Flight Surgeon's Manual - Navy Medicine

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U.S. NAVAL

Flight Surgeon’s Manual THIRD EDITION 1991

Prepared by

NAVAL AEROSPACE MEDICAL INSTITUTE

Under the auspices of THE BUREAU OF MEDICINE AND SURGERY Department of the Navy

For sale by the Superintendent of Documents, U.S. Government Office, Washington, D.C. 20402

Project direction by

Editorial Board Naval Aerospace Medical Institute

Captain Ronald K. Ohslund, MC, USN Captain Conrad I. Dalton, MC, USN Commander Gary G. Reams, MC, USN Commander Jerry W. Rose, MC, USN Lieutenant Commander Richard E. Oswald, MC, USN

Project Managers Commander Jerry W. Rose, MC, USN Lieutenant Commander Richard E. Oswald, MC, USN

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FOREWORD As we quickly approach the 21st Century, the Navy Medical Department stands ready to take on some of the greatest challenges it has ever faced. With the Cold War now a part of history, we must learn to operate within a new world order; one in which we must maintain our level of readiness within the context of an ever changing geopolitical environment. Critical to our future success in responding to the needs of the Fleet and Fleet Marine Force will be our ability to synthesize past experiences into our current knowledge base while simultaneously projecting requirements into the future. One important way of accomplishing such a task is by the sharing of information as quickly and efficiently as possible. The Third Edition of the Flight Surgeon’s Manual represents a major tool in this process. It is the culmination of 13 years of effort in distilling out the very best of aerospace science and technology. We have entered a new era on the battlefield. Technology has made it possible for aircraft to out perform their occupants. Innovation has given us a glass cockpit whose avionics suite can easily overload the aviator not aided by multiple high speed computers. Weaponry has made it possible to inflict devastating physiologic damage without killing an aircraft’s occupants or damaging the airframe. And we are poised on the verge of hypersonic mass transit. Each of these phenomena could not be understood or countered if it were not for the efforts of the Aerospace Medicine Team. The Third Edition is dedicated to the pioneering spirit of those in operational medicine whose interests have kept our country strong and our course true to the cutting edge of technology. For it is only through the noteworthy efforts of all members of the Aerospace Medicine Community over the last several decades that we continue to carry on our proud tradition of quality medical support of the Fleet. James A. Zimble Vice Admiral, Medical Corps United States Navy Director of Naval Medicine/ Surgeon General

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PREFACE The unique aspect of aerospace medicine as practiced by a U.S. Naval Flight Surgeon is the requirement to function independently at isolated duty stations. Whether at sea, on a small patch of land in mid-ocean, or at expeditionary airfield of the Fleet Marine Force, Flight Surgeons are often called upon to make medical and administrative decisions which affect the lives and careers of the most critical assets in the naval service - members of the Naval Aviation community. Not only must we treat the day to day medical problems but we must be prepared to deal with a vast array of casualties which all too frequently remind us of the danger inherent in Naval Aviation. This manual is both an introduction to the various aspects of Naval Aerospace Medicine and a guide for dealing with the other complex administrative procedures known as “the system.” This revision has evolved from questions most frequently asked, errors most commonly made, with a dash of seasoned advice passed down to the youngsters. The manual should stand between the Manual of the Medical Department and a current text on aerospace medicine. It is written to provide the Flight Surgeon with a reminder of the material presented in the formal course of aerospace medicine and as a reinforcement of the fact that the U.S. Naval Flight Surgeon stands at the apex of military operational medicine. The U.S. Naval Flight Surgeon’s Manual was originally designed to be updated at frequent intervals. This revision is the first since 1977 and has therefore resulted in an extensive rewrite of most of the chapters. The plan is to keep the manual current through annual submissions of new material by the Naval Aerospace Medical Institute and through contributions from the users of this text. R.K. Ohslund Captain, MC, USN Commanding Officer Naval Aerospace Medical Institute

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ACKNOWLEDGMENTS The Third Edition of the U.S. Naval Flight Surgeon’s Manual is the result of a team production with each member performing his required task. No one individual or select group of individuals was responsible. Some chapters are updates of the second edition; others have been completely rewritten. The multiple tasks necessary for the publication of this manual were accomplished in addition to the normal duties of each contributor. Special recognition should be made of the contributing authors. They are: Authors, Second Edition LCDR Joseph M. Andrus, MC, USN CDR Don S. Angelo, MC USN CDR C.H. Bercier, MC, USN CAPT O.G. Blackwell, MC, USN CDR W.A. Buckendorf, MC, USN CAPT. Eugene J. Colangelo, MC, USN Ms. Jacque Devine CAPT Frank E. Dully, Jr., MC, USN CAPT F.S. Evans, MC, USN Martin G. Every, MS CAPT J.E. Felder, MC, USN CDR Donald E. Furry, MSC, USN LT James A. Gessler, MC, USN Mr. James W. Greene Frederick E. Guedry, Jr., Ph.D. LT David T. Hargraves, MSC, USN CDR Norman G. Hoger, MC, USN CDR Gary L. Holtzman, MC, USN CDR William M. Houk, MC, USN CAPT Joseph Kerwin, MC, USN CDR T.F. Levandowski, MSC, USN LCDR Neil R. McIntyre, MC, USNR

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U.S. Naval Flight Surgeon’s Manual CDR C.J. McAllister, MC, USN CDR Richard A. Millington, MC, USN CAPT J.D. Morgan, MC, USN LCDR L.P. Newman, MC, USNR CAPT P.F. O’Connell, MC, USNR James F. Parker, Jr., Ph.D. CAPT Joseph A. Pursch, MC, USN Ronald M. Robertson, Ph.D. CAPT. E.J. Sacks, MC, USN CAPT Richard J. Seeley, MC, USN CDR Phillip W. Shoemaker, DC, USN LCDR Felix Zwiebel, MC, USN Authors, Third Editon CDR Michael R. Ambrose, MC, USN CAPT James C. Baggett, MC, USN Annette G. Baisden, MA CDR Robert Bason, MSC, USN CAPT Charles H. Bercier, Jr., MC, USN CAPT S. William Berg, MC, USN CDR Bruce K. Bohnker, MC, USN CAPT Philip T. Briska, MC, USN CDR Jonathan B. Clark, MC, USN CDR D.E. Deakins, MC, USN Chuck E. DeJohn, D.O. LCDR Michael Dubik, MC, USN LCDR William B. Ferrara, MC, USN CDR James R. Fraser, MC, USN Federick C. Guill, B.S.M.E., M.S. LCDR Gerald B. Hayes, MC, USNR LCDR F.D. Holcombe, MSC, USNR CAPT Gary L. Holtzman, MC, USN CAPT Robert E. Hughes, MC, USN CDR Wesley S. Hunt, MC, USN LCDR William L. Little, MSC, USN LCDR Steven G. Matthews, MSC, USN CAPT Andrew Markovitz, MC, USNR

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U.S. Naval Flight Surgeon’s Manual LCDR Michael H. Mittelman, MSC, USN CDR Carroll J. Nickle, MC, USN CDR Richard G. Osborne, MC, USN LCDR Richard E. Oswald, MC, USN CDR Jerry W. Rose, MC, USN CAPT E.J. Sacks, MC, USN The essential logistic, clerical, and secretarial support which was vital to the successful completion of this project was carried out by: Support Personnel

Word Processing Karen Strickland Brewton Sue Bondurant Rose Ann Spitzer Computer Assistants CDR Bruce K. Bohnker, MC, USN Michelle Marshall Technical Publications Editor/Writer Mary M. Harbeson Technical Manuals Writer (Aircraft) Claudia J. Lee Technical Illustrations Robert Lewis Scott Fiscal Officers LT Danny D. Urban, MSC, USNR LTJG Roland E. Arellano, MSC, USN Facilities Management HMl Richard D. Wilson

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TABLE OF CONTENTS Page Chapter 1 Physiology of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1 Chapter 2 Acceleration and Vibration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-l Chapter 3 Vestibular Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1 Chapter 4 Space Flight Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-l Chapter 5 Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-l Chapter 6 Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-l Chapter 7 Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-l Chapter 8 Otorhinolaryngology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-1 Chapter 9 Ophtalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-l Chapter 10 Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-l Chapter 11 Sexually Transmitted Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-1 Chapter 12 Aerospace Psychological Qualifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-l Chapter 13 Aviation Medicine with Fleet Marine Forces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-l

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U.S. Naval Flight Surgeon’s Manual Chapter 14 The Aircraft Carrier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Chapter 15 Disposition of Problem cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Chapter 16 Aeromedical Evacuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16-l Chapter 17 Medication and Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17-l Chapter 18 Alcohol Abuse and Alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Chapter 19 Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19-1 Chapter 20 Thermal Stresses and Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20-l Chapter 21 Toxicology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21-1 Chapter 22 Emergency Escape from Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22-1 Chapter 23 Aircraft Mishap Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-l Chapter 24 Aircraft Accident Survivability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24-l Chapter 25 Aircraft Accident Autopsies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25-l Appendix A Historical Chronology of Aerospace Medicine in the U.S. Navy . . . . . . . . . . . . . . . . . . . . . . . A-l

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CHAPTER 1 PHYSIOLOGY OF FLIGHT The Atmosphere Respiratory Physiology Hypoxia Hyperventilation Positive Pressure Breathing Cabin Pressurization Rapid Decompression Trapped Gas Bubble Related Diseases Oxygen Toxicity Oxygen Equipment References and Bibliography

The Atmosphere The atmosphere of the Earth can be thought of as an ocean of gases which extend from the Earth’s surface to space and is composed primarily of nitrogen, oxygen, argon and trace gases. The specific composition of the dry atmosphere is presented in Table l-l. These fractional concentrations remain relatively constant to the outer limits of the atmosphere. Just as a column of water exerts a force or weight per unit area, the column of air above a specific point exerts a pressure (force), which usually is expressed in millimeters of mercury. Table 1-2 presents many of the units of pressure measurement in common use. This table includes both altitude measures and sea water depth measures. The relationship of pressure and temperature changes produced by the force of the column of air is presented in Table 1-3, from sea level to 100,000 feet, in both English and metric equivalents.

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U.S. Naval Flight Surgeon’s Manual The atmosphere can be divided into several different concentric, spherical divisions based upon physical and chemical properties. DeHart (1985) and Campen (1960) identify principle characteristics of each of the atmospheric layers as illustrated in Figures 1-1, and described in Table l-4.

Table l-l Composition of the Dry Atmosphere at Sea Level

Gas

Fractions Volume (% by volume)

Nitrogen

78.03 20.95 0.93 0.03 1.82 5.24 1.14 5.00 8.70

Oxygen Argon Carbon dioxide Neon Helium Krypton Hydrogen Xenon

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x x x x x

10 -3 10 -4 10 -4 10 -5 10 -6

Physiology of Flight Table 1-2 Equivalent Pressures, Altitudes and Depths

(Billings, 1973b).

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U.S. Naval Flight Surgeon’s Manual Table l-3 Altitude-Pressure-Temperature Relationships Based on the U.S. Standard Atmosphere Altitude

Pressure

1-4

Temperature

Physiology of Flight Table l-3 (Continued) Altitude-Pressure-Temperature Relationships Based on the U.S. Standard Atmosphere Altitude

Pressure

l-5

Temperature

U.S. Naval Flight Surgeon’s Manual

Figure l-l. Identification of atmospheric shells (Ware, in DeHart, 1985).

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Physiology of Flight Table 1-4 Description of Atmospheric Shells Temperature Description

Name Troposphere

Stratosphere

Mesosphere

Thermosphere

The region nearest the surface, which has a more or less uniform degree of temperature with altitude. The nominal rate of temperature decrease is 6.5 °K/km, but inversions are common. The troposphere, the domain of weather, is in convective equilibrium with the sun-warmed surface of the earth. The tropopause, which occurs at altitudes between 6 and 19 km (higher and colder over the equator), is the domain of high winds and highest cirrus clouds. The region next above the troposphere, which has a nominally constant temperature. The stratosphere is thicker over the poles and thinner, or even nonexistent, over the equator. The maximum of atmospheric ozone is found near the stratopause. Rare nacreous clouds are also found near the stratopause. The stratopause is about 25 km altitude in middle latitudes. Stratospheric temperatures are in the order of arctic winter temperatures. The region of the first temperature maximum. The mesosphere lies above the stratosphere and below the major temperature minimum, which is found near 80 km altitude and constitutes the mesopause. This is a relatively warm region between two cold regions, and the region where most meteors disappear. The mesopause is found at altitudes of from 70 to 85 km. The mesosphere is in radiative equilibrium between ultraviolet ozone heating by the upper fringe of the ozone region and the infrared ozone and carbon dioxide cooling by radiation to space. The region of rising temperature above the major temperature minimum around the altitude of 80 km. There is no upper altitude limit. This is the domain of the auroras. Temperature rises at the base of the thermosphere are attributed to too infrequent collisions among molecules to maintain thermodynamic equilibrium. The potentially enormous infrared radiative cooling by carbon dioxide is not actually realized owing to inadequate collisions. Composition

Homosphere

Heterosphere

The region of substantially uniform composition, in the sense of constant mean molecular weight from the surface upward. The composition changes here primarily because of the dissociation of oxygen. Mean molecular weight decreases accordingly. The ozonosphere, having its peak concentration near the stratopause altitude, does not change the mean molecular weight of the atmosphere significantly. The region of significantly varying composition above the homosphere and extending indefinitely outward. The “molecular weight” of air diminishes from 29 at about 90 km to 16 at about 500 km. Well above the level of oxygen dissociation, nitrogen begins to dissociate, and diffusive separation (lighter atoms and molecules rising to the top) sets in. Chemical Reactions

Chemosphere

The region where chemical activity (primarily photochemical) is predominant. The chemosphere is found within the altitude limits of about 20 to 110 km. Ionization

Ionosphere

The region of sufficiently large electron density to affect radio communication. However, only about one molecule in l000 in the F2 region to one molecule in 100,000,000 in the D region is ionized. The bottom of the ionosphere, the D region, is found at about 80 km during the day. At night the D region disappears, and the bottom of the ionosphere rises to 100 km. The top of the ionosphere is not well defined but has often been taken to be about 400 km. The upper limit has recently been extended upward to 100 km based on satellite and rocket data.

(DeHart , 1985)

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U.S. Naval Flight Surgeon’s Manual Ozone (03) is produced in the upper atmosphere by the sun’s radiation. Ozone is a highly toxic gas which significantly impacts respiratory functions. Significant concentrations are found between 40,000 and 140,000 feet as illustrated in Figure l-2. This concentration of ozone is important in that it absorbs the majority of radiation in the ultraviolet range (wave lengths shorter than 2900 angstrom units), thereby screening potentially harmful radiation most often associated with skin cancer.

Figure 1-2. Relationship between temperature, altitude, and atmospheric zones.

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Physiology of Flight The characteristics and divisions of the atmosphere describe the physical features of the atmosphere. In the field of aerospace medicine it is man’s physiological response to the environment which is of primary concern. Based on man’s physiological responses, the atmosphere can be divided into three zones: the physiological zone, the physiologically deficient zone, and the space equivalent zone. Physiological Zone This zone extends from sea level to 10,000 feet. It is the zone to which man’s body is well adapted. The oxygen level within this zone is sufficient to keep a normal, healthy individual physiologically fit without the aid of special protective equipment. The changes in pressure encountered with rapid ascents or descents within this zone can produce ear or sinus trapped gas problems; however, these are relatively minor when compared to the physiological impairments encountered at higher altitudes. Physiologically Deficient Zone This zone extends from 10,000 feet to 50,000 feet. Noticeable physiological deficits begin to occur above 10,000 feet. The decreased barometric pressure in this zone results in a sufficient oxygen deficiency to cause hypoxic hypoxia. Additional problems may also arise from trapped and evolved gases. Protective oxygen equipment is necessary in this zone. Space Equivalent Zone From a physiological viewpoint space begins when 50,000 feet is reached since supplemental 100 percent oxygen no longer protects man from hypoxia. The means of protecting an individual at 50,000 feet or above, are such that they will also protect him in true space (i.e., pressure suits and sealed cabins). The only additional physiological problems occurring within this zone, which extends from 50,000 feet to 120 miles, are possible radiation effects and the boiling of body fluids (ebullism) in an unprotected individual. Boiling of body fluids will occur when the total barometric pressure is less than the vapor pressure of water at 37° C [47 millimeters of mercury (mm Hg)] which is reached at an altitude of 63,500 feet (Armstrong’s Line). Respiratory Physiology Gas physiology is one of the cornerstones of aviation medicine. A great deal of work has been done in this field in connection with high-altitude military and civilian aircraft development as well as in support of manned space flight. The purpose of this chapter is not to present a compen-

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U.S. Naval Flight Surgeon’s Manual dium of this information but rather a skeleton upon which an interested flight surgeon may build through additional reading. The four principal gases of interest in aviation medicine are oxygen, nitrogen, carbon dioxide, and water vapor. The principal functions of respiration are to transport alveolar oxygen to the tissues and to transport tissue carbon dioxide back to the lungs. The process is effected by transporting gases through the upper respiratory tract and trachea to the alveoli, letting the gases of alveoli and pulmonary capillary blood reach equilibrium with each other, transporting the arterial blood to tissue, where tissue gases reach equilibrium with arterial gases in the capillaries, and returning the blood to the lungs to repeat the process. Individual cells within the tissues of the body are basically fluid in composition and, as such, are essentially incompressible. Pressure applied uniformly to a tissue surface thus is readily transmitted throughout the tissue and to adjoining structures. Changes in the pressure environment do not produce cellular distortion but instead simply change the pressure of gases contained within the body. The manner in which changes in gas pressure affect the body can be expressed in terms of the classic laws of gas mechanics. Classic Laws of Gas Mechanics Boyle’s Law. Boyle’s Law states that the volume of a gas is inversely proportional to its pressure, temperature remaining constant. This means that at 18,000 feet, where the pressure is approximately half that of sea level, a given volume of gas will attempt to expand to twice its initial volume in order to achieve equilibrium with the surrounding pressure. Charles’ Law. Charles’ Law states that the pressure of a gas is directly proportional to its absolute temperature, volume remaining constant. The contraction of gas due to temperature change at altitude, however, in no manner compensates for the expansion due to the corresponding decrease in pressure. Dalton’s Law. Dalton’s Law of partial pressures states that each gas in a mixture of gases behaves as if it alone occupied the total volume and exerts a pressure, its partial pressure, independent of the other gases present. The sum of the partial pressures of individual gases is equal to the total pressure. Using this law, one can calculate the partial pressure of a gas in a mixture simply by knowing the percentage of concentration in that mixture.

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Physiology of Flight Henry’s Law. Henry’s Law states that the amount of gas in a solution varies directly with the partial pressure of that gas over the solution. Graham’s Law. Graham’s Law states that the relative rates of diffusion of gases under the same conditions of temperature and pressure are inversely proportional to the square roots of the densities of those gases. Gases with smaller molecular weights will diffuse more rapidly.. Pulmonary Ventilation Ventilation is a cyclic process by which fresh air or a gas mixture enters the lungs and pulmonary air is expelled. The inspired volume is greater than the expired volume because the volume of oxygen absorbed by the blood is greater than the volume of carbon dioxide, which is released from the blood. Since gas exchange occurs solely in the alveoli and not in the conducting airways, the estimation of alveolar ventilation rate (i.e., the amount of gas which enters the alveoli per minute) is the most important single variable of ventilation. Pulmonary ventilation does not occur evenly throughout the alveoli since normal lungs do not behave like perfect mixing chambers, nor is the pulmonary capillary network evenly distributed throughout the lungs. Ventilation, therefore, must be readjusted regionally to match the increased or decreased blood flow, or some of the alveoli will be relatively under or over ventilated. The even distribution of pulmonary capillary blood flow is as important as an even distribution of inspired air to the alveoli for normal oxygenation of the blood.

Gaseous Diffusion Respiratory gas exchange in the lungs is accomplished entirely by the process of simple diffusion. The direction and amount of movement of the molecules depend upon the difference in partial pressure on both sides of the alveolar membrane. Normally, molecular oxygen moves from a region of higher partial pressure to one of lower partial pressure. The volume of gas which can pass across the alveolar membrane per unit time at a given pressure is the diffusing capacity of the lungs. The diffusing capacity is not only dependent on the difference in partial pressure of the gas in the alveolar air and pulmonary capillary blood, but it is also proportional to such factors as the effective surface area of the pulmonary vascular bed. It is inversely proportional to the average thickness of the alveolar membrane and directly proportional to the solubility of the gas in the membrane. The normal values for diffusing capacity range from 20 to 30 ml 02/min/mm Hg for normal young adults.

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U.S. Naval Flight Surgeon’s Manual Pulmonary Capillary Blood Flow Pulmonary capillary blood flow must be adequate in volume and well distributed to all of the ventilated alveoli to insure proper gas exchange. Underperfused or poorly ventilated alveoli can become a serious matter during flight when G forces acting on the body result in a redistribution of pulmonary capillary blood flow. During exposure to positive (+ Gz) accelerative forces, the blood flow is directed to the lung bases, whereas, during exposure to negative (- Gz) acceleration, the flow is toward apical areas. Composition of Respired Air The composition of the atmosphere is remarkably constant between sea level and an altitude of 300,000 feet. Nitrogen and oxygen are the most abundant gases in the atmosphere as shown in Table l-l. From a practical standpoint, in the study of the effects of altitude on the human body, the percent concentrations of the other gases are considered negligible and are ignored. It is convenient, therefore, to consider air as about four fifths (79 percent) nitrogen and one fifth (21 percent) oxygen. Atmospheric Air In the dry air at sea level, the partial pressures of the constituent gases according to Dalton’s Law are: P O 2 = 760 mm Hg x 0.2075 = 157.7 mm Hg P N 2 = 760 mm Hg x 0.7902 = 600.6 mm Hg P C 0 2 = 760 mm Hg x 0.003 = 0.2 mm Hg Tracheal Air When inspired air enters the respiratory passages, it rapidly becomes saturated with water vapor and is warmed to body temperature. The water vapor has a constant pressure of 47 mm Hg at the normal body temperature of 98.6° F, regardless of the barometric pressure. Accordingly, the sum of the partial pressures of the inspired gases no longer equals the barometric pressure, but instead equals the barometric pressure minus the water vapor pressure. Thus, the tracheal partial pressure of inspired gases can be calculated as follows: Ptr = (PB - 47) x FI

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Physiology of Flight where Ptr = The tracheal partial pressure of the inspired gas P B = Barometric pressure FI = The fractional concentration of the inspired gas. Aveolar Air The theoretical alveolar (alv) PO 2 for any altitude can be calculated if one knows the barometric pressure and the dry fraction (percentage) of oxygen in the inhaled gas. A constant, sea level ventilation rate and a normal metabolic rate are presumed for the sake of simplicity. With tracheal (tr) PH2O a constant 47 mm Hg, PCO2 (alv) a constant 40 mm Hg, a barometric pressure at 10,000 feet of 523 mm Hg, and a dry fraction of oxygen of 21 percent, then at 10,000 feet breathing air, PO2(tr) = (PB - PH2O[tr]) x .21 or PO 2 (tr) = .21 (523-47) = 99.96 mm Hg. However, in the transition from tracheal gas to alveolar gas, the PO2 is reduced and PCO2 is increased. The PN2 remains the same. Therefore, PO 2 (alv) =PO 2 (tr) - PCO 2 (alv) PO 2 (alv) = 9 9 . 9 6 mm H g . - 4 0 mm H g . = 6 0 mmH g . Actual measurements of PO2(alv) at various altitudes derived from both breathing air and breathing 100 percent oxygen are presented in Table l-5. The PO2(alv) at 10,000 feet breathing air was measured to be 61 mm Hg. This drop in PO2 with ascent causes a gradually increasing hypoxic stimulus to respiration (via the chemoreceptors in the area of the carotid sinus) resulting in an increased respiratory exchange rate (RER) and an increased PO2(alv) over that calculated. There also is a decreased PCO2(alv). Table 1-5 can be used for calculations when measured data are not available. Table l-6 shows measured changes at sea level in the partial pressure of the gases at various sites in the respiratory cycle. This is illustrated graphically for oxygen and carbon dioxide in Figure l-3.

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Table 1-5 Tracheal Oxygen Pressure, Alveolar Oxygen Pressure, and Carbon Dioxide Pressure in the Alveolar Gas When Breathing Air and 100 Percent Oxygen at Physiologically Equivalent Altitudes

Page 1-14.

Physiology of Plight Table l-6 Partial Pressures of Respiratory Gases at Various Sites in Respiratory Circuit of Man at Rest at Sea Level

Figure 1-3. Partial pressures of O2 (above) and CO2 (below) in air at sea level and at various points within the body (Billings, 1973a).

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U.S. Naval Flight Surgeon’s Manual Oxygen Transport Oxygen is carried in the blood both in simple physical solution and in loose chemical combination with hemoglobin in the form of oxyhemoglobin. The oxygen transport capacity of one gram of hemoglobin is 1.34 ml of oxygen. Therefore, the capacity for 100 ml of blood is about 20 ml of oxygen (presuming normal hemoglobin to be 14.7 gm/l00 ml) and represents 100 percent hemoglobin saturation. Normally, arterial hemoglobin in an individual breathing air at sea level is 98 percent saturated. When breathing 100 percent oxygen at sea level pressure, the hemoglobin becomes 100 percent saturated, and additional oxygen goes into simple solution in the plasma. The total of additional oxygen so transported is 11 percent greater than normal. In Figure 1-4, a family of oxygen-hemoglobin dissociation curves is presented. From these curves it can be seen that the blood leaves the pulmonary capillary bed with the hemoglobin about 98 percent saturated. Even if the PO2(alv) is reduced by 20 mm Hg, the saturation is reduced by only three to four percent. In the tissue capillaries, however, a small decrease in oxygen tension causes changes in the dissociation curve which result in a large quantity of oxygen being made available to the tissues. The upper section of the dissociation curves (Figure 1-4A) remains relatively flat through an oxygen tension change of 40 mm Hg; thus, when the PO2(alv) falls from 100 to 60 mm Hg the blood saturation is reduced only by about eight percent. As the oxygen tension continues to fall, however, an additional reduction of 30 mm Hg results in a precipitous drop in blood saturation to 58 percent. Thus, the characteristic shape of the dissociation curves accounts for the relatively mild effects of hypoxia at low altitude and the very serious impairment of function at higher altitudes.

The oxygen carrying capacity of the blood hemoglobin is also very sensitive to changes in blood pH (Bohr effect), as illustrated in Figure 1- 4B. At an oxygen tension of 60 mm Hg, for example, at pH 7.2, 7.4, and 7.6, the arterial oxygen saturation is observed to be 84, 89 and 94 percent, respectively. Carbon dioxide is the major determinant of blood pH. In venous blood PCO2 is high; accordingly, the pH is low. In arterial blood, the PCO2 is less as a result of the diffusion of carbon dioxide into the alveoli. The arterial blood, therefore, has a higher pH and can carry more oxygen at a given alveolar PO2 that would be possible without this change in pH. In the tissues, the reverse conditions exists.

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Physiology of Flight

Figure 1-4. A. Effect of CO2 on oxygen dissociation curve of whole blood (after Barcroft). B. Effect of acidity on oxygen dissociation curve of blood (after Peters & Van Slyke). C. Effect of temperature on oxygen dissociation curve of blood (Carlson, 1956b).

Control of Respiration The neural control of respiration is accomplished by neurons in the reticular formation of the medulla. This rhythmic activity is modified by afferent impulses arising from receptors in various parts of the body, by impulses originating in higher centers of the central nervous system, and by specific local effects induced by changes in the chemical composition of the blood. A major decrease in arterial PO2 causes slightly increased pulmonary ventilation. However, if the afferent fibers from the chemoreceptive areas are severed, respiration is depressed. Thus, the

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U.S. Naval Flight Surgeon’s Manual direct effect of hypoxia on the respiratory center itself is depressive, but hypoxia will cause increased pulmonary ventilation when the chemoreceptor mechanism is intact. A minute increase of about 0.25 percent alveolar carbon dioxide will lead to a 100 percent increase in pulmonary ventilation rate. Conversely, lowering the alveolar PCO 2 by voluntary hyperventilation tends to produce apnea. From these observations, it may be deduced that control of respiration appears to be governed primarily by the homeostasis of alveolar PCO2. Oxygen lack is a rather ineffective stimulus for pulmonary ventilation. Ernsting (1965b) reports that no increase in pulmonary ventilation occurs with acute oxygen lack until the alveolar PO2 is reduced to about 65 mm Hg, or at approximately 37,000 to 39,000 feet equivalent altitude, breathing 100 percent oxygen. Even a reduction alveolar oxygen to about 40 mm Hg (42,000 feet equivalent altitude) will only increase ventilation by about one third of its normal resting value. The pattern of pulmonary ventilation occurring in hypoxia does not represent a simple reaction to the reduced alveolar oxygen tension. Hypoxia Probably the most frequently encountered hazard in aviation medicine is hypoxia. Records of early balloon and aircraft flights describe tragedies resulting from hypoxia, since even these primitive machines had a higher operational ceiling than the men aboard them. Hypoxia was a serious aviation problem in both World Wars and remains a potential threat even in today’s military aviation. Engineering solutions to the problem have been ingenious. Considerable money has been expended on training of aviators and on procurement of equipment to prevent hypoxia. Yet, hypoxic incidents continue to occur, and the flight surgeon should be well informed concerning this problem. There is a commonly encountered misconception among aviators that it is possible to learn all of the early symptoms of hypoxia and then to take corrective measures once symptoms are noted. This concept is appealing because it allows all action, both preventive and corrective, to be postponed until the actual occurrence. Unfortunately, the theory is both false and dangerous. One of the earliest effects of hypoxia is impairment of judgment. Therefore, even if the early symptoms are noted, an aviator may disregard them and often does, or he may take corrective action which is actually hazardous, such as disconnecting himself from his only oxygen supply. Finally, at high altitudes, hypoxia may cause unconsciousness as the first symptom.

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Physiology of Fight These factors must be kept in mind during a flight surgeon’s study of hypoxia, during the indoctrination and refresher training flights in the altitude chamber at an Aviation Physiology Training Unit, and especially during the flight surgeon’s daily contact with aviators in the ready room, sickbay, or clinic. Despite improvements in oxygen delivery systems, more reliable cabin pressurization systems, and extensive physiology training, hypoxia still remains ever present in today’s military aviation. Each year, approximately 8 to 10 physiological episodes of hypoxia are reported. The most common cause of the hypoxic incident is cabin or cockpit pressurization failure followed by defective oxygen equipment. In these incidents, the pilot or copilot was able to recover the aircraft and avoid a major mishap or fatality. One can only conjecture how many mishaps and fatalities in military aviation have occurred as the direct result of hypoxia. Since hypoxia episodes are still frequently encountered, and in all likelihood contribute to many major mishaps and fatalities, the flight surgeon and aviation physiologist should be well informed of every facet of the problem. Types of Hypoxia The amount and pressure of oxygen delivered to the tissues is determined by arterial oxygen saturation, by the total oxygen-carrying capacity, and by the rate of delivery to the tissues. Hypoxia, defined as an insufficient supply of oxygen, can result from any one of these factors. Accordingly, the following classic types of hypoxia have been distinguished: 1. Hypoxic hypoxia results from an inadequate oxygenation of the arterial blood and is caused by reduced oxygen partial pressure. 2. Anemic hypoxia results from the reduced oxygen- carrying capacity of the blood, which may be due to blood loss, any of the anemias, carbon monoxide poisoning, or by drugs causing methemogiobinemia. 3. Stagnant hypoxia is caused by a circulatory malfunction which results, for example, from the venous pooling encountered during acceleration maneuvers. 4. Histofoxic hypoxia results from an inability of the cells to utilize the oxygen provided when the normal oxidation processes have been poisoned such as by cyanide. There is no oxygen lack in the tissues, but rather an inability to use available oxygen, with the result that the PO2 in the tissues may be higher than normal. Therefore, it is not true hypoxia by the definition used here.

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U.S. Naval Flight Surgeon’s Manual The most common type of hypoxia encountered in aviation is hypoxic hypoxia. This results from the reduced oxygen partial pressure in the inspired air caused by the decrease in barometric pressure. Other types may also affect aircrewmen, such as anemic hypoxia as seen in carbon monoxide poisoning and stagnant hypoxia resulting during various acceleration profiles. Types of Onset of Hypoxia The onset of hypoxia varies with the cause. During ascent to altitude without supplementary oxygen equipment, the onset of hypoxia is as gradual as the rate of ascent. As soon as an inspiration is completed, the alveolar gases approach equilibrium with the inspired gases, and similarly, the arterial gases reach a very rapid equilibrium with the alveolar gases, but the change in barometric pressure is gradual between breaths. In the event of contamination or dilution of oxygen in the mask with some amount of cabin air, due to either a leaky mask or faulty tubing, onset of hypoxia is intermittent. Moreover, the effects are inconsistent because the amount of hypoxia developing varies from one breath to the next, depending on leakage rate, altitude, and body position (which may cause the aperture of a leak to be temporarily closed, partially open, or completely open). This type of hypoxia onset is difficult to trace because it is often difficult to validate that a hypoxic incident occurred, much less to determine the cause. In the case of a supply hose disconnect or other cause of exposure to ambient air, whether known or unknown, the onset of symptoms will be determined by the altitude during exposure. If such a disconnect is immediately discovered, and if no decompression is involved, the aircrewmen should hold his breath while attempting to reconnect, because the alveolar PO2 is higher than the ambient PO2. Breathing in such circumstances will cause a washout of oxygen from the tissues. This must be avoided as long as possible. When rapid decompression occurs, the volume and pressure of alveolar gases become markedly higher than those of the ambient atmosphere, and sudden expulsion of the alveolar gases occurs. At the end of the resulting involuntary expiration, the normal reaction is to inhale, and at the end of that inspiration, the alveolar PO2 is in equilibrium with the ambient air. The resulting effects will depend upon the PO2 at the terminal decompression altitude. Symptomatology Many observations have been made on the subjective and objective symptoms of hypoxia. A detailed analysis of progressive functional impairment indicates that the effects of hypoxia fall in-

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Physiology of Plight to four stages. Table l-7 summarizes the stages of hypoxia in relation to the altitude of occurrence, breathing air or breathing 100 percent oxygen, and the arterial oxygen saturation.

Table 1-7 Stages of Hypoxia

1. Indifferent Stage. There is no observed impairment. The only adverse effect is on dark adaptation, emphasizing the need for oxygen use from the ground up during night flights. 2. Compensatory State. The physiological adjustments which occur in the respiratory and circulatory systems are adequate to provide defense against the effects of hypoxia. Factors such as environmental stress or prolonged exercise can produce certain decompensations. In general, in this stage there is an increase in pulse rate, respiratory minute volume, systolic blood pressure, and cardiac output. There is also an increase in fatigue, irritability, and headache, and a decrease in judgment. The individual has difficulty with simple tests requiring mental alertness or moderate muscular coordination. 3. Disturbance Stage. In this stage, physiologic responses are inadequate to compensate for the oxygen deficiency, and hypoxia is evident. Subjective symptoms may include headache, fatigue, lassitude, somnolence, dizziness, “air-hunger“, and euphoria. At 20,000 feet, the period of useful consciousness is 15 to 20 minutes. In some cases, there are no subjective symptoms noticeable up to the time of unconsciousness. Objective findings include: a. Special Senses. Peripheral and central vision are impaired and visual acuity is diminished. There is weakness and incoordination of the extraocular muscles and reduced range of accom-

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U.S. Naval Flight Surgeon’s Manual modation. Touch and pain sense are lost. Hearing is one of the last senses to be affected. b. Mental Processes. The most striking symptoms of oxygen deprivation at these altitudes are classed as psychological. These are the ones which make the problem of corrective action so difficult. Intellectual impairment occurs early, and the pilot has difficulty recognizing an emergency situation unless he is widely experienced with hypoxia and has been very highly trained. Thinking is slow; memory is faulty; and judgment is poor. c. Personality Traits. In this state of mental disturbance, there may be a release of basic personality traits and emotions. Euphoria, elation, moroseness, pugnaciousness, and gross overconfidence may be manifest. The behavior may appear very similar to that noted in alcoholic intoxication. d. Psychomotor Functions. Muscular coordination is reduced and the performance of fine or delicate muscular movements may be impossible. As a result, there is poor handwriting, stammering, and poor coordination in flying. Hyperventilation is noted and cyanosis occurs, most noticeable in the nail beds and lips. 4. Critical Stage. In this stage of acute hypoxia, there is almost complete mental and physical incapacitation, resulting in rapid loss of consciousness, convulsions, and finally in failure of respiration and death. An important factor in the sequence cited above is the gradual ascent to altitude where the individual can come to equilibrium with the gaseous environment, and physiological adjustments have sufficient time to come into play. This occurs in military aviation only in cases where the aviator is unaware that his oxygen is disconnected or in cases where leaks occur in the oxygen system, causing gradual dilution of the oxygen with cabin air. Of greatest concern to a flight surgeon is hypoxia resulting from the sudden loss of cabin pressure in aircraft operating at very high altitudes. Under these conditions, a loss of pressurization or oxygen supply will cause exposure of the aviator to environmental conditions so stressful that physiological compensation cannot occur before the onset of unconsciousness. Time of Useful Consciousness The time of useful consciousness is that period between an individual’s sudden deprivation of oxygen at a given altitude and the onset of physical or mental impairment which prohibits his taking rational action. It represents the time during which the individual can recognize his problem

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Physiology of Flight and reestablish an oxygen supply, initiate a descent to lower altitude, or take other corrective action. Time of useful consciousness is also referred to as effective performance time (EPT). The time of useful consciousness is primarily related to altitude, but it is also influenced by individual tolerances, physical activity, the way in which the hypoxia is produced and the environmental conditions prior to the exposure. Average times of useful consciousness at rest and with moderate activity at various altitudes are shown in Table 1-8. The subjects were breathing oxygen and produced the hypoxic environments by disconnecting their masks. If an individual breathing air is suddenly decompressed, his time of useful consciousness is shorter than if he had been breathing oxygen (Figure 1-5). The PO2 in his lungs drops immediately to a level dependent only on the final altitude, rather than dropping gradually with each breath of air, dependent on lung volume, dilution of that volume, and altitude.

Table l-8 Time of Useful Consciousness

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U.S. Naval Plight Surgeon’s Manual

Figure 1-5. Minimum and average duration of effective consciousness in subjects following rapid decompression breathing air (lower curve) and O2 (upper curve) (Billings, 1973a; data from Blockley & Hanifan, 1961).

Limit Altitudes and Altitude Equivalents In considering hypoxia, some minimum limit must be set on the supply of oxygen considered ‘adequate’ for the purposes of military aviation. Ideally, one would select sea level conditions as the limit and design and construct oxygen supply systems to maintain them, but this is not feasible considering the altitudes at which Navy and Marine Corps aircraft are capable of operating. In determining a limit altitude, one is actually specifying the maximum level of hypoxia which is acceptable. The Navy NATOPS Manual, General Flight and Operating Instructions, OPNAV Instruction 3710.7 series, specifies the following limit altitudes for crew members aboard naval aircraft: With one exception, all occupants aboard naval aircraft will use supplemental oxygen on flights in which the cabin altitude exceeds 10,000 feet.

Exception: When all occupants are equipped with oxygen, unpressurized aircraft may ascend to flight level 250 (25,000 feet). When minimum enroute altitudes or an ATC clearance requires flight above 10,000 feet in an unpressurized aircraft, the pilot at the controls shall use oxygen.

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Physiology of Flight When oxygen is not available to other occupants, flight between 10,000 and 13,000 feet shall not exceed three hours duration, and flight above 13,000 feet is prohibited. Table 1-9 gives the oxygen requirements for pressurized aircraft flown above 10,000 feet, when cabin altitude is maintained at 10,000 feet or less. The quantity of oxygen aboard an aircraft before takeoff must be sufficient to accomplish the planned mission. In aircraft carrying passengers, there must be an adequate quantity of oxygen to protect all occupants through normal descent to 10,000 feet. Table 1-9 Oxygen Requirements for Pressurized Aircraft Other Than Jet Aircraft

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U.S. Naval Flight Surgeon’s Manual If loss of pressurization occurs, a descent shall be made immediately to a flight level where cabin altitude can be maintained at, or below, 25,000 feet, and oxygen shall be utilized by all occupants. When it is observed or suspected that an occupant of any aircraft is suffering the effects of decompression sickness, 100 percent oxygen will be started and the pilot shall immediately descend and land at the nearest civilian or military installation, and obtain qualified medical assistance. The person affected may continue the flight only on the advice of a flight surgeon. In tactical jet and tactical jet training aircraft, oxygen shall be used by all occupants from takeoff to landing. Emergency bailout bottles, when provided, shall be connected prior to flight. Respiratory Adjustments to Altitude The critical PO2(alv) at which the average individual loses consciousness on short exposure to altitude is 30 mm Hg. This corresponds to 23,000 to 25,000 feet on Curve A of Figure l-6. In the complete absence of respiratory adjustments to altitude, the same PO 2 (alv) would be encountered at about 17,000 feet. Applying similar considerations to 100 percent oxygen breathing altitudes, it is evident that hypoxia-induced hyperventilation, as reflected in the course of the PCO2(alv) on Curve D of Figure 1-6, does improve the PO2(alv) measurably. Thus, the 30 mm Hg PO2(alv) in this case is at 47,000 feet (Curve C) with respiratory adjustment and 44,000 feet without it.

Comparisons can be made between different barometric pressures which produce the same alveolar PO2 when breathing air in one case and 100 percent oxygen in the other, in order to establish “physiologically equivalent altitudes.” Actually, physiological states cannot be compared solely on the basis of PO2(alv). PCO2(alv) and ventilation must be considered also, since a change in one will cause change in the others until a steady state is reached.

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Physiology of Plight

Figure l-6. The partial pressures of respiratory gases when breathing air (A, oxygen; B, carbon dioxide) and using oxygen equipment (C, oxygen; D, carbon dioxide). The interrupted lines represent the theoretical course in the absence of the respiratory response to hypoxia at altitude (Boothby, Lovelace, Benson & Strehler, 1954).

The time necessary to reach a steady state at various altitudes is given in Figure 1-7. Note that even at the relatively low altitude of 18,000 feet, a steady state is reached only after an hour of respiratory adjustment. For practical purposes, the PO2(alv) may be used without considering respiratory adjustment in establishing physiologically equivalent altitudes.

Ten thousand feet during daylight is specified as the limit above which, in non-pressurized aircraft, crew members must use oxygen. The PO2(alv) at 10,000 feet, breathing air, is approximately 61 mm Hg, which produces the maximum acceptable degree of hypoxia which Navy and Marine Corps aircrewmen are allowed to undergo. As a consequence, all oxygen equipment and barometric controls are designed to maintain the user at this physiological equivalent or below.

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U.S. Naval Flight Surgeon’s Manual

Figure 1-7. The respiratory exchange ratio in the course of exposures to l0,000, 15,000, 18,000 and 25,000 feet, indicating the duration of the “unsteady state” (Boothby, Lovelace, Benson, & Strehler, 1954).

Having arrived at the allowable lower limit of PO2(alv), various equivalent altitudes yielding the same PO2(alv) can be compared. In breathing oxygen not under pressure, Table l-10 shows a PO2(alv) of 61 mm Hg at 39,500 feet, which is, therefore, the upper limit for flying without positive pressure breathing. Similarly, other limiting altitudes are noted.

A question may arise as to why 10,000 feet while breathing air, or a PO2(alv) of about 60 mm Hg, was selected as the upper limit for flight without oxygen. Reference to Table l-6 shows that 10,000 feet is the upper limit for the indifferent stage of hypoxia. Even more important, reference to the oxyhemoglobin saturation curve shows that ascent to 10,000 feet causes a decrease of only about seven percent in the oxyhemoglobin saturation, since at 10,000 feet the hemoglobin is still 90 percent saturated. However, rather small increases in altitude thereafter cause a rather marked

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Physiology of Flight Table l-10 Limiting Altitude for Respiratory Functioning

steepening of the slope of the curve. Certainly a 2,000 to 3,000 foot difference would not matter much, but anything over that becomes unacceptable; hence, the NATOPS limitation to 13,000 feet for not over three hours for certain types of flights.

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U.S. Naval Flight Surgeon’s Manual The theoretical considerations just discussed set limits which are useful in making predictions and calculations. In military operations, however, many variable factors must be taken into account. If the oxygen mask suspension is not tightly adjusted, or if the mask is improperly fitted to the aviator, a lower PO2(alv) will be measured in the individual using that equipment than would be predicted, due to dilution of the inspired oxygen with cabin air. There are other factors which could also account for considerable variation in the absolute PO2 delivered to the trachea at the same altitude using the same equipment at the same settings, but on different days or even different flights. Individual variations in diffusion rates for the alveolar membrane, or in the amount of circulating hemoglobin, or in several other physiological variables, could also result in a lower arterial PO2 than expected from the same PO2(alv). The significance is that the range of variability both in supply and among individuals must be compensated for by the supply of oxygen. The mechanical means will be discussed later, but one example of the built-in safety factors in oxygen equipment is given here. From calculations of PO2(alv) as noted in Table 1-10, 33,700 feet is the altitude at which an individual breathing 100 percent oxygen has the same PO2(alv) as an individual breathing air at sea level. If no safety factor were included, the aneroid of the diluter-demand oxygen regulator would be set so that the regulator would deliver 100 percent oxygen at that altitude. Oxygen would be wasted if the regulator were set to deliver 100 percent at any lower altitude. (The reason for attempting to conserve oxygen is that oxygen quantity, like fuel quantity, is a limiting factor on aircraft range.) In actuality depending upon the diluter-demand regulator utilized, 100 delivered between 20,000 to 32,000 feet rather than at 33,700 feet. Such safety to almost all Navy life support equipment, not only to anticipate the wide response, but also to guard against some slight misuse or maladjustment of

percent oxygen is factors are built invariation in human the equipment.

The theoretical upper limit of altitude which can be endured by the unprotected body is the point at which the ambient pressure is equal to or lower than the vapor pressure of water at a body temperature 98.6° F. Above that limit, much of the water in the body would vaporize. Theoretically, this would occur at 63,000 feet with a barometric pressure of 47 mm Hg. Actually this "critical" altitude must be modified upward since the water in the body is contained in the pressure vessels of cells, intravascular spaces, etc. The only situation in which the body water might vaporize is one in which an aviator who is flying at or above this altitude limit, with the cabin pressurized to a much lower altitude, experiences a rapid decompression to ambient pressure.

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Physiology of Flight This upper limit has been tested experimentally and appears to be rather on the low side of the actual figure. In experiments on the unprotected human hand (Figure 1-8), it was found that a pressure below that equal to water vapor pressure at skin temperature was required to cause vaporization of body water. The discrepancy may have been due to the forces exerted by connective tissues within the hand and the elastic nature of the skin covering.

Figure 1-8. Water vapor in tissue at extreme altitudes (Billings & Roth, 1964).

Appearance of water vapor occurred suddenly and manifested itself by marked swelling of the hand after a variable time at altitude. After appearance of swelling, the pressure in the altitude chamber was quickly raised; the hand was examined periodically. The upper point (o) represents the first point at which swelling was no longer visible to the eye. If chamber pressure was again lowered slightly, swelling again appeared, indicating the continued presence of bubble nuclei in the hand tissues. This suggests that once water vapor bubbles

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U.S. Naval Plight Surgeon’s Manual appear, oxygen and carbon dioxide diffuse into the bubbles, which become transformed into bubbles of gas saturated with water vapor. For the Navy and Marine Corps aviator, the NATOPS Manual, OPNAVINST 3710.7 series limits flights in pressurized aircraft flown by aviators not utilizing full pressure suits to 50,000 feet. Hyperventilation Among the perils that test the prudence and stamina of a pilot and is closely associated with hypoxia, is a breathing disorder called hyperventilation. Although unrelated in cause, the symptoms of hyperventilation and hypoxia are similar and often result in confusion and inappropriate treatment. Definition of Hyperventilation Hyperventilation is defined as excessive rate or depth of breathing. The increase in ventilation leads to a lowering of alveolar carbon dioxide tension, a condition referred to as hypocapnia. In addition, the acid-base balance of the blood becomes more alkaline, a condition referred to as a respiratory alkalosis. Causes of Hyperventilation Among the causes that can lead to hyperventilation are hypoxia, pressure breathing, psychological stress, and pharamocological stimuli. Hypoxia With the onset of hypoxia above 10,000 feet, oxygen tension in the lungs and arterial blood is reduced. This reduced arterial PO2 reflexively stimulates the respiratory center via the aortic and carotid peripheral chemoreceptors, causing increased breathing. Pressure Breathing. There is a tendency to over breathe during positive pressure breathing. Positive pressure which is used to prevent hypoxia, creates a reversal of the normal respiratory cycle of inhalation and exhalation. Under positive pressure breathing, the aviator is not actively involved in inhalation as in the normal respiratory cycle. Instead of the aviator inhaling oxygen into the lungs, oxygen, under pressure, is forced into the lungs. During exhalation under positive pressure breathing, the aviator must breathe out against pressure. The force that the individual must exert in exhaling results in an increased rate and depth of breathing.

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Physiology of Flight Psychological Stress. The human psyche can also override the normal respiratory controls. Fear, anxiety, stress or tension, resulting from emotion or physical discomfort, will sometimes cause an individual to override the normal reflex control of breathing. This cause is most frequently encountered during initial low pressure chamber flights and early inflight training, and is probably the most common cause in all types of flying. Pharmacological Stimuli. Pharmacological stimuli to hyperventilation only become important when aircrew who are taking drugs continue to fly. The major groups of drugs that cause hyperventilation are salicylates, female sex hormones, catecholamines and analeptics. Effects of Hyperventilation The two primary results of hyperventilation are hypocapnia and alkalosis. The hypocapnia and alkalosis have an effect on the respiratory, cardiovascular and central nervous systems. Respiratory System. The effect of hyperventilation on the respiratory system is primarily on the blood buffer system. Seventy percent of the carbon dioxide present in the blood is carried as a bicarbonate ion. The overall reaction for bicarbonate formation occurs as follows:

The major influence determining the direction in which the above reaction proceeds is the concentration, or partial pressure of carbon dioxide. When the carbon dioxide levels in the blood increase, the reaction proceeds to the right, toward the formation of greater hydrogen and bicarbonate ions. When the carbon dioxide level decreases, the reaction reverses toward the formation of carbon dioxide and water. When an individual hyperventilates, the excessive elimination of carbon dioxide causes a reduction in hydrogen ion concentration that is too rapid for the blood buffer system to replace. The pH is elevated and a respiratory alkalosis ensues.

Cardiovascular System. It is generally agreed that hyperventilation causes tachycardia, increased cardiac output and reduced systemic vascular resistance and mean arterial blood pressure. Hyperventilation also causes vasoconstriction of cerebral blood vessels, vasodilation of systemic blood vessels and reduced coronary blood flow resulting in lowered myocardial oxygen tension. The combined effects of systemic vasodilation and cerebral vasoconstriction cause a restriction in blood flow to the brain. The primary cardiovascular effect is on the oxyhemoglobin dissociation nerve. Hyperventilation shifts the oxyhemoglobin curve upward and to the left, called the Bohr effect. This shift increases the capacity of blood to onload oxygen on the lung level but restricts

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U.S. Naval Flight Surgeon’s Manual offloading at the tissue level. The combined effect of restricted blood flow and increased oxygen binding results in stagnant hypoxia at the brain which leads to unconsciousness. Central Nervous System. Hyperventilation and the resulting elevated pH cause an increased sensitivity and irritability of neuromuscular tissue. This increase is manifested by superficial tingling and numbness of the extremities and mouth, and muscular spasm and tetany. The tingling usually precedes muscular spasm and tetany. The hands and feet may exhibit carpopedal spasm, a fixation of the hand wherein the fingers are flexed toward the wrist or a marked plantar flexion of the ankle. Muscle spasm usually occurs when the arterial carbon dioxide tension has been reduced to 15 to 20 mm Hg. In more severe hypocapnia, with an arterial carbon dioxide tension less than 15 mm Hg, the whole body becomes stiff (tetany) due to contraction of skeletal muscle. Figure 1-9 summarizes the effects of hyperventilation.

Figure l-9. Effects of hyperventilation.

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Physiology of Flight Signs and Symptoms of Hyperventilation The signs and symptoms of hyperventilation are not easily differentiated from and can easily be confused with those of hypoxic hypoxia. Objective Signs. The objective signs of hyperventilation most often observed in another individual are: 1. 2. 3. 4. 5. 6. 7.

Increase rate and depth of breathing. Muscle twitching and tightness. Paleness. Cold clammy skin. Muscle spasms. Rigidity. Unconsciousness.

Subjective Symptoms. The subjective symptoms, those perceived by the individual include: 1. 2. 3. 4. 5. 6.

Dizziness. Light headedness. Tingling. Numbness. Muscular incoordination. Visual disturbance.

Similarity to Hypoxia While the etiology of hypoxia and hyperventilation are different, the symptoms are quite similar making it difficult to differentiate between the two. There are, however, a few distinguishing differences in these two syndromes. In hyperventilation, the onset is gradual, with the presence of pale, cold, clammy skin and the development of muscle spasm and tetany. In hypoxia, the onset of symptoms is usually rapid (altitude-dependent), with the development of flaccid muscles and cyanosis. Treatment of Hyperventilation Since hypoxia and hyperventilation are so similar and both can quickly incapacitate, the recommended treatment is aimed at correcting both problems simultaneously. There are five steps for treatment:

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U.S. Naval Flight Surgeon’s Manual 1. 2. 3. 4. 5.

Go to 100 percent oxygen if not already on it. Check oxygen equipment to ensure proper functioning. Control breathing - reduce the rate and depth. Descend below 10,000 feet where hypoxia is an unlikely problem. Communicate problem. Positive Pressure Breathing

The requirement for positive pressure breathing in naval aviation is predicated on the degree of hypoxia acceptable for safe mission performance. Safe mission performance is based on a minimal alveolar partial pressure of oxygen of 60 mm Hg. This alveolar partial pressure of oxygen is reached at approximately 39,000 feet breathing 100 percent oxygen. To maintain the minimum alveolar partial pressure of oxygen above 39,000 feet, positive pressure must be applied to the breathing oxygen. Positive pressure breathing in operational aircraft is an indication of an emergency condition which occurs when cabin pressurization is lost at or above 35,000 feet, In the event of cabin pressurization failure at altitudes above 35,000 feet, pressure breathing is employed to maintain consciousness and physical function so that a rapid controlled descent to lower altitudes may be accomplished. As long as the cabin pressurization system is functioning normally, the aviator should not experience positive pressure breathing. Kinds of Positive Pressure Breathing Simply stated, positive pressure breathing is the delivery of a gas to the respiratory tract at a pressure greater than ambient. There are two kinds of positive pressure breathing: intermittent positive pressure breathing and continuous positive pressure breathing. Intermittent Positive Pressure Breathing (IPPB). IPPB provides pressure behind the breathing gas on inspiration, but during expiration the pressure is removed. The mean mask pressure is approximately one third of the highest pressure applied during the inspiratory phase. Continuous Positive Pressure Breathing (CPPB). CPPB provides pressure behind the breathing gas throughout the respiratory cycle. Assuming a good mask fit without leakage, the mean mask pressure is nearly equivalent to the positive pressure delivered by the regulator, and the alveolar gas pressure is correspondingly raised. The highest mean mask pressure of oxygen offers the best physiological protection against hypoxic hypoxia. Since this is obtained with CPPB breathing, this system is utilized in Naval aviation.

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Physiology of Flight Respiratory Effects of Positive Pressure Breathing Distention of Lungs and Chest. The stress on the walls of the lungs normally depends upon their degree of inflation, the support of the walls of the thoracic cavity and the maximum pressure which can be exerted and held in the lungs by active contraction of the expiratory muscles. Pressure breathing tends to distend the chest and lungs. In a relaxed individual, when no muscular effort is made, the lungs are fully distended by a pressure of 20 mm Hg. If the lungs are unsupported by the chest wall (i.e., open thorax) they will rupture when the intrapulmonary pressures exceeds 40-50 mm Hg. When, however, the chest wall is intact, intrapulmonary pressures up to 80 to 100 mm Hg can be tolerated without damage. At intrapulmonary pressures between 80 to 100 mm Hg, parenchymal lung damage secondary to overexpansion may occur if the expiratory muscles are relaxed. While overdistention of the lung is possible, lung rupture is not probable. The greatest pressure output of current naval regulators is 30 mm Hg, well below the threshold of lung damage even in an open chest. Pulmonary Ventilation. In most subjects, pressure breathing causes an increase in minute ventilation. The increase is due to both an increase in tidal volume and frequency of breathing. There is a wide variation in pulmonary ventilation response which depends to a great extent on individual experience with positive pressure breathing. Pressure breathing at 30 mm Hg causes a mean increase in the respiratory minute volume of 50 percent over the resting valve. Some individuals double their minute volume at 30 mm Hg while others hardly respond. Intrapleural Pressure. The increase in intrapleural pressure which occurs during positive pressure is important since it determines the magnitude of insult on the cardiovascular system. The increase in the intrapleural pressure is a function of the applied positive pressure and the degree of lung distention. If there is no increase in lung volume, the intrapleural pressure will equal the applied positive pressure. If lung distension occurs, the intrapleural pressure will be less than the breathing pressure by an amount equal to the pressure produced by the elastic recoil of the distended lung. The elastic recoil pressure of the lung is approximate 4 mm Hg per liter of lung distension. If for example, the lung volume is increased by 4 liters, the rise in intrapleural pressure will be approximately 16 mm Hg less than the applied positive pressure. Breathing Effort. In continuous positive pressure breathing the normal breathing cycle of an active inspiration and passive expiration is reversed to a passive inspiration and an active expiration. This reversal in cycle makes the act of breathing more difficult and increases the work of breathing. Experienced subjects can breathe for short periods at pressures up to about 50 mm Hg, whereas those unaccustomed to this maneuver cannot tolerate breathing pressures greater than 30 mm Hg.

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U.S. Naval Plight Surgeon’s Manual Circulatory Effects of Positive Pressure Breathing. The circulatory disturbances produced by positive pressure breathing depend upon the magnitude and duration of the applied pressure. Positive pressure breathing increases intrapulmonary pressure which in turn results in an increase in intrapleural pressure. It is the rise in intrapleural pressure rather than the increase in intrapulmonary pressure that determines the stress applied to the circulatory system. The heart and intrathoracic vessels are normally subjected to intrapleural pressure. The diastolic pressure within these vessels will be raised at the beginning of positive pressure by an amount equal to the rise in intrapleural pressure. Venous Pooling. At the start of pressure breathing the increase in intrapleural pressure is transmitted to the right atrium and large intrathoracic veins. Since the pressure in the extrathoracic vessels is normally low, this increase in central venous pressure seriously impedes the flow of blood from the systemic veins to the heart and venous outflow from the limbs completely ceases. Although venous outflow from the limbs ceases with the onset of positive pressure breathing, arterial inflow continues. Blood as a result, collects in and distends the venules and veins of the peripheral vascular bed until peripheral pressure exceeds right atria1 pressure. At that point venous return is restored from the limbs thereby increasing the systemic venous return to the heart. This initial phase of reduction of venous return to the heart lasts about 10 to 20 seconds. Reduction in Circulating Blood Volume. Effective blood volume, that volume of blood available for circulation, is reduced during positive pressure breathing by two factors: 1. Initial pooling of blood (described above). 2. Passage of fluid from the capillaries into the tissue. The rate at which fluid leaves the capillaries depend on the rise in capillary pressure which is closely related to the increase in venous pressure. Pressure breathing for 10 minutes at 30 mm Hg has resulted in a loss of 250 ml of fluid while pressure breathing for 5 minutes at 100 mm Hg has resulted in a loss of 500 ml of fluid into the tissue. The total reduction in effective blood volume which occurs during pressure breathing results from the combined effects of initial pooling of blood and the passage of fluid from the circulation into the tissue. During pressure breathing at 30 mm Hg for 10 minutes total reduction is of the order of 450 ml. Pressure breathing at 100 mm Hg for 5 minutes reduces the effective blood volume in the order of 950 ml. Reduced Cardiac Output. The reduction in effective blood volume due to pooling of blood and increase in extravascular fluid results in a reduced cardiac output. Pressure breathing at 30 mm

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Physiology of Flight Hg without trunk counterpressure reduces cardiac output some 30 percent. If counterpressure is applied, 30 mm Hg pressure breathing reduces cardiac output by 15 to 20 percent. Advantages of a Positive Pressure Breathing 1. The equipment is inexpensive, reliable, instantly available, and requires comparatively little maintenance. 2. With a small amount of training, a definite increase in service ceiling can be obtained. Disadvantages of Positive Pressure Breathing. 1. The service ceiling increase is small (about 5,000 feet) and limited. 2. The limitations are those caused by possible injury to the aviator. 3. Pressure breathing is opposite to the normal breathing pattern in that inhalation is passive and exhalation active, thus requiring training and familiarization. 4. The process of pressure breathing is fatiguing. 5. Communications are much more difficult during pressure breathing. 6. Hyperventilation with resulting respiratory hypocapnia is very common even in moderately experienced aviators. Effectiveness of Positive Pressure In view of the major side effects which include decreased venous return, decrease cardiac output, increase arterial blood pressure, distention of extra thoracic veins, tachycardia, possible rupture of alveoli and possible snycope, 15 mm Hg represents a practical maximum for sustained positive pressure breathing. Since roughly 3 mm Hg pressure increase is required for each 1000 feet gain in altitude above 40,000 feet, the 15 mm Hg practical maximum raises the physiological altitude ceiling only from 40,000 to 45,000 feet. This is not really a significant rise in terms of altitude capabilities of current and future operational aircraft. The emergency ceiling of pressure breathing is 50,000 feet. At this altitude the pressure delivered is approximately 33 mm Hg. In sudden decompression to 50,000 feet, positive pressure breathing can be utilized for a brief period of time to sustain useful consciousness and permit a rapid descent to a lower altitude. The minimum and maximum pressures delivered at various altitudes are summarized in Table 1-11.

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U.S. Naval Flight Surgeon’s Manual Table 1-11 Positive Pressure Loading at 10 LPM Ambient Flow

Bailout Oxygen Supply All tactical jet aircraft have an emergency oxygen supply in a high pressure oxygen cylinder. The cylinder is contained in the rigid seat survival kit of the ejection seat. For each type of aircraft seat the cylinder capacity varies. In the F-14 the approximate oxygen supply time is 20 minutes while in the F/A-18 it is 10 minutes. The emergency oxygen supply is automatically actuated during the ejection sequence. Time to Ground. An emergency oxygen supply is necessary for use during the time required for descent by free fall from high altitudes, or the even longer times when the parachute is opened prematurely. Table 1-12 shows that from 40,000 feet, time of useful consciousness is 18 seconds, while time to free fall to 14,000 feet is 90 seconds, and time to descent to 14,000 feet is 900 seconds (or 15 minutes), with the 28 to 30 foot parachute open. Obviously, some provision must be made to keep the pilot alive during such a parachute descent. Barometrically actuated parachute openers allow an aviator to free fall in the unconscious condition and survive, but accidental parachute deployment at high altitude would cause certain death or at least unconsciousness from hypoxia if emergency oxygen could not be supplied. Note that in Figure 1-10 the time to free fall from 28,000 feet to 14,000 feet is the same as the useful consciousness time at 28,000 feet. For rough approximations, therefore, 28,000 feet is the highest altitude from which

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Physiology of Flight free fall can be accomplished while breathing ambient air and retaining consciousness. Actually, the time of useful consciousness increases as the subject falls, but this may be considered a safety factor.

Table 1-12 Period of Useful Consciousness in High Altitude Bailout

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U.S. Naval Flight Surgeon’s Manual

Figure 1-10. Descent to safe breathing altitude (Carlyle, 1963).

Cabin Pressurization The physiological zone which extends from sea level to 10,000 feet, encompasses the pressure area to which man is well adapted. Although middle ear or sinus problems may be experienced during descent or ascent in this zone, most physiological problems occur outside this zone if suitable protective equipment is not utilized. In general, the most effective way of preventing physiological problems from occurring is to provide cabin pressurization so that occupants are never exposed to pressure outside the physiological zone. In these instances when ascent above the physiological zone is required, protective oxygen equipment and pressure garments must be provided.

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Physiology of Flight Methods of Maintaining Cabin Pressure The higher the differential pressure required between cabin pressure and ambient pressure, the greater the capacity of the pressurization system, and the stronger and heavier the fuselage construction; There are two methods of maintaining cabin pressure above ambient. 1. Sealed Cabins. At very high altitudes, a point is reached where the ambient air becomes so thin that it is impossible for the compressor to scoop up enough air for compression. When this occurs the compressor stalls, and the pressurization fails. At approximately 80,000 feet ambient altitude, cabin pressurization cannot be accomplished via the conventional method because of the “rarified” atmosphere. At this point, sealed cabins must be used to maintain an adequate environment. Pressurized gas is carried within the vehicle and the used gas recycled. Since this is a closed system, the environmental gas must be continually purified and recirculated to conserve the supply (Figure 1-11). This system is utilized at extremely high altitudes and in the vacuum of space.

Figure 1-11. Schematic of sealed cabin.

2. Conventional Method. The conventional method for increasing the pressure in aircraft cabins is to use ambient air as the source of gas, forcing it into the cabin by means of a

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U.S. Naval Flight Surgeon’s Manual compressor. Cabin pressures and ventilation can be controlled by varying the amount of air forced into the cabin and the amount allowed to escape through adjustable outflow valves (Figure 1-12).

Figures 1-12. Schematic of pressurized cabin.

The conventional method for cabin pressurization utilizes two types of pressurization schedules. These are the isobaric and the isobaric- differential. a.

Isobaric System. Isobaric Control refers to the condition where the cabin altitude is maintained at a constant altitude or pressure as the ambient pressure decreases (Figure 1-13). This type of pressurization system is found in most cargo and passenger carrying aircraft. Military air transport aircraft (e.g., T-39, C-131, C-9, T-44, P-3) typically maintain a cabin pressure approximately equivalent to 8000 feet of altitude through the ceiling of the aircraft.

b. Isobaric-Differential System. Pressurization of aircraft cabins represents an excellent example of engineering tradeoff. A high differential requires an aircraft structure which is physically stronger and therefore heavier than that required for a lower differential. The increased weight in turn, decreases the payload of the aircraft. Pressurization requires an expenditure of energy; therefore, the larger the differential the greater the power required to provide the desired pressure and less power available for aircraft manuverability. Also, the higher

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Physiology of Flight

Figure 1-13. Isobaric pressure schedule.

the pressure differential, the greater the possibility of a rapid decompression. Tactical jet aircraft are equipped with an isobaric- differential pressurization system. This pressurization system senses both cabin and ambient pressure and maintains the cabin pressure on the basis of a fixed pressure differential of 5 psi. Figure 1-14 shows a typical isobaric-differential pressurization schedule found in Navy tactical jet aircraft. As the aircraft climbs, the aircraft is unpressurized to an altitude of 8,000 feet. From 8,000 feet to approximately 23,000 feet, cabin pressure remains at 8,000 feet (isobaric range). From 23,000 feet up to the ceiling

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U.S. Naval Flight Surgeon’s Manual of the aircraft, the cabin pressure is maintained at a pressure differential of 5 psi. For example, if an aircraft is flying at an indicated ambient altitude of 40,000 feet where the pressure is 2.72 psi outside the aircraft, and the pressurization system is in normal operation, the effective cabin altitude would be 7.72 psi or approximately 16,500 feet.

Figure 1-14. F-14A aircraft cabin pressure schedule.

Advantages of Pressurized Cabins Reducing the probability of hypoxia and decompression sickness are perhaps the two most important advantages of the pressurized cabin. Other advantages of cabin pressurization include: 1. Reduces the need for supplemental oxygen except in tactical jet aircraft where it is required from takeoff to landing. 2. Gastrointestinal trapped gas pains are reduced. 3. Cabin temperature, humidity and ventilation can be controlled within desired comfort levels.

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Physiology of Flight 4. In large aircraft, the crew and passengers can move about freely in a comfortable environment unencumbered by oxygen masks or other life support equipment. 5. Prolonged passenger flights, air evacuation, and troop movements can be accomplished with a minimum of fatigue and discomfort. 6. Protection against pain in the middle ear and sinuses can be provided by permitting the pressure in the cabin to rise slowly in a controlled manner during descent from high altitude to ground level. Disadvantages of Pressurized Cabins The penalties for the above mentioned advantages are the following disadvantages: 1. Increased structural weight and strength of the pressurized area to maintain structural integrity. 2. Additional equipment and power requirements to support the pressurization, ventilation and air conditioning systems. 3. Maximum performance and payload capacity of the aircraft is reduced because of added weight. 4. Additional maintenance and upkeep is needed. 5. Possible contamination of the cabin air from smoke, fumes, carbon monoxide, carbon dioxide and odors. 6. Should a rapid decompression occur, the occupants of the aircraft are exposed to the dangers of hypoxia, decompression sickness, gastrointestinal gas expansion and hypothermia. In addition, the cyclonic winds create the possibility of personnel being lost through the opening. Rapid Decompression Aircrew members are faced with many hazardous factors when performing duties involving flying. Decompression at altitude is one of those factors that can cause significant physiological problems. Decompressions are categorized as either “slow” or “rapid”. A slow decompression can

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U.S. Naval Flight Surgeon’s Manual occur when a leak develops in a pressure seal. This type of decompression is dangerous because of the possible insidious effect of hypoxia. Rapid decompressions are considered more dangerous. They can occur as a result of a perforation of the cockpit or cabin wall or unintentional loss of the canopy or hatch. Factors Controlling the Rate and Time of Decompression The principal factors that govern the total time of decompression include the cabin volume, size of the opening, the pressure ratio, and the pressure differential. Volume of the Pressurized Cabin. The decompression time within a larger cabin area will be considerably slower than that of a cabin with less area. Size of the Opening. The proportionality of cabin volume and cross sectional area of the opening dictates the decompression rate and time. Pressure Ratio. Variables involved in determining the time of decompression are the pressure within the cabin and the outside ambient pressure. If the pressure ratio is increased, then it can be presumed that the time for the air to escape will also be increased. The end result being a greater decompression time. Pressure Differential. The difference between the internal and external cabin pressures will influence both the rate and severity of the decompression. The larger the pressure differential, the more severe the rapid decompression. Physical Characteristics of Rapid Decompression There are a few physical and observable characteristics that help in the recognition of a rapid decompression. All of the following may indicate a loss of cabin pressurization. Noise. When two different air masses contact, there is a noise that ranges from a “SWISH” to a loud explosive sound. It is because of this explosive noise that some people use the term explosive decompression to describe a rapid decompression. Fogging. Air at any temperature and pressure has the capability of holding just so much water vapor. Sudden changes in temperature or pressure, or both, change the amount of water vapor the air can hold. In a rapid decompression, temperature and pressure are reduced. This reduction in temperature and pressure reduces the holding capacity of air for water vapor. The water vapor that cannot be held by the air appears as fog.

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Physiology of Flight Temperature. Ambient temperatures get colder with increasing altitude. If a decompression occurs, cabin temperature will equalize with outside ambient temperature, resulting in a significant decrease in cabin temperature. Chilling or frostbite are possibilities depending upon the altitude. Flying Debris. Upon decompression, the rapid rush of air from a pressurized cabin causes the velocity of airflow through the cabin to increase rapidly as the air approaches the hole. The rush of air has such force that items not secured will be extracted through the opening. There has been an instance of an inadequately restrained individual in the immediate vicinity of an opening being sucked from the aircraft. Physiological Effects of Rapid Decompression The occupants’ primary concerns are hypoxia, gas expansion, decompression sickness and hypothermia. Lungs. The lungs are potentially the most vulnerable part of the body during a rapid decompression. Whenever a rapid decompression is faster than the inherent capability of the lungs to decompress, a transient positive pressure will temporarily build up in the lungs. If the escape of air from the lungs is blocked or seriously impeded during a sudden drop in cabin pressure, intrapulmonary pressure can build up high enough to cause tearing and rupture of the lung tissues and capillaries. If the expanding gas is free to escape from the lungs through an open airway, the risk of lung damage is nonexistent. Momentary breath-holding, such as swallowing or yawning will not cause excessively high intrapulmonary pressure and over expansion of lung tissue. Ears and Sinuses. Decompression of a pressurized cabin is unlikely to cause symptoms in the middle ear and paranasal sinuses. It is more likely, however, that individuals will develop pain in the middle ear and paranasal sinuses during the subsequent emergency descent as they will be exposed to a large and rapid increase of cabin pressure. Gastrointestinal Tract. One of the potential dangers during a rapid decompression is the expansion of trapped gases within the gastrointestinal tract causing abdominal distress. Abdominal distention, if it does occur, may have several important effects. The diaphragm is displaced upward by the expansion of the trapped gas in the stomach which can retard respiratory movements. Distention of the abdominal organs may also stimulate the abdominal branches of the vagus nerve, resulting in cardiovascular depression, and if severe enough, cause a reduction in blood pressure, unconsciousness and shock. Hypoxia. Of all the physiological hazards associated with the loss of pressure, hypoxia is the

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U.S. Naval Flight Surgeon’s Manual most important. The rapid reduction of ambient pressure produces a corresponding drop in the partial pressure of oxygen and reduces the alveolar oxygen tension. A twofold to threefold performance decrement occurs regardless of altitude. The reduced tolerance to hypoxia after decompression is due to (1) a reversal in the direction of oxygen flow in the lung; (2) diminished respiratory activity at the time of decompression; (3) decreased cardiac activity at the time of decompression. Decompression Sickness. in general, decompression sickness does not occur until cabin altitudes of 18,000 feet are reached. The incidence of decompression sickness is small unless the cabin altitude reaches 25,000 to to 30,000 feet. As the duration of exposure to the unpressurized environment increases, so does the incidence of decompression sickness. The incidence of decompression sickness following a rapid decompression appears to be only slightly greater than after a slow decompression to the same altitude. Hypothermia. When cabin temperatures drop because of a decompression, it is likely that injuries such as frostbite and hypothermia will exist. Again, the extent and severity will be dependent on the altitude and the type of protective clothing worn during the decompression.

Trapped Gas During ascent, the free gas normally present in various body cavities expands. If escape of the expanded volume is impeded, pressure builds up within the cavity and pain is experienced. Expansion of trapped gases accounts for abdominal pain, sinus pain or toothache. The effects of decrease barometric pressure on the sinuses, ears and teeth are covered in detail in Chapter 8. Only a brief discussion of the etiology and symptomatology of trapped gas will be given here. Boyle’s Law Trapped gas problems are explained by Boyle’s Law. Boyle’s Law states that the volume of a gas is inversely proportional to the pressure exerted upon it. According to Boyle’s Law, gases trapped in body cavities expand as altitude increases, and contract as altitude decreases. In ascending in an unpressurized aircraft, the atmospheric pressure exerted on various body cavities will decrease. As the atmospheric pressure decreases, gases trapped in body cavities will expand, putting added pressure on the body cavities in which they are trapped. These areas include air spaces in the ears, sinuses, teeth, and gastrointestinal tract.

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Physiology of Flight Ears An in-flight ear block can occur on either ascent or descent when air pressure in the middle ear is unable to equalize with ambient air pressure. This normally occurs because the lower orifice of the eustachian tube, which operates as a one-way flutter valve, fails to function adequately. It may also happen if the eustachian tube should be swollen from a cold or ear infection. The difference in pressure will cause the eardrum to bulge outward on ascent and inward on descent. This may cause discomfort in the form of pressure or pain. As the barometric pressure is reduced during ascent, the expanding air in the middle ear (Figure 1-15) is intermittently released through the eustachian tube into the nasal passages. As the inside pressure increases, the eardrum bulges outward until an excess pressure of approximately 12 to 15 mm Hg is reached. At this time a small bubble of air is forced out of the middle ear and the eardrum resumes its normal position. Just before the air escapes from the eustachian tube, there is a sensation of fullness in the ear. As the pressure is released, there is often a click or pop.

Figure 1-15. Anatomy of the ear. An ear block is much more likely to occur on descent as the ambient pressure increases because of the valve-like action in the eustachian tube which allows gas to pass more readily from the inner ear than into it. The symptoms of an in-fight ear block may include: 1. Pressure or pain.

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U.S. Naval Flight Surgeon’s Manual 2. Muffled sound. 3. Dizziness. 4. Tinnus (ringing in the ear). Descending rapidly from a level of 30,000 to 20,000 feet will often cause no discomfort, whereas a rapid descent from 15,000 to 5,000 feet will cause great distress. This is because the change in barometric pressure is much greater in the latter situation. For this reason, special care is necessary during rapid descents at low altitudes. Protection Against Ear Blocks. Normally, pressure can be equalized during decent by just swallowing, yawning or tensing the muscles of the throat. These procedures cause contraction of pharyngeal muscles which open the orifices of the eustachian tube. If relief is not obtained by this method, a Valsalva Maneuver should be performed by closing the mouth, pinching the nose shut, and blowing gently, thus forcing air through the previously closed eustachian tube into the cavity of the middle ear and equalizing the pressure. Occasionally voluntary maneuvers such as mentioned above are unsuccessful in equalizing the pressure in the middle ear. This is especially true when a pressure differential of approximately 80-90 mm Hg is developed across the middle ear. If this occurs in actual flight, relief can only be obtained by reascent to a level at which equalization of the pressure can be accomplished, followed by a slower descent. If an ear block occurs in an altitude chamber, the middle ear can be equalized by politerization. Postflight Ear Block. On descent from high altitudes, fliers who have breathed pure oxygen during an entire flight sometimes develop an earache several hours after landing even though their ears cleared adequately during descent. Ear pain may awaken them after they have gone to sleep or may be noticed upon awaking in the morning. Gradual absorption of oxygen from the gas contained in the middle ear reduces the middle ear pressure. When the oxygen content is high, as it is after breathing oxygen, the absorption rate is accelerated. An individual who is awake relieves the slight unbalance of pressure by periodic swallowing. This opens the eustachian tubes and admits air at ambient pressure to the middle ear. During sleep, saliva flow is suppressed and swallowing is infrequent; consequently, the middle ear is not ventilated often enough to keep the pressure equalized. The result is similar to that arising from inability to ventilate the ears during descent from altitude - a sensation of blocking or fullness, sometimes pain, and possibly an accumulation of fluid in the middle ear. Usually the condition is mild and easily relieved by the Valsalva maneuver.

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Physiology of Flight Prevention of postflight ear trouble is simple. Valsalva maneuvers performed frequently during the first 1 or 2 hours after landing will lower the concentration of oxygen by flushing the middle ear with ambient air. This preventive procedure is particularly important if the flier is going to bed soon after landing. Sinuses The paranasal sinuses (Figure 1-16) present a condition in flight similar to that of the middle ear. The sinuses are air filled, relatively rigid, bony cavities lined with mucous membranes. They connect with the nose by means of one or several small openings.

Figure 1-16. Location of sinus cavitites.

If the openings into the sinuses are normal, air passes into and out of these cavities at any practical rate of ascent or descent, assuring adequate equalization of pressure. If the openings of the sinuses are obstructed by swelling of the mucous membrane lining (resulting from infection or an allergic condition) or by polyps, or redundant tissue, equalization of pressure becomes impossible. Change of altitude produces a pressure differential between the inside and the outside of the cavity and causes marked pain. Sinus blocks can occur both during ascent and descent. In about 90 percent of the cases, however, pain develops during descent. During ascent the expanding air usually forces its way out past the obstruction.

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U.S. Naval Flight Surgeon’s Manual Sinus blocks most often occur in the frontal sinus (70 percent), followed in frequency by the maxillary sinus. Maxillary sinusitis may produce pain referred to the teeth of the upper jaw and may be mistaken for toothache. Prevention of Trapped Gas Problems of the Sinuses. As with the middle ear, sinus problems are usually preventable. Aircrew members should: 1. Avoid flying with a cold or congestion. 2. Perform the valsalva maneuver frequently during descent. The opening to a sinus cavity is quite small compared to the eustachian tube; unless the pressure is equalized, extreme pain will result. 3. Avoid any further increase in altitude if any pain in a sinus is noticed on ascent. Treatment of Trapped Gas Problems of the Sinuses. I. If a sinus block occurs during descent, avoid further descent. The aircrew member should attempt a forceful Valsalva maneuver. If this does not clear the sinus, ascend to a higher altitude. This ascent will ventilate the sinus. Perform normal Valsalva maneuver during slow descent to the ground. 2. If the aircraft is equipped with pressure-breathing equipment, oxygen, under positive pressure, can ventilate the sinus. 3. If equalization of pressure does not occur after landing, consult the flight surgeon. Barodontalgia Toothache has been reported by individuals during actual or simulated flight. The altitude at which the onset of toothache usually occurs varies from 5,000 to 15,000 feet but a pain referable to a given tooth in a given individual often may show remarkable constancy in the altitude at which it first becomes manifest. The pain may or may not become more severe as altitude is increased. Pain is invariably relieved upon descent, an important feature which helps to distinguish it from pain in the upper jaw due to maxillary barosinusitis. When first recognized, barodontalgia was thought to be due to expansion of entrapped air under restorations. Numerous investigations have experimentally produced air bubbles under

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Physiology of Flight dental restorations and exposed the individuals to low barometric pressure. No symptoms were experienced in these cases. It is now thought that gas expansion is responsible for only a very small proportion of these cases.

Figure 1-17. Dental problems affected by altitude.

The specific mechanism of barodontalgia has not been fully clarified but it is invariably associated with some degree of preexisting dental pathology; completely normal teeth are not affected. Imperfect fillings, pulpitis and carious teeth which were asymptomatic at ground level have all been incriminated. Gastrointestinal Tract Discomfort from gas expansion within the digestive tract is frequently experienced with rapid decrease in atmospheric pressure. Fortunately, the symptom is not serious in most individuals flying at low altitudes. Above 25,000 feet, however, enough distension may occur to produce severe pain. The dramatic expansion of trapped gas as altitude increases is shown in Figure 1-18. Cause of Trapped Gas Disorders of the Gastrointestinal Tract. The stomach and the small and large intestines normally contain a variable amount of gas at a pressure approximately equivalent to the surrounding atmospheric pressure. The stomach and large intestine contain considerably more gas than does the small intestine. The chief sources of this gas are swallowed air and to a lesser degree, gas formed as a result of digestive processes, fermentation, bacterial decomposition, and decomposition of food undergoing digestion. The gases normally present in the gastrointestinal tract are oxygen, carbon dioxide, nitrogen, hydrogen, methane, and hydrogen sulfide. These occur in varying proportions, although the highest percentage of the gas mixture is always nitrogen.

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Figure 1-18. Gastrointestinal tract and trapped gas expansion at increased altitudes.

Effects of Trapped Gas Disorders of the Gastrointestinal Tract. 1. Gastrointestinal pain at high altitude may not only be caused by the absolute volume or location of the gas; sensitivity or irritability of the intestine is a more important cause. Consequently, an individual’s response to high altitude varies depending upon such factors as fatigue, apprehension, emotion, and general physical condition. 2. Gas pains of even moderate severity may produce marked lowering of blood pressure and loss of consciousness if distension is not relieved. Prevention of Trapped Gas Disorders of the Gastrointestinal Tract. Crews should maintain good eating habits to prevent gas pains at high altitudes. Some foods that commonly produce gas are onions, cabbage, raw apples, radishes, dried beans, cucumbers, and melons. Aircrew members who participate regularly in high-altitude flights should avoid foods that disagree with them. Chewing the food well is also important. Air is unavoidably swallowed when crew members drink liquids or chew gum. Drinking large quantities of liquids, particularly carbonated beverages, before high altitude missions, and chewing gum during ascent should be avoided.

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Physiology of Flight Relief from Trapped Gas Disorders of the Gastrointestinal Tract. If trapped gas problems exist in the gastrointestinal tract at high altitude, relief is ordinarily obtained by belching or passing flatus. If pain persists, descent to lower altitude is necessary. Bubble Related Diseases Decompression Sickness Decompression sickness (DCS) is defined as an illness that follows a reduction in environmental pressures sufficient to cause formation of bubbles from gases dissolved in body tissues. Decompression sickness is a true occupational disease first described in relation to syndromes which developed in caisson or tunnel workers working in closed, pressurized spaces during construction of tunnels. DCS was first described as the “bends” because of the development of lower extremity or abdominal pain causing the patient to bend over. It was also designated the “chokes” when associated with dyspnea and a chocking sensation, the “staggers” when accompanied by vertigo related to inner ear disruption, and the “niggles” which refers to unusual skin sensations. Decompression sickness in naval operations is related to high altitude or underwater activities using compressed gas mixtures. Aviation decompression sickness can occur during low pressure chamber (altitude chamber) activities, flight in depressurized or unpressurized aircraft, and in high altitude high opening (standoff) parachute operations. Altitude decompression sickness is induced by exposure to ambient pressures less than sea level. It is related to altitudes usually above 18,000 feet. Aviators are protected from decompression sickness by maintaining cabin altitude via pressurization and by denitrogention by prebreathing oxygen to reduce body nitrogen stores. Prior to flight, aviation personnel can reduce their tissue nitrogen by breathing 100 percent oxygen. Figure 1-19 shows nitrogen washout as a function of time. Currently the highest rate of altitude-related decompression sickness in naval aviation operations involves low pressure chamber activities.

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Figure 1-19. The rate at which nitrogen is eliminated from the body at sea level when pure oxygen is breathed (Clamann, 1961).

Bubble Formation Theory Decompression sickness results from bubbles formed as dissolved gases come out of solution in tissues due to a drop in ambient pressure. The principal gas involved is nitrogen, and to a lesser extent, carbon dioxide. As nitrogen in air is inhaled, it dissolves in the body and reaches equilibrium with the liquid phase (tissue and blood). The concentration of nitrogen dissolved is proportional to the partial pressure of nitrogen in the inhaled gas (Henry’s Law). As one descends below the surface, these partial pressures increase with depth. As one ascends from depth or climbs in altitude, the partial pressures of the gases in the breathing mixture decrease. If the nitrogen partial pressure in the breathing gas is reduced or eliminated, a gradient is established across the alveoli. Nitrogen is offgassed from the various tissue compartments, and may require 12 hours or more to reach equilibrium. The rate of inert gas uptake and elimination depends on: (1) gas concentration gradient between blood and tissue, (2) tissue blood flow, and (3) the ratio of blood and tissue gas solubilities. For example, nitrogen is five times more soluble in fat than in water. Gas uptake and elimination are expressed as tissue half times.

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Physiology of Flight The formation of bubbles is influenced by: (1) supersaturation of tissues with gaseous nitrogen, and (2) the presence of gas micronuclei. Supersaturation results when tissue inert gas tension (PN2) exceeds ambient barometric pressure (PB). Critical supersaturation occurs when inert gas comes out of solution and forms bubbles. Early research suggested that once a critical supersaturation (constant allowable) ratio was attained, bubbles would form. Current theory suggests that supersaturation is related to a variable allowable ratio. This is influenced by time, pressure differential, and tissue nitrogen half time. Gas micronuclei may form in areas of negative hydrostatic pressure, such as in turbulent blood flow or areas of shearing action in joints. Gas micronuclei may arise de novo and are called autochthonous bubbles. Bubbles may form in blood, lymphatics or tissue. Inert gas tension is higher in capillary or venous blood than in arterial blood. To successfully tolerate an ambient pressure reduction, a time-pressure profile must be selected which does not allow this critical ratio to be exceeded. Tabulated safe time-pressure profiles are called decompression tables. Bubbles have two pathophysiological effects. First, the direct mechanical effects of the bubbles may result in vessel obstruction or tissue distortion, causing pain, ischemia, infarction, or dysfunction. The second effect, tissue-bubble interface surface activity, results in denaturation of proteins and aggregation of platelets, causing endotheliai damage and the release of pain mediating substances. Because the bubbles may form in different places in the body, they may give rise to multifocal lesions which do not necessarily follow dermatomal or anatomical distributions. Once the bubbles are formed, they tend to expand as dissolved gases and continue to come out of solution. Carbon dioxide, a highly diffusable gas, contributes to bubble enlargement, especially if formed in excess by vigorous exercise. For this reason, DCS patients should be kept at rest. Decompression sickness is a progressive systemic disease. Although the initial manifestation of DCS may be of a relatively trivial nature, further expansion or formation of bubbles elsewhere may result in a life threatening situation if treatment is not initiated promptly. The various clinical syndromes may occur in any combination. Clinical Syndromes of Decompression Sickness Decompression sickness is classified as either Type 1 or Type II. This clinical classification is useful because it helps establish treatment, prognosis, and aeromedical disposition. Type I Decompression Sickness. Type I decompression includes: (1) limb pain (musculoskeletal

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U.S. Naval Flight Surgeon’s Manual symptoms, (2) skin bends (cutaneous symptoms), and (3) lymphatic bends (lymph node swelling and pain). 1. Limb Pain. The most common presenting symptom of DCS is pain, accounting for 60 to 70 percent of Altitude DCS, and 80 to 90 percent of dive related DCS. Joint pain is by far the most common type. But other types of pain may occur. The shoulder is the most common site of joint pain. The elbow, wrist, hand, hip, knee and ankle may also be involved. Upper extremity pain is more common than lower extremity pain (lower extremity pain is usually seen in saturation divers). The characteristic pain of Type I DCS usually begins gradually. Called the “niggles” by divers, it is slight when first noticed, and may be difficult to localize. It may be located in a joint or may be only a muscle ache. The pain tends to increase in intensity over time and is usually described as a deep, dull ache. The limb may be held preferentially in certain positions to reduce the pain intensity (guarding). The hallmark of Type 1 pain is its dull, aching quality and its confinement to particular areas. It is present at rest and may or may not be made worse with movement. The pain may be relieved by an inflated blood pressure cuff over the site. The most difficult differentiation is that Type I DCS and pain resulting from a muscle sprain or bruise. A sharp, knife-like pain that shoots down an extremity or encircles the body trunk (radicular or dermatomal pain), thoracic or abdominal pain, tingling or burning pain (paresthesias), or pain that moves from one area to another or arises from the nervous system is treated as Type II DCS (see below). If there is any doubt as to the cause of the pain, assume that the diver or aviator is suffering from DCS and treat him accordingly. Frequently, pain may mask other more significant symptoms and a thorough neurological exam is indicated. Pain should not be treated with analgesic medication. Bilateral pain, truncal pain, or hip pain is treated as Type II DCS (see below). 2. Cutaneous (Skin) Bends. The most cutaneous manifestation of DCS is itching. Itching (pruritus) or crawling sensation (formication), usually occurs in dry hyperbaric (chamber) dives and does not require recompression. Mottling or marbling of the skin, known as Cutis Marmorata, is caused by venous obstruction by intravascular bubbles, and precedes the more serious forms of DCS. It usually starts as intense itching, progresses to redness, then to patches or linear areas of dark purple-blue discoloration of the skin. The skin may feel thickened and the rash may be raised. Visible skin bends (marbling) should be treated with recompression. 3. Lymphatic Bends. Lymphatic obstruction by bubbles may cause localized pain in the lymph nodes and swelling of the area. Recompression will usually provide prompt relief of pain. However, the swelling may take somewhat longer to resolve completely and may still be present at the completion of treatment. Lymphatic bends are rare.

