Topic: Common Enrollment Medical

[rcampbell]

Well I got the so-called " Letter of Doom" today. It states I do not meet the common enrollment medical standards for the reg. and res. forces. It says my QT interval is too long. This is pretty deflating news and to be honest a little frustrating. I was in the Navy Reserve for 2 years. I do a lot of physical activity, like cycling a couple hundred km's a week on my road bike and running and have never had a single problem. Is there any form of appeal process or some way I can "prove" I'm fit, or am I just screwed?

[Occam]

Has your family physician ever picked it up?  See your family physician and see if you can get a test done.  The only way you'll ever win is to prove that you didn't have it in the first place, or perhaps that you no longer have it.  Regardless, you need medical evidence that contradicts the CF medical exam.

[rcampbell]

This information was part of a ECG that was done about 6 weeks ago as part of the aircrew medical. It was done at my local hospital and my doc filled out the medical form and indicated no issues. The medical officer in Ottawa says it's an issue though I guess. Also, I assume common enrollment medical means that I am out of luck for any of my three choices, as opposed to no luck for the aircrew choice right?

[Occam]

Again, the only way you're going to get anywhere is for someone equally as well trained (specialist) as the person who reviewed the ECG for the CF to review it and say the results were misinterpreted/misread/incorrect.  Unfortunately, the onus and cost of seeking that professional opinion is yours.  Your first stop should be your family doctor, and they should be able to advise whether it's possible that they themselves missed the diagnosis.  Go from there.

If you don't meet the common enrolment standards, you can't enrol - period.

[Blackadder1916]

Occam provides the best advice.

Your first stop should be your family doctor, and they should be able to advise whether it's possible that they themselves missed the diagnosis.  Go from there.

The cost of disputing this (save, perhaps, for the writing of reports specifically to a third party, i.e. The CF) should not be as onerous as you may think.  The condition that has excluded you from the CF has a name, Long QT Syndrome (LQTS).  It is recognized but is also largely underdiagnosed due to a number of factors.  Because it "could" (say again - "could" - and a faint could) be a significant medical issue for you it should be investigated further for other than the reason of trying to overturn the failure to meet the common enrolment standard.

Here are a few links to info about LQTS

http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3484075/k.F8EF/Heart_disease__What_is_Long_QT_Syndrome.htm

What is Long Q-T Syndrome?

Long Q-T syndrome is a rare disorder of the heart's electrical system that can happen in otherwise healthy people. Its name comes from the way the heart's electrical activity is recorded during an electrocardiogram (ECG or EKG). The electrical activity that is recorded produces a characteristic pattern and the different parts of the pattern are labelled with the letters P, Q, R, S and T. The space between the Q and the T (the Q-T interval) represents the time it takes for the electrical signal to pass through the lower chambers of the heart (the ventricles). If it takes longer than normal, it is diagnosed as a prolonged Q-T interval.

People with long Q-T syndrome do not necessarily have a prolonged Q-T interval at all times. It is possible for patients with this syndrome to have an ECG with a normal Q-T interval. People with this syndrome may show prolongation of the Q-T interval during physical exercise, while experiencing intense emotion or when startled. In one type of inherited long Q-T syndrome, a person is born hearing impaired.

Long Q-T syndrome is often inherited and is usually present from birth (congenital). It can also be caused by certain medications, or it can result from a stroke or some other neurological disorder.

And something geared more to the medical professional.

http://emedicine.medscape.com/article/157826-overview

Background
Long QT syndrome (LQTS) is a congenital disorder characterized by a prolongation of the QT interval on ECG and a propensity to ventricular tachyarrhythmias, which may lead to syncope, cardiac arrest, or sudden death.

The QT interval on the ECG, measured from the beginning of the QRS complex to the end of the T wave, represents the duration of activation and recovery of the ventricular myocardium. QT intervals corrected for heart rate (QTc) longer than 0.44 seconds are generally considered abnormal, though a normal QTc can be more prolonged in females (up to 0.46 sec). The Bazett formula is used to calculate the QTc, as follows: QTc = QT/square root of the R-R interval.
 
To measure QT interval accurately, the relationship of QT to the R-R interval should be reproducible. This issue is especially important when the heart rate is <50 bpm or >120 bpm and when athletes or children have marked beat-to-beat variability of the R-R interval. In such cases, long recordings and several measurements are required. The longest QT interval is usually observed in the right precordial leads.

[ModlrMike]

...propensity to ventricular tachyarrhythmias, which may lead to syncope, cardiac arrest, or sudden death.

