How can I be a good, happy cog in a giant machine?

[Guest]

This is mostly aimed at the other medics, but I'd like to hear from some retrainees on the forum.

The other week, a patient came to my office for a special duty clearance with a very short turnaround. The member had previously applied for an unrelated job and was medically cleared by the person I replaced. He obviously wasn't selected, so he applied for a different position. As he had been approved relatively recently for the first job, he thought it would be a pretty quick review process and relative formality for me to review his record and generate his 422. He's not wrong in that assumption; if another 4E reviewed and cleared him, I hoped the clearance process would be pretty smooth, as any major hiccups should be in the last review notes. But being the good Med. Standards Tech I am, I reviewed the whole record and...

Surprise! Surprise! (who didn't see this coming?) Unresolved diagnosis of likely moderate/severe sleep apnea way back in 2006. I consult with a Flight Doc, who concurs with my findings (though I hoped I was wrong), and now I get to tell the pt. he might be facing MEB and a long delay in any processing. Then I get to notify his PCM of the case and help initiate an AAC 31 DLC. Obviously, the pt. was quite upset. I explained it to him as well as I could. Medical notes say the member was notified to get some follow-up work done to verify suspected diagnosis in 2006 and again in 2009, but I am not shocked when he says he never knew he needed to do more follow-up. Either he wasn't listening, wasn't told, or he didn't want to do it. Whatever the reason, the MDG didn't document it the right way and we failed to make him do the tests. He says it self-resolved several years ago (of course he says that). Too bad, it's in his record saying he probably has it.

TL;DR--He didn't do required tests in 06, we didn't code him and follow-up to make him do the tests, and the person I replaced cleared him by not doing their job well. I've DQ'd plenty of patients in the past for justifiable reasons, but these failures of medical procedure that I was obligated to resolve somehow struck me. I'm passionate about my job. I know it's red tape and bullshit sometimes, but it does need to be done or else you're Air Force is going to be full of Asthmatic Flyers and Epileptic Maintainers that were never fully eval'd. My question is--How can I be a good, happy cog in a giant machine? I've recently had a string of pretty broken patients. Some got cleared but most didn't. None are happy and most don't understand. It feels like this part of my job turns me into a rubber stamp. Does anyone else feel the same? Retraining and special duty clearances are people careers and dreams with real weight on their life--am I supposed to feel crappy when I DQ somebody and tell them the cold truth? Should I be less of a pussy and objectively aloof, uninterested in the wayward Security Forces Airman's plight to get a different job?

Waiting for someone to post that I'm a pussy and just a REMF that needs to find some cajones.

[Guest one]

I was medically DQed on Thursday. I was extremely pissed at the doctor even though he did everything he could for me and was a real nice guy. I don't know if I am in denial but I really believe my medical problem is temporary and strongly disagree with the doctor's decision.

I know it has got to suck to be the bad guy and tell people that they just wasted a year or more of their life towards a goal they can't meet or even worse, tell someone that their career is over. If doctors catch the problems before the patient works so hard towards the goal it will be less painful when they find out.

If you didn't feel crappy while telling someone they are DQed then I would be worried. The last thing I want to do is get bad news from a doctor that seems like he doesn't care. I do not know how many people you DQed in your career but I can't imagine it being an easy job.

Thank you for your service. It is important for the military to have some doctors that actually care. As I am sure you know, some don't.

Edited February 9, 2013 by one

[brickhistory]

Should I be less of a pussy and objectively aloof, uninterested in the wayward Security Forces Airman's plight to get a different job?

Is there any room in your job for judgement calls? Or is is strictly 'by the book?'

I am not asking meaning to be insulting.

I am asking out of curiousity and to answer your question.

If, in your AND the Flt Doc's best, educated opinion, is it necessary for the good of the Service, to DQ someone for whatever malady? Is there wiggle room, and if so, what determines which way the wiggle proceeds?

[ChiefSlapahoe]

Part of what helps me is talking to my peers about people situations over a beer and every time I think I've seen a first I have my bros telling me they just had the same problem two months prior and then talk about how we both handled it.