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Physiology of Flight Type II Decompression Sickness. Type II DCS is present with neurological, cardiorespiratory, or inner toms may be present at the same time. Thirty to 40 associated limb pain. In Altitude DCS cases 85 to 90 Type II DCS.

the most severe form of DCS. Patients may ear symptoms, pain or shock. Type I symppercent of Type II Altitude DCS cases have percent are Type I, and 10-15 percent will be

In the early stages, the symptoms of Type II DCS may not be obvious; and the patient may consider them inconsequential. The patient may feel fatigued or weak and attribute this to overwork. Even as the weakness becomes more severe, the individual may not seek treatment until walking, hearing, or urinating becomes difficult. For this reason, symptoms must be looked for during the postdive or postflight period and treated before they evolve further. Fifty percent of DCS cases present within 30 minutes, 85 percent by one hour, and only one percent after six hours. Many of the symptoms of Type II DCS are the same as those of arterial gas embolism (AGE), although AGE usually presents within 10 minutes. The treatment for arterial gas embolism is also an appropriate treatment for DCS. 1. Neurological Symptoms. These symptoms may be the result of involvement at any level of the nervous system. Peripheral nervous system involvement may present with patchy peripheral paresthesias (burning or tingling) or numbness or weakness (usually mild and confined to one extremity). Spinal cord DCS may present with numbness, weakness, paralysis, or urinary dysfunction. Spinal cord DCS is more commonly the result of diving activities and accounts for less than 10 percent of Type II Altitude DCS cases. Brain DCS is the most common form of Type II Altitude DCS. Disturbances of higher cortical function may result in personality changes, confusion, or inappropriate behavior. Hemiplegia, hemisensory loss, incoordination, or tremor may occur. Symptoms of classic migraine, with unilateral headache and scotoma, may be a presentation of Type II DCS. Headache and visual disturbances occur in 30 to 40 percent of Type II Altitude DCS. Brain DCS signs may be subtle and may be overlooked or passed off as being inconsequential. Loss of consciousness, which may be due to neurological or cardiorespiratory collapse, is a sign of fulminant DCS or AGE. Inner ear DCS may result in vertigo, dizziness, tinnitus, and hearing loss. It may be difficult to distinguish from a round or oval window rupture. Inner ear DCS usually occurs in deep heliumoxygen dives of long duration. Pain that is bilateral or involves the trunk or hip is considered Type II DCS. Divers who develop pain while under pressure should be treated for Type II DCS.

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U.S. Naval Flight Surgeon’s Manual The occurrence of any neurological symptom following a dive or flight should be considered a symptom of Type 11 DCS or arterial gas embolism. Fatigue is not uncommon after long dives or flights. Fatigue that is unusually severe may be a sign of CNS involvement. 2. Cardiopulmonary Symptoms. If profuse intravascular bubbling occurs, symptoms of “chokes” may develop due to congestion of the pulmonary vasculature. Pulmonary DCS or “chokes” is manifested by: (1) burning substernal chest pain, often aggravated by breathing, (2) cough, and (3) shortness of breath (dyspnea). Pulmonary DCS makes up 5 to 10 percent of Type II Altitude DCS. Symptoms of increasing lung congestion may progress to complete circulatory collapse, loss of consciousness, and death if recompression is not instituted. Factors Associated with Decompression Sickness Altitude or Depth Attained. DCS occurring from altitude exposures below 18,000 feet is rare and usually results from other predisposing factors. In an Air Force series of Altitude DCS cases, only 13 percent occurred below 25,000 feet, and 79 percent occurred above 30,000 feet. In diving operations, DCS should not occur in water shallower than the no decompression limit. Deeper and longer dives result in DCS upon return to the surface unless a slow staged decompression back to the surface is followed. Rate of ascent (change in pressure differential) will also effect DCS incidence. Duration of Exposure. Altitude DCS is rare in exposures of less than five minutes at altitude. Exposures of 20 to 60 minutes show an increased occurrence of DCS. Surface Interval Prior to Reexposure. Reexposure to altitudes over 18,000 feet within three hours increases the risk of DCS. Sea level intervals of 24 to 48 hours may be required between altitude exposures to reduce the risk of DCS to baseline. U.S. Navy guidelines for low pressure chamber flights above 18,000 feet include 48 hour surface intervals, and no more than three chamber flights in a seven day period. For altitudes from 10,000 to 18,000 feet, a 24 hour surface interval is required. Surface intervals for dive operations are dependent on residual nitrogen times calculated from the dive tables. Flying after Diving. Following hyperbaric exposure to compressed gas, a person has an excess of dissolved gas (residual nitrogen) which continues to off-gas at a predictable rate. Exposure to a hypobaric environment may accelerate this off-gassing leading to bubble formation and DCS. DCS following diving has occurred as low as 7000 feet. Following a 1600 foot deep saturation dive, team members developed DCS four days later on a commercial air flight. OPNAVINST 3710.7 states “Under normal circumstances, flight personnel shall not fly or perform low pressure

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Physiology of Flight chamber runs within 24 hours following scuba diving, compressed air dives, or high pressure chamber runs. Under circumstances where an urgent operational requirement dictates, flight personnel may fly within 12 hours of scuba diving, providing no symptoms of aeroembolism develop following surfacing and the subject is examined and cleared by a flight surgeon.” Diving at Altitude. Diving at altitude refers to diving at elevations higher than sea level, such as mountain lakes. Current U.S. Navy dive tables are based on sea level surface. Diving at altitude may increase the DCS risk. U.S. Navy diving above 2300 feet requires CNO approval. Prior DCS. In the diving community, prior DCS or subclinical DCS might increase the risk of DCS. Approximately five to 10 percent of Altitude DCS cases had prior DCS. Other factors such as age and injury may be confounding variables. Occupation. Earlier studies revealed higher Altitude DCS incidence in insider observers of low pressure chambers. A recent study found identical rates in students and inside observers. Again confounding variables may be a factor. Age. Incidence rates of DCS in those age 40 to 45 years is three times that of 19 through 25 year olds. U.S. Navy divers over 45 years old must be waived to dive and are restricted to supervisory type dives. Gender. A recent study showed an association of DCS with female sex. The relative risk of Altitude DCS was twice that of men. Other studies have shown that DCS in women is temporarily related with the perimenstrual portion of the menstrual cycle. These results show an association, not necessarily casual, and are being further studied. Exercise. Exercise appears to increase the incidence of DCS. Exercise leads to increased muscle perfusion, an increase in inert gas uptake, shear forces in joints causing gas micronuclei, and increased carbon dioxide which may accelerate bubble growth. Decompression tune is extended for divers engaged in strenuous activity. The altitude equivalent with exercise is an additional 3000 to 5000 feet. Individuals undergoing altitude exposures over 18,000 feet should refrain from vigorous exercise for 12 hours prior to exposure and three to six hours following exposure. This will avoid predisposing factors and confusion regarding musculoskeletal pain and limb bends. Injury. Recent injury may predispose to DCS. Although the exact mechanism is unclear, local inflammatory reaction, changes in perfusion, and gas micronuclei may be involved. Temperature. Very cold ambient temperature increases the risk of DCS perhaps by changes in nitrogen washout from peripheral vasoconstriction.

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U.S. Naval Flight Surgeon’s Manual Body Morphology. Although body weight does not affect DCS incidence, body fat does appear to be a predisposing factor, probably related to increase in tissue nitrogen stores. Inspired carbon dioxide concentration. Increase carbon dioxide in inspired gas predisposes to DCS because of its high solubility in gas micronuclei. Hypoxia. Hypoxia has been antecdotally related to DCS. Personal Factors. Alcohol ingestion, dehydration, and fatigue have anecdotally been associated with DCS. Arterial Gas Embolus. Dive profiles conducive to arterial gas embolus (bouyant ascent) may produce a nidus of bubble nuclei into which dissolved gases could diffuse where they would have otherwise remained in solution. Venous Gas Embolus and Atrial Septal Defects. Venous bubbles are detected by precordial doppler ultrasound following reduction in ambient pressures in otherwise asymptomatic people. These venous gas bubbles are normally filtered from the pulmonary circulation by the lung. Several recent articles have implicated atria1 septal defects such as a patient foramen ovale as predisposing to DCS by allowing these otherwise silent venous bubbles to pass into the arterial circulation where they are spread throughout the body. Patent foramen ovale, detected with bubble contrast ultrasound techniques, has been detected in significantly higher numbers of Type II DCS cases where the dive profile was not likely to cause DCS (undeserved DCS). Patent foramen ovale has also been implicated in Altitude DCS cases. Altitude Decompression Sickness Versus Diving Decompression Sickness. The cause, clinical effects, and treatment of these two syndromes are identical. However, altitude DCS tends to result in cerebral lesions, whereas DCS occurring during diving is more likely to involve lesions of the spinal cord. The reason for this difference is unknown. It is important to note that the entire spectrum of clinical manifestations is possible in either type. Differential Diagnosis of Altitude Decompression Sickness. 1. Musculosketetal (non-DCS) limb pain. 2. Hypoxia. 3. Hyperventilation. 4. Carbon monoxide poisoning. 5. Spatial disorientation.

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Physiology of Flight 6. 7. 8. 9. 10. 11. 12. 13. 14.

Air sickness. Trapped gas abdominal distension. Alternobaric vertigo. Perilymph fistula. Acceleration atelectasis. Spontaneous pneumothorax. Migraine syndrome. Entrapment neuropathy. Cervical radiculopathy.

Pulmonary Overinflation Syndromes The pulmonary overinflation syndromes are barotrauma disorders caused by gas expanding within the lung, resulting in alveolar rupture. The syndromes encountered include arterial gas embolism, pneumothorax, mediastinal emphysema, subcutaneous emphysema, and rarely pneumopericardium. Alveolar rupture may result from excessive positive pressure (failed regulator) or failure of gas to escape from the lung during ascent. This may occur from voluntary breath holding during a panic ascent or from localized pulmonary obstruction (asthma, secretions, and calcification). Pulmonary bullae are particularly susceptible to alveolar rupture. Arterial Gas Embolism Arterial gas embolism is caused by entry of gas emboli into the arterial circulation where they are dispersed throughout the body. The organs susceptible to arterial gas embolism, the CNS and heart, are responsible for life threatening symptoms. In all cases of arterial gas embolism, pneumothorax is a possibility. Symptoms of arterial gas embolism are likely to show up within a minute or two after surfacing. Any CNS symptom other than unconsciousness which occurs much later than 10 minutes after surfacing is rarely the result of arterial gas embolism. Anyone who has obtained a breath of compressed gas from any source at depth, whether from diving apparatus, Helicopter Emergency Escape Device (HEEDS) bottle, or a diving bell, and who is unconscious or loses consciousness within 10 minutes of reaching the surface, must be assumed to be suffering from arterial gas embolism. Recompression therapy must be started immediately.

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U.S. Naval Flight Surgeon’s Manual Characteristics of Arterial Gas Embolism Sudden Onset. The onset is usually sudden and dramatic, often occurring within seconds after arrival on the surface or even before reaching the surface. The signs and symptoms may include dizziness, paralysis, weakness in the extremities, large areas of abnormal sensation, blurring of vision, or convulsions. During ascent, the diver may have noticed a sensation similar to that of a blow to the chest. The victim may become unconscious without warning and may even stop breathing. Similarity to DCS. Some of these symptoms may also be experienced by a diver suffering from DCS. If the dive has been to a depth of less than 33 feet, DCS is unlikely and arterial gas embolism must be assumed. If the only symptom described is pain, arterial gas embolism is unlikely. DCS or one of the other pulmonary overinflation syndromes, which are not usually acute emergencies, should be considered. Masking of Symptoms. Some symptoms may be masked by environmental factors or by other less significant symptoms. A diver who is chilled may not be concerned with numbness in an arm which may actually be a sign of nervous system involvement. Pain from any source may divert attention from other symptoms. The natural anxiety that accompanies a “close call,” such as the failure of the diver’s air supply, or egress from a helicopter lost at sea, might mask a state of confusion caused by an arterial gas embolism to the brain. A diver coughing up blood or bloody froth may be showing signs of ruptured lung tissue, or he may merely have bitten his tongue or experienced a case of sinus squeeze. Spontaneous Improvement. Symptoms of arterial gas embolism may improve spontaneously without treatment. If left untreated, these symptoms may recur with increased severity. Even if the symptoms resolve, treat the diver as if symptoms were still present. Arterial Gas Embolus Versus Decompression Sickness At times it may be difficult to distinguish arterial gas embolism from DCS. The treatment for arterial gas embolism is usually longer and deeper than that for DCS because the danger from brain damage is so much greater. Recompression treatment for arterial gas embolism will also be adequate treatment for DCS. If there is any doubt as to the correct diagnosis, assume arterial gas embolism. Although both DCS and AGE may present within minutes of reaching the surface, symptoms presenting after 10 minutes are not consistent with AGE. AGE usually presents with substantial neurological symptoms localized to brain or higher cortical centers. If spinal cord symptoms are present, it is more likely DCS. Certain dive profiles (short, shallow dives) are not

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Physiology of Flight likely to cause decompression sickness and would be more consistent with AGE (i.e., HEEDS training). Ascents from depth that are uncontrolled are more consistent with AGE. A patient with other signs of Pulmonary Overinflation Syndromes (POIS) is more likely to have AGE. Other Pulmonary Overinflation Syndromes Expanding gas trapped in the lung may enter tissue spaces causing mediastinal emphysema, subcutaneous emphysema, pneumothorax, and pneumopericardium. Tension pneumothorax may be life threatening requiring thorascostomy. Mild pneumothorax may respond to 100 percent 02. Pneumopericardiurn is rare. It is generally reported only on radiographs. Recompression therapy is not necessary for emphysema or pneumothorax, and may convert a simple pneumothorax into a tension pneumothorax. Treatment of Bubble Related Disorders Recompression Therapy. The only satisfactory treatment for DCS or AGE is recompression therapy. Medical therapy and observation only have an adjunctive role in the management of DCS or AGE once the diagnosis is made. Once the diagnosis is made, the patient should be transported as quickly as possible to a recompression chamber where appropriate therapy can be administered according to current protocols (NAVSEA 0094-LP-00l-9010). Chamber personnel are well trained in applying these theraputic methods to patients with DCS and AGE. A brief synopsis of these methods is included here. Actual recompression therapy must be administered by trained chamber personnel in accordance with Navy diving procedures. Air Treatment Tables. A treatment table is a time- pressure profile applied in a recompression chamber to treat patients with DCS and other dysbaric illnesses. The pressure is measured in Feet Sea Water (FSW). There are two basic types of treatment tables, those using air only, and those where 100 percent oxygen is available in the chamber. The first treatment tables introduced were air tables. Patients treated with air tables are pressurized in an air atmosphere while breathing the air in the chamber. Although these patients receive the benefits of pressure, they also take up additional nitrogen during the treatment which must be removed by slow decompression. Therefore, air tables are quite lengthy. Oxygen Treatment Tables. The more recently developed oxygen treatment tables pressurize the patient with air, but oxygen is available for breathing by mask (Built in Breathing System or BIBS). Oxygen breathing provides several advantages. The increased oxygen partial pressure provides life-sustaining oxygen to tissues compromised by bubbles. No nitrogen is inhaled by the pa-

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U.S. Naval Flight Surgeon’s Manual tient so an increased alveolar nitrogen gradient is created to remove nitrogen from the body. Also, no additional nitrogen is dissolved in the patient’s tissues. During the treatment this permits a more rapid reduction of pressure, or ascent, from treatment depth to the surface. As oxygen tables are considerably shorter, there is less risk of DCS to the inside tenders. Oxygen Tables are superior to the older air tables, and should be used whenever possible. A disadvantage of oxygen tables is that oxygen toxicity may occur. The oxygen treatment tables include air breaks (five minute interruptions when air is breathed instead of oxygen) to reduce the likelihood of oxygen toxicity. Acute oxygen toxicity causes increased irritability of the CNS. Symptoms of CNS oxygen toxicity include visual abnormalities (such as tunnel vision), tinnitus, nausea, twitching, irritability, dizziness, and seizures. When oxygen tables are used, the inside tenders (the medical observers inside the chamber) breathe oxygen during part of the treatment to reduce their tissue nitrogen tension and minimize their risk of bends. Indications for Hyperbaric Oxygen Therapy The oxygen treatment tables are useful in treating a variety of nondiving illnesses, such as carbon monoxide toxicity, cyanide poisoning, gas gangrene, and smoke inhalation. The increased oxygen tension will help displace these toxins by mass action. Additionally, enough oxygen will dissolve in serum that significant anemic states can be overcome (serum pressurized to 60 FSW can support life without red cells or hemoglobin). NAVMEDCOMINST 6320.38A limits the use of the US Navy hyperbaric chambers for nondiving illness to carbon monoxide toxicity, cyanide poisoning, gas gangrene, iatrogenic gas embolism, and smoke inhalation. Other uses require prior approval from the Chief, Bureau of Medicine and Surgery. In addition, the Undersea and Hyperbaric Medical Society has approved recompression therapy for radiation necrosis, refractory osteomyelitis, selected bums, nonhealing wounds, failing skin flaps and grafts, necrotizing soft tissue infection, acute anemia, and crush injuries. A number of disorders, such as Multiple Sclerosis and stroke, have been treated with recompression therapy in experimental settings. Indications for Specific Treatment Tables The treatment tables (Table 1-13) were given arbitrary numerical names as they were historically developed. The treatment tables a flight surgeon should be familiar with are Treatment Tables 4, 5, 6, 6A, and 7.

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Physiology of Flight Table 1-13

Treatment Table 5 - Type I DCS Only. Treatment Table 5 (TT 5) in Figure 1-20 is an oxygen table used to treat Type I DCS. At two hours and 15 minutes, it is the shortest table. The patient

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U.S. Naval Flight Surgeon’s Manual is pressurized to 60 FSW for two oxygen periods, brought to 30 FSW for one additional oxygen period, and slowly brought to the surface. The patient also breathes oxygen while changing depths. Five minute air breaks between oxygen periods prevent CNS oxygen toxicity.

Figure 1-20. Treatment Table 5.

Treatment Table 6 - Type II DCS (Except Inner Ear DCS), Type I DCS with Pain Over 10 Minutes at Depth on TT5. if the Type I symptoms do not resolve within 10 minutes at 60 FSW or if the patient has Type II DCS, treatment is completed using Treatment Table 6 (Figure 1-21), (the patient is “brought out” on Treatment Table 6). This oxygen table lasts four hours and 45 minutes. It is similar to Treatment Table 5 except the times at 60 FSW and 30 FSW are increased. Additionally, if clinically indicated (i.e., if symptoms are not resolved), Treatment Table 6 may be lengthened. A total of four additional time periods, called extensions: two at 60 and two at 30 feet may be administered as needed.

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Physiology of Flight

Figure 1-21. Treatment Table 6.

Treatment Table 6A - AGE, Inner Ear DCS. Treatment Table 6A is used to treat arterial gas embolism. Treatment Table 6A is just like Treatment Table 6, except the patient is first brought to 165 FSW for 30 minutes on air to compress intra-arterial bubbles as much as possible. Oxygen cannot be used at this depth because of oxygen toxicity. After the initial period of deep recompression, the patient is brought to 60 FSW. The rest of the treatment is like Treatment Table 6. Treatment Tables 4 and 7. For very sick patients two additional tables are available, Treatment Tables 4 and 7. Treatment Table 4 is used to treat symptoms refractory to treatment at 60 feet by increasing the depth to 165 feet. Treatment Table 4 is also used to allow gas embolism patients more time at 165 feet than permitted by Treatment Table 6. Oxygen cannot be used until the patient reaches 60 feet. Because the tissues become nitrogen-saturated due to the extended time at depth, the patient must be brought to the surface very slowly. Treatment Table 4 takes 38 hours and 11 minutes to complete, and is basically an air saturation decompression table. For the patient with life-threatening DCS unresponsive to treatment, the option of Treatment Table 7 is available. This table provides for maximal treatment time at 60 feet. The treatment includes a stay at 60 feet of at least 12 hours, with an extremely gradual saturation-type ascent

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U.S. Naval Flight Surgeon’s Manual lasting 36 hours. There is no upper limit on the time the patient may be kept at 60 feet. Treatment Table 7 should be used only by a Diving Medical Officer who has support personnel and other assets readily available to properly execute treatment. Treatment Tables 4 and 7 are not used to treat minor neurological deficits which persist during treatment with Treatment Table 6 or 6A. Instead, these patients are retreated daily until symptoms no longer improve. Twenty-four hour consultation is available with the Experimental Diving Unit at Panama City (NEDU) (AUTOVON 436-4351, Commercial (904) 234-4351) or the Naval Medical Research Institute (NMRI) at Bethesda, MD (AUTOVON 295-1839, Commercial (202) 295-1839) for questions regarding hyperbaric treatment or triage. Questions on Hyperbaric Oxygen therapy (HBO) for nonbubble related diseases may be referred to Wright Patterson AFB Medical Center at (513) 257-8603. Triage and Referral of Altitude DCS Patients All patients with Type II DCS must be recompressed urgently or evacuated promptly for hyperbaric treatment. Patients with Type I DCS should be closely questioned about the onset of their symptoms. Patients whose symptoms appear at altitude, then resolve spontaneously on descent, should be placed in 100 percent oxygen and observed for two hours for evidence of presentation or recurrence of DCS. After two hours of observation, they are grounded for one week and returned to light duty. They must be warned to seek treatment promptly if any symptoms reoccur. Any recurrence must be treated with hyperbaric therapy. Patients who first develop Type I symptoms at ground level after flight, or whose symptoms start at altitude and persist at ground level, must be placed on 100 percent oxygen while recompression or evacuation is arranged. If symptoms resolve while awaiting transportation, evacuation is postponed; and, these patients are observed on 100 percent oxygen for 24 hours. Any recurrence must be treated with hyperbaric therapy. Patients who remain symptom-free for the 24 hour observation period are grounded for one week and placed on limited duty with no physical training for at least 72 hours. They are advised to return promptly for reevaluation if symptoms recur. Current U.S. Navy diving medicine protocols are to treat all patients referred for altitude DCS regardless of whether or not their symptoms have resolved. Therefore, once patients are evacuated, they will be treated.

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Physiology of Flight Aeromedical Evacuation The chapter on aeromedical evacuation contains a more thorough discussion of evacuation procedures. However, some points specific to evacuation of hyperbaric patients bear mentioning. First, the flight surgeon should know the location of the nearest recompression chambers, and how to contact personnel there. Contact should be made and the case discussed prior to transport or concurrently with transport. The aircraft should be pressurized to an altitude of 500 feet or less to prevent further bubble formation and expansion. The patient should be placed on 100 percent oxygen if available. Earlier guidelines recommended placing the patient with AGE in the left lateral decubitus position with the head down during transport, apparently to keep the bubbles from the head and heart. This may have the effect increasing intracranial pressure and reducing ventilation. The supine position is appropriate in an alert person. However, an unconscious person may be placed in the lateral decubitus position to prevent aspiration. The patient should be supine, neck in the neutral head position, and uncramped with the extremities uncrossed. The patient should also be placed so that the face is visible to the tender. The patient should not be permitted to sleep, so that changes in neurological status will be readily detected. Intravenous fluids, such as Ringers Lactate or normal saline, should be used. Free water solutions such as D5W should be avoided as they may contribute to cerebral swelling. A plastic IV bag may be used as a pillow. This will also serve to maintain the IV. Dexamethasone, while controversial, can be given 10 mg IV stat followed by 4 mg IV or IM q6hr. Inflatable cuffs, such as endotracheal cuffs, should be filled with water, not air. Flying After Diving Required intervals between diving and flying are given in Table 1-14. Table 1-14 Flying After Diving Surface Interval Before Flight

Category

24 hours

Flight Crew Divers No-Decompression Dive Decompression Dive (nonsaturation) Saturation Dive

12 hours 24 hours 72 hours

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U.S. Naval Flight Surgeon’s Manual Aeromedical Disposition Once the patient has been diagnosed, evacuated, and treated, the question arises as to their flight status. All Type I patients should be grounded for one week; Type II patients for one month. The flight surgeon should conduct a complete fitness to continue physical examination. The aeromedical disposition is made based on diagnosis, classification, treatment course, and duty status. Any documented history of gas embolism should be worked up for pulmonary bullae and other causes of Pulmonary Overinflation Syndrome as well as for atrial septal defects. Any persistent neurological sequelae of DCS or AGE are considered disqualifying. Type II DCS or recurrent Type I DCS is considered disqualifying. However, designated personnel may be considered for a waiver. Type I DCS, single episode, is considered disqualifying in nondesignated personnel. Waivers may be considered. All requests for waivers should be forwarded to the Naval Aerospace Medical Institute (NAMI) Code 42, for consideration by the Hyperbaric Medicine Committee. Observation Time and Travel Restrictions Following Hyperbaric Recompression The required intervals between the completion of recompression treatment and travel in pressurized nontactical aircraft are given in Table I-15.

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Physiology of Flight Table 1-15 Time Following Completion of Recompression Treatment Condition

Time on Station (5 min away)

In Local Area (30 min away)

May Fly After (as passengers)

Type I DCS

2 hrs

24 hrs

24 hrs

Type II DCS

6 hrs

48 hrs

48 hrs

DCS/AGE Treated on TT 6A/4/7

12-24 hrs

72 hrs

72 hrs

DCS/AGE with residual symptoms

12-24 hrs

72 hrs and cleared by DMO

72 hrs and cleared by DMO

Inside Tender on TT 5/6/6A

12 hrs

12 hrs

Inside Tender on TT 4/7

48 hrs

48 hrs

Oxygen Toxicity The need for oxygen to sustain life at any altitude is indisputable. However, excessive amounts of oxygen or excessively high oxygen partial pressures can be detrimental or even fatal. The amounts of oxygen and oxygen partial pressures breathed by aviation personnel are usually not great enough to cause significant harm to the body. However, the problem of oxygen toxicity is more significant in underwater and hyperbaric operations where the partial pressures of the breathing gases are excessive. The harmful effects of elevated partial pressures of oxygen are directly related to the level of elevation of partial pressures and the duration of exposure. There are several types of oxygen toxic effects known to occur in man.

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U.S. Naval Flight Surgeon’s Manual Pulmonary Oxygen Toxicity There is a risk of pulmonary oxygen toxicity whenever there is prolonged exposure (in excess of 12 to 15 hours) to inspired partial pressures of oxygen of 0.5 ATA or more. It is sometimes called the Lorraine Smith Effect after the researcher who first described it. Pulmonary oxygen toxicity begins with a progressive hydration or fluid accumulation of the lungs under hyperoxic conditions. The pulmonary edema leads to greater mechanical difficulties in ventilation together with impaired gas transfer. The individual finds it harder to breathe; he may feel a deep substernal pain and if not returned to a subtoxic breathing mix he may become hypoxic as the alveolar walls swell and the edema further impairs oxygen diffusion. Thus a paradoxical situation is reached in which elevation of the oxygen level in the gas ventilating the lungs actually decreases blood oxygenation in the pulmonary capillaries. Pulmonary oxygen toxicity can progress to a point where hypoxia can result in death unless the alveolar oxygen pressure is elevated to increase the oxygen diffusion gradient to elevate the arterial oxygen pressure. This does provide temporary relief but also causes further edema, a further reduction in the oxygen diffusion capacity and an eventual return to hypoxia until a still higher inspired oxygen pressure is required and so the subject enters a vicious cycle which can only terminate in death. The only known treatment for pulmonary oxygen poisoning is reduction of the inspired oxygen partial pressure to less than 0.5 ATA. Endotracheal intubation and positive end-expiratory pressure ventilation (PEEP) may be necessary in severe cases to allow adequate oxygenation with oxygen partial pressure of less than 0.5 ATA. Central Nervous System Oxygen Toxicity The onset of neurological oxygen toxicity can be quite sudden and dramatic. It is manifested by generalized convulsions, indistinguishable from the convulsions of grand mal epileptic seizure. Central nervous system oxygen toxicity usually occurs when an individual is exposed to inspired oxygen partial pressures about 1.5 to 2.0 ATA. Other manifestations of CNS oxygen toxicity indude dizziness, nausea, tunnel vision, blindness, unusual fatigue, anxiety, confusion, and a lack of coordination in movement. Muscular twitching - particularly lip twitching - can precede a convulsion but no reliance can be placed on this as an early warning. If one displays any signs of CNS oxygen toxicity, the first and most important step in treatment is to quickly switch the victim to air breathing. Chamber depth should not be altered until the victim’s signs or symptoms have cleared. Acceleration Atelectasis Another oxygen effect which may be loosely grouped under the general heading of oxygen tox-

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Physiology of Flight icity is atelectasis while breathing 100 percent oxygen during + Gz acceleration, although the term “oxygen toxicity” in this context is a misnomer. Acceleration atelectasis is included in this section only because it occurs when an aviator is breathing 100 percent oxygen. The primary factor responsible for the atelectasis is probably the complete cessation of basilar alveolar ventilation under acceleration. There is also markedly increased blood flow to the basilar alveoli as opposed to the apical ones, along with a reduction in basilar alveolar volumes as the weight of the lung under acceleration compresses the bases against the diaphragm. With these factors acting in concert, and when the alveoli in question contain only oxygen, water vapor, and carbon dioxide, oxygen absorption (the main cause of acceleration atelectasis) leads to alveolar collapse, and atelectasis can occur very rapidly. If nitrogen is present in the inspired gas, the gas absorption and consequent alveolar collapse are greatly slowed. The time required for complete absorption of gas contained in the lower quarter of the unventilated lung, with normal blood flow distribution, is increased from five minutes on 100 percent oxygen to about 25 minutes on 50 percent oxygen, 50 percent nitrogen. In addition, there is evidence that nitrogen in the lung acts as a “spring” by preventing alveolar collapse when all the oxygen is absorbed. Pulmonary atelectasis during flight may result in several performance-degrading effects, including distracting or perhaps even incapacitating cough and chest pain and arterial hypoxia due to the shunt of venous blood through the nonaerated alveoli. The Flight Surgeon should remain aware that coughing, substernal pain, and decreased altitude tolerance may indicate the development of this condition. In any event, acceleration atelectasis usually resolves itself in a few days with little or no treatment. Oxygen Paradox Restoration of normal alveolar oxygen tension in a hypoxic individual may be accompanied by a temporary increase in severity of symptoms, a phenomenon known as “oxygen paradox.” Like atelectasis, oxygen paradox may be loosely grouped under the heading of oxygen toxicity only because it also occurs when an aviator is breathing 100 percent oxygen. The paradox occurs when reoxygenation is brought about suddenly and in severe cases it can result in muscle spasms and unconsciousness which may last from a few seconds up to a minute. Usually this condition is transient and may pass unnoticed. Accompanying effects are decreased vision, mental confusion, dizziness and nausea. The mechanism responsible for this condition is uncertain, but is thought to be due to a combination of factors which include the effects of hypocapnia, the loss of the PO2 dependent simulation of the aortic and carotid peripheral chemoreceptors, and hypotension.

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U.S. Naval Flight Surgeon’s Manual A decrease in arterial PO2 is a potent stimulus to the carotid and aortic chemoreceptors to cause hyperventilation. The hyperventilation response due to decreased PO2 as a result of aortic and carotid stimulation results in hypocapnia. The ensuing hypocapnia leads to cerebral vasoconstriction and systemic vasodilation. In addition the hyperventilation results in a respiratory alkalosis shifting the oxyhemoglobin dissociation curve upward and to the left (Bohr Effect). This shift increases the capacity of the blood to onload oxygen in the lungs but restricts offloading of oxygen at the tissue level. The combined effects of vasodilation of blood vessels in the extremities, vasoconstriction of cerebral blood vessels, and the shift of the oxyhemoglobin curve to the left reduces blood flow and oxygen supply to the brain (stagnant hypoxia). Upon restoration of oxygen, there is a reduction or cessation of breathing and a hypotension. The reduction or cessation of ventilation (apnea) results from the loss of the PO2 dependent simulation of the carotid and aortic peripheral chemoreceptors. With the administration of 100 percent oxygen following hypoxia, arterial PO2 increases, removing or reducing the one and only stimulus to respiration. The result is a reduction in breathing or a sudden onset of apnea. The hypotension produced by the restoration of oxygen is probably due to vasodilation, which occurs by the direct action of oxygen on the pulmonary vascular bed. The hypocapnic effects of hypoxia and the apnea or reduction of ventilation and hypotension which follow reoxygenation, combine to further reduce cerebral blood flow. This further reduction in blood flow in all probability intensifies an already existing cerebral hypoxia for a short period of time until the cardiovascular effects have passed and carbon dioxide tension returns to normal. Once arterial carbon dioxide tension returns to normal, it will stimulate the central respiratory chemoreceptors to resume ventilation and resolve the cerebral hypoxia. Oxygen Equipment The ability to offset the physiological effects of reduced barometric pressure is as important to the effectiveness of a mission as the aircraft itself. Without compensation, man becomes the weak link in mission performance. Oxygen equipment is one area of development that has enabled man to fly in the environment above 10,000 feet. Aircraft Oxygen Systems Aircraft oxygen systems provide the aircrew member with diluted or 100 percent oxygen for breathing. Aircraft oxygen systems installed in naval aircraft fall in one of the following categories: 1. Gaseous oxygen systems.

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Physiology of Flight 2. Liquid oxygen systems. 3. Onboard oxygen generation systems. Gaseous Oxygen System. Gaseous oxygen systems are used primarily in emergency oxygen systems and in multiplace aircraft where space and weight considerations are less important. Aviators’ breathing gaseous oxygen is designated “Grade A, Type I”, and must meet military specifications MIL-0-27210 for purity and moisture content. Aviators’ breathing gaseous oxygen must be 99.5 percent oxygen by volume and contain no more than 0.02 milligrams of water vapor per liter at sea level and 70° F. It must be odorless and free from contaminants including drying agents. “Aviators” breathing oxygen is not the same and should not be confused with “medical oxygen.” While medical oxygen is more than adequate for breathing, it usually contains excessive amounts of water vapor. Air containing a high percentage of moisture can be breathed indefinitely without any serious ill effects. However, the moisture affects the aircraft oxygen system in the small orifices and passages in the regulator; freezing temperatures associated with ascent to altitude can clog the system with ice and prevent oxygen from reaching the user. Therefore, extreme caution must be taken to safeguard against the hazards of water vapor in oxygen systems. 1. Low Pressure System. Low pressure systems like the portable breathing oxygen cylinder and regulator type MA-l, are self- contained portable breathing devices capable of supply breathing oxygen to flight personnel for normal or emergency use. In these systems, the breathing oxygen is stored in a yellow, lightweight, nonshatterable cylinder. Shatterproofing is accomplished by heat treating or welding metal bands around the cylinder. On the side of the cylinder painted in black letters are the words “Breathing Oxygen, Nonshatterable”. The cylinders have an operating pressure range of 50 to 500 pounds per square inch (psi). If the cylinder is empty it must be purged to eliminate moisture. The low pressure system reduces the possibility of explosion. However, the system is not extremely efficient since the low pressure limits the volume of oxygen. 2. High Pressure Systems. Aviator’s breathing oxygen supply cylinders can be readily identified by their green color and 3-inch wide bank around the upper circumference of the cylinder. “OXYGEN, AVIATOR’S” shall be stenciled in white parallel to the longitudinal axis and on diametrically opposed sides in letters 1 3/4 to 2 inches high. High pressure systems have an operating pressure of 50 to 1800 psi. Cylinders depleted to a pressure of approximately 50 psig shall be marked “EMPTY.” Cylinders which have a pressure below 15 psig shall be removed from service for vacuum and heat drying or hot nitrogen gas drying. High pressure systems may be aircraft mounted, portable, or contained in seat kits. The size of the cylinder varies with the application.

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U.S. Naval Flight Surgeon’s Manual Liquid Oxygen Systems. Liquid oxygen systems are generally used in aircraft where space, weight and mission considerations are paramount. Aviators’ breathing liquid oxygen is designated “Grade B, Type II”, and must also meet military specification MIL-0-27210 for purity and moisture content. Liquid oxygen is a pale blue water-like liquid, extremely cold, and odorless. Liquid oxygen, commonly referred to as LOX, is normally obtained by a combined cooling and freezing process. When the temperature of gaseous oxygen is lowered to -182° F and it is under about 750 psi, it will begin to form into a liquid. When the temperature is lowered to -297° F, it will remain a liquid under normal atmospheric pressure. Once converted into a liquid, oxygen will remain in its liquid state as long as the temperature is maintained below -297° F. A liquid oxygen converter assembly is designed to store and convert liquid oxygen into gaseous oxygen. A typical liquid oxygen converter assembly (Figures 1-22, 1-23) consists of a container sphere, buildup and vent valve, relief valve, and associated tubing and fittings. A capacitance type probe assembly which sends an electric signal to a liquid oxygen quantity gauge that is located in the aircraft is incorporated within the sphere. The quantity gauge indicates the amount of LOX in liters that is contained in the converter. Oxygen in its liquid state is stored in the spherical assembly (Figure 1-22) which consists of an inner and outer shell separated by an annular space!. The annular space is evacuated, creating a vacuum, preventing the transmittal of heat through the space. The thermos bottle effect created retards heating and eventual conversion of LOX to gaseous oxygen. Valves, tubing, and fittings incorporated in the converter assembly convert LOX to gas and direct its flow at a controlled rate (Figure 1-23). Most tactical jet aircraft use the removeable 10 liter LOX converter. Aircraft such as the C-9 use a 25 liter aircraft mounted LOX converter. The potential hazards associated with the handling of liquid oxygen are due to its extremely cold temperature, rapid expansion upon conversion to gas at ambient (room) temperature, and its reactivity with any organic matter or flammable substance with which it comes in contact. Because liquid oxygen has an extremely low temperature (Boiling point - 183 F, Storage temp. -297 F.) it can freeze or seriously damage skin tissue upon contact. Injuries to the skin resulting from contact with liquid oxygen should be treated as frostbite or similar hypothermic injuries. Under the right conditions of temperature and pressure liquid oxygen may react violently with any organic matter, particularly that containing hydrocarbons. Mere mixture of liquid oxygen with powered organic materials under certain conditions may cause an explosion. If liquid oxygen is vaporized and warmed to ambient temperature, one volume of liquid oxygen will expand to 862 volumes of gaseous oxygen. In the aircraft this expansion ratio results in a saving of approximately 82 percent in weight and approximately 75 percent in space. Weight and

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Physiology of Flight space are critical in a jet propelled aircraft because for every pound removed from the aircraft approximately two pounds of thrust are gained. Liquid oxygen systems work on low pressure [110 psig mix] and must be vented to prevent over pressurization. In LOX storage containers are not vented explosive pressures in excess of 12,000 psig will be created. Liquid oxygen demonstrates a high affinity for absorption of impurities and noxious odors, resulting in contamination of complete systems. Suspected impurity contamination of liquid oxygen in aircraft systems has resulted in abortion of numerous inflight missions.

Figure 1-22. Liquid oxygen converter.

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Figure 1-23. Liquid oxygen converter flow diagram.

Onboard Oxygen Generation Systems (OBOGS). The idea of producing oxygen in flight is very attractive since it minimizes logistic support for oxygen and increases operational safety. Several OBOGS systems are currently being evaluated. These systems include electrochemical concentration, fluomine chemical absorption, permeable membrane, and molecular sieve. Currently the Navy’s AV-8B Harrier aircraft utilizes the molecular sieve OBOGS. In the molecular sieve system (Figure 1-24) bleed air from the turbine engine is alternately pumped between two molecular sieve beds containing aluminosilicate crystals called zeolite. The oxygen is separated from the nitrogen and concentrated. The oxygen-enriched air is then available for use through the normal oxygen delivery system. During the separation process using the two-bed systems, as the first bed is concentrating oxygen, the second bed is removing nitrogen and releas-

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Physiology of Flight ing it to the atmosphere. The cycles are then reversed with pressurization of the second bed and exhaustion of the first bed, thus producing a continuous supply of oxygen. System startup is virtually instantaneous. The enriched air supply proceeds directly as the bleed air supply pressurizes the system. When the aircraft is ready OBOGS is ready. The onboard oxygen generating system is a revolutionary oxygen system which yields a continuous supply of breathing oxygen to the aircrew member with no replenishment requirements. If there is any draw back to the system, it might be the fact that at best this system can only provide 95 percent oxygen, with 5 percent argon.

Figure 1-24. Molecular sieve oxygen-enriched air system (OEAS) schematic with inlet accessories.

Oxygen Regulators The purpose of an oxygen regulator is to control the flow of oxygen into the oxygen mask, by reducing oxygen pressure to a breathable level. Regulators are designed for either high or low pressure depending on the application. Regulator features may include diluter demand for diluting the supplemental oxygen with ambient air to extend the duration of the oxygen supply or automatic positive pressure for flights above 30,000 feet. Regardless of the features, each oxygen regulator is in essence a pressure reducer. They range in size from 1 3/4 by 2 l/4 inches to 9 by 10 inches. They are designed to operate in a temperature range of -65° F to 160° F (-54° C to 71.1° C). Continuous Flow Regulators. Continues flow regulators are used in a limited number of naval aircraft. These regulators do not satisfactorily meet all the oxygen requirements for varying

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U.S. Naval Flight Surgeon’s Manual degrees of aircrew activity. Continuous flow regulators are not authorized for use by aircrew members, but are authorized for passenger use. Diluter Demand Type Regulators. The 2858 diluter demand oxygen regulator is panel mounted and is used with the MBU series pressure demand oxygen masks. The regulator incorporates a pressure gauge, a flow indicator, and an air valve lever. It has an operating altitude range from 0 to 37,500 feet (Figure 1-25). The diluter demand regulator provides the aircrewman with an air oxygen mixture, or 100 percent oxygen, depending upon the mode of operation selected. By placing the air valve lever in the “NORMAL” position, the oxygen is diluted with ambient air up to approximately 28,000 to 32,000 feet. The ratio of oxygen to air is automatically adjusted to supply increasing oxygen as altitude increases. At approximately 32,000 feet, ambient air is shut off and the user receives 100 percent oxygen. By selecting 100 percent oxygen, the regulator supplies 100 percent at all altitudes. The diluter demand regulator is located on T-28s and cargo planes that utilize walkaround oxygen bottles.

Figure 1-25. Diluter demand oxygen regulator -2858 serves.

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Physiology of Flight Automatic Positive Pressure Diluter Demand Regulators. These regulators come in two basic types, either torso or aircraft panel mounted. 1. Torso Mounted Regulators. a. Regulator P/N 3260002-0301. This regulator (Figure 1-26) is used as part of the oxygen system in the AV-8 Harrier aircraft. It delivers 100 percent oxygen with safety pressure, or an airoxygen mixture to the aircrewman depending on altitude and mode of selection. With the control knob in the “NORM” mode, an air-oxygen mixture is supplied upon demand up to approximately 20,000 feet. Between the altitudes of 20,000 and 30,000 feet, 100 percent oxygen is supplied upon demand. With the regulator in the 100 percent oxygen setting at a positive pressure (safety pressure) of 0.01 to 2.0 inches of water pressure is supplied from sea level to approximately 30,000 feet. At 30,000 feet, the regulator provides pressure breathing with the pressure increasing proportionally with altitude to a maximum pressure of 15 inches of water pressure at 50,000 feet.

Figure 1-26. Diluter demand oxygen breathing regulator, part number 3260002-0301.

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U.S. Naval Flight Surgeon’s Manual b. Regulator P/N 900-002-051-03 and 900-002-051-04. This regulator (Figure 1-27) is used as part of the oxygen system in all S-3 aircraft. With the regulator in the diluter mode an air-oxygen mixture is provided from sea level to between 27,000 and 29,000 feet. Between the altitudes of 27,000 and 29,000 feet the aneroid expands closing the air valve, preventing ambient air from entering the regulator and the user receives 100 percent oxygen. With the regulator in the 100 percent mode, 100 percent oxygen at a positive pressure (safety pressure) of 0 to 1.5 inches of water pressure is supplied from sea level to approximately 38,000 feet. At 38,000 feet the regulators provide pressure, with the pressure increasing proportionally with altitude to a maximum pressure of 18 inches of water pressure at 50,000 feet.

Figure 1-27. Diluter demand torso-mounted oxygen regulators, part numbers 900-002-051-03 and 900-002-051-04.

2. Aircraft Panel Mounted Regulators. Several types of aircraft panel’mounted regulators are installed in naval aircraft (Figures 1-28, 1-29, 1-30, 1-31). These regulators are supplied in two basic configurations: low pressure (50 to 500 psig operating range), and high pressure (50 to 2000 psig operating range). The most common panel mounted regulator in use at this time is the MD/CRU series #29255 regulator. They can be found in most nonejection seat equipped aircraft using personal oxygen equipment.

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Figure 1-28. Aircraft panel mounted oxygen regulator, type MD-l, CRU-52/A, CRU-54/A CRU-55/A, and CRU-57/A.

Figure 1-29. Aircraft panel mounted oxygen regulator, type MD-2 and CRU-72/A.

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Figure 1-30. Aircraft panel mounted oxygen regulator, low pressure, part numbers 29255-10A-Al, 29255-l0A-B9, 29255-10A-A2, 29255-10A-A4, 29255-10A-A5, 29255-10A-A9, and 29255-10A-All.

Figure 1-31. Aircraft panel mounted oxygen regulator, high pressure, part numbers 29255-6B-Bl and 29255-6B-A1.

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Physiology of Flight The following controls and indicators are located on the front panel of the regulator. The small oblong shaped window area on the left side of the panel marked FLOW, indicates the flow of oxygen through the regulator by a visible blinking action. The pressure gauge is found on the upper right of the panel and indicates inlet pressure to the regulator. The regulator has three control toggles. A supply toggle located on the lower right comer is used to control the supply of oxygen to the regulator. The dilute toggle located on the lower center of the panel has two positions: 100 percent OXYGEN and NORMAL OXYGEN. In the 100 percent OXYGEN position the regulator delivers 100 percent oxygen upon inhalation by the user. In the NORMAL OXYGEN position the regulator delivers a mixture of air and oxygen with the air content decreasing until a cabin altitude of approximately 30,000 feet is reached. Above this altitude 100 percent oxygen is delivered to the user upon inhalation. The emergency pressure control located on the lower left of the panel has three positions: EMERGENCY, NORMAL, and TEST MASK. The EMERGENCY position delivers positive pressure to the outlet at altitudes when positive pressure is not automatically delivered. In the TEST MASK position, oxygen is delivered to the mask under pressure too high to breathe and is used to check the mask. The switch must be in the NORMAL position to assure normal system operation. The MD/CRU series regulators are designed for use to 43,000 feet with an emergency ceiling of 50,000 feet. With the supply lever placed at the ON position, the diluter lever placed in the NORMAL oxygen position, and the emergency lever placed in the NORMAL position; the regulator will supply a mixture of oxygen and ambient air at low altitudes. The percent of oxygen will gradually and automatically increase to 100 percent at approximately 28,000 to 32,000 feet. At cabin altitudes of approximately 27,000 feet the regulator will automatically begin to deliver positive pressure. At 50,000 feet the positive pressure will be approximately 11 to 18 inches of water pressure. Miniature Oxygen Breathing Regulators. Several types of CRU-79/P miniature oxygen breathing regulators are utilized (Figures 1-32, 1-33, 1-34, 1-35). Miniature oxygen regulators reduce and regulate supply pressure and deliver 100 percent oxygen to the user at a breathable pressure. A safety pressure feature automatically maintains a positive pressure of 0 to 2.5 inches of water pressure in the mask at altitudes up to and including 34,000 feet. The pressure breathing feature maintains a positive pressure in the mask of up to 20.0 inches of water pressure at altitudes between 35,000 and 50,000 feet. The positive pressure increases as altitudes increases. Miniature oxygen regulators can be used routinely up to approximately 43,000 feet, with an emergency ceiling of 50,000 feet for very short periods.

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Figure l-32. Miniature oxygen breathing regulator type CRU-79/P.

Figure l-33. Miniature oxygen breathing regulator model 226-20004-3.

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Figure l-34. Miniature oxygen breathing regulator model 29267-A1.

Figure l-35. Miniature oxygen breathing regulator model 3260024-0101.

A-21 Oxygen Regulator. The A-21 type regulator which forms part of the MA-l portable breathing device, is a demand and pressure breathing type regulator which will deliver oxygen to the user upon demand, or provide a positive pressure to the mask or the MBU-12/P oxygen mask configuration. During normal operation the selector knob is positioned in the NORM position and will deliver 100 percent oxygen upon demand. When the selector knob is placed in the 30M, 42M, or EMER position, the unit will deliver 100 percent oxygen at a positive pressure of 1.6 to 14.0 inches of water pressure, depending upon the positioning of the selector knob from sea level to the service ceiling of the aircraft.

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U.S. Naval Flight Surgeon’s Manual Oxygen Masks One of the most critical features in the oxygen supply system is the breathing mask. An oxygen mask is used for the purposes of delivering oxygen to the user’s respiratory system. Oxygen masks are designed for either pressure breathing or continuous flow regulators. The features such as microphones, amplifiers, regulators, or connectors will be determined by the application. All masks include some kind of face seal and an arrangement of valves to direct the flow of inhaled and exhaled gases. The mask provides facial protection from fire and projectiles. Pressure-Demand Oxygen Mask Assemblies. The pressure- demand oxygen mask is used by aircrew members who wear fixed wing helmet assemblies and use oxygen routinely. The pressuredemand oxygen mask is based on the MBU-12/P (Figure l-36) oxygen mask subassembly. The MBU-12/P subassembly features an integral hardshell (polysulphmate) facepiece (silicone), flexible silicone hose, and combination inhalation and exhalation valve. Components must be added to or removed from the basic MBU-12/P subassembly to obtain the desired oxygen mask configuration (Figures l-37 thru 143). The versatility of the pressure demand oxygen mask allows it to be worn with chest mounted regulators in tactical jets as well as panel mounted regulators and walkaround bottles. A properly fitted oxygen mask is essential to helmet retention in high speed ejections.

Figure l-36. MBU-12/P oxygen mask assembly.

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Figure l-37. MBU-14 (V) l/P oxygen mask assembly.

Figure 1-38. MBU-14 (V) 2/P oxygen mask assembly.

Figure l-39. MBU-14 (V) 3/P oxygen mask assembly.

Figure 1-40. MBU-15/P oxygen mask assembly.

Figure 1-41. MBU-16/P oxygen mask assembly.

Figure l-42. MBU-17 (V) 1/P oxygen mask assembly.

Figure 1-43. MBU-17 (V) 2/P oxygen mask assembly.

Quick-Don Oxygen Mask. The MBU-10/P Oxygen Mask Assembly (Figures 1-44, 1-45) consists of a hanging suspension holder, a suspension assembly, an oxygen mask assembly, a cable and plug assembly, and a dust cover. The MBU-12/P oxygen mask subassembly is used and is supplied in one size - regular. The Quick-Donning MBU-10/P oxygen mask assembly permits the aircrew to breathe gaseous oxygen. The oxygen supply enters the facepiece through the valve located at the bottom of the mask. Inhaled air passes out through the same valve. The exhalation portion of the valve is constructed so that a pressure of only one millimeter of mercury greater than the inlet pressure being supplied by the regulator will force open the valve and allow exhaled air to flow from the mask. The mask also provides automatic electrical switching from the headset microphone to the oxygen mask microphone. This feature permits the aircrewmen while wearing the mask to transmit the same as with the headset microphone, without the need to unplug the headset microphone and then plug in the oxygen mask microphone. Currently the MBU-10/P oxygen mask is used on selected C-130 Aircraft.

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Figure 1-44. MBU-10/P oxygen mask.

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Figure 1-45. Donning procedure.

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Physiology of Flight Sierra Quick-Don Oxygen Mask. The Sierra Quick-Don oxygen mask (Figure 1-46) is designed to provide the proper dilution of oxygen with cabin air to conserve oxygen at lower altitudes. The Sierra Quick-Don mask consists of a spring loaded head harness, face piece, microphone, and oxygen supply hose. The mask has two oxygen settings, NORMAL and 100 percent OXYGEN. The selector switch is located on the left side of the regulator attached to the mask. A white button located on the front of the regulator allows the crew member to receive additional oxygen under pressure. The Sierra Quick-Don Mask is carried on some C-9, C-12, CT-39 and T-44 aircraft.

Figure 1-46. Sierra quick-don oxygen mask system.

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U.S. Naval Flight Surgeon’s Manual Full Face Oxygen and Smoke Mask. The full face oxygen and smoke mask (Figure 1-47) is designed to dispense gaseous oxygen from a demand type regulator to the user. The smoke mask provides oxygen and face protection to aircrew members who use oxygen equipment only in rare or emergency situations. The mask also provides protection from smoke, carbon monoxide, or other incapacitating gases. The full face oxygen and smoke mask has a single configuration of the facepiece, delivery hose, and MC-3A connector. The mask consists of a molded rubber face piece with microphone cavity. It has five fitting straps, an acrylic plastic lens, and exhalation valve. The delivery hose (K-4 hard hose) is composed of nonstretch, nonkinking, smooth bore, flexible hose with an integral corrosion resistant wire. The hose cover is knitted or braided of tubular polyamide or polyester. The communication cable is molded into the hose with leads extending for attachment for a mask mounted microphone. It also has a connection for attaching to the aircraft communications system. The MC-3A connector is provided for access to the aircraft oxygen system. The full face oxygen and smoke mask is carried on P-3 and C-130 aircraft.

Figure 1-47. Full face oxygen and smoke mask.

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Physiology of Flight References and Bibliography Agostini, A., Stabilini, R. Bemasconi, C., & Gerdi, G.C. The Hb-O2 dissociation curve in hypercapnic patients. American Heart Journal, 1974, 87, 670-672. Arthur, D., Margulies R. The pathophysiology, presentation and triage of altitude-related decompression sickness associated with hypobaric chamber operation. Aviation, Space and Environment Medicine, 1982, 53, 489-494. Balldin, U.I., & Borgstrom, P. Intracardial bubbles during decompression to altitude in relation to decompression sickness in man. Aviation, Space & Environmental Medicine, 1976, 47, 113-l16. Bason, R., Pheeny, H., & Dully, F.E., Jr. Incidence of decompression sickness in Navy low pressure chambers. Aviation, Space and Environmental Medicine, 1976, 47, 995-997. Billings, C.E. Atmosphere. In J.F. Parker, Jr. & V.R. West (Eds.), Bioastronautics data book (2nd ed.) (NASA SP-3006). Washington, DC: U. S. Government Printing Office, 1973a. Billings. C.E., Barometric Pressure. In J.F. Parker, Jr. & V.R. West (Eds), Bioastronautics data book (2nd ed.) (NASA SP-3006). Washington, DC: U.S. Government Printing Office, 1973b. Billings, C.E., & Roth, E.M. Pressure. In P. Webb (Ed.), Bioastronautics data book (NASA SP-3006). Washington, DC: U.S. Government Printing Office, 1964. Behnke, A.R. Decompression sickness: Advances and Interpretations. Aerospace Medicine, 1971, 42, 255-267. Berry, CA., & Hekhuis, G.L. X-ray survey for bone changes in low pressure chamber operators. Aerospace Medicine, 1960, 31, 760-766. Blockley, W.V., & Hanifan, D.T. An analysts of the oxygen protection problem at flight altitudes between 40,000 and 50,000 feet. Santa Monica, California: Webb Associates, 1961. Boothby, W.M., Lovelace, W.R. II, Benson, O.O. Jr., & Strehler, A.F. Volume and partial pressures of respiratory gases at altitude. In W.M. Boothby (Ed.), Handbook of respiratory physiology. Randolph AFB, Texas: Air University, USAF School of Aviation Medicine, September 1954. Bornmann, R.C. Limitations in the treatment of diving and aviation bends by increased ambient pressure. Aerospace Medicine. 1968, 39, 1070-1076. Boyle, J., III. Theoretical tram-respiratory pressure during rapid decompression: I. Model experiments and II. Animal experiments. Aerospace Medicine. 1973, 44, 153-162. Buckles, R.G. The physics of bubble formation and growth. Aerospace Medicine, 1968, 39, 1062-1068. Brown, H.H.S. The pressure cabin. In J.A. Gillies (Ed.), A textbook of aviation physiology. New York: Pergamon Press, 1965. Bryan, A.C. Breathing. In P. Webb (Ed.), Bioastronautics data book (NASA Sp-3006). Washington, DC: U.S. Government Printing Office, 1964. Campen, C. F., et al (Eds.) Handbook of geophysics (rev. ed.). New York: Macmillan, 1960. Carlson, L.D. Gas exchange and transportation. In T.C. Ruch & J.F. Fulton (Eds.), Medical physiology and geophysics (18th ed.). Philadelphia: W.B.Saunders, 1965a. Carlson, L.D. Gas exchange and transportation. In T.C. Ruch & J.F. Fulton (Eds.), Physiology and biophysics (19th ed.). Philadelphia: W.B. Saunders, 1965b. Carlyle, L. High altitude breathing. Approach January 1963, Pp. 30-35. Catron, P., HaIlenbeck, J., Flynn, E., Bradley, M., & Evans, D. Pathogenesis and treatment of cerebral air embolism and associated disorders. Bethesda, MD: Naval Research Institute, April 1984.

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U.S. Naval Flight Surgeon’s Manual Clamann, H.G. Decompression sickness. In H.G. Armstrong (Ed.), Aerospace medicine. Baltimore: The Williams & Wilkins, 1961. Clark, J.M., & Lambertsen, C.J. Pulmonary oxygen toxicity: A Review. Pharmacological Review, 1971, 23, 37-133. Comroe, J.H., Jr., Physiology of respiration. Chicago: Yearbook Medical Publishers, 1965. Cooke, J.P. Denitrogenation interruptions with air. Aviation, Space and Environmental Medicine, 1976, 47, 1205-1209. Davis, J.C. Hyperbaric oxygen theory. Bethesda, MD: Undersea Medical Society, 1977. Department of the Navy, Bureau of Medicine and Surgery. Policy for clinical use of recompression chambers for nondiving illnesses (BUMEDINST 6320.38A). Department of the Navy, Office of the Chief of Naval Operations. General flight and operating instructions (OPNAVINST 3710.7 series). DeHart, R. L., (Ed.), Fundamentals of aerospace medicine, Philadelphia: Lea & Febiger, 1985. Department of the Navy, Office of the Chief of Naval Operations. General flight and operating instructions(OPNAVINST 3710.7 series). Dhenin, G. (Ed.), Aviation medicine, physiology and human factors. London: Tri-Med Books, 1978. Donnell, A.M., & Norton, C.P. Successful use of the recompression chamber in severe decompression sickness with neurocirculatory collapse. Aerospace Medicine, 1960, 31, 1004-1009. Downey, V.M., Tracy, W.W., Hockworth, R., & Whitley, J. L. Studies on bubbles in human serum under increased and decreased atmospheric pressures. Aerospace Medicine, 1963, 34, 116-118. Duvelleray, M.A., Mehmel, H.C., & Laver, M. Hb-O2 equilibrium and coronary blood flow: A model. Journal of Applied Physiology, 1973, 35, 480-435. Edmonds, C., & Pennefather, J. Diving and subaquatic medicine. Australia: Diving Medical Center, 1981. Ernsting, J. The physiological requirements of aircraft oxygen systems. In J.A. Gillies (Ed.), A textbook of aviation physiology. New York: Pergamon Press, 1965. Ernsting, J. The physiology of pressure breathing. In J.A. Gillies (Ed.), A textbook of aviation physiology New York: Pergamon Press, 1965a. Ernsting, J. Respiration and anoxia. In J.A. GiIlies (Ed.), A textbook of aviation physiology. New York: Pergamon Press, 1965b. Ernsting, J. Some effects of raised intrapulmonary pressure in man (AGARDograph 106). Maidenhead, England: Technivision, 1966. Ernsting, J., & King P. Aviation Medicine. Boston: Butterworths, 1988. Ernsting, J. The use of the pressure economiser oxygen system in high performance aircraft in which crew members are routinely exposed to positive acceleration (FPRC Memo 215). Famborough, EngIand: RAF Institute of Aviation Medicine, September 1964. Evans, A., Bainard, E.E.P., & Walder, D.N. Detection of gas bubbles in man at decompression. Aerospace Medicine, 1972, 43, 1095-1096. Evans, W.O., Robinson, S.M., Horstman, D.H. Jackson, R.E., & Weiskopf, R.E., & Weiskopf, R.B. Amelioration of the symptoms of acute mountain sickness by staging and acetaxolamide. Aviation, Space and Environmental Medicine, 1976, 47, 512-516. Fellenius, E., & Samuelson, R. Effects of severe systemic hypoxia on myocardial energy metabolism. Journal of Scandanavian Physiology, 1973, 88, 256-266.

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Physiology of Flight Flynn, E., Bayne, C.G., & Catron, P.W. Diving Medical Officer’s student guide, Millington: Naval Technical Training Command, 1980. Folbergrova, J., & Siesjo, K. Regulatory mechanism affecting carbohydrate substrates in the brain in hypercapnic acidosis. Journal of Scandanavian Physiology, 1973, 88, 281-284. Fryer, D.I. Evolution of concepts in the etiology of bends. Aerospace Medicine, 1968, 39, 1058-1061. Fryer, D. I. Subatmospheric decompression sickness Technivision, 1969.

(AGARDograph 125). Slough, England:

Fryer, D. I. & Roxburgh, H.L. Decompression sickness. In J.A. Gillies (Ed.), A textbook of aviation physiology. New York: Pergamon Press, 1965. Fulton, J.F. (Ed.). Decompression sickness. Philadelphia: W.B. Saunders, 1951. Furry, D.E. Incidence and severity of altitude decompression sickness in Navy hospital corpsmen. Aerospace Medicine, 1973, 44, 450-452. Furry, D.E., Reeves, E., & Beckman, E. Relationship of SCUBA diving to the development of aviator’s decompression sickness. Aerospace Medicine. 1967, 38, 825-828. Gillies, J.A. (Ed.), A textbook of aviation physiology. New York: Pergamon Press, 1965 (or latest edition). Goodman, M.W. Decompression sickness treated with compression to 2-6 atmospheres absolute. Aerospace Medicine, 1964, 35, 1204-1212. Greenwald, A.J., Allen, T.H. & Bancroft, R.W. Abdominal gas volume at altitude and at ground level (SAM TR-67-102). Brooks Air Force Base, Texas: USAF School of Aviation Medicine, 1967. Guyton, A. C. Textbook of Medical Physiology (7th ed.). Philadelphia: W.B. Saunders, 1986. Hills, B.A. Decompression sickness, Volume 1: The biophysical basis of prevention and treatment. New York: John Wiley and Sons, 1977. Hodgson. C.J., Davis, J.C., Randolf, C.L., & Chambers, G.H. Seven year follow-up x-ray survey for bone changes in low pressure chamber operators. Aerospace Medicine, 1968, 39, 417-422. Hohnstrom, F.M., & Beyer, D.H. Decompression sickness and its medical management. Military Medicine, 1965, 130, 872-877. Hultgren, N.H., & Grover, R.F. Circulatory adaption to high altitude. Annual Review of Medicine, 1968, 19, 119-151. Hurtado, A. Animals in high altitude: Resident man. In D.B. Dill, E.F. Adolph, & C.G. Wilbur (Eds.), Handbook of physiology. Section 4: Adaptation to the environment. Baltimore: Waverly Press, 1964. Johannsson, H., & Siesjo, K. Blood flow and oxygen consumption in the rat brain in dilutional anemia. Journal of Scandanavian Physiology, 1974, 91, 136-138. King, A.B., & Robinson, S.M. Vascular headache of acute mountain sickness. Aerospace Medicine, 1972, 43, 849-851. Lambertsen, C.J. Concepts for advances in the therapy of bends in undersea and aerospace activity. Aerospace Medicine, 1968, 39, 1086-1093. Lambertsen, C.J. Respiration. In Mountcastle, V.B. (Ed.), Medical physiology (Vol. 2. 14th ed.) St. Louis: C. V. Mosby, 1980. Lenfant, C., & Sullivan, K. Adaptation to high altitude. New England Journal of Medicine, 1971, 284, 1298-1308. Luft, U.C., & Finkelstein, S. Hypoxia: A clinical-physiological approach. Aerospace Medicine, 1986, 39, 105-109.

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U.S. Naval Flight Surgeon’s Manual Luft, U.C., Altitude sickness. In H.G. Armstrong (Ed.), Aerospace Medicine. Baltimore: The Williams & Wilkins, 1961. Luft, U.C. Aviation physiology - The effects of altitude. In Fenn W.O., & Rahn, H., (Eds.), Handbook of physiology. Section 3, Vol. II., Respiration. Washington, DC: American Physiological Society, 1965. Maher, J.T., Cymerman, A., Reeves, J.T. Cruz, J.C. Denniston, J.C. & Grover, R.F. Acute mountain sickness: Increased severity in eucapnic hypoxia. Aviation, Space and Environmental Medicine. 1975, 46, 826-829. Malette, W.G., Fitzgerald, J.B., & Cockett, A.R. Dysbarism: A review of 35 cases with suggestions for therapy. Aerospace Medicine, 1962, 33, 1132-1139. Manatt, S.A., Onboard oxygen generation systems. Aviation, Space and Environment Medicine, 1981, 52, 645-653. McFarland, R.H. Human factors in air transportation. New York: McGraw-Hill 1953. Melver, R.G. Management of bends arising during space flight. Aerospace Medicine, 1968, 39, 1084-1086. Mehmel, H.C., Duvelleray, M.A., & Laver, M. Response of coronary blood flow to pH-induced changes in Hb-O2 affinity. Journal of Applied Physiology, 1973, 35, 485-489. Meijne, N.G. Decompression sickness and the cardiovascular system. In D.E. Busby, (Ed.), Recent advances in aerospace medicine. Proceeding of the 18th International Congress of Aviation and Space Medicine, Amsterdam, 1969. Dordrecht, Holland: D. Reidel Publishing, 1970, Pp. 188-197. Naval Sea Systems. U.S. Navy Diving Manual (Vol. 1, NAVSHIPS 0994-LP-001-9010). Washington, DC: U.S. Government Printing Office, 1985. Petty, C.A., & Bogeant, T.B. Effects of morphine, meperidine, fentanyl, and naloxone on Hb-O 2 dissociation curve. Journal of Pharmacology and Experimental Therapeutics, 1974, 190, 176-179. Phillip, R.B., Inwood, M.J., & Warren, B.A. Interactions between gas bubbles and components of the blood: Implications in decompression sickness. Aerospace Medicine, 1972, 43, 946-953. Pittinger, C.B. Hyperbaric oxygenation. Springfield, IL: Charles C. Thomas, 1966. Randel, H.W. (Ed.) Aerospace Medicine. Baltimore: The Williams & Wilkins, 1971. Rayman, R.B., McNaughton G.B. Decompression sickness: USAF experience 1970-1980. Aviation, Space and Environment Medicine, 1983, 54, 258-260. Roughton, F. J., & Severinghaus. J. W. An accurate determination of O2 dissociation curve of blood above 98.7% saturation with data on O2 solubility in blood from 0°C -37°C. Journal of Applied Physiology, 1973, 35, 861-868. Samuelsson, R. Effects of severe systemic hypoxia on myocardial excitation. Journal of Scandinavian Physiology, 1973, 88, 267-280. Scott, V. Anemia and airline flight duties. Aviation, Space and Environmental Medicine, 1975, 46, 830-835. Topliff, E.D.L. Mechanism of lung damage in explosive decompression. Aviation, Space and Environmental Medicine, 1976 47, 517-522. Van Liere, E.J., & Stickney, J.C. Hypoxia. Chicago: University of Chicago Press, 1963. Velasquez, T. Tolerance to acute anoxia in high altitude natives. Journal of Applied Physiology, 1959, 14, 357-362. Wennmaim, A., & Junstad, M. Hypoxia caused prostaglandin release from perfused rabbit hearts. Journal of Scandinavian Physiology, 1974, 91, 133-136.

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Physiology of Flight West, J.B. Hypoxic man: Lessons from extreme altitude. A v i a t i o n , S p a c e a n d E n v i r o n m e n t Medicine, 1984, 55, 1058-1062. Wirjosemito, S.A., Touhey, J.E., & Workman, W.T. Type II Altitude Decompression Sickness (DCS): U.S. Air Force experience with 133 cases. Aviation, Space and Environmental Medicine, 1989, 60, 256-261. Underwater Wood, J.D. Oxygen toxicity in neuronal elements. In C.J. Lambertsen (Ed.), physiology. New York: Academic Press, 1971. Wood, J.D., Peesker, S.J., & Rozdilsky, R. Sensitivity of GABA synthesis in human brain to oxygen poisoning. Aviation, Space and Environmental Medicine, 1975, 46, 1155-1156. Workman, R.D. Treatment of bends with oxygen at high pressure. Aerospace Medicine, 1963, 39, 1076-1083. United States Standard Atmosphere, 1976, Washington, DC: Government Printing Office, 1976.

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CHAPTER 2 ACCELERATION AND VIBRATION Introduction Sustained Acceleration Impact Acceleration Vibration References Introduction Naval aviators are subjected to a constantly changing acceleration environment, which can profoundly affect their mission performance capability. Acceleration is defined as a time rate of change in velocity magnitude and/or direction. To describe an acceleration, both the magnitude and direction must be specified. Acceleration magnitude is expressed as velocity per unit time. For example, if velocity is expressed in meters/second (m/s), then acceleration would be expressed as m/s/s or m/s2. The unit of acceleration commonly used in aerospace medicine is “G” defined by the equation G = a/g, where a is the acceleration of interest, and g is the acceleration of gravity at the Earth’s surface (9.8 m/s2 or 32.2 ft/s2). Thus, an aviator experiencing an acceleration of 64.4 ft/s2 would be experiencing 64.4/32.2 or 2 G. Standard terminology for acceleration direction was developed by an international conference in the early 1960s (Gell, 1961) and is expressed in terms of three axes (X,Y,Z) through the human body. A positive sign indicates the direction of the resultant of the acceleration rather than the direction of the acceleration itself (see Table 2-1). The vernacular section of Table 2-1 provides an easy way to visualize the resultant direction. For example, +Gz is “eyeballs down” (i.e., the resultant of an upward acceleration pushes the body downward in the seat and rotates the eyeballs downward). This chapter addresses three aspects of acceleration: sustained acceleration, transitory or impact acceleration, and vibration.

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Table 2-1 Body Acceleration – Comparative Table of Equivalents

Acceleration and Vibration Sustained Acceleration Sustained acceleration may be defined as acceleration lasting more than about 1 second, as opposed to transitory or impact acceleration, which lasts less than about 1 second. Although the boundary between impact acceleration and sustained acceleration is indistinct, the effects can usually be used to differentiate between them. That is, the effects of sustained acceleration are primarily physiological, and the effects of impact acceleration are primarily mechanical.’ Sustained acceleration most significantly affects the circulatory system and secondarily affects mental and sensory function. Of less significance, musculoskeletal effects impede movements necessary to control the aircraft or execute emergency procedures. At very high acceleration levels, musculoskeletal injury has been reported. Three types of sustained acceleration are commonly seen in aviation: linear, which is a change in speed without a change in direction; radial or centripetal, which results from a change in direction without necessarily a change in speed; and angular, which is rotation around a body axis. Each of these types of acceleration has disorienting aspects, however, these are discussed in the chapter on vestibular function. The physiological effects of G differ markedly, depending on the direction of the G related to the body. Because of this, each G direction will be discussed separately. “Eyeballs Down” (+Gz) Acceleration “Eyeballs down” or +Gz acceleration is the most common sustained acceleration experienced by naval aviators, and it is the most likely to have serious consequences. This type of acceleration is usually a result of radial acceleration due to a change in direction. For an aircraft in a level turn, the G can be calculated by the following formula: a = v2/r where a = acceleration in ft/s2 v velocity in ft/s r radius of the turn in ft The following example is a calculation of G in an aircraft flying at 500 knots and turning with a radius of 2000 ft. (Note that there are 6080 ft/knot and 3600 s/h.) a = (500 knots)2/2000 = ((500*6080)/3600)2/2000 = 356.5 ft/s 2

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U.S. Naval Flight Surgeon’s Manual 2 2 G = a / g = 356.5ft/s /32.2ft/s = 11.07 G

As we shall see, this is well beyond the limits of most naval aviators’ capability. Cardiovascular Effects. For a naval aviator of average stature seated upright, the height of the column of blood from the aortic valve to the eye is about 30 centimeters (cm). At 1 +Gz, this column of blood would result in an approximate pressure drop from heart to eye of 22 millimeters of mercury (mm Hg). Thus, with a mean blood pressure of 100 mm Hg at the aortic valve level, the systolic blood pressure at eye level at 1 +Gz would be 100 minus 22, or 78 mm Hg. For each additional +Gz, the eye level blood pressure is lowered by 22 mm Hg, until at 4.5 G, the mean eye level blood pressure is 0. Therefore, if only the hydrostatic column is considered, the theoretical limit of +Gz tolerance for eye and brain blood flow, and thus eye and brain function, is approximately 4.5 G, unless either the blood pressure at the aortic valve level is increased, or the effective height of the aortic valve to eye blood column is decreased. Other complexities are added, however, in vivo. As the +Gz level increases, compensatory mechanisms begin to act. Baroreceptors in the aortic arch and carotid arteries sense the decrease in pressure and act to increase the blood flow to the head by three mechanisms: peripheral vasoconstriction, increased heart rate, and increased contractile force of the cardiac muscle. These responses occur about 6-10 seconds after stimulation (see Figure 2-1 and Guyton, 1981), and in very fast onset rates of G, may be too slow to avoid serious neurological consequences. (See section on +Gz neurological effects.) Chemoreceptors play a role as pressure drops and as the arterial oxygen partial pressure (PaO2) decreases from the respiratory effects of G. The central nervous system (CNS) ischemic response probably plays a role in recovery when head blood pressure drops to 0 for greater than 5 seconds, resulting in loss of consciousness. Dysrhythmias are frequently seen when subjects are electrocardiographically monitored while undergoing G stress. The most common dysrhythmias associated with +Gz exposure are marked sinus arrhythmia, premature ventricular contractions, and premature atrial contractions (Leverett & Whinnery, 1985, p. 216). It is questionable whether acceleration is more dysrhythmogenic than other physical stresses, such as hard exercise, or whether mechanisms unique to G, such as distortion of heart muscle, have an effect. In healthy aviators, the effects of these dysrhythmias are usually slight, except in rare instances when they may reduce brain blood flow enough to cause neurological symptoms (Whinnery, Laughlin, & Uhl, 1980). There has been concern for many years that subclinical cardiovascular system damage might occur from high G exposure, causing long-term adverse health effects. In fact, endocardial hemorrhages have been reported in pigs exposed to high G, but there is no evidence that cardiac

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Acceleration and Vibration damage occurs in humans who are exposed acutely or chronically to G within tolerance limits (Leverett & Whinnery, 1985, p. 227).

Figure 2-1. Potency of various arterial pressure control mechanisms at different time intervals after the onset of a disturbance to the arterial pressure. Not especially the infinite gain of the renal-body fluid pressure control mechanism that occurs after a few days’ time.

Neurological Effects. Most of the CNS and sensory effects of +Gz are a direct result of the cardiovascular effects. For CNS and eye tissue to function, only brief blood flow interruption can be tolerated. If blood flow to these tissues is interrupted, the tissue reserves of oxygen last approximately 5 seconds. As this minuscule reserve is used up, the tissue ceases its normal function. If blood flow is restored after a brief period of malfunction, the tissue resumes functioning with no residual damage. There is, however, a profound and critical difference between the response of the eye and the response of the brain to blood flow loss from +Gz. First, blood flow to the eye ceases before blood flow to the brain does, because of the internal pressure of the eye (approximately 16 mm Hg average). Because of this early blood loss difference, vision will fail at about 0.7 G below the +Gz level at which cerebral function fails. This is fortuitous for aviators since it

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U.S. Naval Flight Surgeon’s Manual can provide a visual warning of impending loss of consciousness. Aviators frequently use grayout or tunneling of vision as a way to titrate the G load to avoid more serious consequences, but this technique becomes less reliable as the G onset rate increases. To understand this phenomenon, it is necessary to examine the interactions between the 5-second lag from stoppage of blood flow to eye or brain until the development of eye or brain symptoms, and the onset rate of G. Figure 2-2 illustrates this warning time change at a slow and a fast onset rate of G.

Figure 2-2. An illustration of the reduction in warning time between visual symptoms and G-induced loss of consciousness (GLOC) when G onset rate is increased. The dotted line shows a rapid onset of G to 8G in an aviator who loses blood flow to his eye at 6G and to his brain at 6.7G. Vision loss and GLOC occur 5 sec after blood flow to the respective organ stops. The solid line shows the same aviator experiencing a slower onset rate of G. Note the longer time between visual symptoms and GLOC at the slower onset. Figure 2-3 further illustrates the physiology of G-induced visual symptoms and loss of consciousness. Note especially the 5-second oxygen reserve during which no eye or brain symptoms occur. This reserve explains why an aviator can bend an airplane with momentary excessive G, have no ill effects, and as a result, develop an inflated perception of his G tolerance. The dip in the curve in Figure 2-3 illustrates the problem caused by the lag in physiological compensatory

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Acceleration and Vibration mechanisms, especially with high onset rates of G. using vision symptoms that pilots can use effectively why this strategy will not always work with aircraft onset rates of G. There simply is not enough time before G-induced loss of consciousness (GLOC).

Figure 2-4 illustrates the G-titration strategy with slow onset rates of G. It also illustrates such as the F/A-18 that are capable of high for the visual symptoms to provide warning

Figure 2-3. Physiology of G-induced loss of consciousness. (NOTE: There is considerable individual variation in G-level at onset of visual and cerebral symptoms.) Another profound difference between eye and brain response to +G z is the failure and recovery mode. The eye fails and recovers smoothly when blood flow stops. This can be easily demonstrated by digital pressure on the eye to stop the blood flow (Whinnery, 1979). After about 5 seconds of pressure, vision is progressively lost from peripheral vision to central vision. When blood flow is allowed to resume, vision is smoothly and rapidly recovered. Cerebral failure and recovery is much less graceful and predictable (Houghton, McBride, & Hannah, 1985). After about 5 seconds of blood flow stoppage to the brain, GLOC occurs suddenly and lasts from 10 to 30 seconds (average about 13 seconds). When consciousness is regained, it is usually accompanied by brief seizure-like activity and a period of confusion, which lasts about 12 seconds. During this 12 seconds, the aviator is unable to function effectively. An additional period of up to 2 minutes is required before cognitive and pyschomotor performance ability recovers to normal.

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U.S. Naval Flight Surgeon’s Manual

Figure 2-4. Pilots’ G-titration strategy.

Although amnesia for the event of GLOC is common (Whinnery & Shaffstall, 1979), 13 percent of naval aviators questioned in an anonymous survey admitted having GLOC in an aircraft, at least once in their career (Johanson, Flick & Terry, 1986). Total loss of the ability to control a high performance, unstable aircraft for half a minute is obviously a condition to be avoided. Respiratory Effects. There are two primary effects of +Gz on respiratory function. The most serious effect results from a perfusion/ventilation mismatch. As the +Gz increases, the pressure gradient in the lung increases, resulting in reduced perfusion of the upper part of the lung and increased perfusion in the lower part of the lung. This results in an increased physiological dead

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Acceleration and Vibration space in the upper portion and a physiological shunt in the lower portion of the lung, both of which result in a reduced PaO2. In healthy subjects exposed to +7 Gz for 45 seconds, the PaO2 decreased from 91.6 mm Hg. to 50.1 mm Hg despite an almost two-fold increase in tidal volume (Leverett & Whinnery, 1985, p 221). This reduced PaO2 is added to the insult of reduced blood flow to the head and would be expected to contribute to decrements in performance capability. A second problem is G-induced oxygen atelectasis, or aero-atelectasis. The U.S. Navy uses 100 percent oxygen in most tactical jet aircraft breathing systems to simplify the breathing system, to provide an underwater breathing capacity, and to maximize night vision. Aero-atelectasis, especially in the compressed alveoli of the dependent portion of the lung, occurs more readily when 100 percent O2 is used than when an inert gas dilutes the breathing gas, due to the more rapid absorption of O2 from poorly aerated alveoli. The aero-atelectasis sometimes causes mild transient chest pain and coughing after high +Gz maneuvering, but the symptoms are generally not thought to be severe enough to offset the advantages of the 100 percent O2 systems. This is a controversial subject. The USAF and the RAF have elected to use systems that dilute the oxygen in the breathing system with cabin air up to a present cabin altitude, while the Navy continues to consider that underwater breathing capability more than offsets the mild symptoms of aeroateletasis. Musculoskeletal Effects. At 6 +G z , a 160 pound aviator is pressed into his seat with an equivalent of 960 lbs. As +Gz levels increase, purposeful limb movements become progressively more difficult. Neck and back pain may occur and may be the limiting factor for G tolerance in some aviators. Musculoskeletal physical fitness is very important in limiting this performance decrement and discomfort, and enabling the aviator to accomplish the neck and body movement required to search for enemy aircraft. Weight training is currently being evaluated for its cardiovascular and its musculoskeletel effects on G tolerance and shows promise in both areas. Tolerance Limits. Tolerance to +Gz varies considerably from person to person, and in a given aviator, varies from day to day. A simplified theoretical case was discussed earlier with the assumption of an aortic valve to eye column height of 30 cm, and a mean blood pressure at the aortic valve level of 100 mm Hg. The point of loss of brain blood flow would theoretically occur at 4.5 G. in actual practice, determination of G tolerance requires defining the measurement method, which is affected by a complex array of compensatory mechanisms and individual differences. Any measurable, repeatable end point could be chosen; for example, mild peripheral vision loss, total vision loss, or loss of consciousness. An accepted measure of tolerance limits is loss of peripheral vision to a central cone of 60° as measured by the subject tracking his peripheral vision on a light bar (Air Standardization Coordinating Committee, 1986). This degree of vision loss occurs roughly 0.7 to 2.0 G lower than GLOC occurs.

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U.S. Naval Flight Surgeon’s Manual Figure 2-5 illustrates G tolerance measured by peripheral light loss (PLL) in an experiment using a moderately rapid (2- second rise time) onset rate with nonaviator subjects (Cohen, 1983). These G tolerance levels are for a specific group of experimental subjects and, therefore, will vary with the population being tested. Figure 2-5 also shows the increase that can be gamed by use of the anti-G suit (AGS), the M-l straining maneuver, and the pelvis and legs elevating seat (PALE), which is equivalent to a 75° seat back angle.

Figure 2-5. Mean tolerance and mean protection under eight experimental conditions. The mean relaxed tolerance of 3.23 G serves as the O-G baseline for acceleration protection. The “extra protection” is the amount of G tolerance beyond the additive effects of the protective measures (Cohen, 1983).

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Acceleration and Vibration A number of factors affect individual G tolerance. Some of them are: 1. Individual differences in the physiological responses. 2. Physical fitness. Although still under investigation, evidence suggests that weight lifting may increase G tolerance, and aerobic exercise, such as running, has no effect or decreases G tolerance. 3. Dehydration lowers G tolerance by reducing plasma volume. 4. Nutrition. Missing meals reduces G tolerance. 5. Recency of G exposure. G tolerance declines rapidly if frequent exposure to G doesn’t occur. 6. Most illnesses reduce G tolerance. Protective Measures for +Gz. 1. Anti-G suit (AGS). The Navy AGS contains inflatable bladders, which cause constriction around the calves, thighs and abdomen. The suit prevents pooling of blood in the lower extremities and abdomen, thus improving venous return to the heart, and elevates the diaphragm, thus slighting reducing the aortic valve to eye column height, reducing the distortion of the heart by G, and assisting in increasing the intrathoracic pressure. The suit is inflated by an aircraftmounted G valve, which senses G and inflates the G suit in proportion to the G force. Careful fitting of the G suit is critical to its function. A well-fitted G suit will increase G tolerance by about 1 G. 2. Straining Maneuvers. Straining maneuvers increase G tolerance by reducing blood pooling in the extremities and abdomen, and by increasing intrathoracic pressure rhythmically to assist the heart in maintaining head level blood pressure. The “M-1” maneuver consists of tightening the muscles of the extremities, abdomen, and chest; pulling the head down between the shoulders; and grunting against a partially closed glottis. This grunt is maintained for about 3 to 5 seconds, relaxed very briefly to allow inhalation and thoracic venous blood return, and then repeated. A properly performed M-1 increases G tolerance by about 2 G and is roughly additive to the G suit protection, together providing about 3 G additional protection. An improperly performed M-1 may actually reduce G tolerance, probably by reducing cardiac return. Training is critical for the performance of an optimum M-1. The maneuver should be carefully

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U.S. Naval Flight Surgeon’s Manual explained and should be practiced with supervision under +Gz conditions. (It is uncomfortable and perhaps dangerous to practice at 1 G because it markedly increases head level blood pressure.) Practice in an aircraft usually precludes adequate training feedback. A centrifuge provides the best environment for training of the maneuver. The “L-1” maneuver is identical to the M-1 maneuver except that the glottis is completely closed instead of partially closed. It is as effective as the M-1 and probably preferable because it causes less throat irritation. 3. Reclined Seat. Reclining the seat improves G tolerance by reducing the effective aortic valve/eye column height. Figure 2-6 illustrates the effect of various seat back angles (Burns, 1975). The improvement in G tolerance is roughly linear with reduction in effective column height (i.e., at 75° seat back angle, column height is reduced to one half and G tolerance is almost doubled). At high G in the reclined position, G tolerance becomes progressively limited by pain from contact with the seat, from chest compression, and from difficulty inhaling due to the increased weight of the anterior chest wall. These symptoms limit this technique to about 14-15 G maximum. Although reclined seats can dramatically improve G tolerance, they are seldom used because of difficulty providing full use of displays and controls while providing adequate outside vision. 4. Experimental Protective Techniques. Several methods for increasing +G z tolerance are under investigation. These methods include: a. Positive pressure breathing with a chest counterpressure garment. This technique provides a mechanical assist for increasing intrathoracic pressure, and it may be more effective and less tiring than performing a standard straining maneuver. b. Pulsating G suits, synchronized to the electrocardiogram. This technique would provide a pulse superimposed on the systolic pulse, producing a higher systolic pressure at head level. c. Positive pressure breathing with reclined seat. This technique may alleviate inhalation difficulty caused by the increased weight of the anterior chest wall, and thus overcome one disadvantage of the reclined position. d. Optimization of physical fitness training procedures. This may allow a more forceful straining maneuver with less fatigue. e. Drugs to increase head level blood pressure on a short- term basis.

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Acceleration and Vibration

Figure 2-6.

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U.S. Naval Flight Surgeon’s Manual “Eyeballs Up” (–Gz) Acceleration Cardiovascular Effects. In –Gz arterial and venous pressure cranial to the heart are increased. It should be remembered that -1 Gz differs by 2 G from the normally experienced G. The increased pressure in the aortic arch and carotid arteries results in a pronounced bradycardia. Increased venous pressure may result in facial edema, petechiae, sinus pain, and headache. A commonly reported “‘red out” or visual red veil is probably due to the lower lid being forced over the pupil or perhaps to blood staining of the lacrimal fluid from ruptured conjunctival vessels. A rapid transition from –G z to +G z would obviously exacerbate the problem of the delayed physiological compensatory mechanisms and may increase the risk of GLOC. Neurological Effects. Sensory disturbances and severe headache have been reported, as well as confusion and loss of consciousness. These responses are subject to considerable individual variation. Musculoskeletel Effects. The main musculoskeletel effects are impairment of the aviator’s ability to operate controls. For example, in an inverted spin, an inadequately restrained aviator may not be able to manipulate the controls well enough to recover from the spin or to reach the ejection firing control. Tolerance Limits. Discomfort is the primary limiting factor in voluntary exposure to –Gz. Research on the limits has been sketchy due to volunteer subject discomfort and researchers’ fears of untoward side effects. An estimate of reasonable limits is -4.5 Gz for 15 seconds and -3 Gz for 30 seconds (Christy, 1971). Respiratory Effects. Serious respiratory effects have not been reported at the otherwise tolerable levels of –Gz. Protective Measures. The only protective measure currently available is to maintain restraints tight enough to allow operation of both normal and emergency controls. “Eyeballs In” (+Gx) Acceleration “Eyeballs in” acceleration is experienced during forward acceleration, such as catapult shots, with minimal effects other than decreased musculoskeletel control and increased risk of disorientation. The cardiovascular and respiratory effects are simply extensions of those discussed under +Gz in the special case of a 90° seat back angle.