I'm thinking this is the part that got you your "letter of doom". Sudden death seem like a pretty big risk for the CF to take.

It's unfortunate you had to learn of the condition in this manner, but at least now you know. I'm not unsympathetic to your situation, but I don't see any way around it.

[rcampbell]

I totally understand the rationale behind it, and I can't say I disagree, it's just a bit of a punch in the stomach. Just sort of makes a fella feel a little lost. Thanks, for the comments though guys.

[CombatDoc]

Recommend having the ECG repeated by your family doc, and if you still show QT prolongation, s/he could consider referring you to a cardiologist for a specialist opinion.  Based on the specialist opinion, go from there.  All hope is not yet lost.

[rcampbell]

OK, just an update for anyone who might be interested and/or in the same situation. I'm having another ECG done in two days, and my family doc said if there's still a problem we will go from there. My blood pressure was 120/80 and he said S1 and S2 are OK and no murmurs. So hopefully the ECG comes out better this time.

[Occam]

That's good to hear.  If the ECG looks fine, make sure it gets well-documented - that will be the evidence you need to challenge the initial findings.  Mistakes do happen, despite best efforts.  Let us know how it turns out.

[rcampbell]

Just another quick update. I just got back from my ECG appointment. The ECG tech asked why I was having the test done, so I explained to her the situation. She told me that the machine they use has a tenancy to read the QT intervals high. She said probably 4 out of 10 people she sees read a longer QT interval just because of how the machine is setup. So anyway, we did the test and then I asked if I could see the output and it was completely normal. Normal QTc, normal sinus rhythm etc. So I'm hoping that if I send in these updated results then Ottawa will realize I'm in fine health. *crosses fingers*

[rcampbell]

*Quick note. Just got back from the recruiters. The Sgt. there said it was no problem to bring back my updated medical info. He said a medic was even going to be there the end of the month that I could talk with if I wanted. But he said it was no problem to get the info sent to the medical section and to the RMO. So I'm hopeful once more!

[rcampbell]

I have a quick question for someone that might be in the know. I had my ECG repeated, and it came out fine. No warnings of borderline QT on it like the first one. My fam. doc. looked at it again and said that's what he expected and thought I was fine. There is still a frustrating part though. The dr. that looked at the ecg commented that "borderline QT was confirmed on ecg from date xx-xx-xxxx". He wrote this on the new ECG that says at the top, that it's normal. Is the RMO going to look at this and still think I am unfit, or will he know that this doc is just "covering his butt" by remarking that?

[owa]

I have a quick question for someone that might be in the know. I had my ECG repeated, and it came out fine. No warnings of borderline QT on it like the first one. My fam. doc. looked at it again and said that's what he expected and thought I was fine. There is still a frustrating part though. The dr. that looked at the ecg commented that "borderline QT was confirmed on ecg from date xx-xx-xxxx". He wrote this on the new ECG that says at the top, that it's normal. Is the RMO going to look at this and still think I am unfit, or will he know that this doc is just "covering his butt" by remarking that?

I'm pretty sure this is common practice.

It'd be like if you had this reversed, and it first said you were fine but on the second try it said you were afflicted.  It's best to have a complete history (or as close to it as possible) readily available when looking at a document like that.  I'm sure it just means that the CF Medic will have to decide what is what and how to best get a conclusive answer.

[Occam]

I have a quick question for someone that might be in the know. I had my ECG repeated, and it came out fine. No warnings of borderline QT on it like the first one. My fam. doc. looked at it again and said that's what he expected and thought I was fine. There is still a frustrating part though. The dr. that looked at the ecg commented that "borderline QT was confirmed on ecg from date xx-xx-xxxx". He wrote this on the new ECG that says at the top, that it's normal. Is the RMO going to look at this and still think I am unfit, or will he know that this doc is just "covering his butt" by remarking that?

What doctor is this?  Is this a cardiologist?  And is it the same doctor that wrote the first report?

Your explanation is somewhat confusing.

You're going to have to try to explain the positions of the various players who are signing off on these reports.

[Rookie Green]

Best of luck, and keep us posted.

My specialist wrote me a letter addressing every concern in the CFP concerning my condition, and one of the things he wanted me to do was an Echocardiogram. Okay, I did one earlier in the year and nothing showed up. I do my Echo. Something looks sketch. They send me to do an ECG, and now I'm doing an MRI and really concerned with my health. So it could be worse.

That being said, here's my personal experience with inaccurate results: "Normal" adult males have a hemoglobin of 130-165 g/l. I have one around 115 +/- 10 g/l... but one of 80 +/- 10 when I was younger. Guess which number the family doctor wrote down for the RMO when I applied back in 2007?

