# Common Enrollment Medical



## rcampbell (29 Jul 2010)

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?


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## Occam (29 Jul 2010)

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.


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## rcampbell (29 Jul 2010)

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?


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## Occam (29 Jul 2010)

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.


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## Blackadder1916 (29 Jul 2010)

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.
> 
> ...



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.
> ...


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## ModlrMike (29 Jul 2010)

> ...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.


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## rcampbell (30 Jul 2010)

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.


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## CombatDoc (31 Jul 2010)

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.


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## rcampbell (31 Aug 2010)

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.


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## Occam (31 Aug 2010)

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.


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## rcampbell (2 Sep 2010)

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*


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## rcampbell (3 Sep 2010)

*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!


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## rcampbell (28 Sep 2010)

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?


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## owa (28 Sep 2010)

rcampbell said:
			
		

> 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.


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## Occam (28 Sep 2010)

rcampbell said:
			
		

> 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.


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## rcampbell (28 Sep 2010)

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.


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## owa (28 Sep 2010)

rcampbell said:
			
		

> 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.
> ...



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.


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## Occam (28 Sep 2010)

rcampbell said:
			
		

> 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.
> ...



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).


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## rcampbell (28 Sep 2010)

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.


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## owa (28 Sep 2010)

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?"


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## rcampbell (28 Sep 2010)

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.


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## Occam (28 Sep 2010)

rcampbell said:
			
		

> 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.



			
				owa said:
			
		

> 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.


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## owa (28 Sep 2010)

Occam said:
			
		

> 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!


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## Occam (29 Sep 2010)

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.


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## medicineman (29 Sep 2010)

One of the problems with alot of electronic ECG machines is they have a habit of diagnosing and often, over diganosing things that aren't there.  However, ECG's tend to be interpreted by a cardiologist, who will either agree with or trump what comes out as the diagnosis.  They will also do the calculation for the QT/QTc on their own to verify in their mind if the computer is correct in it's measurements.  If they continue to feel that there is an LQTS situation going on, that's what they will/should write on the report.

MM


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## Occam (29 Sep 2010)

Ahhhh, thanks MM.  I hadn't even considered the possibility that it was the ECG machine that was writing "Normal ECG" on whatever it is that the OP is referring to, and not a human.  That makes a lot of sense.  I would say that adds more weight to the suggestion that the OP should check into this with the family doctor, to find out whether the conflicting diagnoses are between man and machine.


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## Blackadder1916 (29 Sep 2010)

First, a bit of an explanation about the reading of EKGs.  Most modern EKG machines can provide a gross computer analysis of the reading; that analysis is not (or should not be) recognized by physicians as a valid interpretation of the test.  It is also not recognized as the "professional" component of the test for reimbursement by any of the provincial health insurance plans.  The only ones (in AB, BC and ON at least, but probably all others) who can interpret an EKG (and get paid for so doing) is a physician who is qualified in Internal Medicine (Cardiology is a sub-spec of IM) or a physician in another specialty who has completed additional training and certification in EKG interpretation.  While many family docs may be able to do a gross reading of an EKG (though I know some who accept their limitations and refuse to even look at an uninterpretated strip), they are neither trained nor certified to do so beyond recognizing obvious abnormalities, nor are they usually able to maintain competency simply because they don't look at that many.

As has been reiterated time and again on this forum, this is not the place to come for a diagnosis based on a person's description of his problem and even an interpretation of  test results is dodgy.  The best that can happen is an explanation of the process and not the outcome.  

It is highly unlikely that the specialist who read the second EKG will change his written interpretation.  Probably two reasons there, firstly is that he probably feels his comments best reflected his analysis of the test (in other words, he thinks he is right) and secondly, this has now changed from an interpretation of a diagnostic procedure in order to provide knowledgeable medical care to a patient to being part of a non-medically necessary process, i.e. getting hired by an employer.  The $15 (or probably not much more) that he was paid for his work doesn't cover that.

What does this mean to rcampbell and his next steps to overturn the decision of the RMO (who is in Borden not Ottawa, unless they have changed his location)?  If I understand correctly, his "letter of doom" simply stated that he did not meet enrolment standards because of the long QT; it was not an invitation to submit additional medical tests or opinions in order to clarify the circumstances and potential outcome of the condition.  Therefore, rcampbell probably has only two courses open to him _if he still hopes to join the CF_ (edited to add this after ModlrMike's following post about reality).  He can submit the second EKG with a request that his situation be re-examined by the RMO; it may be helpful if the second EKG is accompanied by a report from his family doctor explaining the situation and containing his opinion that there is nothing wrong.  However, based on rcampbell's explanation of what his GP has done to definitively rule out LQTS, there may not be a lot of meat in such a report, even if his doctor would so state.  (Of course, my analysis of this may be wrong.)  His second option would be to have a diagnosis of LQTS definitively ruled out by a specialist which at the same time could provide an explanation for the long QT noted in previous EKGs.  If that was to happen, he could then submit that greater evidence for review by the RMO.


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## ModlrMike (29 Sep 2010)

Blackadder1916 said:
			
		

> Therefore, rcampbell probably has only two courses open to him.



You forgot the third option, and I don't mean to be cruel here, just a realist:

3. Accept that everyone gets to apply, not everyone gets to join.


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## Blackadder1916 (29 Sep 2010)

ModlrMike said:
			
		

> You forgot the third option, and *I don't mean to be cruel here, just a realist*:
> 
> 3. Accept that everyone gets to apply, not everyone gets to join.



But if everyone who visited these means were as grounded in reality as the "crusty*" senior members (_*as proven scientifically by Mike Bobbitt_) there would probably be a significant drop in the visits to the forums.

"Go, go, go, said the bird: *human kind
Cannot bear very much reality*."

T.S. Eliot  (1888-1965)
Four Quartets, Burnt Norton, I


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