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Acceleration and Vibration “Eyeballs Out” (–Gx) Acceleration This is a condition seldom experienced by a naval aviator except from impact or for brief periods during a carrier landing or a ditching. It may occur in abnormal conditions such as a flat spin. For example, a flat spin in an F-14 may exert as much as -6 Gz The primary problem in this instance is musculoskeletal (e.g., difficulty in operating the aircraft controls). A special problem occurs when the pilot’s shoulder harness is not locked, and the onset of –Gx is not rapid enough to automatically lock the harness. In this case, the pilot is pressed against the instrument panel and is unable to effectively manipulate the controls. Cardiovascular and respiratory effects are similar to +Gx effects. One special problem encountered in experimental prone position flying is that lacrimal fluid is not cleared normally from the eye under high –Gx and may cause blurred vision. “Eyeballs Left/Right” (Gy) Acceleration Significant Gy is seldom encountered in normal flying, but it may be encountered in future highly maneuverable aircraft. The primary problem in Gy is musculoskeletal, which is increased by the difficulty of restraining the aviator adequately in current seat and restraint designs. Impact Acceleration Impact, an acceleration with a pulse duration of about 1 second or less, may be encountered in normal as well as emergency phases of naval aviation. The flight surgeon investigating an accident will often find it necessary to determine the potential survivability of a particular crash situation. Such determinations are predicated on a knowledge of actual human tolerance to impact. Much impact research has been conducted with regard to automotive and aviation crashes, but many questions remain unanswered. No hard and fast tolerance limits to human impact acceleration have been established, and even estimates must be made while carefully considering a number of factors. Before discussing the human tolerance limits for impact, some discussion of the complexity of the problem is necessary so that the ambiguity in setting tolerance limits will be understood. Human tolerance to impact acceleration is a function of the energy transferred to the body by the impact, or the work done by the impact. This can be calculated by one of the following equations: E = 1/2 MV2 where E = energy M = mass V = velocity (The velocity change during the impact)

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U.S. Naval Flight Surgeon’s Manual or W = Fd where W = work F = force = mass * acceleration d = distance over which the force acts. The units for both E and W are kg M2/s2 or Newton-meters and so are equivalent. Peak acceleration alone does not account for the injury potential of an impact, although maximum G is often used to estimate the injury potential of an impact. Both the maximum G and the time over which the G acts are important factors in determining the injury potential. Onset rate of G is also important because body parts have characteristic resonance frequencies, and if the onset rate provides a frequency input in the range of these resonance frequencies, an amplified response of the body part may occur. The complexity of most impact acceleration waveforms is an additional complication. Figure 2-7 is a typical impact G versus time wave form. To say that a certain G lasted a certain number of seconds is an oversimplified approach to the problem.

Figure 2-7. A typical impact waveform. The following are necessary to adequately describe the injury causing potential of an impact: 1. The acceleration pulse shape. 2. The acceleration direction 3. The acceleration duration from which a velocity change can be computed.

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Acceleration and Vibration 4. 5. 6. 7. 8.

The The The The The

acceleration magnitude. type of seat and restraint system. physical characteristics of the aircrewman. secondary impact of body parts with the airframe or other objects. distribution of the force over body parts.

With this knowledge, one of several existing mathematical models for predicting injury probability can be used, or the wave form can be simplified to a trapezoidal form and compared against available tables of injury probability. These approaches are still inaccurate for the following reasons: 1. Humans may not normally be taken to impact injury limits experimentally, and there is a wide, uncharted gap between voluntary impact limits and the accelerations that cause injuries in accidents. 2. The accelerations involved in uninstrumented accidents are difficult to characterize. 3. Experiments using human subjects, or substitutes such as animals or cadavers, vary widely in restraints, instrumentation, and parameters reported. These experiments are, therefore, difficult to compare. 4. Animals vary enormously in impact tolerance due to size, anatomical and physiological differences. Extrapolation of animal injury findings to human tolerance must be done very cautiously. 5. Experimentally produced injury criteria are valid only when applied to situations meeting the conditions of the experiments. Changes in body support, restraint systems, or type of subject can change tolerances significantly. The purpose of this cautious prologue is to emphasize the importance of recognizing single number listings of acceleration impact tolerance limits for what they are--very rough estimates. Because the existing injury data base is inadequate, every flight surgeon investigating a mishap has an obligation to carefully document injury patterns and severity, to attempt to correlate the injuries with calculated acceleration forces, and to evaluate the function of protective equipment. Mishaps resulting in injuries, loss of life, or loss of aircraft may provide extremely valuable contributions to our understanding of injury causation and prevention, and it is unconscionable to waste these valuable data through careless or incomplete investigation.

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U.S. Naval Flight Surgeon’s Manual A data base commonly used to establish whole body impact acceleration tolerance is a set of curves compiled by Eiband in 1959, from a literature review of voluntary, accident, and animal studies. Combined with later studies, this has provided a basis for estimation of tolerance limits. Some “Eiband Curves” are reproduced in Tables 2-2 through 2-5. Note that injury probability is affected by the duration of the acceleration as well as its intensity.

+Gx

Table 2-2 Acceleration Tolerance Limits

Voluntary instrumented impact exposures have provided some insight into various tolerance limits. Again, G alone is not an adequate description of the impact energy unless time and onset rate of G are included. An experimental subject survived a 45 –Gx acceleration with a 493 G/s onset rate and a velocity change of 56 m/s with minor reversible injury (Stapp, 1951). A well-supported subject survived 40.4 +Gx with an onset rate of 2139 G/s and a velocity change of 14.8 m/s with transient shock and syncope (Beeding & Mosley, 1960). In the ± Z and the ± Y axes, volunteer subjects have been exposed to impacts in the range of 15-20 G with velocity changes in the range of 8-12 m/s with no injury. Occasional bradycardia and syncope at these levels are unexplained, but possible mechanisms are CNS/brainstem stress, or stimulation of the carotid or aortic pressure sensors.

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Acceleration and Vibration Table 2-3 –G x Acceleration Tolerance Limits

+Gz

Table 2-4 Acceleration Tolerance Limits

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U.S. Naval Flight Surgeon’s Manual Table 2-5 –G z Acceleration Tolerance Limits

It is important to recognize that the above levels of impact were sustained by well-supported and well-restrained subjects. Restraint systems in aircraft are limited by weight and space requirements, and the need for aircrew mobility. Actual tolerance limits in the aircraft will probably be lower. Table 2-6 (from Lewis, 1974) contains estimates of tolerance limits that may be applicable in operational aircraft.

Table 2-6 Human Whole-Body Impact Tolerance Limits Based on 250 G/sec Onset Rate

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Acceleration and Vibration In stating tolerance limits, “tolerance” should be defined (e.g., no injury, minor injury, or simply survival). Mathematical models are being developed, which include some of the complexities of calculation of injury potential. Examples are the Dynamic Response Index (DRI), which is an attempt to estimate risk of spinal injury from ejection seats, and the Head Injury Criteria (HIC), which is an attempt to estimate the risk of head injury from a given head impact. These and other mathematical models, although not foolproof, enable an estimation of injury potential if the acceleration profile and other pertinent information are available. None of these models has gained universal acceptance. Impact Protection In general, a spreading out of a given amount of energy over a longer time span and over a larger body surface area will reduce the likelihood of injury. Obviously, a deceleration from 60 knots to a stop in 1 second is more likely to cause injury than the same deceleration in 10 seconds. Thus, the length of the fuselage structure (between the impact point and aircrew) and its crush characteristics are critical in reducing injury. For the same reason, crashworthy seats have been developed in which collapse or crushing of the seat supports is used in a controlled manner to spread the energy of impact over a longer time span, Reducing relative motion and stress between body parts by improvements in restraints will also reduce the risk of injury. The impact injury potential of an aircraft occupant may be amplified in several ways. For instance, if the occupant is poorly restrained, a body part, such as the head, may continue in its initial direction and speed until it impacts an aircraft structure. The head will thus absorb the total energy of the deceleration over a much shorter time than if the head had been well restrained. In another example, if an ejection occurs with a soft cushion on the ejection seat, the seat occupant remains essentially motionless while the seat accelerates upward, and the cushion compresses. After complete cushion compression, the occupant is accelerated over a shorter time period than if he had been closely coupled to the seat at the onset of the acceleration. A number of protective measures are designed to reduce impact amplification, for example, by restraining the occupant as tightly as possible and by limiting the thickness of cushioning materials in ejection seats. The more firmly the occupant is coupled to the seat, the more impact protection is provided, but there is a tradeoff between restraint effectiveness and weight, space, comfort, and mobility requirements of the aircrew. In Stapp’s (1951) record –G x impact experiment, he had almost twice the area of restraint webbing as most military aircraft restraints. The seats must be fixed to the aircraft structure so as not be break loose at otherwise survivable impact forces, or the seat occupant may experience an amplified impact as discussed above.

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U.S. Naval Flight Surgeon’s Manual Equipment and objects must be firmly attached to the aircraft structure so as to avoid becoming missiles in an otherwise survivable crash. (This is the rationale for 40-G coffee pot attachments in aircraft limited to 3 G in normal operation). The aircraft. structure should be strong enough to prevent intrusion into the crew space. All other protective mechanisms are useless if the aircrew station cannot be occupied because of crushing of the aircraft structure into the space. To restrain the head and neck and still allow full mobility is a difficult problem. Consequently, head and neck injuries are the most common serious injuries in aircraft impacts. This problem is sometimes exacerbated by the protective helmet, which increases the mass and changes the center of gravity of the head/neck/helmet combination, thereby increasing the force exerted on the neck in some impacts. The flight helmet is designed to attenuate impact to the head by both increasing the time span for absorption of the energy, and by spreading the energy over a wider surface area. The attenuation material used in the helmet will provide maximum protection, if it is nonelastic (crushable) to prevent a “bounce”, and just dense enough to completely crush at a force level that would be expected to cause severe injury. That is, if the attenuation material transmits enough energy to cause severe head injury before it completely crushes, it is too dense to spread the impact energy over the maximum available time span. Physiological and Pathological Effects of Impact Head injuries are the most common causes of crash fatalities. Frontal impacts tend to be less severe clinically that temporal or occipital impacts since basilar skull fractures and consequent involvement of the adjacent intracranial structures are generally far more serious than frontal impact trauma (von Gierke & Brinkley, 1975). Estimates of acceleration and time necessary to produce concussion injury have been developed by Wayne State University (1980), primarily from cadaver studies (see Figure 2-8). Spinal impact associated with ejection may result in vertebral compression fractures. The most common fracture sites are T-12 and L-1, although other sites may be involved due to poor body position (Rotondo, 1975). The erect or hyperextended posture is ideal for ejections, but during normal operations, pilots are usually in a flexed position. Although –Gz impact has not been well studied, intracranial hemorrhage is speculated to be the limiting factor. This has not been well supported, however, by animal studies. In a well-supported and restrained individual, +Gx impact causes various degrees of shock,

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Acceleration and Vibration which is the main limiting factor. Bradycardia due to vagal activity has been observed. Some evidence of respiratory damage has also been found (von Gierke & Brinkley, 1975). Contrary to the general rule for impact, –G x or eyeballs-out impact may lead to increased hydrostatic pressure in the central retinal artery, causing conjunctivitis and retinal symptoms, such as scotomata (Lewis, 1974; von Gierke & Brinkley, 1975). Where a lap belt provides the only restraint, –G x impact can lead to a ruptured bladder. Lateral impact (+Gy), though not well studied, can lead to cardiovascular shock.

Figure 2-8. Impact tolerance for the human brain in forehead impacts against plane, unyielding surfaces (SAE, 1980).

Ballo and McMeekin (1976) provide further details of the pathological effects of impact. Understanding these effects on various body parts may be valuable in estimating the forces in a crash and in evaluating the effectiveness of restraints and life support equipment. Vibration Vibration has commonly been considered more of an engineering problem than a medical one. It is, however, a commonplace problem in the world of naval aviation and one with far-reaching implications for the aviator’s personal comfort, health and performance. Thus, it is imperative that the operational flight surgeon have a working knowledge of vibration and its effects on man.

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U.S. Naval Flight Surgeon’s Manual Definitions and Terminology In everyday terms, vibration means shaking. In physical terms, it is a series of velocity reversals, implying both displacement and acceleration/decleration. It is described in terms of its frequency, amplitude, anatomical direction with regard to the body, and duration. Frequency is usually expressed in terms of cycles per second, or hertz (Hz). Amplitude, the extent of oscillation, is measured in meters or smaller metric units. The intensity, an extension of the amplitude, is described in terms of its acceleration component, expressed in G. Complex vibrations are often described in terms of the root-mean-square (RMS) intensity, a time-averaged value. The output of many electronic instruments for vibration measurement is proportional to the RMS. For more information see von Gierke, Nixon, and Guignard, 1975. There are four different types of vibration. Sinusoidal or simple harmonic vibration is composed of a single frequency. When two or more sinusoidal vibrations are added together, a compound harmonic vibration results. When the vibration is totally irregular and unpredictable, it is termed a random vibration. Finally, harmonic vibrations can be added to random ones; Graphic examples of these vibrations are pictured in Figure 2-9.

Fiie 2-9. Diagram of waveforms and idealized power spectra of typical varieties of vibration (vonGierke, Nixon, & Guignard, 1975).

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Acceleration and Vibration Resonance Any vibrating system has one or more characteristic frequencies at which forced vibration will elicit maximum or amplification response. The system is said to resonate at that frequency. The amount of amplification at resonance is inversely related to the amount of damping, the process opposing vibration, within the system. The human body can be thought of as a complex vibrating system with a number of subsystems displaying different resonance characteristics. Such a system is illustrated in Figure 2-10.

Figure 2-10. Mechanical model (diagrammatic) of seated and standing man (vonGierke, Nixon, & Guignard, 1975).

Sources of Vibration in Naval Aviation The sources of vibration in naval aviation are myriad. Listed below are some of the principal sources, after von Gierke and Clarke (1971).

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U.S. Naval Flight Surgeon’s Manual Ejection. Once free of the rails, an ejection seat system seeks a stable configuration in the airstream. This normally sets up an oscillation around the center of the seat-man system in the range of 3 to 10 Hz and at a magnitude of 10° to 30°. These vibrations normally damp out rather quickly, but the relatively large oscillations impose considerable threat of flail injury, especially when combined with high aircraft speeds. Low Altitude, High-Speed Flight. Many current military missions include low altitude, high speed flight in an attempt to avoid radar detection. Gust effects in such flights can introduce complicated vibrations in five degrees of freedom, ranging from about 1 to 10 Hz. This can present clinical problems in the areas of vision, speech, respiratory effort, and musculoskeletal stress similar to a high-speed Jeep ride over an open field. Terrain Following. In order to fly in the low-level, high-speed profile, many modern aircraft have systems that allow flight close to the contour of the terrain. Such systems, whether manual or automatic, can induce vibration spectra between 0.01 Hz and 0.1 Hz. This is in addition to the gust response and can add the clinical problem of motion sickness. Storm and Clear Air Turbulence. Storms and clear air turbulence impart vibration spectra that are similar to low altitude, high- speed flight. These vibrations are generally in the very low frequency range, but clear air turbulence can occasionally be of such high frequency and intensity as to preclude control of an aircraft. Helicopter Vibrations. Vibrations are perhaps of greater importance in helicopters than in any other type of naval aircraft. These vibrations arise from mechanical and atmospheric sources, although the atmospheric conditions are not as important as in fixed wing aircraft due to the lower airspeeds. Vibrations in the 3 to 12 Hz range are induced by the main rotor blades, the actual frequency being related to the number of blades. Tail rotors produce higher frequency vibrations, in the range of 20 to 25 Hz. Vibrations produced by the transmission are less well defined. These generally low amplitude vibrations have clinical significance by virtue of the prolonged exposures involved, where physical fatigue results from continuous bracing. Ill-defined musculoskeletel complaints, such as neck and back pain, appear with increased frequency in the rotary wing community. V/STOL Aircraft. V/STOL (Vertical/Short Takeoff and Landing) aircraft in low hover appear to exhibit low frequency range vibrations similar to those found with helicopters. Their significance, however, seems to lie more in their effect on the pilot’s response time than in any purely clinical effect.

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Acceleration and Vibration Effects of Vibration on the Body A number of factors modify the effects of vibration on humans, including tissue resonance, duration of exposure, individual variations, and other simultaneous environmental stresses. For example, acceleration increases the body’s rigidity, reducing its shock-absorbing properties and increasing the transmission of vibration energy to the internal organs (Antipov, Davydov, Verigo & Svirezhev, 1975). The effects of vibration on the body are determined by the frequency ranges involved. Effects at less than 2 Hz. Vibrations in the frequency range of 0.1 to 0.7 Hz most often produce motion sickness in humans. Vibrations of 1 to 2 Hz are generally associated with increases in pulmonary ventilation, heart rate, and sweat production above that level considered normal for any other stress present. Effects from 2 to 12 Hz. Tolerance in this frequency range is usually limited by substernal or subcostal chest pain, with thresholds at approximately 1 to 2 Gz and 2 to 3 Gx. The etiology of the pain is the same for both axes of vibration: displacement of the abdominal and thoracic viscera induces stretching of the chest wall, with torsion at the costochondral junctions of the ribs. Dyspnea is the second most common symptom in this range, apparently with the same etiology as chest pain. Centrally induced hyperventilation can be produced by vibrations around two axes at acceleration amplitudes above 0.5 G in the range of 1 to 10 Hz. Cardiovascular effects are maximized in Gz ± gz (i.e., a Gz-acceleration environment with interposing & gz vibration) at 3 to 6 Hz and in Gx ± gx at 6 to 10 Hz. The changes seen are increases in heart rate, arterial blood pressure, central venous pressure, and cardiac output; these are accompanied by a corresponding decrease in peripheral resistance. These changes all resemble nonspecific exercise responses. Abdominal discomfort and testicular pain are common complaints due to stretching of viscera and force applied to the spermatic cord, respectively. The headache commonly associated with this frequency range has several explanations. In a Gz ± gz environment, the mechanical forces are not well attenuated by the skeletal system. In a Gz ± gz environment, the head is forced out of phase with the headrest and repeatedly impacts against it. In Gz ± gy environments, the problem is the same only more so; strain, spasm, and soreness of the neck are added to the symptoms. Finally, bloody stools, transient albuminuria, and transient hematuria are occasionally seen in

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U.S. Naval Flight Surgeon’s Manual helicopter pilots flying heavy schedules. Such symptoms are attributed to vibration, and they usually disappear after a few days rest. Effects above 12 Hz. In these frequencies, there is more concern about effects on performance (vision, speech, fatigue) than about injuries. Effects of Vibration on Performance. Vibration can greatly affect performance by inducing visual decrements. Frequencies below 2 Hz have little effect, but between 2 and 12 Hz, relatively large displacements of the body with respect to a given point on the instrument panel contribute to increasing visual impairment. The frequency ranges of 25 to 40 Hz and 60 to 90 Hz, however, lead to the greatest visual impairment due to the resonance of the head and eyeballs respectively (von Gierke & Clark, 1971). Performance can also be modified by vibratory effects on speech. Pitch is increased due to generalized muscle tension during exposure. Single-word intelligibility is decreased as a direct function of vibration magnitude and frequency. Speech is least understandable with Gz ± gz in the same low frequencies that induce resonance of the thoraco-abdominal viscera. These problems underscore the importance of standard phraseology in naval aviation; this is, if a word is expected or in a familiar context, it is much more likely to be understood, even if speech is degraded, than if random phraseology is used. Very low frequency, high-amplitude vibrations often cause pilots to postpone flight corrections until after the short surge of vibration is past. This could be an important contributor to pilotinduced aircraft oscillations. Vibrations in the 2 to 12 Hz range cause involuntary movement of the extremities, which, while not forcing control errors, may hinder fine knob adjustment and writing. Pathological Effects of Vibration Animal experiments indicate that acute human injury from exposure to high levels of whole body vibration should resemble impact injuries from accelerations of comparable magnitude and direction. Chronic occupational exposure to vibrational stress has been implicated in a number of disease processes, including Raynaud’s phenomena, neuritis, decalcification and cysts of the carpi and long bones of the forearm, cutaneous scleroderma, osteoarthritis, Dupuytren’s contracture, bursitis, tenosynovitis, amyotropic lateral sclerosis, carpal tunnel syndrome, Keinbock’s disease, and periodontal disease (Haskell, 1975; Strandness, 1974; Wasserman, 1976; Williams, 1975). In most of these cases, the role of vibration has not been firmly established, and much work remains to be done in the area.

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Acceleration and Vibration Vibration Exposure Standards The International Organization for Standardization (ISO) has formed recommendations for whole body vibration exposure standards. A number of countries, including the United States, are currently in the process of adopting these or similar standards. The ISO recommendations (ISO, 1985) are summarized in Figures 2-11 through 2-14. These standards are necessarily subject to change. They are certain to come under much scrutiny, and refinement is inevitable.

Figure 2-11. Longitudinal (a,) acceleration limits as a function of frequency and exposure time; “fatigue-decreased proficiency boundary” (ISO, 1985).

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U.S. Naval Flight Surgeon’s Manual

Figure 2-12. Longitudinal (ax) acceleration limits as a function of exposure time and frequency (centre frequency of one-third octave band); “fatigue-decreased proficiency boundary” (ISO, 1985).

Protection Against Vibration Protective measures against vibration fall into three general categories: control at the source, control of transmission, and attempts to minimize human effects. Control at the source is primarily a problem of engineering, and it will not be discussed further in this chapter. Control of transmission can be attempted in several ways. The use of high-damping materials in new construction and damping treatments of existing equipment can reduce structural resonance, which in turn, reduces transmission. Isolating the individual from the vehicle by means of resilient seat cushions and the like is another method of reducing transmission. The usefulness of this tech-

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Acceleration and Vibration nique is necessarily limited when dealing with ejection seats. The “dynamic overshoot” of a cushion during ejection could cause an unacceptable increase in the +Gz impact acceleration experienced by the aviator.

Figure 2-13. Transverse axay) acceleration limits as a function of frequency and exposure time; “fatigue-decreased proficiency boundary” (ISO, 1985).

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U.S. Naval Flight Surgeon’s Manual

Figure 2-14. Transverse (axay) acceleration as a function of exposure time and frequency (or centre frequency of one-third octave band); “fatigue-decreased proficiency boundary” (ISO, 1985).

The adverse effects of vibration that reach the body can, in some cases, be substantially reduced. Posture can have a great effect. For example, one study of vibration transmission through the trunk to the head showed variations as great as six to one, contingent only on changes in posture (Griffin, 1975). Proper design of displays and flight controls can lead to a cockpit environment that is both more tolerable and more functional during vibration stress. With physical fitness, training, and experience, a considerable amount of adaptation may take place in the aviator. In addition, motion sickness induced by vibration often responds to the standard pharmacological remedies.

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Acceleration and Vibration References Air Standardization Coordinating Committee. Advisory publication 61/103F, methods for assessing visual end points for acceleration tolerance, 1986. Antipov, V. V., Davydov, B. I., Verigo,.V.V., & Svirezhev, Yu. M. Combined effect of flight factors. In Calvin, M. & Gazenko (Eds.), Foundations of space biology and medicine, Vol. II, Book 1. Ecological and physiological bases of space biology and medicine. Washington, DC: National Aeronautics and Space Administration, 1975, pp. 639-667. Ballo, J. M., & McMeekin, R. R. Accident reconstruction from analysis of injuries. Advisory Group for Aerospace Research Development CP-190, 1976. Beeding, E. L., Jr., & Mosley, J. D. Human tolerance to ultra high G forces. Holloman Air Force Base, NM: Air Force Development Center AFMDC-TN-60-2, Aeromedical Field Laboratory, Air Force Missile Development Center, Holloman Air Force, 1960. Burns, J. W., Re-evaluation of a tilt back seat as a means of increasing acceleration tolerance. Aviation, Space, and Environmental Medicine, 1975, 46, pp. 55-63. Christy, R. L. Effects of radial, angular, and transverse acceleration. In Randel, H.W. (Ed.), Aerospace Medicine (2nd ed.). Baltimore, MD: Williams and Wilkins, 1971, p. 187. Cohen, M. M. Combining techniques to enhance protection against high sustained accelerative forces. Aviation, Space, and Environmental Medicine, 1983 54, 338-342. Eiband, A. M. Human tolerance to rapidly applied acceleration: A summary of the literature. National Aeronautics and Space Administration Memorandum 1- 19-59E, June 1959. Evaluation of human exposure is whole-body vibration, Part I. General Reents (1st ed.). International Standards Organization, ISO 2631/1-1985 (E). Gell, C. F. Table of Equivalents for Acceleration Terminology.

Aerospace Medicine, 1961, 32, 1109.

Griffin, M. J. Vertical Vibration of Seated Subjects: Effects of Posture, Vibration Level, and Frequency. Aviation, Space, and Environmental Medicine, 1975, Vol. 46, 269-276. Guyton, A. C. Textbook of medical physiology (6th ed.). Philadelphia, PA: W. B. Saunders Company, Philadelphia, PA, 1981, p. 248. Haskell, B. S. Association of aircraft noise stress to periodontal disease in aircrew members. Aviation, Space, and Environmental Medicine, 1975, 46, 1041-1043. Houghton, J. O., McBride, D. K., & Hannah, K. Performance and physiological effects of accelerationinduced (+G z ) loss of consciousness. Aviation, Space, and Environmental Medicine, 1985, 56, 956-965. Human tolerance to impact conditions as related to motor vehicle design. Society of Automotive Engineers Information Report SAEJ885, April 1980. Johanson, D. C., Flick, V. P., & Terry, D. M. An in-depth look at the incidence of in-flight loss of consciousness within the U.S. Naval Service: A final report (Naval Weapons Center Report NWC TT-6737). China Lake, CA: Naval Weapons Center, June 1986, 44 pp. Leverett, S. D., Jr., & Whinnery, J. E. Biodynamics: Sustained acceleration, In DeHart, R.L. (Ed.), Fundamentals of aerospace medicine, Philadelphia, PA: Lea and Febiger, 1985. Lewis, S. Human tolerance to abrupt deceleration. Unpublished notes from the Crash Survival Investigator’s School, Arizona State University, Tempe, AZ, 1974. Rotondo, G. Spinal injury after ejection in jet pilots: Mechanisms, diagnosis, followup, and prevention.

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U.S. Naval Flight Surgeon’s Manual Aviation, Space, and Environmental Medicine, 1975, 46, 842-848. Stapp, J.P. Human exposures to linear deceleration, Part 2. The forward facing position and the development of a crash harness (Air Force Technical Report 5915). Wright Patterson Air Force Base, OH: Aeromedical Laboratory, Wright Air Development Center, 1951. Strandness, D. E., Jr. Pain in the extremities. In Wintrob, M.W. (Ed.), Harrison’s principles of internal medicine (7th ed.). New York, NY: McGraw-Hill, 1974, pp. 44-48. Von Gierke, H. E., & Brinkley, J. W. Impact accelerations. In Calvin, M. & Gazenko O. G. (Eds.), Foundations of space biology and medicine, Vol II, Book, I, Ecological and Physiological bases of space biology and medicine. Washington, DC: National Aeronautics and Space Administration, 1975, pp. 214-246. Von Gierke, H. E., & Clarke, N. P. Effects of vibration and buffeting on man. In Randel, H. W. (Ed.), Aerospace medicine (2nd ed.). Baltimore, MD: Williams and Wilkings, 1971, pp. 198-223. Von Gierke, H. E., Nixon, C.W., & Guignard, J.C. Noise and vibration. In Calvin, M. and Gazenko, O.G. (Eds.), Foundations of space biology and medicine. Vol. II. Book I. Ecological and Physiological Bases of Space Biology and Medicine. Washington DC: National Aeronautics and Space Administration, 1975, pp. 355-405. Whinnery, J. E. Laughlin, M.H., & Uhl, G.S. Coincident loss of consciousness and ventricular tachycardia during +Gz stress. Aviation, Space and Environmental Medicine, 1980, 51, 827-831. Whinnery, J. E. & Shaffstall. R. M. Incapacitation time for +Gz induced loss of consciousness. Aviation, Space, and Environmental Medicine, 1979, 50, 83-85. Whinnery, J. E. Technique for simulating G induced tunnel vision. Aviation, Space and Environmental Medicine, 1979, 50, 1076. Williams, N. Biological effectsof segmental vibration. Journal of Occupational Medicine, 1975, 17, 37-39. Wasserman, D. Bumps, grinds take toll on bones, muscles, mind. Occupational Health and Safety, 1976, 45, 19-21.

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CHAPTER 3 VESTIBULAR FUNCTION Introduction Structure and Function of the Vestibular System Spatial Disorientation Visual-Vestibular Interactions Relevant to Aviator Vision Vestibular Contributions to Disorientation Disorientation Not Attributable to Strong Vestibular Stimuli Primacy of Vision Prevention of Disorientation Evaluation and Management of Disorientation Problems References Introduction Vestibular problems sometimes encountered by flight personnel in aviation and aerospace missions are very similar to symptoms reported by patients with vestibular disorders of sudden onset. Disorientation (vertigo, dizziness, tumbling sensations), nausea, and vomiting, episodes of blurred and unstable vision, and impaired motor control (disequilibrium) are effects which can occur singly and in various combinations as a result of either exceptional environmental stimuli or episodic vestibular disorders or both. In the aviation environment, the symptoms may be normal reactions to misleading or inadequate sensory stimuli, but they may be coupled with requirements for controlling a high performance aircraft in three-dimensional space. In pathological states, the symptoms result from disordered transduction of central processing of head accelerations, and this is likely to be coupled with requirements for control of head and body motion. In either case, the origin of the aberrant reactions lies in inadequate or misleading information about the state of motion or orientation of the body relative to Earth, and ultimately this constitutes a threat to survival. It is natural, then, that unexpected occurrences of such reactions can be very disturbing. The parallel between pathological states and exceptional environmental conditions can be taken farther. When unnatural motion conditions are frequently experienced, a state of adaptation is frequently achieved in which the disturbance and disequilibrium initially elicited, gradually abate; perceptional aberrations disappear, and control of motion approaches a desirable state of automaticity. A similar process occurs in disease states. Disordered sensory inputs are compensated by central adaptive processes. As a matter of fact, the adaptive process sometimes keeps

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U.S. Naval Flight Surgeon’s Manual pace with a very gradual loss of function, such that no symptoms are experienced. Attention to this parallel is of probable practical importance to both the civilian practitioner and the specialist in aviation medicine. An understanding of the perceptual aberrations and reflexive actions generated by unusual motion stimuli and the process of adaptation to those stimuli may increase our understanding of the symptomatology generated by various disease states, and of course, the converse is also true. Structure and Function of the Vestibular System The vestibular system, almost like sensors in an inertial guidance system, detects static tilt of the head relative to the Earth, change in orientation of the head relative to the Earth, and linear and angular accelerations of the head relative to the Earth. These sensory messages are set off early in life by passive, involuntary movement, and they probably play an important role in development (Guedry & Correia, 1978; Ornitz, 1970). Not long thereafter, however, vestibular messages are frequently elicited by active, voluntary movement, and then they play a role in development of skill in the control of whole-body movement. In ambulatory man, the head is the uppermost motion platform of the body, and to be functional, vestibular messages must be integrated with proprioceptive and visual inputs. Vestibular messages coordinate with these other sensory systems in setting off reactions that reflexively adjust the head, eyes, and body for automatic control of motion. In this chapter, it is assumed that the reader is familiar with the basic anatomy and structure of the vestibular system. However, as a reminder, some basic information about this system will be presented along with a nomenclature convenient for describing stimuli to the vestibular structure. Figure 3-1 illustrates anatomical features of the semicircular canals and of the utricle and saccule. The major planes of the semicircular canal ducts relative to the cardinal head axes are shown in the insets. A gelatinous cupula protrudes into the ampulla of each semicircular duct and serves as a sensory detector of angular accelerations in its plane. Gelatinous pads, one in the utricle and one in the saccule, have calcite crystals imbedded in their surfaces and are sensory detectors of linear accelerations of the head. Note the acute angle of the small ducts connecting utricle and saccule. With saccular destruction, the small duct to the utricle may close, possibly preserving the functional integrity of the utricle and semicircular canals. This possibility is speculative, but it may account for early experimental results indicating lesser equilibration disturbance after saccular as compared with utricular ablation. Utricular ablation would destroy the integrity of both the semicircular canals and utricle.

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Vestibular Function Stimuli to the Vestibular System The vestibular apparatus consists of two distinctive kinds of sense organs: (1) the cupulae in the ampullae of the semicircular canals respond to angular accelerations that occur as head turns start and stop; (2) the otolithic sense organs in the utricle and saccule respond to linear accelerations of the head or to tilting of the head relative to gravity.

Each semicircular canal is stimulated by angular acceleration o in its plane. If there is an angle 8, between the plane of the canal and the plane of the angular acceleration of the head, then the effective stimulus to the canal, Qc, is given by a, = Q coa . This means that if the horizontal canals lie in the plane of a, stimulation of the two vertical canals would be zero since cos 90° = 0. Angular acceleration is independent of the distance from the center of rotation, and the semicircular canals are not responsive to linear accelerations, probably due to the close similarity in specific gravity of the cupula and the endolymph. Recently it has been suggested that substantial contact between the cupula and the interior membranous ampullary wall, all around the periphery of the cupula, would limit deflection of the cupula to its central portion, like the movement of a drum. If correct, this could further reduce responsiveness to this system to linear acceleration. Therefore, a person seated with head erect at the center of rotation of a vehicle undergoing angular acceleration would receive the same stimulus to the semicircular canals as another person seated with head erect five meters, or farther from the center of rotation. The latter would, of course, be exposed to much greater centripetal and tangential linear acceleration, and hence a different otolith stimulus than the former, but the stimulus to the semicircular canals would be theoretically identical. Analysis of the inertial forces and torques which displace the utricular and ampullar sense organs involves a branch of physics referred to as kinetics, but these forces and torques are proportional to linear and angular accelerations of the head. Therefore, the commonly used kinematic descriptions of linear and angular accelerations of the head are sufficient for specifying vestibular stimuli. Linear acceleration is the rate of change of linear velocity, and it can be expressed in cm/sec.2, m/sec. 2 , ft./sec. 2 , or G-units. Acceleration is expressed in G-units when it is given in multiples of 32.2 ft./sec.2 (i.e., in multiples of the acceleration that Earth’s gravity imparts to a freely falling body). When linear acceleration is represented as a vector, the arrowhead points in the direction of acceleration and its length represents its magnitude, but in order to be physiologically meaningful, it must be “man-referenced.” A convenient nomenclature for this purpose is presented in Figure 3-2.

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U.S. Naval Flight Surgeon’s Manual

Figure 3-1. Gross morphology of the membranous labyrinth and cochlea (adapted from Correia & Guedry, 1978).

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Vestibular Function

Figure 3-2. Polarity conventions, planes, and cardinal axes of the head. Linear and angular accelerations are vectors that must be specified in relation to anatomical coordinates of the head in order to be properly described as vestibular stimuli. These head axes, as defined by Hixson, Niven, and Correia (1966), provide a clear anatomical reference to which stimulus parameters can be related. Relations between this and the nomenclature used in Chapter 2 are clarified in Figure 3-6.

Polarity conventions, planes, and cardinal axes of the head. Linear and angular accelerations are vectors that must be specified in relation to anatomical coordinates of the head in order to be properly described as vestibular stimuli. These head axes, as defined in Hixson, Niven and Correia (1966), provide a clear anatomical reference to which stimulus parameters can be related. Relations between this and the nomenclature used in Chapter 2 are clarified in Figure 3-6. Angular acceleration (a) is the rate of change of angular velocity (w), and it can be expressed in any angular unit like deg./sec.2 or rad./sec.2 However, the radian (rad.) must be used in formula for calculating instantaneous linear measures from angular measures when the radius is known. Angular acceleration can also be represented as a vector, as illustrated in Figure 3-2. The angular acceleration vector must be drawn in alignment with (or parallel to) the axis of rotation, and its arrowhead end is determined by following the right-hand rule: When angular velocity is increas-

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U.S. Naval Flight Surgeon’s Manual ing, point the curled fingers of the right hand in the direction of rotation, and when angular velocity is decreasing, point the curled fingers opposite the direction of rotation; in each case, the thumb determines the direction of the arrowhead. Since the Q vector is perpendicular to the plane of rotation, a simple way to envision its effectiveness in stimulating a semicircular canal is to imagine that the canal has an axis. If the vector and canal axis are aligned, then a would be maximally effective in stimulating the canal. The angle between the canal axis and the angular acceleration vector is the same as the angle B mentioned in a preceding paragraph. Thus, a2 (Figure 3-2) would stimulate the lateral (or horizontal) canals and not the vertical canals. Sensory Transduction of Head Motion into Coded Neural Messages There is a spontaneous activity in the vestibular nerve. If the head starts to turn left about the z-axis ( .+cl,), the rings of endolymph in the two lateral (horizontal) canals tend to lag behind due to inertia, thereby deflecting the cupula, as illustrated in Figure 3-3. In the lateral canals, deflection of the cupula toward the utricle (utriculopetal deflection) increases the rate of firing of the left ampullary nerve, while deflection away from the utricle (utriculofugal deflection) in the right lateral canal decreases the firing rate. Therefore, for this particular head movement, the two lateral canals provide a synergistic push-pull input (increased discharge from the left and decreased from the right) to the central nervous system (CNS), while neural input from the two vertical canals, being at right angles to the plane of angular acceleration, remains at spontaneous level. In the vertical canals (the anterior and posterior canals), utriculofugal cupula deflection increases firing rate, while utriculopetal deflection decreases it. Thus, for each different plane of angular acceleration of the head, the canals provide a unique pattern of sensory inputs which can be “interpreted” by the CNS so that compensatory reactions in the appropriate plane are produced. Note that the ability of each canal to increase or decrease the rate of discharge of its ampullary nerve has important functional significance. It means that a single canal is capable of signaling rotation in either direction in its plane. Also a single intact inner ear, due to the orthogonal arrangement of the three semicircular canals in each ear, is capable of signaling direction of rotation in any plane of head rotation. Figure 3-3 is also convenient for visualizing expected initial reactions to peripheral vestibular disorders. The otolithic sensory organs in the utricle and saccule respond to linear acceleration and to tilts of the head relative to gravity (Figure 3-4). Calcite crystals at the surface of the gelatinous plaques that comprise the utricular and saccular sense organs have a specific gravity of 2.71, much greater than that of the surrounding medium, and this property is responsible for these organs acting as density-difference, linear accelerometers. The surface of the utricular otolith membrane is slightly curved, but its plane is approximately parallel to that of the lateral semicircular canals. Linear acceleration, acting parallel to the place of the otolith membrane (frequently referred to as the

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Vestibular Function “shear” direction), is considered the effective stimulus to this sensory system (Fernandez, Goldberg & Abend, 1972). Therefore, a rightward, linear acceleration of 245 cm/sec.2 (equivalent to .25G) would produce a leftward shifting or sliding of the otolith membrane (relative to underlying hair cells (Figure 3-4B)) that would be equal to that produced by tilting the head 15 degrees to the left (Figure 3-4C) because the “shearing” component of the stimulus would be equal in both situations. Actually, a sustained rightward linear acceleration of 245 cm/set.2 is perceived as a leftward tilt of approximately 15 degrees. As in the ampullary nerves, there is spontaneous firing of the utricular and saccular nerves. The hair cells at the base of the utricle are shown diagrammatically in Figure 3-4. Hairs projecting upward from each cell have a morphological polarization determined by the position of one lone distinctive kinocilium relative to rows of stereocilia diminishing in length row by row with distance from the kinocilium (Lindeman, 1969). It has been found that deflection of the hair bundles toward the kinocilium increases the neural discharge rate, whereas opposite deflection decreases the discharge rate relative to the spontaneous level. All cells “point” toward a hookshaped striola that curves through the macular utriculi, and a similar arrangement exists in the saccule. It is also the morphological polarization of hair cells in the cristae of the semicircular canals that determines which direction of cupula deflection increases the neural firing rate. Therefore, direction of tilt of the head is signaled by different topographical patterns of discharge in the utricular nerve. For example, if the head were tilted forward, the cells depicted in Figure 3-4 would be relatively unaffected, that is, the spontaneous firing rate would be approximately maintained, but neural activity triggered by other cells in other locations within the macula would be changed significantly. Amount of tilt in a given direction would be signaled by the amount of change of a specific unique pattern for that direction of tilt relative to the spontaneous firing level. The otolithic receptors have both static and dynamic functions (Fernandez & Goldberg, 1976; Goldberg & Fernandez, 1975) that is, in addition to signaling static position of the head relative to gravity, some nerve fibers from the utricle and saccule respond to change in position. These latter units respond when the otolith membrane is moving relative to the underlying hair cells, thus they respond to change in linear acceleration. This ability of the otolithic receptors to supply both position and change-in-position information will be discussed below in terms of their potential contributions to spatial orientation. Neurophysiological studies also indicate that with sustained tilt, there is some evidence of adaptation in some “position-sensitive” units.

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Figure 3-3. Direction of endolymph displacement (arrows in the lateral semicircular canals) during angular acceleration of the head to the left (counterclockwise as viewed from above). Dashed lines indicate cupula displacement which deflects hairs projecting into cupula. The inset hair cell illustrates stereocilia relative to the kinocihum (dark hair). Deflection of the hair bundle toward the kinocilium increases neural discharge, while deflection away from the kinocilium decreases neural discharge relative to spontaneous level. Irritative and ablative insults which result in similar CNS comparator states tend to produce similar sensations and reflex actions (Correia & Guedry, 1978).

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Vestibular Function

Figure 3-4. Spontaneous neural discharge from utricular nerve and its modulation under various conditions.

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U.S. Naval Flight Surgeon’s Manual Acceleration Principles and Nomenclature Einstein’s Equivalence Principle and Spatial Orientation. In dealing with linear acceleration, it is important to recognize the equivalence of the effects of linear acceleration and gravity. Einstein’s equivalence principle states that a gravitational field of force at any point in space is in every way equivalent to an artificial field of force resulting from linear acceleration. In Figure 3-4B, the reaction to linear acceleration was resolved with the effect of gravity to yield a resultant vector of 1.03 G. Assuming that this condition is sustained, a person experiencing it might be expected to feel tilted about 15 degrees because he is tilted 15 degrees relative to the existing force field. Also, according to Einstein, space is isotropic, that is, vertical is not a special dimension, it only seems that way because of man’s limited view of the universe. However, we are dealing with man, whose perceptions develop from a very limited view early in life and expand somewhat with experience, yet, many effects of ontogenetic and phylogenetic development remain. Moreover, in the practical business of landing an aircraft or even walking on Earth, the vertical is a special dimension which must be accurately estimated one way or another. From the point of view of understanding spatial orientation, it is important to recognize the equivalence of linear acceleration and gravity while remembering that man usually operates as though the vertical and horizontal are special dimensions. Thus, when a linear acceleration and gravity are vectorially resolved to give a new direction to the acceleration field, this new direction may be accepted by the man as vertical, depending upon his perceptual and intellectual assessment of how his position was attained. Pilots learn that the resultant of gravity and an accelerative force in flight can seem to be vertical when it is “tilted” relative to Earth. An Example of the Use of Acceleration Nomenclature. Consider a pilot (Figure 3-5) in an aircraft that increases speed at a constant rate for ten seconds in going from 440 mph to 500 mph during level flight (i.e., a speed change of 60 mph). The aircraft imparts a linear acceleration to the pilot along his x-axis, and it has a magnitude of 8.8 ft./sec2 By the nomenclature, the sign of this acceleration relative to the man is defined as positive, and the magnitude is indicated by the length of the vector, which would be 8.8/32.2 or 0.27 of the length of the arrow designating the magnitude of gravity. Thus the linear accelerations, expressed in G-units, along the head axes are Ax= + .27 g, Ay = O, and Az = + 1 g. Now consider the flight engineer in Figure 3-5 seated facing an instrument display on one side of the aircraft. While the aircraft is accelerating, his linear acceleration can be described by Ax = O, A y = -.27 g, and Az = + 1 g. The resultant has moved from his z-axis toward his y-axis; it has rotated in the y-z plane about the x-axis as shown in Figure 3-5. The resultant vector, Ayz,

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Vestibular Function makes an angle + 41~ = 15.3 degrees, with the engineer’s z-axis. (The positive sign of the angular displacement, &., can also be established by the right-hand rule of rotation. When the thumb of the right hand is pointed along the + x head axis, the curled fingers point in the direction of rotation.) The two men receive the same acceleration, but the physiological effects are different because the men are oriented differently in the aircraft. If the direction of the resultant acceleration in Figure 3-5 (Axz for the pilot and Ayz for the flight engineer) is accepted as upright, the pilot will perceive a backward tilt and the flight engineer will perceive a leftward tilt. However, both would be likely to perceive a nose-up attitude of the aircraft, assuming that each is aware of his orientation relative to the aircraft. Representation of the Direction of Gravity. In Figure 3-4, the vector (G) representing gravity is a downward-directed arrow, whereas in Figure 3-5 it is an upward-directed arrow (g). This inconsistency was purposely introduced to illustrate that there is some variation in aerospace medicine in regard to the directional representation of force vectors. There is a choice as to which of the following shall be represented -- (1) the action of a force on the body, or (2) the reaction of the body to the force. When an aircraft in level flight increases forward speed, vectorial representation of the acceleration and of the force applied to the pilot by the back of the seat would be forward, as illustrated in Figure 3-6A. The body reacts to this force by an equal and opposite backwarddirected (inertial) force (Figure 3-6B), and since the body is not rigid and is not of uniform density, some organs within the body will be displaced slightly backward relative to the skeletal system. Likewise, the seat is applying an upward-directed force, equal and opposite to the weight of the man on it. However, the effect of gravitational attraction is to displace organs downward relative to the skeletal system, just as though the man were being accelerated upward. If actions of the seat on the man are represented, that is, if the forward acceleration is represented by a vector pointing forward, then gravity must be represented by an upward-directed vector as in Figure 3-6A. If reactions are represented, that is, direction of displacement of body organs relative to skeletal system, then the x-axis vector must point backward and the gravity vector downward as in Figure 3-6B. Note that the length and line-of-action of resultant vectors (heavy black arrows) are the same in Figures 3-6A and B, whereas the resultant line-of-action represented in Figure 3-6C is incorrect because a mixture of action and reaction vectors has been used.

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U.S. Naval Flight Surgeon’s Manual

Figure 3-5. Different perceptions of tilt in a pilot and flight engineer in an aircraft accelerating during level flight. The resultant of the linear acceleration and gravity rotates toward the x- axis in the pilot and toward the y-axis in the flight engineer.

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Page 3-13.

Figure 3-6. The directional representation of action and reaction vectors. The line of action of the resultant vector is incorrect in (C). in aviation medicine, reaction vectors are frequently used, and gravity is often symbolized by G and a downward-directed vector. For man-referenced reaction vectors, +Gz is usually defined as the head-to-seat direction (see Chapter 2), whereas for action vectors as defined by Figure 3-2, +Az is defined as the seat-to-head direction.

U.S. Naval Flight Surgeon’s Manual Coding of Vestibular Messages. In the aerospace environment, unusual linear and angular accelerations occur frequently. The occurrence of a single, exceptional linear or angular acceleration component can induce disorientation or vertigo, but more typically, one must consider combinations of stimuli to appreciate troublesome situations. To comprehend the functional significance of unusual stimuli combinations, it is helpful first to appreciate the coding of normal vestibular messages that occur in natural movement (i.e., movement not involving vehicular transport). In natural movement, whenever the head is tilted away from upright posture, the semicircular canals and otoliths always provide concomitant, synergistic messages. For example, during backward head tilting from upright posture, change in neural activity from the four vertical canals and absence of change from the two horizontal canals is a coded message to the CNS signifying angular velocity of the head about its y-axis,+. Concomitantly, changes in neural activity would be generated by the otolithic receptors. During the head tilt, the utricular otoliths would slide backward, triggering change-in-position receptors as well as position receptors in a pattern signifying a position change about the y-axis, and the final coded utricular position information would be predictable from the preceding change-in-position information. Likewise, it has been shown that integration of the angular velocity information from the semicircular canals can be subjectively performed to obtain an angular displacement estimate equal to the position change which has occurred (Guedry, 1974,50-56), and hence, equal to that signaled by the otoliths. When the head is turned about an axis that is aligned with gravity (for example, the head turns about the z-axis in upright posture or about the y-axis while lying on one side), the semicircular canals are stimulated, but there is no change in orientation of the otolith system relative to gravity, and hence, no change-in position information from the otolith system. Under this circumstance, that is, when the axis of rotation signaled by the semicircular canals is aligned with the gravity vector as located by the otolith system, these two classes of vestibular receptors do not reinforce one another, but it should be noted that there is no conflict in their information content. Consider now the situation depicted in Figure 3-5. During forward acceleration of the aircraft, the resultant linear acceleration, Ax2, rotates from alignment with the pilot’s z-axis forward toward his x-axis through an angle designated as +$. As was pointed out earlier, this is the same change relative to the existing force field that would occur if head and body were simply tilted backward relative to gravity 15 degrees. However, during the “tilting” process, the vestibular message would be quite different in these two situations. In the latter situation (real tilt), the synergistic messages from the semicircular canals and the otolithic receptors as described above would be present. Degree of backward tilt would be quickly and accurately perceived. During the dynamic phase of the stimulus in the former situation (forward acceleration), change-in-position and position information from the otolithic receptors would be unaccompanied by synergistic information from the semicircular canals. “Tilt” relative to the resultant, Axz, would be greatly

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Vestibular Function underestimated or not perceived at all (cf., Guedry, 1974, p. 106-108); rather, the individual would perceive forward linear velocity (i.e., he would perceive what is actually happening). However, if the forward linear acceleration is sustained for a while, then, in this “steady state” condition, the otolithic position input would signal tilt, and, as in static tilt relative to gravity, otolithic or semicircular canal change-in-position information would be absent. In this case the individual would experience backward tilt as though he were tilted relative to gravity, but only after a delay or lag. Each of the conditions just described, except sustained horizontal linear acceleration, occurs in natural movement, and each produces a pattern of vestibular input that is familiar and perceived quickly and accurately if the observer chooses to attend to it. In subsequent sections of this chapter, conditions of motion will be described that produce conflicting vestibular inputs, and these are usually confusing, disturbing, disorienting, and nauseogenic. In partial summary, the semicircular canals localize the angular acceleration vector relative to the head during head movement and contribute the sensory input for (1) appropriate reflex action relative to an anatomical axis and (2) for perception of angular velocity about this axis. Perception of how this axis is oriented relative to the Earth depends upon sensory inputs from the otolith and somatosensory systems, and thus, appropriate reflex actions relative to the Earth depend upon these other systems working synergistically with the semicircular canals. The otoliths provide both static and dynamic orientation information (relative to gravity) and contribute to the perception of tilt and also to the perception of linear velocity. The perception of linear velocity derives from a combination of (1) change-in-position information from the otoliths and (2) the absence of angular velocity information from the canals. The otoliths provide change-in-position information when the cilia are in motion, and the stimulus required is change in linear acceleration. Spatial Disorientation in an aviator, spatial disorientation usually refers to the inaccurate perception of the attitude or motion of his aircraft relative to the coordinate system constituted by the Earth’s surface and gravitational vertical, and it can endanger flight safety. Spatial disorientation has been estimated to account for between four and ten percent of major military aircraft accidents and even higher percentages of fatal accidents (Gillingham & Krutz, 1974, p. 66; Hixson & Spezia, 1977). From 1977-1981, disorientation was a direct or contributing cause of 31 percent of pilot-error accidents in the U.S. Navy, and in the U.S. Airforce (from 1980-1985) the figure was 34 percent. In private civilian aviation in the U.S. from 1964 to 1972, disorientation and closely related categories accounted for 37 percent of all fatal accidents (Benson, 1974b). Disorientation is a normal reaction in many conditions of flight, and it is probably experienced by all pilots at one time or another. Common experiences with disorientation are listed in Table

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U.S. Naval Flight Surgeon’s Manual 3-1. It illustrates that there are similarities in disorientation encountered in different types of aircraft and also across a span of 14 years (Clark, 1971). Table 3-2 lists some common disorientation incidents in U.S. Navy helicopter operations (Tormes & Guedry, 1975). The implications of disorientation incidents range from fatal accidents to inconsequential events that may be instructive to the pilot. Between these extremes are nonfatal accidents, aborted missions, mission degradation, and mission completion but with persisting unfavorable effects on the pilot. A number of factors combine to determine the consequences of a disorientation incident. Clearly one factor is when and where the incident occurs. Sufficient altitude with no other plane or object nearby can provide abundant recovery time and reduce risk, and conversely, proximity to the Earth’s surface or other aircraft increases risk. This factor and its relation to items in Tables 3-1 and 3-2 are obvious and will not be elaborated here, but it is a factor that predominates and influences all others. A pilot may be considerably disoriented, but he may be unaware of it. His control actions, based upon perceptual misinformation will place him at risk. When the action is taken, the response of the aircraft may prompt an instrument check which ordinarily will lead to proper corrective action. An important exception occurs when the conflict between an immediate false perception of aircraft orientation and instrument information provokes an excessive emotional reaction; then the pilot remains at risk. Most importantly, the pilot may remain unaware of his disorientation until it is too late for corrective action. In formation flight the pilot’s attention is focused on another aircraft, and the perceived aircraft altitude often differs drastically from true altitude because the pilot has been concentrating on maintaining position relative to the other aircraft. Severe disorientation revealed by shift of attention to flight instruments delays appropriate corrective action beyond the point of no return due to proximity of other aircraft or the ground.

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Table 3-1 Percentage of Pilots Reporting Disorientation in Current Aircraft Compared with the Percentage of Pilots Reporting in 1956

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Table 3-1 (Continued) Percentage of Pilots Reporting Disorientation in Current Aircraft Compared with the Percentage of Pilots Reporting in 1956

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Vestibular Function Table 3-2 Survey of helicopter Pilot Disorientation Experiences

Described Circumstance

Sensation of not being straight and level after bank and turn (“the leans”) Low altitude hover over water, night Reflection of anti-collision light on clouds and fog outside the cockpit Transitioning from IFR to VFR and vice versa Misinterpretation of relative position or movement of ship during night approach Head movement while in bank or turn Landing on carrier or other aviation ship, night Night transition from hover over flight deck to forward flight Misperception of true horizon due to sloping cloud bank Inability to read instruments due to vibration Take-off from carrier or other aviation ship Reflection of lights on windshield Awareness of flicker of rotors Misperception of true horizon due to ground lights Fatigue Distraction by aircraft malfunction Formation flying, night Misled by faulty instrument Vibration Misjudgment of altitude following take-off from carrier or other aviation ship Going IFR in dust, snow, water, in low hover Loss of night vision Take-off or landing in strong cross winds Symptoms of cold or flu Low altitude hover over water, day Formation flying, day Low altitude hover over land In-air refueling from moving ship Self-treatment with over-the-counter drugs Landing on carrier or other aviation ship, day

(Adapted from Tormes & Guedry. 1975).

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Percentage of 104 Pilots Reporting Disorientation 91 81 70 62 58 56 51 49 47 45 39 36 35 33 32 29 25 25 24 21 19 15 13 11 10 8.6 6.7 2.8 1.9 0.96

U.S. Naval Flight Surgeon’s Manual On the other hand, there are many maneuvers which induce disorientation, but the pilot is so aware of its occurrence that he may not be at all disturbed by it. For example, a plane flying in a level, coordinated, gentle bank and turn may be perceived as though it were in straight and level flight for reasons made clear in earlier sections and illustrated in Figure 3-7. The pilot who initiates the maneuver knows what to expect, and for this reason, the perceptual experience seems “natural” and is consistent with the intellectual information derived from his instruments. A pilot may not even refer to a false perception of the plane’s attitude as disorientation if he is keeping track of the flight situation. This was illustrated by comments from an experienced F-4 pilot who, while serving as a backseat subject in an in-flight experiment, reported that a head movement induced an apparent 30 to 40 degree nose-down attitude of the aircraft which at the time was in a 2 g level bank and turn. When this experience was later referred to as an example of disorientation, the pilot-subject denied that he was disoriented at all because he was completely aware of the true attitude and condition of the aircraft. This illustrates an important point. The dangerous aspects of disorientation are considerably diminished if the pilot alertly keeps track of the true condition of the aircraft. When disorientation inputs become second nature to him, perceptualmotor reactions are probably modified and, in their modified form, may even enhance his control of the aircraft.

Figure 3-7. The somatogravic or oculogravic illusion. In a coordinated turn, the aviator may accept the resultant vector as gravitational vertical.

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Vestibular Function There is an exception, that being the case where a pilot may have persisting, strong disorientation, such as a severe case of “the leans.” The emotional reaction to the disorientation stress may impair instrument scan and normal control function. Here, the magnitude (or persistence) of the erroneous perception is a threat to the pilot. As in the case of the unanticipated disorientation, control of the aircraft may be jeopardized through the deleterious effects of hyperarousal (cf., Benson, 1965; Malcolm & Money 1972). Several points emerge from these considerations of the etiology of dangerous disorientation conditions: (1) Familiarity with conditions that produce disorientation and a “second-nature” anticipation of its occurrence can reduce its serious implications and may even be useful to the aviator; (2) Failure to keep track (i.e., intellectual updating) of the condition of the aircraft can convert even relatively benign flight conditions into potentially hazardous situations. For these reasons, training concerning conditions that can be expected to produce disorientation will have beneficial effects, and occasional refresher training is a worthwhile measure for the experienced aviator, especially after a period away from flying. Visual-Vestibular Interactions Relevant to Aviator Vision Tbe Vestibulo-Ocular Reflex The vestibulo-ocular reflex influences vision during natural movement much more than is generally appreciated, and it is capable of subtle and occasional profound influence on vision in aviation. Most physicians or physiologists think of nystagmus, an oculomotor pattern which occurs in certain unnatural motion profiles and in pathologic states, in relation to vestibular stimulation, but nystagmus is probably the least typical form of the vestibulo-ocular reflex in healthy individuals during natural movement. A more common oculomotor response consists of nearly smooth, sinusoidal eye oscillations that almost perfectly compensate for head oscillations that occur during walking, running, or simply shaking one’s head, as in signifying “yes” or “no”. For example, in the latter situation as the head turns right, the eye turns left, thereby compensating for the head movement (cf., Benson 1972). Gresty and Benson (in preparation) describe fairly high-frequency components (in the range 1 to 10 Hz) in angular oscillations of the head during whole-body movement and also in aircraft. It is important to note that the visual system is very poor at tracking Earth-fixed targets at these frequencies if it is unaided by the vestibuloocular reflex. Therefore, this reflex plays an important role in stabilizing vision relative to the Earth during many kinds of natural motion. The reader can demonstrate this to himself by holding his head stationary and oscillating this page back and forth on a desk top at a frequency just sufficient to blur the print. To complete the demonstration, and this is the crux of it, oscillate your head at the same frequency while the page remains stationary on the desk top, and observe that the print remains perfectly clear. Note also that even with much faster head oscillations it still remains clear. The vestibulo-ocular reflex automatically stabilizes the eyes relative to external

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U.S. Naval Flight Surgeon’s Manual visual surroundings during head movements to maintain visual acuity for Earth-fixed targets. This is the reason that individuals without vestibular function report “jumbled vision” during motion, especially vehicular motion involving vibratory oscillation. However, following loss of vestibular function, the influence of neck proprioception on eye movement may increase to improve ocular stabilization during voluntary movement. This highly advantageous vestibular-ocular reflex can become disadvantageous (inappropriate), however, in aircraft, surface ships, or other moving platforms since the head moves in inertial space, while visual displays, such as aircraft instrument panels, may move in unison with the head. If there is a tight coupling between head and display during such movement, then at certain frequencies and peak angular velocities, the vestibulo-ocular reflex will interfere with vision for the display (Guedry & Correia, 1978). Vision and the Dynamic Response of the Cupula-Endolymph System The probability of encountering problems with vision and also with disorientation in a given flight environment depends, among other things, on the dynamic response of the cupulaendolymph system to various profiles and frequencies of angular acceleration. Understanding this aspect of vestibular function is therefore helpful in analyzing problems arising from pathological conditions during natural movement or from normal responses to unusual motion. Because the cupula-endolymph ring has the structural characteristics of an overcritically damped torsion pendulum, its behavior and that of the responses it controls are theoretically predictable when acceleratory movements of the head are known. Much information was accumulated to indicate when such predictions are accurate and when they are not (cf., Guedry, 1974). Figure 3-8 illustrates predicted changes in cupula displacement relative to the skull throughout two motion conditions. Figure 3-8A, depicting cupula deflection during a simple, natural head turn to the left, illustrates several important points. Notice that the cupula deflection curve looks like the stimulus angular velocity curve and are not like the angular acceleration curve. In natural head turns, the dynamic response of the end organ is such that the input sensory message matches the instantaneous angular velocity of the head relative to the Earth (like a tachometer), even though angular acceleration is the effective stimulus. For this reason, the turning sensation (subjective angular velocity) controlled by cupula deflection is accurate during and after the turn. Similarly, the vestibulo-ocular reflex is accurate during natural turns in that the reflexive eye velocity compensates for the head velocity and stabilizes vision relative to Earth-fixed targets. In contrast, Figure 3-8B illustrates vestibular effects of an unnatural motion involving sustained rotation. Inertial torque deflects the cupula during the initial brief angular acceleration, but it is absent during the following constant angular velocity. Consequently, the cupula, because of its

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Vestibular Function restorative elasticity, returns toward rest position. Then, being near rest position when deceleration occurs, it is deflected in the opposite direction by the inertial torque from the deceleration (angular acceleration in the opposite direction). The turning sensation controlled by cupula deflection is accurate only during the initial acceleration. During constant velocity, the sensation of turn will diminish and stop; then, the deceleration will produce a reversed sensation of turning which can persist for 30 to 40 seconds after stopping. Obviously, with the unnatural stimulus, the semicircular canals do not perform their velocity-indicating function satisfactorily, and their input can be the basis of disorientation and impaired visual performance.

Figure 3-8. Comparison of cupula deflection during a natural short turn (A) and during a sustained turn of several revolutions (B).

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U.S. Naval Flight Surgeon’s Manual This unnatural stimulus produces the particular pattern of oculomotor response called nystagmus. During the initial acceleration in Figure 3-8B, the eyes drift right (relative to the skull) as the head turns left. This drift, which compensates approximately for the turn, is called the slow phase of nystagmus, but as the head continues to turn, the eyes “recenter” themselves, that is, catch up, by a fast or saccadic eye movement called the fast phase, which has extremely high velocity (300 to 600 degree/second). Because the directions of the slow and fast phase of nystagmus are opposite, there has been inconsistency in designation of the direction of nystagmus. When viewed by a medical examiner, the fast phase (saccade) is easiest to see, and this led to the convention of designating nystagmus direction by its fast phase relative to the examinee. However, owing to recent strong clincial interest in quantification of nystagmus (electronystagmography - ENG) which emphasizes measurement of slow-phase velocity, designation of slow-phase direction has gained popularity. To avoid confusion, it is best to specify slow or fast phase when nystagmus is described. Figure 3-9 illustrates ENG as it typically appears when angular displacement of the eyes relative to the skull is recorded and also when the slow-phase velocity of each nystagmus waveform (beat) is quantified and plotted. The slow and fast phases create a sawtooth pattern. As the head commences to turn left during the initial acceleration, the eyes drift right (slow phase), adequately compensating for the head velocity. With continued rotation, the eyes catch up, (fast phase) and then recommence drift. During the period of constant head velocity, slow-phase eye velocity, as it abates, would be less and less effective in assisting the eye to see Earth-fixed targets. During deceleration, the reversed direction of nystagmus and its persistence after stopping could only impair vision for either Earth-fixed or head-fixed targets. The nystagmus illustrated in Figure 3-9 approximates a typical response recorded in complete darkness. The maximum slow-phase velocity illustrated is 100 degrees per second. The nystagmus of a person with vision restricted to the interior of a rotating vehicle would be suppressed by any visible head-fixed display. With visual suppression, a maximum slow-phase velocity of about 14 degrees per second would occur (in other words, the visual/vestibular fixation index is about 0.14). This is sufficient to degrade visibility of fine detail on instruments briefly, until the suppressed vestibular nystagmus abates somewhat. The degradation is far less, however, than the total blurring of vision that would occur if the 100 degree/second slow-phase velocity were unsuppressed. There are a number of conditions that influence visual suppression. With oscillatory motions, the frequency of oscillation is very important. During low frequency, whole-body oscillation (e.g., .01 Hz), the gain of the semicircular canal output response (peak slow-phase velocity/peak stimulus velocity) is low even in darkness, and the visual fixation index is favorable (.14 ± .05 S.D.), so that visual fixation is apt to “win out” over vestibular nystagmus even with fairly high peak stimulus velocities.

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Page 3-25.

Figure 3-9. Electronystagmogram of cupula deflection and eye movements during and after prolonged rotation. Measuring the slope of the angular displacement tracing during a slow phase gives the slow phase velocity of the eyes.

U.S. Naval Flight Surgeon’s Manual However with high frequency head oscillation (e.g., 1.0 to 5.0 Hz), the gain of the vestibular output response is high (Benson 1970, 1972), and moreover, the fixation index becomes unfavorable. It approaches one, tantamount to little or no visual suppression. Thus, vision for head-fixed targets will be very poor even though the peak head velocity may be only 15 to 20 deg./sec., and the angle of oscillation only a few degrees (Barnes, Benson, & Prior, 1974). Individual differences in visual suppression of vestibular nystagmus in apparently healthy persons can be quite large. A small amount of practice improves the visual fixation index (VFI) substantially in many but not in all persons. A fact that could be very important to an aviator is that a small amount of alcohol, two or three social drinks, degrades the VFI and associated visual acuity substantially for about four hours (Guedry, Gilson, Schroeder & Collins, 1975). One site of influence on the VFI is the cerebellum, particularly the flocculus (Lisberger & Fuchs, 1974; Miles & Fuller, 1975; Takemori & Cohen, 1974). Nystagmus in the absence of unnatural motion stimuli is a clinically significant sign, although positional nystagmus can occur during alcohol intoxication (Positional Alcohol Nystagmus I -PAN I), and it can return, though reversed in direction (PAN II), during “hangover.” Some pathological states reduce or eliminate visual suppression of nystagmus, and for this reason the VFI is a useful adjunct to other tests in diagnosing CNS disorders such as multiple sclerosis (Baloh, Konrad & Honrubia, 1975; Ledoux & Demanez, 1970). However, in many pathological states, especially peripheral vestibular- disorders, visual suppression is effective. For example, nystagmus attributable to reduced function in one ear (see Figure 3-3) will be visually suppressed, and it may not be detectable by direct observation. For this reason, eye movements should be recorded by ENG in darkness. Alternatively, the physician may be able to detect nysagmus if he observes movement of the corneal bulge under the closed eyelid, of if the patient wears Fresnel lenses to blur vision. Visibility of Cockpit Instruments Loss of visibility of cockpit instruments has been indicated as a factor in disorientation in aviation (Melvill Jones, 1965; Tormes & Guedry, 1975). Malcolm and Money (1972) include inability to read flight instruments during vibration and turbulence as one of the conditions common to “Jet Upset Phenomenon,” a situation in which pilots of large jet aircraft have gone into severe and disasterous nose-down attitudes to compensate for erroneous sensations of extreme nose-up attitudes (cf., Martin & Melvill Jones, 1965). Factors which may influence the visibility of flight instruments, separately and in combination, are the vestibulo-ocular reflex at high frequencies of head oscillation, poor visual system tracking with high-frequency instrument vibration relative to the head, the brightness and wavelength of light from the instruments, and the complexity of the

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Vestibular Function instrument display. Further complications may be introduced by tendencies toward “grayout” from changing G-loads which may be exacerbated by vestibular stimuli (Melvill Jones, 1957; Sinha, 1968). Visibility Outside the Cockpit Visibility of the Earth’s surface could actually be improved by the vestibulo-ocular reflex in some circumstances, although there is no certainty that the complex vibratory motions in flight would set off optimal oculomotor stabilization for Earth-fixed or other exernal visual targets. Some maneuvers, such as several consecutive complete turns, can produce vestibuar aftereffects which tend to degrade vision due to nystagmus, while also disorienting the pilot. Despite good visual suppression of such effects, if maneuvers are sufficiently strong (e.g., five turns in ten seconds), vestibular nystagmus after stopping such a turn can blur vision for both cockpit instruments and Earth reference (Benson & Guedry, 1971; Melvill Jones, 1957). It has also been indicated that anticompensatory reflexes (Melvill Jones, 1964) and vestibulo-ocular accommodation reflexes (Clark, Randall & Stewart, 1975) may degrade vision in some flight conditions. Vestibular Contributions to Disorientation Aircraft maneuvers may involve both unnatural turns and unusual changes in the direction and magnitude of resultant linear force vectors. Moreover, the seated pilot does not necessarily continually update his orientation assessment as one does automaticaly while walking or running. Thus, both the pattern of vestibular stimulation and the response to it differ from those encountered in natural movement. Somotogyral and Oculogyral Illusions Aircraft maneuvers involving several complete revolutions (turns, rolls, or spins) tend to produce an illusion of turning in the opposite direction just after the maneuver is completed. Contributing to this effect are semicircular canal responses as described above. Stimulus and vestibular response characteristics which control the magnitude of the per and postrotatory vestibular effects are the velocity of rotation achieved, the duration of the rotation, and, with some stimuli, the particular set of canals stimulated (Benson & Guedry, 1971). Constant velocity need not be maintained during the turn for some illusory aftereffect to occur. Whenever angular acceleration of constant direction is applied for several seconds, the continued cupula displacement is opposed by the elastic restoring force of the cupula, whereas, when the deceleration commences, the elastic restoring couple works with the inertial torque from the

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U.S. Naval Flight Surgeon’s Manual “stopping” stimulus to produce cupula overshoot. Information from the semicircular canals would therefore signal “stop” before the actual maneuver ends, and would signal “reversed turn” from the cupula overshoot for any long duration triangular or sinusoidal waveform of angular velocity, even though no period of constant velocity interposed between the starting and stqpping acceleration. This sequence of perceptual events, when observed in complete darkness, has been called the “somatogyral illusion” (Benson & Burchard, 1973). Essentially the same sequence, when observed in darkness with only a small head-fixed visual display in view, has been called the “oculogyral illusion” (Graybiel & Hupp, 1946). In the latter case, the perceived motion of the body is referred to the visible display which therefore seems to be turning with the observer. However, the display may appear to lead slightly (i.e., be displaced from “apparent dead ahead” in the direction of the apparent motion), and it may be slightly blurred while the vestibular signal is strong enough to generate nystagmus in spite of visual suppression. The threshold for detection of angular acceleration seems to be lower for the oculogyral illusion than for the somatogyral illusion (Clark & Steward, 1969). From the point of view of aviation, it is important to note that these illusionary effects occur even in a well- illuminated cockpit if external visual reference is absent or ill-defined. There is a curious difference in the aftereffects of active and passive whole-body rotation. The reader can demonstrate this to himself by standing and, with arms folded, executing eight, smooth, continuous ambulatory turns in about 20 seconds with eyes closed. Upon stopping (eyes still closed), if the body is allowed to remain fairly relaxed, the head, torso, and legs tend to twist in the same direction as the previous turn. The motor effects are in the expected compensatory direction from the deceleratory stimulus to the semicircular canals; they are compensating for a body motion which is not taking place. Under this circumstance, the aftersensation in most individuals is not one of turning in opposite direction, as would be predicted from the semicircular canal response, but rather of turning in the same direction as the preceding turning motion. The spinovestibular feedback apparently dominates the perceptual experience. This demonstration has two potentially important implications in aviation. First, it illustrates that unusual vestibular stimuli can induce reflexive motions of the head, torso, and limbs that may not be appreciated by the pilot, yet they may influence performance. Secondly, the difference in aftersensation between active and passive turning may have implications for the perceptual experiences of pilots who actively generate unusual vestibular stimuli in flight maneuvers and, of course, continue to control the aircraft after maneuvers are completed. Experienced pilots develop what is referred to as “fusion,” in which the aircraft is said to become a mere extension of their voluntary control of motion (Reinhardt, Tucker & Haynes, 1968). Thus, the sensations of experienced pilots are probably shaped by their active control functions and may

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Vestibular Function be a little different than would be deduced from passive stimulation in laboratory devices. This would account for several indications that experienced pilots are much more disturbed by fixedbase flight simulators (Reason & Brand, 1975) with moving visual scenes than is the novice. The likelihood that the pilot’s active control of his aircraft reflexively shapes his perceptual experience also has implications for the importance of maintaining flying practice. Somotogravic and Oculogravic Illusions The somotogravic and oculogravic illusions are sometimes referred to as the otolithic counterparts of the somatogyral and oculogyral illusions. They are apt to occur when the head and body are in a force field which is not in alignment with gravity, a condition that occurs frequently during flight and which is usually studied in the laboratory by means of a centrifuge. Although otolith stimulation plays a role in the effects of such stimuli, certainly other somatosensory receptors are also involved. Individuals without vestibular function experience these “illusions,” although their perceptions differ somewhat from those of individuals with vestibular function (Graybiel & Clark, 1965). The perception of feeling upright during a coordinated bank and turn (Figure 3-7) or its converse of feeling tilted when the resultant force field is not aligned with gravity, has been referred to as the “somotogravic illusion” (Benson & Burchard, 1973). For situations in which an observer views a line of light and either estimates its apparent tilt or attempts to adjust it to apparent vertical, the perceptual error has been called the “oculogravic illusion” (Graybiel, 1952). However, the important point for the aviator is that accelerations in flight can yield a resultant force vector which may be perceived as upright, even though it is substantially “tilted” relative to gravity. Even in a diving turn, the resultant force can give the illusion of approximately level flight. Concentrating on maintaining positive relative to another aircraft, the pilot may feel approximately straight and level while in rapid descent. Even on a clear day over water, the horizon may not be immediately locatable, without immediate clear visual reference. The pilot is at high risk due to unrecognized disorientation. While the direction of the resultant force vector provides a fairly close approximation of the subjective vertical in “steady state” conditions (i.e., conditions in which the observer experiences prolonged static tilt relative to the resultant force vector), there are a number of definite departures from this rule. One such departure results from conditions of dynamic (changing over time) linear and angular accelerations, as explained in the previous discussion of the coding of vestibular messages. During horizontal linear acceleration of an upright, forward-facing

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U.S. Naval Flight Surgeon’s Manual observer, the resultant linear acceleration vector rotates in the pitch plane of the head and body. The otolith stimulation is as though the head and body had rotated backward relative to gravity, but, because the head is fixed in an upright position, there is no angular acceleration to stimulate the vertical semicircular canals. Under these circumstances, the immediate perceived change in orientation is usually less than that which would be calculated from the immediate stimulus to the otolith (Guedry, 1974, p. 105 f; cf., Stockwell & Guedry, 1970). This kind of situation occurs in linearly accelerating or decelerating aircraft, and, though some change in attitude is experienced, if the head does not rotate on the neck during the linear acceleration or deceleration, then the experienced change in attitude is probably less than the dynamic rotation of the linear acceleration resultant vector and hence closer to the actual attitude of the aircraft. Even so, there can be enough change in perceived attitude to introduce dangerous reactions in flight (Collar, 1946). An extreme example of this kind of stimulus occurs during a catapult launch from an aircraft carrier (Figure 3-10) (cf., Cohen, Crosbie, & Blackburn, 1972). During the catapult launch, a peak forward linear acceleration of about 4.5 g is generated. When resolved with gravity, the resultant linear acceleration vector makes an angle of about 77 degrees relative to gravity. In a few seconds, the resultant vector changes in magnitude and rotates relative to the pilot’s head. Because the head has not actually rotated, the semicircular canals do not signal a corresponding rotation. The absence of vertical semicircular canal input combined with the dynamic otolith input produces a forward velocity sensation and less perceived nose-up attitude than would be predicted from the 77-degree change in direction of the resultant vector. A second circumstance in which judgments of vertical are apt to depart from alignment with the existing force field occurs in the presence of a structured visual field. A prominent visual frame of reference with linear dimensions tilted relative to the direction of the existing force field will frequently produce a compromise estimate of the vertical between visual and force-field cues. It appears that some individuals are relatively more influenced by visual reference, whereas others may be more force-field oriented, and there has been some interest in exploring the implications of such differences for aeronautical adaptability (Brictson, 1975). Flight conditions giving rise to misleading visual reference will be discussed briefly in a later section. Judgments of vertical may also depart from alignment with the resultant force field when the magnitude of the force differs substantially from the customary 1.0 g field. Systematic departures which appear to be attributable to differences in otolith displacement during static tilt in “hyperg” fields have been observed (for an overview cf. Guedry, 1974, pp. 96-103). Illusions Associated With Head Movements Nuttall (1958) attributed a series of fatal aircraft accidents to pilots’ head movements required

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Vestibular Function by the necessity to shift radio frequencies during procedural turning maneuvers at low altitudes. Several illusory effects can be elicited by head movements during such turning maneuvers.

Figure 3-10. Actual aircraft attitude, predicted pitch-up illusion, and perceived pitch-up illusion during a catapult launch.

The Cross-Coupling Coriolis Illusion. When an aircraft rotates at some angular velocity 01, about one axis while the pilot tilts his head about an orthogonal axis at some angular velocity ~2, the head undergoes an angular acceleration of magnitude 01 ~2, about a third axis, orthogonal to the other two axes. A specific example will serve to clarify the effects that such a stimulus produces. Assume that an observer, on a turntable which has been rotating in a counterclockwise direction at a constant velocity 01 of 60 deg./sec. for 20 to 30 seconds, has his head fixed in tilted position toward his left shoulder. If he then moves his head to an upright position, he experiences a forward tumble and a slight leftward rotation. Vestibular nystagmus produced by the canal

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U.S. Naval Flight Surgeon’s Manual stimulus is primarily down (fast phase) and slightly to the left. An important point to note here is that just after the head is upright, the otolith system would signal the true head position relative to gravity, yet the fairly strong residual effects from the stimulus to the vertical canals give a sensation of forward tumble (i.e., a perceived attitude change of the body and entire vehicle relative to Earth-vertical). Here, then, is a situation in which accurate information provided by the otoliths regarding orientation relative to the Earth is compromised by misleading canal signals, resulting in an illusory change in attitude. The perception is confusing and disturbing, probably because of the intravestibular conflict, and substantial, erroneous changes in attitude are reported (Clark & Stewart, 1967; Collins, 1968). This effect is sometimes referred to as a Coriolis effect because the inertial torque which stimulates each canal can be derived by integrating the components of the linear Coriolis acceleration which act in alignment with the canal walls. From a practical point of view, the conditions that control the magnitude of the disturbing effect of natural rate head movement in flight are the total angle through which the head is turned (the greater the angle, the greater the total integrated stimulus) and the angular velocity (01) of the aircraft. Time elapsed between the head movement and the onset of vehicle turn is also an important determiner (Guedry & Benson, 1976). Aircraft in a bank and turn commonly do not have a very high angular velocity 01. Under these conditions, the magnitude of cross-coupled (Coriolis) effects from head movements would be relatively slight, but, in the unstable conditions of flight, even slightly disorienting effects could be dangerous if external visual reference is either absent or misleading. In higher rate sustained turns, these effects can be strong, and since they may also induce physiological changes conducive to vasovagal syncope, it is not only disorientation but also a possibility of reduced g-tolerance which could affect the pilot (Sinha, 1968). The “g-Excess” Illusion. There is another effect during head movements in aircraft which is apt to occur whenever the aircraft is generating an abnormal force field. This effect was observed during coordinated 2.0 g turns about a large radius (r) of several miles. In this maneuver, the aircraft speed (tangential linear velocity) is very high, but the angular velocity (~1) is very low, about 4 deg./sec. or .07 rad./sec. The center of turn may be at a radial distance of one or two miles from the aircraft. The 2-g resultant is obtained by resolving the gravity vector with the centripetal vector (a%). To calculate centripetal acceleration, 01 must be expressed in radian units. The low angular velocity means that the cross-coupling (Coriolis) effects described in the preceding paragraphs would be almost negligible. Yet, during head movement in such turns, observers reported experiencing peculiar sensations sometimes involving sudden shifts in the apparent attitude of the aircraft, together with nausea which would undoubtedly culminate in sickness in some individuals if frequent head movements were made in this situation. This has been called a

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Vestibular Function “g-excess” because sensory signals from the otolith system when the head is moved in a high-g field would exceed those produced by the same head movement in a 1.0 g field. The extra otolith input may be perceptually attributed to a sudden maneuver of the aircraft, in which case a change in aircraft attitude in the plane of the head movement would be experienced. The perceived attitude change would be at right angles to the cross-coupled (Coriolis) effects. This is comparable to the effects of force-field magnitude on estimates of verticality described previously, except that head movement introduces a dynamic stimulus to the otolith system, and the perception is more confusing and less consistently reported (Gilson, Guedry, Hixson, & Niven, 1973). Note also that the head movements in weightless states are also nauseogenic and disorienting (Graybiel, Miller & Homick, 1974). While this phenomenon is not completely understood, it could be an example of intravestibular conflict (i.e., the head movements induce normal semicircular canal responses unaccompanied by the usual otolithic and proprioceptive feedback).

Pressure (Alternobaric) Vertigo Pilots sometimes experience strong, sudden vertigo involving sensations of spinning, rolling, or tilting, and nystagmus sufficient to blur vision during or soon after ascent or descent. The pilot may feel his ears clear suddenly (sometimes a hissing sound is reported) and simultaneously experience strong vertigo. In one case, a member of one of the famous military aerobatic flight teams was so afflicted shortly after landing that for several minutes he was unable to walk from his plane to join his fellow team members who were being greeted by waiting dignitaries. Surveys (Lundgren & Malm, 1966; Melvill Jones, 1957) have indicated that from 10 to 17 percent of pilots experience pressure vertigo at one time or another. Usually the vertigo is transient, 10 to 15 seconds, but it may last much longer. Pressure vertigo is vestibular in origin, but its exact mechanism is not understood. Even slow changes in ambient pressure can produce symptoms in some individuals. It is also sometimes induced by the Valsalva maneuver. High forcing pressures for opening the eustachian tube on one side, i.e., asymetry in pressure equalization, seem to be common in individuals who experience pressure vertigo, and experimental studies (Tjernstrom, 1974) indicate that some individuals are much more susceptible to this form of vertigo than others. Aside from dangers associated with barotrauma, the strength of some attacks of pressure vertigo militate against flying with any condition which threatens pressure equalization in the middle ear. The Giant Hand Phenomenon. Extreme disorientation where pilots have been unable to make corrective control stick actions with one or both hands has been referred to as the Giant Hand effect. This motor control anomaly appears to be induced by high stress due to sudden appreciation

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U.S. Naval Flight Surgeon’s Manual of disorientation occasioned by a shift in the direction of the resultant force that was not perceived because the pilot had been distracted from control of the aircraft by other tasks. Upon releasing the control column, pilots have reported that the stick returned to a central position by itself and that they were able to effectively control the stick by use of the thumb and forefinger (Malcolm & Money, 1972). Recently, this effect has been reported to occur, to some degree, in about 18 percent of pilots interviewed (Simpson and Lyons, 1978). There has been some indication that high-level sound, sustained and repetitive, and infrasound can also occasionally induce vestibular disturbances. (Parker, Ritz, Tubbs, & Wood, 1976). Disorientation Not Attributable to Strong Vestibular Stimuli-Primacy of Vision Many of the disorienting conditions described in previous sections would be considerably ameliorated or overcome by good visual reference to the Earth’s surface. The single most important cause of pilot disorientation is the absence of adequate visual reference to the Earth because of darkness or adverse weather conditions. Certain flying conditions can introduce visual information that may be either directly disorienting or misinterpreted, but the crucial factor in the human response is that, without good visual reference to the Earth’s surface, the remaining sensory data on spatial disorientation are not sufficiently reliable to permit safe piloting of aircraft. This was nicely demonstrated by Krause (1959) who measured times from occlusion of pilots’ visual reference until the aircraft assumed a condition requiring 10,000 feet for recovery. Following banks and turns, times were typically 20 to 30 seconds, but even after level flight, mean times were on the order of 60 seconds. Many instances of pilot disorientation are less attributable to some overwhelming misleading vestibular response than to some subtle perceptual inconsistency or even to perceptual insensitivity to the acceleration environment. Autogyral and Autokiietic Illusions It is well known that a small, single, stationary light in an otherwise dark room will appear to move in a more or less random path, and that the direction and extent of apparent movement can be influenced by suggestion or the expectation of a stationary observer. A number of instances in which pilots have mistaken stars and other fixed light sources for moving aircraft have probably involved this “autokinetic” effect (Benson, 1965). Perhaps less well known is the fact that individuals in a rotatable but stationary structure frequently perceive rotation of the entire structure. This “autogyral” effect occurs in darkness or in illuminated but enclosed devices. Absence of specific motion cues does not ensure perceived stability when motion expectations are high.

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Vestibular Function Perception of Tilt Typically, mean judgments of verticality are fairly accurate perceptions, but the range of judgments usually includes a few large errors even though an observer can devote his entire attention to this one task. In long flights where vibration and a number of momentary accelerations from turbulence do not demand corrective responses from the pilot, the threshold of corrective responses to vestibular stimuli may be raised by the “acceleration noise level.” Perceptual errors may then approach the occasional extreme errors encountered in laboratory experiments and also those found in water immersion studies where very large errors in the perceived vertical have been noted (cf., Guedry, 1974, 88-92). Even without a background of “acceleration noise” or water immersion, there are large mean errors in estimates of verticality when tilts occur very slowly. For example, pitch and roll attitudes of 10 degrees are typically regarded as upright, whereas sensitivity to detection of slow tilt increases substantially if the subject is rotated about the axis that is being tilted (Benson, Diaz, & Farrugia, 1975). Very slow or sustained tilts diminish rate information from the otoliths and corroborative information from the semicircular canals, and thus increase the likelihood of adaptation effects (see the section on the sensory transduction of head motion into coded neural messages). In flight, a gradual roll or pitch away from straight and level flight sometimes occurs at rates below the semicircular canal or otolith threshold perceptual levels. Adaptation can make a tilted position seem upright, so that return to upright produces a definite sensation of tilt in the opposite direction (Passey & Guedry, 1949). If a flight slowly entered a coordinated bank and turn, alignment of the resultant vector with the head to seat axis would allow for still further undetected deviation from straight and level flight. If the pilot should then become aware of the aircraft attitude from instrument information or external reference, his corrective actions could introduce vestibular stimuli considerably above threshold levels, indicating a definite change from an attitude which had just been perceived as straight and level. Circumstances such as these produce “the leans,” one of the most common forms of disorientation reported by pilots (Clark, 1971). The cockpit instruments show that the aircraft is straight and level, yet the pilot feels that he is in a bank and turn. Though the pilot may be able to fly successfully by his instruments, prolonged perceptual conflicts can eventually degrade his performance. Curiously, “the leans” may persist for 30 minutes or more, much longer than predictable after-responses of the vestibular system. It is as though once the perceived vertical is displaced from the initial noncompelling sensory information about upright, then this displaced perception may sustain itself until the pilot attends for awhile to some other aspect of the flight task, or until there is a good visual reference to the Earth (Benson & Burchard, 1973). Emotional disturbances may further degrade “position sense.”

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U.S. Naval Flight Surgeon’s Manual Visual Stimuli and Disorientation Considering the range of positions which may be judged to be vertical in the absence of clearly misleading information, it should not be surprising that “the leans” could also be provoked by misleading visual stimuli, such as sloping cloud banks, slanting rays of sunlight through clouds, rows of lights erroneously believed to be horizontal, and even the edge of the instrument glare shield sloping over the attitude gyro (Figure 3-11). Pilots occasionally find themselves in nearly inverted flight when just prior to the discovery they had believed themselves to be in normal level flight. The probability of this kind of error is enhanced by the fact that man’s estimates of vertical are relatively poor in some tilt positions and especially when he is inverted (Graybiel & Clark, 1962). In these position, visual cues assume a more predominant role (Young, 1973). Erroneous perception of aircraft attitudes can result in erroneous perception of aircraft altitude. A pilot whose aircraft is in nose-high attitude may, on viewing ground lights in his line of flight, believe his altitude to be considerably greater than it is because of the downward angle of his view of the lights. Similarly, a pilot flying over water with his port wing high may, on viewing shore lights on his port side at an approximately known distance, again considerbly overestimate his altitude if he is unaware of the aircraft attitude (Cocquyt, 1953). Visual effects at high altitude can also induce erroneous perceptions of attitude (Benson, 1965; Melvill Jones, 1957). At high altitude, the horizon is depressed with respect to the true horizontal so that orientation of the aircraft to this false reference may result in the aircraft being flown with one wing low or with a nose-down attitude. The magnitude of this error is not large, being about four degrees at 50,000 feet, but confusion can occur when the pilot looks out on the other side and finds that he is flying wing-high with respect to the visible horizon on that side. Another illusion resulting from high altitude has been observed in which the pilot looks out from the aircraft and sees the moon and stars below the apparent horizontal. From this, he presumes that the aircraft must be flying in a banked or even inverted attitude. A number of pilots have made control movements to bring the aircraft back to what they thought was a normal attitude, before closer attention to their instruments revealed the erroneous nature of the visual percept (Melvill Jones, 1957). A similar situation may occur in the prolonged low altitude circling involved in ASW maneuvers. As indicated earlier, a sustained, coordinated bank and turn can easily be perceived as straight and level flight. If this occurs, a view from wing-high wide of the aircraft could place the moon and stars considerably below the erroneously perceived horizontal (Figure 3-12). possibly leading to the same kind of control errors reported by Melvill Jones in high-altitude flight.

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Vestibular Function

Figure 3-11.

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U.S. Naval Flight Surgeon’s Manual

Figure 3-12. In a coordinated bank and turn, the pilot may see the moon and stars below the apparent horizontal. This can produce a momentary illusion of nearly inverted flight and lead to erroneous movements.

