Wayne Smith, MD

04/12/2025

I was floored recently by a post I saw on X, exhorting readers to not be organ donors. The implication was that if you check the organ donor consent on your driver's license, that you may have your organs taken before you are dead.

This is something I have experience interacting with, from my nursing days, from residency, and from my current career, and I would like to clarify the issue for my readers and explain the process.

There are several types of organ and tissue donation:

1. Living donor
2. Donation after brain death
3. Donation after cardiac death
4. Post-death tissue donation

Living donor would be a donation of one kidney, part of a liver, bone marrow, plasma, or blood. These donations do not significantly impact the longevity of the donor in most cases (barring unforeseen surgical complications). They are, aside from plasma donation, strictly due to a generous person being willing to help another human.

Donation after brain death is the most common organ transplantation, in my understanding. To explain the process, I must first explain brain death.

Brain tissue lives inside a closed box, which we think of as our skull. It does not expand, and when the brain swells after an injury in the same way we swell in other areas after injury, there's no place for the swollen organ to expand to. Pressure inside the skull (cranium) rises, and eventually blood cannot flow in to feed the brain. Brain tissue uses a lot of energy to work, and when fuel (glucose) and oxygen stop flowing to the brain, it starts to die in 6 minutes or less. Once dead, it's not coming back.

So, after a head injury or major stroke, this can happen. The autonomous parts of the body, including heart and blood vessels, continue to function, albeit without the normal controls from the brain, as long as we keep air moving in and out of the lungs and fluid and electrolytes balanced in the blood, for a period of time, generally a few days.

The donation process in this situation is that the donor services are notified of a likely impending death, and they send a representative who reviews the status of the patient and the likelihood that there may be viable organs. This person has no influence on care, does not talk with the family, begins coordinating for potential organ matches, and remains on standby until the team caring for the brain-injured patient has exhausted all options for survival and has determined that the patient is brain dead. This is usually confirmed by a blood flow study that proves no blood flow to the brain.

Only after brain death is declared do the transplant coordinators make contact with family, explain the process, and receive consent for donation. While your registration is legally all that is required for consent, family consent is usually attempted and honored. In the event that family is not available, donation can proceed based on the patient's opt-in status.

Once the donation process begins, the transplant coordinator assumes the role of advising care along with the primary medical team. This includes ordering various drugs and labs and managing fluid and electrolyte replacement. This process continues up to the point of the surgical removal of viable organs.

In the operating room, the anesthesia team provides surgical anesthesia just like any other surgery. Even though there is no brain function, the spinal cord still has functioning reflex circuits, so anesthesia limits these responses. The anesthesia team remains active until the heart and lungs have been removed.

Donation after Cardiac Death (DCD) is a more recently accepted procedure where a patient in a persistent vegetative state has care withdrawn and then organs are removed after cardiac death has been confirmed. This is less common, and organ viability is lower than donation after brain death or living donor donation. Again, safeguards are in place so that donation does not influence the decision to withdraw care. I do not have any interface with this process, so I can't comment beyond what I've read.

Post-death tissue donation includes donation of cornea tissue, and bone and tendon donation. These are low-metabolic-activity tissues that do not have as tight a time window for donation.

As physicians, nurses, and support personnel, we take the ethical concerns surrounding the donation process seriously, and we honor the safeguards that are set up to prevent perverse incentives from influencing our care of the living patient.

The online criticism I'm seeing regarding organ donation suggests otherwise, and there are those seeking to spread fear and mistrust regarding organ donation.

Some imply that the financial incentives of donation lead to patients being declared brain dead when they are not, or that care is withdrawn for the purpose of donation. I acknowledge that it could in theory be possible, and I've heard many rumors of this being done in China to political prisoners. But here, in the United States, this would not be tolerated, and I expect that anyone who might do this would be reported by other care team members quite readily.

COVID deepened the mistrust of the health-care industry, and this mistrust feeds into the traction that that these online purveyors of the anti-organ-donation narrative are getting. While I understand that feeling, I believe strongly that it is misplaced, and that the organ donation process in the United States is as ethical as it can be made to be. Many people simply do not understand the process, or actively seek to get attention by telling falsehoods about it.