[rcampbell]

Occam, I'll try to be a little more clear, I know it's sort of confusing to read...

ECG #1
Was sent to RMO as part of the Aircrew Medical requirements. RMO wrote back saying I was unfit for service because the ECG said I was borderline Long QT. When I received these results, I went to follow up with my fam. doc. and he requested another ECG be done as a starting point to see what might, if anything, would have to be done.

ECG #2
The doc that reviewed these results at the hospital before sending them back to my fam. doc. put a comment on this ECG saying that borderline Long QT was confirmed on ECG #1, even though ECG #2 indicates it's normal. So ECG #2 looks confusing because in one spot it says everything is normal, and then it has a comment that says the previous ECG was confirming borderline long qt. Got the results back and discussed with family doc. He said it was a normal ECG and that I have nothing to worry about.


My main concern is that RMO will look at the comment on ECG #2 about the first ECG and still think i'm unfit, and completely ignore the normal results of ECG #2.

[owa]

Occam, I'll try to be a little more clear, I know it's sort of confusing to read...

ECG #1
Was sent to RMO as part of the Aircrew Medical requirements. RMO wrote back saying I was unfit for service because the ECG said I was borderline Long QT. When I received these results, I went to follow up with my fam. doc. and he requested another ECG be done as a starting point to see what might, if anything, would have to be done.

ECG #2
The doc that reviewed these results at the hospital before sending them back to my fam. doc. put a comment on this ECG saying that borderline Long QT was confirmed on ECG #1, even though ECG #2 indicates it's normal. So ECG #2 looks confusing because in one spot it says everything is normal, and then it has a comment that says the previous ECG was confirming borderline long qt. Got the results back and discussed with family doc. He said it was a normal ECG and that I have nothing to worry about.


My main concern is that RMO will look at the comment on ECG #2 about the first ECG and still think i'm unfit, and completely ignore the normal results of ECG #2.

If the medical person is doing their job, they will take all information into account and likely have a recommendation for you in terms of how best to go about continuing the application process.  It would be unlikely that they stick completely with, "Well, we found something and that means you're done." After a second opinion, I'm sure they will take it all in and then tell you what the next course of action should be to completely confirm your medical.

[Occam]

Occam, I'll try to be a little more clear, I know it's sort of confusing to read...

ECG #1
Was sent to RMO as part of the Aircrew Medical requirements. RMO wrote back saying I was unfit for service because the ECG said I was borderline Long QT. When I received these results, I went to follow up with my fam. doc. and he requested another ECG be done as a starting point to see what might, if anything, would have to be done.

ECG #2
The doc that reviewed these results at the hospital before sending them back to my fam. doc. put a comment on this ECG saying that borderline Long QT was confirmed on ECG #1, even though ECG #2 indicates it's normal. So ECG #2 looks confusing because in one spot it says everything is normal, and then it has a comment that says the previous ECG was confirming borderline long qt. Got the results back and discussed with family doc. He said it was a normal ECG and that I have nothing to worry about.


My main concern is that RMO will look at the comment on ECG #2 about the first ECG and still think i'm unfit, and completely ignore the normal results of ECG #2.

I've highlighted something above that looks funny.  Was ECG #1 the first ECG that you've ever had?  If the answer is yes, then how can LQTS be confirmed when ECG #2 doesn't jibe with it?  ECG #1 would only be confirmed if ECG #2 agreed with ECG #1.

Let me clarify where I'm going with this.  Normally a technician does x-rays, CT scans, ECGs, ultrasounds, and the like.  They don't interpret, they just do the procedure.  The product of the test such as a CT goes to a radiologist for interpretation.  Likewise, I would expect ECG tape or electronic version would go to a specialist (cardiologist?).  If the cardiologist who read your first ECG came to the conclusion that you have LQTS, and then you were referred back for another ECG and the result was again interpreted by the specialist as LQTS, then you're in trouble.  The specialist is going to trump your family doctor. 

However (!), if the second ECG report from the specialist has conflicting information, for example stating that it's normal in one place, and borderline long QT in another, then that's something your family doctor should be taking up with the specialist.  The family doctor should be impressing that you need either a clean bill of health, or a diagnosis of LQTS - not a report that is unclear and falls somewhere in the middle, or else they're just wasting their own time as well as yours.  If the ECG was normal, then the report really needs to say that, and only that.

Don't make the RMO people try to read between the lines and try to figure out what your status is - the reports being sent up need to be clear and unambiguous.  (That's directed to your medical people, not to you).