Dynamic Visual Stimulation Large moving visual fields (visual angle greater than 30 degrees) can induce the sensation of body motion within three seconds and also substantial sensations of body tilt (Brandt, Dichgans, & Koenig, 1973; Brandt, Wist, & Dichgans, 1971; Dichgans, Held, Young, & Brandt, 1972). Of considerable interest are apparently related findings that large moving visual fields modulate neural activity in the vestibular nuclei even when the head and body remain stationary (Dichgan, Schmidt, & Graf, 1973; Young & Finley, 1974). In lower animals, vestibular stimulation modulates responses in central visual projection fields even when the retinal image is fixed (Bisti, Maffei, & Piccotino, 1974; Grusser & Grusser-Kornehls, 1972; Horn, Steckler, & Hill, 1972). These various results point to the intimate relations between the visual and vestibular systems in both the “feed forward” and “feedback” loops involved in the control of whole-body motion. In aviation, either a large tilted frame of reference from cloud formations, etc., or uniform motion in the pilot’s visual field can induce illusory perceptions of the attitude and motion of the aircraft. Such effects could influence the pilot in high-speed, low-level flight, or in any of several situations. A visually induced illusion appears to have been important in the following disorientation accident involving the loss of an aircraft. Toward the end of a long day of flying, a student pilot was flying on the starboard wing of his instructor’s aircraft. The student’s view was fixed on the instructor’s aircraft, and because of this formation, his line of sight was turned almost 90 degrees to the line of flight as they descended for some time through heavy mist and layered

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Vestibular Function clouds. The unidirectional streaming of the peripheral visual field was therefore almost ideal for inducing sensations of whole-body turning to the right. As the student shifted his attention to his cockpit instruments, he experienced a strong illusory sensation of right bank and turn, although he was in fact in level flight. Following an erroneous corrective action based on his false perception, the student, now at fairly low altitude, ejected from his aircraft. Contributing to this unfortunate incident were a number of factors. The conditions were adequate to set up a normal illusory reaction to an unusual motion condition: The pilot had just transitioned from an external reference to instrument flight; the pilot was relatively inexperienced and fatigued; altitude and proximity of another aircraft provided little time for corrective actions. Probability of disorientation is high when pilots keep station on another aircraft. Flicker Vertigo Flashing light from sun rays or shadows reflecting from helicopter rotors or from blades of propeller driven, fixed wing aircraft can be very disconcerting, and, in exceptional cases, epileptiform seizures have resulted. In prop planes, the phenomenon may be strongest while the aircraft is taxiing into the sun so that the blades are rotating at relatively low rpm, and intense light flashes may be reflected into the eyes. In a helicopter survey, 35 percent of the pilots responding reported disturbance by flicker from rotors, but 70 percent reported difficulties arising from reflections from the anticollison light (Tormes & Guedry, 1975). Perception of Vertical Linear Acceleration Misjudgment of helicopter motion during hover was found to be a prominent factor in a number of disorientation incidents during conditions of poor external visibility. Moreover, extraneous motion stimuli such as a visible “salt” spray through rotor blades, wave motion, ship motion during night landings, and even wind currents in the cockpit can exacerbate the situation in naval helicopter operations (Tormes & Guedry, 1975). Vertical linear oscillations introduce linear accelerations that are aligned with gravity so that the magnitude of the resultant force field changes relative to the head, but its direction does not. If an erect observer is oscillated vertically, the changing linear acceleration is approximately perpendicular to the utricular otolith plane, and, therefore, it is ineffective as a utricular stimulus. Its approximate alignment with the saccular otolithic plane would introduce an effective saccular “shear” stimulus, but the saccular otoliths, already deflected by a 1 g shear force, may be relatively insensitive to added acceleration in the same plane. From this theoretical point of view, otolithic insensitivity to vertical linear oscillation (VLO) as compared with its sensitivity to horizontal Linear oscillation (HLO) might be expected. Von Bekesy (1940) reported accurate

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U.S. Naval Flight Surgeon’s Manual amplitude estimates of high frequency (up to 4 Hz), small amplitude VLO, but his stimuli involved high peak accelerations at frequencies where otolith gain may be high. Recent neurophysiological findings (Fernandez & Goldberg, 1976) do not support the idea that otolithic neural input information would limit perception of VLO as opposed to HLO, but some perceptual data suggest that perceptual deficiencies may occur with low frequency stimuli. Walsh (1964) reported higher thresholds for 0.11 Hz VLO than he had previously reported (1961a, 1961b, 1962) for HLO, although his data are not entirely consistent (cf. Benson et al., 1975). Several experiments (Malcolm & Melvill Jones, 1974; Melvill Jones, Rolph, & Downing, 1974-1976) have indicated perceptual inaccuracies with VLO that seem excessive relative to fairly accurate perceptions of HLO in other studies (Guedry & Harris, 1963; Young & Meiry, 1968). Walsh (1964) reported large stimulus response phase errors (individuals experienced maximum downward travel during upward travel) at 0.11 Hz and zero phase error at 1.0 Hz. Other phase data (Melvill Jones et al., 1974-1976; Young & Meiry, 1968) for HLO and VLO are not consistent with Walsh (1962, 1964), probably due to differences in reporting methodology and in high-frequency stimulus artifacts. However, the averaged oculomotor responses in Melvill Jones et. al. (1974-1976) exhibited stimulus-response phase angles at 0.11 Hz and 1 Hz, consistent with Walsh’s subjective data. Differences in body position (reclining in Walsh’s studies, erect in other studies) may also contribute to some of the interexperimental differences. Spinovestibular interactions may modulate perceptual experience in the erect observer during VLO through mechanisms similar to those involved in the very different perceptual experiences noted above in the aftereffects of active versus passive turning. The presence of substantial perceptual phase errors and even the inconsistencies within and between studies are relevant to the problems of aviators, especially pilots of helicopter and vertical/short takeoff and landing V/STOL aircraft. If methodological differences and stimulus artifacts influence perceptual consistency in formal experiments, the pilot will also be subject to perceptual inconsistencies and occasional large phase errors in the noisy acceleration environment of flight where he is variously occupied with different elements of his flight task. Prevention of Disorientation Disorientation of flight will be experienced at one time or another by all pilots who fly more than a few hours under conditions of poor visibility. However, the intensity of the experience, the ease with which it is resolved, and the frequency vary. Some pilots may be aware of disorientation on every flight while others are rarely troubled (Aitken, 1962). About 58 percent of the helicopter pilots questioned by Tormes and Guedry (1975) indicated one or more episodes of severe disorientation. It is therefore important to provide information and training on means and methods of avoiding disorientation, of overcoming it when it occurs, and of reducing residual anxieties resulting from disorienting experiences.

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Vestibular Function Aircrew Instruction on Causes of Disorientation (cf., Benson, 1974b) It is important that aircrew know the following: 1. That disorientation is a normal reaction to a number of unusual conditions of motion that occur in flight. 2. The various types of illusory perceptions that are apt to occur in flight. 3. The flight conditions and maneuvers likely to produce disorientation. 4. How to cope with disorientation. Disorientation Threat Checklist. Navy pilots receive indoctrination on aspects of all of these points in the course of their training, but reminders are necessary. Material presented earlier in this chapter will assist the flight surgeon in ampliflying on Points 1 and 2. The following is a useful checklist for reviewing factors which constitute disorientation threats to the avaiator in a helicopter or in fiied wing aircraft. 1. Flight Environment. a. IFR - in particular, the transfer from external visual to instrument cues. b. Night - ground/sky confusion. Isolated light sources enhance the probability of oculogravic oculogyral, and autokinetic illusions. c. High Altitude - false horizontal reference. Dissociative sensations of detachment or remoteness from aircraft, from Earth, or from reality (break-off phenomenon). “Break-off” may occur in helicopter pilots at lower altitudes or on crossing escarpments. d. Flight Over Featureless Terrain - false perception of height. 2. Flight Maneuvers. a. Prolonged acceleration and deceleration in line of flight and catapult launches somatogravic and oculogravic illusions. b. Prolonged angular motion - sustained motion not sensed; somatogyral illusions on recovery; no sensation of bank during coordinated turn; cross-coupled and “g-excess” illusions if head movement is made while turning. c. Subthreshold changes in altitude - “the leans” induced on recovery. d. Workload of flight maneuvers - High arousal enhances disorientation and reduces the ability to resolve perceptual conflict. e. Ascent or descent - pressure vertigo. f. Cloud penetration - VFR/IFR transfer and attendant problems especially when flying in formation or on breaking formation. In the “lean on the sun” illusion a

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U.S. Naval Flight Surgeon’s Manual bright spot in the cloud may be interpreted as up. Depending upon the heading of the aircraft relative to the bright spot, the false vertical reference may induce attitude errors in roll and pitch. 3. Aircraft Factors. a. Inadequate instruments. b. Inoperative instruments. c. Visibility of instruments. d. Badly positioned diplays and controls - head movement required to see and operate. e. High rates of angular and linear acceleration, high maneuverability. f. View from cockpit - Lack of visible aircraft structure enhances “break-off” and provides a poor visual frame of reference. 4. Aircrew Factors. a. Flight experience. b. Training, experience, and proficiency in instrument flight. c. Currency of flying practice. d. Physical health - upper respiratory tract infection and “pressure vertigo”. e. Mental Health - High arousal and anxiety increase susceptibility to disorientation. f. Alcohol and drugs - impaired mental function. Alcohol and barbituates, even at low levels, impair ability to suppress nystagmus. g. Fatigue or task overload. Flight Conditions. Table 3-2 and the following specific list of conditions leading to disorientation were derived from a survey of Navy helicopter disorientation incidents: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Perception of the wind through cockpit side window while in hover or translational lift. Flying into smoke flares. Task saturation. Wave motion interpreted as aircraft motion. Hot switch (crew change while rotors engaged) at night. Low-altitude search pattern at night. Night launch from forward spots on flight deck. Lack of recent instrument flying. Relative immobilization by wet suit for prolonged periods. Communication difficulty (noise, poor radio discipline). Excessive translational lift vibration. Hover not level.

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Vestibular Function 13. 14. 15. 16.

Reflection of anticollision lights. Vibration dampeners on instrument panel inadequate, allowing blurring of instruments. Light from middle console reflects on middle windscreen. Cyclic stick not in center neutral position in level flight.

These lists of flight conditions and maneuvers that induce disorientation are helpful, but they are certainly not all-inclusive. For example, maneuvers such as barrel rolls and Cuban eights that involve temporary inverted flight can induce confusion. At the point of inversion, the pilot tends to move his controls in the wrong direction for completing the maneuver. The interested Flight Surgeon can develop a substantial catalog of flight conditions that tend to induce disorientation by dialogue with pilots. Pilots are frequently interested in describing their experiences and also their methods of resolving problems with disorientation. Aircraft Factors. It is important to remember that there are factors peculiar to each aircraft which can contribute to disorientation. For this reason, Flight Surgeons should be alert to these factors in discussions with pilots because of knowledge of conditions peculiar to a given aircraft may be useful information for general dissemination to the squadron and may also be helpful in understanding problems reported by individuals. Aircrew Factors. Surveys have shown that flight experience does not prevent disorientation (Moser, 1969; Ninow, Cunningham, & Radcliffe, 1972), but the incidence appears to be reduced with increasing experience. Current flying practice is helpful in several ways. A number of studies of repeated exposure to unusual motion have shown that both disturbance and counter productive reflexive actions are diminished or modified in a productive direction as a result of repetitive experience with unusual motions (Guedry & Correia, 1978). It is not unlikely that disruptive perceptual-motor reflexive responses diminish and in their modified form are useful to the pilot at a subconscious level in providing the feel of flight maneuvers. Something like this is needed to account for the fact that highly experienced pilots are highly disturbed, whereas the novice is not, by fixed base simulators in which the visual scene moves in response to control action. Instrument skills are highly dependent upon practice. Interpretation of instrument information is an intellectual function which demands integrating symbolic orientation cues from some instrument with digital information from others. Recently, there have been efforts to make use of the strong perceptual effects of large moving visual displays (cf., Dichgans et. al., 1972) to combat “the leans.” Servo-driven artificial horizons subtending a 160 degree can be projected onto aircraft instrument panels, and they appear to be more compelling than information intellectually derived from the usual, small aircraft instruments (Malcolm, Money, & Anderson, 1975). However, with current aircraft instruments, the information provided may be far less compelling

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U.S. Naval Flight Surgeon’s Manual than the direct perceptual response to some unusual flight conditions. Yet, the pilot must use the intellectually derived information from his instruments. By the time instrument scan information becomes second nature, the pilot may be unaware of many disorienting sensations because his control actions may be overriding these sensations, and he is also highly proficient in the use of his instruments. The out-of-practice, “experienced” pilot may have partially lost both of these advantages and may be more at risk than the novice if he is overconfident and enters threatening flight conditions. For this reason, refresher training in the form of lecture material, demonstrations, and dual flying prior to resuming operational flights is desirable. Some experienced pilots may feel they are immune to disorientation, but exposure to a simple, ground based motion device is ordinarily sufficient to remind the aviator that he is, in fact, not immune. The pilot with many flying hours will have learned much about disorientation and coping with it, but the causes of disorientation are so numerous that he is unlikely to have had experience with every type. Pressure vertigo may occur only one time, but awareness of its potential effects may be sufficient to cause the pilot with a cold to avoid flying, or to enable the pilot who experiences it to remain sufficiently calm to combat it. Thus, knowledge of conditions that increase the probability of disorientation can serve to avoid it and also serve to reduce debilitating hyperarousal when and if it occurs. Ground based demonstration of normal disorientation experiences has been received with enthusiasm by experienced as well as beginning aviators in the RAF and is considered critical to effective training (Benson, 1980). The Multistation Spatial Disorientation Demonstrator (MSDD, Pensacola) provides demonstration of all of the effects produced by the RAF demonstrator, as well as additional visual effects. Aircrew Instruction on Prevention and Coping witb Disorientation Although knowledge of conditions that produce disorientation is important to aircrew, they should never hear about the illusions occurring in flight and the consequences of disorientation without also hearing the instructions for how to deal with the problem. In this connection, several articles (Benson, 1974b; Benson & Burchard, 1973) have listed practical advice to aircrew for preventing and coping with disorientation. How to Prevent Disorientation. 1. Remain convinced that you cannot fly by the “seat of your pants.” 2. When flying wing on another aircraft, remember your perceived aircraft attitude often differs substantially from your true aircraft attitude because you are concentrating on the other aircraft. This is a dangerous form of disorientation. 3. Do not allow control of the aircraft to be based at any time on “seat of the pants” sensations, even when temporarily deprived of visual cues.

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Vestibular Function 4. Do not unnecessarily mix flying by instruments with flying by external visual cues. 5. Aim to make an early transition to instruments when flying in poor visibility, once established, stay on instruments until use of external cues is clearly practical. 6. Maintain high proficiency and practice in flying under IFR conditions. 7. Become thoroughly familiar with instruments. When transitioning to newer aircraft, new instruments are often confusing. 8. Do not fly with an upper respiratory tract infection, when under the influence of drugs or alcohol, or when mentally or physically debilitated. 9. Remember, experience does not make you immune. How to Cope With Disorientation. 1. Persistent minor disorientation (e.g., the leans) may be dispelled by making a positive effort to redirect attention to other aspects of the flying task; a quick shake of the head, provided aircraft is straight and level, is effective with some pilots. 2. When suddenly confronted by strong illusory sensations or when experiencing difficulties in establishing orientation and control of the aircraft, follow these procedures: a. Get onto instruments; check and crosscheck. Ensure good illumination. b. Maintain instrument reference. Control the aircraft in order to make the instruments display the desired flight configuration. Do not attempt to mix flight by external visual references with instrument flight until external visual cues are clearly practical. c. Maintain correct instrument scan; do not omit altimeter. d. Use advance headwork on necessary control actions in those maneuvers that typically produce confusion (e.g., inverted position in barrel roll). e. Seek help if severe disorientation persists. Hand over to copilot (if present), call ground controller and other aircraft, check altimeter. f. If control cannot be regained, abandon aircraft. 3. Remember: Nearly all disorientation is a normal response to the unnatural environment of flight. If you have been alarmed by a flight incident, discuss it with colleagues, including your medical officer or flight surgeon. Your experiences wilI probably not be as unusual as you thought. Additional Information for Helicopter Crews. A list for avoiding and coping with disorientation in helicopters (Tormes & Guedry, 1975) was essentially a duplicate of the above except for the following items: 1. When disorientation occurs, fly straight and level and increase forward airspeed.

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U.S. Naval Flight Surgeon’s Manual 2. 3. 4. 5.

In weather, turn off the forward rotator beacon. Always fly with a trimmed stick, (i.e., aircraft flies level with stick neutralized). When disorientation occurs in hover, depart hover, and increase forward airspeed. Upon entry into a cloud bank, turn 180 degrees unless under positive control. Evaluation and Management of Disorientation Problems

One major factor in coping with disorientation is the pilot’s ability to maintain composure and intellectual command of the aircraft despite distractions and disorienting inputs. Psychological disturbance is, therefore, one factor to be seriously considered by the Flight Surgeon in pilots whose presenting symptom is disorientation (O’Connor, 1967). Impairment of higher mental function and the reduced motor coordination that frequently accompany hyperarousal can obviously be side effects of fatigue, tension due to personal problems, or poor health. Alcohol and various drugs are additional threats to the effective resolution of disorientation problems. To a surprising degree, they can reduce visual control of eye movements in motion environments, while at the same time risking impairment of necessary intellectual control. While probing for psychological factors, it is, however, necessary to bear in mind that individuals who experience strong vertiginous episodes as a result of some pathological condition are also frequently greatly disturbed by the experience. The emotional disturbance may then lead to the conclusion by the doctor as well as by the patient’s friends that the whole episode is a sign of neurosis or an anxiety reaction. The same is true of the aviator who has had an exceptional disorientation episode. Whatever the actual cause of the disorientation, the emotional overlay that is likely to result from the episode must be dealt with. In handling such cases, it is important for the doctor to show that he is interested. This will ordinarily be accomplished in the process of taking a history of the incident and relevant background material. A thorough history is perhaps the most important step in the examination. It is first necessary to establish clearly whether or not the occurrence of disorientation in a pilot is due to a natural response to an unusual flight condition. The absence of similar reports by others in the aircraft does not by itself constitute evidence of an abnormal reaction from the pilot. Crew members may have been equally disoriented without awareness of the fact because awareness sometimes depends upon checking the perceptual event against information from the instrument panel or from sudden VFR contact.

In attempting to relate disorientation to flight conditions, items in the check lists should be considered. When it appears that disorientation is attributable to normal reactions to either aircraft

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Vestibular Function or flight conditions, then reassurance that the reaction was normal, possibly including discussion with other pilots, may be sufficient to allay anxiety. If concern persists, then a period of dual flight may serve to restore confidence, but it may be necessary to seek the help of a specialist (cf., O’Connor, 1967). There is some evidence that acquired fear of some aspect of flying in a previously confident aviator is amenable to treatment with a fairly high probability of success (Goomey, 1973; O’Connor, Lister & Rollins, 1973). Organic causes of disorientation are discussed in Chapter 8 on Otorhinolaryngology. References Aitken, R.C.B. Factors influencing flight safety (IAM Rept. R-209). Farnborough, England: RAF institute of Aviation Medicine, 1961. Baloh, R.W., Konrad, H.R., & Honrubia, A. Vestibulo-ocular function in patients with cerebellar atrophy. Neurology, 1975, 25, 160-168. Barnes, G.R., Benson, A.J., & Prior, A.R.J. Visual suppression of inappropriate eye movements induced by vestibular stimulation. Workshop of the European Brain and Behavior Society: Vestibular Function and Behavior, Pavia, Italy, April 25-26, 1974. Benson, A.J. Spatial disorientation in flight. In J.A. Gillies (Ed.), A textbook of aviation physiology. London/New York: Pergamon Press, 1965. Benson, A. J. Interactions between semicircular canals and gravireceptors. In D.E. Busby (Ed.), Recent advances in aerospace medicine. Proceedings of the 18th International Congress of Aviation and Space Medicine, Amsterdam, 1969. Dordrecht, Holland: D. Reidel Pub. Co., 1970. pp. 250-261. Benson, A.J. Effect of angular oscillation in yaw on vision. Proceedings of the Aerospace Medical Association Scientific Meeting. Washington, D.C.: Aerospace Medical Association, 1972, 43-44. Benson, A.J. Modification of the response to angular accelerations by linear acceleration. In H.H. Komhuber (Ed.), Handbook of sensory physiology (Vol. VI, Part 2). Berlin/Heidelberg/New York: Springer-Verlag, 1974a. 281-320. Benson, A.J. Orientation/disorientation training of flying personnel: A working group report (AGARDR-625). London: Technical Editing and Reproduction Ltd., 1974b. Benson, A.J. The Royal Air Force Spatial Disorientation Familiarization Device. NATO/AGARD Conference Proceedings No. 287 (AGARD-CP-287), pp. B-11-1 through B-11-7, October 1980. Benson, A.J., & Burchard, E. Spatial disorientation in flight. A handbook for aircrew (AGAR-Dograph AG-170). London: Technical Editing and Reproduction Ltd.,1973. Benson, A.J., & Guedry, F.E. Comparison of tracking task performance and nystagmus during sinusodial oscillation in yaw and pitch. Aerospace Medicine, 1971, 42, 593-601. Benson, A.J., Diaz, E., & Farrugia, P. The perception of body orientation relative to a rotating linear acceleration vector. In H. Schone (Ed.), Mechanisms of spatial perception and orientation as reIated to gravity. Stuttgart: Gustav Fisher-Verlag, 1975. Bisti, S., Maffei, L., & Piccotino, M. Visual-vertibular interactions in the cat superior colliculus. Journal of Neurophysiology, 1974, 37, 145-155.

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U.S. Naval Flight Surgeon’s Manual Brandt, T., Dichgans, J., & Koenig, E. Differential effects of central versus peripheral vision on egocentric and exocentric motion perception. Experimental Brain Research, 1973, 16, 476-491. Brandt, T., Wist, E., & Dichgans, J. Oprisch indeczierte pseudocoriolis- effekte and circularvektion. Archiv fuer Physchiatrie und Nervenkrankheiten (West Germany), 1971, 214, 365-389. Brictson, C.A. Evaluation of the special senses for flying duties: Perceptual abilities of landing signal officers (LSO’s) (AGARD CP-152). London: Technical Editing and Reproduction Ltd., 1975. Clark, B. Pilot reports of disorientation across four years of flight. Aerospace Medicine, 1971, 42, 708-712. Clark, B., & Stewart, J.D. Attitude and Cotiolis motion in a flight simulator. A e r o s p a c e Medicine, 1967, 38, 936-940. Clark, B., & Stewart, J.D. Effects of angular acceleration on man, thresholds for the perception of rotation, and the oculogyral illusion. Aerospace Medicine, 1969, 40, 952-956. Clark, B., Randall, R., & Stewart, J.D. Vestibulo-ocular reflex in man. Aviation, Space, and Environmental Medicine, 1975, 46, 1336-1339. Cocquyt, P.P. Sensory illusions. Shell Aviation News, 1953, pp. 178-186. Cohen, M.M., Crosbie, R.J., & Blackbum, L.H. Disorienting effects of aircraft catapult lauches. In A.J. Benson (Ed.), The disorientation incident (AGARD CP-95 - Part 1). London: Technical Editing and Reproduction, Ltd., 1972. Collar, A.R. On an aspect of the accident history of aircraft taking off at night. Aeronautical Research Council Reports and Memoranda No. 2277. London: HMSO, August 1946 Collins, W.E. Coriolis vestibular stimulation and visual surrounds. Aerospace Medicine, 1968, 39, 125-138. Correia, M.J., & Guedry, F.E. The vestibular system: Basic biophysical and physiological mechanisms. In R.B. Masterson (Ed.), Handbook of behavioral neurobiology. New York: Plenum Publishing Corp., 1978. Dichgans, J., Held, R., Young, L.R., & Brandt, T. Moving visual scenes influence the apparent direction of gravity. Science, 1972, 178, 1217-1219. Dichgans, J., Schmidt, C.L., & Graf, W. Visual input improves the speedometer function of the vestibular nuclei in goldfish. Experimental Brain Research, 1973. 18, 319-322. Fernandez, C., & Goldberg, J. Physiology of peripheral neurons innervating otolith organs of the squirrel monkey. Journal of Neurophysiology, 1976, 39, 970-1008. Fernandez, C., Goldberg, J.M. & Abend, W.K. Response to static tilts of peripheral neurons innervating otolith organs of the squirrel monkey. Journal of Neurophysiology, 1972, 35, 978-997. Gillingham, K.K., & Krutz, R.W. Effects of the abdominal acceleratory environment of flight (SAM TR-74-57). Brooks AFB, Texas: USAF School of Aerospace Medicine, 1974. Gilson, R.D., Guedry, F.E., Hixson, W.C., & Niven, J.I. Observations on perceived changes in aircraft attitude attending head movements made in a 2-g bank and turn. Aerospace Medicine, 1973, 44, 90-92. Goldberg, J.M. & Fenandez, C. Vestibular mechanisms. Annual Review of Physiology, 1975, 37, 129-162. Goorney, A.B. Assessment of behavior therapy in the treatment of flying phobias. In P.J. O’Connor (Ed.), Clinical psychology and psychiatry of the aerospace operational environment (AGARD CP-133). London: Technical Editing and Reproduction Ltd., 1973. Graybiel, A. Oculogravic illusion. AMA Archives of Ophthalmology 1952, 48, 605-615. Graybiel, A., & Clark, B. Perception of the horizontal or vertical with the head upright, on the side, and

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Vestibular Function inverted under static conditions, and during exposure to centripetal force. Aerospace Medicine, 1962, 33, 147-155. Graybiel, A., & Hupp, D.I. The oculogyral illusion. Journal of Aviation Medicine, 1946, 3, l-12. Graybiel, A., & Clark, B. The validity of the oculogravic illusion as a specific indicator of otolith function. Aerospace Medicine, 1965, 36, 1173-1181. Graybiel, A., Miller, E.F., & Homick, J.L. Experiment M-131. Human vestibular function. In R.S. Johnston & L.F. Dietlein (Eds.), The proceedings of the Skyfab life science symposium (Vol. 1) (NASA TM X-58154, JSC-09275). Houston, Texas: NASA, Johnson Space Center, November 1974. Gresty, M., & Benson, A.J. Movement of the head in pitch during whole body activities. 1976 Grusser, O.J., & Grusser-Komehls, U. Interaction of vestibular and visual inputs in the visual system. In A Brodal & O. Pompiano (Eds), Progress in Brain Research, 1972, 37, 573-583. Guedry, F.E. Psychophysics of vestibular sensation. In H.H. Komhuber (Ed.), Handbook of sensory physiology (Vol. VI, Part 2). Berlin/Heidelberg/New York: Springer-Verlag, 1974. Guedry, F.E., & Benson, A.J. Coriolis cross-coupling effects: Disorienting and nauseogenic or not? (NAMRL-1231). Pensacola, FL: Naval Aerospace Medical Research Laboratory, 1976. Guedry, F.E., & Correia, M.J. Vestibular function in normal and in exceptional conditions. In R.B. Masterson (Ed.), Handbook of behavioral neurobiology. New York: Plenum Publishing Corp., 1978. Guerdy, F.E., & Harris, C.W. Labyrinthine functions related to experiments on the parellel swing (NSAM-874, Rept. No. 86). Pensacola, FL: Naval School of Aviation Medicine, 1963. Guerdy, F.E., Gilson, R.D., Schroeder, D.J., &Collins, W.E. Some effects of alcohol on various aspects of oculomotor control. Aviation, Space, and Environmental Medicine, 1975, 46, 1008-1013. Henn, V., Young, L-R., & Finley, C. Vestibular nucleus units in alert monkeys are also influenced by moving visual fields, Brain Research, 1974, 71, 144-149. Hixson, W.C., & Spezia, E. Incidence and cost of orientation-error accidents in Regular Army aircraft over a five-year period: Summary report (NAMRL-1238, USAARL 77-19). Pensacola, FL: Naval Aerospace Medical Research Laboratory, 1977. Hixson, W.C., Niven, J.I., & Correia, M.J. Kinematics nomenclature for psychological accelerations (Monograph 14). Pensacola, FL: Naval Aerospace Medical Institute, 1966. Horn, C., Steckler, G., & Hill, R.M. Receptive fields of units in the visual cortex of the cat in the presence and absence of bodily tilt. Experimental Brain Research, 1972, 15, 113-132. Krause, R.N. Disorientation: An evaluation of the etiologic factors. Brooks AFB, Texas: Air University, School of Aviation Medicine, 1959. Ledoux, A., & Demanez, J.T. “Ocular fixation” index in the caloric test. In J. Stahle (Ed.), Vestibular function on Earth and in space. Oxford: Pergamon Press, 1970. Lindeman, H.H. Studies on the morphology of the sensory regions of the vestibular apparatus. Berlin/Heidelberg/New York: Springer-Verlag, 1969. Lisberger, S.G., & Fuchs, A.F. Response of flocculus Purkinje cells to adequate vestibular stimulation in the alert monkey: Fixation versus compensatory eye movements. Brain Research, 1974, 69, 347-353. Lundgren, C.E.G., & Malm, L.U. Alternobaric vertigo among pilots. Aerospace Medicine, 1966, 37, 178-180. Malcolm, R., & Melvill Jones, G. Erroneous perception of vertical motion by humans seated in the upright position. Acta Otolaryngologica (Stockholm), 1974, 77, 274-283.

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U.S. Naval Flight Surgeon’s Manual Malcolm, R., & Money, K.E. Two specific kinds of disorientation incidents: Jet upset and giant hand. In A.J. Benson (Ed.), The disorientation incident (AGARD CP-95 - Part 1). London: Technical Editing and Reproduction Ltd., 1972. Malcolm, R., Money, K.E. & Anderson, P. Peripheral vision artificial horizon display. In H.E. von Gierke, (Ed.), Vibration and combined stresses in advanced systems (AGARD CP-145). London: Technical Editing and Reproduction Ltd., 1975. Martin, J.F., & Melvill Jones, G. Theoretical man-machine interactions which might lead to loss of aircraft control. Aerospace Medicine, 1965, 36, 713-717. Melvill Jones, G. Current problems associated with disorientation in man-controlled flight (FPRC Rept. 1021). Farnborough, England: RAF Institute of Aviation Medicine, 1957. Melvill Jones, G. Predominance of anticompensatory oculomotor response during rapid head rotation. Aerospace Medicine, 1964, 35, 965-968. Melvill Jones, G. Disturbance of oculomotor control in flight. Aerospace Medicine, 1965, 36, 461-465. MelvilI Jones, G., Rolph, R., & Downing, G.H. Human subjective and reflex responses to sinusoidal vertical acceleration (DRB Aviation Medicine Research Unit Reports [Vol V]). Montreal: McGill University and Ottawa: Defense Research Board, 1974-1976. Miles, F.A., & Fuller, J.H. Visual tracking in the primate flocculus. Science, 1975, 189, 1000-1002. Moser, R. Spatial disorientation as a factor in accidents in an operational command. Aerospace Medicine, 1969, 40, 174-176. Ninow, E.H., Cunningham, W.F., & Radcliffe, F.A. Psychophysiological and environmental factors affecting disorientation in naval aircraft accidents. In A.J. Benson (Ed.), The disorientation incident (AGARD CP-95 - Part 1). London: Technical Editing and Reproduction Ltd., 1972. Nuttall, J.B. The problem of spatial orientation. Journal of the American Medical Association, 1958, 166, 431-438. O’Connor, P.J. Differential diagnosis of disorientation in flying. Aerospace Medicine, 1967, 38, 1155-1160. O’Connor, P.J., Lister, J.A., & Rollins, J.W. Results of behavior therapy in flying phobia. In P.J. O’Connor (Ed.), Clinical psychology and psychiatry of the aerospace operational environment (AGARD CP-133). London: Technical Editing and Reproduction Ltd., 1973. Ornitz, E.M. Vestibular dysfunction in schizophrenia and childhood autism. Comparative Psychiatry, 1970, 11, 159-173. Parker, D.E., Ritz, L.A., Tubbs, R.L. & Wood, D.L. Effects of sound on the vestibular system (AMRL TR 75-89). Oxford, Ohio: Miami University, 1976. Passey, G.E., & Guedry, F.E. Perception of the vertical. II. Adaptation effects in four planes. Journal of Experimental Psychology. 1949, 39, 700-707. Reason, J.T., & Brand, J.J. Motion sickness. London/New York: Academic Press, 1975. Reinhardt, R.F., Tucker, G. J., & Haynes, J.M. Aerospace psychiatry and neurology. In U.S. Naval Flight Surgeon's Manual. Washington, D.C.: U.S. Government Printing Office, 1968. Simpson, C.G. & Lyons, T.G. Giant hand phenomenon. (Abstract) 58th Annual Scientific Medical Meeting of the Aerospace Medical Association, Las Vegas, May 1987. Sinha R. Effect of vestibular Coriolis reaction on respiration and blood-flow changes in man. Aerospace Medicine, 1968, 39, 837-844. Stockwell, C.W., & Guedry, F.E. The effects of semicircular canal stimulation during tilting on the

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Vestibular Function subsequent perception of the visual vertical. Acta Otolaryngologica (Stockholm), 1970 70, 170-175. Takemori, S., & Cohen, B. Loss of visual suppression of vestibular nystagmus after flocculus lesions. Brain Research, 1974, 72, 213-224. Tjemstrom, O. Alternobaric vertigo. An experimental study in man of vertigo due to atmospheric pressure changes. Thesis, printed in offset, Malmo General Hospital, Malmo, Sweden, 1974. Tormes, F.R., & Guedry, F.E. Disorientation phenomena in naval helicopter pilots. Aviation, Space, and Environmental Medicine, 1975 46, 387-393. Von Bekesy, G. Uber die starke der vibrationsempfindung und ihre objektive messung. Sonderdruck aus “Akustische Zeits”, 1940, 5, 113-124. Walsh, E.G. Role of the vestibular apparatus in the perception of motion on the parallel swing. Journal of Physiology (London), 1961a, 155, 506-513. Walsh, E.G. Sensations aroused by rhythmically repeated linear motion-phase relationships. Joumal of Physiology (London), 1961b, 155, 53P-54P. Walsh, E.G. The perception of rhythmically repeated linear motion in the horizontal plane. British Journal of Physiology, 1962, 53, 439-445. Walsh, E.G. The perception of rhythmically repeated linear motion in the vertical plane. Quarrerly Journal of EperimentalPhysiology, 1964, 49, 58-65. Young, L.R. On visual-vestibular interaction. In Fifth Symposium on “The Role of the Vestibular Organs in Space Exploration” (NASA SP-314). Washington, D.C.: U.S. Government Printing Office, 1973. Young, L.R., & Meiry, J.L. A revised dynamic otolith model. Aerospace Medicine, 1968, 39, 606-608.

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CHAPTER 4 SPACE FLIGHT CONSIDERATIONS Introduction Manned Space Flight Programs for the 1990’s Medical Standards for Shuttle Astronauts Physiological Considerations in Space Flight References and Bibliography Introduction The role of the flight surgeon in support of space operations and travel has continued to expand exponentially. Much information has been realized since the onset of manned space flight some three decades ago. While most direct care of Shuttle astronauts remains the bailiwick of National Aeronautics and Space Administration (NASA) physicians, the naval flight surgeon should be cognizant of fundamental physiological changes experienced during Shuttle operations in the event that they were to be involved in astronaut care at auxiliary landing sites, or as the result of an emergency requiring the Shuttle to ditch at sea. This chapter is not meant to be an exhaustive compendium of space medicine. Rather, it should serve to acquaint operational physicians with characteristics unique to manned space flight. More specific questions should be directed to the physicians at NASA, or retrieved from existing data bases at the Johnson Space Center laboratories in Houston, Texas. Manned Space Flight Programs for the 1990’s A new vista in manned space flight was reached on 12 April 1981 when the Space Shuttle made its maiden voyage. With it came the ability to extend the time spent in orbit to weeks and months. As conditions associated with space travel cannot be duplicated anywhere else on Earth, plans are underway to build and operate a manned space station early in the next decade. Other plans in the next two decades entail interplanetary travel, potentially years in duration. No longer are these plans the work of our great fictional writers. Therefore, it behooves all personnel associated with or interested in aerospace medicine to acquaint themselves with these programs and the unique biomedical problems associated with microgravitational states.

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U.S. Naval Flight Surgeon’s Manual Medical Standards for Shuttle Astronauts As mission requirements change, so to do the physiological requirements associated with them. The requirements specified in Table 4-1 are meant to answer basic questions concerning NASA’s requirements for each of the four medical classes of astronauts. A more detailed discussion of each category can be found in NASA publications JCS 11569, 12 – 83; JSC 11570, 12 – 83; JSC 11571, 12 – 83; and Class IV criteria updated 12 – 84. Class 1 (pilot) astronauts, Class 2 (mission specialist) astronauts, and Class 3 (payload specialist) astronauts require selection and annual medical recertification. Class 4 space flight participants must be selected and pass medical certification germane to individual mission requirements.

Physiological Considerations in Space Flight The Neurovestibular System Some 40 to 50 percent of those who travel in space for any length of time can be expected to experience some form of space motion sickness. It is generally felt to be caused by the lack of gravitational effect on the otolith organ and the semicircular canals. Onset of the symptoms occurs after establishing orbital velocity. Sympathetic symptoms include pallor, flushing, cold sweats, nausea, and emesis. More centralized symptoms include anorexia, lethargy, malaise, headache, confusion, spatial disorientation, anxiety, and depression. The symptoms last from about several hours to four or five days. Postflight vestibular symptoms last up to a week, depending upon the length of time spent in space. Standard autogenic biofeedback techniques such as those currently employed by the Navy and Air Force to desensitize susceptible aircrew members suffering from air sickness have proven effective in reducing the incidence and severity of the symptoms. Promethazine hydrochloride and ephedrine sulfate (25 mg each PO) or a combination of scopolamine hydrobromide (0.3 mg PO) and dextroamphetamine (5.0 mg PO) have proven to be highly effective in relieving these symptoms. Use and effectiveness varies from one individual to another. Therefore, if one drug or drug combination doesn’t work, the flight surgeon should try others until a suitable combination is found. Alternate administration routes (transdermal, intramuscular, etc.) are currently being investigated.

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Space Flight Considerations Table 4-1 NASA Medical Class Standards

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U.S. Naval Flight Surgeon’s Manual The Cardiovascular System Nearly all astronauts experience a cephalad – central fluid shift of 1 to 2 liters during space flight. The fluid shift is generally accompanied by increased heart rates well within the tachycardic range (110-160 BPM). Neither phenomenon is seemingly related to the length of the flight. The major sources for the fluid shifted cephalad comes from the lower extremities and the pelvis. Symptomatology experienced after the shift in fluids includes a feeling of nasal stuffiness, a full feeling in the head, and facial edema. Prominent jugular and temporal veins are also noted. With longer missions, several fluid shifts from cephalad to caudad and vice versa can be expected. These symptoms are generally self – limiting and do not require any type of medical intervention. These fluid shifts are also accompanied by orthostatic intolerance during the first week of space flight. This is generally followed by postflight syncope. No therapy is required for inflight orthostasis. However, it has been noted that having the astronauts drink 1 liter of normal saline immediately prior to initiation of the landing sequence has reduced the severity of postflight syncope. Cardiovascular parameters on electrocardiograms, echocardiograms, and vectorcardiograms undergo changes throughout space flight. For a complete discussion of these changes, please refer to Nicogossian (1981). These changes take up to several weeks to return to baseline. Crew members in earlier space programs were noted to experience rare PVC’s (numbers above their preflight baseline). Shuttle astronauts have been noted to experience up to 16 PVC’s per minute during reentry. The exact extent to which dysrhythmia can be attributed to space flight remains under investigation. Occurrences over baseline should be expected. No fatal dysrhythmias or circulatory collapse have been reported in relation to these dysrhythmias. Bone and Mineral Metabolism Both U.S. and Russian data indicate that mineral loss occurs during space flight. This results in the loss of both compact and trabecular bone. Loss of calcium begins about 10 days into space flight. While the rate of loss is slow at first (around 140 mg per day), by 84 days into flight it approaches 300 mg per day. This remains a significant factor in extended missions. Recovery and bone remodeling is gradual after a return to Earth. Time taken to remodel lost bone mass parallels the time spent in space during which it was lost. Recovery is not generally felt to be complete, with trabecular bone possibly being permanently affected. There are several methods used to counter the adverse bone effects experienced in space flight. First, exercise during space flight has been reported to help reduce bone loss. However, the results are contradictory. Calcium and phosphate dietary supplements have been shown to be efficacious for brief periods of time (short missions). Preflight diets rich in calcium and phosphate are also

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Space Flight Considerations helpful. Fluoride and clodronate disodium (a diphosphonate) have shown promising results in bed – rest simulation models. Artificial gravity systems are under development and show promise especially for the space station. Lastly, electrostimulation of muscle groups has been somewhat helpful in reducing the effects of weightlessness on bone loss. Hematological and Laboratory Parameters Significant reductions occur in both the plasma volume and the red blood cell mass. Plasma volume decreases soon after the onset of weightlessness, remains low throughout the flight, and generally returns to baseline in about one to two weeks after landing. An early reduction in red blood cell mass also occurs. It seems to plateau around the 60th day of weightlessness and returns to baseline about two to three weeks postflight. The reticulocyte count is noted to be decreased postflight on most missions, returning to normal approximately three to four week after return to Earth. On longer missions ( > 55 days), the reticulocyte count is higher than normal at the three week postflight point, and remains elevated for a number of weeks thereafter. Erythropoietin levels decrease around 24 hours after launch and continue to decrease during and after the flight. For a list of other useful laboratory parameters, see Tables 4 - 2 and 4 - 3.

Waste Management Personal hygiene and waste management prove to be a challenge in space travel. Prompt removal of all biohazards is paramount in assuring the health of the crew throughout the flight. While earlier manned flights used devices that required contact with the individual, present programs incorporate air flow for the collection and separation of excreta. Urine is generally expelled from the spacecraft, while fecal material and food remnants are freeze dried and returned to Earth on the Shuttle for final disposal. For future interplanetary missions, systems will have to be designed to reclaim water from urine, feces, and unused foodstuffs. A workable shower system was developed for the Skylab program. However, a suitable model for the Shuttle program remains in the developmental phase. As current missions are generally short in nature, the only method for bathing is via a handwashing device and sponge bath. Longer missions will necessarily require a more thorough means for bathing without compromising water availability. Special Toxilogical Hazards There are many toxic substances found aboard the Space Shuttle. Table 4 - 4 is an abbreviated

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U.S. Naval Flight Surgeon’s Manual list of some of the more commonly encountered substances aboard as well as treatment guidelines for acute exposure to them.

Table 4-2 Selected Immunological and Hematological Values

VALUE

Total White Blood Cell Count Eosinophil Count Neutrophil Count T Lymphocyte Count T Lymphocyte Function Immunoglobulin G * Lmmunoglobulin A * C3 & C4 *

TREND

Increased Decreased Increased Decreased Decreased Decreased (short flight) Increased (long flight) Decreased (short flight) Increased (long flight) Increased

* Values return to baseline in about 3 weeks.

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Space Flight Considerations Table 4-3 Selected Endocrine Laboratory Parameters

VALUE

Adrenocorticotrophic Hormone Atrial Natriuretic Factor Anti-Diuretic Hormone Aldosterone Antiotensin I Cortisol High Density Lipoprotein

IN-FLIGHT TREND

POST-FLIGHT TREND

Increased

Increased

Increased, Then Decreased Increased Decreased Decreased Decreased

Increased, Then Decreased Normal Increased Increased Increased Markedly Decreased No Change Increased No Change Increased Increased

Growth Hormone Insulin T3 T4 Thyroid Stimulating Hormone Urine Catecholamines

Increased

Circadian Rhythm Alterations Space travel is particularly disruptive to entrained circadian rhythms. Not only does the “new environment” of space and microgravity serve to disrupt sleep – wake cycles; but, there is a substantial lack of zeitgebers (natural cues) to readjust biological clocks once they uncouple. Because of the lack of zeitgebers, most crew members revert back to a 25 hour schedule. Experience has shown that for Shuttle crew, it is probably best to keep them on their Earth – bound sleep – wake cycles where possible. This further serves to minimize the impact of other disruptive environmental changes. Light-dark cycles occur every 100 minutes in the shuttle crew members.

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U.S. Naval Flight Surgeon’s Manual Therefore, artificial day – night cycles have to be developed and maintained throughout the mission to assure adequate crew rest. While ultrashort acting benzodiazipines have been found to be of some use in combatting jet lag, a paucity of information exists concerning their role in space flight. Table 4-4 Common Shuttle Hazards and Treatment

Agent

Color

Smell

Category

Symptoms

Treatment

Ammonia

colorless

pungent

mucous membrane irritant

conjunctivitis flush area with H2O eyelid edema coughing/dyspnea O2, ACLS nausea/emesis pneumonitis burns

Freon

colorless

odorless

asphyxiant, CNS depressant cardiac sensitizer

arrythmia mental status changes, dermatitis

remove from source, O2, ACLS

Hydrazine

colorless

oxidant like ammonia convulsant hepatoroxin hemolysis carcinogen

convulsion skin burn hepatits nephritis death

remove from source, anticonvulsant med Vit B6

Nitrogen Tetroxide

yellow brown red

pungent oxidant explosive

remove from yellow skin source, O2 stains. burn, ACLS blindness, pulmonary edema

Isopropyl Alcohol

colorless

disagreeabk irritant CNS depressant odor

nausea. coma

O2, IV ACLS

Mercury

silvery metal

metallic taste

systemic poison

ataxia, nausea. renal damage

remove from source

Lithium Hydroxide

white crystal

pungent

reducing agent irritant

flush, O2 severe mucous membrane irritant

*Adapted from Table 19-3, Nicogossian, A.E., Space Physiology and Medicine.

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Space Flight Considerations References and Bibliography Bungo, M.W., & Johnson, P.C. Cardiovascular examinations and observations of deconditioning during the space shuttle orbital flight test program. Aviation Space and Environmental Medicine, 1983, 54, 1001-1004. Bungo, M.W., & Johnson, P.C. Cardiovascular deconditioning during space flight and the use of saline as a countermeasure to orthostatic intolerance. Aviation Space and Environmental Medicine, 1985, 56, 985-990. Bungo, M.W., & Goldwater, D. J., et.al. Echocardiographic evaluation of space shuttle crew members. Journal of Applied Physiology, 1987, 62, 278-283. Calvin, M., & Gazenko, O.G. Foundations of space biology, (NASA SP-374). Washington, DC: US Government Printing Office, 1975. Cann, C. Determination of spine mineral density using computerized tomography: A report. Washington, DC: XII US/USSR Joint Working Group Meeting on Space Biology and Medicine, 1981. Coleman, M.E. Atmospheric contamination control, space station medical science concepts (NASA TM - 58255). Houston: Lyndon B. Johnson Space Center, 1984. DeHart, R.L. Fundamentals of Aerospace Medicine. Philadelphia: Lea and Febiger, 1985. Gazenko, O.G., Grigor’yev, A.I., & Natochin, Y.V. Fluid electrolyte homeostasis and weightlessness. Space Biology and Aerospace Medicine, 1980, 14, 1-11. Graybiel, A., Wood, C.D. et.al. Human assay of anti-motion sickness drugs. Aviation Space and Environmental Medicine, 1975 46, 1107-1118. Henry, W.L., Epstein, S.E., et.al. Effect of prolonged space flight on cardiac function and dimensions, biomedical results from Skylab (NASA SP - 377). Washington, DC: U.S. Government Printing Office, 1977. Homick, J.L., Kohl, R.L., et.al. Transdermal scopolamine in the prevention of motion sickness: Evaluation of the time course of efficacy. Aviation Space and Environmental Medicine, 1983, 54, 994-1000. Hoffler, G.W. Cardiovascular studies of U.S. space crews: An overview and perspective, cardiovascular flow dynamics and measurements. In Hwang, N.H.C. & Normann, N.A. (Eds.), Baltimore: 1977. Hoffler, G.W., & Johnson, R.L. Apollo flight crew evaluations, biomedical results of Apollo (NASA SP-368). Washington, DC: U.S. Government Printing Office, 1975. Hoffler, J.L., Johnson, R.L., Nicogossian, A.E., et.al. Vectorcardiographic results from Skylab medical experiment M092: Lower body negative pressure, biomedical results from Skylab (NASA SP - 377), Washington, DC: U.S. Government Printing Office, 1977. Leach, C.S. An overview of the endocrine and metabolic changes in manned space flight. Acta Astronautica 1981, 8, 977-986. Leach, C.S. Biochemistry and endocrinology results, the Apollo-Soyuz test project medical report (NASA SP-411). In Nicogossian, A.E. (Ed.), Washington, DC: U.S. Government Printing Office, 1977. Money, K.E. Motion Sickness. Physiology Review 1970, 50, 1-39. Nicogossian, A.E. Space physiology and medicine. Philadelphia: Lea and Febiger, 1989. Nicogossian, A.E., LaPinta, C.K., et.al. Crew health: The Apollo-Soyuz test project medical report (NASA SP -411). In Nicogossian, A.E. (Ed.), Springfield, VA: National Technical Information Service. 1977.

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U.S. Naval Flight Surgeon’s Manual Proctor, N.H., Hughes, J.P., & Fischman, M.L. Chemical hazards of the workplace. New York: J.B. Lippincott, 1988. Reason, J.T., & Brand, J.J. Motion sickness. London: Academic Press, 1975. Reason, J.T. & Graybiel, A. An attempt to measure the degree of adaptation produced by differing amounts of coriolis vestibular stimulation in the slow rotation room (NAM1 - 1084, NASA Order R - 93). Pensacola: Naval Aerospace Medical Institute, 1969. Smith, R.F., Stanton, K., et.al. Vectocardiographic changes during extended space flight: Observations at rest and during exercise biomedical results from Skylab (NASA SP - 377). Washington, DC: U.S. Government Printing Office, 1977. Stupakov, G.P. Artificial gravity as a means of preventing atrophic skeletal changes. Space Biology Aerospace Medicine, 1981, 15, 88-90. Vogel, J.M., & Whittle, M.W. Bone mineral changes: The second manned Skylab mission. Aviation Space and Environmental Medicine, 1976, 47, 396-400.

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CHAPTER 5 INTERNAL MEDICINE Section IV: Metabolic Disorders (Continued) Disorders of Glucose Metabolism Hyperlipidemias Obesity Section V: Pulmonary Disease Pulmonary Function Testing Aviation Effects on Pulmonary Function Asthma Spontaneous Pneumothorax Sarcoidosis Pulmonary Emboli Airway Bums Section VI: Infectious Disease Viral Disease Tuberculosis Malaria Amebiasis Traveler’s Diarrhea Section VII: Renal Disease Urinary Tract Infection Hematuria/Proteinuria Nephrolithiasis Section VIII: Malignancy References and Bibliography

Section I: Cardiology Introduction Basics of Electrocardiography Axis Complexes and Intervals Normal Electrocardiographic Variants Abnormalities of Conduction Arrhythmias Acquired and Congenital Structural Heart Disease Endocarditis Prophylaxis Atherosclerotic Heart Disease Hypertension Section II: Gastroenterology Esophageal Reflux and Hiatai Hernia Peptic Ulcer Disease Inflammatory Bowel Disease Alcoholic Liver Disease Section III: Hematology Anemias - An Overview Hemoglobinopathies Section IV: Metabolic Disorders Adrenal Disorders Thyroid Disorders

SECTION 1: CARDIOLOGY Introduction The electrocardiogram (ECG) is an invaluable diagnostic aid and clinical tool. It is not meant to replace a thorough review of a patient’s medical history nor a carefully conducted physical ex-

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U.S. Naval Flight Surgeon’s Manual amination. Rather, the standard basic cardiovascular examination. dealing with a completely normal necessarily imply immediate and

12-lead ECG provides additional information to amplify the The ECG, if normal, offers no guarantee that a physician is cardiovascular system. Conversely, the abnormal ECG does not unalterable catastrophe in a patient.

In the majority of instances, a flight surgeon will be dealing with healthy, young adult males. It is important, therefore, that the normal ECG be recognized in its various forms. The following review stresses the identification and evaluation of the normal tracing. In so doing, it is hoped that the identification of abnormal tracings can be aided. Basics of Electrocardiography In order to determine whether a tracing is normal or abnormal, a clear knowledge of lead placement (Figure 5-l), electrocardiogram components (Figure 5-2), and normal variants is necessary. A definite and systematic approach quite similar to the preflight checklist used in naval aviation should be adopted in the interpretation of any electrocardiogram. The first step is to scan the ECG tracing for basic items of information and organization. Patient identification, including name, rank and serial number, should be on the tracing. Also included must be relevant clinical information, such as age, sex, and current medication. The tracing should present all 12 leads, with proper standardization in all leads and a 1.0 millivolt (10 millimeter (mm)) deflection. This initial scan should also attempt to detect any 60 hertz interference due to improper grounding, evidence of muscle tremor or similar artifacts, or a wandering baseline. The ECG next should be examined for regularity of rhythm. If there is an essential regularity, is it sinus, junctional, or idioventricular? With an irregular rhythm, is there is a definite pattern to the irregularity? Are there beats grouped in pairs? Are there dropped beats? Is there an erratic irregularity? Finally, the initial scan should assess the rate of heart beat. This can be done if one understands standard recording procedures. The electrocardiogram is inscribed on a background of one millimeter squares with each fifth line thicker than the intervening four. The horizontal span between the thickened lines is 0.20 seconds (l/5 second). Thus, the time elapsing between each mm square (at a standard speed of 25 mm/second) is 0.04 seconds, the basic interval for timing electrocardiographic events. Also, there are three-second marginal markers on most ECG paper; knowing this, the simplest system to estimate rate is by multiplying the number of cycles in six seconds by ten. If the tracing is not long enough to allow this, the number of fifths of a second between cycles can be determined, and this number then divided into 300.

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Figure 5-1. Precordial lead placement for horizontal plane leads.

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Figure 5-2. Basic electrocardiographic measurements and complexes. Axis The orientation of the heart’s electrical activity in the frontal plane may be expressed in terms of the “axis” or “heart position”. To calculate the numerical axis, one must know the Hexaxial Reference System, as presented in Figures 5-3 and 5-4. The electrical impulse writes the largest deflection on the lead whose line of derivation is parallel to its path. it writes the smallest deflection on the lead perpendicular to its path. To calculate the frontal plane axis, it is easiest to look initially for the lead with the smallest deflection (i.e., the one most nearly isoelectric). The axis of

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Figure 5-3. Development of hexaxial reference system from standard bipolar and augmented limb leads.

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Figure 5-4. Hexaxial reference system.

the heart is perpendicular, or nearly so, to this lead and lies parallel to the lead with the largest deflection. The normal axis of the heart is generally accepted as being between 0° and +90°. There are differences of opinion, however, among various authorities. The New York Heart Association accepts +30° to +60° as normal. The meaning of various axis deviations is shown in Table 5-1. The principles and methods used in determining axis deviation also may be applied in examining P- and T-waves. Here, it is best to plot the QRS and T-axis and to symbolize them as long and short arrows, respectively. Note especially that the QRS-T angle should normally be no greater than 60°. Table 5-2 presents etiologies for both right and left axis deviation.

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Internal Medicine Table 5-l Axis Deviation Shifts Extent (Degrees)

Classification Slight Left Axis Deviation

0 to -30 (Probably WNL)

Slight Right Axis Deviation

90 to 120 (Probably WNL) 0 to -90

Left Axis Deviation

90 to 180

Right Axis Deviation Marked Left Axis Deviation

-30 to -90

Marked Right Axis Deviation

120 to 180

Extreme Left Axis Deviation

-90 to -120

Extreme Right Axis Deviation

180 to -150

Table 5-2 Etiologies for Axis Deviation Left

Right Normal Variant

Normal Variant

Mechanical Shifts -

Mechanical Shifts -

Inspiration, Emphysema Right ventricular hypertrophy

Expiration, Elevated Diaphragm from Ascites, Tumor, Pregnancy, etc.

Right bundle branch block’

Left ventricular hypertrophy*

Left posterior hemiblock

Left bundle branch block*

Dextrocardia

Left anterior hemiblock* Wolff-Parkinson-White

Left ventricurlar ectopy

Right ventricular ectopy *Axis deviation may or may not be present in these instances. (Marriott, 1972).

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U.S. Naval Flight Surgeon’s Manual Complexes and Intervals Electrocardiogram complexes are groupings within an specific cardiac activity. Complexes which are displaced biphasic (or diphasic). Complexes showing equal excursions equiphasic. Leads in which equiphasic complexes are seen

overall ECG tracing which indicate both above and below baseline are above and below baseline are termed are called isoelectric.

P-Wave The P-wave is an electrocardiographic representation of atria1 depolarization. In a sinus mechanism, the P-wave is the initial wave of the ECG complex. The normal P-wave is less than 0.11 seconds in duration, is less than 2.5 mm in height, and can show notching of up to 0.04 seconds. The mean P-wave axis normally is 0° to +90° in the frontal plane. P-waves normally are upright in I, II, and aVF leads, inverted in aVR, and variable in III, aVL, and V leads. Normal variance includes the so-called coronary sinus rhythm with inversion of P-waves in II, III and aVF (frontal plane axis of -45° to -75°) and normal P-wave configuration in the V leads. Another normal variant is the left atrial rhythm, showing P-wave inversion in II, III, aVF, and V2 or V3 - V6. P-R Interval and Segment The P-R interval is measured from the onset of the P-wave to the onset of the QRS complex. It measures the time required for the electrical impulse to travel from the S-A node to the ventride. The normal range is from 0.12 to 0.20 seconds however, it is generally shorter in children than in adults. The P-R interval may exceed 0.20 seconds in some normal individuals (i.e., well-conditioned young adults with a high degree of vagal tone who show normalization of the P-R interval during exercise). The P-R segment is defined as the interval after cessation of P-wave activity to the onset of the QRS complex. Normally, it is isoelectric. QRS Complex This is the most important ECG complex, in that it represents ventricular activation (depolarization). Here proper terminology is essential. If the initial deflection is negative to the baseline, it is a Q-wave. A negative deflection following the R-wave is an S-wave. Subsequent positive deflections are termed R', R", etc., with subsequent negative deflections termed S' and S".

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Internal Medicine If a QRS complex is excessively positive, points at the beginning and end of the complex are labeled Q and S, respectively. An entirely negative wave is called a QS wave. In an inspection of a QRS complex, there are six features of importance which should be examined: 1. Duration 2. Amplitude 3. Presence (and Duration) of Q-waves 4. Electrical Axis 5. Precordial Transition Zone 6. Timing of “Intrinsicoid Deflections” in V1 and V6 Duration. The normal duration of the QRS complex is 0.05 to 0.10 seconds. Occasionally, duration intervals exceeding these criteria, in either direction, are encountered and may be normal. These durations are based on measurement by standard leads. Use of precordial leads may result in slightly longer durations. Amplitude. The minimal frontal plane QRS amplitude is 5 mm. Minimal amplitudes using precordial leads are V1, V6 - 5mm, V2, V5 - 7mm, and V3, V4 - 9mm. Normal upper limits are more difficult to establish, although frontal plane QRS amplitudes of up to 20 to 30 mm are seen in lead II in some normal individuals. Maximum amplitudes with precordial leads may be 25 to 30 mm, and on occasion even to 35 mm. Q-waves. This feature of the complex is important, but often it is difficult to assess. Salient features to observe with Q-waves are the width of the Q, leads in which the Q’s appear, and the clinical setting. Size is important, with a diminutive Q of 1 mm having possible significance that a QS of 10 mm does not have. A narrow Q in I, aVL, aVP, and V5-V6 is normal, and the absence of such a Q-wave may be of significance. QS or QR complexes are normal in aVR, while a QS may normally be found in III, V1, or V2. Duration of the Q-wave is considered normal up to 0.03 seconds. Electrical Axis. The electrical axis of the QRS complex is of consequence and, as noted earlier, should form an angle with the T-wave no greater than 60°.

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U.S. Naval Flight Surgeon’s Manual Precordial Transition Zone. This refers to the horizontal plane rotation. The direction of rotation is specified as viewed from the inferior cardiac surface looking upward from the diaphragm. The normal transition zone is V3-V4. A clockwise rotation is a shift of the horizontal plane axis to the left or a delay in the typical LV pattern beyond V5. Counterclockwise rotation shows displacement to the right, resulting in a typical LV pattern as early as V2. Intrinsicoid Deflection. Since direct epicardial lead placement is impractical, indirect precordial leads must be used to produce patterns of precordial activity. In these clinical leads, the downward deflection is the analogue of the intrinsic deflection (i.e., the so-called intrinsicoid deflection). The intrinsicoid deflection records the instant at which the cardiac muscle immediately below a unipolar electrode has been completely depolarized. Figure 5-5 depicts the sequence of ventricular activation and the resultant complexes obtained from RV and LV unipolar electrodes. The intrinsicoid deflection (i.e, the peak of the R, should be reached in V1 within 0.02 seconds (0.03 seconds maximally) and in V5, V6 within 0.04 seconds. ST Segment. The St segment is that part of the tracing immediately following the QRS with the “take-off” point called the “J-junction”. The ST segment should be observed for its level relative to the baseline and for its shape. Normally, the ST segment may be initially elevated 1 mm in the standard leads and 2 mm in precordial leads, although in some instances of early depolarization up to 4 mm may be observed. The ST segment should not be depressed beyond 0.5 mm. The contour of the ST segment is a gentle, upward slope which blends into the proximal limb of the T-wave. T-Wave. This wave represents the recovery period of the ventricle or ventricular repolarization. The T-wave normally is upright in I and II and in V leads over the LV. It is inverted in aVR and is variable in other leads. Also, the T-wave normally is upright in aVL and aVF if the QRS is greater than 5 mm. The QRS-T angle, as noted earlier; should not exceed 60° in the frontal plane. In precordial leads, the tendency to inversion of the T in early leads diminishes rapidly with age. In some normal athletic young adults, the T-wave inversion occasionally extends beyond V4. Generally, the shape is rounded with some loss of symmetry. T-waves usually are not larger than 5 mm in standard leads or 10 mm in precordial leads. QT Duration. This feature of a tracing measures the total electromechanical duration of ventricular systole. It varies with heart rate, sex and age. Generally, the QT interval is less than onehalf the preceding R-R interval. At heart rates below 65 beats per minute (bpm), the QT falls further below this value. At bpm above 90 to 100, it often exceeds one-half the R-R interval.

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Figure 5-5. Sequence of ventricular activation.

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Figure 5-5 (Continued). Sequence of ventricular activation.

U-Wave. This wave represents a ventricular after-potential. Normally, it is smaller than the preceding T-wave. Its normal polarity is in the same direction as the T-wave. The U-wave is best discerned in V3. Normal Electrocardiographic Variants ECG’s performed on a young, athletic, and generally healthy population, such as aviators, often show variant patterns which experience has shown are not associated with underlying heart disease. Common normal variants are listed.

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Internal Medicine Sinus Bradycardia Sinus bradycardia is characterized by an otherwise normal ECG with a rate less than 60 beats/minute. The heart rate should increase appropriately with exercise. Sinus Arrythmia Sinus arrythmia is distinguished by constant P-R intervals with varying R-R intervals. Abnormal P Axis With an abnormal P axis (“coronary sinus rhythm”) atrial depolarization arises from an ectopic focus, resulting in inverted P-waves in the inferior leads.

Early Repolarization Early repolarization is a normal variant of the ST segment which is very common in the young adult age group of all races. It is seen most commonly in males but is also found in females. The most common configuration is an elevation of the J-point takeoff and a concave upward ST elevation in V3-V5, I and aVL although all leads can be affected (ST depressions in a VR are sometimes seen). T-waves are usually peaked but can occasionally be inverted. Pseudo-LVH Pseudo-LVH is distinguished by large S waves in V1-V2 and large R waves in V4-V6 which meet voltage criteria for LVH in an otherwise normal ECG. Echocardiographic measurements have consistently shown normal left ventricular size in these patients. Left ventricular hypertrophy is very difficult to diagnose in this population by the commonly applied voltage criteria for LVH. S1 S2, S3, Pattern The S1, S2, S3 pattern is characterized by S waves in leads I, II, and III, a QRS duration between 0.10 and 0.11 seconds) and frequently an interventricular conduction delay noted in Vl. Vectorcardiographic analysis of this pattern reveals a terminal right-sided, superoposterior conduction delay. The standard ECG often shows an ambiguous axis or left axis in the frontal plane. Follow-up of over 50,000 ECG tracings at the Naval Aerospace Medical Institute (NAMI) has

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U.S. Naval Flight Surgeon’s Manual failed to demonstrate any defects or disability from this pattern and it is therefore considered a normal variant. Incomplete Right Bundle Branch Block Normally the last part of the myocardium to depolarize is the right ventricular outflow tract. There are few Purkinje fibers in this area and transmission is slow across the muscle fibers. In young people this area, called the crista supraventricularis, may be prominent and therefore, its depolarization may appear prominent or be delayed. The resultant “crista pattern” shows an R' in V1 and a deep, late S wave in V5 and V6. The configuration resembles right bundle branch block (RBBB) but its width should not exceed .10 seconds. When this pattern is combined with right axis deviation, which is common in this age group, it may even suggest RVH. Only the physical exam will separate the normal from the abnormal in these situations. If exam and history are normal, no further evaluation is required and the ECG may be interpreted as normal. Abnormalities of Conduction

Figure 5-6. Cardiac conduction system.

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Internal Medicine The heart not only is capable of initiating its own rhythmic depolarization but also has specialized neuromuscular tissue capable of conducting the depolarization wave throughout the cardiac muscle. From the S-A node (Figure 5-6), the depolarization wave spreads throughout the atria via three internodal tracts. These are the anterior (Bachman), the middle (Wenckebach), and the posterior (Thore). Between these tracts, interconnecting fibers merge just proximal to the A-V node. Not all fibers enter the A-V node, however. Some fibers bypass it and enter the conduction system distal to this node. The A-V node is located on the endocardial surface of the right side of the atrial septum. Here, the impulse is normally delayed for approximately 0.07 seconds. The impulse then passes into the His bundle, located on the endocardial surface of the right side of the atrial septum distal to the A-V node. The common (His) bundle subdivides in the membranous portion of the ventricular septum into a right bundle branch and a left bundle branch. The left bundle branch further subdivides into the anterosuperior division and the posteroinferior division. After traversing the right and left bundles, the impulse passes into multiple small branches (the Purkinje system) and into the ventricular myocardium. The principal classes of conduction abnormality are presented in Table 5-3. The following sections describe these classes in some detail. Table 5-3 Principal

Conduction

Abnormalities

Incomplete A-V block 1° A-V block 2° A-V block Mobitz I Mobitz II High degree-A-V block Complete A-V block Right bundle branch block Left bundle branch block Left anterior hemiblock Left posterior hemiblock Complete left bundle branch block Bilateral bundle branch block Pre-excitation [Wolff-Parkinson-White)

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U.S. Naval Flight Surgeon’s Manual First Degree A-V Block A first degree A-V block is caused by a delay in conduction through the AV node and is manifested by a P-R interval greater than 0.21 seconds. It may be seen in a variety of clinical conditions including rheumatic fever, myocarditis, chronic ischemic heart disease and infarction, certain drugs (ie., digitalis, quinidine, propranolol and slow calcium channel blocking agents), hyperthyroidism, adrenocortical insufficiency, hypoxia, infiltrative cardiomyopathies, and various congenital heart lesions. Fist degree A-V block may also result from increased vagal tone on the A-V node and represent a normal variant in physically conditioned individuals. It is present in up to one and a half percent of normal young individuals and up to 33 percent of trained athletes. In a normal heart, the P-R interval shortens with an increase in heart rate and thus may be distinguished from pathological P-R prolongation. Individuals showing a physiological response (P-R shortening to within normal limits) with exercise are physically qualified for duty involving flying. Second Degree A-V Block

Figure 5-7. 2° A-V block (Wenckebach). Mobitz Type I. Mobitz I (Wenckebach) is a progressive AV block manifested by a sequential increase in the PR interval until a beat is completely blocked (Figure 5-7). In the aviation setting,

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Internal Medicine as with first degree AV block, it is usually caused by a high degree of vagal tone in normal, conditioned individuals, for example, 23 percent of trained athletes. However, many of the conditions associated with pathological first degree AV block may also cause Wenckebach. Aviation personnel showing the Mobitz I pattern should undergo a noninvasive workup including a graded exercise test, 24-hour ambulatory ECG monitoring, and an echocardiogram. They are considered qualified for flying if no underlying heart disease is found and no further conduction abnormalities or arrhythmias are discovered. Mobitz Type II. This abnormality is characterized by a constant PR interval with some beats completely blocked (Figure 5-8). It is frequently associated with bundle branch blocks, where the dropped beat represents intermittant blocking of the other bundle. It may be caused by the same underlying disorders as first degree AV block and Mobitz I, but is much more likely to represent underlying heart disease and is therefore disqualifying for all flying duties.

Figure 5-8. Mobitz II, 2° A-V block.

Third Degree A-V Block With a third degree A-V block (complete heart block), the atria and ventricles beat independently of one another; no atrial beats are conducted to the ventricles (Figure 5-9). Always

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U.S. Naval Flight Surgeon’s Manual indicative of serious cardiac disease, complete heart block requires pacemaker therapy and is, of course, disqualifying for aviation.

Figure 5-9. High degree A-V block. 3° A-V block.

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Internal Medicine Right Bundle Branch Block The sequence of ventricular activation in right bundle branch block (RBBB) is shown in Figure 5-10, with the resulting recordings presented in Figure 5-11. Initial septal activation is normal; thus, an initial small R-wave will be recorded in Vl, as will a small Q-wave in V6. Since the right bundle branch is blocked, the impulse will travel down the left bundle branch into the LV, resulting in an S-wave in Vl and an R-wave in V6. RV depolarization follows, as the LV activation wave envelopes the RV free wave, resulting in an R' in Vl and an S-wave in V6. The QRS duration is 0.11 to 0.12 seconds or greater (Figure 5-10). Right bundle branch block may result from advancing coronary artery disease, pulmonary hypertension (from various causes), inflammatory or infiltrative diseases of the myocardium, or congenital lesions involving the septum. It may also be found in about 0.2 to 0.6 percent of individuals without evidence of heart disease. Extensive evaluation of 394 USAF aircrewmen with an acquired RBBB, including cardiac catheterization and electrophysiological study of the conduction system, found 94 percent with no evidence of any underlying heart disease. If a noninvasive workup, including echocardiogram, Holter monitor, and stress testing, fails to demonstrate any cardiac disease or arrhythmias, aviation personnel with RBBB are considered physically qualified. Left Bundle Branch Block The sequence of ventricular activation in left branch block (LBBB) is shown in Figure 5-12, with the corresponding recording presented in Figure 5-13. Septal activation begins from right to left, giving rise to a small Q-wave in Vl and an initial small R-wave in V6. Since the left bundle branch is blocked, RV activation proceeds normally, giving rise to an R-wave in Vl and an S-wave in V6. Delayed LV activation begins as the impulse passes into the LV, giving rise to an S-wave in Vl and an R-wave in V6. The QRS duration is 0.12 seconds or longer. Left bundle branch block, although occasionally seen in normal individuals, is more likely than RBBB to be associated with underlying heart disease including coronary artery disease, cardiomyopathies, acute myocarditis, hypertension, and extensive calcification of the aortic annulus. Extensive workup and extended close followup of individuals with acquired LBBB finds about 70 percent with no evidence of underlying heart disease. Thirty percent, however, are found to have a significant problem, usually coronary artery disease (18 percent) or a cardiomyopathy (6.5 percent). Designated aviators are grounded and must undergo an extensive cardiac workup, including echocardiography, coronary arteriography, and radionuclide scanning prior to consideration for a waiver to resume flying. If waived, annual cardiology followup, induding echocardiography, is required.

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Figure 5-10. Sequence of ventricular activation in right bundle branch block.

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Figure 5-11. Complete right bundle branch block.

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Figure 5-12. Sequence of ventricular activation in left bundle branch block.

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Figure 5-13. Complete left bundle branch block. Preexcitation Syndromes Preexcitation results from early activation of the ventricles from AV conduction over atria1 ventricular by-pass tracts. Wolff-Parkinson- White Syndrome. The Wolff-Parkinson-White (WPW) syndrome, perhaps best known of the preexcitation syndromes, occurs in about one percent of the population and is characterized by a short P-R interval and wide QRS and delta waves (Figure 5-14). Up to 40 percent of individuals with WPW have arrhythmias, including paroxysmal supraventricular tachycardias and atria1 fibrillation. The PSVT’s occuring in WPW are usually (95 percent) conducted in an antegrade direction down the AV node and retrograde up the accessory pathway, resulting in a narrow QRS tachycardia indistinguishable from PSVT in an individual without WPW. In the remaining 5 percent, antegrade conduction down the accessory pathway causes a wide complex tachycardia that can resemble ventricular tachycardia. Atrial fibrillation is occasionally associated with high degrees of AV antegrade conduction down the accessory pathway resulting in ventricular rates of over 300, a potentially lethal arrhythmia. A WPW ECG pattern is disqualifying for entry into aviation. However, a waiver may be granted on a case by case basis for those candidates who exhibit normal electrophysiologic studies and who are clinically assymptomatic. Designated personnel may receive waivers if, by history, exercise stress testing, and 24-hour ambulatory ECG monitoring, there is no evidence of any tachyarrhythmias.

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Figure 5-14. Wolff-Parkinson-White.

Other Preexcitation Syndromes. The Lown-Ganong-Levine (LGL) syndrome and other short P-R, normal QRS preexcitation syndromes are associated with tachyarrhythmias to a lesser extent than the WPW syndrome. Aviation candidates with a short PR interval are found qualified if the history, exercise stress test, and 24-hour ambulatory electrocardiogram are negative for arrhythmias.

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Internal Medicine Arrhythmias Sinus Tachycardia Sinus tachycardia, defined as a heart rate over 100 with a normal, stable, P-QRS relationship, is usually a normal physiological response to some underlying stress such as exercise, fever, hypovolemia, thyrotoxicosis, anemia, hypoxia, anxiety, congestive heart failure, pulmonary embolism, pain, or myocardial infarction. Less commonly, it is caused by reentry within the SA node (paroxysmal sinus tachycardia) or by either abnormally high sympathetic tone or abnormally low vagal tone (chronic nonparoxysmal sinus tachycardia). Persistent heart rates over 100 (supine) or 110 (standing) are disqualifying. Premature Atria1 Contractions Premature atria1 contractions (PAC’s) are seen as early P waves that may be abnormally configured; PR intervals that may be short, normal, or long; and, QRS complexes that are usually normal, but may be aberrantly conducted if they occur early enough and find part of the bundle branch system still refractory. PAC’s are very common in healthy individuals (e.g., 78 percent of 55 year old males) and are commonly associated with anxiety, fatigue, and the use of caffeine, nicotine, and alcohol. They are also caused by structural heart disease, especially those causing atria1 enlargement, such as mitral stenosis and cor pulmonale. PAC’s are not disqualifying in the absence of underlying heart disease. Premature Ventricular Contractions

Premature ventricular contractions (PVC’s) are wide (>0.12 second), bizzare shaped QRS complexes arising from ectopic foci in the ventricles. They are not associated with P waves, and usually result in full compensatory pauses, since the SA node is not reset and the next P wave finds the conduction system still refactory and is therefore not conducted. They may arise from one ectopic focus (uniform) or several (multiform) and may occur in repetitive patterns, such as bigeminy (every other beat is a PVC), trigeminy (every third beat), etc. Three or more PVC’s in succession constitutes ventricular tachycardia (see below). PVC’s are very common, even in normal individuals (up to 50 percent), with the incidence increasing with age. They are frequently asymptomatic, but may cause palpitations. The clinical significance of PVC’s depends entirely on the presence or absence of underlying heart disease. In-

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U.S. Naval Flight Surgeon’s Manual dividuals without underlying heart disease do not appear to be at an increased risk for malignant arrhythmias. In and of themselves, PVC’s are not disqualifying. Frequent or multiform ventricular ectopy should be evaluated by a noninvasive workup, including a 24 hour Holter monitor, graded exercise test, and an echocardiogram. Asymptomatic individuals without evidence of underlying heart disease or ventricular tachycardia, and with normal exercise tolerance tests, are qualified for all flying duties, including acceptance for flight training. Supraventricular

Tachycardia

Paroxysmal Supraventricular Tachycardia. Paroxysmal supraventricular tachycardia (PSVT’s) are regular, usually narrow QRS complex tachycardias with rates generally between 180 and 200 (Figure 5-15). The abnormal P waves are usually buried within the QRS complex. Most PSVT’s are caused by reentry within the AV node (60-90 percent), but may also be caused by reentry within the SA node (paroxysmal sinus tachycardia), atrial-ventricular bypass tracts (Wolff-Parkinson-White Syndrome, up to 30 percent), Lown-Ganong-Levine Syndrome, and ectopic atrial pacemakers. Most episodes of PSVT occur in otherwise healthy individuals, where smoking, caffeine, fatigue, emotional stress, and especially alcohol may be precipitating factors. They are also associated with coronary artery disease, rheumatic heart disease, hypertension, thyrotoxicosis, and, as noted above, Wolff-Parkinson-White Syndrome.

Figure 5-15. Paroxysmal supraventricular tachycardia (PSVT).

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Internal Medicine PSVT is disqualifying for aviation. After six months grounding, designated personnel may be considered for waiver of a single episode of PSVT, unassociated with structural heart disease, hypertension, thyrotoxicosis, WPW, etc, provided there are no recurrences. Recurrent PSVT is generally not waiverable. Atria1 Fibrillation. This is caused by chaotic atrial activity and manifested by fibrillatory waves occurring at a rate between 300 and 600, and an irregularly irregular ventricular response, generally between 120 and 180 (Figure 5-16). Slow ventricular responses may be caused by drugs that slow conduction through the AV node, such as digoxin, and in individuals with AV nodal disease. Occasionally, a healthy, athletic individual with high resting vagal tone will also have a slow ventricular response. Atria1 fibrillation is associated with rheumatic heart disease, especially mitral stenosis, atrial septal defects, cardiomyopathies, coronary artery disease, hypertension, pericarditis, and thyrotoxicosis. It may also occur in individuals with no underlying abnormality. These “lone fibrillators” have frequently overindulged in the use of caffeine, nicotine, and, most especially, alcohol (so called “holiday heart” syndrome). Atrial fibrillation may cause a significant decrease in cardiac output, as well as myocardial and cerebral blood flow. These adverse hemodynamic effects are of particular concern in the aviation environment where G forces and hypoxia may additionally reduce tissue perfusion and oxygen delivery. Furthermore, persistent and recurrent atria1 fibrillation is associated with a significant increase in the risk of embolic strokes, even for “lone fibrillators.” Atria1 fibrillation is disqualifying for all flying duties. Designated aviation personnel with a single episode of atrial fibrillation unassociated with underlying heart disease or other predisposing condition may be waived after six months grounding. Recurrent atria1 fibrillation is permanently disqualifying. Atrial Flutter. This arrhythmia, which is probably caused by a reentry mechanism, is characterized by a rapid atrial rate (280-320) and a variable degree of AV block, most commonly 2:l (Figure 5-17). One to one conduction is poorly tolerated, and, fortunately, uncommon. Higher degrees of AV block, as high as 8:1 are seen, with 4:l the next most common. High degrees of AV block may be associated with drugs such as digoxin, beta blocking agents, or verapamil, or by underlying AV nodal disease. Atrial flutter is an unstable rhythm that frequently deteriorates into atrial fibrillation, occasionally reverts to sinus rhythm. Atrial flutter may be caused by many of the same disorders that are associated with atria1 fibrillation, but is much less likely to be seen in an otherwise normal individual, and is therefore disqualifying for all duty involving flying.

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U.S. Naval Flight Surgeon’s Manual

Figure 5-16.

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Internal Medicine

Figure 5-17. Atrial flutter.

Ventricular Tachycardia. Ventricular tachycardia and ventricular fibrillation are life threatening arrhythmias that are uncommon in the active duty population. The flight surgeon should be ACLS certified and therefore prepared to diagnose and treat V-tach and V-fib. They are, of course, disqualifying for all aviation personnel. This includes nonsustained ventricular tachycardia, which may occasionally be seen in what appear to be otherwise healthy individuals. Brief episodes of ventricular tachycardia may occur during graded exercise testing of individuals without underlying heart disease. Such individuals are not at increased risk for cardiovascular complications and may be waived to return to flying, provided a complete cardiovascular workup is normal. This may require coronary arteriography in individuals over 35 years of age or with significant risk factors of coronary artery disease. Acquired and Congenital Structural Heart Disease Structural disease of the valves and walls of the cardiovascular system can present to the flight surgeon in a variety of ways. A new murmur, a subtle ECG finding, or a suspicious X-ray may be the first clue. Conversely, a well-documented lesion that may or may not have had surgery might be the presenting factor. Structural defects and aviation are not necessarily incompatible. Knowledge of the current cardiovascular status and the natural history of the lesion, particularly with regard to the risk of sudden incapacitating arrhythmias, is essential to intelligent management. A good history, physical examination, ECG, chest X-ray, echocardiogram (including color flow/doppler study), 24-hour Holter monitor, and graded exercise test can give an excellent assessment of current function. Some disorders may require cardiac catheterization. The patient’s future in aviation will depend on the demonstration of normal cardiovascular function, a low risk of eventual slow decompensation, and virtually no increase arrhythmia risk over the general population. Several of the more likely defects to occur in the otherwise healthy, young adult deserve further comment.

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U.S. Naval Flight Surgeon’s Manual Functional (Innocent) Murmurs These murmurs, by definition, do not represent cardiac defects, but differentiating them from true disease can be difficult. The classical functional murmur is a low-frequency, musical, or buzzing murmur, less than II/VI in intensity, appearing in early to mid-systole and localized to the left sternal border. There must be no diastolic component, and the second sound must be normally split. Such a murmur presumably represents blood flow across a normal pulmonic or aortic valve and is more common in slender, athletic individuals. An innocent systolic murmur with characteristics similar to the above has been described at the cardiac apex. Special care must be taken to differentiate it from mitral murmurs, particularly the mitral valve prolapse syndrome. Congenital Shunts Septal defects occuring at both the atrial and ventricular level and patent ductus arteriosus are the most common shunts that may be present in a seemingly fit young adult. Any of the three may present de novo, if small, or may present many years after surgical repair. Atrial Septal Defect. Small atrial septal defects (ASD) may exist through a normal lifespan and be detected only at autopsy. The flight surgeon, however, may detect them in the course of a workup for a systolic murmur, right bundle branch block, or a fullness of the right ventricle or pulmonary artery on X-ray. The characteristic, widely split second sound, pulmonic flow murmur, and right ventricular enlargement solidify the diagnosis. Cardiac catheterization is always indicated, and all but the smallest defects should be closed. Normal right ventricular and pulmonary artery pressures carry an excellent prognosis postsurgery, but there is a small increase in the risk of supraventricular tachycardias. Candidates for aviation training with an ASD, repaired or not, are not accepted. If ASD is detected in a designated aviator, he or she may be considered for waiver if the shunt is trivial or the defect is repaired, provided that the patient has normal pulmonary artery and right sided pressures and no evidence of supraventricular tachycardias during a six month period of grounding. Ventricular Septal Defect. Ventricular septal defects (VSD) are usuaIly diagnosed in infancy. Moderately large shunts that are repaired in childhood with normal intracardiac pressures postsurgery have an excellent prognosis, but an increased risk of arrhythmias is disqualifying for an aviation career. A slight VSD in the asymptomatic child progressively becomes smaller as the child grows and thus may present in the young adult as only a positive history with or without a systolic murmur. The natural history of this lesion is virtually normal and thus is compatible with

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Internal Medicine military aviation. Nevertheless, a complete, normal cardiovascular examination, including 24-hour ECG monitoring and echocardiogram, is needed. Subacute bacterial endocarditis (SBE) prophylaxis is also indicated in these patients. Patent Ductus Arteriosus. A patent ductus arteriosus surgically corrected in childhood with normal cardiovascular function one year postsurgery has an excellent prognosis and presents no contraindication to an aviation career. The small ductus that remains undetected and asyrnptomatic until young adulthood is rare. In these patients, pulmonary plethora, left ventricular enlargement, or a continuous high frequency murmur under the left clavicle may suggest the diagnosis. The chest X-ray may show the ductus as a convexity between the aorta and the pulmonary artery. Cardiac catheterization is always indicated. If the shunt is small (less than 1.5:1) and all pressures are normal, the prognosis is generally excellent, although SBE prophylaxis is indicated. These people may qualify for aviation. Large shunts require surgery, and the decision to pursue a career in aviation should be deferred until at least one year postsurgery. Congenital Valvular Malformations Mild stenosis of the pulmonic valve is consistent with near normal growth, virtually symptom free, carrying only the diagnosis of “functional murmur.” However, mild exercise intolerance, evidence of right ventricular enlargement on physical examination, large anterior R-waves on ECG, and poststenotic dilation on chest X-ray should make one suspicious of the diagnosis. Cardiac catheterization is necessary for full evaluation. Since normal right ventricular pressures are mandatory for military aviation, individuals with this uncorrected malformation are generally disqualified. Surgery with near normal postoperative pressures is associated with excellent results, but, again, the small arrhythmia risk usually disqualifies the individual from an aviation career. Congenital aortic stenosis, though often with a more benign prognosis than its rheumatic counterpart, still has a risk of eventual myocaridal decompensation and arrhythmias and is therefore unacceptable for aviation. The bicuspid aortic valve is a very common congential abnormality occurring in 0.4 percent of individuals, with a male to female predominance of 4:l. Though the initial clinical course is benign and asymptomatic, leaflet thickening invariably occurs by age 40 with later progression of calcifications and stenosis. For this reason, individuals with bicuspid aortic valves should be evaluated for any evidence of an increased gradient across the aortic valve, or left ventricular hypertrophy by echocardiography and doppler study. Applicants for flight training are disqualified even with otherwise normal echo and doppler studies. Designated aviators with bicuspid aortic valves should have their cardiovascular function assessed by noninvasive means and

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U.S. Naval Flight Surgeon’s Manual followed for the possible development of hemodynamically significant aortic stenosis or aortic regurgitation. Coarctation of the Aorta A coarctation is usually diagnosed in the pediatric population, but occasionally a mild one will not be detected until young adulthood. Upper body hypertension, a systolic murmur that radiates to the back, rib notching on chest X-ray, and evidence of left ventricular enlargement are the presenting signs in the adult. Additionally, bicuspid aortic valves and berry aneurysms are associated with coarcts. The disease is progressive and surgery is almost always indicated. In spite of possible excellent hemodynamics postsurgery, patients with coarcts have an increased risk of intracranial hemorrhage, eventual hypertension, and accelerated coronary artery disease. Thus, their place in military aviation is limited, and most, if not all, should be disqualified. Rheumatic Valvular Disease Valvular dysfunction on a rheumatic basis, even if mild, is associated with an increased risk of arrhythmias, cardiac failure, and emboli, and thus is disqualifying. Valve replacement, though often of great benefit hemodynamically, is inconsistent with a career in military aviation. A history of acute rheumatic fever (ARF) without evidence of valvular dysfunction is not disqualifying. Antibiotic prophylaxis against recurrent ARF is also not disqualifying.

Mitral Prolapse Syndrome (MVP) Mitral valve prolapse (MVP) is the most common valvular abnormality, affecting from between two and 10 percent of the population. Primary mitral valve prolapse affects women more commonly than men and may be inherited as an autosomal dominant trait. Mitral valve prolapse may be associated with a number of other disorders including Marfan syndrome, cardiomyopathies, coronary artery disease, Ehlers-Danlos syndrome, WPW, and congenital defects such as ASD. Most individuals with idiopathic mitral valve prolapse are asymptomatic, but some experience atypical chest pain, fatigue, dizziness, and syncope. About 50 percent of patients have arrhythmias, including PSVT, PVC’s, AV blocks, and V-tach. Some studies indicate an increased risk of sudden death. A definitive diagnosis may be made by ascultation. Single or multiple mid-to late systolic clicks associated with a late systolic crescendo murmur are characteristic. The click(s) and murmur typically move earlier in systole during maneuvers that decrease the LV size such as moving from supine to sitting or squatting to standing.

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Internal Medicine A definitive diagnosis may also be made by two dimensional echo. Definite systolic prolapse of one or both mitral leaflets and the point of coaptation above the mitral annulus on multiple views should be demonstrated. An echocardiographic diagnosis of MVP should not be based on the apical four chamber view alone. Individuals with MVP may experience PSVT, infective endocarditis, embolic cerebral vascular accidents, progressive mitral regurgitation, and possibly sudden death. MVP is therefore disqualifying for aviation, and applicants found to have MVP are rejected. Designated personnel may be waivered to all service groups provided they are asymptomatic, they have no underlying condition that is itself disqualifying, they have no evidence of arrththmias by history or on 24-hour Holter monitoring, and there is no significant mitral regurgitation or left atria1 enlargement on echo/doppler. Obstructive Hypertrophic Cardiomyopathy Obstructive Hypertrophic Cardiomyopathy is an inherited disorder transmitted as an autosomal dominant trait with a high degree of penetrance although sporatic cases are not unusual. The hypertrophied left ventricle impedes ventricular filling during diastole resulting in increased left ventricular end diastolic pressures which are transmitted to the left atrium and pulmonary circulation causing dyspnea, the most frequent symptom. Other symptoms include angina, palpitations, snycope, and sudden death which may be the first manifestation of the disease. It is the most frequent cause of sudden death in young athletes. On physical examination a systolic ejection murmur if heard thar increases with maneuvers that decrease the size of the left ventricle such as standing, valsalva, amyl nitrate, and is decreased by squatting and during hand grip. The diagnosis is confirmed by two dimensional echocardiography, where LVH with a septum posterior wall ratio of 1.3:1 is found. Obstructive Hypertrophic Cardiomyopathy is disqualifying for the duties involving flying, with no waivers granted. Endocarditis Prophylaxis Individuals with prosthetic heart valves, valvular heart disease, and certain congenital heart defects are at increased risk for endocarditis following certain medical procedures on the oral cavity, respiratory, genitourinary, and gastrointestinal tracts. Table 5-4 lists the conditions for which prophylactic antibiotic therapy is indicated. Table 5-5 lists the procedures requiring prophylaxis and Tables 5-6 and 5-7 summarize the prophylactic regimens recommended by the Committee on Rheumatic Fever and Infective Endocarditis of the American Heart Association.

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U.S. Naval Plight Surgeon’s Manual Although most of the conditions in Table 5-4 are disqualifying for aviation, aircrew members with bicuspid aortic valves and mitral valve prolapse may be waived and may require SBE prophylaxis. Mitral prolapse with single or multiple clicks but without a murmur does not require SBE prophylaxis. Table 5-4 Cardiac Conditions for Which Endocarditis Prophylaxis is Recommended

Endocarditis prophylaxis recommended Prosthetic cardiac valves (including biosynthetic valves) Most congenital cardiac malformations Surgically constructed systemic-pulmonary shunts Rheumatic and other acquired valvular dysfunciton Idiopathic hypertrophic subaortic stenosis Previous history of bacterial endocarditis Mitral valve prolapse with insufficiency Endocarditis prophylaxis not recommended Isolated secundum atrial septal defect Secundum atria1 septal defect repaired without a patch 6 or more months earlier Patent ductus arteriosus ligated and divided 6 or more months earlier Postoperatively after coronary artery bypass graft surgery

Atherosclerotic Heart Disease Myocardial ischemia occurs when oxygen delivery is insufficient to meet myocardial oxygen demand. High +Gz forces can greatly increase myocardial oxygen demand, with heart rates over 200 beats per minute and left ventricular pressures of almost 300 mm Hg. At the same time, +Gz forces tend to reduce coronary artery blood flow due to reduced aortic pressures, decreased duration of diastole, and increased myocardial compressive forces. Through neural influences and autoregulation, the normal coronary circulation is able to increase coronary blood flow from four to six times the resting state in response to maximal stress, and clinically apparent myocardial ischemia does not occur before the onset of +Gz induced loss of consciousness. Coronary

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Internal Medicine arteries with obstructions, however, have a limited ability to increase blood flow. Obstruction of 80 to 90 percent of the arterial lumen allows for no increase in flow while obstructions of 40 percent and less do not limit flow even at maximum demand, unless there is superimposed coronary artery spasm. Myocardial ischemia presents clinically as angina, myocardial infarction, depressd LV function, and sudden death, all of which can cause sudden and unexpected in-flight incapacitation. For this reason, known coronary artery disease of any severity, even if asymptomatic, is disqualifying for aviation.