Organ donation saves lives.

I am a registered organ donor, and have no concerns about that process being abused.

(And yes, the professionals who are part of the process of organ donation do get paid our regular salary, but did you expect us to work for free? It isn't like any of us get a bonus because we recruited a donation. Instead, we get a nice letter from the donor services, telling a little bit about who received the organs.)

04/08/2025

Advice from your friendly Aviation Medical Examiner:

The FAA Aeromedical system is designed with traps that create unnecessary problems.

One of them is that how the medical application is worded. It asks if you ever, in your life, had any of the following list of diagnoses, and on that list is included "other illnesses, hospital admissions, or surgeries."

It also asks what medications you take, and expects you to list every medical provider visit in the past 3 years.

Most of us humans, including yours truly, have a hard time being able to remember all of our medical histories, doctors' visits, etc.

For a pilot to be fully compliant, you need to log your healthcare as carefully as you log your flight time.

Keep a running list of your doctor's visits.
Keep a list of every diagnosis, hospital visit, and current medication.
Keep a copy of every MedXpress application.

If in doubt, talk to your AME as a consult prior to beginning your official flight physical. Once we open your chart, we have 14 days to complete and submit it.

If you have a condition that requires documentation, you have to be able to gather that documentation in the 14-day window or I have to defer your application to the FAA. That process will take far too long for your happiness.

For a long list of conditions, I can issue your certificate if you meet certain criteria, which usually include a detailed clinical progress note from your treating physician, based on a visit within the past 90 days. If you arrive with that progress note for your physical, I can probably issue your certificate. This is one value of having a consult prior to sitting down with me.

Let's say you have a second class certificate. You have well-controlled asthma. If you have a progress note stating that your asthma is well-controlled on your current treatment, I can issue.

If you don't have that note, but we talk before I open your chart, I can send you back to your P*P to get that note, without a hard time limit. If you run over, no foul. Your certificate remains valid until its expiry. If you decide you're done with professional flying and want to go BasicMed, you can.

But if I don't know you have asthma, and I open your chart, and we have to send you for your detailed clinical progress note, and your doc doesn't have an opening for 6 weeks, I have to defer you. If you don't complete the process, you will be denied. And now you don't even qualify for BasicMed.

The system is filled with opportunities to make you look bad or to ground you for reasons that do not include your fitness to fly.

Filling out your next MedXpress application and leaving out a prior reported condition can look like falsification of your application, and can lead to very expensive fines and loss of your hard-earned FAA certificates.

And, if you think you have a real appeals process, you're wrong. The appeals process is heavily weighted against you, even with good attorney representation. The first appeal is before an FAA employee administrative law judge. The second appeal is before an NTSB administrative law judge. You're almost guaranteed to lose. After that, the appeal is to a real judge, but the facts by this point are irrelevant, and that judge is just looking for process errors, as far as I can tell. And, after all that, you'll pay the fine, lose the certificates, AND have to pay for your attorney.

So be organized.
Be thorough.
And stay safe!

Send a message to learn more

02/19/2025

Humans are non-rational for the most part.

The scientific method was developed to find truth in spite of this characteristic of humans.

The practice of medicine is not science. We are not, generally, conducting placebo-controlled double-blind studies on our patients, unless we are in a research institution.

So, by definition, practicing physicians are not scientists.

Instead, we are trained to consume the output of scientists, and to carefully and curiously assess our patients, their complaints, and their physical manifestations, and then to methodically process those findings in light of the research (the "evidence"), formulate a strategy to improve the life experience of the patient, and then convince the patient to follow this strategy.

It's a very unique skillset, and, if the science is truthful and complete and the patient is willing, we can make a positive difference for our patients.

But humans are loathe to make needed changes, because, as I said, humans are non-rational.

Sure, we sometimes have a patient who is more attached to wellness and longevity than to their daily routines, habits, and addictions, and they do the work.

They make us feel really good about our work.

Often, though, patients have been programmed to buy and consume unhealthful foods, drinks, and substances, have been trained to equate pleasure with well-being, and only want a symptom to go away. They arrive expecting a remedy in the form of a pill, shot, or surgery, and will destroy you in reviews or in court if they do not get the resolution they expected.