Personally, I don't think you're being a ######, you're being a human. Take out the humanity and then you soon turn into a dry husk that rubber stamps DQ paperwork without caring about the patient at all.

[matmacwc]

Not a pussy, should have cleared it up himself. I am proactive in medical shizzle, even if I'm trying to talk the Doc into something, never let it be. Ask yourself if this was the same dude in 06 you were seeing, that's where you earn your "not douchebagness" not years later when he should have listened.

Edited February 10, 2013 by matmacwc

[Motrin]

Did he get a sleep study and not follow up? Or not get the sleep study. And what job is he going for. Kind of depends on why he was sent in the first place. Is he an obese hypertensive smoker sick call surfer. Or a fit guy with a big neck or some other anatomical consideration. If the latter, have his PCM work up, get a UPPPlasty or use Positioning techniques and voila waiver possible. I haven't read the new OSA waiver guide but I know it's gotten easier to waive recently. I didn't think you needed to code OSA unless they are on cpap, the standards changed. And the board is a fast track now.

Any way my advice is try try try. It's easy to throw cases like these away because the sgp is in a hurry to go pull gs or play golf or somethingr, but put yourself in their shoes. Everybody deserves a fair shot. Remember that you can always scrutinize previous diagnoses if you think it's incorrect.

Edited February 11, 2013 by Motrin

[RASH]

Did he get a sleep study and not follow up? Or not get the sleep study. And what job is he going for. Kind of depends on why he was sent in the first place. Is he an obese hypertensive smoker sick call surfer. Or a fit guy with a big neck or some other anatomical consideration. If the latter, have his PCM work up, get a UPPPlasty or use Positioning techniques and voila waiver possible. I haven't read the new OSA waiver guide but I know it's gotten easier to waive recently. I didn't think you needed to code OSA unless they are on cpap, the standards changed. And the board is a fast track now.

Any way my advice is try try try. It's easy to throw cases like these away because the sgp is in a hurry to go pull gs or play golf or somethingr, but put yourself in their shoes. Everybody deserves a fair shot. Remember that you can always scrutinize previous diagnoses if you think it's incorrect.

Disclaimer: I'm not a doc, however

DO NOT get a UPPP under any circumstances. I got one in 1996, and have had problems swallowing/eating ever since. It did NOTHING for my snoring, not to mention the fact it hurt like hell for about 3 weeks afterwards. I've also spoken with several others who had the same results, and I have yet to meet anyone who said it works. YMMV...

[Fud]

Should I be less of a pussy and objectively aloof, uninterested in the wayward Security Forces Airman's plight to get a different job?

I believe there is an underlying reason why you may be asking this question, otherwise, why would you post on this topic. If the condition he has clearly limits or disqualifies the applicant, then your question is answered. However, I know that everything is waiverable until all petitions are made up to the highest levels.

If it were me, and I don't have any other context than what you provided, I would try and resolve the issue before coming to some sort of solution. I would advocate for him and see what the circumstances were. I would suggest to the flight doc that he be re-tested and see what the new results are. Some people are misdiagnosed, while it may be a diagnosis supported by what you find. Either way, it will not hurt anyone or anything to try and help him out. You may have done that in this situation, but I wasn't sure.

[Guest]

Any way my advice is try try try. It's easy to throw cases like these away because the sgp is in a hurry to go pull gs or play golf or something[...]

I thought this was obvious but I guess not--my original post was a conglomerate of several patients in several similar instances. I'll never post exact specifics of a case on here. For the theme of this thread, consider it one patient, but know that this is not a single instance. Something similar to the above happens at least once a month in my MDG.

Also, what kind of SGP do you have that cuts work early to go golf?

Anyway, I submit plenty of waiver requests for the patients that come through my door. Some get waived, some don't. The ones that definitely don't are the ones with less than a week leeway for clearance. I don't always need a week to review your record, but when I find something on the 4th day, you're screwed if you need follow-up eval.s with less than 2 days left in your window.

Is there any room in your job for judgement calls? Or is is strictly 'by the book?'