Table 5-5 Procedures for Which Endocarditis Prophylaxis is Indicated

Oral cavity and respiratory tract All dental procedures likely to induce gingival bleeding (not simple adjustment of orthodontic appliances or shedding of deciduous teeth) Tonsillectomy or adenoidectomy Surgical procedures or biopsy involving respiratory mucosa Bronchoscopy, especially with a rigid bronchoscope Incision and drainage of infected tissue Genitourinary and gastrointestinal tracts Cystoscopy Prostatic surgery Urethral catheterization (especially in the presence of infection) Urinary tract surgery Vaginal hysterectomy Gallbladder surgery Colonic surgery Esophageal dilatation Sclerotherapy for esophageal varices Colonoscopy Upper gastrointestinal tract endoscopy with biopsy Proctosigmoidoscopic biopsy

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Table 5-6 Summary of Recommended Antibiotic Regimens for Adults Having Dental or Respiratory Tract Procedures

Standard Regimen For dental procedures that cause gingival bleeding, and oral or respiratory tract surgery

Penicillin V, 2.0 g orally, 1 hour before, then 1.0 g 6 hours later. For patients unable to take oral medications, 2 X 106 U of aqueous penicillin G intravenously or intramuscularly 30 to 60 minutes before a procedure and 1 X 106 IJ 6 hours later may be substituted.

Special Regimens Parenteral regimen for use when maximal protection is desired, for example, for patients with prosthetic valves

Ampicillin, 1.0 to 2.0 intramuscularly or intravenously, plus gentamicin, 1.5 mg/kg body weight intramuscularly or intravenously, 0.5 hours before procedure, followed by 1.0 g or oral penicillin V 6 hours later. Alternatively, the parenteral regimen may be repeated once 8 hours later.

Oral Regimen for patients allergic to penicillin

Erythromycin, 1.0 g orally 1 hour before, then 500 mg 6 hours later.

Parenteral regimen for patients allergic to penicillin

Vancomycin, 1.0 g intravenously, slowly over 1 hour, starting 1 hour before. No repeat dose is necessary.

Table 5-7 Summary of Recommended Regimens for Adults Having Gastrointestinal or Glenitourinary Tract Procedures

U.S. Naval Flight Surgeon’s Manual Screening Asymptomatic Individuals for Coronary Artery Disease If a noninvasive test for detecting coronary artery disease were available it would be desirable to screen aviation personnel for coronary artery disease and exclude affected individuals. The most common available test is the exercise electrocardiogram which has a specificity of 84 percent and a sensitivity of 66 percent. Leaving aside the poor sensitivity, the application of such a test to a patient population with a low prevalence of a disease, such as coronary artery disease in asymptomatic individuals under the age of 45, results in many more false positive tests than true positive tests. This creates a serious disposition problem since coronary artery disease must be reasonably excluded in everyone with a positive test. The result would be a large number of expensive, time consuming, and frequently invasive workups in healthy individuals. For this reason, the routine use of graded exercise testing to detect coronary artery disease in asymptomatic individuals cannot be justified. Evaluation of Individuals with Chest Pain The workup of symptomatic patients must be individualized. At one extreme are young individuals without multiple coronary risk factors and atypical chest pain for whom graded exercise testing is the most that would be required, while patients with multiple risk factors and exertional chest pain would require coronary arteriography. Treated Coronary Artery Disease Many patients with coronary artery disease are now undergoing coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) with excellent results. Many are asymptomatic with normal maximal exercise testing, but they are still considered disqualified for all duties involving flying. Graft (CABG) and coronary artery (PTCA) patency remain a significant and unpredictable problem, and coronary atherosclerosis tends to be a progressive disorder that will eventually affect other portions of the coronary anatomy. Hypertension

Hypertension is one of the most important health problems facing the flight surgeon, because: 1. It is a very common condition. 2. It is usually asymptomatic until late on, when significant target organ damage has already occurred.

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Internal Medicine 3. It is associated with serious complications, including coronary artery disease, congestive heart failure, stroke, and renal failure. 4. Effective treatment is readily available. The first step is to correctly establish a diagnosis. It is easily overdiagnosed; 40 percent of patients with diastolic pressures over 90 are found to be normotensive on followup, and 21 percent of patients found to have persistently elevated diastolic pressures on three successive visits to the doctor’s office are found to be normotensive by 24-hour ambulatory blood pressure monitoring (“white coat” hypertension). An inappropriate diagnosis of hypertension may have serious adverse effects on employment, life and health insurance, and may commit the individual to lifelong treatment unnecessarily. What constitutes hypertension? This question is not as easily answered as might be expected, since the distribution of blood pressures is represented by a unimodal curve; there is no sharp distinction between “normal” pressures and “high” pressures associated with an increased risk of complications. The U.S. Navy standards for blood pressure are as follows: less than 140/90 SNA, SNFO, DNA SG I and II (under age 36); less than 150/90 - DNA SG I and II (36 and older); less than 154/94 - DNA SG III, NFO, Flight Surgeon, etc. Once the presence of hypertension has been established, a workup is necessary to exclude secondary causes and search for target organ damage. Inappropriate hypertension (Table 5-8) should trigger a careful search for secondary hypertension. Some of the more important secondary causes of secondary hypertension include: renal and adrenal disorders and disorders of the aorta. Renal Parenchymal Disease (up to 0.4 Percent) Many acute and chronic renal disorders are associated with hypertension. A urinalysis with careful examination of the sediment, BUN, and creatinine will reasonably screen for most of these. Renovascular Hypertension (0.2 Percent) Obstruction of a renal artery tends to occur in younger patients (under 30, female > male) due to fibromuscular dysplasia, and older patients (over 50, male > female) due to atherosclerosis. Suggestive features include an abdominal bruit, especially if there is a diastolic component, appropriate age, and a rapidly accelerating course.

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U.S. Naval Flight Surgeon’s Manual Table 5-8 Features of Inappropriate Hypertension

1. Onset before the age of 20 or after 50. 2. Blood pressure greater than 180/110. 3. Evidence of target organ damage: a. Grade 2 or greater fundoscopic changes. b. Decreased renal function. c. Cariomegaly or left ventricular hypertrophy. 4. Signs or symptoms suggestive of secondary hypertension: a. Unprovoked hypokalemia. b. Abdominal bruit. c. Wide variations in blood pressure associated with spells of sweating, tachycardia, and tremulousness. d. Family history of renal disease. 5. Difficult to control hypertension.

Adrenal Causes Primary Aldosferonism (0. 1 to 1 Percent). Primary aldosteronism is caused by an adrenal adenoma or primary adrenal hyperplasia. This is marked by unprovoked (i.e., diuretic Rx) hypokalemia.

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Internal Medicine Cushing's Syndrome (0.1 Percent). Cushing’s Syndrome is suggested by typical physical findings of central obesity, moon facies, and purple striae. Pheochromocytoma (0.2 Percent). Pheochromocytoma is manifested by marked swings in blood pressure, a significant orthostatic drop in blood pressure, and spells of sweating, tachycardia, and tremulousness. Coarctation of the Aorta (0.1 to 0.2 Percent) This is usually asymptomatic. Physical findings include a wide pulse pressure in the upper extremities, a lower than expected blood pressure in the lower extremities, a delay in the femoral pulse compared to the brachial pulse, and a systolic murmur between the scapulae. The chest X-ray may show post stenotic dilatation of the aorta and notching of the inferior edge of the ribs. Diagnosis and Treatment of Hypertension A good history, physical examination, and some easily obtained laboratory studies can effectively screen for secondary hypertension. Since secondary hypertension may be curable, or represent a serious underlying condition, this workup is necessary. Documented or suspected cases of secondary hypertension should be referred for further workup and treatment. The hypertension workup is completed by a search for target organ damage in the eyes (fundoscopic exam), heart (ascultation, chest X-ray, 12 lead ECG, and, possibly, echocardiogram), and kidneys (active sediment or protein in the urine, elevated BUN or creatinine.) Ninety-five percent of hypertensive individuals have no underlying cause and are labeied “essential” hypertensives. Nonpharmacological therapy including weight reduction (if appropriate), sodium restriction, and regular aerobic exercise, is appropriate initial treatment for mild or moderate essential hypertension. Aviation personnel with essential hypertension controlled with nonpharmacological treatment are not considered disqualified and therefore do not require a waiver. Drug therapy is required for hypertension not controlled by nonpharmocological means. Hydrochlorothiazide is a reasonable first step drug that does not require a waiver. It is effective in the majority of individuals with mild hypertension and is usually well tolerated. Adverse biochemical effects, usually mild, include hyperuricemia, hypercalcemia, hypercholesterolemia, and hypokalemia.

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U.S. Naval Flight Surgeon’s Manual All other antihypertensive agents are disqualifying for aviation. Waivers are readily granted for the angiotensin converting enzyme inhibitor enalapril, which decreases peripheral vascular resistance but has little effect on cardiac output, heart rate, glomerular filtration, or salt and water balance. This drug is usually very well tolerated and most importantly, has none of the adverse CNS effects common with other antihypertensive agents. Beta blocking agents have the potential for adverse hemodynamic and CNS side effects, and therefore are rarely waived, and then only in SG III and Class 2 personnel. If a beta blocking agent is necessary, a lipid insoluble drug, such as atenolol, is preferrable since CNS penetration is minimal and undesireable CNS effects avoided.

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Internal Medicine SECTION II. GASTROENTEROLOGY Esophageal Reflux and Hiatal Hernia Symptomatic gastroesophageal reflux is an extremely common disorder, involving up to 33 percent of the population infrequently and about 10 percent with frequent or severe symptoms. About two thirds of symptomatic patients have transient decreases in lower esophageal sphincter (LES) pressure allowing the reflux of gastric contents into the esophagus resulting in damage to the esophageal mucosa from acid and pepsin (less commonly, bile and pancreatic enzymes). The remaining third have persistantly low or absent LES pressures and free reflux, resulting in more severe esophagitis and a higher likelihood of complications. Gastric volume is also important and may be increased, for example, by delayed gastric emptying. Another related factor is the esophageal clearance of acid which is increased by swallowing, due to esophageal peristalsis and ejection of acid into the stomach, and by neutralization of acid by swallowed saliva. Since swallowing and salivation virtually cease during sleep, clearance of refluxed gastric contents is reduced at night. There is no clear relationship between hiatal hernia and reflux esophagitis. While many symptomatic patients have hiatal hernias, most individuals with a hiatal hernia do not have reflux esophagitis. It is possible that the presence of a hiatal hernia may decrease the clearance of acid in symptomatic patients. Mild to moderate esophagitis is manifested by epigastric and substernal burning. Other symptoms may reflect complications and include regurgitation; aspiration, as evidenced by pneumonia, morning hoarseness, and nocturnal choking; dysphagia caused by a peptic stricture; severe chest pain which may be caused by severe esophagitis, esophagael spasm, or an esophageal ulcer; and occasionally odynophagia. Complications associated with gastroesophageal reflux include hemorrhage and perforation, both of which are unusual; pulmonary complications such as aspiration pneumonia; peptic strictures that are usually of mild to moderate degree; and Barrett’s esophagus. Barrett’s esophagus is the replacement of the normal squamous esophageal epithelium by columnar epithelium, which may be metaplastic. A high percentage of patient’s with Barrett’s esophagus have strictures (up to 60 percent), and there is an increased risk of esophageal adenocarcinoma (up to 10 percent). Although patients with mild or moderate esophagitis frequently have normal upper GI studies, except possibly for the demonstration of gastroesophageal relux, barium studies are useful to ex-

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U.S. Naval Flight Surgeon’s Manual clude other disorders, such as peptic ulcer disease, and to detect peptic strictures, Barret’s esophagus, and ulceration. Perfusion of the distal esophagus with acid (Bernstein test) usually reproduces the patient’s symptoms with esophagitis and is useful to exclude coronary artery disease. Additional studies, such as endoscopy +/-biopsy, 24-hour pH monitoring, and esophageal manometry may be useful when the diagnosis is still in doubt, the patient is unresponsive to intensive medical management, or an abnormal barium swallow (stricture, Barrett’s esophagus) requires it. Initial management of reflux esophagitis includes elevation of the head of the patient’s bed with six inch blocks; dietary modifications including restriction of caffeine, specific irritants such as citrus juice, tomatoes, etc, multiple small meals, and no eating within several hours of going to bed; no smoking; and, the use of alginic acid and an antacid (Gaviscon) 30 minutes pc and hs. For patients uncontrolled by these measures, one of H2 antagonists (cimetidine, ranitidine, or famotidine) would be the next appropriate step, followed by bethanochol or metachlopramide. Antireflux surgery, such as the Nissen fundoplication, is reserved for patients unresponsive to medical management. Aeromedical Disposition Aircrew members with mild or moderate symptoms, no complications, and who are controlled by nonpharmachological measures and Gaviscon, are physically qualified for all flight duties. Patients with severe esophagitis and with complications are NPQ. Aircrew in tactical jet aircraft may be at an increased risk of aspiration if they experience the reflux of a large volume and regurgitate while performing anti-G maneuvers. Waivers may be granted for nightly use of ranitidine orfollowing successful anti-reflux surgery. Peptic Ulcer Disease Duodenal Ulcers Approximately 10 percent of males and 4 percent of females will develop a symptomatic duodenal ulcer (DU) at some times during their life, with the peak incidence in the fifth and sixth decades. Dietary factors, including alcohol and caffeine, do not appear to be related to DU’s. Cigarette smoking is probably a risk factor for the development of peptic ulcer disease and is clearly associated with a much higher rate of recurrence. Nonsteroidal anti-inflammatory agents are not a proven risk factor but have been shown to cause inflammation and erosions of the duodenal and gastric mucosa. There is no proven association between ulcers and corticosteroid therapy.

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Internal Medicine Classic symptoms for duodenal ulcers include postprandial and nocturnal epigastric pain and burning relieved with food and antacids. However, some patients have atypical symptoms or are asymptomatic, and duodenal ulcers cannot be distinguished from gastric ulcers or other disorders such as reflux esophagitis and nonulcer dyspepsia by history alone. Upper GI barium studies can miss up to 50 percent of duodenal ulcers, although the detection rate may be as high as 80 to 90 percent with double contrast studies performed by an experienced radiologist. Endoscopy detects over 95 percent of duodenal ulcers, and is able to detect other disorders not seen by barium studies such as gastritis, esophagitis, and small ulcers. It is more expensive, however, and associated with a small risk of complications such as perforation. Duodenal ulcerations tend to heal without treatment, although patients become more rapidly asymptomatic and have higher healing rates if treated. Standard treatments include the H2 blocking agents cimetidine, ranitidine and famotidine; antacids; and sucrafate, a cytoprotective agent that does not inhibit acid formation. The rate of healing is about the same with any of these medicines, and there is no clear evidence that combination therapy is superior. In fact, sucrafate requires an acidic pH to be active and may not be effective when combined with antacids or H2 receptor agents. The H2 receptors have been shown to be equally effective when given as a single nightly dose (cimetidine 800 mg hs or ranitidine 150 mg hs) compared to divided daily doses for uncomplicated duodenal ulcers. Peptic ulcer disease is disqualifying for aviation. The overall recurrence rate is from 50 to 80 percent within the first 12 months, and there is a significant risk of serious complications having the potential for sudden inflight incapacitation. Designated personnel should undergo endoscopy, if available, or an upper GI series for diagnosis, and then be placed on one of the standard therapies. It is essential for these patients to avoid smoking, nonsteroidal anti-inflammatory agents, and, during the acute phase, alcohol. They are grounded for a six week period during treatment. If they are asymptomatic while off all medications and have experienced no complications (bleeding, perforation, or obstruction) they may be waived to resume flight duties. Repeat endoscopy or Upper GI series is required to document ulcer healing. Patients with intractable symptoms, frequent recurrences (two or more a year), or complications must be carefully evaluated. Individuals taking nightly maintenance doses of ranitidine may be waivered in selected cases. Some individuals may be returned to flight duties after successful ulcer surgery. Gastric Ulcers In general, gastric ulcers are diagnosed and managed in the same manner as duodenal ulcers. They tend to occur in older patients and, unlike duodenal ulcers, have a significant risk of malignancy (about 20 percent). Double contrast upper GI studies detect most (90 percent) gastric

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U.S. Naval Plight Surgeon’s Manual ulcers and can most often distinguish between benign and malignant lesions. However, all patients with gastric ulcers should undergo endoscopy to exclude the presence of malignancy. The aviation disposition for an uncomplicated benign gastric ulcer is the same as for a duodenal ulcer.

Inflammatory Bowel Disease Crohn’s disease and ulcerative colitis are inflammatory disorders of the colon and, in the case of Crohn’s disease, other parts of the GI tract. They are characterized by diarrhea, abdominal pain, rectal bleeding, and by involvement of other organ systems including joints, liver, eyes, and skin. They are differentiated by histology, and by typical involvement, with ulcerative colitis involving the rectosigmoid and extending for variable degrees proximally without skipped areas, and Crohn’s disease most frequently involving the distal ileum, variable and patchy involvement of the colon with skipped areas, but with the potential for involving any portion of the GI tract. Crohn’s frequently causes penetration of the intestinal wall and fistulous tract formation. The fluctuating and unpredictable clinical course of both these disorders makes them disqualifying for all flight duties. Some patients with ulcerative proctitis (involvement less than 20 cm) have mild symptoms that are easily treated with hydrocortisone or 5-ASA enemas, and progress to involve more of the colon only about 15 percent of the time. These individuals may be waived provided they are asymptomatic on medicated enemas and/or 2 grams of sulfasalazine per day. Alcoholic Liver Disease Alcoholism remains a serious problem for the Navy. Beyond the very serious consequences of driving (and in rare instances flying) while intoxicated, most of the 200,000 alcoholics who die annually in the U.S. die from complications of alcoholic liver disease. About 15 to 20 percent of individuals who drink more than 40 to 80 gms of ethanol a day for over 10 years will develop cirrhosis. Some, mostly women, will develop cirrhosis from drinking much less. Fatty Liver The mildest form of liver involvement is a fatty liver. Patients with fatty liver are usually asymptomatic, although they may have tender hepatomegaly. Liver enzymes and bilirubin are normal or only mildly elevated. These patients have an excellent prognosis if they abstain from alcohol. The fatty changes are rapidly reversible once drinking is discontinued. Aviation personnel should be grounded and treated aggressively for alcohol dependance. The decision to return them to flying duties is usually dependent on the success of their achieving and maintaining

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Internal Medicine sobriety. From an internal medicine standpoint, they are qualified to resume flying if they have normal hepatic function, as evidenced by normal liver enzymes, bilirubin, albumin, prothrombin time, and CBC; and, there is no history or evidence of portal hypertension. Alcoholic

Hepatitis

Alcoholic hepatitis is a much more serious disorder characterized by anorexia, nausea, vomiting, weight loss, abdominal pain, fever, and jaundice. Portal hypertension may cause ascites, spleenomegaly, and bleeding esophageal varicies. Liver enzymes are elevated five to 10 times normal, with SGOT being significantly more elevated than SGPT. Jaundice is present at times accompanied by hypoalbuminemia, prolonged prothrombin times, and anemia. Some patients may progress to hepatic failure or hepatorenal syndrome. Although some patients recover fully, most either continue to have hepatitis or develop cirrhosis. individuals with alcoholic hepatitis will rarely be considered for a return to flying. Cirrhosis Cirrhosis represents the end stage of alcoholic liver disease where the liver has dense bands of connective tissue and areas of micronodular regeneration. Symptoms are caused by hepatic dysfunction and portal hypertension. Cirrhosis is permanently disqualifying for aviation duties.

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U.S. Naval Flight Surgeon’s Manual SECTION III: HEMATOLOGY Anemias - An Overview Due to the vast scope of this subject, the reader is referred to standard medical texts and hematology references for detailed studies of specific hematological topics. A basic classification of anemias will be outlined herein as a general diagnostic aid. Morphological classification of anemias is a simple method which directs further investigational study. Three measurements of red cell morphology are utilized in determining cell size and hemoglobin concentration: 1. Mean Corpuscular Volume (MCV). 2. Mean Corpuscular Hemoglobin (MCH). 3. Mean Corpuscular Hemoglobin Concentration (MCHC). The listed values can be determined on the basis of results provided by a complete blood count, though are usually already calculated on automated cell counters widely used. Table 5-9 provides an outline for the morphological classification of anemias to aid the investigator in his pursuit of the cause of a patient’s anemia. By obtaining a complete blood count (CBC) on a patient in whom anemia is suspected, the physician can categorize the anemia into its appropriate morphological type. Thus, insight is provided into subsequent diagnostic studies necessary to determine the precise disorder involved. The importance of determining the etiology of the anemia cannot be overstated; “anemia” in and of itself is not a specific diagnosis. Administration of blood, iron, or vitamins on the basis of “anemia” without a specific diagnosis is completely inappropriate.

In general, uncorrected anemia is cause for grounding of an aviator. If the etiology of the anemia is found and corrective measures are taken, the aviator can be returned to an “up” status as long as the patient’s hemoglobin and hematocrit remain at acceptable levels and the underlying cause of the anemia is not itself disqualifying. The following limits are acceptable for aviation personnel:

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Internal Medicine Table 5-9 Morphologic Classification of Anemias

HCT Males Females

HGB

40 to 52 percent 37 to 47 percent

14 to 18 gms/dl 12 to 16 gms/dl

If the average of three hematocrits falls outside of the acceptable range, but falls within the following ranges: Males Females

38 to 39.9 percent 35 to 36.9 percent

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52.1 to 54 percent 47.1 to 49 percent

U.S. Naval Flight Surgeon’s Manual a hematology consultation is required. If no underlying disorder is discovered, the condition is not disqualifying. Values outside these ranges must be carefully evaluated and waivers considered on a case by case basis. Hemoglobinopathies Again, this topic is quite lengthy; discussion herein will be primarily limited to sickle cell diseases and thalassemia. Sickle cell hemoglobin (HGB S) represents a qualitative hemoglobin abnormality, while thalassemia represents a quantitative disorder of hemoglobin. Sickle Cell Disease HGB S aggregates when deoxygenated, thus distorting red cells and impairing microcirculation. Clumps of sickled cells occluding circulation result in local pain, necrosis, and fibrosis; often, symptoms of “crisis” are bizarre and involve many areas of the body simultaneously. In addition to hemolytic anemia and vascular occlusion, patients with sickle cell anemia may have severe infections. Sickle cell trait, the heterozygous condition (HGB A-S), is rarely associated with clinical disease though the aeromedical literature contains conflicting reports of splenic infarctions and crisis after exposure to hypoxia. Previously, all individuals with sickle cell diseases were disqualified for duty involving flying. However, BUMEDINST 6260.26 of 27 November 1981, allowed individuals with 41 percent or less HGB S to enter aviation and diving training and established the Sickle Cell Trait Study Protocol to determine the true risk to these individuals in aviation and diving duties. As before, sickle cell anemia (HGB S-S) and the mixed heterozygous conditions (HGB S-C, HGB S-D, HGB S-thalassemia, etc.) are disqualifying for aviation. Thalassemia Thalassemia, as used here, refers to A2 thalassemia (a variety of beta-thalassemia) in which the A2 hemoglobin fraction is elevated. Fetal hemoglobin (HGB F) levels are slightly elevated, and microcytosis with target cells can be seen on the peripheral smear. Examination may demonstrate moderate splenomegaly. There are three clinical subdivisions of thassemia: (1) thalassemia minor; (2) thalassemia intermedia; and (3) thalassemia major. Thalassemia minor is usually discovered by accident during a routine physical examination of an asymptomatic patient. This “silent” form (sometimes described as thalassemia minor, variant minima) is compatible

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Internal Medicine with a normal life-span during which there are no clinical manifestations of the disorder. This diagnosis, if confirmed by the hemoglobin electrophoretic pattern in an asymptomatic patient, is not disqualifying for aviation, provided hematocrit levels are in the acceptable range. In thalassemia intermedia, there is mild to marked splenomegaly, jaundice, recurrent abdominal pain (as a result of cholelithiasis or splenic enlargement), and skeletal changes similar to those in thalassemia major. Both thalassemia intermedia and thalassemia major are disqualifying.

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U.S. Naval Flight Surgeon’s Manual SECTION IV: METABOLIC DISORDERS Adrenal Disorders A brief summary of adrenal disorders is as follows: 1. Glucocorticoid Excess a. Cushing’s Disease (Pituitary ACTH excess). b. Cushing’s Syndrome (either adrenal neoplasia or ectopic ACTH production). 2. Glucocorticoid Insufficiency a. Primary Adrenocortical Failure (Addison’s). b. Secondary Adrenocortical Failure. c. Adrenogenital Syndrome (rare and extremely unlikely to be disclosed in aviation personnel). The flight surgeon is referred to standard medical texts for complete discussions of these dysfunctions. Either state is a grounding defect and warrants follow-up within the hospital system. Return to aviation following treatment is most unlikely. Thyroid Disorders Hyperthyroidism Simply defined, hyperthyroidism is excessive production of thyroid hormones resulting in a hypermetabolic state with associated adrenergic-like symptoms. Hyperthyroidism may be subdivided into relatively common and relatively rare forms. most common forms include Grave’s disease, toxic multinodular goiter, toxic adenoma, and titious hyperthyroidism. Relatively rare forms include choriocarcinoma, metastatic testicular bryonal cell carcinoma, and struma. Treatment of hyperthyroidism includes medical agents surgical approaches. Medical management may take the form of:

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The facemand

Internal Medicine 1. Iodine (for emergency treatment of thyroid storm or in preoperative patients) to reduce thyroid vascularity. 2. Propylthiouracil (PTU)/methimazole (Tapazole). 3. Propranolol. 4. Radioactive iodine (treatment of choice). Surgical treatment is utilized in patients with solitary nodules. It is of importance to point out that hyperthyroidism is disqualifying in the aviator unless definitive treatment (either 1131 or surgical thyroidectomy) has been undertaken. In either of these instances, the potential for subsequent hypothyroidism is present. Hypothyroidism Hypothyroidism is a state of thyroid insufficiency in which a hypometabolic condition opposite that of hyperthyroidism ensues. The most common form of hypothyroidism is that of primary hypothyroidism in which the thyroid gland itself cannot synthesize sufficient thyroid hormone for metabolic needs. The second most common form of hypothyroidism is observed following therapy. Radioactive 1131 therapy results in 25 percent of patients being hypothyroid at the end of one year and 50 percent of patients being hypothyroid at the end of 10 years. Other causes of hypothyroidism are uncommon, but virtually all require thyroid replacement (i.e., unless oversuppression by medical therapy for hyperthyroidism is the etiology). If replacement therapy results in a euthyroid state, the aviator may be considered for a return to flight status, as long as follow-up thyroid studies and replacement therapy can be made available. Disorders of the Glucose Metabolism Diabetes Mellitus Diabetes mellitus is a functional disturbance of pancreatic islet cells resulting in metabolic abnormalities in the handling of not only sugars, but proteins and fats as well. It constitutes the fifth leading cause of death in the United States behind coronary artery disease, cancer, accidents, and

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U.S. Naval Flight Surgeon’s Manual renal disease. Over 50 percent of diabetics die because of coronary artery disease; diabetes is also the leading cause of adult blindness. Diabetes has been recognized to result from two distinct clinical entities: insulindependent (juvenile-onset), and noninsulin-dependent (adult-onset) diabetes. Insulin-dependent diabetes is noted to have HLA related genetic transmission, reduced serum insulin levels and may lead to ketoacidosis. Noninsulin-dependent diabetes has non-HLA associated genetic transmission, normal or high serum insulin levels, and rarely, if ever, results in ketoacidosis. Laboratory diagnosis is a controversial issue, especially in terms of interpretation of the glucose tolerance test (GTT). Conditions under which a GTT should be done must be rigorous: 1. The patient must be on a carbohydrate-loading diet (300 gm/day) for a minimum of three days. 2. The patient must be rested, relaxed, and fully ambulatory. 3. The test must be in the morning. 4. The patient must be free from acute illness. 5. The patient should not be taking medication nor should he smoke during the test. The physician must, himself, be acquainted with the laboratory techniques since plasma values are 15 to 20 percent higher than whole blood values. Two commonly used criteria for interpretation of GTT’s are outlined in Table 5-10. Fajans-Conn criteria require that all three values (1, 1 1/2, and 2 hours) be exceeded for the diagnosis. For a positive diagnosis under the U.S.P.H.S. point system, two points are required. Bear in mind that an abnormal GTT (i.e., one which does not meet the above diagnostic criteria) is not the equivalent of diabetes. The oral GTT is a poorly reproducible study and, for that reason alone, must be viewed with caution. To improperly label a patient as diabetic is as grave an injustice to him as is missing the diagnosis in a patient who is clearly diabetic on clinical and laboratory grounds. For these subclinical or latent diabetics (“glucose intolerance” being a better choice of terms in most instances), weight control and dietary programs are likely indicated.

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Internal Medicine Table 5-10 Interpretation of Values for the Standard GTT

To make a point, there is no place in naval aviation for the overt diabetic, insulin-dependent or not. Oral hypoglycemics should not be considered as a means of keeping the pilot “up” since undesired side effects (e.g., hypoglycemia) may bring catastrophic results. Hypoglycemia Hypoglycemia indicates excessively rapid removal of glucose from the blood or an inability of gluconeogenesis to sustain adequate glucose levels. When blood sugar falls at a precipitous rate, the patient displays signs of hyperepinephrinemia (e.g., nervousness, palpitations, sweating, pallor, hunger, headache, and tremulousness). A slower fall in glucose (which may result in a lower blood sugar than the former state) may give rise to cerebral symptoms (e.g., blurred vision, somnolence, syncope, coma, and even seizures). Hypoglycemia, which is not a specific disease state in and of itself, is classified as being either functional or organic. Organic hypoglycemia is related to a known anatomical lesion. Examples include beta-cell tumor of the pancreas, adrenocortical hypofunction, anterior pituitary hypofunction, epithelioid tumors derived from neural crest (e.g., insulin-producing carcinoid tumor). Functional hypoglycemia has no specific anatomical lesion. Examples include:

1. Exogenous hypoglycemia: a. Iatrogenic - the diabetic who takes too much insulin. b. Factitous - abuse by patients who have access to hypoglycemic drugs.

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U.S. Naval Flight Surgeon’s Manual 2. Reactive hypoglycemia: a. Alimentary hypoglycemia in postoperative gastrectomy or gastrojejunostomy patients. b. As a manifestation of glucose intolerance in the subclinical or latent diabetic. c. “Functional” hypoglycemia in the tense, anxious patient. 3. Hepatic dysfunction resulting in decreased gluconeogenesis. Most commonly, this is seen in the alcohol abuser who drinks excessively after periods of relative malnutrition or starvation. In aviation personnel with a history suggestive of hypoglycemia, extensive evaluation may be required to document the abnormality and, whenever possible, the underlying cause. Caution should be observed in performing studies such as a 72-hour fast or tolbutamide tolerance test; these should be reserved for the hospitalized patient under careful observation. As stated previously, the interpretation of oral GTT’s is an area fraught with pitfalls. The asymptomatic patient whose blood sugar at three hours falls to 50 mg per decaliter from a two-hour level of 90 mg per decaliter is more likely to be a variant of normal than is the patient who develops symptoms at three hours with a blood sugar of 65 mg per decaliter, having fallen from a two-hour value of 165 per decaliter. If disclosed, any underlying anatomical disorder in a patient demonstrating hypoglycemia should be treated. In those who have no evident etiology, dietary management (to include high-protein, six-meal diet) should be employed. Appropriate control of hypoglycemic episodes must be attained prior to the patient’s return to an “up” status; such control may take six months or more to achieve. In those aviators with continued episodes while under optimal dietary management, permanent grounding may be in order. Hyperlipidemias Classification of Hyperlipidemias. Hyperlipoproteinemias may be classified into five groups on the basis of plasma appearance and electrophoretic pattern, serum cholesterol, and triglyceride concentration. 1. Type I. Type I is characterized by increased chylomicrons in the blood serum which produce a milky fasting serum. If the specimen is allowed to stand at 4° C overnight, lactescence will rise

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Internal Medicine like cream, leaving a transparent infranate. Triglyceride levels of 1,000 to 10,000 mg per decaliter are seen. Ultralow density particles derived from the diet via lymphatics (i.e., chylomicrons), form a dense band on electophoresis. The underlying abnormality appears to be a genetic defect (recessive trait) which results in a lipoprotein lipase deficiency. The disease may appear in early childhood and presents as abdominal pain, distention, and an increase of pancreatic enzymes. Xanthomas, hepatosplenomegaly, and lipemia retinalis may be present. 2. Type II. Type II accounts for a sizable number of individuals who are identified by an elevation of serum cholesterol. Familial Type II is an autosomal dominant trait, and evidence is strong for the presence of accelerated vascular disease. In the homozygous state, coronary artery disease may express itself in childhood. Tendinous xanthomas of the Achilles tendon or other extensor tendons may occur. Tuberous xanthomas over the elbow, knees, buttocks, and hands are common. Xanthelasmas may be present, along with arcus comealis. Cholesterol is elevated, and the plasma is clear (Type IIA) to very slightly turbid (Type IIB). Electrophoresis shows a broad B-band (with a pre-B band in may Type IIB’s). 3. Type III. Type III is probably an autosomal recessive trait. It is less common than Types II and IV. Both triglycerides and cholesterol are moderately elevated, and serum allowed to stand overnight at 4° C takes on a moderately tubid appearance. A dense, broad B-band (generally fused with a pre-B band) is present on electrophoresis. Xanthomas, xanthelasmas, and corneal arcus may be present. 4. Type IV. Type IV is probably the most common lipid disturbance in the adult American Population. It is clearly exacerbated by obesity and alcohol; two-thirds of the patients have glucose intolerance. Cholesterol is normal to slightly elevated; triglyceride levels range from 200 to 2000 mg per decaliter. A dense pre-B band is present on electrophoresis; serum takes on a turbid appearance overnight at 4° C. Fasting plasma lactescence may be present, indicative of “hepatic particles” (triglycerides synthesized in the liver). Xanthomas, corneal arcus, and premature vascular disease may develop, depending upon lipid levels, at least in part. 5. Type V. Type V patients have both elevated cholesterol and triglycerides. The triglycerides, themselves, are an admixture of chylomicrons and hepatic particle triglycerides. Obesity, abdominal pain, pancreatitis, lipemia retinalis, and xanthomas are common. The trait is likely recessive. Dense chylomicron, B-, and pre-B-bands are seen on electrophoresis; plasma after overnight refrigeration separates into a cream-layer supematant and a milky infranatant. Treatment. Diet is the fundamental treatment for all forms of hyperlipidemia. A basic diet such as the following can be adapted for individual conditions:

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U.S. Naval Flight Surgeon’s Manual 1. Caloric reduction to attain ideal body weight. 2. Reduction in cholesterol intake to less than 300 mg/day. 3. Reduction in fat intake to 30 to 35 percent of total calories. 4. Decrease in saturated fat to no more than 10 percent of calories. Patients with hypercholesterolemia may need further reduction in cholesterol intake and patients with hypertriglyceridemia often need more stringent weight and alcohol reduction. The hyperlipidemias, particularly hypercholesterolemia, are risk multipliers for coronary artery disease and the management of these conditions in aviators should emphasize the overall cardiac state.

Obesity Almost all cases of obesity are due to exogenous factors, specifically caloric intake in excess of caloric expenditure. Other causes are not worthy of review; neither will space be taken to reproduce weight standards for aviation. For case of calculation, one can utilize the figure of 3500 calories as equivalent to one pound of body fat. Multiplication of 3500 by the number of pounds in excess of standards (or desired weight) results in calculation of total number of calories in excess. For example, a 73-inch male weighs 219 pounds, which is ten pounds over maximum aviation weight standards for height; 3500 cal./lb x 10 lbs. = 35,000 calories in excess. To calculate rate of loss, maintenance caloric intake is first figure by multiplying present weight 219 Ibs. x 10 (cal./lb.). Therefore, 2190 cal./day are required in order to maintain weight. Maintenance caloric intake minus specified caloricrestricted diet provides the daily caloric deficit. In this instance, an 1800 calorie diet is ordered, giving a daily caloric deficit of 390 calories (2190-1800). The deficit is divided into the total caloric excess, thereby calculating the number of days required to lose the excess weight (i.e., 3500 cal./390 cal./day = approximately 90 days). The desired weight can be maintained, thereafter by 2090 cal./day (209 lbs. x 10 cal/lb.). In essence, obesity is almost uniformly exogenous in etiology; most other causes are readily diagnosed by physical examination and through historical information. Weight loss requires insight and determination on the part of the patient, but it also requires concern and support (including referral of patient and spouse to the dietitian) on the part of the physician. The results of

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Internal Medicine patient effort and participation are easily seen and can be monitored by a simple device, the scale. Obese patients should be grounded until the desired weight is attained; follow-up to observe continued maintenance of desired weight is necessary and should include grounding if interval weight gain is present. Obesity in the Navy is defined in relation to the percent of body fat. The equation of Wright, Dotson and Davis is used to estimate the percent body fat in males. A nomogram was developed at NAMI from this equation for easy determination of body fat and is included at the end of this chapter. Body fat equations are available for women, also, though due to the added variables needed to yield adequate correlations to immersion weighing, are not easily reduced to nomogram format. Methods and tables for determining body fat in women are also included at the end of this chapter. Standards for maximum allowable body fat for men and women of the Navy and Marine Corps change periodically and are subject to the regulations of the respective services. Reference should be made to the current applicable instructions of each service when using the measurement of body fat for administrative purposes (OPNAVINST 6110 and MARINE CORPS ORDER 6100 series).

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U.S. Naval Flight Surgeon’s Manual SECTION V: PULMONARY DISEASE Pulmonary Function Testing Although a great deal can be learned about the lungs from the history, physical examination, and chest X-ray, pulmonary function testing can be a useful adjunct to describe and quantify many properties of the respiratory system. Several of the more important and simple tests will be discussed here and applicability to aviation medicine situations will be noted. Volume-Time Spirometry Volume-time spirometry measures the traditional forced vital capacity maneuver (Figure 5-18). A diminution of the vital lung capacity represents significant restrictive disease of the lung (e.g., collapse, infilitrates, chest wall deformities, or neuromuscular dysfunction). The amount of air expired in the first second of this forced maneuver (FEVl) is the classical, but insensitive, indicator of airway obstruction (e.g., significant bronchitis, acute asthma). These tests may be useful in following the recovery from reversible lung disorders in pilots, but their insensitivity makes their use as a screening tool unwarranted.

Figure 5-18. Graph of forced volume-time spirometry.

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Internal Medicine Flow Volume Spirometry This test (Figure 5-19) uses the same forced vital capacity maneuver as volume-time spirometry, but here the flow rates are measured and plotted against the percentage of vital capacity expired. This is useful for measuring the mid- and end-expiratory flow rates, so difficult to determine from the volume-time curve. It is these flow rates that are felt to be sensitive indicators of airway dysfunction in otherwise asymptomatic individuals. Presumably, abnormalities here reflect a predisposition to subsequent obstructive pulmonary disease. Thus, these measurements are potentially useful screening tools to identify high risk groups in an effort to alter their pulmonary stress factors (e.g., smoking, environment). Newer techniques comparing flows at room air versus flows using helium may enhance their effectiveness.

Figure 5-19. Graph of flow-volume spirometry.

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U.S. Naval Flight Surgeon’s Manual Single Breath Closing Volume Like the mid- and end-expiratory flow measurements described, this test is thought to be a simple and accurate indicator of early airway dysfunction. The procedure measures the dilution of residual nitrogen in the lung after a single breath of 100 percent oxygen. Airway dysfunction and collapse give a characteristic uneven dilution profile through expiration. Maximum Mid-Expiratory Flow Rate The maximum mid-expiratory flow rate (MMEFT), also called the forced expiratory flow through the 25th through 75th through 75th part of the vital capacity (FEF25-75), has been found to corelate well with the closing volume and is an easy way to measure the function of the small airways from the simple spirogram. It also represents a relatively effort-independent portion of the expiratory cycle. Diffusing Capacity This test does not depend upon airway function but rather measures the permeability of the alveolar capillary membrane by use of carbon monoxide inhalation and uptake measurements. It is useful in describing dysfunction in interstitial diseases of the lung such as sarcoid or the pneumoconioses. It can be of help in following the recovery of a pilot from a reversible disorder, but has little screening potential. Arterial Blood Gases These measurements, particularly if done at near maximal exercise, give a good indication of overall pulmonary function as ventilatory, diffusing, and perfusion capabilities of the lung all come into play. Aviation Effects on Pulmonary Function The safe and effective operation of a combat aircraft stresses the oxygen delivery system to its limits. Oxygen demand may rise by a factor of 15 in certain high performance situation. The oxygen demand is met by a greater extraction of oxygen from the hemoglobin (the shape of the oxygen-hemoglobin dissociation curve allows this to happen with a minimal drop in PO 2 ). However, much of this demand must be supplied by an increased cardiac output coupled with an increased pulmonary oxygen delivery.

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Internal Medicine The pulmonary role can be divided into several steps. First, adequate oxygen must be available in the environment. Secondly, airways must be open and functional. Thirdly, the alveolar capillary membrane must allow efficient diffusion of oxygen. And lastly, pulmonary blood flow must not only be of a sufficient magnitude, but it must be appropriately matched to ventilated alveoli. Immediate or Short-Term Effects High G-Forces. The effects of high G-force can alter several of these pulmonary functions. First, it can both reduce, as well as redistribute, pulmonary blood flow to dependent lung fields. Secondly, it can cause collapse of these same dependent lung fields (atelectasis). The collapse of dependent alveoli is further encouraged if the alveolar gas is 100 percent oxygen rather than air containing mostly nitrogen since oxygen is readily absorbed across the alveolar membrane. The net effect of these alterations is both a decrease in vital capacity and an effective matching of blood and air, producing a significant compromise in the lung’s ability to deliver oxygen. Due to the pulmonary changes described above, tactical aviators often experience symptoms of dyspnea and cough following high G flights such as air combat maneuvers (ACM’s). Physical examination during the symptomatic period reveals rales and chest X-ray may show basilar atelectasis. The condition rapidly clears and leaves no residua. Deep breathing, cough and reassurance are the treatments. This clinical entity has been called aeroatelectasis, postflight atelectasis, or acceleration atelectasis. The combination of high G flight and oxygen breathing predisposes the aviator to aerotelectasis and since neither may or should be eliminated, education and awareness of this condition is necessary. Chest Constraints. Chest constraints have small but significant effect on pulmonary function. The vital capacity is somewhat decreased and the work of breathing slightly increased by these devices. Oxygen-Delivery Systems. Oxygen delivery systems are needed to maintain an adequate PO2 in the inspired air while flying at altitude. However the dryness of the gas, the slight positive pressure, the possibility of contaminants, and perhaps the direct effect of 100 percent oxygen on the cilia and mucose, all contribute to airway irritation and transient airway flow measurement abnormalities following jet flights.

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U.S. Naval Flight Surgeon’s Manual Long-Term Effects It has always been thought that the vital capacity and flow measurement decreases immediately postflight reflected a totally reversible situation. Indeed, atelectasis, chest complaints, and volume-time spirogram abnormalities generally are resolved by 12 hours postflight. There are pathological and physiological data, however, that suggest that progressive, subtle, and permanent changes are occuring in the lungs of jet aviators. What the etiological factors are and what relationship, if any, these changes have to chronic lung disease remains to be explained.

Asthma Asthma is a state of bronchial hyperreactivity to a number of stimulants. The classical childhood variety results from a characteristic IgE allergic phenomenon. The less well understood “adult” variety develops later in life, has a less clear relationship to allergies (although nasal polyps and aspirin sensitivity are common), and seems more related to prolonged environmental stresses such as chronic infections, smoking, physical and chemical irritants, and anxiety states. Most childhood asthma will spontaneously regress by young adulthood, but the Navy regulations disqualify the candidate whose symptoms have persisted past the age of 12. On the other hand, adult asthma develops in the age group containing already designated aviators. The future of such an individual is a difficult decision for the flight surgeon. In general, adult asthma usually stabilizes or improves with age, although a significant percentage of patients go on to develop chronic obstructive disease. Furthermore, the clinical picture runs a wide spectrum of severity. Thus, the approach should be individualized. The pilot with mild symptoms once a year during a bout of the flu, and with normal pulmonary function tests off medications the remainder of the lime, need not be permanently grounded. Conversely, severe attacks, permanently abnormal pulmonary function tests, and a need for chronic medication all constitute reasons for disqualifications. Spontaneous Pneumothorax Although uncommon, the acute spontaneous pneumothorax can strike any age group unpredictably and be acutely debilitating. Aviation candidates at risk (e.g., bullous disease, history of pneumothorax in previous years) are disqualified before entry into the flight program. Nevertheless, this does not eliminate all those at risk, for example, those with the presumed congenital alveolar defects that are not detectable clinically.

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Internal Medicine The acute episode may range from a sudden, mild pleuritic pain to a full cardiopulmonary arrest. Rest and analgesia are often all that is required for small pneumothoraces, but a chest tube for reexpansion may be required if large or seriously symptomatic. Following a single, spontaneous pneumothorax, the risk of recurrent pneumothorax is high for at least one year (up to 30 percent). Because of this, aviators should be grounded for at least this period of time. A second pneumothorax is permanently disqualifying, unless surgical stripping or adherence of parietal and visceral pleura is done. In those postsurgical cases, exercise tolerance and pulmonary function testing must be normal before the patient is returned to flight status. The air evacuation of patients with pneumothorax is discussed in Chapter 16, Aeromedical Evacuation. Sarcoidosis This is an interesting granulomatous disease of unclear etiology. It frequently present as asymptomatic bilateral hilar adenopathy in routine chest X-ray. The disease, however, can produce interstitial lung disease, erythema nodosum, uveitis, liver function abnormalities, and depression of cellular immunity. Hypercalcemia, bone lesions, splenomegaly, and neurological symptoms are rarer. Diagnosis is made by biopsy (noncaseating granuloma). Asymptomatic hilar adenopathy alone is virtually diagnostic of the disease. Acute sarcoidosis occurs in young adults and most will completely resolve within two years without sequelae. Steroids may be useful for transient control of symptoms. Following such a course, a return to flight status is reasonable providing ECG, exercise tolerance, pulmonary function, and all signs of the disease have returned to normal. The more insidious and chronic form of sarcoidosis occurs in an older population with more severe pulmonary and extrapulmonary symptoms. Prognosis here is poor with few remissions. These individuals are generally disqualified from aviation. Pulmonary Emboli Emboli to the lung can result in syndromes ranging from mild pleuritis to an acute asthmatic attack to a sudden new supraventricular tachycardia to a cardiopulmonary arrest. The diagnosis should be suspected in those predisposed to thromboemboli (e.g., venous disease, autoimmune phenomenon, right heart endocarditis) in whom acute pulmonary problems develop. The diagnosis is made by a good history, findings of pleuritis, arterial oxygen desaturation, and evidence of a lung perfusion defect on scan or arteriogram.

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U.S. Naval Flight Surgeon’s Manual The aviation future of individuals postemboli depends on two things. First, there must be no residual cardiopulmonary dysfunction as determined by exercise testing, pulmonary function, and 24-hour ECG monitoring. Second, the source of the emboli must be completely resolved. Airway Burns Hot irritant gases such as ammonia, nitrogen oxide, sulfur dioxide, and sulfur trioxide are common in smoke from burning material. Phosgene is another toxic irritant gas that is produced when carbon tetrachloride from fire extinguishers comes in contact with hot surfaces. Airway burns are produced by these substances when inhaled. The clinical spectrum ranges from mild dyspnea, and coughing to severe pulmonary edema and “shock lung.” Furthermore, these serious complications may not appear until three to 72 hours after exposure. Return to flight status is reasonable when symptoms clear, and testing of airway function and diffusing ability have returned to normal.

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Internal Medicine SECTION VI: INFECTIOUS DISEASE Infectious disease in the aviation community is generally limited to the acute contagious infections because of the young age group, requirement for excellent physical conditioning, aggressive preventive medicine programs, and the semiclosed population. These infections include the more common viral diseases, veneral diseases, tuberculosis, Neisseria meningitis, and protoza. Two handbook references that are continuously current are the Handbook of Antimicrobial Therapy and the Guide of Antimicrobial Therapy. The infectious disease section in Harrison’s Principles of Internal Medicine is an excellent textbook reference. In general, the rigid demands of the aviator require that he be grounded while symptomatic and for 24 hours after completion of medical therapy. Viral Disease Viral disease in the aviation community is a major cause of “down” time. This category includes upper respiratory infection, influenza, infectious mononucleosis, and hepatitis. Treatment is symptomatic with observation for complication. With an infection of viral etiology, prophylactic antibiotic therapy should be withheld because of the risk of secondary infection with a resistant organism, toxicity of drugs, expense, and confusion with improperly treated bacterial infections. Antibiotic prescription in these situations is a poor substitute for frequent clinical observation and appropriate cultures. If bacterial etiology is suspected, cultures should be taken and antibiotic therapy begun. This should be terminated in five days if clinical or culture results are negative.

Upper Respiratory Infection Rhinorrhea, pharyngitis, and sinus congestion compromise the patency of the Eustachian tube and, in the aviation environment, predispose to middle ear disorders such as vertigo or bacterial infection. Treatment is symptomatic with rest, increased fluids, and antihistamine therapy. The aviator is grounded until he has been off medication for 24 hours and proof of normal tympanic membrane motion is obtained. In recurrent illness, an allergic process should be sought. Secondary complications including otitis media, sinusitis, or bronchitis increase “down” time. Influenza The military community is considered a high risk group for influenza. There are three types of influenza virus, labeled A, B, and C. Influenza C causes mild upper respiratory infection symptoms. Influenza B causes mild flu symptoms. Influenza A causes the major epidemic at two to

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U.S. Naval Plight Surgeon’s Manual four year intervals, and its antigenic changes result in morbidity and mortality as recorded in the epidemics of 1918 - Swine flu, 1957 - Asian flu, and 1968 - Hong Kong flu. BUMED recommendations for vaccination are reviewed yearly to reflect the situation actually present for that year. The vaccination program should be scheduled so that the entire unit is not incapacitated at the same time. The aviator is down for at least eight hours and preferably for 24 hours post-vaccination with observation for acute anaphylactic reaction and influenza syndrome. The incubation period is less than three days, and the acute symptoms last an average of three days. During an acute episode, the aviator is in a “down” status and treated symptomatically with rest, analgesics, increased fluids, and observations for secondary complications, mainly bacterial pneumonia. Prophylactic antibiotic and amantadine therapy are not recommended. Cigarette smoking has been shown to be a major risk factor for acquiring influenza and determining the subsequent morbidity from infection. In an unusual epidemic situation, the infectious disease department of the regional medical center or the Communicable Disease Center should be contacted for guidelines on the need for typing of virus and the vaccination programs. A special awareness is required to assess the impact of influenza on the readiness of the aircrewmen to resume flying duties in the presence of the ill-defined, but important, postinfluenza syndrome characterized by nonspecific fatigability and vague lassitude. In such an instance, where physical examination and laboratory values are normal, return to flight status should be delayed pending resolution of the syndrome complex. Infections Mononucleosis The clinical syndrome of fever, pharyngitis, lymphadenopathy, and lymphocytosis with many atypical lymphocytes in the young adult suggests mononucleosis caused by the Epstein-Barr virus. It warrants a mononucleosis heterophile test, and if negative, the test should be repeated in two weeks for confirmation. The acute illness lasts from two to four weeks with gradual return to full capacity. Treatment is symptomatic with rest, analgesics, and observation for complications which include airway obstruction, aseptic meningitis, encephalitis, Guillain-Barre syndrome, and splenic rupture. Prednisone 40 to 60 mg g.d. is recommended for treatment of these severe complications. The aviator is in a “down” status until he is returned to normal activity following convalescence. A medical board or convalescent leave may be necessary in protracted cases. The persistent presence of a peripheral right shift or splenomegaly as the only disease residual in clearly recuperating patients constitutes objective evidence that the patient is not yet ready for aviation duties.

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Internal Medicine Hepatitis Acute viral hepatitis is a commonly encountered clinical problem in operational medicine. The outcome and course of many military operations have been measurably altered by hepatitis outbreaks. Since 1968, knowledge of the etiological agents responsible for the symptom complex of anorexia, nausea, right upper quadrant pain and tenderness, hepatomegaly, jaundice, and elevation of AST and ALT enzymes (formerly called SGOT and SGPT) has become much more precise. The two principal viral agents, hepatitis A virus (HAV), and hepatitis B virus (HBV), are responsible for the vast majority of cases worldwide. The former, spread by the fecal-oral route, is much more likely to be responsible for outbreaks of epidemic proportions and is amenable to prophylactic measures including steps to ensure proper handling of food, water, and human wastes. The prophylactic administration of Human Immune Serum Globulin is discussed below. HBV, formerly called “serum” hepatitis, presents less of a problem but is less amenable to large scale prophylactic measures. Both forms of hepatitis have become endemic in homosexual male populations and are now considered sexually transmitted diseases. In 1982, the FDA released the HBV vaccine. BUMEDINST 6230.13E outlines the preliminary recommendations for use of the HBV vaccine. Serology. Both forms of acute viral hepatitis have serological markers which enable the clinician to distinguish between the viral causes of virtually identical clinical presentations, thus helping to predict chronic sequellae and infectivity in HBV infections. 1. HAV In virtually all cases of acute hepatitis from HAV, an abrupt rise in antibody to HAV of an IgM subclass is measureable. The detection of this antibody rise is both highly sensitive and specific when associated with the appropriate clinical presentation. The Ig subcomponent also seen in most cases of HAV hepatitis appears later and has neither the sensitivity nor the specificity to distinguish the various causes of elevation of AST and ALT because the antibody elevation usually persists for years. Neither the IgM nor the IgG anti-HAV have any significance in predicting infectivity which usually ends with the onset of clinical symptoms. 2. HBV. In contrast to HAV, HBV has a plethora of serological viral markers which have both diagnostic as well as prognostic significance. Table 5-11 list the various serological markers for HBV and depicts the source of those particles.

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U.S. Naval Flight Surgeon’s Manual Table 5-11 Seriological Markers for HBV and Their Sources

Serological marker

Source/Significance

Hepatitis B surface antigen (HBSAg)

Antigenic determinant found in the HBV viral coat; present during acute and chronic HBV infections.

Hepatits core Antigen (HBcAg)

Antigenic component of double stranded DNA core; generally not directly detectable.

Hepatits e Antigen (HBeAg)

Released from wre during viral replication; directly correlates with HB infectivity.

Hepatitis B surface Antibody (HBsAb)

Reflects immune response to HBV infection; directed against surface antigen.

HBV Core Antibody (HBcAb)

Core antibody is an immune response to viral replication. An IgM cAb reflects acute infections while an IgG cAb reflects old or chronic infection.

Hepatitis B e Antibody

Antibody directed against e antigen, reflects decreasing viral replication and beginning of resolution of the infection.

The clinical interpretation of the serological markers for HBV is summarized in Table 5-12.

3. Non-A/Non-B Hepatitis. To date, there are no serological markers for this form of viral hepatitis which has so far been exclusively associated with blood transfusions. Thus the diagnosis is by exclusion in the appropriate clinical setting. Some evidence exists that screening blood donors with elevations of ALT/AST will substantially decrease the risk of subsequent infection with non-A/non-B hepatitis. Though the clinical course of non-A/non-B hepatitis is usual-

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Internal Medicine ly milder than hepatitis caused from HAV or HBV, a much larger percentage of infected persons go on to a chronic hepatitis. Treatment and Medical Disposition. The standard clinical texts each present excellent monographs on the care of individuals with acute viral hepatitis. The majority of cases may be cared for in shipboard medical departments where impatient facilities exist. With Fleet Marine units ashore, referral to first eschelon medical facilities with inpatient facilities is indicated. Considerations in the decision to medevac infected individuals include: 1. Severity of infection. 2. Logistical support of forward medical unit (e.g., is laboratory support available?) 3. Will future operational requirements preclude future medevac? 4. Does the infected individual present a risk to other members of the crew or unit? The usual course of acute viral hepatitis is six to 10 days of acute symptoms associated with a variable rise in ALT/AST and bilirubin. In individuals with fulminant infections, the prothrombin time will increase which is a poor prognostic sign. If the clinical course is benign, the patient may return to activities as tolerated as soon as his appetite returns. Complete normalcy of AST/ALT is not a prerequisite for return to duty. While cases must be individualized, excessive convalescent leave is rarely indicated. Adequate outpatient follow-up, though, is mandatory in HBV infections. Serological markers to follow include HBSAg, and HBcAb if persistently positive HBSAg exists. The AST and ALT should be followed at monthly intervals after the initial decline has been documented. Human Immunodeficiency Virus (HIV) The human imunodeficiency virus is a retrovirus which was recognized as an infectious cause of an unusual immunodeficiency syndrome in otherwise healthy homosexual males in 1982. Since then, the virus has been recognized as a major public health problem for men and women, with between 5 and 10 million persons thought to be infected worldwide.

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Table 5-12 Clinical Interpretation of Seriological Markers for HBV

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Internal Medicine HIV is transmitted in a similar mode to that of hepatitis B virus; it can be acquired by homosexual or heterosexual intimate contact, by receiving infected blood or blood products, or by inoculation via needles contaminated with infected blood (IV drug use, tatooing, etc.). There is good evidence that transmission via open skin wounds exposed to infected blood or saliva occurs, but such transmission is rare. Pathogeneis and Complications. HIV infects predominantly T 4 (helper) lymphocytes and macrophages. These cells express the CD4 surface antigen to which the virus surface glycoproteins bind. Once bound, the virus inserts its RNA genome into the cell which undergoes reverse transcription to viral DNA. This DNA is then incorporated in the host genetic material where it can either remain dormant, express new viral RNA to make new virus, or possibly serve as an oncogene. The destruction of infected lymphocytes and other immune cells results in a state of immunodeficiency. Some patients experience a flu-like illness when initially infected, but often there are no symptoms. A very variable, prolonged period may pass in which there are no signs or symptoms as immunosuppression proceeds. When the immune system is sufficiently impaired, infections with various organisms usually not pathogenic occur. These so-called opportunistic infections include fungi (Cryptococcus neoformans, Histoplasma capsulatum, Candida species, etc.) viruses (Herpes species, Cytomegalovirus, Varicella, etc.), bacteria (Mycobacterium tuberculosis, M. avium, encapsulated organisms, etc.), and parasites (Pneumocystis carinii, Giardia species, Toxoplasma gondii,etc.). No curative therapy exists at this time for HIV infection. Therapy is directed at treatment of complications, and some progress is being made in antiviral therapy. Although it is beyond the scope of this discussion, excellent reviews are available in the standard textbooks of Internal Medicine reviewing pathogenesis, complications, and management of HIV infection. One complication that bears specific mention is a global dementia that occurs in the absence of an opportunistic infection of the CNS. This appears to be a direct consequence of HIV viral infection and precedes any other clinical manifestation in between 10 and 25 percent of infected patients who develop AIDS. Initially, there are mild cognitive defects involving judgement and memory, which progress to a severe global dementia. In light of this complication, HIV infection regardless of symptoms or signs is disqualifying for all special duty including aviation-related duties. Disposition of HIV Positive Individuals. Screening of all applicants to military service is performed using enzyme linked immunosorbent assay (ELISA) to detect antibodies to the virus in

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U.S. Naval Flight Surgeon’s Manual patient serum. If positive, the test is repeated. A positive repeated test is confirmed using a Western blot technique for specific antibodies before a patient is identified as “HIV-positive”. HIV positivity, thus defined, is disqualifying for enlistment and commissioning in the armed forces. Seroconversion while on active duty requires an inpatient evaluation at a major treatment facility for classification, according to the Walter Reed Staging System outlined in Table 5-13.

Table 5-13 Walter Reed Staging System

As mentioned previously, all seroconverters are permanently disqualified from all special duties, including aviation. Patients in Navy Category A (asymptomatic, with normal T4 cell numbers) may continue serving their obligated service period in CONUS only and in nondeployable billets, but are ineligible for reenlistment. Any patient staged at Navy Category B or C is medically retired, as are Category A patients who progress to a higher category while on active duty.

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Internal Medicine Tuberculosis Extensive instructions for testing, treatment, and disposition of tuberculosis (TB) cases are contained in NAVMED P-5052-20 and BUMEDINST 6224.ID. All cases of active TB are to be expeditiously transferred to a tuberculosis treatment center. These are NRMC, Portsmouth, Va., and NRMC, San Diego, Ca. A Disease Alert Report, MED-6220-3, is submitted. The aviator is grounded for the duration of chemotherapy and then returned to active flying status if there are no residual physical disqualifying defects. Preventative therapy of TB is based on the facts that transmission of TB is by aerosolized droplets and that the natural history of TB includes the reactivation of dormant disease. With discovery of an active case of TB, a contact investigation is begun. This includes all who share the same berthing facilities, those in close contact during duty hours, regular liberty mates, and dependents of patients. This is extended on ships to include the entire ship’s company, if less than 350 onboard personnel, or crew members served by the same ventilation system, and in commands with exceptionally close conditions. Decontamination of affected spaces involves changing of filters in ventilation systems and cleaning of the patient’s berthing spaces and bedding. The screening examination for close contacts includes skin testing using five units of purified protein derivative (PPD) of tuberculin intradermally and chest X-ray with results recorded on NAVMED 6224/l in the Health Record. Reexamination is done at three, six, and 12 months. Previous tuberculin reactors are screened with chest X-ray only. If no active disease is present, but PPD is greater than 10 mm, isoniazid (INH) 300 mg q.d. is given for one year unless contraindications exist. If the screening test is negative, isoniozid (INH) prophylaxis may begin based on the clinical situation, to be discontinued at three months if reexamination continues to be negative. INH preventive therapy is a balance between the risk of reactivation of disease over a period of time and the risk of side effects, namely INH hepatitis. Current recommendations are to begin 12-month INH prophylaxis in the following cases: 1. PPD converter in the past two years. 2. Positive PPD with chest X-ray consistent with inactive TB, with negative AFB smear and culture, and without prior adequate chemotherapy. 3. Positive PPD with diabetes mellitus, hematological or reticuloendothelial disease, prolonged steroid therapy, immunossuppressive therapy, silicosis, and postgastrectomy.

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U.S. Naval Flight Surgeon’s Manual 4. Mandatory for PPD-positive children under six years and highly recommend to age 35 years, unless specific contraindications exist. Specific contraindications to INH therapy include previous INH hepatic injury, adverse reaction to INH such as drug fever, chills, rash, and arthritis, acute liver disease of any etiology, and pregnancy. Special attention should be paid to people on long-term medications such as phenytoin, daily users of alcohol, patients with chronic liver disease, and those with a history of prior discontinuance of INH secondary to questionable reaction. Individuals on INH chemoprophylaxis should be educated about toxic symptoms and queried monthly about signs and symptoms of hepatitis. Should they occur, the patient is instructed to immediately discontinue INH therapy and report for evaluation of liver disease. Routine liver function tests are not recommended. An isolated SGOT elevation less than 100 I.U. is not sufficient reason for stopping therapy. The aviator is returned to flight status while receiving INH prophylaxis once the flight surgeon has established that no untoward reactions are ongoing. This may require an initial two-week grounding with biweekly clinical observation. Malaria Malaria is transmitted by the bite of the Anopheles mosquito and should be suspected in any ill person returning from an endemic area. The symptoms of chills, fever, headache, muscle pains, associated spenomegaly, and anemia should occur within three weeks of exposure. The first attacks are severe, but repeated attacks become milder. The diagnosis is confirmed by finding parasitized erythrocytes on Wright’s or Giemsa-stained smears. The parasites should be seen and diagnosed on at least one slide, if blood is obtained every six hours during a 24-hour period. Associated laboratory finding are a normal or low white count and an elevated erythrocyte sedimentation rate. Complications associated with malaria are spontaneous rupture of the spleen, bacillary dysentery, cholera, and pyogenic pneumonia. The treatment of acute attack generally consists of chloroquine, 0.6 gms initially, 0.3 gms six hours later, 0.3 gms daily times two, and pyrimethamine, 25 mg b.i.d. for three days, If a patient is suspected of having drug resistant P. fulciparum, a combination of quinine, pyrimethamine, and sulfonamide or sulfones should be given for 10 days. To clear the liver of parasites as in P. vivax P. ovale or P. malariae, a 14-day course of 15 mg. primaquine base will effect cure in most cases. Current and specific treatment

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Internal Medicine recommendations can be obtained from the Navy’s Environmental and Preventitive Medicine Units (EPMU’s) or the CDC. Prophylaxis regimes should be guided by current estimations of the prevalence and drug susceptibility of the malaria in each specific area. The EPMU or the CDC can provide this information also. Aviators may take chloroquine, primaquine or pyrimethamine/sulfadoxine (FansidarR) in prophylactic doses and continue in a flight status after clearance by the flight surgeon of allergic, idiosyncratic or other untoward side effects (i.e., G.I. intolerance, rash). Hemolysis in G-6-PD deficiency is most commonly associated with daily primaquine, however it has occured with weekly primaquine as well as the sulfa drugs. Individuals with G-6-PD deficiency should be carefully observed for hemolysis when these drugs are used. Amebiasis The major protozoal diseases with world wide distribution are amebiasis and malaria. Both diseases are more common in underdeveloped tropical and subtropical countries, but they are also seen in military personnel and civilians returning from these areas. Amebiasis is caused by Entamoeba histolytica. It is the only one of the seven different species which parasitize the mouth and intestine of man, causing disease. There are two forms of Entamoeba histolytica, the motile trophozoite and the cyst. The trophozoites are passed in the stool unchanged when diarrhea is present. If there is no diarrhea, the trophozoites will encyst before passage in the stool. It is the cyst which causes disease, and the usual route is through fecal contamination of food and water. The diagnosis is made by finding the cyst in formed stools or the trophozoite in liquid stool. The clinical manifestations of symptomatic intestinal amebiasis are intermittent diarrhea, progressing to fulminant attacks of amebic dysentery with high fever, severe abdominal cramps, and profuse bloody diarrhea with tenesmus. In these patients, trophozoites are numerous in stools and on the material obtained from ulcers in the cecum and rectum. Hepatic amebiasis occurs as a result of the parasite invading of the liver via the portal vein. This may be followed by the development of a single hepatic abscess in the posterior portion of the right lobe of the liver. Clincial findings of the abscess are fever, night sweats, weight loss, and sometimes, tender hepatomegaly. Occasionally, an abscess will extend into the right pleural cavity and lung. These people will present with cough, pleural pain, fever and leukocytosis as a rule. A secondary bacterial infection is frequent.

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U.S. Naval Flight Surgeon’s Manual Metonidazole (Flagyl R ) is the drug of choice for both intestinal and hepatic amebiasis. Aviators receiving any form of treatment for amebiasis should be grounded. Traveler’s Diarrhea Acute diarrhea occuring with travel to developing regions of the world is the most common infectious disease limiting the operational effectiveness of the military. Enterotoxigenic Escherichia coli have been found to be the major pathogen in 40 to 70 percent of cases. Shigella is found in five to 20 percent, and less commonly, Campylobacter, Reovirus and Norwalk virus are isolated. Treatment of traveler’s diarrhea consists of generous fluid replacement and bowel rest (clear liquids). Pepto-BismolR in doses of two to four tbsp. every half hour for eight doses has been shown to reduce the frequency and the severity of the diarrhea. Prevention of traveler’s diarrhea has been attempted with various agents. Pepto-BismolR, two tbsp. twice a day prophylactically, appears to bind the enterotoxin and confer relative immunity. Doxycycline, 100 mg. daily, has also demonstrated effectiveness in preventing most acute traveler’s diarrhea. Trimethoprim sulfa (TMP/SMX) prophylaxis may also be effective. Widespread use of prophylactic antibiotics will undoubtedly induce bacterial resistance and is therefore not recommended. The risk of virulent superinfection is also present with routine antibiotic administration. The synthetic opiates (diphenoxylate and loperamide) are often prescribed and may reduce fluid secretion from the bowel. Excessive use of these agents, however, may actually worsen the illness and prolong the carrier state. Aviators with acute traveler’s diarrhea should be grounded during the acute illness and while taking the opiate-type drugs. Under certain extenuating circumstances, the use of prophylactic antibiotics, though not generally recommended, may be consistent with continued flight status once the flight surgeon has determined that the aviator is free of untoward side-effects.

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Internal Medicine SECTION VII: RENAL DISEASE Significant renal disease in the aviation community is limited to acute infection, asymptomatic or symtomatic hematuria, and nephrolithiasis which, if recurrent, may be disqualifying. Urinary Tract Infection It is rare for a male under the age of 50 years to get urinary tract infection. Other infectious processes such as gonorrhea and prostatitis should be ruled out. With clinical evidence of pyelonephritis, an obstructive process must be ruled out with the IVP. The infecting organism should be documented with cultures, and sensitivities should be obtained to guide antibiotic selection. The aviator is grounded until 24 hours after completion of therapy. In cases of recurrent infections, infection with an unusual organism such as Proteus or Pseudomonas, or evidence of obstructive process, referral for complete urological evaluation is recommended. Hematuria/Proteinuria The discovery of hematuria/proteinuria is an asymptomatic individual on routine screening urinalysis requires that an etiology be determined. Initially, the test should be repeated ensuring that proper collection technique is followed. A three bottle collection may be helpful with the because the upper tract etiology will show consistent abnormality with the lower tract only at the beginning or end of collection. Benign etiologies include postural proteinuria, proteinuria following intercourse, hematuria/proteinuria following vigorous exercise, and certain febrile illnesses. Infection is the most common etiology. Other etiologies in order of decreasing frequency include neoplasm, trauma, calculi, glomerulonephritis, and bleeding disorders. Evaluation of blood urea nitrogen, serum creatinine, and 24-hour urine for creatinine, total protein, and total volume, serum uric acid, serum protein electrophoresis, serum complement, fluorescent antinuclear antibody, prothrombin time, partial thromboplastin time, and IVP gives an assessment of renal function and some diagnostic information. Symptomatic patients, and asymptomatic patients (if it is necessary to establish the diagnosis), should be grounded and promptly referred to a urologist or nephrologist for a complete evaluation. The aviator’s status depends upon the underlying disorder (e.g., glomerulonephritis may be self-limiting). If the condition is benign or self-limiting, the aviator is returned to flight status, whereas a progressive neoplasm or renal disease will render a patient permanently NPQ.

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U.S. Naval Flight Surgeon’s Manual Nephrolithiasis Nephrolithiasis is a vexing problem in the aviation community. The risk to be appreciated by the flight surgeon is sudden incapacitation in flight which applies with equal importance, but differing implications to all aircrewmen. In symptomatic airmen or applicants presenting with a history of renal stones, the stone screening battery should be obtained. Stone Screening Battery (Drach Protocol) Urinalysis

Urine culture

CBC

Serum

Serum Ca + + , Pod4, uric acid

24 - hr. urine for CA + + , PO4, uric acid

Nephrotomograms Stone analysis Cysteine screen (if available)

electrolytes

IVP Urine pH (meter) (if available)

Other Tests Additional studies such as parathormone assay, renal scan, and urinary oxalate measurements as well as urological evaluation may be indicated on an individual basis. Disposition Designated aviators with nephrolithiasis should be grounded. If the metabolic work-up is negative, the aviator may be returned to unrestricted flight status two weeks after spontaneous passage of the stone, four weeks following stone manipulation, or three months following open surgery. If the metabolic work-up is positive and the underlying process is treatable, a waiver should be submitted and the aviator may be returned to a SG-III flight status for three months for evaluation of adverse medication side-effects. After that period, and with clearance from the flight surgeon the aviator may return to SG-I.

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Internal Medicine If the metabolic work-up is positive and the process is not treatable or the aviator has retained stones, he is permanently grounded. Cases with frequent recurrences (generally more than two a year or three in five years) or retained parenchymal stones should be submitted for waiver by BUMED and considered on a case-by-case basis. Applicants for aviation duty with a history of renal calculi will be considered only if the metabolic work-up is negative, there are no retained calculi, and a year has passed since the stone passage.

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U.S. Naval Flight Surgeon’s Manual SECTION VIII: MALIGNANCY With earlier detection combined with improved and aggressive combinations of surgical therapy, chemotherapy, immunotherapy, and radiation therapy, there are increased numbers of long-term survivors and apparent cures of malignancies (e.g., Hodgkin’s lymphoma). Moreover, there is expected to be further improvement with present investigative programs. However, survivors of childhood cancer will often have a residual deformity that renders them NPQ for aviation. For survivors without physical impairment, type of tumor, therapy given, current prognosis, and need of the aviation community will have to be individually considered. Ideally, entrance into the aviation community will require that the patient be considered permanently cured after more than five years after definitive therapeutics with no residual physical impairment. The designated aviator who is one year past a major therapeutic program, resulting in a permanent cure, and with no residual disqualifying physical impairment should request a waiver for placement back to flight status. REFERENCES AND BIBLIOGRAPHY Abramovicz, M. (Ed.) Handbook of antimicrobial therapy- New Rochell, N.Y.: The Medical Letter on Drugs and Therapeutics, 1985. Alavi, J.B. Sickle cell anemia: Pathophysiology and treatment. Medical Clinics of North America, 1984, 68, 545-556. Bates, D.V., Macklem, P.T. & Christie, R.V. Respiratory function in disease. Philadelphia: W.B. Saunders, 1971. Beumer, H.M. A ten year review of spontaneous pneumothorax in an armed forces hospital. American Review of Respiratory Diseases, 1964, 90, 261. Berenson, A.S., Control of communicable Public Health Association, 1985.

diseases

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man (14th ed.). Washington, D.C.: American

Braunwald, E., Isselbacher, K.J.. Petersdorf, R.G., Wilson, J.D., Martin, J.B., & Fauci, AS. Harrison’s principles of internal Medicine (11th ed.). New York: McGraw-H& 1987. Bruce, R.A. Exercise testing of patients with coronary heart disease. Principles and normal standards for evaluation. Annals of Clinical Research, 1971,3, 323-332. Castell, D.O., The lower esophageal sphincter: Physiological and clinical aspects. Annals of Internal Medicine, 1975, 83, 390-401. Clark, J.M., & Lambertson, C.J. Pulmonary oxygen toxicity, a review. Pharmacological Review, 1971, 23, 37-133. Cooper, D.S. Antithyroid

drugs. New England Journal of Medicine, 1984,311, 1353-1362.

Department of the Navy, Bureau of Medicine and Surgery. Manual of the Medical Department (NAVMED P-117). Washington, DC, 1980.

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Internal Medicine Department of the Navy, Bureau of Medicine and Surgery. The diagnosis and management of tuberculosis. (NAVMED P-5052-20). Washington, DC, 3 February 1973. Department of the Navy, Bureau of Medicine and Surgery. Tuberculosis control program (BUMEDINST 6224.1D). Washington, DC, October 1986. Dreifus, L.S. (Ed.). Cardiovascular problems associated with aviation safety: Eighth Bethesda conference of the American College of Cardiology. American Journal of Cardiology, 1975, 36, 573-628. Dodds, W.J., et.al. Pathogenesis of reflux esophagitis. Gastroenterology, 1981, 81, 376. DuPont, H.L., et.al. Treatment of traveller’s diarrhea with trimethoprimsulfamethoxisole and with trimethaprim alone. New England Journal of Medicine, 1982, 307, 841-844. DuPont, H.L., et-al. Chemotherapy and chemoprophylaxis of traveller’s diarrhea. Annals of Internal Medicine, 1985, 102, 260-261. Fanta, C.J., Rossing, T.H., & McFadden, E.R. Treatment of acute asthma. American Journal of Medicine, 1986 80, 5. Gitnick, F.L., Goldberg, L.F., Korentz, R., & Walsh, J.J. The liver and antigens of hepatitis B. Annals of Internal Medicine, 1976, 85, 488-496. Goldstein, R.A., (Ed.). Advances in the diagnosis and treatment of asthma. Chest, 1985, 87, 18-113s. Gregory, P.B., Knauer, C.M., Kempson, R.L., & Miller, R. Steroid therapy in severe viral hepatitis. New England Journal of Medicine, 1976, 294, 681-687. Hamrick, R.M., & Yeager, J., Jr. Tuberculosis update. American Family Practice, 1988, 38, 205-213. Ho, B.L. A case of spontaneous pneumothorax in flight. Aviation, Space, and Environmental Medicine, 1975, 46, 840-841. Holt, K.M., & lsenberg, J.I. Peptic ulcer disease: Physiology and pathophysiology. Hospital Practice, 1985, 20, 89. Ingbar, S.J. The thyroid gland. In Wilson, J.D., & Foster, D.W. (Eds.), William’s textbook of endocrinology (7th ed.). Philadelphia: Saunders, 1985. 730-733. Jones, N.L. Exercise testing in pulmonary evaluation. New England Journal of Medicine, 1975, 293, 647-650 and 864-865. Jones, S.R., Binder, R.A., & Donowho, E.M., Jr. Sudden death in sickle cell trait. New England Journal of Medicine, 1970, 282, 323-325. Kilbourne, E-D., (Ed.). Influenza virus and influenza. New York: Academic Press, 1976. Leavall, B.S. & Thorup, O.A. Fundamentals of Clinical Hematology (3rd ed.). Philadelphia: Saunders, 1971. Marriot, H.S. Practical

eltrocardiography

(7th ed.) Baltimore: Wiiams and Wilkins, 1983.

Mills, J. Update in the management of enteric infections. Modern Morris, J.G., & Black, R.E. Cholera Medicine, 1985, 312, 343-350.

and

Medicine, 1988, 56, 115-124.

other vibrioses in the United States. New England Journal of

National Diabetes Data Group. Classification and diagnosis of diabetes mellitus and other categories of glucose intolerance. Diabetes, 1979, 28, 1039-1057. Resenkov, L. (Ed.). The cardiac disturbances. Medical Clinics of North America, 1976, 60, Part I and Part II. Rose, D.N., Schlechter, C.B., & Silver, A.L. The age threshold for isoniazed chemoprophylaxis. A decision analysis for low risk tuberculin reactors. Journal of the American Medical Association, 1986, 256, 2709-2713.

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U.S. Naval Flight Surgeon’s Manual Ross, D.S. New sensitive immunoradiometric essays for thyrotropin. Annals of Internal Medicine, 1986, 104, 718-720. Slesinger, M.A., & Fordtran, J.S. Gastrointestinal disease, pathophysiologv diagnosis, and management (3rd ed.). Philadelphia: Saunders, 1983. Standards for cardiopulmonary resuscitation and emergency Medical Association, 1974,227, 833-868, Supplement.

cardiac care. Journal of the American

Stead, W.W. Benefit -risk considerations in preventive treatment for tuberculosis in elderly persons. Annals of Intenal Medicine, 1987, 107, 843-845. Strumm, W.B., Update on traveller’s diarrhea. Postgraduate Medicine, 1988, &, 163-170. Sunder-am, G., et.al. Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS). Journal of the American Medical Association, 1985, 25, 362-366. The Expert Panel: Report of the National Cholesterol Education Program Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults. Archives of Internal Medicine, 1988, 148, 36-69. Treatment of Malaria. Medical Letter on Drugs and Therapeutics, 1988, 301, (759), 21-24. What science knows about AIDS. Scientific American, 1988, 249, (4), Entire issue.

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CHAPTER 6 AVIATION PSYCHIATRY Introduction The Context The Psychology of Flying The Psychopathology of Flying Psychopathology in the Military Psychiatric Evaluation Psychological Testing The Psychiatric Report The Evaluation of Candidates The Evaluation of Students Evaluation of Designated Flight Personnel Aeronautical Adaptability Administrative Psychiatry Treatment Modalities Psychoses Depressions - Mood Disorders Anxiety Disorders Sleep and Insomnia Psychiatric Emergencies and Suicide Prevention Drug Overdose Family Crises Combat Psychiatry The Psychology of Survival and the Repatriated Prisoner of War References and Bibliography Appendix 6-A - Outline for Psychiatric Reports Appendix 6-B - Psychiatric Standards - Guidelines for Naval Aviation Introduction Naval Aviation Psychiatry is a unique blend of psychodynamics, operational medicine, general medicine, and common sense gleaned from extensive operational experience. This chapter is a

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U.S. Naval Flight Surgeon’s Manual historical accumulation of the outstanding pioneers in this field. The last revision of this material was in 1977. Since that time, psychiatric theories, philosophy, and treatment modalities have been refined and redefined. DSM-III was just being introduced in 1977. In July of 1987, DSM-III-R was introduced. A plethora of new psychotropic medications have been introduced. However, the basic functioning and personality style of the aviator remain the same. The stressors inherent to naval aviation remain and disposition challenges are unchanged. In this edition of the U.S. Naval Flight Surgeon’s Manual an attempt has been made to update time-dependent material, and terminology has been adjusted to correspond to DSM III-R. Additional areas of interest have been added. Exposure to the Naval Aviation environment and its people remain the best teachers of aviation psychiatry. The Context A 23-year-old, Lieutenant (jg) naval aviator, flying an F-8 Crusader fighter, is returning to his ship with 20 minutes of fuel remaining. Following instructions from the ship, while making a radar carrier-controlled approach (CCA), he turns four miles astern the ship to make his final approach. His altimeter reads 500 feet when he is informed that the ship’s height-finding radar is inoperative, which means they can’t tell him how high he is over the water, which he can’t see. He’s in solid fog and overcast until one mile astern the ship, when he breaks into the clear 300 feet over the water. Now flying at 140 knots, he glances at the “meatball” light on the carrier deck, which tells him that he is about on glide path. The red glare of the oxygen warning light gets his attention for two or three seconds. He asks himself, “Could the gauge be inoperative, the fitting defective; should I simply jerk the mask off? Sure, I don’t need oxygen at this altitude. Better check the meatball again -fallen too low - headed directly for the carrier ramp - add full power - too late? No coming up - thank God! - now try to land this beast - missed the first wire - second - third -I’ve had it! No, caught number four. Full stop. Cut power. - from Fear of Flying by Captain Roger F. Reinhardt, MC, USN (Ret.) The Psychology of Flying “When I strapped that A-4 on, it wasn’t the A-4 that was flying, it was me flying up there all over the sky.” That A-4 pilot is saying that flying is really as natural as breathing and fun to boot. His airplane became a part of him. Curiosity and exploration are basic and compelling human drives, and fly-

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Aviation Psychiatry ing is one of the best expressions of them. But people fly, especially in the military, for other reasons, too. Those who fly for “neurotic” or maladaptive reasons are of particular concern to aviation psychiatry. For those who are naturally drawn to flying, there seems little else in the world as exciting or worth doing. For those who fly for more “neurotic” reasons, it can be thrilling or at least satisfying, but it can also be fraught with anxiety which must be defensively dealt with, either in a healthy, adaptive manner or maladaptively. It takes a bit of the obsessive-compulsive temperament to endure the tedious patrols of a P-3 and a bit of the hysteric to risk life and limb as an F-18 pilot. When, however, these defensive colorings of character become overstressed, they turn maladaptive, and psychopathological responses to flying are encountered. The Psychopathology of Flying Psychopathology means the existence of any of the symptoms (uncomfortable feelings) or signs (abnormal behavior) listed in the Diagnostic and Statistical Manual of the American Psychiatric Association, DSM III-R of 1988. The psychopathology of aerospace medicine is no different from that found in any other area of living. What is distinguishing is the context in which it arises - the stresses peculiar to military flying. These include: moving in three dimensional space; complex, high performance aircraft; adverse weather; frequent family separations; combat; the oneto-one student-instructor relationship so conducive to transference and countertransference phenomena; the responsibilities of command; and the return to operational flying after long absences occasioned by intermittent staff assignments, schools, or instructor billets. A few flight students experience problems with space, becoming one with the aircraft, or with the responsibility of solo flight. The most common difficulty in the training period involves the student-instructor relationship. The most common symptoms are airsickness, anxiety, forgetting procedures, gastrointestinal complaints, and depression with its somatic equivalents. In the professional years, self-esteem is more at stake, with flight anxiety, conversion symptoms, and psychophysiological symptoms the rule. The conversion symptoms usually involve the special senses required to fly, that is eyes, ears, and balance. If psychophysiological symptoms are present, the pilot is usually highly motivated to continue flying, and this can be allowed if health and safety are not threatened. Phobias do occur but are uncommon. When anxiety is present, it is usually expressed as simple fear (anxiety) of flying. In the professional years, one always has to look beyond aviation to search for clues to the pilot’s discomfort. Accident proneness may emerge at any time. It is currently considered to be the result of the character traits of extreme sensitivity to criticism with a penchant for acting out emotional tur-

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U.S. Naval Flight Surgeon’s Manual moil. It can also occur as a result of depression, excessive life changes, or of a basic temperament favoring carelessness. The patient may send out warnings in the form of personality changes or minor blunders in various areas of his life. As the years pass and the pilot becomes a senior aviator, depression or alcoholism are more apt to be encountered. The naval aviator approaching retirement has to be scrutinized closely for the appearance of these symptoms. The thrill of flying sustains the aviator and the flight officer throughout their careers. It declines through the years, slowly at first, precipitously around thirty, then slowly again. Side by side with the thrill of flying and the fulfillment of belonging to an elite group, there gradually emerges a recognition of the limitations of aircraft, of the dangers, and of family responsibilities, resulting in some realistic, conscious anxiety. The balance of these two - thrill and anxiety, the “love and fear” - determines, at any point, the motivation to continue. The point to be made is that if a young student complains of anxiety or any of its myriad manifestations, something is wrong, and intensive evaluation is indicated. However, if the senior aviator presents similar complaints, it may not necessarily be abnormal. It is normal for him to be aware of some conscious anxiety, and it may not be necessary to ground him. Ventilation of the anxiety and some reasonable discussion to help him weigh his needs and options and arrive at a mature decision may be all that is required. Pressure from sources other than flying may also arise and interfere with his motivation to continue. Marital adjustment is probably the most common. Captain Frank Dully, MC, USN (Ret.), in his lecture, “Sex and the Naval Aviator,” points out that a man’s masculinity is at stake both in the cockpit and in his home. If it suffers in one area, the conflict and the feelings may be displaced to and affect the other area. Psychiatric symptoms and impaired flight performance can result. OccasionaIly, however, flying may be the only conflict-free area and a haven of respite in a troubled life. Because of the close association between the flight surgeon and his men, they may be embarrassed to explore marital problems with him. One flight surgeon found it worked quite well to trade squadrons with his counterpart when it came to treating problems of this sort. A feeling of confidentiality was better preserved, and treatment was more successful. Combat, with its acute dangers, aggressions, and horrors, may call for the full gamut of defenses. This can range from first line defense mechanisms, such as denial, “It can’t happen to me,” or to projection, “I’d never pull a stupid stunt like that,” through compulsive preflighting, counterphobic daring and carelessness, and somatizations, all the way to an acute psychotic break. The flight surgeon must take the context into consideration, and treatment calls for the time tested principles of proximity, immediacy, and expectancy.

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Aviation Psychiatry Psychopathology in the Military Military people are shaped partly by the constraints of the military environment, but they also choose this environment to meet their intrapsychic needs. Most officers and enlisted function proudly and well. Only the legendary five percent create the equally legendary ninety-five percent of the administrative vexation in a command. Professionals, including pilots and flight surgeons usually have a very adaptive compulsive personality core. If excessively compulsive, over stressed, or if “control” is threatened, the resulting maladaptive behavior may have to be evaluated. By far the most common source of turmoil and discontent in the younger sailor is the passiveaggressive personality. He comes tailor-made to misfit, engaging in constant battles with authority. He enters the Navy hoping for better and finds worse. An unsuitability discharge is often the only therapy he will accept. Very dependent people enter the Navy optimistically, but a few cannot tolerate the separation from home or meet the demands for mature, responsible behavior. Few in number, but significant in their ability to create turmoil, are the persons with borderline personality organization and narcissistic personalities. Rarely can these people function effectively in the military environment. They usually are administratively separated either for unsuitability, if they are recognized early enough, or for misconduct if too late. They are unmotivated for military service and, therefore, for therapy, which at best carries a very poor prognosis. The antisocial personality usually creates headaches for both his command and his flight surgeon. Legal or administrative separation is usually indicated. Occasionally, well-educated or highly intelligent young enlisted personnel become unhappy, bored, resentful, and unable to function. Unfortunately, there is no administrative relief from their particular problem, and they may become mired in disciplinary difficulty for the first time in their lives. They may initially be treated as an adjustment disorder but, if symptoms of maladaptive behavior persist, then a personality disorder may be diagnosed. There are many real stresses to which the enlisted person is heir. As previously noted, resulting maladaptive behavior may appropriately be labeled as an adjustment disorder (manifested by the presenting symptoms and signs). Pay insufficient to meet the needs of a burgeoning family, moves, separations, combat, moonlighting, and frequent watchstanding are just a few of the stresses. These stresses are usually met at a relatively young age and with few educational, emotional, family, and financial resources. A social worker or family services counselor, if available,

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U.S. Naval Flight Surgeon’s Manual is often better able to handle these real, rather than intrapsychic, stresses than the psychotherapist flight surgeon. Alcoholism is as serious a problem in the Navy as it is elsewhere. Approximately one individual in ten over the age of 21 will become a problem drinker or alcoholic. It takes about ten years to manifest classical physiological alcohol dependence. About one person in a group of one hundred officers and enlisted personnel will be suffering from it at any one time. Alcohol abuse can produce behaviors in the younger individual as destructive as full blown alcohol dependence (alcoholism). For aviation disposition, there should be no distinction, as a rule, in management of abuse and dependence. DSM-III-R has tremendously “narrowed the gap” in its present diagnostic criteria. Diagnosis of alcoholic behavior can be difficult. One of the obvious signs of a severe problem is that the patient can no longer control his drinking; he cannot plan or predict where, when, or how he will drink. Another is that his drinking is detrimental to his health, marriage, family life, social life, or occupation, and he cannot modify the behavior. This occurs in spite of counseling (formal or informal) and knowledge of the adverse consequences of his continued maladaptive behavior. The definition, diagnosis, and detoxification procedures for alcoholism as well as the Navy’s rehabilitation program are discussed in detail in Chapter 18, Alcohol Abuse. The procedures to be followed when rehabilitation is unsuccessful are outlined in Chapter 15, Disposition Problem Cases and utilize NAVMILPERSCOMINST 1910.1 series. Following rehabilitation, psychotherapy may or may not be indicated. The persistence of psychopathology (symptoms and signs) will be decisive in this regard. The patient should be helped to plan and maintain his own program of sobriety. If he is in a flight billet, the flight surgeon must follow the dictates of NAVMEDCOMINST 5300.2 series regarding the procedures for ultimate return to full flight status. OPNAVINST 5350.4 series is an excellent primer on the medical officer’s role in drug and alcohol abuse. One has to be careful that proper management is not neglected just because a diagnosis of alcohol abuse and not alcohol dependence is given. Although the problem of drug abuse is less pervasive, the success of its treatment is more uncertain. Often a serious personality disorder is involved, particularly in the younger person. The treatment for this situation is problematic at best. The Navy’s “zero tolerance” policy makes it unlikely that a truly drug-dependant enlisted person will be retained on active duty. For officers and chiefs the chance is nil. Refer to OPNAVINST 5350.4 series and NAVMILPERSCOMINST 1910.1 series for further guidance.