The drug industry responds to the desire for symptom treatment by engineering molecules that are designed to reduce or remove the symptom. With some exceptions, they do not address the underlying disease process. The scientific method is applied to determining if the molecules do what is desired, and determining the safety of the molecules.

Then the manufacturer produces and sells the molecules, priced in part on how badly the patient wants the symptom to go away.

All the while, the underlying disease continues. Because, often the underlying disease is actually the patient's lifestyle.

Take, for example, type 2 diabetes.

This disease is the end manifestation of long-term high insulin levels. The insulin levels are high because of an excess intake over time of carbohydrates, and especially sugars.

Over a period of years, the high insulin levels cause the target cells to pay less attention to insulin. This leads to an increased level of circulating glucose (sugar) in the blood, which causes a long list of damaging effects.

This can be effectively treated by massive lifestyle change.

Removal of all processed sugar and most carbohydrates from the diet quickly normalizes blood sugar. We see this happen in a period of days.

Not long after carbs are removed, excess weight begins to disappear. Brain function improves. Joints feel better. Back pain and radicular pain may go away. Mobility improves. Sleep apnea may improve.

It can happen and it does happen.

But only in people motivated to make meaningful life-long change.

More often, they get a cursory talk on diet changes and a prescription for something that addresses the blood sugar, something that addresses cholesterol, and a pill to protect the kidneys (with the added benefit of improving blood pressure).

If they are morbidly obese, they may be take a surgical route to diet control via gastric bypass or another surgery with similar effects.

This is all because humans are non-rational.

Patients don't usually change their lifestyle.

Physicians are often too burned out and rushed to do much more than assess and prescribe, and curiosity is discouraged.

Drug companies make money from symptom relief.

Regulatory bodies have a revolving door with drug manufacturers.

And scientists have bosses.

A rational system would test insulin levels, not A1c, to screen for early insulin resistance instead of developed diabetes. Intervention would happen a decade or two earlier in many patients. And the market would not be incentivized to addict us to carbs.

I want us to at least have a more rational health system, while still having excellent treatments for disease.

The experts have presided over the road we have taken to get here.

I'm hopeful that the current focus on making America healthy again could be the reset that we as a society so desperately need.

Disclaimer: there are many examples of diseases that are not associated with poor lifestyle choices, including childhood cancers and type 1 diabetes. My critique of the healthcare delivery system above is intentionally simplified.

12/04/2024

Pilots:

Starting January 1, new applicants for FAA flight medicals will be required to pass a computer color vision screening for an unlimited medical certificate.

Pilots who have passed a color screening in the past are not required to re-screen.

If you are a third-class certificate holder who has a letter of demonstrated ability for color vision limitation, and wish up upgrade to first- or second-class, you must be screened and go through the process just like a new applicant.

If an applicant fails the color vision screening but is otherwise qualified, they can receive a third class medical certificate with the limitation of "Day VFR only" on the certificate.

The screening exam is an additional cost, as each office is now forced to purchase access to an approved test program.

To reiterate, if you already hold a letter of demonstrated ability, you will be grandfathered.

11/13/2024

My new website is active for my aviation endeavors. From flight instruction to aviation medical examinations, the office is now in use. You can fly in for your medical.

Appointments required, and two-way communication must be established before any appointment is confirmed.

Helping Pilots Become Safer And More Proficient What I Offer Flight Instruction $80 per hourAll flight instruction, including flight reviews and tailwheel endorsements, are charged at this price per clock hour. Piper Pacer Rental $150 per tach hourI’ve always hated being billed off the Hobbs. I th...

11/04/2024

Allow me to (re)introduce myself. I'm an active pilot with 31 years of flying and nearly 5,000 hours of experience. I also am a physician, providing anesthesia services as my primary work.

As a pilot, I have a strong focus on pilot proficiency and safety, and, to that end, I became a flight instructor earlier this year, with a major focus on tailwheel training, flight reviews, and proficiency training.

I'm now offering FAA Aviation Medical Examiner services, by appointment only, at my office at the Elizabethton airport, 0A9. Please leave a message on my office number, 423-430-9619, or message me on FB Messenger.

