Allergic Rhinitis and PVC's

[Tony Gio]

Hello,

I am hoping someone can ease some of my worries regarding my medical record.

First of all I have researched this topic extensively and am aware that allergic rhinitis after age 12 is a DQ, however, I have somewhat of an extenuating circumstance.

I am applying for guard units and work as a full time firefighter as a civilian. Common practice in the fire service is to get a prescription for Flonase as working the large wild land fires we have in California for weeks on end is a recipe for congestion. I explained this to my doctor in 2011 and in order to get the prescription he gave me the diagnosis of allergic rhinitis which I do not technically have (should have just stuck with OTC decongestants). I have refilled the prescription multiple times, but only when the medication expires to insure I have it on hand in case of a large campaign fire. If I explain this during my flight physical will it increase my chances of getting a waiver? Or did I potentially screw my self by getting this prescription?

Also, in one of the physicals for an urban search and rescue specialist position in the fire department, we were required to wear an EKG halter monitor. During the 24 hour period with the monitor on I threw a few PVC's, so again, the doctor put in my medical record that I have PVC's. They were determined to be benign and not cause for concern but is this something I should worry about during the flight physical?

Lastly, has anyone heard of doctors removing a diagnosis (such as the allergic rhinitis) from a medical record based on a possible incorrect diagnosis?

I appreciate any guidance or suggestions.

[deaddebate]

Here's the reg's you're working against.

E11 A verified history of allergic, nonallergic, or vasomotor rhinitis, after age 12, unless symptoms are mild and can be controlled by a single approved medication.

E12 Allergic rhinitis, unless mild in degree, controlled by use of approved medications, and considered unlikely to limit the examinee’s flying activities.

Get seen again and try to get diagnosed with MILD seasonal allergic rhinitis (SAR), then provide that documentation to your Recruiter/commissioning POC. You'll need to be controlled with a single, approved med. Doctors will frequently change a patient's diagnosis. As long as there is some justification or explanation in the record, this is fine and totally understandable. Stress to the Doc that you only use medications infrequently and as needed in conjunction with periods of heavy environmental irritants (smoke, pollen, debris from a fire).

Avoid inhaled steroids like Singulair or Flonase if possible, as that is a flag to a doc to suspect Asthma/RAD/EIB or chronic Bronchitis/Pneumonia/Coccidioidomycosis. Though these meds are usually fine for "as needed" use with Flying Status, the underlying condition sometimes requires an MEB (possible medical separation from service or permanent deployment limitations). Even if at present you don't have a more serious pulmonary condition, chronic prescriptions of inhaled steroids can mask the symptoms that might develop later. Additionally, these meds are more commonly used to treat Moderate and Severe Rhinitis (in addition to the other diagnoses) rather than simple mild SAR.

You could use an OTC nasal spray of saline solution ONLY without any concerns, but if there is a medication in the spray, like Afrin, then it gets a bit tougher. Allegra or Claritin are your best bet. If you need something to control any symptoms. Maybe try an OTC trial and see how you feel. Crolom/Cromolyn is OK, but not ideal, again as it is often used for Asthma, but it is better than a steroid if Allegra/Claritin aren't good enough. In all, I think your situation isn't DQ'ing and you won't even need to be considered for waiver.

Hopefully @JCJ can answer your cardio question. That's out of my league.

[Tony Gio]

Deaddebate,

Thank you for the reply. I only use the flonase a few times a year, so I will take your advice and talk to my doctor about changing the diagnosis. Recently, I have been using the saline rinses during fires, as you mentioned, and have not needed any other medication, prescription or otherwise. Again, thank you for the information and hopefully as you mentioned JCJ or another member with some insight can answer the PVC question.

[jcj]

Assuming you have no other symptoms of cardiac disease, and you had a few isolated single PVC's on a 24 hour Holter, I think you'll be fine. It turns out that almost no one has a 24 hour Holter without some ectopy (only 13% of aviators had a completely ectopy-free Holter in one study quoted in the USAF waiver guide).