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Aviation Psychiatry Psychiatric Evaluation Flight surgeons are faced with assessing, as accurately as possible, the ever shifting balance of natural and “neurotic” motivations for and attractions to flying. This balance is mirrored in the physiological or pathological alterations of personnel who appear as pilots, NFO’s, and aircrew, or applicants and students who apply for and undertake flight training. These conflicts of nature’s laws and human nature’s intrapsychic forces result in maladaptations to flying. The evaluation entails uncovering these contexts in the life of the patient and evaluating his mental and physiological responses to, and ability to cope with, the balance of intra- and extrapsychic forces impinging upon him. There are two time-honored approaches to the psychiatric interview: The classical approach is to elicit a spontaneous unfolding from the patient of his troubles. This may take extended periods of time. The approach most commonly taught in diagnostic interview techniques today is direct, structured questioning by the psychiatrist preceded by a short interval in which the patient is allowed to “tell his story.” A thorough evaluation is an artful combination of these two approaches - eliciting spontaneously and tracing the patient’s feelings, and laboriously extracting the dry details of his present and past life. Together, ideally, they should lead to a comprehensible picture of his emotional illness. Emotional illness almost always occurs in the context of social interaction when core conflicttriggering persons or situations are encountered. These situations very frequently represent major life changes or crises related to the milestones or maturational tasks reflected in the phases of the psychosexual/psychosocial scale of development (e.g., dating, graduating, occupational choice, marriage, parenthood, entrance into the military, return to civilian life, etc.). The need to suppress painful affects, forbidden impulses, or the memory of the original core conflict or fantasized elaborations of it, lead either to defensive symptom formation or defensive, immature behavior. If incapacitation is severe, the symptom formation appears as an Axis I psychiatric illness. The defensive, immature behavior, when persistent and maladaptive, appears as a personality disorder. For the diagnosis of a personality disorder there should be evidence of maladaptive behaviors, painful affect, forbidden impulse, or core-conflict situations at several points in the past history. This would be reinforced by evidence from the present illness setting and the mental status examination of the psychiatric interview. During psychotherapy, the conflict is unravelled and eventually resolved. The military environment is not suitable for the psychodynamic treatment of personality disorders.

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U.S. Naval Flight Surgeon’s Manual Axis I disorders should meet DSM-III-R criteria, but again may have historical roots and reinforcement in the presentation and mental status examination. Psychological Testing A wide variety of psychometric procedures are frequently used in the Navy to augment data obtained through the clinical interview. These instruments are designed to provide objective, standardized, and normative data regarding a wide variety of symptoms, signs, syndromes, and skills. The selection, administration, and interpretation of appropriate procedures requires an active consultative process between the flight surgeon and the clinical psychologist. To the extent that referral questions can be specified, the experienced clinical psychologist may provide a unique contribution to the evaluation of a wide variety of patients. Psychological testing will not be helpful if referral questions are vague; if testing is obtained out of “routine,” if the primary care provider requests specific tests, or if the assessment is otherwise treated as if it were a laboratory procedure rather than a professional consultation. The following information is provided to give the flight surgeon a heuristic appreciation of the more frequently administered procedures. Emotional Status and Personality Objective Tests. These include the Minnesota Multiphasic Personality Inventory (MMPI) and Millon Clinical Multi-axial Inventory (MCMI). These self-report, pencil and paper inventories are designed to provide nomothetic, actuarial, information regarding the probability of psychiatric illness. Sophisticated “validity scales” attempt to establish the patient’s test-taking attitude and associated desires to either minimize or exaggerate psychiatric symptoms. Projective Tests. These include the Rorschach, Thematic Apperception Test (TAT), Sentence Completion, and Drawing Techniques. These procedures utilize a wide variety of ambiguous stimuli to obtain ideographic information regarding the form and content of a patient’s thought process. Reality testing, perceptual accuracy, interpersonal style, and affective control are also assessed. Cognition Intelligence/Aademic Achievemmt. These include the Wechsler Adult Intelligence ScaleRevised (WAIS-R) and the Wide Range Achievement Test - Revised (WRAT-R). Assessment of intellectual skills, to include verbal IQ and performance (visuospatial) IQ, provides an estimate of

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Aviation Psychiatry the patient’s general cognitive ability. Utilization of previously learned information and active problem solving is addressed on individual subtests which use a wide variety of stimulus-response formats. Functional reading, spelling, and arithmetic skills are assessed by standardized tests of academic achievement. Comprehensive Neuropsychological Assessment. The Benton Tests and the Halstead-Reitan Battery are included. For those patients with known or suspected neurological injury or illness, specific tests of memory, attention and concentration, information processing, executive function, language, and visuospatial skills can assist in the differential diagnosis of neurobehavioral symptoms, monitoring the course of illness, and documenting responses to treatment. Aviation-Specific Evaluations. Evaluations, interpretation and recommendations may be obtained by the flight surgeon or the clinical psychologist, in consultation with the Psychiatry Department, Naval Aerospace Medical Institute (NAMI) Code 21. The Psychiatric Report Any psychiatric evaluation should be thorough, concise, and credible. The format at NAMI was designed with these considerations in mind and has been used successfully for many years. The format is very similar to that used in most military psychiatry training programs. The art of writing a good psychiatric report is a product of two simple concepts: Symptoms occur in a specific context to somebody who by virtue of an idiosyncratic weakness is unusualIy vulnerable to that particular context at that particular moment in his life. The meaning of symptoms is discernible only in this context; they have no meaning in and of themselves. The point of departure for exploration is always the symptoms or signs that led to psychiatric referral. The behavior for which a patient is referred may not always be related to a developmental conflict, and occasionally a patient may be seen with significant conflicts from more than one stage of development. In such cases, the flight surgeon should strive to pinpoint either the conflict that is earliest, or the one which is most prominent in the present illness. Appendix 6-A presents a detailed outline for psychiatric reports. As a brief review: 1. Paragraph I should contain identifying information and a list or description of the symptoms and signs that led to the patient’s referral. 2. Paragraph 2 is an outline of the patient’s everyday world - where he lives, with whom,

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U.S. Naval Flight Surgeon’s Manual where he works, major illnesses other than psychiatric, and any stressors that impose special burdens on him or others. 3. Paragraph 3 should describe the context in which the symptoms and signs arose, and the precipitating event. If the problem is based on personality functioning, then this context or event, by definition, will be a fresh version of prior conflict-evoking traumas or events reaching far back into the patient’s past. The patient may be only vaguely aware of what is upsetting him and will unconsciously attempt to avoid exploring it because of the intense anxiety that it can provoke. It may take very perceptive and tactful questioning to elucidate the actual context. Often it may come to light only through the process of analyzing and removing defenses in the process of psychotherapy. On the other hand, if the problem is real, rather than the result of personality functioning, the context will be quite apparent and will be such that the average person could be expected to react to it with psychopathology - symptoms and signs. The diagnosis will then be one of adjustment disorder or another Axis I diagnosis such as affective disorder, phobia, or anxiety disorder. Paragraph three should not consist of simply a more exhaustive description of the symptoms and signs (as might be appropriate in general medicine) with no mention of the context. This is one of the most common errors of the nonpsychiatrically oriented examiner. There is no point in reiterating what is already wellknown to the referring source while missing the precipitating context and its significance. 4. Paragraph 4 is a description of the patient, the somebody, as revealed by past history from a psychological vantage point. The past history will provide psychosocial information that wiIl support the diagnosis that will be established at the very end of the report. It should outline episodes in the patient’s life that will highlight developmental issues such as major stressors, behaviors or risk factors in childhood, adolescence, school, community, and occupation. A family history of risk factors is extremely important. Typically, there will be prior versions of the present problem. Many times a reasonable diagnosis can be based on historical data alone. This can be documented by interview, information on the patient questionnaire, health record review, and information from significant others. 5. Paragraph 5 is the Mental Status Examination. It should reflect the here and now; it is the most current cross section of the patient’s life. It should reflect how he relates to the flight surgeon in the interview and how the flight surgeon thinks he would relate, at that same moment, to significant others in his life outside the interview. The Mental Status Examination assesses not only the patient’s organic intactness but equally, or more importantly from the psychiatric standpoint, his functional or emotional

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Aviation Psychiatry intactness and potential. The most natural breakdown of mental status is psychological vs. organic functioning. There is one further breakdown be be kept in mind, and that is defenses. Defenses, in this conception, include not only mechanism of defense, but all defenses against anxiety even if some (e.g., the psychophysiological disorders) are somatic expressions of it as well. These breakdowns will help the examiner to organize, in his mind and in his report, myriad possibilities of psychological functioning. The patient’s general appearance (this should be the opening item) is added to this and then the description of the psychological functioning is followed with the organic functioning in terms of sensorium (orientation and memory) and intellect. Finally, the patient’s judgment, insight, and potential for therapy are discussed. These latter stand out separately because they partake of both psychological and organic functioning and intactness. The results of any psychological tests (Section XXIII) complete the picture of the patient’s functioning in the here-and-now, and current moment in his life. 6. Paragraph 6 is a capsule summary of the patient and his difficulty. It comprises three elements - his personality pattern (be it healthy, or characterologically impaired), the context, and the symptoms and signs. This is the gist of paragraphs one, three, and four. From these and paragraph five, comes the diagnoses in paragraph seven. 7. Paragraph 7 is written using the multiaxial system. Axis I delineates diagnosed mental disorders and V codes. Axis II identifies personality traits and disorders. Axis III lists any physical illness. 8. Paragraph 8 contains the recommendations from the military psychiatric standpoint, and these recommendations are in two categories. The first category is administrative disposition physically qualified (PQ)/aeronautically adaptable or adapted (AA)/fit. for duty. The second category is medical which includes the medical care, follow-ups, and referrals. When structured in this manner, the report strikes the reader with coherence and persuasiveness. One part relates perfectly and logically with another, and the diagnosis falls naturaIly into place. The patient comes across as a comprehensible human being and the reader will believe what is said and will more likely do what is advised. The Evaluation of Candidates Future performance is best predicted by past performance; only failure can be predicted with any acceptable degree of reliability. Therefore, when there is evidence of psychopathology in a candidate which has significantly interfered with his adjustment in the past and which has not

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U.S. Naval Plight Surgeon’s Manual been resolved, the flight surgeon may feel secure in rejecting him either on the basis of his maladaptive personality style (lack of aeronautical adaptability), or by actually establishing an Axis I diagnosis. In considering whether to establish a psychiatric diagnosis, however, he should keep in mind that the candidate has not come to be penalized by being tagged with a label that may follow him for the rest of his life. He wants only to fly and seeks an opinion about it. It is often better to give the label of “not aeronautically adapted, ” with reference to personality style. As will be discussed later, this is of significance only in naval aviation. Persons labeled NAA are usually suitable for routine naval service. If legitimate, adjustment disorder may be a useful diagnosis. This is especially true for enlisted aircrew candidates with multiple life stressors. The best approach for evaluation is the use of the structured format. The patient’s referral symptoms should be looked upon as the chief complaint and his conscious and unconscious reasons for doing so as the context. Although it is nearly impossible to predict success in military aviation, the flight surgeon can look for evidence of early interest in flying, such as building model airplanes, frequenting airfields to watch the planes take off and land, and identification with parents’ interest in aviation. Further, there should be evidence of maturing in motivation from the romanticism of the boyhood years to the practical exploration of alternatives of the postadolescent years. Reinhardt (1970) has shown that the outstanding jet naval aviator is an extroverted, first-born, problem solver. He also observed, culminating his remarks on selection, that any normal, red-blooded American boy can learn to fly. Many, however, may lack the basic temperament and motivation for the demands of military flying. The Evaluation of Students When students experience problems in learning to fly, the flight surgeon first ascertains the particular aspect of training confronting them and then discerns within it what is stressful for them -the context. Is it the three dimensional aspect of space, a new, more complex aircraft, the idea or feeling of being number one in the plane, of being solely responsible, a real or “neurotic” reaction to the instructor, or perhaps stresses external to flying? From the past history, he must uncover what there is about the student that renders him pathologically susceptible to the particular stress. Is this an overly compulsive student overwhelmed by too rapid a presentation of new material; is this an hysterical individual reacting to unconsciously perceived danger with a conversion symptom or careless, risky flying, or is this a characterologically “normal” student reacting to real and abnormally intense stresses in or out of aviation? Evaluation of Designated Flight Personnel The seasoned professional typically may be facing a transition from a staff assignment or school to a new, unfamiliar, more complex, and powerful aircraft, reacting to an incident or acci-

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Aviation Psychiatry dent, or, just as likely, experiencing problems external to flying. In other words, here the stress is more likely to be real and intense, rather than intrapsychic; the flight surgeon is more likely to be dealing with an adjustment disorder rather than a manifestation of repetitive maladaptive personality functioning. Family stressors, financial difficulties, and potential career changes should be thoroughly explored. Aeronautical Adaptability Aeronautical Adaptability - Present Status in the U.S. Military Navy. All active flight personnel have to be “AA” (Aeronautically Adaptable or Adapted). On each physical examination of designated aviation personnel, there has to be a finding not only of physical qualification but also of aeronautical adaptability. In addition, all personnel evaluated upon entry into the flight program in the Navy have to have an assessment made of their aeronautical adaptability, in accordance with the Manual of the Medical Department (MANMED), Chapter 15. Air Force. The Air Force uses a version of the ARMA, even though ratings are applicable only at the time of selection. Army. The Army has used various versions of the Adaptability Rating for Military Aviation (ARMA) since World War II. Originally, this was a system in which various points are given or deducted for a particular problem. The rating system contained a total of 200 points, and it required 160 points to be considered to have an adequate ARMA rating. The Army is currently using an ARMA that addresses many areas of past and present psychosocial function. The Flight Surgeon makes a judgment assessment and declares either a “satisfactory” or “unsatisfactory” ARMA. This determination can be made at any stage of an Army pilot’s career, but as compared to the Navy usage of AA/NAA, an Army aviator can be reinstated as “satisfactory” under certain conditions. History of Navy Involvement in Aeronautical Adaptability Even though the concept of Aeronautical Adaptability has appeared in the literature since 1918, it was only in the late 1920’s that the formal application of aeronautical adaptability appeared in the aviation selection process. At the beginning of World War II, there was no mechanism for disposition of Navy pilots who did not appear adaptable, but instead, they were often labeled as “cowards” or “yellow.” This disposition was indeed unfortunate. The

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U.S. Naval Flight Surgeon’s Manual Psychiatry Department at the old Naval School of Aviation Medicine was tasked with addressing this problem. The term “Not Aeronautically Adaptable” then began to be formally used in the Navy in a non-punitive manner as a reason to disqualify an individual from flying. By design, the definition of aeronautical adaptability was very vague and ill defined. Aeronautical Adaptability continues to be a significant issue both in the Training Command and in the fleet, and is a major problem each flight surgeon faces during his tour. As behavioral medicine becomes more scientifically based, quality assurance becomes more of an issue and credibility has to be maintained. More effort is being expended to qualify, quantify, and make reproducible, the concept of aeronautical adaptability. Derivation of the Current Usage of Aeronautical Adaptability in Naval Aviation As of December 1990, the Manual of the Medical Department, Chapter 15, states “The examiner shall summarize his impression of the individual’s aeronautical adaptability which shall be recorded as ‘favorable’ or ‘unfavorable’. When an individual is found to be physically qualified but his aeronautical adaptability is regarded as ‘unfavorable,’ the entry of findings on SF-88 as finally recorded shall be ‘physically qualified but not aeronautically adapted....’ When an individual is found not aeronautically adapted, sufficient comment and information shall be furnished under Remarks or Notes to justify such a conclusion.” Impact of DSM-III and DSM-III-R 1. This manual carefully delineates criteria for each disorder in almost a cookbook approach. 2. Inter-rater reliability for personality diagnoses is probably around 40 to 50 percent. It has been most reliable with the antisocial personality for which there are specific objective criteria. There are no reliable studies on maladaptive personality trait disturbance and the inter-rater reliability varies from study to study. 3. The issue is prediction of behavior. It is known that the patient has a problem but what needs to be known is what effect this will have on his future behavior. The issue is one of predicting behavior in an individual and what criteria we use to make this kind of assessment. Excerpts from a presentation to the Aeromedical Advisory Committee on 12 August 1987 amplify and clarify the concept of aeronautical adaptability and its relationship to Axis II DSM-III-R personality structure. They conclude that: “Aeronautical adaptability has long been recognized as one of the most ambiguous concepts in naval aviation medicine. Some recent papers have addressed the topic from various perspectives. Those most often referred to are: “Aeronautical Adaptability” by Cap6-14

Aviation Psychiatry tain Patrick F. O’Connell in May, 1981, “Aeronautical Adaptability of Designated Naval Aviators” by Commander John Mangrum in November, 1985, and the NAVAIRPAC Medical Update Letter, Volume 12, 5 January 1981, by Captain Frank Dully. From my review, Captain O’Connell’s summary reflects the general trend of naval aviation psychiatry thought on the subject.” Aeronautical adaptability as described in MANMED 15.73(l) (Change 100 of August 1986) includes “physical findings and the result of the neuropsychiatric examination.” The very fact that the Standard Form 88 requires attention to both physical qualifications and aeronautical adaptability makes it practical and necessary to separate those entities. The logical approach would confine those entities with physical and psychiatric Axis I findings to the physically qualified PQ/not physically qualified NPQ arena. Aeronautical adaptability then would encompass the personality traits and personality functioning of the individual as it pertains to the three dimensional environment of aviation and the individual’s functioning as it impacts on aviation safety. Working Definitions of the Concept Aeronautically Adaptable (Students and Candidates). “Having the potential to adapt to the rigors of the aviation environment by possessing the temperament, flexibility, and appropriate defense mechanisms necessary to suppress anxiety, maintain a compatible mood, and devote full attention to flight and successful completion of a mission.” Aeronautically Adapted (Designated Aviators and Aircrew). “Those having demonstrated the ability to utilize long term appropriate defense mechanisms and displaying the temperament and personality traits necessary to maintain a compatible mood, suppress anxiety, and devote full attention to flight safety and mission completion.” Successful completion of a mission in this context includes not only the safety and crew coordination involved in actual flight but also the ability of the individual to work harmoniously with other squadron members and authority figures. The stresses of operational training and deployment should be easily tolerated. Personal behavior and habits should not impact on his Navy job or flight status. Helpful Definitions as Defined by DSM-III-R Mental Disorder. A mental disorder is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual that is typically associated with either a painful symptom, distress, or impairment in one or more areas of a person’s subjective

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U.S. Naval Flight Surgeon’s Manual life. Formal mental disorders are coded on Axis I and are considered to be entities worthy of formal treatment, always with some hope of resolution or stabilization. V Codes. V codes, even though coded on Axis I, are described as conditions that are a focus of attention, or even treatment, but that are not attributable to a recognized mental disorder. As a general rule, V code diagnoses do not result in significant or prolonged social or occupational malfunction. Unusual psychological distress or discomfort associated with the diagnosis of V codes is usually a component of the individual’s style of personality functioning with or without a concomitant diagnosable Axis I or Axis II disorder. Personality Disorder. Personality disorder is a concept paramount to the understanding of the NAA issue. Personality disorders are considered a repetitive, historically documentable, maladaptive pattern of behavior that is demonstrable in most areas of the subject’s life. This impairment is usually most evident in interpersonal relationships. The usual result of an Axis II diagnosis (or disorder) is significant impairment in social and occupational functioning and/or subjective distress. Personality disorders are generally manifest by late adolescence and continue throughout adult life. Personality traits, in contrast, are considered to be one’s own individual but enduring pattern of perceiving, relating to, and thinking about the environment and oneself, and are exhibited in a wide range of important social and personal contacts. Personality traits may fluctuate in nature and intensity from situation to situation depending on the individual, and usually are socially and occupationally adaptive. Stress may exacerbate traits to a maladaptive level. Personality Traits. Personality traits, personality style, and personality disorders as defined are usually identifiable and deeply ingrained in an individual by late adolescence. Personality styles are often exacerbated by stress. The currently accepted biopsychosocial model of personality development does look upon an individual’s personality and personality function as being a dynamic concept. Mounting evidence indicates that life experience, repeated stressors, or formal psychotherapy may modify or alter a person’s pattern of perceiving and relating to the world. A restructuring of his entire personality style can result. It is the last concept of dynamic transformation that is probably the focus of most confusion and concern about the concept of aeronautical adaptability. Aeronautical Adaptability as a Durable Quality It is recognized that persons genuinely not psychologically adaptable to the aerospace environment or who constitute a safety hazard due to their personality traits and inability to suppress anxiety are removed from aviation training programs early on. From this observation comes the concept that aeronautical adaptability as evidenced by earning one’s wings is usually considered permanent in a designated naval aviator. All problems thereafter relating to his flight perfor-

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Aviation Psychiatry mance should be of an administrative vice a medical nature. As a general statement, this could be true. The confounding variable is that utilizing the dynamic concept of personality structure, prolonged stressors, significant life events, or psychotherapy can result in a changing of life goals and changing of life philosophy. The revised pattern of personality traits may result in an individual being not aeronautically adapted. Conversely, persons through maturity, learning experience, and behavioral modification over time may go from a condition of not aeronautically adaptable to one of aeronautically adaptable. Appreciation of subtle but profound change in personality structure after being designated as a naval aviator is probably in the domain of experienced psychiatrists with a broad knowledge of the psychological factors of the aerospace environment and the unique psychological and physical factors of the naval aviation community. On 12 August 1987, the Aeronautical Advisory Committee endorsed the following concepts: 1. Axis I diagnoses (other than V codes) by definition are considered disorders that warrant treatment and have some hope of resolution and therefore result in an NPQ status for naval aviation. NPQ would be appropriate if the condition were treatable with a high probability of full recovery. After treatment and resolution of symptoms, the patient could be reevaluated with three choices of disposition: (1) permanently NPQ, (2) NPQ with waiver, or (3) PQ if the illness has fully resolved. 2. Axis II diagnoses of a personality disorder would usually result in a designation of NAA. This is with the knowledge that true disorders involve significant difficulty with interpersonal relationships, and acting out or other maladaptive behavior. 3. Personality traits not constituting a disorder manifested by a stress-induced pattern of maladaptive behavior or loss of mature defenses resulting in anxiety, depression, or poor judgment (i.e., loss of suppression) would result in a designation of not aeronautically adaptable if safety of flight, crew coordination, or mission completion were impacted. Unacceptable behavior related to a personality style may itself be reason to administratively remove the individual from the aviation environment. 4. V code diagnoses concurrent with significant occupational or social dysfunction would have to be evaluated in terms of an underlying personality dysfunction (NAA) or true Axis I mental disorder (i.e., adjustment disorder) (NPQ). 5. Axis III disorders would result in a designation of not physically qualified as determined by appropriate authority.

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U.S. Naval Flight Surgeon’s Manual With these definitions and concepts in mind, further attention can be given to the utilization of the aeronautically adaptable/not aeronautically adaptable concept. A recommended approach to aeronautical adaptability would be as follows: 1. Once designated, all naval aviation personnel would be considered aeronautically adaptable in spite of performance, motivation, or technical ability. The Field Naval Aviator Evaluation Board (FNAEB) would be the mechanism for handling those administrative difficulties encountered with aviator (a) motivation, (b) performance, (c) attitude, or (d) technical ability. The FNAEB could ask the flight surgeon for opinions on a pilot’s PQ/AA status as part of the process. The FNAEB decision could incorporate that opinion. 2. Those aviators presenting with situational stress, anxiety, poor coping, or other problems of a perceived psychological or psychiatric nature would initially be deemed temporarily not physically qualified while appropriate investigations and specialty consultations were made. 3. Aviation personnel who demonstrate anxiety, insidious discomfort with flight, or who have undergone life changes of such a magnitude that personality traits have been modified, might have their aeronautical adaptability questioned. This should initially be investigated by a Local Board of Flight Surgeons. Their background investigations then should be submitted to the Aerospace Physical Qualifications Department, NAMI, Code 42 for review and referral for psychiatric review. 4. The diagnosis of not aeronautically adaptable in a designated aviator with a large time investment in his career has significant consequences. This diagnosis should not be taken lightly and should at the minimum have a NAMI psychiatry review and written concurrence. 5. These criteria should be applicable to naval aviation personnel regardless of geographic location, rate, rank, or designator. The Manual of the Medical Department, as currently being revised in 1991, addresses the issue of aeronautical adaptability in the following manner 1. Candidates or students must demonstrate reasonable perceptual, cognitive and psychomotor skills on the AQT/FAR (officer candidates only) and must have the potential to adapt to the rigors of aviation by possessing the temperament, flexibility, and mature defense mechanisms to

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Aviation Psychiatry allow for full attention to flight and successful completion of training. The flight surgeon’s interview should explore vital areas such as motivation, stress, coping and social adaptability. 2. Once designated, aviation personnel are generally considered aeronautically adapted, based on demonstrated performance, stress coping and use of mature personality defense mechanisms. Personality Disorders or maladaptive personality traits manifested by patterns of chronic maladaptive behavior, emotional instability or impaired judgment would result in a determination of not aeronautically adapted only if safety of flight, crew coordination or mission execution were affected. 3. Apparent loss of aeronautical adaptability in a veteran aviator may be an indication of a serious underlying emotional or physical problem and a complete and thorough evaluation is imperative. 4. When a flight surgeon suspects the loss of aeronautical adaptability in a designated aviator, that individual shall be referred to the Naval Aerospace Medical Institute for evaluation. 5. The Field Naval Aviation Evaluation Board (FNAEB) is the naval mechanism for handling administrative difficulties encountered with aviator performance, motivation, attitude, technical skills, flight safety and mission execution. 6. Unacceptable behavior outside the arena of mission safety and mission execution, whether or not associated with a maladaptive personality style or disorder is administrative in nature and should be managed in accordance with existing directives, e.g. JAGMAN, MILSPERSMAN, and/or pertinent SECNAVINST. Administrative Psychiatry Disposition of Evaluation Ultimate disposition is contingent on the patient’s motivation and safety in the aviation environment. A patient suffering from a conversion symptom usually cannot fly safely and must be grounded, at least temporarily until therapy can be used in an attempt to resolve his symptom. One who has a minor psychophysiological disorder, however, may well fly safely, be strongly motivated to continue flying, and may be permitted to do so with or without therapy. In most other cases, symptoms must be resolved before flying can be resumed, and there is good evidence that there is little likelihood of their recurrence. In questionable situations, the patient’s case should be brought before a Local or Special Board of Flight Surgeons for disposition.

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U.S. Naval Flight Surgeon’s Manual A Review of Administrative Psychiatry 1. General Principles of Administrative Psychiatry a. Psychiatric dispositions should be made in accordance with current selection, retention, and separation criteria. b. For general duty, general requirements must be met, usually in accordance with the Manual of the Medical Department and if doubt exists, Medical Board and departmental reviews should take place. c. For special duty (including aviation), both general and special requirements must be met.

2. When individual behavior violates military regulations, psychiatry may become involved in the disposition. a. Psychiatric consultation may be requested for diagnosis, treatment, and disposition of a compensable mental disorder. b. Psychiatric consultation may be requested to determine the absence of a compensable mental disorder before a member is processed for administrative separation. c. Psychiatric consultation may be requested to facilitate various legal processes. 3. Generally, there are three broad areas of patient disposition. a. Medical - a person has a medical condition which renders him unsuitable to continue to perform duties effectively or safely. b. Administrative - a person has a pattern of behavior or other unusual circumstance that is a burden to the Navy. c. Special Duty - To clarify physical or psychiatric suitability for special assignments, such as aviation, or to continue in a special designation.

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Aviation Psychiatry Administrative Disposition 1. Performance and conduct are key factors influencing administrative separation decisions. 2. Individuals must be counseled and provided with an opportunity to correct deficiencies prior to the initiation of administrative separations in the areas where performance or conduct form the basis for separation, as documented in the member’s record. NAVMILPERSCOMINST 1910.1 series currently governs administrative discharges. a. It requires the commands to expend every effort, via counseling, education, and discipline, to salvage an individual whose performance may be defective. b. Administrative dispositions should be pursued when a command has exhausted resources mentioned above, and the individual becomes a burden and drain on the command resources. c. Commands are instructed to use rapid compliance with the processing of administrative separations only after all legal charges have been resolved. d. If an individual has served six years, he or she has a right to an Administrative Field Board, at which he or she may be represented by counsel in his or her own defense as a part of the separation process. e. Some formal reasons for administrative separation are listed below: (1) Expiration of service obligation. (2) Selected changes in service obligation. (3) Convenience of the government. (4) Defective enlistment - MILPERSMAN 3620280. (5) Fraudulent enlistment - MILPERSMAN 3630100. (6) Entry-level performance or conduct - MILPERSMAN 3630200.

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U.S. Naval Flight Surgeon’s Manual (7) Unsatisfactory performance - MILPERSMAN 3630300. (8) Homosexuality - MILPERSMAN 3630400. (9) Drug abuse rehabilitation failure - MILPERSMAN 3630500. (10) Alcohol abuse rehabilitation failure - MILPERSMAN 3630550. (11) Misconduct - MILPERSMAN 3630600. (12) Separation in lieu of trial by court martial. (13) Security. (14) Unsatisfactory participation in Ready Reserve. (15) Separation in the best interest of the service. 3. Convenience of the Government specifically includes (MILPERSCOMINST 1910.1 series): a. Personality disorder. b. Parenthood. c. Obesity. 4. Confusion often arises over the reasons for discharge versus the type of discharge. The five types of discharge are: a. Honorable discharge. b. General discharge. c. Discharge under conditions other than honorable. d. Bad conduct discharge (must be at the direction of a court martial). e. Dishonorable discharge (must also be at the direction of a court martial).

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Aviation Psychiatry Aviation Disposition (Special Duty) 1. An individual unfit for military service is also not physically qualified for aviation, but one may be not physically qualified for aviation and physically qualified for general military service. 2. Therefore, to qualify for aviation duty, one must be fit for full duty. 3. Medical Boards and Special Duty - The function of the Medical Board in this situation is to return the patient to full or limited duty, if warranted. If the Medical Board (or consultant) decides that the patient is fit for full duty, they should so state. The question of special duty must be separately addressed by those who have received special training. In the case of aeronautically designated personnel, MANMED 15-67 places the responsibility for flight status determination on the shoulders of the flight surgeon. If the patient is placed on limited duty, even the patient’s flight surgeon cannot return the patient to flight status. 4. Local Board of Flight Surgeons - described in MANMED, Chapter 15. Usually convened by the squadron commanding officer. 5. Special Board of Flight Surgeons - described in MANMED, Chapter 15. Convening authority is the Commanding Officer of NAMI. Medical Disposition Via Medical Board - MANMED, Chapter 18 - 7/32 1. Nine reasons for Medical Boards: a. Physical defect which precludes military service. b. Military service will aggravate an existing physical problem. c. Long hospitalization or intense medical supervision is required. d. Condition is temporarily incompatible with unrestricted duty but full recovery is anticipated. e. Ultimate recovery is uncertain, and a period of evaluation is desirable. f. Condition requires geographic or other limitations of assignment.

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U.S. Naval Flight Surgeon’s Manual g. Mental competency is in question. h. Patient refuses indicated treatment. i. A condition likely to recur needs to be formally documented. 2. Three Medical Board recommendations are possible: a. Fit for full duty. b. Fit for limited duty. c. Referral to the Physical Evaluation Board (PEB), usually via NAVMEDCOM departmental review. 3. The Central Physical Evaluation Board determines: a. EPTE vs. DNEPTE (Existence prior to entry). b. Line of duty vs. misconduct. c. Disabling compensable disorder. d. Disability rating. 4. Temporary Duty Retired List, (TDRL) - TDRL’s are usually reevaluated by the specialty clinic. Personnel may be found permanently disabled after five years of TDRL. 5. Appeals - Everyone who receives a medical board should be encouraged to submit a rebuttal at all levels if legitimate and sufficient cause exists. Treatment Modalities Brief Psychotherapy Everyone carries recorded in his mind affectively colored experiences and fantasies that shape his map of reality (and behavior) and may lead him to misperceive his present situation and to respond inappropriately. Painful feelings and symptoms may be the result. The therapist attempts

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Aviation Psychiatry to help the patient recover these latent memories and fantasies with their associated feelings so that he can reassess and interpret accurately what is going on in the here and now, relinquish symptoms and painful feelings, make realistic decisions, and take appropriate action. In earlier teachings these feelings were termed “neurotic.” Now using DSM III-R terminology they usually fall in the realm of Axis II - personality styles, traits, or disorders. An Axis I diagnosis may also be present. Brief psychotherapy is crisis and present-problem oriented. In its effort to relieve painful feelings, it delves only into that aspect of the past that directly pertains to the presenting problem. It takes advantage of the fact that the patient’s greatest motivation for change occurs in times of crisis and that the solution of one problem may lead to beneficial alterations in the total personality with considerable maturation of the individual. It is a mixture of techniques from as simple and practical as providing a good night’s sleep to as esoteric as dealing with transference. The crucial element in brief psychotherapy, however, is the working or therapeutic alliance - one adult working with another within the mature aspects of their personalities to help the patient shed pathological defenses or maladaptive behavior and resume responsibility for his life and future. A balance is struck between a purely supportive approach and the superficial uncovering of counseling vice a purely psychodynamically oriented mode of therapy. Since identification with the therapist is fostered or at least not discouraged as one means of maturing and improving defenses, it follows that the therapist must be a model of incorruptibility. Further, he should be the vehicle for “corrective emotional experiences” with responses different from the presumed pathological ones of the patient’s parents or parental surrogates or others in his past life who may have reinforced maladaptive behavior. In brief psychotherapy, the number of sessions is set from the beginning. Usually ten to twenty sessions are adequate to promote the exploration of dependency, conflicts, and separation anxieties. Separation and fear of abandonment are common problems of our age, particularly exacerbated in the military environment and by the solitary nature of some aspects of military flying. The Technique of Brief Psychotherapy. 1. The therapist is much more active than in traditional psychotherapy, and therapy is face to face. 2. The diagnostic process as described in the section on psychiatric evaluation is undertaken with assessment of personal strengths, defense mechanisms, and suicidal or homicidal risk.

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U.S. Naval Flight Surgeon’s Manual 3. The focus is on the main conflict in the here and now. The context of the symptoms, the current life crisis, the emotionally hazardous situation, and the patient’s perception of the feared stimulus are explored (Mitchell, 1976). 4. The working alliance is actively fostered via appealing to the rational person, encouraging positive transference, and instilling the feeling of hope. 5. Negative transference is promptly interpreted. 6. Time limits are set early in the therapy to promote an active working alliance and to set the stage decisively for the activation and exploration of dependency conflicts and separation anxieties. Some Principal Elements of Treatment. 1. The reduction of anxiety by: a. The showing of interest and respect for the patient’s worth as a human being and by taking a careful history. b. Medication and rest (may even include brief hospitalization). c. If referral or hospitalization is indicated, the therapist should explain thoroughly what the patient can expect on admission and be prepared to deal with the anger or rejection. Talk of more lengthy treatment should be deferred until the therapist has accomplished what he can do, otherwise, his efforts will come to a screeching halt the moment the patient realizes that his therapist is going to refer him to someone or somewhere else. 2. Ventilation - This implies listening on the part of the therapist. The patient voluntarily exposes himself mentally to what he fears as he ventilates. This is a form of selfdesensitization to the feared stimulus and is ameliorative, if not curative. The degree to which the patient ventilates varies directly with his confidence and trust in the therapist’s acceptance. 3. Reality testing - This is indicated if the patient is anxious, depressed, or confused. Methods are:

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Aviation Psychiatry a. Defining the problem - context of symptoms - such as: (1) Lack of fusion with the aircraft. (2) Being in control. (3) Student-instructor relationship. (4) Problems external to flying. b. Reviewing goals - reminding the patient why he chose to fly. c. Reminding the patient that a modicum of anxiety is normal under his circumstances, and that he is like everyone else. 4. Emphasis of assets, especially the ability to solve the newly-defined problem. Initiative is given to the patient. 5. The clear definition of the presenting problem. Goals for the therapy relative to the presenting problem are set. 6. Wherever possible, the elicitation from the patient of a firm contract for a specific behavioral change, a change highly desired by the patient. This has the added advantage of simultaneously bringing his defenses and inhibitions into the sharpest possible focus for therapeutic scrutiny and resolution. 7. Agreement between the patient and therapist on what the signs will be that the contract has been fulfilled, so that they will clearly know when that takes place. 8. Repair of feelings of low self-esteem via identification with the therapist and using him as a role model. 9. Loosening of rigid or pathological defenses. This is fostered by confrontation and interpretation. 10. Encouragement and strengthening of healthy defense mechanisms. 11. Encouragement of the patient to meet his responsibilities and, where possible, to face what he fears in manageable increments.

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U.S. Naval Flight Surgeon’s Manual 12. Emphasis on his success, no matter how small, for positive feedback. 13. Interpretation of genetic or psychosocial determinants or risk factors. This means exploration of the patient’s past, but only as it relates to the present problem and only as the patient is able to tolerate the feelings. 14. Occurrence of insights with opportunities for the patient to change, redecide old issues, relinquish archaic ties, make new decisions, and take initiatives. Interpretation and insight are therapist and patient forms of graduated, feared-stimulus exposure and desensitization in psychotherapeutic terms that lead to amelioration or cure. 15. Environmental manipulation. This can range from a night’s rest, rescheduling a flight, or changing instructors, to the extreme of hospitalization. Manipulation is to be used sparingly because it is infantilizing. It is better to encourage him to make necessary changes himself. A permanent change of station (PCS) can usually be recommended only in the context of a Medical Board, and only as part of a therapeutic plan. 16. Finally, termination as agreed upon, or earlier, if the patient is able to take over and solve his problem. The termination interview should include interpretation of any anger at rejection and an open invitation to return. Three Phases of Therapy. 1. The Opening Phase. The patient attempts to develop trust in the therapist, and for a time, becomes symptom-free as he finds someone in whom he can gratify his infantile needs. This can lead a therapist to conclude that he has accomplished a miraculously speedy cure. 2. The Middle Phase Symptoms return and work begins. 3. The Closing Phase. Dependency, conflicts and separation anxieties exacerbate as the patient realizes that termination is imminent. Symptoms may temporarily erupt again as a defense against having to leave the therapist. There may also be an unconscious anger at being rejected, and the defense and anger must be identified and interpreted. Other Important Concepts. 1. Countertransference - the often irrational and infantile feelings generated in the therapist by the patient that come from the unresolved conflicts in the therapist’s past. These can be used to

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Aviation Psychiatry advantage or can be detrimental to the therapy. This phenomenon can alert the therapist to the fact that the patient is dealing with neurotic conflicts and feelings. The patient may try to “hook” the therapist, so to speak, into neurotic interaction to gratify infantile needs. The therapist may succumb wittingly or otherwise, and the therapy will be sabotaged. If the therapist finds himself unable to resist the latter outcome, the patient must be referred to someone else. Few therapists can deal with all types of patients, particularly without psychotherapy themselves to remove as many of their blindspots as possible. 2. Note-taking during sessions may be appropriate if used sparingly for the initial evaluation, but in therapy it is to avoided. After the therapy session is over, the therapist may find it helpful to reduce his thoughts to the format of the SOAP formula of the PROMIS system. The themes of the hour can be summarized under “Subjective.” Any changes in the mental status (a sort of mini-mental status), for example, alterations in defenses or development of insight, can be recorded under “Objective,” as well as any laboratory findings, current tests, additional outside information, or the results of consultations with other specialists. Thoughts about what is going on, or a major shift in diagnosis can be briefly put down under “Assessment.” Recommendations and follow-up for the next hour will come under “Plan”. This method will keep the therapist from straying, wandering, and wasting precious time, a thing all too easy to do in such a potentially nebulous undertaking as psychotherapy. Marital Therapy - A Brief Summary Marital therapy is not individual therapy with two people; there are unique, complex dynamics involved in the marital relationship that extend beyond the boundaries of the marital partners. However complex this relationship, it is still possible to unravel and understand enough of it to effect a change in a disturbed marriage. The responsibility for change rests with the husband and wife, whether it be to make the change within the marriage or to change by separation. There even may be the decision not to change but to keep the status quo as the least painful of the three choices. Any one of the three decisions - stay married and change, divorce, or make no change - is legitimate, but it should be made on the basis of information derived from the marital therapy process. The marital therapy process is based on two concepts germane to any interpersonal relationship - needs and communication. If needs complementary to the marriage, conscious or unconscious, are met, then the relationship remains stable. If these needs are not met, then communication is necessary to establish an awareness and a means whereby they will be met. It is helpful to have the couple enumerate their needs both as individuals and as partners in a marriage. Thii serves two purposes: one, to bring into mutual awareness the expectations each holds for himself and the

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U.S. Naval Flight Surgeon’s Manual partner which then can develop into a mutually shared experience that underlies every successful marriage, and two, to introduce fundamental communication usually lacking in problem marriages. Communication is not limited to mere verbal exchange, but it includes connotation and nonverbal cues as well. The flight surgeon will probably not have time to do long-term marital therapy; what he can offer will be short-term, supportive counseling. Referral sources such as Family Services, chaplains, local ministers, other medical and psychological specialists, and even books on the subject are invaluable in extending his limitations for comprehensive treatment. If long-term therapy is indicated, the flight surgeon should have available a list of appropriate referral sources that includes payment modality and personal knowledge of qualifications. Because of the frequent absence of the spouse due to deployments and unaccompanied-tour duty stations, the effectiveness of marital therapy may be compromised. Supportive therapy and use of referral sources become essential in treating only one partner. For the husband, the flight surgeon may be limited to treating the symptoms, depression, anxiety, etc., and simply being available as someone for him to talk to. For the wife, the flight surgeon will be limited to his list of referral sources and making appropriate recommendations. The kinds of problems encountered may range from newlyweds’ initial adjustment arguments to complex sexual dysfunction involving other psychiatric problems extending to the entire family. The flight surgeon’s goals and values underlying marital therapy should allow for divorce or separation as a realistic “treatment” alternative and prepare him to assist in that task. If divorce is the result of therapy, the goal should then be to return each partner to a functional status. Behavior Therapy Theories of Behavior Therapy. All behavior therapies rest on the assumption that most human behavior, normal and abnormal, is learned. As such, behavior treatment involves the application of learning principles to modify or eliminate maladaptive behavior and to acquire behaviors considered to be adaptive. 1. Respondent (Classical) Conditioning. If a neutral stimulus becomes temporarily associated with another stimulus which naturally evokes an unlearned response (reflex), and the two are paired repeatedly, the neutral stimulus alone will then evoke the unlearned response (reflex). The formerly neutral stimulus has now become a conditioned stimulus and the reflex a conditioned response. This principle is applied in a wide variety of behavioral treatment techniques such as aversive conditioning and systematic desen-

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Aviation Psychiatry sitization. This concept is frequently used in working with symptoms of performance anxiety and motion sickness. 2. Operant Conditioning. When a response is made to a given stimulus (which results in something happening) that increases the probability that the stimulus-response connection will be made again (reinforcing), operant conditioning has taken place. This learning principle finds application in the treatment of many psychopathological conditions ranging from schizophrenia to conduct disorders in children, and it is also employed in assertiveness training. 3. Social Learning. Repeated animal and human studies demonstrated that subjects could learn quite complex behaviors simply by seeing and hearing other subjects model these behaviors. There are many variables that influence learning through modeling, such as the observer’s sex and age in relation to the model. Group therapies, including Alcoholics Anonymous, play therapy, and marital therapy, are some settings in which social learning principles are used in behavioral treatment. Techniques of Behavior Therapy: Relaxation Therapy, Biofeedback, and Systematic Desensitization. Anxiety related to specific situations is effectively treated via relaxation with desensitization. Relaxation therapy or biofeedback can be very effective in treating anxiety symptoms in which no specific context can be identified. Respondent conditioning principles apply in these techniques. 1. Relaxation Therapy. The following procedure is used in teaching the patient relaxation “exercises:” a. Sit or lie comfortably in a chair or sofa in a quiet, semi-darkened room. b. Tense and relax individual muscle groups (forehead, face, neck, shoulders, arms, back, stomach, thighs, calves). Tense each muscle group for about three seconds before relaxing and going on to the next. c. Focus and concentrate on rhythmic breathing, deeper muscle relaxation, and the imagination of a pleasant, relaxing experience. d. Lie totally relaxed for approximately one minute, then awaken by counting backwards from five to one.

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U.S. Naval Flight Surgeon’s Manual This procedure, elaborated upon in various text books, is practiced by the patient twice a day for approximately a week, or until he is able to relax himself at will using the technique. Commercial audio and video tapes are available. 2. Systematic Desensitizalion. The application of relaxation in systematic desensitization begins with the patient constructing an “anxiety hierachy,” a graded list of situations or events which evoke anxiety. The patient then imagines each item on the hierachy while in a deeply relaxed state. In particularly difficult cases, drug relaxants or hypnotics may be used in conjunction with the relaxation procedure described above. The patient progresses from least to most anxietyarousing events as each evokes absolutely no anxiety when vividly imagined by the patient. Invivo desensitization is also practiced by the patient, if practicable (e.g., sitting in the cockpit of an aircraft for flight anxiety). 3. Biofeedback. Biofeedback utilizes the same techniques plus electronic monitoring of the tension of specific muscle groups. This allows the patient more control and provides instant awareness of progress. Other Techniques. Modeling and role-playing are general methods of behavior therapy which simply involve the interaction of patient and therapist and the patient and important others as models for desired behavior acquisition. The selected behavior is observed, then practiced, until skill is attained and anxiety is absent. Assertiveness training, fixed-role therapy, and a wide variety of group and play therapies employ modeling and role-playing. This form of therapy is usually utilized only in specialized situations and by therapists specially trained in the methods. Aversive Conditioning. Aversive conditioning is used in the treatment of alcoholism by developing an aversion towards alcohol through the ingestion of Antabuse. Narcotic and tobacco addiction are treated in the same manner but by different drugs as the aversive stimulus. Chemotherapy General Considerations. More and more of the organic substrate of emotional illness is being discovered. This does not mean, however, that the psychological factors can be discarded. They must both be dealt with, or the patient will remain partially crippled. He may be so confused, upset, or depressed that he cannot think about his problems until some physical or chemical stability is restored. On the other hand, to restore him chemically and ignore his interpersonal problems is to invite their recurrence. Specific chemotherapies will be elaborated upon later in the text.

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Aviation Psychiatry Patient Personality and the Placebo Effect. A significant portion of the effect of any medication is a function of the physician’s relationship with the patient and the phenomenona of transference and countertransference. On the negative side, the patient may have an unconscious need to defeat the therapist by being noncompliant. As a matter of fact, to recover may mean facing some anxiety, giving up a secondary gain, or both. If the medication fails to work and produces unpleasant side effects in the bargain, damaging effect on rapport and morale are a likely outcome. Patients should be given verbal and written explanations of the usual side effects of any psychotropic medications. It is often useful to take into account the personality and traits of the patient when prescribing psychotropics. Elaborate detail, perhaps even a minor ritual, may be helpful for the obsessivecompulsive patient; conversely, a minimum of detail, leaving as much control to the patient as possible, may be appropriate for the passive-aggressive, and firm insistence may be indicated in dealing with the patient who must deny dependency and who, for that reason, normally shies away from all medication. Hazards of Drug Therapy in Psychiatric Treatment. One must think twice before prescribing medication for the alcoholic, the compulsive overeater, or the overtly dependent patient. In a depressed patient, suicidal risk must be balanced against the need for trust in a therapeutic relationship. If the patient departs from the regimen prescribed (for defensive reasons), gentle confrontation and interpretation are indicated. Physiological side effects may be sufficient to result in increased, rather than decreased, anxiety and may be misinterpreted by the physician, leading him to overprescribe or add other medication, compounding the problem and seriously eroding trust. Lastly, the therapist must avoid using drugs as a substitute for psychotherapy rather than as an adjunct. In dynamic psychotherapy, the use of medication tends to focus the patient’s attention on reality issues and away from unconscious factors and feelings. As a general rule prescribe no more than a week’s supply of medication at a time for suicidal risk patients. Monitoring of side effects and serum levels will give other confirmatory information that the patient is not hoarding medication for suicidal purposes. Psychoses Psychotic or bizarre behavior in an active duty member not only tends to create turmoil in an operational unit but also tends to tax the abilities of the flight surgeon. Psychotic behavior can occur in any age, rate, or rank. In the military environment, medical disorders and intoxication always have to be considered. Schizophrenia is the prototype for psychotic behavior. One of the

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U.S. Naval Flight Surgeon’s Manual popular, but not confirmed, current organic explanations of schizophrenia is that an excess of dopamine is produced by a deficit of dopamine B-hydroxylase, the enzyme that normally converts dopamine to norepinephrine in noradrenergic neurons. This may also explain the depression and apathy that often accompany the disturbance of thought processes. It is of interest to note that alcohol consumption leads to an increased synthesis of these same catecholamines, leading to the possibility of aggravating schizophrenia. This process might also explain why alcohol might relieve depression temporarily. Other studies suggest that Antabuse inhibits dopamine B-hydroxylase, thereby mimicking or aggravating schizophrenia and producing the occasional Antabuse psychosis. Antipsychotic drugs (e.g., the three major groups - phenothiazines, butyrophenones, and thioxanthenes) have many properties, but they all share one, the ability to block dopamine receptors. This same property is responsible for two other effects, extrapyramidal symptoms and tardive dyskinesia. Fortunately, the anticholinergic drugs, such as Bentropine (Cogentin) can partially overcome this by readjusting the balance between acetylcholine and dopamine. Those phenothiazines with the most prominent anticholinergic properties (e.g., Mellaril) are least likely to produce extrapyramidal symptoms. Unfortunately, there is no “best” treatment for tardive dyskinesia. An unconfimed popular irony of tardive dyskinesia is thought to be the result of a progressive hypersensitivity of the blocked dopamine receptors to the presence of even small amounts of dopamine. Neuroleptic malignant syndrome is an entity characterized by hyperthermia, tachycardia, tachypnea, increased WBC and CPK. It is life threatening. Neuroleptics should be discontinued and standard medical textbooks should be consulted for current treatment modalities. Lorazepam may be an alternative drug if psychotic symptoms persist. The antipsychotics are the treatment of choice for psychotic behavior, even that of toxic or infectious etiology. It is wise to become well-acquainted with two members of this class of drugs. A sedative drug and a high potency drug are recommended. The sedative effect is immediate. The antipsychotic effect is cumulative and may be delayed from hours to days. Therefore, once the patient is under control, the total daily dose may be given at bedtime to take advantage of the sedative effect at night and not hinder the patient during the day. Suggested medications to become familiar with would be Thorazine for the sedating type and Halopenidol (Haldol) or Fluphenazine (prolixin) for the nonsedative high potency type. Recent literature suggests concomitant administration of lorazepam (Ativan) may be helpful, especially in severely agitated patients. Haldol in a dose of 2 to 5 mg p.o. or IM every 30 to 60 minutes until calm is usually adequate for most psychoses. On occasion, restraints may be necessary until the patient calms. If hypotension occurs and threatens the patient, Levophed or Neosynephrine may be given, but

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Aviation Psychiatry epinephrine-like compounds may potentiate the hypotension because phenothiazines are A-adrenergic blockers. If extrapyramidal symptoms incapacitate the patient, Benztropine (Cogentin) 1 mg, may be given I.V. or I.M. STAT and then p.o. from 1/4 to 1 mg b.i.d. Diphenhydramine (Benadryl), 25 to 50 mgm, I.V., is a reasonable alternative and preferred by some. Anticholinergic excess in its own right can produce psychotic symptoms. Therefore, the least amount necessary should be used, and the patient should be titrated off of them when possible. It may be sufficient from the outset simply to lower the antipsychotic medication. Severe extrapyramidal symptoms could be life threatening if not treated. All patients exhibiting psychotic behavior should be stabilized and referred to the nearest medical treatment facility. Psychotic behavior is always NPQ for aviation. As a general rule, such cases should be referred to a medical board to determine suitability for general duty. Recidivism and complicated management make further active duty unlikely. Mood Disorders Mood disorders, including major depression and dysthymia, are not uncommon presentations in the operational environment. Proper intervention and treatment may allow later return to aviation duty by waiver. Bipolar disorder usually presents in a very dramatic fashion. Management is often difficult and such cases are permanently disqualified for aviation duty. Mood disorders are thought to be a result of a change in the functional availability of neurotransmitter catecholamines, including norepinephrine. The norepinephrine level may be increased, but symptoms will not manifest themselves unless the serotonin level is low. Serotonin deficiency seems to be associated with insomnia; acetylcholine increase or norepinephrine decrease is associated with psychomotor retardation. If norepinephrine or other catecholamines are in excess, agitation is produced. Antidepressants, now often called heterocyclics, are the drugs of choice for depression, as they act to increase the catecholamines and serotonin by blocking their reuptake, and they have some anticholinergic effect. The dosage may vary somewhat according to specific type. The rule of thumb is to start low and go high. The most common error is undertreatment. The single biggest cause of refractoriness to antidepressant treatment is inadequate dosage. Dose equivalents should be between 150 and 300 mg of imipramine for four weeks before considering alternative medication or supplementary medication. Desipramine, imipramine, and trazodone are commonly used in the military. Amitryptiline and other sedating, heavily anticholinergic medications usually have such serious side effects that they are not practical for outpatient use.

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U.S. Naval Flight Surgeon’s Manual Fluoxetane (Prozac) is a new serotonergic antidepressant that has a minimum of side effects and offers promise. Most experts feel the therapeutic benefit is the same for all of the antidepressants. The physician should try to utilize one with the fewest side effects. The sedative effect, as with the antipsychotics, is immediate. The antidepressant effect is cumulative and delayed. For this reason, all the medication may be given at bedtime to take advantage of the sedative effect. Before declaring a treatment failure, the medication should be continued for at least three weeks, all the time striving for a therapeutic dose. Improvement will often take that long to become evident. The risk of suicide rises as the patient becomes more energetic; he must be observed closely until improvement is sustained and he resumes functioning. In severe cases of depression, electro-shock therapy may be resorted to as an emergency measure against the danger of suicide. Remission of the illness is evident when the patient begins eating and sleeping normally, and his energy seems restored. The antidepressant dosage should be maintained for a minimum of six months. After six months, if the patient is completely symptom free then the medication should be tapered off completely over a three-week period. If symptoms return, then twelve months of maintenance dosage is in order. Authors agree that the more intractable the initial symptoms, the longer the maintenance period must be. As a general rule, all military patients being treated with antidepressants should be on a limited duty board. After a single episode of major depression, and in full remission, a member, when returned to full duty, is NPQ for aviation but may warrant a waiver for return to aviation. Patients with recurrent depressions are permanently NPQ and should be referred for a medical board to determine fitness of general duty. Bipolar disorder is theorized to be due to an excess of norepinephrine or other neurotransmitters. Bipolar illness usually responds very well to lithium, but it takes several days, four or more, for an effective blood level to be reached. In the interim, Haldol or Thorazine are the drugs of choice, with 2 to 5 mg of Haldol or 50 to 100 mg of Thorazine I.M., a starting doses. They may be given every 30 to 60 minutes until the patient is calm. Lithium is thought to act by accelerating the catabolism of norepinephrine, inhibiting the release of norepinephrine and serotonin, and stimulating the norepinephrine reuptake process. Further, it appears to stabilize intracellular sodium (thought to be increased in depressions) via the sodium-potassium-adenosine triphosphatase system, which is also magnesium dependent, and is possibly involved in corticosteroid stabilization. More lithium is required in the early agitated phase, as much as 1500 to 2000 mg per day, but the requirement quickly falls with the patient’s improvement to about 600 to 1200 mg per day for a blood level that ranges from 0.8 to 1.5 mEq/L. Hydration must be carefully maintained. Any febrile illness with diaphoresis or loss of fluid through diarrhea may result in toxicity, which will occur rapidly above 1.5 mEq/L, and death

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Aviation Psychiatry may supervene at 3.0 mEq/L. Signs and symptoms are those of the central nervous, gastrointestinal, and cardiac systems. Lithium must be promptly discontinued until proper hydration is regained; the level will fall quickly. Lithium cannot safely be prescribed without the ready availability of a competent laboratory. Those with illnesses requiring lithium are always NPQ for aviation. Due to the hazards associated with lithium, its use in any operational setting should be discouraged, and in general, the patient should be referred to a Medical Board. Anxiety Disorders The physiology of anxiety is just beginning to be unraveled. The GABA (gamma aminobutyric acid) system of the brain, with its suggested benzodiazepine receptor system, is proving to be a fruitful area of research. Most commonly used anxiolytics are in the benzodiazapine family and all have a high potential for physiological dependence. Anxiolytics should only be considered short-term adjuncts to other forms of therapy in cases of situational anxiety. In those cases where a more severe diagnosis exists, long term therapy may be necessary to maintain function. The safety of long-term benzodiazedine use continues to be documented. Therapy should not be withheld if justified by the diagnosis. Panic disorder should be considered in anyone with recurrent “anxiety” accompanied by autonomic symptoms. Generalized anxiety disorder and post-traumatic stress disorder are occasionally encountered in the active duty population. Obsessive compulsive disorder is less frequently encountered. Individuals with these disorders are considered NPQ for aviation, and usually unsuitable for general duty. Treatment should be rendered under the auspices of a Limited Duty Medical Board. A waiver for return to aviation duty might be considered after the patient has been symptom free for one year. Xanax (alprazoalam), appears to be the drug of choice for uncomplicated anxiety and panic attacks. Its initial sedative effect rapidly disappears in most cases. The effective dose ranges from 0.25 mg. Q.I.D. to 2 mg. Q.I.D. in some cases of panic disorder. On higher doses and longer periods of time, physical withdrawal must be considered. Always taper the dose. A good rule is to taper by 0.5 mg per week. Buspirone (Buspar), a noncontrolled anxiolytic, is now available for anxiety disorders. Reports on its usefulness are conflicting. In using anxiolytics, as with all psychotropics, the sedative side effects must be stressed. Patients should be cautioned against the concomitant use of alcohol.

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U.S. Naval Flight Surgeon’s Manual Sleep and Insomnia Insomnia is an ubiquitous complaint, especially in psychiatric patients. Rather than automatically prescribing a sedative, however, the physician should investigate for the many causes of insomnia and, where possible, treat the basic cause. Situational anxiety is probably the most common cause of insomnia, followed by depression. Antidepressants rather than sedatives may be the treatment of choice. If a sedative is appropriate, however, a short-acting benzodiazepine is the drug of choice such as Triazolam (Halcion) in doses of 0.125 to .5 mg p.o. HS. The short half-life reduces the chance of hangover. Some reports suggest retrograde amnesia when taken in conjunction with alcohol. Even though useful, it seems wise not to prescribe benzodiazepines for more than a few nights, while attacking the basic problem through other avenues. Benadryl 50 mg p.o. HS can be a useful, nonaddicting sedative to use. Recent studies also have suggested the usefulness of L-tryptophan in doses up to one to two grams at bedtime. The use of sedatives to assist sleep in sustained operations is a continuing debate. The British use of Halcion in the Falklands war increased interest and also demonstrated effectiveness when used under proper conditions. Psychiatric Emergencies and Suicide Prevention True psychiatric emergencies are those that require the extreme of intervention in a patient’s life - providing him with prosthetic controls, either, chemical or structural, usually accompanied by hospitalization. This provides him with additional control over his impulses when his controls are insufficient for his or others’ safety. The situations that meet these criteria are those of confusion, psychosis, and impending suicide or homicide. Another way to define this is defining the patient as gravely disabled or a threat to himself or others. In the military, administrative situations may dictate admissions. Confusion, as an emergency, means that the patient is unable to manage his life. In treating it, the physician must distinguish between organic and functional causes and treat accordingly. Helpful in this regard is a history from a reliable informant and the signs that are characteristic of CNS involvement - disturbance of orientation, memory, intellect, affect, and judgment, and visual hallucinations. Auditory hallucinations are more typical of the functional illnesses. In any psychiatric emergency, a complete medical evaluation is indicated.

Other emergency presentations and management have been discussed in the sections on treatment modalities, psychoses, mood disorders, anxiety disorders, and drug overdose. The danger of suicide generally presents as ideation, gesture, or attempt. When ideation

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Aviation Psychiatry presents, estimating the danger of it being translated into action is difficult. All attempts at selfharm should be taken seriously. Determining some of the following risk factors may be helpful: 1. The presence of depression and a hopeless or bleak outlook. 2. The loss of friends or relatives, or of self-esteem, or of a body part or function highly valued by the patient. 3. A plan to kill oneself. 4. A lethal means (gun - pills). 5. A past history of suicidal ideation, or of a gesture or an attempt. 6. A history of drug or alcohol abuse (30 percent of suicides are alcohol related). 7. Poor health. 8. A concomitant Axis I on Axis II diagnosis. 9. A family history of suicide or major psychiatric illness. 10. The patient’s estimate of risk. 11. The physician’s empathetic estimate of risk. Gesture and attempts may be difficult to differentiate, and in general should be taken equally seriously. Both may be associated with personality disorder and manipulation or they may be expressions of bona fide depression and a desire to be dead. Long-term treatment depends on correct diagnosis and a proper response to an estimate of the self-destructive risk. The medical officer should follow NAVMEDCOMINST 6520.1 series for disposition. When in doubt, hospitalize, and always follow-up. Always notify the cognizant command of your follow-up plan. Suicide patients, even those with manipulative suicide behavior, do not belong in the operational environment. The flight surgeon should closely coordinate cases of suicidal ideation or behavior with the nearest medical treatment facility. The risk of homicide may derive either from psychiatric or organic illness and is historically nearly impossible to predict. If the etiology is functional, the following have been associated with increased homicidal risk:

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U.S. Naval Flight Surgeon’s Manual 1. Abusive parents, especially the father. 2. A borderline or schizoid pattern of adjustment. 3. A seductive mother. 4. A triad of cruelty to animals, fire setting, and enuresis. 5. A paranoid pattern of adjustment with chronic anger. If the illness is organic, there may be increased risk if the basic personality pattern has been paranoid. 6. A history of violent behavior or assaulting others. The Center for the Study of the Prevention of Violence in Los Angeles has uncovered a rather high percentage (42 percent) of soft neurological signs in studies of violent patients. In the individual case, an estimate of the following may be helpful in assessing homicidal potential: 1. The degree of unreality in the paranoid ideation. 2. The adequacy of contact with reality in general. 3. The intensity of anger. 4. The history of impulse control. 5. The adequacy and stability of relationships. 6. Self-esteem. 7. The presence of the paranoid defense as a major coping device. 8. The patient’s estimate of his current control. Studies suggest that only a very small percentage of those presenting with homicidal risk ever act on their impulse. Treatment consists of the imposition of chemical or physical controls (in the form of hospitalization) as in suicidal potential, until the danger is over. The Tarasoff court deci-

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Aviation Psychiatry sions in California has set the standard that the intended victim and police must be notified. In the military this would include the cognizant commanding officer. Drug Overdose The following general principles are accepted for the treatment of drug overdose: 1. Identification of the drug. 2. Evacuation via emesis and lavage. 3. Neutralization via antidote. 4. Symptomatic treatment and supportive measures. In overdose with psychotropic medications, the following steps should be taken: 1. Ensure an adequate airway - intubation or, rarely, tracheostomy if necessary in the comatose patient. 2. Emesis in the conscious patient - syrup of ipecac, one teaspoon for a child, two for an adult. This may be repeated in fifteen minutes. 3. Gastric lavage. Do not attempt this in the comatose patient without intubation and cuff to preclude aspiration pneumonia. Use a solution of 0.5 percent normal saline activated charcoal. Continue lavage until returned solution is clear. In the case of tricyclics, one author recommends lavage for 24 hours on the basis that the excretion of tricyclics occurs partly in the stomach. 4. An I.V. with five percent glucose in saline. Maintain fluid balance. One author recommends an immediate injection of 50 cc of 50 percent glucose for saline in comatose patients considering that hypoglycemia as a possible cause is thereby quickly and simply treated or ruled out. 5. Blood and urinalysis to identify the drug, as well as a history from a reliable informant. 6. Other supportive measures as may be indicated - indwelling catheter, cardiac monitoring, treatment for shock, hyperpyrexia, and potential seizures.

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U.S. Naval Plight Surgeon’s Manual It has already been mentioned that epinephrine and related compounds must be avoided for the hypotension due to the antipsychotic and antidepressant medications in order to avoid paradoxical further lowering of the blood pressure. Levophed or phenylephrine are the drugs of choice, one ampule, titrated in an I.V. drip. If sedation is required for agitation or the danger of seizures, oral or I.V. Valium, 5 to 20 mg, appears to be the drug of choice. Where the overdose is from amphetamine or related compounds, the use of a phenothiazine for sedation may precipitate an intractable hypotensive reaction. The central anticholinergic syndrome (CAS) may be a concomitant of overdose with antipsychotic and antidepressant drugs, as well as with the anticholinergics prescribed to relieve the pseudo-Parkinsonian symptoms induced by the antipsychotics (Holinger & Klawans, 1976). The central nervous system symptoms and signs of anticholinergic overdose are: 1. Agitation. 2. Disorientation. 3. Hallucinations - visual and auditory. 4. Anxiety. 5. Purposeless movements. 6. Delirium. 7. Stupor. 8. Coma. The peripheral nervous system symptoms and signs are: 1. Flushing. 2. Dry mouth. 3. Constipation.

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Aviation Psychiatry 4. Mydriasis. 5. Temperature elevation. 6. Motor Incoordination. 7. Tachycardia. Another way to remember anticholinergic overdose is by this rhyme: Red as a beet, Blind as a stone, Mad as a hatter, Dry as a bone. These symptoms and signs are all dose related. They are the result of a competitive inhibition of acetylocholine. The antidote, physostigmine, which unlike neostigmine can cross the blood-brain barrier, inhibits the enzyme anticholinesterase, permitting an increasing build up of acetylcholine that finally overcomes the block at the receptor sites. Profound coma and other characteristic symptoms of the CAS syndrome may be relieved immediately by the administration of physostigmine in doses of 1 to 4 mg as often as indicated, usually every hour until symptoms and signs permanently abate. This is usually no more than 24 hours, at most. Family Crises There are two other types of emergency with which the flight surgeon will surely be confronted. They differ in character from those described above. The first is that of the distraught, and perhaps lonely and dependent, military wife whose husband is at sea or overseas, possibly in a combat area. The second is that of the young military wife who has just lost her husband in an aircraft mishap or in combat. In the first type, the emergency may either be real or the expression of immaturity and predominantly intrapsychic factors. If it is a true emergency, the social worker may be the proper helping person. If the symptoms are mainly intrapsychic, the flight surgeon psychotherapist, in addition to the social worker, may be necessary to support the patient. If the husband must be returned or the children need care or supervision, family services, social services, and the chaplain may need to get involved. For the stress of military separation, prevention, in the form of

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U.S. Naval Flight Surgeon’s Manual preparation of the family by the military member, is by far the best form of treatment. This should include emotional preparation for the absence and the necessary shift in roles, agreements for communication by writing or other means, power of attorney for legal problems, and plans for adequate residence, medial care, financial, and other crises that may arise. Knowledge of the various helping agencies and what they can realisticaIly do should help to allay separation anxiety and forestall emotional crises. The articles, Emotional Cycle of Deployment (Logan, 1987) and Growing Up Military (Long, 1986) will greatly assist the flight surgeon in understanding the unique stressors of military life. At some time the flight surgeon will surely be called upon to accompany the chaplain and commanding officer to notify a young wife of the loss of her husband in an aircraft mishap or in combat. Recalling the stages normal to grief reactions, the flight surgeon will realize that one of the most important elements of treatment is helping the patient and encouraging the relatives to help the patient to experience, ventilate, and express her feelings, whatever they may be. Sedation or tranquilization should therefore be minimal, but the patient needs at least enough sleep to function. Prescribing Halcion 0.25 HS, for several nights may be very helpful in supporting the patient through the most trying period. It may also be important to have a friend or relative of the patient’s choosing stay with her for a day or so, particularly if she would otherwise be alone. Remember to fully utilize the service of the unit CACO - casualty assistance and counseling officer . Combat Psychiatry In combat and other sustained operations, including aviation combat, the emphasis in understanding psychological reactions is on the external stress. The symptoms and signs run the full gamut of psychiatric nomenclature, but quick recovery is the rule when the patient is removed from the stress. Experience has shown over and over that if a combatant is treated quickly, close to his unit, and led to expect that he will return as soon as possible to his unit, results are not only very good, but far superior to those obtained when a man is treated a long way from his buddies, with some delay, and with uncertain expectations. The cardinal principles of combat psychiatry are Proximity, Immediacy, and Expectancy (PIE). Historically these principles are “relearned” at the beginning of each new conflict. Principles Further Refined Daring the Korean War 1. Treat as near to the unit as possible. 2. Segregate the most agitated patients until they can be adequately sedated.

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Aviation Psychiatry 3. Sedate sufficiently to reduce overwhelming anxiety and insure sound sleep. 4. Accept the patient not as a casualty, but with the attitude that his symptoms are transient and that he will recover and go back to his unit. 5. Say or do nothing that would indicate evacuation. 6. Ventilation is encouraged; interpretation avoided. 7. Once disposition is decided, inform the patient, avoiding argument. 8. Return the patient to duty as soon as possible, often within 24 hours. 9. As a guideline, evacuate patients with the following conditions. a. The obviously psychotic - rare in combat. b. Conversion reactions - the blind and paraplegic. c. The severely apathetic who appear emotionally depleted. d. Those who show gross tremor and chronic startleability. e. The NCO or officer with impaired judgment or who may set a bad example. “Combat fatigue” has been defined as a transient, pathological reaction in a basically healthy personality to the severe stress of combat. The terminology tends to be confusing. By DSM III-R criteria, acute reactions would fall into acute traumatic stress syndromes. Later symptoms would be in the posttraumatic stress syndrome category. Frequently Used Mnemonic: “BICEPTS” B - Brevity

- Treat for as short a period as possible to return to function, 48 hours at the first echelon.

I - Immediacy - Intervene before the individual is incapacitated. C - Centrality

- Triage and locate combat fatigue cases away from the wounded, in a central area.

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U.S. Naval Plight Surgeon’s Manual E - Expentancy - From the beginning, the patient is given the expectation of returning to his unit. P - Proximity

- Treat as close to his unit as possible.

T - Treatment - Should include rest, food, warmth and short acting sedatives if necessary. S - Simplicity - Front line measures should be simple and easily monitored. For disasters involving multiple casualties and death, rapid intervention by trained professionals will assist in alleviating long-term symptoms in both survivors and rescuers (posttraumatic stress syndrome). The SPRINT teams (Special Psychiatric Rapid Intervention Teams) at the Naval Hospitals San Diego and Portsmouth are available for rapid on-site assistance. The Psychology of Survival And The Repatriated Prisoner of War General Concepts With today’s ultramodern communications and locating devices, one is much less likely to be faced with surviving in a hostile geographic environment than as a prisoner of war (POW). Some of the helpful techniques and concepts that have been learned or proven from the Vietnam experience are included in this discussion from the point of view of a captured pilot. Family Preparation A family’s ability to face and survive a long period without the head of the family will be measurably enhanced if they prepare for it ahead of time, before his deployment. In the event of capture, the prisoner can then be somewhat less worried about how his family is managing. The military member should prepare his wife and children, within the limits of their emotional comprehension, for the shift in responsibilities and roles that his absence will entail. He should consider granting power of attorney and prepare his wife for any legal problems that can be foreseen. He can provide plans for residence, medical care, financial, and other crises that may arise in the event of his capture and imprisonment. “Shoot Down” and Culture Shock For a few pilots shot down in the Vietnam conflict, the abrupt transition from the highly ordered, time-structured, mechanized world of the cockpit to the anachronistic, agrarian, il-

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Aviation Psychiatry literate world on the ground was momentarily disorganizing, producing a feeling of unreality. This persisted until one set about laying realistic plans and trying to cope, even though captured. The best preparation for this stress should be SERE (Survival, Evasion, Resistance, and Escape) school. Coping in Captivity There are many things that one can do in captivity to enhance the ability to survive. The greatest single shock to the POW was breaking under torture, and the unbelievable rapidity with which it could happen. It simply did not fit with the POW’s image of himself as a redblooded American fighting man. This rent the man from his identification with his group and produced enormous guilt and depression that could usually only be alleviated by sharing the experience with a fellow POW. His understanding and encouragement brought the first man relief and repaired the rift. Although the Code of Conduct was a rallying point, it was meant to be applied flexibly, and it is so stated in the Code. Those who applied it rigidly because of their early SERE training were prone to be broken needlessly over information or behavior of minimal value. Unified resistance was extremely important for morale, and it made each POW much less vulnerable to the enemy’s blandishments and torture. But, the POW’s soon learned that it made more sense not to resist to the point of confusion or insensibility because, then, one might give truly valuable information to the captor without realizing it. It was better to stop just short of that point and give some misleading or useless bit of information. In the oriental environment of Vietnam, saving face was an important concept in the give-andtake with the captor. If the captor was required by his superiors to extract a bit of information or behavior from a POW, he had to return with something. It did not matter what it was or, at times, even whether it made sense; knowing this could sometimes save a POW needless injury. Conversely, if one could figure out how to put the captor in one’s debt, the face-saving concept could again be turned to advantage for the POW, with the captor overlooking some bit of forbidden behavior or perhaps providing medical care. Saving face was also a problem for some of the POW’s who felt constrained to “go to the mat” at the slightest provocation from their captor. It often took several beatings for a POW to realize that this was a foolish and losing game and that pride consisted of more important things. Torture could be and was applied again and again over weeks and months. The POW’s learned

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U.S. Naval Flight Surgeon’s Manual roughly how much they could endure before breaking, that they could recuperate, and, depending on the gravity of the injuries inflicted, about how long it would take. They gradually realized that one could survive even extensive torture, and this in itself was reassuring. This realization underscored the importance of keeping fit to improve to the utmost one’s recuperability. Three to four hours a day might be devoted to physical fitness exercises of various sorts. POW’s soon appreciated that “healthy bodies meant healthy minds.” Food was equally important in this regard. The POW’s learned to eat things that were normally revolting, though of some nutritional value. It has been shown from earlier wars that weight loss in captivity was the only apparently significant variable which could be related to disability which developed as late as eight to ten years after repatriation. Shortly after capture, the POW was tortured to extract short-lived information. Then, he was normally isolated, sometimes for months, even years. To avoid boredom, depression, or a break with reality, the POW had to “keep busy.” This could be done either inside or outside one’s head. One had to be involved, to move into some kind of future, even, paradoxically, if it meant exploring the past. One of the first things a POW did was to go over his entire life, in a piecemeal fashion. This might take three to four months; the longer, the better. He would recall events or people he had not thought of in years. He might, for example, recall everyone in his third grade dass. He reevaluated all the decisions and choices he had made. Sometimes major shifts in values occurred. It was a private psychoanalysis. This process could be repeated several times before it burned itself out. Then, the POW might engage in imaginary activities, such as building an entire housing subdivision or a house or a truck, brick by brick or bolt by bolt. Others who could communicate studied languages, history, or philosophy, played chess or worked calculus problems. Some studied the local insects, playing games or experimenting with them. Depressing thoughts had to be avoided. As one POW put it, “they could ruin your day.” The need to communicate with fellow prisoners was so strong that one would risk torture to do so, and all sorts of measures were devised. A tap code could be sent by tapping, sweeping, spitting, coughing, etc. Carbon or the lead from toothpaste tubes was used to scribble notes left in secret hiding places. Communication was the cornerstone of another basic necessity for survival - unity and group identification, with a hierarchy of leadership. As one POW put it, war with the enemy had not ceased upon ejection from his aircraft; only the mode and the front had changed. As “home with honor” was the slogan for survival, unity and communication were the means by which it was achieved. If a man was not incorporated quickly into the communication network, he was fair game for the enemy to divide and conquer. The tactics of the captor were to fmd weak links among the POWs and then to persuade them to collaborate either by force, leniency, deception,

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Aviation Psychiatry or blackmail. Leaders especially were their targets, and they suffered most. A few were isolated for several years to sequester them from their men and they were subjected to frequent and intense torture. In this connection, the prisoners were subjected to incessant propaganda and classes in communist ideology. Most authorities reject the term “brain-washing” because it suggests that by some magical and nefarious means the prisoner’s mind is erased clean of former convictions and loyalties, and these are supplanted by communist ideology and attitudes espoused willingly and permanently. They prefer the term “thought reform,” which is a lengthy process of confession and persuasion in a group setting by the behavioral conditioning of reward and punishment. Successful thought reform, however, requires that the prisoner have been brought up in an environment where group orientation is a very strong and potent force for influence. The methods of the Vietnamese captors were regarded as crude by Western POW’s and were essentially ineffective. Any propaganda that appeared to have been absorbed was quickly repudiated when the pressure was removed. The few exceptions were those POW’s who had been extremely naive, passive, rootless, or isolated in their own countries, with no firm convictions or loyalties to begin with. In other times and places, more forceful and relentless tactics, such as drugs, sensory and sleep deprivation, torture, and endless interrogation were applied to a few persons with results that might be termed “brainwashing,” but even here there is room for doubt. This does not mean that one cannot be made to lose one’s sensibilities for a time, to become disoriented, or even subject to hallucinations, but at least one can be reassured that this is not a permanent state of affairs. Organic brain syndromes with hallucinations occurred in the context of physical abuse, sleep deprivation, or malnutrition, or a combination of all of them. These symptoms remitted and at the present time there is no sign of residual symptoms. This again provides reassurance that one can survive and even recover from enormous amounts of physical abuse and torture. Realizing this ahead of time can add to one’s survivability by relieving a person of much of the fear of anticipated permanent disability. Sexual functions appeared not to be a problem in captivity or after repatriation as some prisoners feared. Some POW’s worried about dreaming at first, until they discovered that they only dreamed pleasant escape dreams. These dreams always ended, however, with the necessity for returning to the prison environment. When one prisoner in his dream refused to go back, he claimed he never dreamed again in captivity.

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U.S. Naval Flight Surgeon’s Manual There is a suggestion that a certain amount of time, somewhere between six weeks and six months, was required to adapt to the shock of capture and captivity. The time was necessary for anxiety and depression to subside to at least tolerable levels so that the individual could begin to function again, to move ahead in his daily life, and to contemplate a future, however uncertain and bleak. A few who were repatriated with a shorter period of captivity were still likely to be quite anxious and to have difficulty sleeping, making decisions, performing complex manual tasks, and thinking, concentrating, and remembering. This may be an aspect of the initial depression because the symptoms are similar to those of any typical depression, and the time required to adapt reflects the time typically required to recover from an untreated depression in any other setting. Frequently, this period of depressive symptoms was terminated, often rather abruptly, when the prisoner made a firm decision to survive and began to look and plan ahead. Recovery was especially facilitated by the relief of sharing his initial capture and torture experience with a fellow POW. Repatriation In captivity, time to think, to ponder, to deliberate, to make the most minute, inconsequential decision, was abundant. When repatriation finally occurred, the pressure of events and people and, by contrast, the frequent demand for rapid, important decisions and for equally rapid role reintegration resulted in reentry or reverse culture shock. This often was as stressful and devastating for a few as the initial one. This might last from as little as a month to as long as a year. It was variously reflected in persistent anxiety, insomnia, indecision, depression, difficulty driving, and for a few, excessive drinking. In most cases, marital discord was the commonest expression. This discord was often intensified by unconscious hostility on the part of the wife over having been abandoned (during captivity) and was compounded by her realistic anger if the repatriated prisoner of war (RPW) seemed thoughtlessly to allow his time to be monopolized by well-meaning relatives, friends, and well-wishers, numerous banquets, public appearances, and requests for speeches to which he felt obligated to respond. Regardless, the great majority of the RPW’s negotiated repatriation successfully. Conclusion Personality and temperament are undoubtedly important variables not only in coping with torture, but also in unwittingly inviting it. The Center for Prisoner of War Studies is exploring these variables and their relation to resistance postures. Does the hysteric unconsciously invite torture by “going to the mat” at every provocation no matter how slight; does the passive or schizoid person escape attention; is the compulsive person more apt to capitulate and cooperate or, through rigidity, to bring excessive torture upon himself? How does the intensely sensitive person fare or the calm, tough-minded individual, with a high threshold for anxiety and pain?

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Aviation Psychiatry In retrospect, it would appear that survivability from shootdown to repatriation ultimately depends upon and requires recovery of self-esteem through reintegration with the group - the POW group in captivity and the military, the family, and society at large upon repatriation. To the degree that there is failure in this, there will be symptoms and signs of psychopathology.

References and Bibliography Alexander, F., & French, T.M. Psychonanalytic therapy principles and applications. New York: Ronald Press, 1946. American Psychiatric Association. Diagnostic and statistical manual of the American Psychiatric Association, DSM III-R. Washington, DC: American Psychiatric Association, 1987. American Medical Association. Drug evaluations (6th Ed.). Chicago: AMA 1986. Appleton, W.S. Third psychoactive drug usage guide. Diseases of the Nervous System, 1976, 39-51. Basch, Michael F. Doing psychotherapy. New York: Basic Books, 1980. Dahlstrom, W.G., & Welsh, G.S. An MMPI handbook: A guide to use in clinical practice and research. Minneapolis: University of Minnesota Press, 1960. Dahlstrom, W.G., Welsh, G.S., & Dahlstrom, L.E. An MMPI handbook, Volume 1: Clinical interpretation. Minneapolis: University of Minnesota Press, 1972. Hanke, N. Handbook of emergency psychiatry. Lexington, MA: Collamore Press Dil, Heath and Company, 1984. Holinger, P.C., & Klawans, H.I. Reversal of tricyclic-overdosage-induced central anticholinergic syndrome by physostigmine. American Journal of Psychiatry, 1976, 133, 1018-1023. Kolb, L.C. Modern clinical psychiatry. Philadelphia: W.B. Saunders Co., 1982. Long, P. Growing up military. Psychology Today, December 1986, 31-37. Logan, K.V. The emotional cycle of deployment. Proceedings, February 1987,43-47. Mann, J. Time-limited psychotherapy. Cambridge, MA: Harvard University Press, 1973. MacKinnon, R.A., & Michels, R. The psychiatric interview in clinical practice. Philadelphia: W.B. Saunders, 1971. Munoz, R.A. Treatment of tricyclic intoxication. American Journal of Psychiatry, 1976,133, 1085-1087. Reinhardt, R.F. Fear of flying. Presentation at the Annual Meeting of the American Psychiatric Association, May 1965. Reinhardt, R.F. The outstanding jet pilot. American Journal of Psychiatry, 1970, 127, 732-735. Sadock, V. Marital therapy. In B. Sadock, H. Kaplan, & A. Freedman (Eds.), The sexual Baltimore: Williams & Wilkins, 1976.

experience.

Sadock, B.J., & Kaplan, H.I. Comprehensive textbook of psychiatry. Baltimore: Williams & Wilkins, 1985. Strange, R-E., & Arthur, R.J. Hospital ship psychiatry in a war zone. American Journal of Psychiatry, 1967, 124, 281-286. Sonnenburg, S.M., Blank, AS., & Talbott, John A. (Eds.). The trauma of war: Stress Vietnam veterans. Washington, DC: American Psychiatric Press, 1975.

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and recovery in

U.S. Naval Flight Surgeon’s Manual Talbott, J.A., Hales, DE., & Yudofsky, S.C. (Eds.). Textbook of psychiatry. Washington, DC: American Psychiatric Press, 1988. Wolpe, J., & Lazarus, A. Behavior therapy techniques. New York: Pergamon, 1966.

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Aviation Psychiatry APPENDIX 6-A OUTLINE FOR PSYCHIATRIC REPORTS Report Outline The outline for consultations and reports should correspond to the traditional medical format: 1. Identifying information and symptoms and signs.

(CC)

2. Patient profile according to the PROMIS system. 3. Context - event or situation precipitating the symptoms and signs.

(PI)

4. Background history - the personality.

(PH)

5. Mental status examination and psychometrics.

(PE)

6. Summary statement correlating 1, 2, and 3.

(DX)

7. Diagnosis and complementary statements. 8. Recommendations; therapy plan.

(RX)

Report Format For brevity’s sake, certain phrases and items of information should be constant. Paragraph 1. Identifying Information This is a standard paragraph and is always in the same format: This year old (marital status), (rank/rate), with about years of continuous active (broken) service, was referred for psychiatric evaluation on from (activity) , with the diagnosis , because of (symptoms and signs). Paragraph 2. Patient Profile A brief outline of the patient’s every day world, responsibilities and stressors.

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U.S. Naval Flight Surgeon’s Manual a. Unit assignment. b. Responsibilities. c. Performance. d. Where he lives and with whom. e. Stressors. f. Patient’s perception of his referral. g. Administrative or legal difficulties. Paragraph 3. - Present Illness a. Details of onset of present symptoms as presented by patient. b. Why now. c. Patient’s perspective on his behavior. d. Include information secured from other sources. e. Behaviors or significant changes in patient’s attitude noted during the evaluation. Paragraph 4. Past History a. Family: (1) Parents’ marital status, geographic, and socioeconomic data. (2) Patient’s sibling rank and parent’s sibling rank. (3) Family history of mental illness, suicide, or psychiatric hospitalization. b. Personal: (1) Early childhood events.

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Aviation Psychiatry (2) Adolescence: behavior problems, hetero or homosexual development and experience, friends and social adjustment, interests and hobbies. (3) Substance abuse. c. Social: (1) Disciplinary problems. (2) Educational level achieved. (3) Marital relationship history. (4) Plans and goals. (5) Work history, dismissals. (6) Military adjustment. Paragraph 5. Mental Status and Psychological Testing Mental status examination is referred to in previous parts of this outline. A “normal” mental status examination might be written as follows: a. The patient was dressed in appropriate military attire, he was well groomed, pleasant and cooperative. He sat comfortably in the examining chair exhibiting no unusual signs of anxiety. His speech was logical and coherent with his thought pattern focused on his difficulty in getting along with his superiors. He described his mood as “upset” but had an appropriate wide range of affect. The patient exhibited no psychotic tendencies. The patient denied suicidal ideation. The patient denied homicidal ideation. He was alert and oriented to time, person, place, and situation. His intelligence was clinically judged as average. The patient’s memory, including past, recent, and immediate recall were adequate. The patient’s cognition and abstraction were determined to be adequate. The patient’s insight and judgment were adequate. The MMPI was read as valid and not suggestive of overt psychopathology. b. It may be helpful to memorize this outline: (1) General appearance.

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U.S. Naval Flight Surgeon’s Manual (2) Speech and coherence of thought. (3) Mood and affect. (4) Perception - psychotic symptoms. (5) Suicidal or homicidal thoughts. (6) Orientation. (7) Memory. (8) Intelligence level. (9) Cognition and abstraction. (10) Insight and judgment. (11) Psychological testing. Paragraph 6. Summary and Formulation a. Brief correlation of symptoms, stressors, and personality traits. b. How they combine to produce a working diagnosis or no diagnosis.

Paragraph 7. Multiaxial Diagnosis a. Axis I: Clinical syndromes or V codes. b. Axis II: Personality trait disorders, specific developmental disorders. c. Axis III: Physical conditions or disorders. d. Axis IV: Severity of psychological stressors (0 - 7). e. Axis V: Global assessment of functioning scale (absence of symptoms to grossly impaired).

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Aviation Psychiatry Paragraph 8. Recommendations. Military psychiatric recommendations usually include two parts: administrative recommendations, and therapeutic recommendations. Medical recommendations would include any therapy indicated, any need to return for further therapy or referral if necessary. a. Administrative statements: (1) PQ and AA. (2) Is/Is not considered a significant suicidal or homicidal risk. (3) Fit for duty and responsible for his actions. (4) Recommend administrative management IAW - Instruction number with month and year of issue. b. Medical/psychiatric: (1) Personal therapy. (2) Marital and family therapy. (3) Environmental manipulation. (4) Referral to other appropriate source.

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U.S. Naval Flight Surgeon’s Manual APPENDIX 6-B PSYCHIATRIC STANDARDS FOR NAVAL AVIATION A Reference Guide for Flight Surgeons, Psychiatrists, and Psychologists with Suggestions for Further Medical Disposition. References 1. U.S. Navy Manual of the Medical Department, Chapter 15, Article 67. 2. U.S. Navy Manual of the Medical Department, Chapter 18, Medical Disposition. 3. SECNAVINST 1850.3 Series, Physical Disabilities. 4. MILPERSCOMINST 1910.1 series, Administrative Separation. 5. SECNAVINST 1920.6 series, Administrative Separation of Officers. 6. MILPERSMAN 3620200, Administrative Separation. 7. CNO Message 201614Z FEB 87, 9 NAVOP 13/87. 8. Aeronautical Advisory Committee, NAMI, Minutes of 24 April 1989. Psychiatric Disorders (DSM-III-R) as They Relate to Naval Aviation In most cases these determinations are appropriate to any special duty or operational setting. (From Reference Guide, dated May 1989). Mental Retardation. Determination of NPQ for aviation or general duty. Refer to a Medical Board for action as a noncompensable disability. Pervasive Developmental Disorders. Are disqualifying for enlistment and not usually encountered as an active duty problem. Specific Developmental Disorders. Result in a determination of NPQ for aviation if the skill involved impacts on aviation training, as is usually the case. Suitability for general duty may have to be addressed by a Medical Board as an EPTE (Enlisted Prior to Entry) disorder.