Most exams will be evenings or weekends. Initially, I'll be doing one per day, until I have more experience with the FAA computer system.

And yes, my office is in the FBO, so flying in for you exam is an option!

If you are unsure of if you might pass the flight physical, or have questions or concerns, I also offer consult services. Please plan to bring in your most recent medical records from all physicians you see, and I will go over them with you, and look at the FAA requirements to see what path might be available for an airman medical certificate.

Once you fill in the MedExpress application and I open it, I am obligated to complete and submit it, and so the role I play is one of a representative of the FAA once I open your application. My opening your chart to document my exam starts a 14-calendar-day clock for completing and submitting my findings.

Here's the importance of a consult first: If you have one of the CACI-qualified conditions (there is a list), and additional documentation is required, you may be hard-pressed to gather that information in that 14-day window. If we talk first, I can give you a sheet listing what I will need, and you can gather your info before I start my exam.

If we uncover an issue during your official exam, and it is something I might otherwise be able to issue, but the 14-day limit is reached, I will have to defer your certificate and submit what I have. This may create unnecessary delays.

My basic exam rate is $200, for either second or third class certificates.

Consults are $100, of which I would apply half to your official visit.

Should I have to defer your application (meaning the FAA will need more information), I can assist you in the process of gathering and uploading records. These services will be billed based on time required. You are also able to submit directly to the FAA regional flight surgeon's office.

I'm looking forward to serving our community of aviators!

Send a message to learn more

10/24/2024

Story time.

Why am I here in Oklahoma City this week?

Why have I worked this year to add two credentials to my resume?

Labor Day weekend of 2022. A physician coworker of a friend, flying with his wife, turned into a storm cell at 9,000 feet over Bradley County, TN, destroying the plane and killing them both.

October 18, 2022. A friend, also a physician, had an engine failure and was unable to safely land in a field near Brentwood, TN. His last words on the radio were "Tell my family I love them."

May 7, 2023. In an eerie echo of the first crash, a plastic surgeon from Georgia, a friend of a number of my friends, flies into a storm at 9,000 feet, very close to the site of the first crash, breaking up his plane in flight. The wreckage landed a very short distance from where my parents used to live in Polk County, TN.

We physicians kill ourselves in airplanes far too often, and we need to stop. These crashes, more than most, really hit me hard.

So I decided it was time to go back, get more training, become a certified flight instructor, and work on making physicians and other pilots more safe.

Then I decided that I might get even more opportunities to influence pilots to improve their safety if some of them came to me to get their FAA flight physical, so I'm training this week to become an Aviation Medical Examiner.

Will I fix this plague killing our docs? Not likely.

But will I have the chance to maybe help some of us make better decisions, fly more, or fly better?

I hope so.

If you know me, you know that I love to fly more than to eat, to sleep, or almost to breathe.

And you know that I love to talk about flying, to teach the skills, to share my passion.

But I no longer encourage everyone to learn to fly. There are stages in life where becoming a pilot is a really bad idea.

This is especially true if you're a physician or other professional actively pursuing your career who feels the duty of many people depending on you.

If you cannot dedicate enough of your time to honing your pilot skills, not just for the 40-60 flight hours you'll take to get your license, but for the first thousand or two, and then more after that, should you fly yourself around?

Too many pilots and planes only fly 10-25 hours a year.

It is irrational to believe that only 10-25 hours a year is enough to be safe.

Yes, you can be current, by FAA standards, with that little flying.

But the chances of you screwing up and killing yourself, your passengers, or people on the ground are too high if flying is just a "hobby" for you.

So that's why I'm here.

We can do better.

10/07/2024

Morning thought: PTSD is the result of unprocessed trauma, not simply of trauma.

If you have experienced traumatic moments or days from our local disaster, connect with people who will listen, and spend intentional time talking through what was left in your mind.

Do this face-to-face. Virtual is not the same.

If your gift is empathetic listening, do that.

Check on your friends.

Listen.

These people don't need you to fix them.

They need to do their processing work in the presence of someone who cares.

You don't need a degree or license to be a friend.

09/17/2024

Trust the process.

During my flight instructor training, the concept of "readiness to learn" was introduced.

