Updated: May 19, 2020
Last week, pilot and medical doctor Dr Jeremy Robertson became the first person with type 1 diabetes in Australia to attain Class 1 medical clearance from the Civil Aviation Safety Authority (CASA), allowing him to fly commercially. Our CEO Bec Johnson interviewed him – watch his interview or read his story below.
Since I passed the medical, I feel so much lighter. It’s simultaneously very exciting and kind of a giant relief because it’s something I’ve been working on for a very long time.
I was diagnosed in 2010 when I was 31 years old. At that stage, I’d been flying with QANTAS for 9 years and I was First Officer on the Boeing 767, flying a mix of domestic and international routes on that aeroplane. It was great fun.
I went to America to do a course on test flying, and I’d been in Los Angeles for about a week, getting more and more thirsty and tired, urinating more and more, and then one day my vision went blurry and it didn’t matter if I was wearing my glasses or not. I took myself to a medical centre and my sugar level was 25.5mmol/L, and I was diagnosed with type 1.
I knew that having diabetes precluded you from holding a Class 1 medical, and that my flying career was over then and there.
I was diagnosed six weeks before my wedding. I had to figure out what to do with the rest of my life. There were so many different layers of stress: new diagnosis, new chronic disease, loss of my career and the only thing I’d ever wanted to do professionally, financial uncertainty – it was a difficult time.
Medicine kind of bubbled up slowly for me. I finished my engineering degree but it wasn’t my passion. Much like flying, medicine is a complicated environment, there is lots of problem solving and decision making, there is human interaction and it’s a team experience – and medicine offered the chance to have a positive impact in people’s lives and that appealed to me. I felt I had been given a unique opportunity to start over and do something completely different.
Having completed my medical degree, I’m currently halfway through training as a GP and halfway through aviation medicine- and now for some more career confusion, I can be a pilot again!
Five years after my diagnosis, I first started informal discussions with CASA in 2015 about re-applying for my Class 1 medical. The unofficial answer was that it would just be a no because there was no protocol for it in Australia, there was no precedent for it in Australia, and there was no real published medical evidence to support a change in that direction.
However, about 18 months later a report was published in the UK on their experience of allowing insulin-treated pilots to fly at a commercial level, and it was very supportive. I thought – ah-ha! This is the data that I need to support an application.
I thought – they don’t have a protocol, so I will write one. I based my protocol on the UK protocol and I backed it up with the published evidence, and I included all my own data about my diabetes management. I submitted it in January 2017.
I didn’t get an answer about the protocol for about 9 months, when I got a phone call from a doctor at CASA who indicated that it was of interest – and then everything went very quiet.
At the start of this year the USA announced that it was allowing insulin-treated pilots to fly, and so I re-submitted my protocol and application highlighting the new precedent. I got the news last week (May 2020) that I had passed, and that the new protocol is now in place in Australia.
There are three components to the protocol: sets of requirements around medical fitness, in-flight processes and renewal, because the medical is only valid for 12 months.
You have to be able to demonstrate that you have relatively stable diabetes management and a low risk of hypoglycaemia. You don’t have to be a superhuman diabetic – but you do need to be free from diabetes complications and have an HbA1c below 8%. You also must be able to show that your CGM is between 5mmol/L and 15mmol/L at least 80% of the time, and below 4mmol/L less than 5% of the time.
There are rules about where your glucose level needs to be when flying. If you’re between 5mmol/L and 15mmol/L you are free to control the aeroplane. If you’re slightly on either side of those values, ie between 4 and 5 mmol/L or 15 and 20mmol/L, you need to show you’re taking corrective action. If you’re below 4mmol/L or above 20mmol/L you need to hand over control of the aeroplane to the other pilot until you’re back in range.
I also must make sure I’ve got sufficient rapid-acting carbohydrate with me and a spare glucometer, and I have to log everything and submit all my data to CASA every year.
I use insulin pens rather than a pump; I’m happy with my level of control and I’m in a good routine. Class 1 medical allows pilots to wear pumps though, and I’m watching the hybrid closed-loop systems become better and better. As soon as a really good system is available I’ll be looking pretty hard at that.
I use a Dexcom CGM. My level shows up on three devices when I fly - on my phone in my pocket, on my watch, and I also blutack the receiver to the dashboard in front of me, so I have two tactile warnings and the visual warning too.
I find my diabetes is more stable when I eat less carbohydrate and this is certainly true when I fly so I tend to minimise my carbs before I fly. I always eat a well-known, easy to calculate meal before I go flying.
The goal before I fly is to get my glucose level as stable as possible, and then my snacks in-flight are based on the rate of change in my glucose level. If it’s trending sideways, I eat low carb snacks, if it’s slowly dropping I eat something that has some carbs that are absorbed slowly, and if it’s dropping rapidly I use jellybeans.
I’ve always loved the serenity of being up in the air and away from it all. All your troubles are left on the ground.
From a professional point of view, flying requires understanding and operating a complex piece of machinery, real-time problem solving in a dynamic environment, good hand-eye coordination and strong interpersonal and communication skills. And the body of knowledge you need to acquire to be a pilot is so broad - it’s fascinating. I find flying really rewarding.
Changing the Class 1 medical to allow people with type 1 to fly commercially wasn’t something I deliberately set out to do. I just dawned on me at one point that I was probably the only type 1 diabetic doctor pilot in Australia so if anyone was going to do it, it was me, so I had better just get on with it.
I think if you love something, pursue it. There will be hurdles but if you love it, you won’t let anything stop you.