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Aviation Psychiatry Disruptive Behavior Disorders. Determination of NPQ for aviation. They are best managed by a Medical Board and referral to Naval Military Personnel Command, NMPC, for administrative action. Anxiety Disorders of Childhood/Adolescence (History of). Individual is usually not allowed to enlist. If symptoms are active, individual is NPQ for aviation and general duty. Refer for departmental review as an EPTE disorder. Eating Disorders. Anorexia nervosa and bulimia nervosa both result in a determination of NPQ for aviation due to the recidivism and complications of the illnesses. Attempts at treatment in the military setting are not practical or cost effective. These cases are best referred via a Medical Board for departmental review. Gender Identity Disorder. Determination of NPQ for aviation. Proper management may necessitate referral to NMPC via NAVMEDCOM departmental review. TIC Disorders. If very mild, military member would be considered NPQ for aviation with a waiver recommended. If severe enough to impact on a patient’s professional performance or social interaction in the squadron, this condition would result in a determination of NPQ with no waiver recommended. Referral via Medical Board departmental review to NMPC is indicated. Elimination Disorders. Determination of NPQ for aviation. MANMED considers enuresis past age 16 as disqualifying for general service. Management is in accordance with MILPERSMAN 3620200. Speech Disorders - Not Elsewhere Classified. Individual should be considered NPQ for aviation. Dementias. Result in a determination of NPQ for naval aviation and for general duty. These cases should be referred to NAMI Physical Examinations Department via a Medical Board. This is a compensable disorder. Psychoactive Substance Induced Mental Disorders and Substance Dependence. Result in a determination of NPQ. Alcohol abuse results in a finding of NPQ until satisfactory completion of Level II. Alcohol dependence results in a finding of NPQ. DSM-III-R criteria should be followed. After treatment at Level III, in accordance with MEDCOMINST 5300.2, a waiver can be recommended. Illicit substance abuse acknowledged and waivered by the Recruit Command prior to acceptance into naval aviation is not considered disqualifying. Repeat use of illicit

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U.S. Naval Flight Surgeon’s Manual substances (treatment failures) will result in a finding of NPQ and should be managed in accordance with OPNAV 5300.4. In cases of Level II or Level III treatment, it is imperative that a copy of the treatment summary be forwarded to NAMI (Code 42). Organic Mental Disorders. Delirium should be managed appropriately in the context of the precipitating circumstances. If the precipitating organic factors are identified and considered not likely to recur, the patient may be considered PQ. Antabuse psychosis is an example of this. Physical illness or other disorders causing persistent delirium are permanently disqualifying and should be referred to a Medical Board. All other categories of organic mental disorders are physically disqualifying for naval aviation. Schizophrenia. Individual is NPQ for aviation or general duty, refer to Medical Board. This is a compensable disorder. Delusional (Paranoid) Disorder. Individual is NPQ for aviation or general duty, refer to Medical Board. Psychotic Disorders Not Elsewhere Classified. Result in a determination of NPQ for naval aviation. The relapse rate, in an operational setting, of such diagnoses as brief reactive psychosis and psychotic disorder not otherwise specified is felt to be high and unpredictable. These should be referred to Medical Board and departmental review for determination of continued service. Mood Disorders. 1. Bipolar Disorder. Individual is NPQ for naval aviation and usually for general duty. This is a compensable disorder and a Medical Board referral to PEB is indicated. 2. Major Depression, Single Episode. without complications, should be treated under the auspices of a Limited Duty Medical Board. When the individual is free of symptoms for one year without medication, a waiver to return to flight status could be considered. 3. Major Depression, Recurrent. individual is considered NPQ for naval aviation and usually should be referred by Medical Board to PEB as this condition, if recurrent, usually impacts on satisfactory performance of general duty. 4. Dysthymia. Usually results in a determination of NPQ for naval aviation and for other special duty. The patient should appropriately be treated on a Limited Duty Medical Board. If symptoms remit, and the patient is free of symptoms for one year, he could be considered to

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Aviation Psychiatry return to flight status by submission of a waiver. Recurrent or unremitting dysthymic episodes should be referred by a Medical Board to PEB for determination of continued duty. Anxiety Disorders. 1. Panic Disorder. Individual is NPQ for aviation. If treatment is indicated, this should occur under the auspices of a Limited Duty Medical Board. When free of symptoms and medication for one year, the patient could be returned to an aviation status by waiver request. The patient should not be returned to full duty while still having active attacks or requiring medication to control the attacks. 2. Social Phobias. Result in a determination of NPQ if the behavior impacts on the patient’s professional performance. Refer via a Medical Board for departmental review. 3. Simple Phobias. If they impact on the performance or safety the individual is considered NPQ. If the symptoms impact on shipboard life or general duty, (as claustrophobia), the problem should be referred to PEB, usually as an EPTE disorder. 4. Obsessive-Compulsive Disorder. Results in a determination of NPQ for aviation. Refer to PEB for determination of continued duty. 5. Postraumatic Stress Disorder (PTSD). The individual is NPQ for aviation. If the symptoms require ongoing treatment, the patient should be treated under the auspices of a Limited Duty Medical Board. A waiver for naval aviation will be considered if the patient remains symptom free for one year. Continued symptoms should be referred by a Medical Board to PEB for disability determination. 6. Generalized Anxiety Disorder. Individual is considered NPQ and referred by a Medical Board to PEB. Treatment rendered should be under the auspices of a Limited Duty Medical Board. Somatoform Disorders. Result in a determination of NPQ for naval aviation, and if treated, should be under the auspices of a Limited Duty Medical Board. Continued symptoms, or severe symptoms, warrant referral to PEB. Disassociative Disorders. Result in a determination of NPQ for naval aviation. The individual should be referred for departmental review for a determination of continued duty.

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U.S. Naval Flight Surgeon’s Manual Sexual Disorders. As a general rule do not impact on a person’s aviation performance. If they do, the individual is considered NPQ. If the patient becomes professionally dysfunctional due to his sexual disorder, he can be referred by Medical Board for departmental review to evaluate continued service. Paraphilias are a common occurrence, and in general, the individuals are PQ and AA. Many cases are more appropriate for administrative disposition because of the social consequences that impact on military order and discipline. Sleep Disorders. Result in a determination of NPQ for aviation. Those with disorders, such as narcolepsy, should be referred by Medical Board to PEB. Somnambulism should be managed in accordance with MILPERSMAN 3620200. Factitious Disorders. Individual is considered NPQ and should be referred to Medical Board and departmental review for evaluation of continued service. Disorders of Impulse Control. Individual is considered NPQ for naval aviation and should be referred by Medical Board for departmental review to evaluate for continued service. Administrative and legal difficulties may preclude medical management. Adjustment Disorder. Results in a determination of NPQ for aviation while the patient is in the active phases. When the adjustment disorder can be described as “resolved,” the patient can be considered fully physically qualified and returned to active flight status. Be sure that symptoms and stressors meet DSM-III-R criteria and do not use this as a “wastebasket” diagnosis or as a “less demanding” diagnosis to cover more serious pathology. Psychological Factors Affecting a Physical Condition (Psychosomatic). Result in a determination of NPQ if the physical symptoms are such that they impact on the individual’s performance. On occasion, a waiver for aviation may be appropriate. If general duty performance is impacted, or inordinate medical support is required, the member should be referred to the PEB. V-Codes. In general individuals are considered PQ unless an inordinate amount of impairment or treatment becomes necessary. If this occurs, a concomitant Axis I or Axis II diagnosis should be seriously considered. Personality Disorders and Severe Maladaptive Personality Styles. In aviation personnel usually result in a finding of NAA. In deploying units, ships and isolated duty stations, aviation and nonaviation personnel with maladaptive behavior can be a hazard to mission completion. Special care should be taken in

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Aviation Psychiatry evaluation of patients with suicidal behavior or other impulsive self-harm behavior. Because of the high incidence of suicide and poor tolerance to stress, persons diagnosed as borderline personality disorder should not be sent back to an operational unit for management. This is crucial if the unit is in a deployed status. Those with paranoid and schizotypal personality disorders are also unusually prone to turmoil and disruptive behavior and are very difficult to manage in the operational environment. Instructions previously noted give guidance in management and administrative separation of those with personality disorders. Waivers Waivers for some conditions are possible if the condition is resolved or in prolonged remission (usually at least one year) and if the chances for relapse are considered minimal. Requests for a waiver are submitted by the cognizant flight surgeon along with a copy of the psychiatric evaluation and current flight physical. Standards Only by adhering to set standards with continued communication between mental health professionals in the Navy, can we hope to maintain the quality and best functional capability of our operational forces. Further Information For further information, clarification or guidance in aviation disposition: Psychiatry Department (Code 21) Naval Aerospace Medical Institute Naval Air Station Pensacola, Florida 32508-5600 Phone: Autovon 922-4238/3974 Commercial - (904) 452-4238/3974

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U.S. Naval Flight Surgeon’s Manual Acknowledgments Special thanks to Captain Ben Ogbum, former Head, NAMI Psychiatry Department, for his editorial review and to Captain Noel Howard, Medical Member of the Navy Disability Evaluation System for their assistance in formulating the suggestions for further medical disposition. This reference guide was prepared with the assistance and support of NAMI (Code 42) -Aerospace Physical Qualifications - and the Aeromedical Advisory Council.

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CHAPTER 7 NEUROLOGY Introduction General Neurological Examination Headaches Seizures and Other Spells Vertigo and Disequilibrium G-Induced Loss of Consciousness (G-LOC) Management of Coma and Unresponsiveness Disposition of Naval Aviation Personnel Following Head Trauma Management of Acute Spinal Cord Injuries Common Spine and Peripheral Nerve Problems Central Nervous System Infections References and Bibliography Appendix 7-A Cognitive Capacity Screening Examination: Mini Mental Status Exam Appendix 7-B Galveston Orientation and Amnesia Test (GOAT) Appendix 7-C Neurological Examination Form Appendix 7-D Approach to New Onset Seizures Appendix 7-E Approach to Status Epilepticus Appendix 7-F Syncope Test Battery Appendix 7-G Vestibular Function Testing Appendix 7-H Spine and Nerve Evaluation Introduction This chapter is written for the practicing flight surgeon who will frequently encounter patients with neurological complaints in his day to day practice. Two aspects to be covered here are common neurological complaints and life threatening neurological disorders. This chapter is to provide basic guidelines so the flight surgeon may adequately diagnosis and treat these conditions. In addition, significant emphasis will be placed on aeromedical disposition. As the flight surgeon will inevitably find himself in a situation where neurological consultation and expensive neurodiagnostic testing are not readily available, emphasis will be placed on the history and examination as an aid to neurological diagnosis and treatment.

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U.S. Naval Flight Surgeon’s Manual General Neurological Evaluation The neurological history and physical examination has, as their primary goals, determining placement of the lesion in the neuroaxis and establishment of a pertinent differential diagnosis. It would be adequate to be able to identify the region of the neuroaxis affected at the level of: 1. 2. 3. 4. 5.

The cerebral hemisphere (i.e., supertentorial) The brain stem or cerebellum (i.e., intratentorial) The spinal cord level Peripheral nerve and/or nerve root Muscle.

In addition, be aware that musculoskeletal problems in isolation can present as neurological complaints. The general neurological differential diagnosis can be remembered by using the mnemonic VIN DIITTCH MD: V I N D I I T T C H M D

-

vascular infectious neoplastic demylinating idiopathic immune trauma toxic congenital hereditary metabolic degenerative

Every effort should be made to obtain a thorough history with specific emphasis on the patient’s chief complaint. It is helpful to establish the temporal relationship of the patient’s symptom or sign, including onset, course, and resolution of complaint or neurological deficit with respect to time. The time course of a disease process will often be a clue to the most likely etiology. For example, a chronic, slowly progressive condition might be indicative of a neoplastic or degenerative process, whereas an intermittent condition would suggest a vascular or demyelinating condition. With severe, sudden or recurrent neurological complaints, consideration should be made for early presentation of a potentially life threatening condition.

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Neurology The mnemonic LEARNIT can be applied in the taking of a history of neurological complaints, particularly pain syndromes: L E A R N I T

-

location exacerbating factors alleviating factors radiation nature intensity timing

The past medical history should include potential occupational problems such as exposure to toxic substances and solvents in the work place, high intensity noise exposure, overseas travel in an area endemic for certain tropical diseases, etc. The examination should include the overall general physical examination with attention directed to the head, spine and extremities. Congenital or hereditary problems would be suggested in someone who has dysmorphic facial features, subtle differences in extremity size, flat feet or high arched feet, etc. The neurological examination traditionally begins with the mental status examination. Generally this is a part of the overall response of the patient to the doctor; however, should the patient be complaining of specific problems of thinking, such as memory or decline in work performance, further mental status examinations should be performed. Formal mental status tests include the Mini Mental Status Exam (MMSE) (APPENDIX 7-A), the Galveston Orientation and Amnesia Test (GOAT) (APPENDIX 7-B), and Halstead Reitan Test Battery. Mental Status Examination The mental status examination includes level of alertness, orientation to person, place and time, affect, and physical appearance. An evaluation of memory function would include immediate recall - digit span (forward and reverse), short term memory - object recall after three minutes or the ability to recall a previously told short story, and remote memory tests - past presidents, or specifics of the patient’s past collaborated from the member’s service jacket or health record. The patient’s level of education can be estimated by the FAR/AQT or enlisted AFQT. Judgment, insight, and abstracting ability may be tested by asking the patient to interpret proverbs or make comparisons between similar objects. Calculations can be tested by having the patient subtract seven from 100 and each successive number or by telling bow many nickels are in a $1.35 or some other coin exchange problem.

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U.S. Naval Flight Surgeon’s Manual The next section of the neurological examination is an evaluation of the cranial nerves. In a patient complaining of visual difficulties, visual acuity, monocular color vision, and visual fields should be tested. Refractive error can be compensated for as a cause of decreased visual acuity while having a patient stare through a pin hole or rerefracting him. The pupils should be measured in a light and dark background and a record made of the pupil size response to direct light and accommodation. The pupils should react to the same degree with the same light source and the patient can be asked if the lights have the same brightness in either eye. An unequal response or subjective difference in light intensity is suggestive of optic nerve disease and is manifested by an afferent pupillary defect (APD) or Marcus Gunn pupil. Difference of shade of a red colored object with either eye covered would be an indication of an subtle optic nerve disease. Visual fields may be tested by finger count confrontation, with stationary fingers placed in the central 30 degrees of vision and the patient asked to give the total number of fingers. All four quadrants should be tested in each eye separately. The fundiscopic examination should include the optic disk, macula, blood vessels, nerve fiber layer, and as much of the surrounding retina area as possible. Several conditions of disc elevation simulate papilledema, such as myelinated nerve fibers, or optic nerve drusen. The extraocular muscle examination should include a comment on eyelid symmetry. The eye muscles should be tested in the six cardinal fields of gaze and taken to their endpoint. Subtle clues of eye muscle imbalance include corneal light reflex asymmetry with the eyes in the cardinal fields of gaze, or when more scleral margin is seen in one direction than in another. The eyes are tested in the cardinal fields by turning the head with the eyes still looking at the eye chart. Formal testing using the phoropter, red lens, or Maddox rod with prism bars will give a more accurate measurement of misalignment. Eye muscle imbalance may be detected using the cover/uncover (tropia) or alternate cover (phoria) method. The patient is directed to fixate on the smallest letter visible on an eye chart and then the eye is covered and uncovered and movement of the eye from the covered to uncovered position is noted. The eyes are tested in the cardinal fields by turning the head with the eyes still looking at the eye chart. An eye that moves from inward to outward on the cover/uncover method would be indicative of esotropia. On alternate cover testing one eye is always occluded and any latent deviation of the eye is noted, deviation from inward to outward would be an example of an esophoria. The sensory Trigeminal (V) nerve is tested by eliciting the cornea reflex or the sternutatory reflex. The corneal reflex may be tested by applying a wisp of cotton on the cornea or by gently blowing on each eye separately. The stemutatory reflex is tested by sticking a small object up the nose and looking for a blink or cough. Trigeminal motor function tests the muscles of mastication (masseter, temporalis, and pterygoids which move the jaw front, back and side to side). Facial nerve testing includes test of lacrimation (Schirmer Test), stapedial reflex (tested on

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Neurology audiograms), taste (anterior 2/3 of the tongue), and function of facial expression (forehead wrinkles, eye closure, smiling and pursing of the lips). The Glossopharyngeal (IX) and Vagus (X) nerves are tested by the gag reflex, by assessing the position of the palate at rest, by saying “ah”, and testing phonation (saying consonants ba, da, fa, la, ga). The Spinal Accessory (XI) cranial nerve is tested during the muscle exam by having the patient turn the head to either side and by shrugging the shoulders (trapezius muscles). Hypoglossal (XII) nerve function is tested by having the patient protrude his tongue forward and to either side. Cerebellar Station and Gait Testing Cerebellar testing includes finger to nose, heal to shin, and rapid alternating movements as well as rebound (ability to hold extremity with changing loads). Gait testing combines cerebellar, motor, and sensory function. Normal gait is tested by having the patient walk up and down the hallway, and doing rapid turns. Stress gait is tested by having the patient walk on the outsides and insides of the feet, then duck walking. This may enhance the detection of reduced arm swing or hand posturing (subtle paresis). Tandem gait testing (axial cerebellar function) is performed having the patient walk heel to toe (like a tightrope walker with eyes open/then closed). Station is tested by having the patient stand with feet together (Romberg position) with the eyes opened or dosed. If done without difficulty, test next in the tandem position, with one foot in front the other and the eyes open and then closed (Tandem Romberg). Finally test in the sharpened Romberg position with the one foot in front of the other, head tilted back toward the ceiling, eyes opened then closed. Motor Examination Motor examination signed to detect muscle weakness in a pattern which localizes the level of involvement (central nervous system, spinal cord, peripheral nerve, or muscle). The motor examination begins proximally and goes distally starting with neck flexion, extension, and rotation then abduction, adduction, internal and external rotation then shrugging of the shoulders. The elbow is tested in flexion, extension, pronation, and supination. Flexion and extension of the wrist is followed by finger flexion and extension then spreading of the fingers. In the lower extremities, hip flexion, extension, abduction and adduction are tested. Knee flexion and extension, ankle dorsi-flexion, plantar-flexion, then toe flexion and extension are tested. Motor strength is graded according to a 0-5 point scale, (0) being no movement, (1) being a flicker, (2) being movement of the muscle with gravity removed, (3) movement overcoming gravity but not against resistance, (4) being able to move against resistance, and (5) being normal strength. Tone of the muscle should be noted for stiffness, elasticity, rigidity, cogwheeling and the presence of postural tremor, resting fasiculatation, or atrophy.

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U.S. Naval Flight Surgeon’s Manual Sensory Testing The sensory system is divided into fine sensation (carried in the posterior column of the spinal cord) or course sensation (carried in the spinothalamic tract). The fine sensation includes vibration, proprioception, and two point discrimination. Cortical sensation, processed from signals from the fine sensory system, can be tested by having the patient identify numbers written on the palms and soles (graphesthesia), or identifying objects placed in the palm such as coins (sterognosis). Double simultaneous stimulation, tested by applying stimuli on one side, the other, or together simultaneously, is another test of cortical sensory function. Crude sensory function, carried in the spinothalamic tracts, is tested by light touch, temperature, and pin prick. Reflex Testing Reflex testing is divided into muscle stretch or deep tendon reflexes, frontal release reflexes, and cutaneous reflexes. Frontal lobe reflexes include the glabellar sign, elicited by tapping on the forehead and observing the eyes continually blinking, and the root or snout reflex which is tested by having the patient look straight ahead and tapping on or above the lips, or scratching the side of the mouth and looking for a rooting contraction of the mouth. Palmomental sign is elicited by scratching the palm and observing for twitching of the mentalis muscle, just underneath the lower lip. The positive Wartenberg reflex is elicited by having the patient very gently flex the fingers against resistance and observing the thumb crossing over into the palm of the hand. Reflex assessment of the upper extremities should include at least the biceps tendon and triceps tendon reflexes. Other reflexes that can be tested are the superficial radial (brachioradialis) elicited by tapping over the radial aspect of the forearm and the deltoid and pectoral reflexes, tested by tapping over the deltoid and pectoralis muscles respectfully. The fmger flexion reflexes seen with normal brisk reflexes, include Hoffman and Tromner signs. The Hoffman reflex is triggered by taking the middle finger and flicking away from the palm and observing a pincher movement between the thumb and index finger; The Tromner sign is elicted by elevating the middle finger from the rest of the hand and flicking it toward the palm again looking for the pincher movement between the thumb and index finger. These two reflexes are not necessarily a sign of pathology but rather a sign of a brisk muscle stretch reflexes. Asymmetry may be significant. Reflexes in the lower extremity include the quadriceps reflex (knee jerk) and the gastrocnemieus reflex (ankle jerk). In addition, reflexes of the hamstring muscles (biceps femoris) can also be tested. In the lower extremity the planter response, commonly called the Babinski sign, should also be tested. This extensor planter reflex or positive Babinski sign, refers to the initial dorsiflexion of the great toe upward and spreading of the other toes and is indicative of cortiospinal tract

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Neurology dysfunction. This is elicited by a gentle stimulus applied to the lateral aspect of the sole in a fashion starting over the heel and extending upwards to the base of the little toe. This can also be applied to the side of the foot in a similar manner which is called the Chaddock’s sign. Other reflexes similar to the Babinski sign can be tested by laterally abducting the little toe in a brisk manner and allowing it to slap back against the foot again looking for dorsiflexion of the great toe, or flicking the third or fourth toe down in a rapid manner, again looking for great toe dorsiflexion (abnormal or positive sign). These could be helpful if the patient’s leg is casted and you are unable to scratch the sole of the foot. Cutaneous superficial abdominal reflexes should be tested by scratching from the margins toward the umbilicus and observing a quivering motion of the abdominal muscles. The deep abdominal reflex is elicited by tapping over the anterior rectus abdominal muscle sheath and observing a contraction of the abdominal muscles. Other superficial cutaneous reflexes are the cremasteric reflex (in males), tested by stroking the thigh and observing the ascent of the testicles, the anal wink reflex (anus contraction to light pin prick), and the Bulbocavernosis reflex (contraction of the anal sphincter by stretching the penis). These reflexes are usually tested in spinal cord injury. The neurological examination is directed toward the patient’s chief complaint, with emphasis on important areas in the history (APPENDIX 7-C). In a patient with a rapidly evolving syndrome, the most important part of the neurological examination is reevaluation and reassessment. Headaches Introduction Headache is one of the most common complaints that plague mankind and is one of the most common symptom seen by a neurologist. As aviators are aware of the implication of headaches on their flight status, the fact that they come to a physician for evaluation is indicative that their symptoms are more substantive than most patients who present to a physician with headaches. Every effort should be made to categorize the headache into a syndrome, and establish the likelihood of an organic or life threatening cause. Pain sensitive structures implicated in headaches include blood vessels of the scalp and skin, cerebral blood vessels of the skull base (large intracranial sinuses and intracranial arteries), the dura (including the falx), and the sensory cranial nerves (V, IX, X) and the upper cervical nerves. The brain parenchyma itself is insensitive to pain. Mechanisms of pain in headache include trac-

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U.S. Naval Flight Surgeon’s Manual tion, inflammation, or noxious stimulation of pain sensitive structures, distension or dilation of pain sensitive blood vessels, pressure on cranial or cervical nerves, or contraction of the cranial or cervical muscle bed. An ad hoc committee was formed in 1962 to standardize and classify headaches. They developed a classification scheme based on 15 possible headache categories. A more practical approach to headache classification divides headaches into one of three categories: (1) vascular, (2) tension (muscle contraction), or (3) traction/inflammatory headache. Approach to Headaches In approaching headaches in aviators it is important to ask three questions: 1. Does this headache fall into a clinical syndrome? 2. Does this headache represent a sign of a life threatening medical condition? 3. What impact does this headache have on aeromedical safety? Of the three clinical headache syndromes, the traction/inflammatory headache is the most likely type to represent a serious medical condition. Factors suggestive of a traction/inflammatory headache include associated loss of consciousness, sudden onset of severe incapacitating headache, associated focal neurological signs, meningeal signs (stiff neck, photophobia, pain on eye movement), altered level of alertness or cognition, change in personality, or associated medical condition such as hypertension or endocrine disease. A headache associated with effort or position change, a change in headache pattern, a headache which no longer responds to treatment, or a headache in a person over age 50 may represent a serious headache. Immediate hospitalization or referral to the appropriate consultant would be indicated if there was an associated recent head injury, focal neurological deficit, sudden onset of severe headache, altered level of consciousness, papilledema, fever, hypertension, or headache in pregnancy.

The Headache History History is very important in the evaluation of a patient complaining of headache as physical signs are rarely evident. The LEARN-IT mnemonic is useful in obtaining a history. L is for Location. Vascular headaches tend to be unilateral in the distribution of a blood vessel. The location for muscle tension headache is usually bandlike around the front and back of the head or the suboccipital region. Traction/inflammatory headaches tends to be retro-orbital or diffuse. Although 2/3 of migraine headaches are unilateral, the possibility of an intracranial mass must be considered if recurrent headaches are always located to one side. Migraine headaches, although they may preferentially affect one side, will occasionally alternate sides. In-

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Neurology tracranial lesions may cause a unilateral headache if there is traction on blood vessels or dura, or may be diffuse if there is obstruction of cerebrospinal fluid pathways. Headaches in an elderly patient, particularly if unilateral, throbbing, or associated with neurological findings, may be due to cerebral vasculitis or temporal arteritis, and necessitate an urgent neurological referral. E is for Exacerbating Factors. Exacerbating factors precipitate, aggravate, or worsen a headache. Such factors might include stress, certain foods, bright lights, etc. A is for Alleviating Factors. Alleviating factors reduce or terminate the headache, and might include rest, medication, a dark room, etc. R is for Radiation. This refers to spread after the onset of headache (i.e., where the headache progresses to). N is for Nature. The nature or character of a headache will help classify it as vascular, tension, or traction/inflammatory. Vascular headaches tend to be throbbing in nature, tension headaches tend to be characterized by a bandlike sensation of pressure and traction/inflammatory headaches tend to be characterized by deep aching pressure, although it may also be stabbing, sharp, or dull. I is for Intensity. Headaches should be rated on a scale of one to ten with ten being the worse and one the least. The patient should give a value for the average headache and the maximum headache, and relate the intensity of the headache to time from onset. T is for Timing. A time intensity curve may help categorize the type of headache. Vascular headaches tend to build over several minutes to an hour. In the classic migraine vascular headache, the intensity builds to a maximum in 20-30 minutes. Tension headaches tend to increase slowly over hours to days. Traction/inflammatory headaches, depending on the type of pathology involved, may develop over a very short or very long period. The subarachnoid hemorrhage headache usually has a very acute onset over seconds, being described as a lightning bolt headache. Meningeal irritation headache may develop over days: A tumor headache may develop over weeks or months. The time of day or day of week of onset may be important. Headaches that occur early in the morning or awaken a person from sleep may be suggestive of a serious, possibly life threatening headache; however vascular cluster headaches commonly occur at night and awaken the patient from sleep. Tumor headaches tend to be worse with position change and are worse on awakening. Tension headaches tend to be worse on weekdays and are reduced on weekends, and usually intensify as the day progresses. Headaches due to caffeine withdrawal occur on weekends.

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U.S. Naval Flight Surgeon’s Manual Clinical Evaluation Most patients with headaches will have a normal physical and neurological examination. The examiner should pay attention to the head and neck, including inspection and palpation of the scalp, sinuses, and cervical spine for tenderness. The routine neurological examination should include an evaluation for any signs of neurological deficit, particularly focal neurological findings. A number of ancillary tests may be obtained in the evaluation of a headache patient, induding blood count, chemistries, urinalysis, serology, and vasculitis screen. Radiographs of the sinuses, orbits, and temporal bone may be indicated. Clinical studies, such as electroencephalography, visual fields, and evoked potentials may also be helpful in identifying focal neurological abnormalities. Structural workups such as computerized axial tomography (CAT) or magnetic resonance imaging (MRI) may be indicated if neurological findings are present, there is a history of trauma, severe headache, or a traction/inflammatory headache. Lumbar puncture and spinal fluid analysis may be indicated in meningeal inflammation is suspected. Muscle Contraction Headache Tension or muscle contraction headaches account for over 40 to 50 percent of the headaches seen in a general neurology setting. The tension headache is usually described as an ache, tightness, pressure, crushing, or bandlike constriction, varying in intensity, frequency, and duration. These headaches often last days, and are commonly located in the frontal and suboccipital region. These headaches may be as severe or incapacitating as the vascular or migraine headache. The classic muscle contraction headache begins in late morning and progresses with intensity over the afternoon and evening and tends to be worse on weekdays. An intense muscle contraction headache often runs from the suboccipital region down to the shoulders. The most reliable features of muscle contraction headache are the sensation of tightness, pain in back of the neck, pain that intensifies as the day progresses, and pain and muscle contraction associated with anxiety or tension. Depression may also be a feature of this headache syndrome. Other medical conditions, such as cervical spondylosis or nocturnal chewing (bruxism), may contribute to muscle tension headaches. A number of chemical subtrates may aggravate muscle tension such as bradykinin or prostaglandins, and have been implicated in the headache associated with systemic illness. Tension headache may result from occupational conditions, such as prolonged sitting over a desk, looking at video display terminals, or in combat maneuvering if the head was extended and rotated off axis while sustaining high Gs. Treatment for tension and muscle contraction headaches should include elimination of possible stress factors, or other aggravating conditions. In the aviator, medication for headaches are not waiverable. Relaxation therapy such as biofeedback should be initiated. Medication for treat-

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Neurology ment of muscle contraction headaches include aspirin, acetaminophen, nonsteroidal antiinflammatory drugs, and when indicated, muscle relaxants. Therapy with tricylic antidepressant compounds such as amitriptyline, may also be helpful, particularly in mixed headaches. The compound Fiorinal, which contains aspirin, phenacetin, butalbital, and caffeine, may also be effective. Generally, no headache medicines are waivered for flight activities. Posttraumatic Headache Ten to forty percent of patient’s with minor head injury, particularly with scalp, skull, or sinus involvement, may have an associated headache. Pain may be steady, cap like, or superficial over the impact site, and may be aching or throbbing. Prominent neck injury may also be a factor. Headache after head injuries may be due to injury to the scalp vasculature or muscles, or stimulation of small nociptive pain fibers. Posttraumatic headaches are often associated with imbalance, personality changes, or difficulty concentrating. These headaches usually resolve within several months. Persistent posttraumatic headaches may be the basis of compensation for accidents or medicolegal factors. Treatment generally includes analgesics and nonsteroidal antiinflammatory medication. Resolution of any litigation is essential, as this inevitably contributes to the symptoms. Vascular Headaches Vascular headaches are associated with a cerebral blood vessel, either intracranial or extracranial. These headaches are often unilateral and are characteristically pounding or throbbing. Vascular headaches can be divided into nonmigraine vascular headaches and migraine vascular headaches. Nonmigraine Vascular Headaches. Nonmigraine vascular headaches may be associated with a variety of medical, environmental, and physical conditions which may precipitate a throbbing unilateral headache. Medical conditions associated with headaches include cerebral vascular disease, hypertension, seizure, or endocrine dysfunction (hypopituitarism, Addison’s disease, hypothyroidism, or pheochromocytoma). Environmental or physical factors may precipitate a vascular headache, such as hypoxia, anemia, or high altitude. 1. Altitude Headache/Mountain Sickness. Mountain sickness is often accompanied by severe pounding headache with associated nausea and dimness of vision. The altitude headache is usually a throbbing vascular headache often generalized and more evident over the frontal areas. It is unusual at altitudes below 8,000 feet, and almost universal feature over 12,000 feet in nonacclimatized individuals. It usually occurs in mountain climbers but may occur in those fly-

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U.S. Naval Flight Surgeon’s Manual ing in unpressurized aircraft above 12,000 feet. The headache is not due to hypoxia alone as symptoms are not necessarily relieved by oxygen. The onset may be delayed six to 96 hours after arrival at higher altitudes. Altitude headache tends to be aggravated by movement, coughing, straining, or exertion. Evidence suggests that this may be due to an increase in intracranial pressure, based on the findings of papilledema, retinal hemorrhages, and elevated cerebrospinal fluid pressure or lumbar puncture. Treatment has included the use of mild analgesics to relieve the pain, and furosemide, acetazolamide, and dexamethasone to relieve intracranial hypertension. The cause of this headache may be aggravated by an underlying migraine condition. 2. Effort/Exertional Headache. Another nonmigranious vascular headache which may be related to environmental or physical factors is the effort or exertional headache. This headache may occur in a variety of situations such as following intense physical exercise, coughing, or straining (during weight lifting or during sexual activity). The cough headache may be due to organic causes, such as intracranial tumors or the Chiari malformation, although the majority of effort headaches are due to benign conditions. If this headache is persistent or associated with vomiting, a structural workup and specialty consultation would be indicated. Effort and exertional headaches have been observed in highly trained athletics and may be indistinguishable from a migraine headache. These individuals may aggravate their condition by becoming dehydrated, developing excessive heat production from muscle activity, or becoming hypoglycemic from sustained activity. 3. Immersion Headache. In naval aviation water survival training, a distinct effort headache, the immersion headache, is seen in susceptible individuals. This water immersion headache commonly occurs after the tower jump and underwater swim in flight gear and results in an explosive, throbbing, severe headache that usually occurs while underwater and reaches its maximum upon surfacing or shortly thereafter. Although the character suggests structural causes such as subarachnoid hemorrhage, this entity is usually benign. Immersion headache is precipitated by a specific situation and represents a variant of the exertional vascular headache. Immersion headaches following water survival training tend to be recurrent in repeated water survival situations, which are required for refresher training. Water immersion may be required in emergency egress, and aircrew and rescue swimmers may be required to perform this maneuver in tactical situations. Patients with immersion headaches are not physically qualified (NPQ) with no waiver recommended. 4. Sexual Headache. The sex associated headache occurs under situations of exertion and may result in a sudden excruciating vascular headache. Headaches usually occur at the time of mounting sexual arousal and also may be aggravated by anxiety, including that precipitated by il-

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Neurology licit sexual activity with non spousal partners. Although they are usually not recurrent, these headaches may be incapacitating at the time. 5. Food/Chemical Headache. A variety of food and chemical subtrates may precipitate vascular headaches. These substances are implicated in precipitating both migraine and nonmigraine headaches. The non-migraine food associated headache is precipitated only by the substance, and is not otherwise characteristic of migraine. In the migraine food associated headache, classic migraine headache would occur in other situations besides those precipitated by food or chemicals. Chemical substances suspected of triggering vascular headaches include tyramine, phenylethylamine, monosodium glutamate (MSG), nitrites, and aspartame. Tyramine and phenylethylamine are in foods such as aged cheese, chocolate, yogurt, buttermilk, nuts, bananas, onions, avocados, figs, and red wines. Nitrites and nitrite compounds are used as food additives for purposes of preservation and to improve flavor and are in foods such as smoked fish, hot dogs, bacon, sausage, baloney, corn beef and pastrami. Monosodium glutamate is a common food additive, in oriental dishes, instant and canned soups, potato chip products, processed meat, gravies, TV dinners, and gourmet seasoning. Aspartame, an artificial sweetener used in drinks and other food substances has been implicated in precipitating headaches. Caffeine products have also been implicated in precipitating vascular headaches. Caffeine headaches are associated with excessive caffeine use (coke, coffee, tea, and colas) on weekdays and relative abstinence on weekends. Caffeine has a vasoconstrictive effect on blood vessels, and as it is metabolized and wears off, the blood vessels dilate, which may precipitate a vascular headache. By judiciously tapering off caffeine or reducing caffeine usage these headaches may be avoided. Medications implicated in vascular headache include reserpine, nitroglycerine, hydralazine, and oral contraceptives. Withdrawal from corticosteroid medication may precipitate headaches. Illicit drugs such as PCP, amphetamines, and cocaine may also trigger vascular headaches. Migraine Headache Syndromes. Migrainous vascular headaches encompass a number of characteristic syndromes such as common migraine, classic migraine, cluster headache, and lower half (facial) migraine. Migraine syndromes associated with persistent neurologic deficits include the complicated migraine and acephalgic migraine. Vascular headaches of the migraine type are recurrent attacks of headaches, varying in intensity, frequency, and duration. They are commonly unilateral in onset, associated with anorexia, nausea and vomiting, and preceded by conspicuous sensory, motor, or mood disturbances. These characteristics are not necessarily present in each attack or in each patient. Features suggestive of migraine headaches include childhood onset of headache, cyclic vomiting or carsickness, a lifelong history, strong family history of similar hemicranial throbbing headaches, and response to ergot medication during the acute headache phase. The most characteristic feature of migraine is the classic prodrome, or aura that preceeds the headache. Symptoms of the migraine aura include nonspecific nausea, vomiting,

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U.S. Naval Flight Surgeon’s Manual anorexia, or a variety of transient neurologic symptoms (the migraine accompaniment). The incidence of migraine headache in the general population ranges between 3 and 20 percent. In one study of the young adult population, 20 percent of males and 50 percent of females described at least one severe headache associated with features of migraine. 1. Common Migraine. Common migraine accounts for 70 to 80 percent of migraine patients. The prodrome of common migraine tends to be vague and symptoms may last hours rather than the characteristic 20 to 30 minute aura that proceeds classic migraine. The headache is throbbing and usually unilateral, but may be bilateral. A family history of headache occurs in 65 to 90 percent of migraine patients. 2. Classic Migraine. Classic migraine accounts for 10 to 20 percent of migraine patients. The classic prodrome occurs 20-30 minutes prior to the onset of headache. This prodrome has a characteristic march, that is, the symptoms seem to build in intensity over a 20 to 30 minute period. The migraine accompaniment is the transient neurological went which accompanies the migraine. Neurological manifestations are often contralateral to the side of the headache. Such symptoms include visual, sensory, motor, or speech symptoms. Visual symptoms described indude visual distortions, flickering lights, the classic fortification scotoma (teichopsia), described as jagged streaks of light resembling a sawtooth that shimmer and spread from the central vision to the periphery or from the peripheral to the central vision over 20 to 30 minutes. Other visual symptoms include a halo phenomenon (objects appear to have halos around them) or a shimmering heat wave appearance similar to heat radiating off hot pavement. Visual symptoms may be either monocular in the ocular (retinal) migraine, or bilateral (hemianopic visual fields) in the case of occipital (ophthalmic) migraine. Visual distortions may include alterations in color or size (micropsia or macrosia), tilting of the visual environment, multiple visual images (polyopia), or persistent visual images (allesthesia). Visual symptoms are usually positive phenomenon, that is, they appear as light as opposed to dark phenomenon (absence of vision). The visual field defect may progress until tunnel vision and actual blindness occur. The symptoms march over a 20 to 30 minute period and are followed by a unilateral throbbing headache. Other migraine accompaniments (transient neurological symptoms), include sensory symptoms, such as the cheiro-oral paresthesia, transient hemiparesis, hemiplegia, dysarthria, or aphasia. These neurological symptoms generally proceed the headache; however, they may occur during or after the onset of headache. Photophobia may accompany the visual symptoms. 3. Cluster Headache. Another characteristic migraine syndrome is the cluster migraine. This accounts for two to five percent of migraine patients and has a strong male predominance (five or six to one, male to female), usually affecting the young adult. Cluster headaches are named because of their seasonal cluster and tendency to occur in the Spring and Fall. They occur

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Neurology approximately one to three times per day, last about 1 hour, recur over weeks to months and are followed by headache free intervals of months to years. There are two categories of cluster headaches; the episodic cluster headaches occur with long refractory headache free periods, while in chronic cluster, remissions (headache free periods) are less than 12 months. Cluster headaches are characteristically very severe and disabling and are often described as boring, searing, or stabbing. Characteristic associated symptoms include lacrimation, rhinorrhea, nasal stuffiness, and a partial Home’s syndrome (ptosis and miosis). Unlike common or classic migraine, where the patient seeks a quite room and rest, the cluster patient will pace and walk around. Cluster headaches tend to occur in very perfectionist, obsessive-compulsive people. During the susceptible cluster period, the patient is sensitive to alcohol. Even very small doses of alcohol may precipitate a cluster attack. Only 15 to 30 percent of cluster patients have a family history of headaches, which is less than the usual 50 to 90 percent positive family history in common and classic migraine patients. The cluster headache, on initial presentation, will usually be referred for specialty consultation and structural workup to rule out intracranial pathology. Headaches tend to occur during periods of REM sleep and the patient often awakens from sleep with a severe headache. The mainstay of therapy is prophylatic treatment with Sansert (methysergide), lithium, ergotamine, and oxygen therapy. The aeromedical disposition of this condition is NPQ for duty involving flying (DIF) with no waiver for designated or nondesignated personnel. Generally these patients are NPQ for general military duty, due to the severe incapacitation associated with this headache. 4. Complicated Migraine. Neurological symptoms associated with migraine headaches are called migraine equivalents or migraine accompaniments. Neurological symptoms and signs that persist beyond the headache are called persistent migraine equivalents, and when they last over 24 hours after the headache, the condition is called complicated migraine. Persistent or complicated migraine equivalent syndromes include the hemiplegic migraine, basilar artery migraine, and ophthalmoplegic migraine. A number of other less common syndromes are the dysphrenic migraine, recurrent migrainous vertigo, abdominal migraine, cardiac migraine, and paroxysmal tachycardia. Hemiplegic migraine consists of persistent hemiparesis or hemiplegia following a headache and generally there is a strong family history. Basilar artery migraine is a migraine which is restricted to the posterior cerebral circulation. It usually presents in childhood and often there is a strong family history of headache. The headache is followed or proceeded by symptoms of paresthesia, vertigo, ataxia, dysarthria, and occasionally transient loss of consciousness. Ophthalmoplegic migraine is a rare migraine syndrome, usually presenting in early childhood or young adolescence. The patient presents with pain followed by extraocular muscle palsy ipsilateral to the side of the headache. The cranial nerves affected are, in order of decreasing frequency of involvement, the Oculomotor (III), Abducens (VI), Trochlear (IV), and Trigeminal (V). The ophthahnoplegia may persist for several weeks. The pupil may not be

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U.S. Naval Flight Surgeon’s Manual spared, with both sympathetic and parasympathetic pupil dysfunction. Generally there is no aura preceding the headache and because of the persistent neurological deficits, urgent specialty consultation and structural workup is indicated. History of complicated migraine in applicants is disqualifying for duty involving flying and if episodes were recurrent would be disqualifying for general duty. 5. Acephalgic Migraine. Approximately 20 percent of migraine patients do not experience headaches with their neurological symptoms. A migraine not associated with a headache is termed an acephalgic migraine. Migraines associated with neurological signs or symptoms beyond 24 hours, particularly when not associated with a headache, represent a complicated diagnostic challenge. On initial presentation these patients deserve a thorough workup for vasculitis and other forms of vascular disease such as atherosclerosis, embolic disease, etc. The most common migraine symptom to occur without headache are visual symptoms. When visual symptoms are confined to one eye (transient monocular blindness) this may mimic Amurosis Fugax due to vascular disease. Characteristic migraine visual phenomenon are positive (flash or bright light) phenomenona, whereas embolic or atheromatous disease affecting the retinal circulation tends to be a negative phenomenon (dark rather than light). Acephalgic migraine symptoms usually spread over 20 to 30 minutes, which is characteristic of migraine, while transient cerebral ischemic attacks (TIA) usually develop suddenly without a march of symptoms. A seizure disorder may march, but the seizure marchs over seconds or minutes. Another common neurological symptom to occur without headache is paresthesia (transient sensory phenomenon). Other transient symptoms which may develop include speech difficulties (dysarthria), alexia, and recurrent vertigo. In children, acephalgic migraine may be manifested by acute confusional states, transient global amnesia, and dysphrenic states (psychic or mood migraine). 6. Facial Migraine. Facial migraine presents in the older population with jaw, neck (carotidynia), periorbital, or maxillary pain and is described as sharp icepick like jabs. Serious medical conditions, such as temporal arteritis or cerebral vascular insufficiency, must be differentiated from this condition. Temporal arteritis occurs in patients over 60 years of age who complain of jaw cladication, headache, fatigue, polymyalgia rheumatica, and have an elevated ESR and anemia on laboratory studies. The diagnosis is made by temporal artery biopsy. Temporal arteritis is treated with corticosteroids to prevent symptoms of blindness or neurological dysfunction. Carotidynia or lower half headache is usually diagnosed when the other studies fail to identify either ischemic vascular disease or temporal arteritis. 7. Migraine Pathogenesis. The theory behind migraine has traditionally involved vascular dysfunction. Presumably the neurological symptoms are due to vasoconstriction and the headache is due to vasodilatation resulting in stretching of pain sensitive fibers in the blood

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Neurology vessels. Other factors appear to be evident as well, however. Other phenomenon associated with migraine include a spreading depression of cortical activity, preceded by increased metabolic activity, which progresses across the cerebral cortex. Regional blood flow studies have indicated that in classic migraine, hypoperfusion (reduction in blood flow) occurs over the cerebral cortex and spreads at a rate of two to three millimeters per minute. This reduction in cortical flow may be a manifestation of neuronal dysfunction rather than a primary vascular problem. During the prodromal phase there is an increase in serotonin release from the platelets, which increases platelet adhesion and aggregation in the blood vessel. This is followed by a decrease in serotonin levels during the headache. Prostaglandins, platelet factor 4, and beta thrombogloblin, may also be increased, resulting in platelet emboli, possibly aggravated by vascular endothelial changes. Treatment of Headaches In general, if a precipitating factor can be found that aggravates or causes a headache, reducing or eliminating this factor may reduce or prevent the headache. A careful diet history and avoidance of provocative foods and substances may relive headaches. Alcohol consumption should be tapered and caffeine history, if considered excessive, should be considered as a possible cause. Hormonal changes seem to be implicated, as migraines are more common in women. As estrogen levels fall, migraines may be precipitated. This accounts for the increase in migraines during the premenstrual period and a change in migraine character with menopause or hormonal manipulation. Pregnancy may also alter the migraine (favorably or unfavorably) and oral contraceptive use is implicated in increasing migraine severity. There is an increased likelihood of ischemic vascular event in a patient with a migraine history, oral contraceptive use and smoking. Psychological factors such as stress, fatigue, and sleep deprivation should be avoided if possible. Physical factors known to precipitate headaches, such as exertion, exposure. to smoke, solvents, or glare should be avoided. Vascular migraine headaches are approached three ways: (1) symptomatic therapy for the infrequent headache, (2) prophylactic therapy if the headache occurs more than once or twice a week or is associated with severe incapacitating pain or neuological symptoms, and (3) abortive therapy if a classic prodromal phase occurs. Ergotamine remains the single most effective abortive agent and is administered either sublinqually, intravenously, or rectally. Gastrointestional motility is reduced during migraine attacks and delays absorption of orally administered medication. Prophylactic therapy includes beta blockers (propranolol), tricylic antidepressants (amitriptyline or nortriptyline), and calcium channel blockers (nefidipine, ditalezam). Symptomatic therapy includes a variety of analgesic and anti-inflammtory medication. No headache medications are waivered for flight status.

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U.S. Naval Flight Surgeon’s Manual Aeromedical Disposition of Headache Headache in any form is detrimental to safe flight as it may distract the flier from his duties. Migraine headaches in particular are worrisome because of the associated visual phenomenon which could interfere with collision avoidance, instrument interpretation, or depth perception. Associated symptoms of vertigo and paresthesias may also affect flying duties. Permanent visual field loss in migraine patients have been reported. A documented history of migraine headaches or of any recurrent or incapacitating headache would be disqualifying for duty involving flying in nondesignated personnel (aviation candidates). Following flight training, designated aviation personnel with less than two episodes a year of non disabling migraines would be NPQ with waiver recommended to service group III or Class II. Individuals with persistent neurological sequela with or without headache would require an extensive neurologic workup. If the evaluation found no organic pathology such as vascular disease, the designated flier would be NPQ and waivers would be considered on an individual basis. in general the patient would have to be symptom free for 12 months. All migraines waivered would need automated visual fields submitted with their annual flight physical to detect any permanent visual field loss. Seizures and Other Spells Spells are defined as an abrupt (paroxysmal) disruption of a person’s normal interaction with the environment. Spells in an aviator represent one of the most perplexing complaints a flight surgeon will encounter. The differential diagnosis of spells includes a variety of neurological, systemic, and psychiatric conditions. The usual presentation of the patient with a spell is the sudden onset of either alteration in mental status, loss of muscle tone and posture, or an excessive amount of motor activity. The neurological differential diagnosis of spells includes seizures, vascular events (TIA or stroke), atypical migraine (basilar artery migraine), syncope including convulsive snycope, paroxysmal sleep disorders (narcolepsy), intermittent movement disorders (paroxysmal choreoathetosis), myoclonus, essential startle response, fluctuating metabolic encephalopathies (hypoglycemia), and transient global amnesia. The psychiatric differential diagnosis of spells include anxiety attack, psychogenic fugue, catatonia, psychogenic amnesia, multiple personalities, depersonalization, episodic discontrol, and pseudoseizures. Evaluation of Spells The history is the most important part of the evaluation of a spell in an aviator. The quality of the history often depends on the time from the event to the time of the evaluation. The neurological examination is unremarkable, except during the event. The most likely diagnosis is derived from history, which is usually obtained from witnesses. Factors that should be evaluated

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Neurology include the time course of onset (i.e. whether it came on over seconds or minutes), and whether there were any preceding or precipitating factors, such as sleep deprivation, alcohol consumption, or hyperventilation. The duration of the event is important, as well as the time of recovery. The time of the event, such as its relationship to onset of sleep, time of day, or meals, may also be important. Muscle tone and position prior to the event should be established. The level of arousal at the beginning, during, and after the event are important clues to the etiology of the spell. The overall appearance at the time of the event (pallor, cyanosis) as well as the type of injuries (bitten tongue, bruises) sustained should also be investigated. Seizures and Epilepsy A seizure is an uninhibited sudden discharge from a group of neurons resulting in epileptic activity (neuronal storm or excessive paroxysmal neuronal discharge). Epilepsy is derived from the Greek word meaning “to seize or lay hold of.” A seizure is a single episode of excessive neuronal discharge and epilepsy is a propensity for recurrent seizures. It is estimated that two to five percent of the general population will have one epileptic seizure during their life and that recurrence could be expected in approximately half of these people. It is estimated that 70,000 new cases of epilepsy are diagnosed each year. The prevalence of epilepsy in the U.S. population is approximately four million. The implications in the aviation environment are substantial and accurate diagnosis is crucial to aeromedical disposition. Seizures are classified according to 1) type or 2) etiology (cause) of the seizure. The seizures types are either (1) partial (focal) seizures, (2) primary generalized seizures, or (3) partial seizures with secondary generalization. Primary generalized seizures always involve an alteration of consciousness and include absence (petit mal), myoclonic seizures, clonic seizures, tonic clonic seizures, and atonic seizures. Partial seizures are seizures that originate in a focal area of the brain and may or may not propagate to other areas. Simple partial seizures do not alter consciousness. Complex partial seizures, which result in altered consciousness may begin as a simple partial seizure, or start as a complex partial seizure. A complex partial seizure may or may not progress into a generalized tonic clonic seizure. Depending on the area of the brain involved, the partial seizure may begin with motor, sensory, autonomic, or psychic phenomenon. Since partial seizures may not always progress to tonic clonic movement or alteration in consciousness, this condition represents one of the most elusive diagnoses in neurology and is frequently misdiagnosed. One of the most helpful points in the partial seizure history is the stereotypical premonitory epileptic event, the aura. The patient will often describe the aura as a virtually identical sensation every time. The typical progression of simple partial to complex partial to secondary generalized seizure is as follows: 1) an aura, 2) a cry, 3) a

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U.S. Naval Flight Surgeon’s Manual fall, 4) the fit, which starts as tonic activity then progresses to clonic activity, and finally 5) incontinence. The seizure aura is one of the most important items in the history of partial seizure disorders. Aura means “breeze” in Greek, and literally is like the wind blowing over the patient prior to his seizure. It is often described as a premonition or vague sensation of strangeness. Depending on the area of brain involved, a variety of experiences may be encountered. The patient may feel a vague epigastric sensation, such as an empty, sick, nauseated feeling rising up out of the stomach into the mouth. A variety of affective symptoms have been described including fear, pleasure, depression, eroticism, and rarely anger. The patient may have a feeling of familiarity (de-ja-vu), or a feeling of unfamiliarity or depersonalization (jamais vu). A variety of hallucinations may also be experienced. Sensations may be quite vivid, and like all partial seizure auras are usually very stereotypic. Auras may be described as 1) formed visual hallucinations, 2) auditory hallucinations, such as music, (not voices), 3) olfactory hallucinations (unpleasant smells such as burning), or 4) gustatory sensations (metallic taste). Sensory aura phenomenon include tingling, numbness, electricity, or heat. Visual illusions may also be encountered, usually distortions in shape or size of objects. The aura may or may not progress to an alteration in consciousness as the epileptic discharge progresses through adjacent areas of the brain. Another characteristic feature of the partial complex seizure is the semipurposeful automatism. Automatisms are more or less coordinated, semipurposeful, involuntary, motor activity. They occur during the altered consciousness, during or after the seizure, and are frequently followed by amnesia of the event. Some examples of automatism include chewing, swallowing, repetitive vocalization, humming, singing, laughter, mimickery, non- directed anger, blinking, gesturing, wandering, fumbling, fidgeting, or non-directed genital activity. If a seizure generalizes, there will be an initial tonic phase, which starts as a transient flexion of trunck and extremities, followed by a 10 to 30 second period of extension of the head and neck, axial rigidity, clamping of the jaws, and transient respitory arrest. Shortly thereafter the clonic phase ensues with 30 to 60 seconds of convulsive activity, which most people would recognize as a seizure. There may be labored breathing and salivating. As the clonic phase progresses, there is a decrease in frequency and an increase in amplitude of convulsive movements. The flaccid phase may result in urinary or fecal incontinence. This flaccid phase may last two to 30 minutes and may be asymmetric (Todd’s paralysis) in recovery. The ictal (tonic-clonic) phase of a seizure may be as short as several seconds to as long as eight minutes, but usually lasts one to two minutes. The postictal phase, heralded by the patient’s gradual return to consciousness, may last as short as several seconds to as long as 30-60 minutes and averages about five to 15 minutes. It is this

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Neurology postictal phase (postictal confusion) which is the most helpful historical clue in establishing whether or not someone had a seizure. In general, a person who has lost consciousness because of syncope, even if observed to have convulsive syncopal movements, would recover consciousness fairly quickly upon return of normal blood pressure. The patient who had a true epileptic event would regain their normal level of awareness over a much longer period of time. Confusion arises when a syncopal patient sustains a head injury and is dazed and confused from the injury. It is absolutely crucial to obtain the history from observers actually present at the time to establish the period of recovery or postictal confusion. Absence (petit mal) seizures are the one exception to postictal confusion in generalized seizures. Absence spells occur during adolescence, last less than 10 seconds, may exhibit a variety of automatisms, but have no substantial postictal confusion. Absence seizures may occur several hundred times a day and commonly present as poor school performance. They may progress to generalized tonic-clonic seizures in adulthood. Etiology of Seizures. Seizures may be due to vascular, infectious, neoplastic, traumatic, degenerative, metabolic, toxic, or idiopathic causes. The idiopathic category accounts for 40 to 50 percent of all seizures in adults. In the early years, birth trauma, metabolic, infectious, and idiopathic causes predominate, in the mid adult age group trauma, tumor and idiopathic causes are common; and in the older age group tumor and vascular disease are implicated. Drug induced seizures are usually seen with medications parenterally administered in high doses in a patient with a seizure predisposition or exhibiting some altered metabolism which affects drug clearance (liver or kidney disease). Antibiotics (particularly IV penicillin), antihypoglycemics, antiarrhythmics, antidepressants, (amitriptyline and imipramine), anticholinlergics, stimulants (amphetamine), aminophyllin, and lithium have been implicated in seizures. Alcohol related seizures that occur in the acute phase of alcohol consumption are due to the toxic affects of alcohol. Alcohol withdrawal seizures occur 24 to 48 hours after ceasing alcohol consumption. Seizures occuring three to eight days following cessation, are suggestive of delirium tremens. Posttraumatic epilepsy (PTE) is divided into early epilepsy, which occurs in the fast week, and late epilepsy, which develops after the first week. Posttraumatic epilepsy is significantly related to the degree of brain injury. In penetrating (missile injuries) the incidence of posttraumatic epilepsy is well over 35 percent, whereas in nonpenetrating (non missile injury) the incidence is usually less than five percent. Posttraumatic epilepsy usually occurs within the first several years after the traumatic event. Approximately 80 percent of patients who develop posttraumatic epilepsy will do so within two years of the trauma. Factors influencing the development of late posttraumatic epilepsy include an early posttraumatic seizure, depressed skull fracture, intracranial hematoma, dural penetration, focal neurological deficit, and posttraumatic amnesia over 24 hours with the presence of a skull frac-

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U.S. Naval Flight Surgeon’s Manual ture or hematoma. Post traumatic anterograde amnesia (PTA) has been implicated as a risk factor for posttraumatic epilepsy. In the absence of a skull fracture or hematoma, amnesia longer than 24 hours is associated with an incidence of epilepsy of only 1.5 percent while amnesia of less than 24 hours has an incidence of epilepsy of less than one percent, implying amnesia without other risk factors may not be as significant a factor in the development of posttraumatic epilepsy as was previously thought. Pseudoseizures. Pseudoseizures, also called psychogenic seizures or nonepileptic seizures, are a type of behavior which resembles an epileptic event but are voluntary and not due to organic pathology. They may resemble organic seizures. As there are no absolute criteria to make the diagnosis; pseudoseizures are often a diagnosis of exclusion, requiring extensive testing at a specialty center. To make matters worse 10 to 30 percent of patients with pseudoseizures also have organic seizures. It is estimated that 5 to 15 percent of patients with refractory seizures, not controlled with medication, are actually having pseudoseizures. There are several factors that are helpful in distinguishing an organic seizure from a nonepileptic seizure. Pseudoseizures are generally not stereotypic and usually have bizarre behavior and extreme variation. There may be a family history or past medical history of psychiatric disease. The ictal phase of an epileptic seizure is usually less than 100 seconds while the ictal phase in pseudoseizures is usually over 200 seconds. Eye flutter or twitching eyelids occur during the ictal phase of an epileptic seizure and is usually not seen in nonepileptic seizures. Epileptic seizures are more common in men while pseudoseizures are more common in women in the 15 to 35 year old age group. Pelvic thrust movements are not usually seen in epileptic seizures but are common in pseudoseizures. Generally there is not vocalization except at the very beginning of an epileptic seizure (the cry). Vocalization or interaction with the observer may occur throughout the course of a pseudoseizure. In epileptic seizures there is usually minimal resistance to eye opening, in the pseudoseizure there is marked resistance to eye opening and the eyes have a tendency to look away from the observer no matter what direction the observer approaches the patient from. Any injury, such as tongue biting or loss of muscle tone resulting in injury, is uncommon in a pseudoseizure, but may be seen in true epileptic seizures. A prolactin level drawn within 20 minutes of a seizure would be markedly elevated (above l000MU/L) in a generalized tonic clonic seizure, and will be above 500MU/L in a partial complex seizure, but in a pseudoseizure will be within normal limits. In most cases patients presenting with recurrent seizures suspicious of pseudoseizures require video monitoring and referral to a seizure center. Aeromedical disposition of Seizure Patients. Any seizure or epileptic convulsion, with the exception of a single simple febrile seizure occuring before age 5 years old is considered disqualifying for aviation duty in nondesignated and designated aviation personnel.

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Neurology Assessment and Treatment. For Assessment and treatment of seizures see: Appendix 7-D, Approach to New Onset Seizures, and Appendix 7-E, Approach to Status Epilepticus. Syncope Syncope is in the differential diagnosis of spells (abrupt alteration in the normal interaction with the environment). Syncope is the sudden transient loss of consciousness and muscle tone due to a sudden impairment of brain metabolism due to a reduction in blood flow, oxygen, or energy substrate to the brain. In most cases the distinction between syncope and seizures is made from the history. Classically, the syncopal patient was in an upright posture and often had a presyncopal sensation (feeling of lightheadedness or loss of vision) prior to the event. Upon losing consciousness, the snycopal patient is flaccid, pale, and sweating and has usually not sustained any injury because the loss of muscle tone was gradual enough to allow the patient to reach the ground without serious injury. The tongue has usually not been bitten. Incontinence can be seen with either syncope or seizure and is usually not diagnostic. Difficulty arises when the syncopel event is associated with tonic-clonic muscle activity (anoxic myoclonic jerks). Myoclonic jerks, seen in syncope, are termed convulsive syncope or anoxic myoclonus, and are likely to occur if loss of consciousness exceeds 15 to 20 seconds. The key to differentiating syncope from a seizure is the recovery of consciousness. Following a fainting spell, blood pressure rapidly returns, and consciousness returns to normal without any period of postical confusion or disorientation in the syncopal patient, unless the patient sustained a head injury from the fall. Classification of Syncope. Syncope can be divided into one of four categories. Reflex syncope, called vagal syncope in older literature is the most common type of snycope in the young population. Respiratory snycope, cardiac snycope, and areflexic (paralytic) syncope make up the other categories. In reflex snycope a variety of situations may be implicated, such as emotion, or anxiety, pain, venipuncture, prostate exam, oculovar pressure, micturition, defecation, or postural change. Situational reflex syncope may result from an increased or hypersensitive reflex mechanism. Reflex Syncope is subdivided into vasodepressor or cardioinhibitory syncope. Vasodepressor syncope is due to peripheral vasodilatation of the muscle bed. Cardioinhibitory syncope is due to an increased vagal tone, which slows the heart rate. In vasodepressor syncope the patient looks pale and feels cold, due to vasoconstriction of the skin and the presence of sweat. There are four physiological phases of vasodepressor syncope. In the presyncopal phase there is a gradual fall in blood pressure and cardiac output. In the compensatory phase there is a gradual increase in heart rate and peripheral vascular resistance in response to the falling blood pressure and cardiac

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U.S. Naval Flight Surgeon’s Manual output. Finally in the syncope phase there is a percipitous drop in peripheral vascular resistance due to vasodilatation of the skeletal muscle bed, resulting in a drop in a blood pressure and heart rate. In the recovery phase, blood pressure, heart rate, and cardiac output increase and there is a gradual rise of peripheral vascular resistance. Although a variety of precipitating events such as change in posture, diminished blood volume, anoxia, or fear may trigger vasodepressor syncope, they all progress through these phases. Some situational reflex syncopes such as micturition and carotoid sinus syncope may result from vagal slowing due to a cardioinhibitory response. Vagal (cardioinhibitory) syncope is less common than vasodepressor syncope and may result in syncope even in the recumbent position. Cardioinhibitory syncope has been implicated in cardiac arrest in athletes and sudden infant death in children. The next category, respiratory syncope, occurs in a variety of situations, such as coughing, playing wind instruments, or during weight lifting. Respiratory syncope may result from an increase in intrathoracic pressure (over 250 to 300 mm Hg) resulting in an increase in cerebral venous pressure, subsequent elevation in intracranial pressure, and reduced cerebral perfusion pressure. Increased intrathoracic pressure may also cause impaired venous return to the heart reducing cardiac output. A cardioinhibitory mechanism may result from a transient rise in blood pressure resulting in a carotid sinus response causing vagal slowing of the heart, or an overactive pulmonary stretch receptors in the lung wall, causing a pulmonary stretch reflex, resulting in cardiac slowing. Cough syncope, called laryngeal vertigo in older literature, occurs in obese males with chronic bronchitis and emphysema and commonly results in a baroreceptor response and vagal slowing. The valsalva maneuver causes less elevation in the atrial blood pressure, however, intrathoracic pressure is sustained for a longer period of time and may result in a hyperactive pulmonary stretch reflex and vagal slowing. The next category is cardiac syncope, which is due to a reduction in blood flow due either to a dysrhythmia or outflow obstruction. Examples of cardiac syncope include the Stokes Adams’ attack (complete heart block), the sinoatrial node dysfunction (sick sinus syndrome), and the tachycardia bradycardia syndrome, seen in paroxysmal atrial tachycardia and paroxysmal supraventricular tachycardia. Syncope occuring during exercise or exertion, may be due to ventricular outflow obstruction from aortic stenosis, or underlying cardiac disease, such as cardiomyopathy. The final category of syncope is areflexic (paralytic) syncope. Unlike reflex syncope, where a hypersensitive reflex is responsible for the drop in blood pressure, in areflexic syncope there is a loss of the automatic reflex arch which results in loss of the normal compensatory mechanisms which the body uses in controlling blood pressure. In areflexic syncope the skin remains warm, sweating is present, and the heart rate remains unchanged. In vasovagal syncope the skin initially

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Neurology appears pale, cold, and the heart rate usually drops. The reflex failure in areflexic syncope may be due to preganglionic, ganglionic, or post ganglionic sympathetic fiber damage. Preganglionic damage occurs in Tabes Dorsalis, ganglionic involvement occurs in Shy Drager syndrome and spinal cord injury, and post ganglionic arreflexic syncope may occur following sensory neuropathy. With dysautonomic or areflexic syncope, patients are more susceptible to dehydration or drug affects. Drugs which may precipitate syncope include oral diuretics, antihistamines, tricyclic antidepressants, benzodiazine, ganglionic blockers, barbiturates, and antiparkinson medication. Evaluation of Syncopal Patient. The goals of the syncope evaluation are: (1) Establish a precipitating event or situation, (2) determine any predisposing factors, (3) identify a deficiency in the normal compensatory mechanism, and (4) identify hypersensitive physiological responses. Factors which may predispose or contribute to syncope include inadequate diet, dehydration, fatigue, sleep deprivation, emotional stress, anxiety, underlying infection, excessive caffeine use, alcohol intake, and self medication. These factors should be thoroughly explored in aviation personnel, as most flyers will fall into the category of reflex syncope. A format for evaluating the syncopal patient is enclosed in Appendix 7-F and includes testing designed to stimulate hypersensitive cardioinhibitory reflexes or detect deficient compensatory responses. In addition to the physical examination and the syncope test battery, laboratory workup might include a complete blood count, electrolytes, glucose tolerance test, graded exercise test, 24-hour holter monitor, echocardiography, and electroencephalography, depending on the most likely etiology. Aeromedical Disposition of Syncopal Patients. Syncope is a relatively common complaint and in medically prescreened aviation personnel, most likely represents a benign process. Every effort should be made to establish a predisposed factor or a specific situation which contributed to the syncopal event. If a benign etiology is established and an underlying predisposing factor eliminated, then an aviator could be returned to flight status. In general, the reflex syncope is the most benign of the group, and cardiac and areflexic snycope are more serious. In designated personnel with recurrent syncope or syncope due to serious conditions, waivers might be considered on an individual basis, generally by referral to a Special Board of Flight Surgeons. Respiratory syncope may pose a threat to aviation safety, particularly in the tactical community where the anti G straining maneuver would necessitate an increase in intrathoracic pressure. If syncope is reproduced in an aviator during provocative syncope evaluation testing, this usually indicates a hypersensitive physiological response, and may indicate a predilication for recurrent syncope. Non-designated aviation personnel would be NPQ with no waiver, and designated personnel would be considered for a waiver only for nontactical aircraft in Service Group III or Class II personnel. The waivered flyer should be cautioned to avoid any precipitating event.

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U.S. Naval Flight Surgeon’s Manual Vertigo and Disequilibrium Introduction Patients with dizziness, vertigo, and disequilibrium may present to the flight surgeon with a variety of complaints or symptoms. Patients with vertigo may complain of dizziness, lightheadedness, unsteadiness, imbalance, spinning, floating, and swaying, just to name a few. The history is one of the most important aspects of the dizziness evaluation. Based on the history, dizziness should be classified into one of four types: 1. 2. 3. 4.

True vertigo - definite rotational sense. Presyncope/syncope - sensation of impending faint or loss of consciousness. Disequilibrium - sensation of unsteadiness or loss of balance. Ill defined lightheadedness not otherwise classified.

By classifying the patient into one of these four categories, a more pertinent differential diagnosis is established. This is further augmented by the examination and diagnostic tests and guides therapy and medical treatment. Despite a thorough evaluation, an identifiable etiology may not be established. The sensation of vertigo and disequilibrium may be due to: 1. 2. 3. 4.

Peripheral vestibular dysfunction. Central vestibular dysfunction. Systemic dysfunction. Nonorganic (psychiatric) dysfunction.

The characteristics and pattern of the vertiginous sensation should be thoroughly evaluated. The rapidity of onset and duration of vertigo, should be established. Factors which make the vertigo worse, such as positional changes, or whether the eyes are open or closed may also be helpful. Associated auditory symptoms such as tinnitus, ear fullness, pain, or hearing loss usually indicate peripheral vestibular dysfunction. Signs of central neurological dysfunction include diplopia, ataxia, dysphagia, dysphonia, or sensory or motor complaints. Important historical factors include prior head injury, recent viral infection, toxic exposure, or medication use. Physiological Substrates of Vertigo Spatial orientation is accomplished by utilizing sensory information from the visual, vestibular, and somatosensory systems, which are processed in the brain stem, then finally integrated into the cortical perception system. Disruption or altered processing of signals from the visual, vestibular,

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Neurology or somatosensory system may cause disorientation or vertigo. For example, a patient who has undergone cataract extraction may have distortion of his visual system and may be profoundly disoriented. A patient with a peripheral neuropathy may have a diminished sense of proprioceptive input from joints and muscles, resulting in substantial disequilibrium, particularly in a low light situation, where the reduction in visual input further degrades orientation. Vertigo is defined as a hallucination of movement or erroneous perception of self or object motion. It is usually an unpleasant sensation due to distortion of static gravitational orientation perceived by the cortical spatial perceptional system. This erroneous perception of motion of person or environment may be linear or angular (rotatory). This section will focus primarily on the vestibular system and its relationship to vertigo and disequilibrium. The orientation function of the vestibular system is twofold: 1) maintenance of postural tone and 2) stability of visualocular position. The utricle and saccule are linear accelerometers detecting linear motion in the front to back (transverse) plane and side to side (saggital) plane, respectively. These linear motion detectors provide input to the postural maintenance section of the vestibular system. This vestibulospinal system is responsible for maintaining an erect posture and counteracting the effects of gravity on body position. The angular accelerometers, the semicircular canals, provide input to the oculomotor system, which maintains ocular stability, particularly during movement. Linear accelerometers are found in such primitive creatures as the jellyfish, and angular accelerometers are found in such primitive creatures as the octopus. As animals evolved evolutionarily, these linear and angular accelerometers became more sophisticated. Vertigo and disequilibrium may result from a mismatch of sensory signals from either the static or dynamic spatial orientation systems. There is overlap among the visual, vestibular, and somatosensory signals that are centrally processed. Central compensatory mechanisms enable deficiencies in one area to be overcome by other intact sensory systems. As a result of this reprocessing of signals by the central nervous system, symptoms of peripheral labyrinth dysfunction will eventually recover. Symptoms of central nervous system dysfunction, although usually milder, tend to persist over time. The intensity of the vertiginous or disequilibrium sensation is a function of the degree of mismatch between functioning and dysfunctioning or nonfunctioning sensory systems. Because of the interaction between the various central processing systems, other symptoms besides vertigo may be experienced. Vertigo itself is a symptom that is perceived at a higher cortical level. Vertigo may be due to excessive physiological stimulation or pathological dysfunction. Gait imbalance or ataxia results from inappropriate or abnormal signals from the vestibulospinal system. Nausea and vomiting may occur from activation of the chemoreceptor trigger zone (medullary vomiting center). Nystagmus (rhythmic jerking eye movements) may be

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U.S. Naval Flight Surgeon’s Manual observed with dysfunction of the vestibulo-ocular brain stem processing center or peripheral vestibular system. Physiological Vertigo Syndromes In physiological vertigo the sense of disequilibrium is due to physiological excess of visual, vestibular, or somatosensory signals which cannot be compensated for by the other systems. In pathological vertigo there is an abnormal sensory signal (from the sensors) or abnormal signal processing (by the central nervous system). Examples of physiological vertigo (due to inappropriate stimulation) include motion sickness, space sickness, height vertigo, visual vertigo, somatosensory vertigo, head extension vertigo, and bending over vertigo. These physiological vertigo states have significance in aerospace medicine, particularly the type of motion sickness seen in neophyte fliers - airsickness. Motion Sickness Motion sickness is due to sensory conflict. We make several assumptions of our visual world. With a head movement in one direction, the visual scene should move in the opposite direction. As we have evolved in a one G horizontal plane, we are accustomed to gravitational movements in the horizontal plane only, not the vertical plane. The angular accelerometers (semicircular canals) sense turns and the linear accelerometers (otolith organs) detect to and fro and side-to-side motion. Motion sickness appears to be worse at frequencies of vibration or oscillation from 0.2 to 0.6 Hz. Although infants under age two are quite resistant to motion sickness, it becomes a problem particularly in the adolescent and young adult. Motion sickness is worsened by removing or altering the surrounding visual environment. Motion sickness is worse in aircrew, particularly Naval Flight Officers, who stare at their instruments, when the outside reference horizon is lost (instrument flight conditions), or during rapid changes in aircraft attitudes. Motion sickness is overcome by central adaptation and habituation. This may be augmented by reducing anxiety (relaxation techniques, reducing life stress), keeping well hydrated, getting a good night’s sleep, engaging in regular exercise, eating regular meals, and avoiding tobacco, caffeine, and alcohol. In aviation personnel who wear contact lens it is important to continue to wear the same contacts and not alternate between contact lenses and glasses because this will change the vestibulo-ocular reflex and make one more prone to visual conflict. In aviators who only wear their glasses at night, they may develop motion sickness and disorientation for the same reason. In neophyte aviators pharmacologic intervention may accelerate this adaptation. One of the most effective medications is scopadex (25 mg of scopolamine hydrobromide with 5 mg of dexamphetamine). Another effective medication is promethazine (25 mg) with ephedrine (25 mg.). Pharmacological intervention is a temporizing measure and a positive effect should be seen within

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Neurology three to five doses, and should be used in conjunction with continued flight training to be maximally effective. An airsickness desensitization program is available at NAMI which involves a potent vestibular stimulus, cross coupled coriolis effect. Balance practice may enhance adaptation to visual vestibular conflict. In the balance practice, the patient stands in the tandem position with one foot in front of the other with the head extended (as if looking at the ceiling), hands placed across the shoulders and the eyes closed. Enhancement of this test can be performed by standing on one foot, which is extremely difficult. This test enables the person to become habituated to sensory stimuli without visual input. This position places the linear accelerometer (otolith organs) outside of their normal range of sensitivity and may allow the patient to adapt to sensory conflict. Inflight techniques for managing airsickness include avoiding hyperventilation, establishing a reference horizon, and going on 100 percent oxygen. The most important consideration with airsickness in flight is to maintain flight safety (aviate, see and avoid other aircraft) and establish crew coordination. Space Motion Sickness Another type of physiological vertigo is space sickness. Space motion sickness (SMS) includes headache, malaise, lethargy, stomach awareness, nausea, and vomiting due to increased sensitivity to motion and head movements. Space sickness probably results from vestibular mismatch between the otolith organs and the semicircular canals, or the side to side difference in otolith input in the microgravity environment. Space sickness occurred in 35 percent of Apollo astronauts, 60 percent Skylab crew, and has plagued 67 percent of the Space Shuttle missions, where over 50 percent have moderate or severe symptoms. It seems to occur when astronauts engage in free movement, unlike the restrained position in the space capsule of the Mercury and Gemini missions. It begins 15 minutes to six hours after launch, but may be delayed up to 48 hours, with peak severity occurring two to four days into the flight. Habituation occurs within three to five days. On short duration missions, SMS may cause significant incapacitation and thus compromise mission effectiveness. SMS has had an operational impact, delaying extravehicular activity (EVA) until after the third postlaunch day, and has limited minimum duration flights in the space shuttle to three days, to ensure that the crew is recovered prior to reentry and landing. Height Vertigo Height vertigo is a type of physiological vertigo due to visually induced instability and occurs when the observer is a certain height above the ground where stationary objects in the visual field are far off in the distance. Height vertigo usually occurs above three meters and reaches it’s maximum at 20 meters of height. Ordinarily, the body has a normal amount of body sway which is constantly being corrected for. The further away a stationary object is, the greater the degree of

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U.S. Naval Flight Surgeon’s Manual body sway must occur before a movement is detected and compensated for. This is the physiological basis for height vertigo which over time may progressively worsen and become a fear of heights with its associated psychological reactions. Height vertigo is worsened by standing, staring at moving objects overhead such as clouds, and by looking through binoculars which reduce the peripheral field. Height vertigo is reduced by sitting or lying down or looking at a stationary object which is on the same plane and close to the observer. Visual Vertigo Another type of physiological vertigo is visual vertigo, also called optic kinetic motion sickness, or pseudo-coriolis vertigo. This is induced by viewing moving objects and responding to the perceived motion with a change in posture. For example, while viewing a movie of an automobile, airplane or other type of movement, the viewer characteristically turns their body in the direction of the visual stimulus in an attempt to accomplish postural stability. This pseudocoriolis effect is quite potent and can be every bit as disorienting as vestibular vertigo. Somatosensory Vertigo Somatosensory vertigo or arthrokinetic vertigo, is due to an illusion of movement caused by muscle or tendon input over a certain area. This is commonly referred to as seat of the pants vertigo and may occur in an aircraft in a turn where the gravity vector is increased or redirected off the normal gravitational plane resulting in the “leans”. False input from the otoliths may also contribute to this illusion. Physiologicl Positional Vertigo Two other types of physiological vertigo are head extension vertigo and bending over vertigo. Positional physiological vertigo may be encountered when the linear accelerometers (otolith organs) are pushed beyond their optimal functioning range with the neck extended or flexed, and are worsened by the removal of alteration of visual input (closing eyes or looking up at moving clouds). Psychogenic Vertigo Psychogenic vertigo may result from hyperventilation or occur in a patient with known psychiatric disease. A patient with psychogenic vertigo may have a subjective complaint of severe vertigo without associated nystagmus or other physical findings. Severely incapacitating vertigo may be seen in anxiety attacks or in severe height vertigo (acrophobia). Psychogenic vertigo

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Neurology would be treated based on the underlying psychiatric diagnosis. Psychotherapy and desensitization procedures are often useful. A diagnosis of psychogenic vertigo presumes that no physical findings substantiate an organic cause for the vertigo symptoms. Pathological Vertigo Syndromes Pathological vertigo results from abnormal sensory input or abnormal central processing. Pathologic vertigo may be either visual, somatosensory, or vestibular. Pathological visual vertigo may occur in patients following cataract extraction, where high plus glasses used to correct for the loss of the lens cause a significant alteration in the vestibular ocular reflex resulting in ocular vertigo. This may also be seen in patients who have a substantial difference in visual acuity between the two eyes. Somatosensory pathological vertigo may occur in patients with peripheral neuropathies. The loss of sensory input from the muscle spindles and tendon organs reduce the amount of information that tells the patient from a proprioceptive standpoint where they are relative to their environment. Sensory deficits are additive, so a patient with visual dysfunction and peripheral neuropathy may have more disequilibrium than either alone. Pathological vestibular vertigo can be due to either peripheral labyrinth dysfunction, systemic derangement (such as metabolic, endocrine, or circulatory abnormalities), or central vestibular dysfunction. True vertigo can be divided into one of four clinical syndromes. The fast syndrome is paroxysmal rotational vertigo which occurs in definite attacks. The second type is sustained rotational vertigo, lasting a considerable period and not occurring in discrete attacks. The first two categories are not positionally induced or aggravated. The third type is positional vertigo, (i.e., induced or aggravated by positional changes). The fourth category is linear vertigo, either a sideto-side or to and fro disequilibrium. Paroxysmal Nonpositional Vertigo Rotational vertigo attacks in children and young adults are most likely benign paroxysmal vertigo of childhood or basilar artery migraine. In adults, late life migraine equivalents (vertebrobasilar migraine) or basilar artery insufficiency (in older people with vascular disease) should be considered. Other conditions which may also occur in acute discrete attacks are Meniere’s disease, familial periodic vertigo, and rarely, vestibular epilepsy. Sustained Nonpositional Vertigo Sustained rotational episodes may be seen in Meniere’s disease, acute vestibular neuronitis, and vestibular nerve lesions (acoustic neuroma), and brain stem lesions.

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U.S. Naval Flight Surgeon’s Manual Positional Vertigo Positional vertigo may occur in brief attacks when in provocative positions, or may persist after the position change. Positional vertigo most commonly is due to benign paroxysmal positional vertigo (BPPV) but may also occur in perilymph fistula, positional alcohol vertigo and nystagmus, various toxic conditions, basilar artery insufficiency, and central nervous system lesions of the vestibular nucleus or midline cerebellar region. Linear Vertigo Linear vertigo, resulting in disequilibrium and postural imbalance, may be seen in peripheral or central nervous system pathology. Lateral (side- to-side) imbalance and disequilibrium may be seen in either otolith organ dysfunction, or disease of the vestibular nucleus or midline cerebellum, (lateral medullary syndrome due to vertebral artery occlusion). The fore- and-aft postural imbalance occurs in upper brain stem dysfunction due to a variety of pathological conditions (degenerative, neoplastic, toxic, and vascular disease). Specific Vertigo Syndromes Benign Paroxysmal Positional Vertigo. One of the most common peripheral vestibular syndromes is benign paroxysmal positional vertigo (BPPV), which may occur at any age. The characteristic history is of brief episodes of positionally induced vertigo, particularly with rapid changes in position such as getting out of bed. The true vertigo or rotational sensation usually lasts less than one minute; however, a nonspecific dizziness, often described as a swimming sensation or disequilibrium, may last hours to days. Although BPPV may remit spontaneously, fully one third of patients have recurrent symptoms for more than one year. Vestibular Neuronitis. Acute unilateral labyrinth dysfunction (vestibular neuritis or neuronitis) presents with the acute onset of severe vertigo with associated positional imbalance, nausea, and nystagmus. This syndrome is different from benign paroxysmal vertigo in that it has a much more prolonged course, is usually more severe, and is not positionally induced, as is benign positional vertigo. Vestibular neuronitis often occurs in epidemics, is often due to a viral etiology, and may be a variant of Bell’s palsy of the vestibular nerve. This syndrome may involve the semicircular canals or otolith organs, and depending on the area affected, may result in linear or rotational vertigo. In vestibular neuronitis, due to the reduced signal from the affected side, the nystagmus fast phase is directed away from the affected side. There are two sensations of body motion. The environment appears to move away from the side of lesion and the postural reaction which attempts to compensate for this, causes past pointing and falling toward the side of the lesion.

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Neurology Viruses known to affect the auditory, vestibular, and facial nerves include mumps, measles, infectious mononucleosis, and herpes zoster. Herpes zoster can present with ear pain, facial palsy, deafness, and vertigo and is diagnosed if vesicles are present in the external ear (Ramsey Hunt syndrome). Management and therapy for acute unilateral labyrinth dysfunction (vestibular neuritis) is dependent on the clinical stage of the symptoms. In the first three days, when there is a significant amount of nausea and vertigo, it is recommended that the patient follow a regimen of strict bed rest with the eyes closed with no exercise or head movement. It is during this phase that antihistamines, antivertiginous and antiemetic medications may be useful. Three to five days after the onset of acute vertigo the patient will probably have spontaneous resolution of nausea and be able to partially suppress nystagmus by fixation. During this phase, mild exercise in bed (going from the supine to sitting position), practicing fixation on a slow moving finger, or maintaining fixation on a stationary finger while the head is slowly rotated in opposite directions, can be attempted. As improvement is obtained with these measures, the patient may try sitting unassisted. In five to seven days, after resolution of all nausea and only mild residual vertigo, the patient should be able to totally suppress nystagmus by fixing on an object. There may still be nystagmus with fixation removed (frenzel lenses). At this stage the patient can try resting on all four extremities, then resting on both knees, and if this is tolerated well the patient may stand erect with legs spread apart. As symptoms improve, opening and closing the eyes with the neck extended may be attempted. As balance improves, an aggressive eye tracking exercise can be performed by having the patient follow a finger through rapid transitions of gaze or fixating on an object while the head is rotated back and forth at ever faster rates. Generally within two to three weeks all vertigo ceases and even spontaneous nystagmus with frenzel lenses is reduced. At this stage the patient may try balance walking in the tandem position with the eyes closed and the head extended. Drug therapy is effective only in the first three to five days, and is intended to reduce the severe vertigo and nystagmus in the acute phase. The overall goal is for brainstem compensation mechanisms to readapt to the altered signals. Continued use of medication after five days may actually delay recovery. Exercises using eye, head, and body movement are designed to actually provoke the sensory mismatch and allow this compensation to more rapidly be accomplished. Meniere’s Disease. Meniere’s disease (endolymphatic hydrops) is a common cause of recurrent vertigo and auditory symptoms, and accounts for approximately 10 percent of with patients vertigo. Early in the course of Meniere’s disease there is a fluctuating hearing loss in the low frequencies, a sensation of ear fullness or pressure, and tinnitus (unilateral and may persist between episodes). There may be prolonged vertigo reaching its maximum over minutes and resolving over hours with associated postural imbalance and nausea. There is often a low tolerance for loud noises. Early in the course of the disease the hearing loss is reversible but as the disease progresses, the hearing loss becomes permanent, usualIy affecting the low frequencies initially. Late in the course of the disease vestibular drop attacks, due to loss of reflex postural tone, may cause sud-

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U.S. Naval Flight Surgeon’s Manual den falls to the ground. During the vertigo attack, which usually lasts 30 to 60 minutes, a characteristic nystagmus is seen, with the fast phase away from the affected ear. Following the attack, during the recovery phase, the nystagmus beats toward the side of the lesion. The main abnormality in Meniere’s disease is endolymphatic hydrops, which is distension of the endolymphatic sac. As the membraneous labyrinth progressively dilates, it makes contact with the foot plate or aqueduct, initially affecting the auditory system. As the disease progresses there is disruption of otolith organs and semicircular canals, resulting in the vestibular symptoms. Dilatation of the membranous labyrinth leads to the rupture of endolymph membrane. This rupture allows endolymph to leak into the perilymph, which causes immediate damage to the auditory and vestibular hair cells and nerve fibers. Distension of the endolymphatic sac may be due to two causes; insufficient fluid reabsorption by the endolymphatic sac, or blockage of the endolymphatic duct. Several etiologies have been identified in Meniere’s disease. Approximately 50 percent of the patients have a positive family history, suggesting some type of genetic predisposition. Trauma, infection, or inflammation may block the endolymphatic sac, blocking reabsorption, and leading to endolymphatic sac distension. Thirty percent of patients with Meniere’s disease will progress to bilateral involvement. Up to 80 percent will have remission lasting over five years, however in some patients the progression of symptoms may be quite disabling. The diagnosis of Meniere’s disease is based on the characteristic clinical history. A number of clinical tests have been developed. In classic Meniere’s disease the low frequency hearing loss will reverse itself upon administration of a dehydrating agent such as oral glycerol. In the classic diagnostic response, the hearing loss will improve by at least 15 to 20 decibels within one to two hours after oral glycerol. Medical therapy is the mainstay of treatment for Meniere’s disease. Commonly employed therapy includes a low salt diet (800 to 1000 mg of sodium a day) combined with a diuretic such as hydrochlothiazide 50 mg QD. Penilymphatic Fistula. Perilymphatic fistula is a cause of episodic vertigo and sensorineural hearing loss. The vertigo is usually not as severe as in benign positional vertigo and there is usually a history of trauma or ear surgery. The trauma may be relatively trivial and may have occurred after diving, strenuous exercise, exertion, or air travel. Generally the symptoms of vertigo are precipitated by some type of exertion, valsalva, or position change. The symptoms generally last somewhat longer than benign positional vertigo. The pathology involved in perilymph fistula is elasticity of the bony labyrinth around the round or oval window. Because of this elasticity any increase in venous pressure or middle ear pressure can be directly transmitted into the membraneous labyrinth of the auditory-vestibular apparatus. This is the basis for several of the

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Neurology fistula tests, designed to increase this pressure. Common fistula tests include compression on the tragus, applying positive or negative pressure, or a loud noise to the tympanic membrane, or having the patient swallow or valsalva. Exacerbation of symptoms with these maneuvers would suggest perilymph fistula; however, vertigo may be induced by valsalva in the Chiari brain stem malformation. Causes of post traumatic vertigo include benign positional vertigo and cervical (whiplash) vertigo, as well as perilymph fistula. Management of perilymph fistula includes bedrest, head elevation, and avoiding valsalva maneuvers by using stool softeners. If the symptoms persist and remain disabling after four months then surgery should be considered. Positional Alcohol Nystagmus and Vertigo. Anyone who has “tied one on” can attest to the severe disorientation and vertigo that accompany alcohol excess. When alcohol exceeds 40 mg percent, the alcohol diffuses into the angular accelerometers of the semicircular canal. Because it diffuses into the cupula (hair cell area) faster than into the surrounding endolymph, there is an imbalance between the respective specific gravities. This turns the angular accelerometers into linear accelerometers and makes them susceptible to any gravitational position change. Positional vertigo and nystagmus develop (with the nystagmus fast phase component beating to the lower or down most ear). As the alcohol gradually diffuses into the endolymph it equilibrates and three to five hours after cessation of alcohol consumption, this positional vertigo resolves. As the alcohol is metabolized it diffuses out of the system, leaving the hair cell (cupula) region before leaving the endolymph, again causing an imbalance between the endolymph and the hair cells. This phase occurs five to ten hours after drinking and the fast phase of nystagmus now beats toward the upper ear, usually as the alcohol level drops below 20 mg percent. This imbalance causes the significant disequilibrium and motion sickness which is a major component of a hangover. A morning-after drink may temporarily reequilibrate the specific gravity differential between the endolymph and hair cells, causing a reduction in symptoms; however, this is only a transient effect. This imbalance may persist 10 to 12 hours after the last drink, and this is one reason why alcohol consumption should cease at least 12 hours prior to flight activities. Toxic Vestibulopathies. Toxic substances known to cause vertigo and auditory symptoms include heavy metal exposure and medications. Aminoglycoside antibiotics such as streptomycin and gentamicin are known vestibular toxins, while neomycin and kanamycin are ototoxic. Other vestibular and ototoxic medication include aspirin intoxication (tinnitus is common in therapeutic doses), chloroquine, lasix, quinidine, and quinine (including tonic water). Toxic vestibulopathies may persist. Less Common Causes of Peripheral Vestibular Dysfunction. Other causes of peripheral vestibular dysfunction include diseases of the bony labyrinth, such as Paget’s disease, otosclerosis, chronic mastoiditis, and congenital or acquired syphilis. Labyrinthine infarction

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U.S. Naval Flight Surgeon’s Manual associated with vascular disease may cause episodic vertigo. Autoimmune disease such as Cogan’s Syndrome (episodic vertigo, tinnitis, bilateral, deafness, and interstial keratitis-photophobia, ciliary injection, decreased vision) may affect the auditory-vestibular system. Central Vestibular Vertigo. Central causes of vertigo are less common than peripheral or systemic causes. Although lesions of the vestibular nuclei and the vestibular portion of the cerebellum may cause vertigo, nystagmus, disequilibrium, and nausea, there are usually other signs of central nervous system dysfunction. Symptoms result from involvement of brain stem structures responsible for eye movement, speech, sensation of the face, extremities, and trunk, and motor control of the facial muscles and extremities. Causes of vestibular vertigo run the spectrum of neurological disease including migraine, vascular disease, epilepsy, demyelinating disease, neoplastic disease, degenerative disease, infectious disease, and congenital malformations. The presence of other neurological signs helps distinguish central from peripheral vertigo. Central vertigo tends to be less severe with fewer autonomic symptoms (such as nausea and vomiting). Central vertigo tends to persist over longer periods of time and tends to occur in less sudden or severe attacks, except in the case of migraine or vascular disease. Evaluation of nystagmus, discussed in the section on vestibular function testing, may help differentiate between central and peripheral vertigo. Miscellaneous Causes of Central Vertigo. The Arnold Chiari malformation may result in vertigo with increased intracranial pressure, (valsalva maneuver) or with certain positions (head hanging or neck extension, which compresses the brain stem). Multiple sclerosis is the great imitator of neurological disease. Multiple sclerosis accounts for less than five percent of vertigo, but would be a likely diagnosis if other neurological findings, such as optic neuritis and spinal cord involvement, had occurred on different occasions. A number of degenerative brain stem conditions may result in vertigo, and often have a positive family history. Meningitis or encephalitis affecting the brain stem may result in vertigo, usually in association with other cranial nerve and brain stem signs. Extrinsic and intrinsic tumors which may result in vertigo include acoustic neuroma, meningioma, cholesteotoma, chordoma, glomus jugulare tumor, epidermoid tumor, and intracranial meatastasis. Intrinsic tumors of the brain stem and cerebellum also result in vertigo. Neoplastic processes usually have a slowly progressive course and rarely cause acute sudden vertigo unless they hemorrhage and suddenly increase in size. Central Vertigo - Summary. Due to the dysfunction of brain stem compensating structures in central vertigo syndromes, vertigo, as well as the rhythmic jerking eye movements (nystagmus), may persist over considerable periods of time. Central nystagmus looks more severe than the patient’s corresponding symptoms of vertigo or nausea. Postural changes tend to stimulate peripheral vertigo more than central vertigo. Peripheral vertigo tends to be reduced with fixation

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Neurology (with the eyes open). Central vertigo tends to be worse with the eyes open, because of the conflict of visual and vestibular information. With the eyes closed, the visual information is reduced, which reduces the visual vestibular conflict and reduces the sense of vertigo. Peripheral vertigo tends to fatigue with repeated head movements because of adaption of brainstem compensation mechanisms. In central vertigo, the vertigo may not fatigue or habituate with repeated movements, however it may vary on a day to day basis. Vestibular Function Testing Routine clinical laboratory tests of vestibular function include electronystagmography (ENG) and brain stem auditory evoked response (BSAER). Clinical tests may help establish an etiology in patients with vestibular symptoms. Clinical testing of the vestibular system should include a general neurological examination to establish any other areas in the nervous system that may be involved. Specific vestibular tests (See Appendix 7-G) include evaluation of the vestibular spinal reflexes, the vestibular ocular reflexes, the visual ocular reflexes, station and gait, and provocative tests (posture, position, and fistula testing). The search for spontaneous or positional induced nystagmus is an essential part of this examination. Vestibular function tests are important in establishing the type of nystagmus, and whether it is central or peripheral in etiology. Central types of nystagmus imply a more serious prognosis and usually requires referral to a neurological center for further evaluation including neuroradiological studies. As with all neurological evaluations the associated neurological findings may be very pertinent in establishing the diagnosis. Specialized tests for evaluating vestibular dysfunction, such as the vestibular ocular reflex pendular eye tracking (VORPET) test, and the visual vestibular interaction test (VVIT), are available at the Naval Aerospace Medical Institute. Vestibulospinal Reflexes. Vestibulospinal reflex tests include test of posture, extremity drift, station, and gait. One test of the extremity vestibulospinal reflex is past pointing which is a reactive deviation of the extremities caused by an imbalance in the vestibular system. In past pointing, which is different from cerebellar dysmetria (finger to nose test), the patient extends his arms and touches his index fmger to the examiner’s index finger. The patient then closes his eyes, raises his extended arm to the overhead vertical position, then attempts to return his index fmger to the examiner’s. Damage to the vestibular system causes lateral deviation of the arm and finger on returning to the original position. This assumes that other extra-labyrinthine function is intact (i.e., no weakness). With acute peripheral vestibular dysfunction past pointing occurs toward the side of the lesion, however with compensation, past pointing will cause deviation to the opposite side of the lesion. Another variant of past pointing is the Quix test. The patient stands, eyes closed, with arms straight ahead. Lateral drift would be considered a positive (abnormal) test.