[rcampbell]

I agree Occam, I am getting somewhat annoyed with this foolishness. You are correct, ECG#1 was the first I've ever had in my life. ECG#2 was the second I've ever had. I explained my situation to my fam. doctor and he understands and realizes a more definitive answer is desired. He was on the phone with the Int. Med. Spec. that reviewed ECG#2 and they would not change or remove their comment about borderline LQTS being confirmed on ECG#1. I don't have much medical knowledge, but it doesn't take a doctor to realize the fault in this logic. The worst part is that now that it's in the system, I'm worried that even if I get a 3rd test done, the reviewing dr. will still feel the need to propagate this comment about borderline lqts being confirmed in ECG#1. I'm getting frustrated and trying to figure out the best next step.

[owa]

Ever think of contacting the CF Medical Person and simply asking, "If the first test was incorrect, what is the procedure I have to undertake in order to have my medical cleared?"

[rcampbell]

Yes I've thought that. But I it went all the way to Ottawa and then a Major, who's name I forget, was the Dr. who reviewed and rejected it. I wasn't sure how to get a hold of him directly. Or if that was possible even.

[Occam]

I agree Occam, I am getting somewhat annoyed with this foolishness. You are correct, ECG#1 was the first I've ever had in my life. ECG#2 was the second I've ever had. I explained my situation to my fam. doctor and he understands and realizes a more definitive answer is desired. He was on the phone with the Int. Med. Spec. that reviewed ECG#2 and they would not change or remove their comment about borderline LQTS being confirmed on ECG#1. I don't have much medical knowledge, but it doesn't take a doctor to realize the fault in this logic. The worst part is that now that it's in the system, I'm worried that even if I get a 3rd test done, the reviewing dr. will still feel the need to propagate this comment about borderline lqts being confirmed in ECG#1. I'm getting frustrated and trying to figure out the best next step.

I still think your best bet is your family doctor.  I'm sure he's familiar with the politics of the civilian medical system, and is probably your best bet at getting a favorable ECG report from the people who are best qualified to interpret the results.  If there are two different interpretations written on the second report (one saying the ECG is normal, and the other saying you have borderline LQTS - who wrote that it was normal, by the way?  Is there a signature?), then there's something wrong.  Either it's normal, or it's inconclusive, or you have LQTS.  If it's normal, that's all the report should say.  If it's inconclusive, then one would assume that they're going to be doing more digging to find out for sure.

I really don't know what will happen if an ambiguous report is sent up to the people making the medical recruiting decisions in the CF.  It's a crap shoot.

Ever think of contacting the CF Medical Person and simply asking, "If the first test was incorrect, what is the procedure I have to undertake in order to have my medical cleared?"

The CF medical system just doesn't work that way.  You'll find that out firsthand.  Potential recruits just don't pick up the phone and call Majors in Ottawa.  You have to play by the system.  In the meantime, I don't really think you're offering much help as you're out of your lane. 

[owa]

The CF medical system just doesn't work that way.  You'll find that out firsthand.  Potential recruits just don't pick up the phone and call Majors in Ottawa.  You have to play by the system.  In the meantime, I don't really think you're offering much help as you're out of your lane.

Hmm, maybe you didn't read his posts completely or maybe my post came off too broad...  In any case, this is what he said:

"He said a medic was even going to be there the end of the month that I could talk with if I wanted."

I meant he should ask this person.

If that fails, he could go through the "system" by talking to his Recruiting Center as any questions I had over my colour blindness and vision problems were dealt with quite quickly and effectively.  Might take some time, but if he is truly medically able to be in the CF, the switch will be made.

But I never said he should contact a Major.  Not sure where you got that from! 

[Occam]

It's unlikely (possible, but unlikely) that a Med Tech will be able to offer up any more information about LQTS than what rcampbell has already gotten from his family doctor.  I didn't suggest that you meant to call the Major in Ottawa, but it needed to be said that the system works in a certain way, and if you take shortcuts, you may shoot yourself in the foot.

The OP's best friend right now is his family doctor.  What the OP needs is a clean bill of health.  The ambiguous reports coming from the specialists are going to raise eyebrows at the RMO, and that's not what anyone wants.  You want a nice, simple report that says LQTS has been ruled out, or that the most recent ECG is normal.  Nice reports that don't need a lot of interpretation and follow-up phone calls for clarification are going to get the OP through the CF's door.  I think the family doctor is in the best position to articulate to the specialist that the most recent report is ambiguous and needs clarification, be it either to say the ECG is normal, or that the diagnosis of LQTS after the first ECG was confirmed by the second ECG.  There can't be any middle ground.