an alpha-gal IGE level to assess the current condition. Dr. Wyrick, would you like to close us out? Yes. Just again, I want to thank everybody for your interest in aviation safety. And again, especially for our international participants tonight. And again, and I see another one of my colleagues from New Zealand, Dr. Sarita Dara is on here tonight. And Sarita, thank you for joining us. And I know it's early over there. And just appreciate everybody. Appreciate everybody joining us. And I just want to say, again, when you look up in the sky and you see that contrail, you played a big part in getting that airplane up there. And thank you, everybody. We hope you found this helpful. And we'll look forward to seeing you the next time at Grand Rounds. And on behalf of Dr. Northrup, and just if you could, just one moment. I just want to take one more. So a year ago, we have made tremendous progress in the realm of medical certification. A year ago, we had a backlog of over 12,000 cases. Some of those cases were over 700, 800 days old, waiting for our medical decisions. Under Dr. Northrup's leadership, we have improved that statistic where today, we have just slightly over 4,000 cases waiting aeromedical decision. The vast majority of those were waiting for paperwork from the airman and the oldest case that we now have is less than 350 days old. And again, and that's because I'm a softie. And I tend to give the people who are overseas a bit of a break and also for the military members who can't. We're really trying to turn this thing around. Here's one other fact that most of you don't realize. When Dr. Northrup came into town six years ago, she came into town six years ago, we were doing 29,000 special issuances a year. This year, this past year, we did over 61,000 special issuances. Okay. And again, I go back to Dr. Northrup is all about, we're not protecting planes from pilots. Our job is to keep pilots in the cockpit. And if they fall victim to injury or illness to get them back into the cockpit. Can't do it without you guys though. Thank you so much for what you're doing. Thank you for helping us out and thank you for putting up with it. And we're always trying to make it better. Look forward to seeing you guys next time. Thank you so much.