And in recent days, that concept has been highlighted in my mind.

I've heard concepts over and over in many areas of my life, but only when I was ready for the idea did I really learn it.

For example, one of my forms in Tae Kwon Do has been giving me a challenge in understanding the sequence of moves. One of the Master instructors walked me through the context of the sequence, and suddenly it gelled for me.

But here's the thing: I'd heard that explanation before.

I just wasn't ready before.

I couldn't be made ready.

I had to reach the point of being ready.

So many times, I've imagined that what was missing for people around me was data.

If the people only knew *x*, then they would do *y*.

If the addict knew how damaging their addiction was, they would stop.

If the kid knew how the habit would hurt them later, they would break it.

If the pilot knew why the plane turns left, he'll stay on the centerline during takeoff.

But life is a journey toward readiness, over and over.

So yes, it's ok, and maybe even helpful, to provide the data, but only in a small fraction of your interactions will your data cause a change.

It's far better to build and maintain relationship.

And be open to the idea that our data isn't the solution.

It might not even be True.

05/08/2024

It's Nurses' Week, and that gives me a chance to think back to when nurse was my own title.

What I remember most from my years as a nurse are the patients.

The old man in the ER in the mid-90s, who said "Did they tell ya I have AIDS? Yeah, I have one in each ear!"

The pleasantly confused cirrhosis patient who had hepatic encephalopathy but told some of the best stories that likely were the product of his disease.

The lady in her late 60s who I was helping fill out her menu preferences and who, when I asked what condiments she wanted, said "What on earth would I do with those??" When we established that it was no, in fact, condoms that I was asking about, we both had a good laugh.

The old man with heart disease who was admitted for chest pain who also had a history of a head injury and was convinced that we were keeping him against his will and offered to knock my head into next week if I didn't let him put his clothes on and leave, only to have another round of crushing chest pain and changed his mind.

The mid-20s diabetic patient, blind from diabetic damage to his eyes, who taught me to listen when he said his sugar was low for him. Sadly, he died months later from his disease.

The angry lady with kidney failure and on dialysis whose only goal was to outlive "that a$$%( of an ex" husband. She didn't, but it sure seemed like she was going to.

I watched people live when I thought they would die, and other people die when I thought they would live.

I learned more and more that I didn't know enough. That lesson remains to this day.

It was a chapter in my life, but it was a very good one.

To my nursing colleagues, I'm thankful for you. It was a hard job when I did it. It's a harder job now.

Remember what brought you here. When all of the naysayers are trying to bring you down, go back to the basics.

It's about our patients.

05/05/2024

I didn't write this, but the writer put down many of my thoughts over the past year.

https://www.kevinmd.com/2024/04/10-harsh-truths-doctors-must-understand-to-avoid-burnout.html?fbclid=IwZXh0bgNhZW0CMTEAAR2W3eQZSR4o_ZZp-gyiGQfcXI3dPPznx-YIaxDBwVtsB_m8ToZIEqo17L8_aem_AbgqCEOMWrF4jj2y2T6Y4pc89SaMSSI1tj50G6ynoJaWKgkmi1Xh8IvWOOah5_uyWtoavWYjkAUQPFG1URMH_Z17

05/02/2024

Yesterday, I started working through a flight review with the builder of this beautiful SuperSTOL.

The FAA has a minimum requirement of one hour of ground and one hour of flight training for the required flight review. But a flight review takes as long as it takes.

One of the weaknesses, in my opinion, of the experimental amateur built world of general aviation is that there is a serious lack of opportunity for these builders to get flight training in the aircraft they built.

Most instructors don't have a level of comfort with E-AB planes, and especially with those that are designed for STOL (Short Takeoff and Landing) operations.

By the FAA rules, this owner/builder could get a flight review in a rented Cherokee and be legal to jump back into his plane, but that won't make him handle his SuperSTOL better.

But he will get a much more practical flight review if we fly his plane and focus on his areas of interest and need.

And, while I might be happy with his performance in the Cherokee (because it's a very simple plane to fly), it may take more than the minimum one hour for me to put a flourish on my signature on his flight review.

Flight reviews should make pilots better pilots, not just legal pilots.

(Plus, you never know where I might have you land!)