I am not asking meaning to be insulting.

I am asking out of curiousity and to answer your question.

If, in your AND the Flt Doc's best, educated opinion, is it necessary for the good of the Service, to DQ someone for whatever malady? Is there wiggle room, and if so, what determines which way the wiggle proceeds?

For me, there is almost no subjective interpretation of the regulation; if there is ever a real question of qualification, I notify the PCM or Profile Officer, who has much stronger position to interpret individual situations, though that is still a relatively small gray area.

MEB's (kicking someone out for a medical reason) is a very lengthy process involving the PCM, Senior Profile Officer, local Chief of Medicine, and an AFPC appointed Doc. Regulation of whether or not to MEB someone is a bit less stringent, but the outcome of whether to retain, permanently limit assignment, or separate is highly subjective.

But I would always look for reasons why you can help someone, rather than reasons why you can't. You can find justification for either side of the argument.

I work late to help people get cleared, and to do my other primary duties. I want to clear people, but I need time. A medical ETP needs submittal to the Career Field Manager. Known conditions often need re-evaluation (sometimes by specialists). Conditions disqualifying for the desired position, but not the current position, are generally unknowable until the review process starts. The most important thing an applicant can do is be conscientious of their time frame and anticipate medical's bottle neck for their clearance. If you have a short turn-around for a package submittal, get proactive immediately.

I believe there is an underlying reason why you may be asking this question, otherwise, why would you post on this topic. If the condition he has clearly limits or disqualifies the applicant, then your question is answered. However, I know that everything is waiverable until all petitions are made up to the highest levels. If it were me, and I don't have any other context than what you provided, I would try and resolve the issue before coming to some sort of solution. I would advocate for him and see what the circumstances were. I would suggest to the flight doc that he be re-tested and see what the new results are. Some people are misdiagnosed, while it may be a diagnosis supported by what you find. Either way, it will not hurt anyone or anything to try and help him out. You may have done that in this situation, but I wasn't sure.

The question isn't whether I should clear the patient--it's already known he's DQ'd for the indeterminate future. Also, the patient had less than 2 weeks to submit his special duty The question is whether I should feel badly he's DQ'd. We might get the guy cleared if he had the time, but the Vol By date cares not one whit whether medical is still evaluating him.

[Boxhead]

Disclaimer: I'm not a doc, however

DO NOT get a UPPP under any circumstances. I got one in 1996..... and I have yet to meet anyone who said it works. YMMV...

Hello. Nice to meet you! Had mine done in 1998 @ WPAFB and I never knew you were supposed to feel so good when you woke up. UP3 worked awesome for me.

[RASH]

Hello. Nice to meet you! Had mine done in 1998 @ WPAFB and I never knew you were supposed to feel so good when you woke up. UP3 worked awesome for me.

Good on ya! You're the first of over 40 folks I've spoke with who had success with it. My snoring actually worsened after it healed up, and continued to get worse for the last 13 years of my career. I retired in 09, had a sleep study done after my fini flight, and got the CPAP. I've worn the mask every night with no problems, and just like you I didn't know it was possible to feel that rested after sleeping for 8 hours.

[Motrin]

The question is whether I should feel badly he's DQ'd

No, you should not feel badly. He had a disqualifying condition for entry into a special duty; perhaps more time and workup woud yield a better diagnosis, but it's actually not our job to do that for initial entry physicals -- you make the call right then and there with what information you have, not always what information you could obtain. We do not make policy, nor do we enforce it; we abide by it. You did your best and you should be able to sleep at night. Flight medicine is occupational medicine and sometimes you have to be the bad guy. I'm all for advocating and fighting for trained assets, however.

as far as sleep apnea and UP3, YMMV. Sure, CPAP is a one-size fits all way to beat it and works for most people. I was speaking more to Aeromedical disposition. In any medical case, you would be well served by ignoring its implications on continued flying and undergoing the best available medical treatment, allowing the aeromedical aspect to fall into place. Most aviators dislike that path, though, since it inevitably involves temporary grounding.