The relevant portion of the USAF Waiver guide is pp 323 - 326, I've made a pdf of just those pages & attached to this post to make it easier to look at the primary source information. It uses the term "ectopy", that's a general term for abnormal electrical activity of the heart that includes premature heart beats - Premature Atrial Contractions (PAC's) start in the upper chamber of the heart, Premature Junctional Contractions (PJC's) start in the junctional tissue between the upper and lower chamber of the heart and Premature Ventricular Contractions (PVC's) start in the lower chamber of the heart.

All of these are heartbeats where - for a single beat - the heart beats in some way other than it's usual organized pattern. This is because there's an abnormality in the electrical signal for that beat that causes the heart muscle to squeeze out of sequence, causing the abnormal heart beat.

PAC's and PJC's have similar origin and effects, so sometimes they are just lumped together as PAC's or Premature Supraventricular Contractions (PSVC's). PVC's (especially frequent or multiform) are more worrisome in critically ill patients and patients with severe underlying heart disease, because they can lead to more dangerous continuous heart rhythms or even cardiac arrest. Occasional PVC's in someone who is otherwise healthy and has no other heart issues is almost always benign and usually unnoticed unless you undergo an in-depth physical. Occasionally you can feel them as a "skipped beat" but even then if you are otherwise in good health and have no heart problems, it's very likely not a problem at all.

Where this would usually be seen in a flight physical is on the EKG. For isolated PVC's, what the waiver guide says is if you have more than one PVC on a 12 lead EKG or a rhythm strip you then undergo a 24 hr Holter. If 10% or less of the total beats on the Holter are PAC's or PVC's, and there are less than 10 paired ectopic beats on the Holter, then you're still good to go. If you have more ectopy than this on the Holter, you'll get referred for more workup (Echo, treadmill) and a decision made based on that.

You are in the unusual position of already having done a Holter study. I've never seen a physical exam before that required a Holter, but I could see where a physical for an extremely strenuous job such as you mentioned might require one. As always, when asked about it just tell the truth & be prepared, if you can, to have documentation of the holter and interpretation.

Bottom line - if you are otherwise in good health with no heart disease and they did an appropriate interpretation of your Holter with a finding of isolated, few or infrequent PVC's (which is what I'm interpreting what you wrote) I think you'll be fine.

USAF Waiver Guide - Ectopy.pdf

Edited June 29, 2014 by jcj

[jcj]

I also had a thought on your use of flonase question - and this is just additive to the info that deaddebate has already given you.

I would agree that based on the info you've given, a diagnosis of allergic rhinitis is incorrect. Allergy is a specific condition where the body has an exaggerated, IgE mediated inflammatory reaction to something that is otherwise harmless. For example, most people can eat food containing peanut products with no problem - because peanuts are a normal, harmless food product for most people. But a person with peanut allergy may have a life threatening inflammatory reaction (that is mediated by a specific body immune system protein called IgE) because they've been exposed to peanut product - something that's harmless to everyone else.

Smoke from a wildfire is not a harmless substance, and it's likely that most normal people who are exposed to it will develop inflammation of their nasal passages. So the correct diagnosis is acute chemical rhinitis or acute irritant rhinitis, not allergic rhinitis. You are not allergic to wildfire smoke because it is an irritant to everyone, not just you. It is also acute, not chronic because (I am assuming) you've never had an episode that's lasted six weeks or longer. Even if you have this every fire season, it's still acute irritant rhinitis as long as any single episode doesn't last six weeks or longer. Nasal flonase is a recommended and approved treatment for acute irritant rhinitis.

For the reasons you've alluded to and deaddebate has explained, having the exact correct diagnosis can be really important when you're undergoing a physical exam for a qualification or job, such as a flight physical. This is medical nitpicking, but it can be really important because of situations like yours where having a 'just about right" but not exactly right diagnosis can be a problem later on. And yes as deaddebate mentioned a doctor can change the diagnosis - we do it all the time for inpatients. He/she just needs to document the change and the reason in your medical records. It won't erase your prior records, but it's not unusual for us to find that a previous diagnosis was incorrect - usually because some part of the problem hadn't made it's appearance yet. We just document everything in the medical record so it's clear what we did & why, and move on.