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U.S. Naval Flight Surgeon’s Manual Another vestibulospinal reflex test is the patient’s stance or station, the Romberg test. There are three Romberg positions, the standard Romberg (feet next to each other), the Tandem Romberg (the patient stands with one foot in front of the other), and the Sharpened Romberg (same tandem stance but with the patient’s head placed first straight ahead then in full neck extension looking at the ceiling). The patient is tested in each position with the eyes opened then closed, observing for deviation or falling, which is usually toward the damaged side. The sharpened Romberg is very difficult, and may be made more difficult by having the patient stand on one foot or placing the hands on the opposite shoulders. The time that the patient remains erect is recorded (best of three trials). A healthy naval aviator should be able to stand in the Sharpened Romberg position with the head extended and eyes closed for 30 seconds, and on one leg with hands on his shoulders for 10 seconds. Another test of the vestibular spinal reflex is the step test. In the Fukuda Step Test the patient walks three steps forward then three steps backward, with his eyes closed for at least 20 cycles, looking for deviation or rotation toward one side. This indicates labyrinthine dysfunction in the absence of cerebellar or proprioceptive dysfunction. The Unterberg step test is conducted in a similar fashion with the patient essentially marching in place over the same spot, again looking for deviation or rotation. Tandem gait should be tested looking for deviation. Vestibular Ocular Reflex Tests. Vestibular ocular reflex testing can be done in a variety of ways. A very sensitive test is the dynamic illegible E test, which involves having the patient read a visual acuity chart while rotating the head in the horizontal, vertical or lateral tilt planes, at a frequency of approximately two cycles per second. This may be done starting in the primary position, rotating the head side to side (testing horizontal canals), then up and down (testing vertical canals). The head is placed left or right then rotated up and down, as the patient continues to read the chart. The head is then tilted backwards or forwards (neck extended or flexed) and the head is rotated side-to-side. This version of the dynamic illegible E test places the eyes at the extremes of gaze. Ordinarily there should be no decrement of visual acuity while performing this test unless there is dysfunction of the vestibular ocular reflex (VOR). The VOR may be tested by Barany chair rotation with the eyes closed. The chair is rotated 10 rotations in 20 seconds and then post rotatory nystagmus is observed. Bedside caloric testing is performed by irrigating the external auditory canal with water at 44° C and 30° C. The fast phase of nystagmus will develop in the direction opposite to the side irrigated with cold water and vice versus with warm water. In peripheral labyrinthine dysfunction the caloric responses are diminished on one side using hot and cold water, while in central lesions the eye movement shows a directional preponderance (the nystagmus is more prominent in one direction than the other direction).

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Neurology Visual Ocular Reflex Tests. The visual ocular reflex test involves visually induced (optokinetic) nystagmus. This is tested with the optokinetic tape moved in one direction, then the opposite direction, in both horizontal (left and right), and vertical (up and down) planes. A similar optokinetic visual ocular reflex can be tested in the Barany chair by having the patient stare off in the distance as the chair rotates. This induces a full field optokinetic response, which should be tested in each direction. Position Tests. Position tests are used to stimulate eye movements. The head hanging, lateral decubitus, and Hallpike positions are common provocative position tests. Head hanging involves placing the patient in a supine position with the head and neck extended backward over the exam table. The eyes should be tested both with fixation (staring at an object) and without fixation (using high plus cataract glasses or Frenzel lenses). Next the patient should be tested in the lateral decubitus position with the ear down to stimulate positional nystagmus and vertigo. The Hallpike (Dix-Hallpike) maneuver, used to stimulate nystagmus and vertigo, involves rapidly taking the patient from the sitting position with the head and neck straight ahead to the supine position with the head and neck extended 45 degrees and rotated 45 degrees, and with the patient looking toward the ground. The maneuver is tested in both directions and the eyes observed for at least 60 seconds for the development of classic positional induced nystagmus. Nystagmus that is only elicited in one direction is characteristic of benign paroxysmal positional vertigo (BPPV). Nystagmus Evaluation. The evaluation of nystagmus should include a description of the type of nystagmus. Nystagmus may be pendular, sawtooth, or exponential (increasing or decreasing). Classic vestibular nystagmus has a sawtooth appearance whereas pendular or exponential types indicate cerebellar or congenital nystagmus. The direction of the fast phase of nystagmus should be noted as well as whether the nystagmus is present in the primary position (looking straight ahead) or is gaze evoked, (brought on by looking in a particular direction). Characteristically nystagmus increases in amplitude when looking in the direction of the fast phase of the nystagmus (Alexander’s Law). Nystagmus may be horizontal (left or right), vertical (up or down), or torsional or rotatory (clockwise or counterclockwise). In general, peripheral nystagmus tends to be mixed (looking one direction the nystagmus is horizontal while looking in the other direction it tends to be rotatory or torsional). Pure vertical nystagmus usually implies a central origin; however, central nystagmus is often mixed as well. Nystagmus may be either conjugate (nystagmus beats the same way in both eyes) or discongugate. The latency (delay in onset) of nystagmus following a position change should be noted. Central nystagmus usually starts immediately upon the patient assuming a certain position. Peripheral nystagmus usually exhibits a delay in onset, but this is not absolute. Nystagmus that fatigues on continued evaluation (reduction in amplitude or frequency), or on repeated testing (habituation) is characteristic of peripheral nystagmus. Central compensation over time causes a reduction in frequency or amplitude of the

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U.S. Naval Flight Surgeon’s Manual nystagmus. The effect of fixation on nystagmus should also be evaluated (have the patient focus on an object or a removing fixation by using frenzel lenses). The nystagmus should be evaluated in the provocative positions (head hanging, lateral decubitis, and the Hallpike position). Fistula testing provocative maneuvers (valsalva, tragus compression) may reproduce symptoms or elicit nystagmus. Substantial vertigo and nausea of acute onset are more likely in peripheral lesions, whereas in central nystagmus the nystagmus appears to be quite prominent, however the symptoms are minimal. In general, peripheral nystagmus is inhibited by fixation. Central nystagmus shows an increased amplitude with fixation although the velocity of the slow phase may be reduced with fixation. Positional nystagmus that lasts over 30 seconds in the provocative position usually indicates central nystagmus, however 50 percent of persistent positional nystagmus cases have no identifiable etiology (idiopathic). Disposition of Aviation Personnel with Vertigo Obviously vertigo represents a significant threat to aviation safety because of the possibility of sudden onset, incapacitation, and unpredictability. No medications used to treat vertigo would be waived and any patient with symptoms of disequilibrium or vertigo should be grounded and a thorough evaluation should be performed. Following an evaluation and establishment of the probable cause of the vertigo, aeromedical disposition is considered. Any aviator with central neurological cause for vertigo would be found not physically qualified (NPQ) and no waiver would be recommended as inevitably compensation mechanisms would break down and generally these imply a more serious prognosis. In general, nondesignated personnel with a history of vestibular disease (central or peripheral) are NPQ with no waiver granted. In designated aviation personnel, waivers would be granted on an individual basis. Consideration should be made for the aircraft type and mission. Meniere’s disease (endolymphatic hydrops) would not be waived because it to tends to be recurrent and progressive and may occur acutely. Vestibular neuronitis and benign positional vertigo tend to have a more benign course and the flier should be grounded for three to six months following relief of symptoms. Following grounding and assuming the patient has been asymptomatic, Class II personnel may be returned to flight status and aviators might be waived to Class I Service Group III status. Following a 6 month period on a Service Group III if no further symptoms had developed consideration for Service Group I or II might be entertained on an individual basis. Aviation personnel with a history of vertigo should be cautioned about excesses that may precipitate vertigo such as contact sports, alcohol consumption, and any medication, including over the counter medication.

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Neurology As always, aeromedical safety is the prime concern, and if there is a likelihood of incapacitation on an acute basis this would be a major consideration in returning someone to flight status. Obviously no medication for the treatment of vertigo or disequilibrium would be waived. Physiologic vertigo syndromes, such as motion sickness are handled on an individual basis. Assuming a successful desensitization program, personnel may be returned to flight status in an unrestricted capacity. Occasionally an experienced aviator may develop significant leans. This is seen in aviators after return from a non flying billet or following periods of minimal actual instrument time. These aviators may have lost or degraded their scan pattern or become overcome by the seat of the pants sensation. These flyers may benefit from extensive instrument retraining to develop proficient scan patterns. Initially this should be performed in simulators, then as progress develops they may return in dual controlled aircraft. Even complex motion simulators cannot reproduce the sustained changes in gravity vectors that occur in a banked turn or decceleration to the landing configuration that actual flight produces. As proficiency returns, the patient may return to Service Group I status.

G-Induced Loss of Consciousness (G-LOC) G-induced loss of consciousness (G-LOC) is an altered perception wherein one’s awareness of reality is absent as a result of a sudden critical reduction of cerebral blood flow caused by increased G-forces. G-induced loss of consciousness, was first recognized as an aviation hazard in World War I. The British neurologist, Henry Head, described “fainting in the air” in pilots of small fighter biplanes, particularly very maneuverable ones. He even noted that prior to losing consciousness a haze or mist covered the eyes and then finally all vision became dark. G-LOC was also identified as a problem in the air races of the 1920’s. It was again recognized as a problem in World War II, particularly in dive bomber crews after pulling up from a steep dive or in fighter pilots during air combat maneuvering. With the advent of today’s high technology fighter, G-LOC has again emerged as a aeromedical safety issue. Based on surveys in tactical aircrew in the U.S. Navy and Air Force, it is estimated that G-LOC occurs in 12 to 30 percent of aircrew in tactical aircraft. Several mishaps have been attributed to G-LOC. The first human studies in the United States were done in the 1938-1939 period. Several sequelae were noted, including the visual symptoms of grayout and blackout, and G-LOC, which was described as a coma which occurred between 6 - 9 G (+Gz). It was also noted that during recovery, the subject experienced a brief period of apparent bewilderment. It is now recognized that G-LOC includes both an ab-

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U.S. Naval Flight Surgeon’s Manual solute period of unconsciousness and a relative period of unconsciousness. Both of these combined give a total period of incapacitation which may last up to 40 seconds. G-LOC results from a reduction in cerebral perfusion pressure due to hydrostatic drop in blood pressure and reduced cardiac output occurring as a delayed effect of venous pooling in the lower extremities. Blood pressure at the level of the head drops 22 mm Hg for each 1 +Gz. Two physiological protective mechanisms occur during G-LOC. The first is the metabolic reserve of central nervous system neurons. After reduction of cerebral blood flow (and hence reduction in glucose and oxygen), neuron metabolism ceases. The second compensatory mechanism is the cardiovascular baroreceptor reflex which detects a reduction in blood flow at the level of the carotid body. This reflex result in reflex tachycardia and an increase in systemic vascular resistance. Both the duration of G-stress and the G-onset rate have an effect on the development of G-LOC. The incapacitation time for G-LOC is dependent upon the G-onset rate. Incapacitation times are longer for a gradual onset rate (0.1 G per second) than with rapid onset rates (greater than 1 G per second). Although the period of incapacitation may be greater with gradual onset rates, rapid onset rates are associated with the onset of LOC without the premonitory visual symptoms of grayout or blackout. As aircrews commonly use grayout as a sign that they are approaching their G-tolerance limit, the lack of visual symptoms may result in G-LOC without any warning. Amnesia for G-LOC is common and occurs in over 50 percent of the individuals experiencing GLOC on centrifuge training runs. G-LOC results in two types of responses. Type 1 G-LOC is of short duration, approximately 30 seconds of total incapacitation, and convulsive movements are absent. Type 2 G-LOC has a more prolonged period of unconsciousness and incapacitation and there are associated convulsive (flail) movements similar to anoxic myoclonus. The period of incapacitation is longer, usually over 40 seconds, and is often followed by a variety of symptoms, such as denial, a dream like state, confusion, paresthesias, gustatory sensations, as well as amnesia. In addition to G-LOC, G-induced pain, particularly in the cervical region, ‘has been reported by aircrews. G-LOC is reported by 12 to 30 percent of tactical aircrew. G-LOC occurs with the same incidence in pilots and aircrew (weapons systems operators and naval flight officers). Factors implicated in G-LOC include rapid G onset rate, sustained G-pull, too many Gs being pulled, anti-G suit failure, and ineffective anit-G straining maneuver. Age, height, and weight do not appear to be related to the incidence of G-LOC. In initial studies, the F/A-l8 had the highest incidence of G-LOC of aircraft in the Navy inventory, but in a followup survey G-induced G-LOC appeared more commonly in the AV-8, T-2, and TA-4. This may reflect training programs designed to increase fleet awareness of G-LOC.

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Neurology A number of secondary protective mechanisms are used to combat G-LOC. Perhaps the most important of all these is a proper anti-G straining maneuver (AGSM). This maneuver involves vigorous tensing of the extremity muscles to prevent venous pooling and a cyclic increase in intrathoracic pressure, by tensing abdominal and chest muscles. The increase in pressure of the thoracic cavity is accomplished by a three second cycle (two 1/2 seconds expiration and 1/2 second inspiration). Expiration against a closed glottis, causing a groaning sound, is the classic L1 maneuver. The M1 maneuver is better tolerated because it doesn’t interfere with communication. During the M1 anti-G straining maneuver, the expiration phase is performed against a partially closed glottis. An effective anti-G straining maneuver has improved G-tolerance up to four additional Gs. The anti-G suit and anti-G suit valve, used to enhance performance in the high G environment, had its inception in the mid 1940s and underwent further technical development in the 1950s and 60s. The standard anti-G valve inflates at 1.5 PSI per G starting when 2 Gs are reached, inflating to a maximum of 10 PSI. This inflation rate may not be fast enough to provide adequate inflation. Over an extended period of high G maneuvering this may actually act as a venous occlusion cuff. Anti-G suit and valves improve G tolerance from G level of 4.5 +Gz for an unprotected individual (no anti-G suit or straining maneuver) up to 5.5 +Gz, (1 additional G). Newly developed valves increase the inflation rate in an attempt to enhance the effectiveness of the anti G suit. Development of the sequential inflating suit also holds promise. Ideally, a G-valve should inflate to 5 PSI as soon as possible, preferably in 1 second, to prevent early venous pooling. The high flow only (HFO valve) inflates 33 percent more rapidly than the standard valve and shows improvement in cardiac output during high-G maneuvers. Advanced valves such as the servo controlled anti-G valve (SCAG) and the bang-bang servo valve (BBSV), start inflating at approximately 1.5 G, and inflate at a rate of 2.5 to 5 PSI per second. A recently developed servo valve uses microprocessor technology, which integrates with the flight control systems in fly-by-wire aircraft, allows the anti-G valve to respond to flight control inputs prior to the rapid onset of Gs. The seat angle is another factor in the G enhancement program. The standard tactical seat back angle is approximately 13 degrees. in the F-16 a 30 degree seat back angle is used and this improves G tolerance by an additional 1 G. New engineering technologies are looking at the movable seat angle (supinating seat) which will allow a seat angle of up to 75 degrees, which improves resting G-tolerance to up to 8 Gs. The supinating seat will have significant cockpit engineering challenges, due to difficulty with escape systems, headrest angle, restricted rear visibility, and an increase in chest pain, discomfort, and dyspnea with the increased seat back angle. G-tolerance conditioning includes avoidance of G degrading factors, aerobic physical conditioning programs, and centrifuge training. The Air Force has conducted a vigorous centrifuge

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U.S. Naval Flight Surgeon’s Manual training program for their tactical aircrews. The aircrews have shown an improvement in G-tolerance after practicing the anti-G straining maneuver in a realistic environment and pilot awareness of the premonitory G-LOC symptoms has been improved. Positive pressure breathing may also improve G-tolerance. Unassisted positive pressure breathing is probably of limited value. The addition of chest counter pressure and face mask positive pressure breathing, called assisted positive pressure breathing (APPB), increases blood pressure and facilitates inspiration, both considered beneficial in the high G environment. Assisted positive pressure breathing is less effective in protecting against G-LOC if the patient is relaxed prior to high onset G rates, but would be effective in combination with the rapidly acting G- value or a supinating seat. Positive pressure breathing system increase at a rate of 12 mm HG per G after reaching 4 G, up to the maximum of 60 mm of HG. A distinct advantage of assisted positive pressure breathing is the reduction in fatigue from breathing and performing the anti-G straining maneuver. This may improve G-tolerance, particularly during the sustained high G environment of air combat. The final category of protective mechanisms against G-LOC are aircraft recovery systems, currently in the research phase, which assess pilot and aircraft performance. Two mechanisms are involved in recovery systems. One method involves stimulation of the pilot by either auditory or visual signals in an attempt to arouse the person prior to G-LOC. Another technique is a positive aircraft control recovery system which would control the aircraft following G-LOC if the aircraft entered a nose down attitude at low altitude. A number of physiological monitoring systems, have been developed. During G-LOC the electroencephalogram (EEG) shows high amplitude slow waves during the period of incapacitation. Another method involves assessing cerebral metabolism using near infrared spectrophotography detectors placed over the head. The near infrared cerebral metabolism monitor can assess hemoglobin, oxygenation, and blood volume in the brain. Another method of detecting G-LOC involves the EKG pulse wave delay. Normally there is a delay between the R wave on the EKG and the arterial pulse wave recorded over the skull or scalp. This pulse wave can be detected using ultrasound doppler over the superficial temporal artery, infrared optical reflective plethysmography over the forehead, or the peak enhanced electroencephalogram, called the rheoencephalogram. Normally this pulse wave delay increases with increasing Gs, and this delay increase may be used as a tool for detecting G-LOC before it actually occurs. The acceleration and performance of modern tactical aircraft has improved beyond the pilot’s physical ability to tolerate them. With advanced aircraft technology, aircrew engaged in air combat maneuvering will be increasingly exposed to potentially hazardous situations. The incidence of G-induced LOC will increase if protective mechanisms and technology are not developed and

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Neurology implemented. With improved centrifuge training, physical conditioning, proper performance of the anti G-suit and valve, seat angle, positive pressure breathing and recovery systems, the physiological effects of the high G environment in air combat can be lessened and our aircrews given the tactical advantage to win in combat. Management of Coma and Unresponsiveness Consciousness is a state of awareness and appropriate interaction with the environment. There are two aspects of consciousness which come into play in evaluation of a comatose patient. First is the level of content i.e. mental and cognitive function, and second, level of arousal (i.e. the degree of wakefulness). An alteration or reduction in consciousness is due to either diffuse or bilateral impairment of the cerebral hemispheres (cortex) or dysfunction of the brain stem reticular activating system. Clouding of consciousness implies either an inappropriate content or inappropriate level of arousal. Early in the course of coma, a patient may exhibit alternating excitability and drowsiness, incorrect sensory perceptions, decreased attention span, or misinterpretation of external stimuli. Dementia or senility implies an irreversible loss of cognitive function and memory and is usually seen over a more protracted course although it may be acutely precipitated by other problems such as electrolyte derangement. Delirium is a more agitated state of disorientation where the patient’s level of arousal may be increased, however his content is markedly reduced. This is a common feature of toxic and metabolic encephalopathy, drug overdose, major organ failure, severe head injury, systemic infection, or subarachnoid hemorrhage. The degree of drowsiness is often misrepresented on the patient’s record. The terms obtundation, stupor, and coma are often used interchangeably. It is best to note the response the patient makes with their environment (i.e., responds to soft verbal stimuli, loud verbal stimuli, physical stimuli such as shaking, or deep painful stimuli to the extremities). Coma or absence of arousal to any external stimuli is mimicked by several other clinical conditions which may be confused with coma. These conditions include: (1) locked in syndrome, (2) psychogenic coma, (3) persistent vegetative state, (4) akinetic mutism, (5) hypersomnolence (exaggerated sleep response,) and (6) brain death. Locked in syndrome is seen in brain stem infarction or metabolic conditions which cause paralysis of all four extremities without loss of consciousness, or acute motor paralysis due to peripheral nerve or neuromuscular junction blockade. There may be preservation of eye movements and blink reflex. Communication may be established by eye blinks. Psychogenic coma should be considered if the patient has intact brain stem reflexes, including caloric, nystagmus, pupillary reactions, and optokinetic nystagmus. In psychogenic coma there is an active resistance to eyelid opening and the eyes will tend to avoid looking at the examiner. Persistent vegetative state resembles coma. This condition occurs from severe injury to higher

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U.S. Naval Flight Surgeon’s Manual cortical structures resulting in a total lack of response to the external environment, however the patient may still have sleep and wake cycles and spontaneous eye opening. Akinetic mutism results from damage to specific areas of the frontal or limbic cortex, resulting in a loss of interest in the environment, even though the patient may appear otherwise neurologically normal. Excessive sleepiness (hypersomnolence) conditions may mimic comatose states. Brain death may also mimic coma. Nonpsychiatric (organic) coma may be due either to structural, metabolic, or toxic conditions. Structural lesions may involve the supratentorial or infratentorial regions. A history of drug abuse, headache, fever, or previous medical condition might be significant. The patient may not be able to provide a history, so much of the evaluation will depend on the examination and diagnostic tests. Examination The general physical examination should include the vital signs. Evaluation of the skin may reveal needle tracks, cyanosis, dehydration, rash (Meningococcal infection), or uremeia. Bullous skin lesions may occur from drug effect (barbituates, carbon monoxide, phenothiazine, imipramine and mepbrobamate). Breath may reveal alcohol, acetone, hepatic failure, or uremia. Cardiac examination may be helpful in finding a murmur, suggesting endocarditis; or arrhythmias, which may result from subarachnoid hemorrhage or a brain stem lesion. Hypothermia may be due to exposure, overwhelming sepsis, drug effect, hypoglycemia, hypothyroidism, of Wernicke’s encephalopathy. Altered ventilatory patterns may be indicative of metabolic acidosis or respiratory alkalosis. The neurological examination should include a general assessment of consciousness, including response to voice, or painful stimuli. Cranial nerve evaluation is important particularly the pupillary light reflex. It is important to use a bright light when evaluating pupillary responses. Local eye trauma, cataracts, or eye surgery may alter the pupillary response. Preservation of the pupillary light reflexes suggest metabolic coma. Atropine (given following cardiac arrest) amphetamine intoxication, and postanoxia may cause fixed and dilated pupils. A fixed midposition pupil may be seen with hypothermia or glutethimide. Small, fixed pupils may be seen with opiates, organophosphates, pilocarpine, phenothiazine, and following respiratory arrest from barbiturates. Brain herniation may result in fixed pupils even though the herniation may be a primary metabolic process such as cerebral edema. The position of the eyes in their primary resting position should be recorded and whether they are congugate or discongugate, abnormal deviation (horizontal or vertical), and spontaneous eye movements (roving eye movements, bobbing, or nystagmus) should be evaluated. Assessment of brain stem

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Neurology reflexes should include the corneal reflex, gag reflex, stemutatory reflex, oculocephalics, and vestibular reflexes. Motor function testing should assess spontaneous movements, such as myoclonic jerks posturing, asterixis, or seizure activity, or if response to stimuli is appropriate, purposeful, or nonpurposeful. Some general rules apply in the comatose patient. Usually, focal neurological signs indicate a structural lesion, however focal signs may be seen in Todd’s paralysis following a generalized seizure disorder or if there is a preexisting focal deficit such as an old stroke. Nonfocal neurological signs usually indicate toxic or metabolic coma, however nonfocal signs also occur in subarachnoid hemorrhage, bilateral subdural hematoma, or vasculitis. A fluctuating neurological examination usually indicates a toxic or metabolic coma, but may also be seen in fluctuating intracranial pressure elevation or status epilepticus (during the refractory or twilight phase). Toxic or metabolic coma usually has an incomplete and symmetric affect on the nervous system, affecting many levels of the neuraxis simultaneously while retaining integrity at other levels. In metabolic coma there is no regional (focal) anatomic defect such as occurs in structural coma. Toxic and metabolic coma generally does not cause impairment of horizontal and vertical vestibular ocular reflexes (Doll’s eyes). Respiratory patterns may localize the level of the neurological lesion. Damage to the cerebral hemisphere may result in “Cheyne-Stokes” respiration, a hyperventilation pattern with a crescendo- decrescendo amplitude. Damage to the midbrain and higher brain stem structure may result in central neurogenic hyperventilation, which is a hyperventilatory pattern in excess of 20 respirations per minute without the crescendo amplitude seen in Cheyne-Stokes respiration. Damage to the midbrain or pons may cause apneustic or cluster breathing, resulting in a prolonged pause following inspiration. Finally, with damage to the lower brain stem region the medulla ataxic breathing, similar to a hiccup pattern, may be seen. Hiccups often imply an impending neurological crisis involving the lower brain stem (medullary chemotactic trigger zone). Respiratory patterns suggest involvement at certain levels but are not always diagnostic. Laboratory Assessment A screening laboratory evaluation may aid in establishing the cause of coma. Neurological effects often outlast metabolic electrolyte derangement. Evaluation should include complete blood count, electrolytes, arterial blood gases, toxin and drug screens. The electroencephalogram, CT scan, and lumbar puncture may also aid in diagnosis. Treatment for coma should include: (1) the initial establishment of the ABCS (2) Thiamine 100mg IV push, (3) Dextrose 50 ML of D50W (4) Narcan 2 amp IV push. Once the patient is stabilized from a circulatory and respiratory standpoint, signs of impending herniation syndromes should be sought. If a herniation syndrome is present the patient should be treated for intracranial pressure

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U.S. Naval Flight Surgeon’s Manual evaluation. Treatment of coma is dependent upon establishing the etiology. The diagnostic tests described above are useful in establishing the appropriate cause. As with all evolving neurological crises, it is extremely important to continually reassess the patient with serial examinations. Disposition of Naval Aviation Personnel Following Head Trauma Current policy with regard to disposition of aviation personnel following head trauma is determined by the period of posttraumatic amnesia (PTA) and the associated risk of posttraumatic epilepsy (PTE). The current guidelines state that for a period of amnesia of less than one hour, the patient should be grounded for a period of three weeks. For moderate brain injury associated with PTA of one to 24 hours, grounding for 12 months was recommended. For severe brain injury (i.e., with PTA greater than 24 hours) grounding for 30 months was recommended. Injuries causing PTA of over one hour are considered disqualifying (CD) with waivers considered. For mild and moderate injury in Class II personnel, waivers are considered after shorter grounding periods. Head Injuries in Aviation Personnel Requiring Aeromedical Disposition 1. Loss of consciousness or inability to recall events for more than five minutes after the accident (see Tables 7-l and 7-2). 2. Neurological deficit, or loss or alteration of motor, sensory, or special sensory (vision, hearing) function. 3. Substantial laceration or contusion of scalp (may indicate more substantial CNS injury). 4. Otorrhea, rhinorrhea, or any skull fracture. 5. Any penetrating head injury. 6. Posttraumatic seizure. 7. Cranial computed tomography evidence of hematoma including epidural, subdural, or intracerebral hematoma. Aeromedical disposition of head injured aviation personnel should be based on: 1. 2. 3. 4.

Absence of physically disqualifying conditions. Absence of posttraumatic syndrome. Risk of posttraumatic epilepsy (as determined by period of posttraumatic amnesia). Cognitive function.

Following mild head injury, patients often have vague neurological sequelae. This has been termed the posttraumatic syndrome or postconcussive syndrome. Common symptoms of the

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Neurology posttraumatic syndrome include headache, emotional liability, personality and mood changes, poor concentration, sleep disturbance, fatigue, imbalance, and disequilibrium. These symptoms are often subtle and only noticed by close friends or relatives. Because the onset of these symptoms is delayed following apparent recovery from mild head injury, an appropriate grounding interval is indicated even after relatively insignificant neurological injury.

Table 7-1 Gradation of Brain Injury Brain Injury

Loss of Consciousness or Posttraumatic Amnesia

Glasgow Coma Scale Score

Minimal Mild Moderate Severe Very Severe

less than 5 minutes less than 1 hour 1 to 24 hours 1 to 7 days more than 7 days

15 13 to 15 9 to 12 3 to 8 3 to 8

Personnel with asymptomatic head injuries will be placed in two groups based on the presence or absence of disqualifying conditions (see Head Injury Groups 1 and 2). These disqualifying conditions represent a high risk for the development of posttraumatic epilepsy, and for which no waiver could be recommended. Head injuries may occur away from the local command and acute management is often made by civilian providers. Every effort should be made to obtain pertinent medical records and X-rays (i.e., CT scans) as the patient will usually not be able to provide complete details. After review of the records, those without a physically disqualifying condition would then be assessed for cognitive dysfunction after an appropriate grounding period. These recommended grounding periods are guidelines and are conservative. Waivers occasionally are considered after shorter grounding periods. Individual cases may be considered depending on such factors that may effect post traumac amnesia (PTA), such as post injury medication anesthesia, or inadequate records (i.e., failure to adequately assess the return of normal memory). Formal amnesia screens, such as the Galveston Orientation and Amnesia Test (GOAT) (See APPENDIX B), administered as soon as possible, may obviate the need for prolonged grounding because of delayed evaluation (artificially prolonged amnesia period). It is incumbent upon the squadron Flight Surgeon to assess the flyer as soon as possible following a head injury to assist in potential aeromedical disposition problems.

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U.S. Naval Flight Surgeon’s Manual Table 7-2 Glasgow Coma Scale Score

Response Eye Opening Spontaneous To speech To pain Nil (no response)

(E) 4 3 2 1

Best Motor Response (Test each extremity) Obeys Localizes Withdraws Abnormal flexion Extensor response Nil (no response)

(M) 6 5 4 3 2 1

Verbal Responses (Indicate if patient can’t talk, e.g., intubated) Oriented Confused conversation Inappropriate words Incomprehensible sounds Nil (no response)

(V) 5 4 3 2 1 3 to 15

Coma Score (E + M + V) =

A factor often neglected in determining the return to flight status following head injury is the cognitive dysfunction sustained from head injury. Assessment of cognitive dysfunction should be included in the evaluation of aviation personnel with head injuries of moderate or severe nature (as judged from the length of PTA), especially those who are being considered for an up status after a shorter interval than traditionally recommended. A cognitive assessment computer software program has been developed to evaluate aviation specific cognitive abilities (Unified Triservice Cognitive Performance Assessment Battery), and will soon be available to the fleet. Routine

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Neurology neuropsychometric testing, such as the Wechsler Adult Intelligence Scale, MMPI, Halstead Test Battery, and Trail Making Test, are available at major medical treatment facilities. A NATOP’s Flight Simulator check ride could also function as a screen for cognitive dysfunction. Should cognitive assessment testing be within age matched standards, then a return to flight status would be granted if the patient is otherwise asymptomatic. For those demonstrating deficits on cognitive assessment, retesting could be considered after a period not to exceed their original grounding period. Following the determination of up-status, aviation personnel should undergo a low pressure chamber (altitude chamber) run to evaluate adverse hypoxic effects on the CNS, and to ensure the sinuses clear adequately after head injury. Head Injury Groups Group 1 No Neurologically Disqualifying Defects. Personnel with asymptomatic head injuries will be placed in Group 1 if the following conditions are absent: neurological deficits, hematoma, depressed skull fracture or seizures. 1. PTA More Than Five Minutes and Less Than One Hour. Ground for three weeks. If no sequelae, normal exam, then patient is PQ. 2. PTA From 1 to 24 Hours. Ground for 12 months, classify as NPQ, reevaluate and consider for waiver if there are no sequelae and results of cognitive function tests are normal. 3. PTA Longer Than 24 Hours. Ground for 30 months, permanent NPQ; reevaluate every year, consider waiver after grounding if no sequelae are present and normal results are obtained on cognitive function tests. Group 2: Neurologically Disqualifying Defects. If any of the following conditions are present, asymptomatic head injury patients will be placed in Group 2 and the disposition will be as follows: 1. Depressed Skull Fracture. NPQ and No Waiver. 2. Intracerebral Hematoma. NPQ and No Waiver. 3. Neurological Deficit. NPQ and No Waiver. 4. Dura Penetrated. NPQ and No Waiver. 5. Seizures. NPQ and No Waiver.

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U.S. Naval Flight Surgeon’s Manual Management of Acute Spinal Cord Injuries Introduction Injury to the spinal column and spinal cord represent one of the most significant injuries in terms of medical complications and economic impact. Like head trauma, spinal cord injury can be divided into penetrating and nonpenetrating injuries. The majority of the injuries are nonpenetrating, and are usually due to decceleration forces from motor vehicle accidents, airplane crashes, falls, diving accidents, contact sports, or crush injuries. The injury may affect the spinal column (bone and ligaments), spinal cord (neural elements), or both. Classification of Spinal injuries Spinal injuries are classified according to: 1) the mechanism of impact leading to the injury, 2) or the pathophysiological damage to the spinal cord and column. Spinal column injuries are divided into: 1) fractures, 2) dislocations, or fracture-dislocations (the most common type). Injury may affect the ligaments (dislocation), the osseous elements (fracture), or both. Following initial stabilization of the injury, it is important to identify the level of injury, bearing in mind that approximately one third of spinal injury patients may have other systemic injuries or another level of the spine affected. Spinal cord injuries may be classified according to the area of cord damaged or the extent of clinical symptoms: (complete versus partial; anterior cord, posterior cord, or central cord). Vertebral injury may be classified according to the direction of force vectors applied to the vertebral column. These injury patterns include flexion, extension, axial compression, lateral flexion, rotation, or a combination of patterns. Flexion and extension may be further subdivided into disruptive or compressive injury (flexion and extension). Certain predisposing factors can aggravate or precipitate acute spinal injury, such as preexisting spondylitic disease, osteoporosis, ligament hypertrophy, or spinal stenosis. Evaluation of Spinal Injuries Spinal injury, particularly cervical spinal injury, should be suspected in anybody who has sustained an injury above the clavicle, or who has sustained head injury and is unconscious. Other clues to the presence of a spinal cord injury include neck or back pain, tenderness on palpation, a step-off deformity, muscle spasm or swelling, an electrical sensation with neck movement, flaccid extremities, absent reflexes, incontinence, diaphragmatic breathing, or asymmetric weakness (distal greater than proximal), and priapism.

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Neurology Management of Spinal injuries As with management of acute head trauma, the most important aspect is to ensure the ABC’s, (airway, breathing, and circulation). Throughout the initial management of the trauma patient it is extremely important to prevent further damage to the spinal cord. This is accomplished by avoiding flexion or extension of the neck, and maintaining neutral head position. Prior to extraction, the patient should be placed on a short spine board and immobilized with sandbags, tape, or straps. Plastic IV bags may be used in lieu of sandbags. The patient should be lifted onto a long spine board and then secured with straps. Obviously in a situation where the patient is in a dangerous position, such as a burning aircraft, these considerations would have to be hastened or bypassed to save the individual’s life. In general, the plastic Philadelphia collar or the Hare extrication collar should be used in combination with sandbags, tape, and spine boards. These collars primarily limit extension, but do little to limit flexion. Examination should include palpation of the cervical, thoracic, and lumbar spine, an adequate motor, sensory, and reflex examination of the upper and lower extremities, and a rectal exam. Continued reassessment of the ABCs and neurological examination are indicated. Significant injuries of the upper thoracic spinal column are often associated with respiratory distress from flail chest, hemopneumothorax, or circulatory compromise from aortic arch dissection, myocardial contusion, or cardiac tamponade. Injuries to the lower thoracic spinal column are often associated with intra-abdominal injury and renal damage. Delayed neurological deterioration in a spinal injury patient could signify the development of a spinal epidural hematoma, spinal abscess, or vascular or neural compromise of the spinal cord. Injuries to the thoracic and lumbar spinal column are common complications of aircraft accidents, and occur in 30 to 60 percent of ejections or crash landings. In acceleration/deceleration in the Gx plane, the greater mobility of the cervical spinal column accounts for a higher incidence of injuries to the cervical spinal cord. Injuries in the thoracolumbar area may result in significant neurological sequela, because there is less space available for the cord in this region. Spinal cord blood supply is the thoracolumbar region is tenuous compared to the high thoracic and cervical areas. Injury forces required to injure the thoracic spinal column involve a greater amount of destruction and displacement, which may result in intra-thoracic and intra-abdominal injuries. Prior to transport of the spinal injury patient, it is extremely important to adequately pad areas that have become anesthetic from the spinal injury. Casting of an anesthetic extremity should be avoided. An alternative would be to apply bivalved casts, splints, or external fixation devices. Spinal cord injury patients often have urinary drainage complications and may require intermittent catheterization or an external condom catheter. Treatment with ascorbic acid and Mandelamine helps to reduce urinary tract infections. Prophylactic treatment with antacids is

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U.S. Naval Flight Surgeon’s Manual also important as these patients are prone to stress ulcers. Long term complications from spinal cord injury include pneumonia, pulmonary embolism, gastrointestinal hemorrhage from ulcers, renal stones, urinary tract infections, and decubitus ulcers. Attention to the nursing management problems in spinal cord injury patients is essential to preclude or alleviate these complications. The use of glucocorticoids and antibiotics remains a controversial area and should be given only at the direction of specialty consultants. Referral to a neurosurgical center should be accomplished as soon as feasible for any patient with a neurological deficit or unstable spinal injury. Spinal Radiography Following spinal stabilization on a long spine board and a neurological evaluation including sensory, motor and reflex examination, the patient should undergo radiographic evaluation (see cervical spine radiology sheet). The acutely injured patient should undergo cross table lateral C-spine X- ray which should include the C7-T1 level. When stable, AP radiographs of the cervical, thoracic, and lumbar spine should be obtained, as well as an open mouth odontoid. Radiographic findings that may simulate fractures or ligament injuries include the pseudosubluxation of C2-C3 (seen in one to seven year olds), incomplete ossification of the posterior elements, spina bifida, the mach band variant, unfused secondary ossification centers (apophysis), butterfly vertebra, or soft tissue ossification. The following provides a general approach to evaluation of cervical spine films. Abnormal Findings on Cervical Spine Radiology. 1. Soft Tissue a. Widened b. Widened c. Widened d. Tracheal

prevertebral fat stripe (C-2) > 7 MM retropharyngeal space (C-3) > 5 MM retrotracheal space (C-6): child > 14 MM, adult > 22 MM deviation/laryngeal dislocation on AP film.

2. Vertebral Alignment a. Loss of lordosis b. Kyphotic hyperangulation > 11 degrees c. Torticollis d. Widened interspinous space e. Vertebral body rotation f. Space available for cord (SAC) < 14 MM.

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Neurology 3. Joint Abnormalities a. Axis-Dens interspace (ADI): child (< 8yr) > 5MM, adult > 3 MM b. Disc space disruption c. Apophyseal joint widening. Use of the Gardner-Well Tongs Ideal management of the suspected spine injury patient involves the use of skeletal traction, such as the Gardner-Wells or Crutchfield tongs. These require either mechanical weights or spring tension devices, usually seven to 10 pounds. In aeromedical evacuation, the William’s traction apparatus, which is attached to the standard military litter, is the preferred method of applying weight to the tongs. The Williams traction apparatus provides tension from a spring device and avoids the swinging weights which might aggravate a medivaced spinal cord injury patient. The Gardner-Wells tongs should be placed over the patient’s scalp, and if time permits, an area of the scalp over the tong insertion point should be shaved and prepped with an antiseptic solution and infiltrated with local anesthetic. Placement of the Gardner-Wells tongs is approximately two finger widths above the external ear in the plane of the external auditory canal. The squamosal line, where the temporalis muscle inserts, is a helpful landmark. Tong placement should be below this line to allow adequate traction. The tongs are screwed in equally on both sides and a small spring-loaded protuberance will stick out of one side of the tongs when adequate tension is applied. The securing nuts should be tightened to prevent the tongs from loosening. The tongs should be readjusted one day later, again setting the tension spring so that it sticks out approximately one millimeter from the spring-measuring device. This is the only time that the tongs should be readjusted, as further tightening will result in erosion of the tong point through the skull with obvious complications. Patients with skeletal traction should have daily lateral C-spine series, and be X-rayed when weights are changed, to assess vertebral alignment. Aeromedical Disposition of Spinal Injured Aviation Personnel Aviation personnel sustaining cervical spinal cord injury or cervical spine column injury would be not physically qualified. Waivers could be considered on an individual basis if the patient was entirely asymptomatic (i.e. without any pain), had full range of motion, and had a normal neurological examination without signs of spinal cord or nerve root damage. Flexion and extension views of the cervical spine should be obtained prior to return to flight status to ensure that there is no excessive range of motion due to ligamentous instability. In injuries of the thoracic and lumbar region, such as vertebral fractures, aviation personnel

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U.S. Naval Flight Surgeon’s Manual could be returned to flight status following an appropriate grounding period, assuming they were pain-free, had full range of motion, were on no medications, and had a normal neurological examination. In general, individuals with compression fractures of less than 15 percent, or minimal anterior chip fractures, could return to flight status, including flying ejection seat aircraft, following a six-week period of grounding, assuming they were pain-free and had full range of motion. Those with compression fractures of less than 25 percent are grounded for six months for ejection seat aircraft, and three months for nonejection seat aircraft; again, the patient must be pain-free, be normal neurologically, and have full axial range of motion. Patients with compression fractures of less than 50 percent could be returned to nonejection seat aircraft in six months or to ejection seat aircraft in twelve months. Compression fractures over 50 percent, or spinal column damage with posterior element instability or instability on flexion or extension views require neurosurgical or orthopedic for surgical consultation. Such individuals should be grounded for two years prior to return to ejection seat aircraft or grounded for one year prior to return to nonejection seat aircraft. Follow-up evaluations should include thorough neurological and spinal examinations and flexion and extension spinal X-rays to determine any progression of the compression fracture or increase in angulation or presence of instability. Kyphotic curves of over 30 degrees due to compression fractures are likely to increase in angulation and require more frequent follow-up. Nuclear medicine bone scans usually remain hot for a significant period past the healing phase, so may not be an adequate reflection of active vertebral spine pathology.

Common Spine and Peripheral Nerve Problems Back Pain Low back pain is one of the most common conditions affecting Americans, costs an estimated $16 billion a year in lost wages and medical costs, and disables approximately five and one-half million Americans. It is estimated that the lifetime prevalence of low back pain is in 40 percent. Approximately one percent will develop localizing extremity symptoms of radiculopathy (sciatica). Low back pain is clearly an occupational disease and is associated with activities requiring heavy lifting and exposure to vibration. Back pain can be divided into four phases: acute, subacute, chronic, and recurrent. Acute low back pain occurs and resolves within six weeks and accounts for 75 percent of the population of back pain patients. It is estimated that only 20 percent of these patients wiIl have clearly identifiable diagnosis. Subacute back pain resolves within 12 weeks and accounts for about 10 percent of all back pain patients. Chronic and recurrent back pain patients account for 85 percent of the low back pain costs. Chronic low back pain lasts over 12 weeks and accounts for 5 percent of the low back population. Recurrent low back pain, often a disabling condition, accounts for approximately 10 percent of the low back pain patients.

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Neurology Management of Acute Low Back Pain. As with most neurological conditions, the most important thing is to establish whether or not a life-threatening condition is occurring. In the management of acute low back pain, several factors may suggest a possible early presentation of a serious condition. Urgent evaluation should be considered for any patient who is in severe, writhing pain, as this may be the early presentation of an intra-abdominal vascular process, such as a dissecting abdominal aortic aneurysm. Patients who have significant pain at rest may be harboring an infectous or neoplastic process involving the spine or spinal column. Finally, any patient with an evolving neurological deficit such as sacral anesthesia, bowel or bladder incontinence, or progressive sensory motor dysfunction, should be referred to an appropriate center for urgent evaluation. The mainstay of treatment for acute low back pain is bedrest. Recent studies have shown that two days of bedrest are as effective as seven days of bedrest and result in 45 percent less time lost from work. Generally in a military environment, where a patient is either fit or not fit, it is often not feasible to return a patient to partial work status, so that prolonged bedrest may be indicated in certain occupational rates. During the bedrest phase, a variety of medications can be considered, such as analgesics, muscle relaxants, or nonsteroidal anti-inflammatory medication. Drugs with a high narcotic potential, such as Percocet or Percodan, should be avoided and Valium should not be used as a muscle relaxant as it also has a serious side effect of depression. In some situations, tricyclic antidepressants are effective as analgesics. Upon resolution of the severe back pain, once the patient is ambulatory, a variety of physical therapy programs should be considered, including strengthening exercises, range of motion, ultrasound, heat and cold packs, and transcutaneous nerve stimulation. In general, gravity traction or bedrest traction is ineffective and can lead to serious secondary complications and should be avoided. Perhaps the most important aspect following improvement of the acute phase, is the back education program, the so-called “low-back school”, available in some physical therapy departments. An evaluation by an experienced physician in the workplace may lead to improvements in occupational procedures to reduce recurrence of low back pain. Manipulation may temporarily decrease pain but has no long-lasting benefit. In general, manipulation with rapid changes of direction may actually further weaken spinal ligaments. Soft tissue massage and pressure point techniques may be better tolerated. Conservative therapy of acute low back pain with sciatica is usually effective, as 50 percent of patients with sciatica will usually resolve their symptoms within six weeks. Those who fail to respond to conservative therapy should be referred for surgical intervention. Patients whose symptoms continue for more than six weeks should undergo further medical evaluation including a complete blood count and sedimentation rate, and consideration for radionuclide bone scan and lumbosacral spine X-rays.

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U.S. Naval Flight Surgeon’s Manual Lumbar Radiography. Indications for spinal X-rays include age over fifty years, history of trauma, history of cancer, unexplained weight loss, pain at rest, illicit IV drug use, steroid use, fever, neurological deficit, and medicolegal considerations. In most cases spinal radiographs are normal or show only nonspecific findings; however, there may be findings on the X-ray which suggest pathology such as: Spondylolysis Spondylolisthesis Disc narrowing Schmorl’s nodes Lumbarization of S-1 Sacralization of L-5 Osteophyte formation Traction spurs Facet sclerosis Vertebral sclerosis Sciatica. Sciatica, or lumbar radiculopathy is manifested by pain, weakness, or sensory loss in a nerve root distribution in the lower extremity. Although, it is commonly due to a herniation of the nucleus pulposus with impingement of the nerve root, it may also be caused by compression of the cauda equina from tumor, abscess, or hemorrhage, or impingement of the nerve root by hypertrophy of the lumbar facets, causing spinal stenosis. Other less common causes include congenital anomalies of the nerve roots, nerve and bone tumors, metastatic disease, and degenerative synovial cysts (Tarlov cysts). Sciatic leg pain may also be caused by extraspinal involvement of the lumbosacral plexus, by tumors or endometriosis involving the pelvic peritoneum, or by compression of the sciatic nerve near the hip due to external compression from a wallet or prolonged sitting, or by localized tumors of the sciatic nerve. Despite this rather extensive differential of sciatica, the majority of cases are related to a degenerative condition of the lumbar disk. The most likely levels involved are the L4-L5 disk causing an L-5 radiculopathy, or the L5-S1 disk causing an S-1 radiculopathy. The L-5 radiculopathy causes weakness of the dorsiflexors and evertors of the foot and numbness and pain over the lateral aspect of the leg and ankle and dorsal aspect of the foot. The S-1 radiculopathy results in weakness of the ankle plantar flexors and hamstrings and numbness and pain over the lateral aspect of the sole of the foot. Another clinical entity is lumbar neurogenic claudication, usually due to lumbar spinal stenosis. Narrowing of the central canal and lateral aspect of the spinal column results in low

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Neurology back pain and bilateral leg pain primarily while ambulating. This condition often mimics vascular insufficiency of the lower extremities. Lumbar neurogenic claudication, seen with degenerative spine disease, is characterized by the lack of signs of vascular insufficiency (atrophic skin and diminished distal pulses). Neurogenic pain usually resolves after resting for 15 or 30 minutes, whereas pain due to vascular insufficiency, which is usually confined to the calves, resolves immediately with rest. Persons with lumbar spinal stenosis walk in the flexed position because in the extended position, the central canal is compressed, resulting in prominent pain and weakness. Evaluation of the Lumbar Spine and Lower Extremity Nerve Roots. Examination of the lumbar spine should include physical examination of the spinous processes and alignment, looking for excessive lordosis, scoliosis, and vascular skin lesions (birthmarks). Examination of the extremities should provide assessment of muscle atrophy. Evaluation: of the spine should include range of motion (extension, flexion, lateral flexion, and lateral rotation). Extreme range of motion can be ascertained by having the patient bend and touch his toes. Examination of the muscle groups of the lower extremity should include individual muscle group testing of the hip flexors, extensors, abductors, and adductors; knee flexors and extensors; ankle dorsiflexors, plantar flexors, invertors and evertors; and toe dorsiflexors and plantar flexors. Muscle strength may also be tested by having the patient heel walk, toe walk, hop on one foot, duck walk, and do one-legged deep knee bends. A spine evaluation form is enclosed as APPENDIX 7-H. Provocative maneuvers may detect lumbar disc disease or joint pathology. The straight-leg raising maneuver is conducted with the patient lying supine. The leg is slowly elevated and if pain is reproduced in the back of leg, the angle the leg is raised to produce pain should be noted. Leseque’s maneuver is a modification of the straight leg raising sign. The leg is raised to a level just prior to eliciting backpain or leg pain, then Leseque’s maneuver (dorsiflexion of the foot) is performed, and development of leg or back symptoms are noted. Both these are signs of lumbar disc disease. The femoral stretch maneuver starts with the patient in the prone position and the leg extended at the knee. The hip is gradually extended posteriorly. This stretches the lumbar L-4 nerve root and reproduction of symptoms may be indicative of lumbar disk disease at the L3-L4 level. A maneuver to detect musculoskeletel problems at the hip is Patrick’s sign or the FABERE maneuver, which stands for hip flexion, abduction, external rotation and extension. This maneuver is designed to reproduce pain of a musculoskeletel nature. Sensory examination of the lower extremities should include light touch and pinprick. If bowel or bladder symptoms are present, test sensation around the anus and perineal region. Reflex examination should include the quadriceps (knee jerk) and gastrocnemius (ankle jerk) reflex. The cremasteric and bulbocavernous reflex should be tested if the patient has bowel or

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U.S. Naval Flight Surgeon’s Manual bladder symptoms. Patients who fail to respond to conservative therapy and have signs of radicular symptoms over six weeks should be referred for neurological or orthopedic evaluation. Patients with low back pain whose symptoms are unremitting or severe, or have profound weakness should be evaluated on an urgent basis, particularly if there are indications of a neoplastic or infectious process. Chronic low back pain may occur in a variety of hereditary and metabolic conditions, such as spondylolysis, osteochondrosis (Schuermann’s disease), osteoporosis, ankylosing spondylitis, fibromyalgia, idiopathic sclerosis, Paget’s disease, and vertebral body fusion (Klippel-Feil syndrome). Neck Pain and Upper Extremity Radioculopathy A variety of conditions may cause pain in the neck or upper extremities. Perhaps the most common is cervical spondylosis or disc disease of the cervical region. The most common disc syndrome in the cervical region is a C-6 radiculopathy, which causes weakness of the proximal upper extremity (deltoid, biceps, and wrist flexors), diminished biceps and brachioradialis reflex, numbness over the thumb and index finger, and pain in the arm radiating to the thumb and index finger. The next most common disc syndrome is a C-7 radiculopathy, which causes weakness of the triceps and wrist extensors, numbness of the middle finger and diminished triceps reflex. C-8 radiculopathy causes pain in the arm radiating to the ring and little finger and weakness of the hand intrinsic muscles, primarily finger flexors. Cervical disc disease is managed similar to lumbar disc disease, with bedrest and analgesics as necessary, and physical therapy after the acute phase. Peripheral Neuropathies Peripheral neuropathies are due to a variety of etiologies, but in the young active-duty military population, they are most commonly due to trauma or chronic entrapment syndromes. In the older age groups, diabetes and alcohol are possibilities, as well as inflammatory peripheral neuropathies. Toxic neuropathies can occur from exposure to a variety of solvents and chemicals used in aviation maintenance and ordinance. Hereditary neuropathies are quite common, and may be cumulative with the effects of other neuropathies. Peripheral nerves may be injured by a variety of physical means, including percussion, traction, compression, ischemia, cold, or by transection. An injury classification of peripheral nerve injuries is based on anatomic damage. The most common injury type of peripheral nerves is neuropraxia, which is a localized (segmental) demyelination. This type of nerve injury will resolve within hours to days. The next injury type is axonotomesis, which is damage to the axon cylinders of the nerve. Damage of this type requires

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Neurology a longer period for recovery and this type of nerve injury may take months to recover. The last, and worst type of injury is neurontomesis, which is a disruption of both the axon cylinder and myelin. It is commonly due to laceration, where the nerve is no longer in physical continuity with the other portion of the nerve. Common Entrapment Neuropathy Syndromes Suprascapular Neuropathy. This neuropathy is due to entrapment of the suprascapular nerve at the shoulder. It is also called rucksack palsy, which is due to the straps of a heavy rucksack compressing the suprascapular nerve. This is a pure motor nerve disorder and causes weakness of the external rotators of the arm and the shoulder abductors. Median Nerve Entrapment Neuropathies. 1. Pronator Teres Syndrome. The median nerve may become entrapped at several locations. Entrapment of the median nerve may occur in the anticubital fossa (medial elbow), where the median nerve passes between the pronator teres muscle. The pronator teres syndrome may be seen in a variety of conditions. It may affect weight lifters who overdevelop their forearm muscles, or in pilots who roll their flightsuits over the forearms. It causes weakness of the wrist and finger flexors. Entrapment of the median nerve proximally causes weakness of the hand flexors and of the first and second fingers and thumb, causing the appearance of the papal hand sign. 2. Anterior Interosseous Nerve Syndrome. The median nerve may become entrapped in the lateral forearm. In the anterior interosseous nerve syndrome, or honeymoon palsy, may occur when the spouse’s head rests on the forearm overnight and resulting in weakness of the thumb and index finger flexors and pronator quadratus. This results in difficulty with pincher movements of the thumb and index fingers. 3. Carpel Tunnel Syndrome. The most common entrapment neuropathy, the carpal tunnel syndrome, results from entrapment of the distal median nerve in the wrist as it passes through the carpal tunnel. This causes weakness of the LOAF muscles (lumbricals, opponens, abductor and flexor of the thumb). This results in atrophy of the thenar eminence. Because of weakness of the thumb muscles, the thumb falls back into the planes of the hand, causing the “simian hand” or monkey hand. Tapping the median nerve over the wrist may cause an electrical sensation, and is characteristic of carpal tunnel syndrome (Tinel’s sign). Symptoms may also be reproduced by hyperflexing the wrist (Phalen’s sign). Ulnar Entrapment Neuropathies. The ulnar nerve may be entrapped above the elbow by the ligament of Struthers, at the elbow in the olecrenon groove, and below the elbow in the cubital

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U.S. Naval Flight Surgeon’s Manual tunnel. Ulnar entrapment at the elbow causes a sensory loss of the little finger and the lateral aspect of the ring finger and weakness and atrophy of the hypothenar eminence, resulting in the “claw hand” deformity. Percussing the nerve above, at, or below the elbow may cause electrical sensations or pain, which is diagnostic of entrapment at that region (Tinel’s sign). Entrapment of the ulnar nerve at the elbow is very common with trauma, particularly fractures of the elbow, athletic injuries, or chronic compression over the ulnar groove from pressure to the elbow. The ulnar nerve may also be entrapped in the wrist in Guyon’s canal. The ulnar nerve is a pure motor nerve without any sensory component, so entrapment would cause only weakness of the hypothenar muscles. It also results in weakness and atrophy of the thumb dorsal interosseous muscle, the large muscle between the thumb and index finger over the back of the hand. Weakness of the thumb abducting against the index finger is called of Froment’s sign. Injury to the wrist, from fractures or chronic pressure (use of power tools), may result in median (more commonly) or ulnar nerve compression at the wrist. Radial Nerve Palsies 1. Radial Nerve Entrapment. The radial nerve may undergo damage in the arm at the spiral groove of the humerus causing paralysis of the wrist extensors but sparing the triceps. This syndrome is also called Saturday night palsy, crutch palsy, or honeymoon palsy and is due to a pressure over the spiral groove compressing the radial nerve and causing subsequent weakness. This may occur from falling asleep with the arm draped over a chair following a heavy night of partying or having a crutch incorrectly fitted and putting pressure on the humerus of the arm rather than in the axilla, or from having one’s spouse fall asleep with the head pressing against the humerus. 2. Handcuff Palsy. The sensory radial nerve can be compressed over the dorsal aspect of the wrist, in the region of the anatomic snuff box. This causes a pure sensory syndrome with numbness over the dorsal aspect of the thumb. Sensory radial palsy is also called handcuff palsy, because it occurs if handcuffs are applied too tightly. Thoracic Outlet Syndrome. Another condition affecting the upper extremity is the thoracic outlet syndrome which is due to compression of the lower portion of the brachial plexus or the thoracic vascular system. It may result in motor and sensory symptoms in the hand. Provocative maneuvers that reproduce the thoracic outlet syndrome include the costoclavicular maneuver (pulling the shoulders back) and Adson’s sign (abducting, and externally rotating the arms over the head, then changing head position). Distal radial pulses should also be palpated as this may be a vascular insufficiency problem.

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Neurology Lateral Femoral Cutaneous Neuropathy. The lateral femoral cutaneous nerve entrapment (neuralgia paresthetica) is due to nerve entrapment in the inguinal ligament. This nerve innervates the lateral aspect of the thigh and may cause numbness or burning over the lateral thigh. It may be seen in obese people, diabetics, and also may result from a tight-fitting torso harness. Sciatic Nerve Entrapment. Sciatic nerve entrapment, called “wallet sciatica” or “toilet seat neuritis”, occurs following prolonged sitting, particularly on hard surfaces where the sciatic nerve is compressed, resulting in weakness of the plantar and dorsiflexors of the feet and toes and numbness of the entire foot. Peroneal Neuropathy. The peroneal nerve may be entrapped at the fibular head, either due to trauma or compression (prolonged leg crossing) and results in weakness of the dorsiflexor of the ankle and toes, foot evertors, and numbness of the dorsal aspect of the foot. This syndrome may be confused with an L-5 radiculopathy but without back pain. Tarsal Tunnel Syndrome. A branch of the posterior tibial nerve may be compressed in the tarsal tunnel in the foot due to tight-fitting boots or prolonged running. Morton’s Neuroma. Claw foot or Morton’s neuralgia may occur with compression of the digital nerves of the toes. It may be quite painful and may respond to padding between the toes.

Aviation Disposition of Spine and Nerve Conditions Entrapment neuropathes usually resolve following relief of the offending compression but may require several weeks or even months to resolve fully. Sensory symptoms such as numbness often do not resolve. Patients should be without neurological deficit and be pain-free prior to return to flight status. Patients with back or neck conditions that have not been surgically treated should be pain free and without substantial neurological deficit prior to returning to flight status. The flyer’s clinical syndrome would have to be viewed with respect to his aviation duties. Subtle weakness or numbness may affect flight performance. Air combat maneuvering places a significant strain on the cervical region and may prolong recovery or further aggravate a radiculopathy. Undesignated aviation personnel who are manifesting low back pain or radiculopathy could be expected to have further problems from the physical stress of naval aviation, and would generally be NPQ with waiver not recommended.

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U.S. Naval Flight Surgeon’s Manual Patients who have undergone cervical or lumbar laminectomy would be NPQ and waivered to Class II or Service Group II after six months of grounding from the date of surgery or resolution of neurological deficits. After 12 months, waivers would be considered for Service Group I or II. Undesignated personnel who have undergone spine surgery are not good candidates for flight training due to the chance of recurrence and waivers are generally not recommended. Scoliosis over 25 degrees is considered disqualifying (CD) for flight duties. Scoliosis over 20 degrees should be evaluated by an orthopedic specialist. Kyphosis over 20 degrees should be evaluated by an orthopedic specialist and is disqualifying if over 45 degrees. Spondylolysis (Pars interarticularis defect) is disqualifying with no waiver for nondesignated personnel but may be waivered if asymptomatic in designated personnel. Central Nervous System Infections Introduction A variety of organisms may infect the central nervous system, often with life threatening consequences. CNS infection may result from viral, bacterial, fungal, protozoal, or rickettsial organisms. Before central nervous system infection can occur the organism must gain access by penetrating extra neural structures, overcome local defense mechanisms, cross the blood brain barrier, then persist and reproduce despite host defenses. Organisms may gain access via direct penetration of the skin (following trauma or surgical procedures), spread from adjacent cranial sinus or bone infection, uptake by the peripheral nerve axonal transport system from wounds (rabies, tetanus, or Simian B monkey virus), or by directly penetrating the olfactory mucosa. Most organisms gain access to the central nervous system via hematogenous (blood-borne) spread. Acute Bacterial Meningitis The most common bacterial infection of the central nervous system is acute pyogenic meningitis, which is a life threatening condition. Bacterial meningitis was first described in 1805 and the first therapy occurred with the advent of lumbar puncture. Intrathecal antiserum was injected via lumbar puncture in 1913 by Flexner and this reduced the mortality of bacterial meningitis from 90 to 30 percent. With the advent of antibiotics in the 1930s, mortality rate dropped to 14 percent, however despite the improved antibiotics available today, overall mortality rate

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Neurology for acute pyogenic meningitis remains about the same. Pathogenesis of meningitis depends on (1) a defect in the blood brain barrier (2) bacterial virulence factors and (3) host defense factors. The type of micro-organism in meningitis is related to patient age and the presence and nature of underlying medical conditions or predisposing factors in the host. Bacterial meningitis is a dynamic process, involving central nervous system penetration, then unimpeded bacterial multiplication in the spinal fluid, followed by a secondary bacteremia, and finally a continuous reseeding of the intracranial spaces. Meningitis may alter the blood brain barrier permeability and result in other sequela such as venous thrombosis and brain edema (vasogenic, cytotoxic, and interstitial). Bacteria have developed factors which enhance their survival and facilitate penetration into the nervous system. Perhaps the most striking example is the protein coat of the bacteria capsule which is present in the four major bacterial pathogens: S. pneumoniae, H. influenza, N. meningitis, and E. coli. This encapsulation antagonizes phagocytosis by the white blood cells. In the early infant and neonatal period the primary bacteria involved in meningitis are the gram negative rods (Escherichia coli), and group B streptococcus. In infants over three months of age, Hemophilus influenza is the leading cause. Maternal placentally transferred antibodies protect the infant from H. influenza in the immediate post natal period. After three years of age, H. flu drops in incidence, and Streptococcus pneumonia and Neisseria meningitis become the most frequent pathogens. A variety of medical and surgical conditions may predispose the patient to bacterial meningitis. An immunocompromised state or debilitation, such as chronic alcoholism, may predispose a patient to Hemophilus influenza, Streptococcus pneumonia, and Listeria monocytogenes. Burn patients are more susceptible to Pseudomonas. Patients with splenic dysfunction or sickle cell disease are predisposed to Streptococcus pneumonia and Hemophilus influenza. Chronic sinusitis may predispose the patient to anaerobic Streptococcus, S. pneumonia, and gram negative rods, such as Bacteroides fragilis. Penetration of the skin and dura following post traumatic spinal fluid leak or neurosurgical procedures, predisposes a patient to S. pneumonia, Staphylococcus aureus, and gram negative meningitis. A patient with subacute bacterial endocarditis may develop Staphylococcus epidermitis meningitis. Bacterial meningitis in a patient with an underlying medical condition will have a more profound effect on central nervous system function, often with decreased level of consciousness. Septicemia, overwhelming fever, and deteriorating vital signs are common manifestations of the big three bacterial meningitis organisms: S. pneumonia, H. influenza, N. meningitis. Rash and petechiae are common in N. meningitis but may also present in S. aureus, Hemophilus influenza, Streptococcus pneumonia, or viral meningitis (Coxsackie Echo 9). Signs of meningeal irritation, such as nuchal rigidity, fever, photophobia, headache, and pain on eye movement, may not be present in a infant or child, or in an immunocompromised or elderly individual.

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U.S. Naval Flight Surgeon’s Manual An early diagnosis is crucial and the diagnostic procedure of choice is the lumbar puncture and spinal fluid analysis. It is important not to delay antibiotic therapy while waiting for a lumbar puncture, or if indicated, a CT scan to be performed. Cerebrospinal fluid findings in bacterial meningitis include (1) an elevated white blood cell (WBC) count, particularly > 1000 WBCs/ cubic mm and > 50% polymorphonuclear neutrophils (PMNs), (2) an elevated spinal fluid protein > 50mg% or (3) a glucose level < 2/3 of simultaneously obtained serum glucose level. Early identification of the responsible organism will aid in the appropriate selection of antibiotics. Bacterial culture and sensitivity assay is essential for guiding antibiotic therapy. The CSF gram stain may provide an immediate clue to the etiology while the culture and sensitivities are pending. Counterimmune electrophoresis (CIE) provides early identification of the common bacterial pathogens (H.flu, N. meningititis, and S. pneumococcus) within hours. Serum, urine, and spinal fluid CIE levels should be obtained. Failure to grow or isolate an organism may be due to: 1) prior antibiotic use (often as self treatment for a presumed cold), 2) meningitis due to a nonbacterial infection (fungal, viral, protozoal, Rickettsial), or an unsuspected bacterial infection (Lyme disease, tuberculosis, or syphilis), 3) the meningitis is due to a parameningeal infection (subdural empyema or brain abscess). Every effort should be made to diagnose these conditions, particularly if the patient deteriorates or fails to improve after the administration of broad spectrum antibiotics. If a bacterial meningeal infection is suspected it is crucial that antibiotic administration not be delayed while diagnostic tests are performed. In severe life threatening sepsis and meningitis, with cerebral edema, the patient may need intubation, intracranial pressure monitoring, and treatment of intracranial hypertension. Hyperthermia should be aggressively treated. Treatment of Bacterial Meningitis. Community acquired bacterial meningitis in a previously healthy adult will usually respond to penicillin. With the extensive use of antibiotics, bacteria have become increasingly resistant to commonly administered antibiotics. Penicillin resistance in S pneumonia and Neisseria is increasing as a result of a viral plasmid transmitted factor which carries the enzyme, beta-lactamase, which disrupts the antibiotic structure, rendering it ineffective. In H. influenza ampicillin resistance is present in approximately 25 percent of cases and 1 percent are resistant to chloramphenicol. The most appropriate antibiotic is determined by the bacterial sensitivity to antibiotic minimum inhibitory concentrations of less than 0.1 MG/ML. For meningitis of unknown etiology broad spectrum antibiotic coverage is indicated. IV antibiotic therapy should continue for at least 7 to 10 days following the return of normal temperature and clinical stability. Repeat spinal fluid analysis may be indicated within 2 to 3 days if the patient deteriorates. Followup spinal fluid analysis after completion of an antibiotic course may also be indicated if the patient relapses. Third generation cephalosporins are becoming increasingly popular because of their broad coverage and the emergence of penicillin resistant organisms. Gram negative meningitis may be

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Neurology found in septic urinary tract infections, penetrating head injury, or following neurosurgical procedures. Third generation cephalosporins in combination with aminoglycosides, are effective against gram negative meningitis. Intrathecal antibiotics are occasionally indicated for gram negative meningitis, such as hospital acquired psueudomonas in an elderly debilitated patient. Patients with neurosurgical appliances (shunts), should have the shunt tapped for spinal fluid analysis. If CSF infection is present, removal of the shunt may be necessary, as a foreign body tends to worsen the clinical situation. Patients allergic to penicillin may require erythromycin, cloramphenicol, or a cephalosporin. Prophylactic treatment with rifampin is indicated for Neisseria meningititis for all close contacts of the index case, such as household members, workers, shipmates, or squadron mates who are in close contact, or close contacts in infant day care centers. Casual contacts do not need to be treated. The secondary attack rate for close contacts is about 1 percent and is higher for younger children. All contacts should be treated simultaneously. Throat cultures are not effective in deciding who should receive prophylaxis. In adults, rifampin is given on a dose of 600 mg q 12 hours for a total of four doses. Minocycline may be effective but causes substantial vestibular reactions. Chemoprophylaxis for Hemophilus influenza exposure depends on the age of close household contacts. If the close contacts are children less than four years of age in the household of the index case then all household members should receive rifampin (20mg/kg/d dose for 4 days). Infants in day care centers may be considered close contacts in some situations and therapy should be started as soon as possible within seven days of discovery of the index case. After seven days the use of chemoprophylaxis with rifampin has not been shown to be effective. If the index case and close contacts are over four years of age then chemoprophylaxis is not indicated. Parameningeal Infections Sinusitis may erode through the dura and may result in meningitis, osteomyelitis, epidural abscess, subdural empyema, subdural abscess, brain abscess, or venous sinus thrombosis. The most common organisms are S.peneumonia, Streptococcus, Straphlococcus, and H.influenza. Paramenigeal infection is a life threatening condition and may be more serious than acute bacterial meningitis. Depending on which sinuses are involved, there may be a variety of clinical presentations. Mastoid sinusitis and involvement of the lateral portion of the petrous portion of the temporal bone may result in a brain abscess with focal neurologic deficits, seizures, and signs of increased intracranial pressure (headache, vomiting, and decreased level of consciousness). Sphenoid sinusitis may present with septic thrombophlebitis and cavernous sinus thrombosis, which may involve the optic nerve (visual loss), the trigeminal nerve (facial numbness), or the oculomoter nerves (double vision). Frontal sinusitis and skull osteomyelitis may cause Pott’s

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U.S. Naval Flight Surgeon’s Manual Puffy Tumor, resulting in a unilateral or occasionally bilateral swelling of the orbital region due to a subperiosteal abscess. Occasionally the infection extends into the epidural region. A dural tear from previous head trauma, may result in a subdural empyema, resulting in rapidly progressing neurologic deterioration, meningeal signs, focal neurologic deficits, and seizures. Treatment is dependent on the responsible organism. The organism usually comes from the adjacent sinus, and is often penicillin resistant S. aureus or a gram negative rod. Subdural empyema requires prolonged (2-4 weeks) IV therapy with a penicillinase resistant penicillin, such as nafcillin (12 gm per day), or chloramphenicol, or an aminoglycoside. An abscess in the subdural or intracranial space should be surgically treated, to identify the organism, and institute appropriate antibiotic therapy, and to reduce the mass effect. Nonbacterial Infections Nonbacterial organisms may involve the sinuses, causing acute neurologic deterioration. In diabetics and leukemics, molds, such as Rhizopus and Mucormycosis, may result in a fulminant meningoencephalitis, progressive neurologic deterioration, cranial nerve palsies, seizures, and infarction. The therapy for fungal brain infection is IV amphotericin B; and, mortality is very high. Malignant otitis extema is seen in diabetics who develop Pseudomonas cellulitis, which spreads intracranially, resulting in meningitis or meningoencephalitis. The protozoan Naegleria may cause a fulminant and usually fatal meningoencephalitis following swimming in infected fresh water. Treatment with amphotericin B and miconazole is a last ditch effort. Spinal fluid analysis in Naegleria menigoencephalitis reveals a polymorphonuclear pleocytosis, occasional eosinophils, and mobile ameba. Systemic fungal infections are common complications of acquired immune deficiency syndrome (AIDS). Four drugs available for treating systemic fungal infections are Amphotericin B, flucytosine, miconazole, and ketoconazole. Rickettsial infections, such as Rocky Mountain Spotted Fever and scrub typhus are treated with a tetracycline or chloramphenicol. Lyme disease, due to a bacterial spirochete, is effectively treated with tetracycline or penicillin. Cerebral malaria is a life threatening complication of infection with Plasmodium falcipirum. Cerebral malaria is characterized by profound mental obtundation, psychosis, seizures, and hyperreflexia. The cerebral spinal fluid shows an elevation of pressure and protein but no pleocytosis. Fourteen days following the mosquito bite the patient develops prodromal chills, spiking fever, which progresses to intense headache and muscle pain. The pathogenesis of cerebral malaria is a mechanical distortion of the blood vessels due to rapid proliferation of the parasites, causing stagnation of blood, or possibly some toxic effect on the vascular endothelium or an immune complex vasculitis. Treatment of cerebral malaria is with intravenous quinine.

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Neurology Glucocorticosteroids, used to treat cerebral edema, have been shown to prolong the coma and increase complications without affecting mortality and now appear to be contraindicated in cerebral malaria. Viral CNS Infections Viral infections of the nervous system produce three classic clinical syndromes: (1) meningitis, (2) encephalitis, or (3) poliomyelitis. Viral meningitis produces a milder clinical syndrome than in bacterial meningitis. The patient has a mild headache, less prominent meningeal irritation, and spinal fluid analysis reveals a elevated white blood cell count that is predominantly lymphocytic. The spinal fluid protein usually remains within normal limits and the spinal fluid glucose remains within 2/3rds of serum glucose. Viral encephalitis is divided into two categories, infectious encephalitis, due to the direct effects of the virus, and parainfectious encephalitis, due to associated reactions in the immune system affecting the central nervous system. Para-infectious complications include a perivenous inflammatory response and leucoencephalitis. Other post infectious syndromes include cerebellar ataxia, and peripheral nerve disorders, such as GuillainBarre syndrome. Viral encephalitis is classified as (1) arbovirus (arthropod borne), (2) enteroviruses, (3) childhood viruses, (4) other. The most common sporadic (nonepidemic) viral encephalitis is herpes simplex encephalitis. This form of viral (HSV) encephalitis may result from either exogenous infection (entrance via olfactory mucosa) or from dormant (latent) virus residing inside the host nervous system (trigeminal sensory ganglion). The characteristic clinical course for herpes simplex encephalitis is an acute or subacute syndrome of headache, fever, behavioral disturbance, seizures and progressive cortical dysfunction. Herpes simplex encephalitis causes a necrotizing hemmorrhagic encephalitis, primarily involving the frontal, temporal, and limbic lobes. Spinal fluid analysis reveals red blood cells due to brain hemorrhage and necrosis. Oligoclonal bands on immunoglobin protein electrophoresis may be present in the spinal fluid. EEG will reveal periodic spike and slow waves over the temporal lobes and the CT scan reveals bitemporal necrosis and hemorrhage of the frontal and temporal region. This mass effect is usually present within the first five days of onset. Temporal lobe biopsy is the diagnosis of choice and reveals characteristic intranuclear inclusion bodies. Treatment of HSV encephalitis is with intravenous Acyclovir. Epidemic encephalitis is usually related to vector spread, such as insects. The most common arthropod borne virus is St. Louis encephalitis. St. Louis encephalitis may present with seizures, tremor, myoclonus, vertigo, or electrolyte imbalance. Arboviruses tend to occur during the summer months. The most fulminant of the Arboviruses is Eastern Equine Encephalitis, which affects horses and pheasants prior to spread in man. Arboviruses tend to affect children more than

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U.S. Naval Flight Surgeon’s Manual adults. Encephalitis due to mumps and lymphochoriocytic meningitis occur primarily in the winter months. Except for herpes virus there is no specific antiviral therapy other than symptomatic treatment of fever and anticonvulsant therapy if seizures are present. References and Bibliography

General Adams, R.D. & Victor, M. Principles of Neurology (3rd Ed.). New York: McGraw-Hill, 1985. American Medical Association. Neurological and neurosurgical conditions associated with aviation safety. Archives of Neurology, (Special issue), 36 (12), 1979, 36 (120) 0 Asbury, A.K., McKhann, G.M., & McDonald, W,I., Diseases of the nervous system (Vol I & II). W.B. Saunders, 1986. Mayo Clinic. Clinical examinations in neurology. Philadelphia: W.B. Saunders, 1976. Flight Surgeon Quick Reference. Naval Aerospace Medical Institute Press, 1988. Headache Anderson, C.D., & Franks, R.D. Migraine and tension headache - Is there a physiological difference? Headache, 1981, 21, 63-71. Appenzeller, O. Altitude headache. Headache, 1972, 12, 126-129. Bartleson, J.D. Transient and persistent neurological manifestations of migraine. Stroke, Mar-Apr 1984, 15, 383-386. Freidman, A.P., Finley, K.H., Graham, J.R., et al. Classification of headache. Journal of the American Medical Association, 1962, 179, 717. Kunkel, R.S. Acephalgic migraine. Headache, 1986, 26, 198-201. Lance, J.W. Headache. Annals of Neurology, 1981, 10, 1-10. Moskowitz, M.A. The neurobiology of vasculz head pain. Annals of Neurology, 1984, 1 6 , 157-168. Riley, T.L. Muscle contraction Headache. Neurologic Clinics, 1983, 1, 489-500. Wolff, H.G. Wolff's headache and other head pain (4th ed.). Dalessio, D.J. (Ed). New York: Oxford University Press, 1980. Vertigo Baloh, R.W., & Honrubia, V.H. Clinical neurophysiology of the vestibular system. Philadelphia: F.A. Davis, 1979. Baloh, R.W. Dizziness, hearing loss and tinnitus: The essentials of neurotology. Philadelphia: F.A. Davis, 1984. Baloh, R.W. Honrubia, V., & Jacobson, K. Benign positional vertigo: Clinical and oculographic features in 240 cases. Neurology, 1987, 37, 371-378. Brandt, T., & Daroff, R.B. The multisensory physiological and pathological vertigo syndromes. Annals of Neurology, 1980, 7, 195-203.

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Neurology Brandt, T., & Daroff, R.B. Physical therapy for benign paroxysmal positional vertigo. Archives of Otolaryngology. 1980. Drachman, D.A., & Hart, C.W. An approach to the dizzy patient. Neurology, 1972, 22, 323. Halmagyi, G.M., & Gresty, M.A. Clinical signs of visual-vestibular interaction. Journal of Neurology, Neurosurgery, and Psychiatry, 1979, 42, 934-939. Syncope Blackburn, L.H. The evaluation of physiological syncope in aviation personnel. Aerospace Medicine. 1964, 35, 1212-1216. Buley, L.E. Incidence, causes and results of airline pilot incapacitation while on duty. Aerospace Medicine, 1969, 40, 64-69. Day, S.C., Cook, E.F., Funkenstein, H., et al. Evaluation and outcome of emergency room patients with transient loss of consciousness. American Journal of Medicine, 1982, 73, 15-23. Kapoor, W.N., Karpf, M., Maher, Y., et al. Syncope of unknown origin: The need for a more costeffective approach to its diagnostic evaluation. Journal of the American Medical Association, 1982, 247, 2687-2691. Kapoor, W.N., Karpf, M., Wieand, S., et al. A prospective evaluation and followup of patients with syncope. New England Journal of Medicine, 1983, 309, 197-204. Rayman, R.B. In-flight loss of consciousness, Aerospace Medicine, 1973, 44, 679-681. Rayman, R.B., McNaughton G.B. Sudden incapacitation: USAF experience, 1970-1980. Aviation Space and Environmental Medicine, 1983, 54, 161-164. Rayman, R.B. Sudden incapacitation in flight 1 Jan 1966 - 30 Nov 1971. Aerospace Medicine, 1973, 44, 953-955. Ziegler, D.K., Lin J, Bayer, W.L. Convulsive syncope: Relationship to cerebral ischemia. Transactions of the American Neurological Association, 1978, 103, 150-154. Spine Trauma Charlton, O.P., Gehweiler, J.A., Jr., Martinez, S. Roentgenographic evaluation of cervical spine trauma. Journal of the American Medical Association, 1979, 242, 1073-1075. Cloward, R.B. Acute cervical spine injuries. CIBA Clinical Symposia, 1980, 32 (l), 1-32. Crooks, L.M., Long term effects of ejecting from aircraft, Aerospace Medicine, 1970, 41, 803-804. Ewing, C.L., King, A.I., & Prasad, P. Structural considerations of the human vertebral column under +Gz impact acceleration. Journal of Aircraft, 1972, 9, 84-90. Gehweiler, J.A., Osborne, R.L., & Becker, F. The radiology of vertebral trauma. Philadelphia: WB Saunders, 1980. Panjabi, M.M., & White, A.A. Basic biomechanics of the spine. Neurosurgery, 1980, 7, 76-93. Rothman, R.H., & Simeone, F.A. The spine (Vol I & II). Philadelphia: WB Sanders, 1982. Smelsey, S.O. Study of pilots who have made multiple ejections. Aerospace Medicine, 1970, 41, 563-566.

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U.S. Naval Flight Surgeon’s Manual Spine and Peripheral Nerve Dawson, D.M., Hallett, M., & Millender, L.H. Entrapment neuropathies. Boston: Little, Brown, 1983. Dyck, P. J., Thomas, P.K., Lambert, E.H., & Bunge, R., (EdS). Peripheral neuropathy. Philadelphia: WB Saunders, 1984. Frymoyer, J.W. Back pain and sciatica. New England Journal of Medicine, 1988, 318, 291-300. Gilliatt, R.W. Physical injury to peripheral nerves. Mayo Clinic Proceedings, 1981, 56, 361-370. Leech, J.J., Klara, P.M., Gunby, E.N. Management of low back pain in the military population. Military Medicine, 1988, 153 (10), 501-505. Medical Research Council. Aids to the examination of the peripheral nervous system (Memorandum No. 45). London: Her Majesty’s Stationary Office. Spencer, P.S., & Schaumburg, H.H. (Eds). Experimental and clinical neurotoxicology. Baltimore: William & Wilkins, 1980. Sunderland, S. Nerves and nerve injuries. Baltimore: Williams & Wilkins, 1978.

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Neurology APPENDIX 7-A Cognitive Capacity Screening Examination Mini Mental Status Exam Date

Examiner

Instructions: Check items answered correctly. Write incorrect or unusual answers in space provided. If necessary, urge patient to complete task. Introduction to patient: “I would like to ask you a few questions. Some you will find very easy and others may be very hard. Just do your best.”

Trial Date/Time:

1.

What day of the week is this?

2.

What month?

3.

What day of month?

4.

What year?

5.

What place is this?

6.

Repeat the numbers 8 7 2.

7.

Say them backwards.

8.

Repeat the numbers 6 3 7 1.

9.

Remember these numbers 6 9 4. Count 1 through 10 out loud, then repeat the numbers (6 9 4) if help needed use numbers 5 7 3.

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U.S. Naval Flight Surgeon’s Manual Mini Mental Status Exam (Continued) 10. Remember these numbers 8 1 4 3. Count 1 through 10 out loud, then repeat the number (8 1 4 3). 11. Beginning with Sunday, say the days of the week backward. 12. 9 + 3 is 13. Add 6 (to the previous answer or “to 12”). 14. Take away 5 (“from 18”). Repeat these words after me and remember them. I will ask for them later: HAT, CAR, TREE, TWENTYSIX. Name

SSN

Rank

15. The opposite of fast is slow. The opposite of up is 16. The opposite of large is 17. The oppositve of hard is 18. An orange and a banana are both fruit. Red and blue are both 19. A penny and a dime are both 20. What were those words I asked you to remember? (HAT) 21. (CAR) 22. (TREE)

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Neurology (Mini Mental Status Exam continued) 23. (TWENTY-SIX) 24. Take away 7 from 100, then take away 7 from what is left and keep going: 100-7 is (93) 25. Minus 7 (86) 26. Minus 7 (79) 27. Minus 7 (72) 28. Minus 7 (65) 29. Minus 7 (58) 30. Minus 7 (51) TOTAL CORRECT (Maximum score 30) Patient’s occupation (previous, if not employed) Education Age Education, occupation, and history, not on test score): Below average Average, Patient was: Cooperative Lethargic

Above

. Estimated intelligence (based on

average

Uncooperative Other

Depressed

IF PATIENT’S SCORE IS LESS THAN 20, THE EXISTENCE OF DIMINISHED COGNITIVE CAPACITY IS PRESENT. THEREFORE, AN ORGANIC MENTAL SYNDROME SHOULD BE SUSPECTED AND THE INFORMATION ON THE FOLLOWING PAGE OBTAINED.

Rank

Name Temp.

BUN

SSN

Drug Screen

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U.S. Naval Flight Surgeon’s Manual (Mini Mental Status Exam continued) B.P. HR Hct WBC Na K LFT/TFT HCO3

Glu PO2 PCO2 CA MG

EEG ECG

Heavy Metal ETOH Level Clinical History Medical History: Drugs/Medication: Focal neurological signs:

Date

Signature & Title Patients Identification: NAME: SSN: RANK: DUTY STATION:

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Neurology APPENDIX 7-B Date of Test

Name

mo Age Date of Birth Diagnosis

Sex

M

day

yr

Day of the week: s m t w th f s PM Time: AM Date of injury mo da yr

F

GALVESTON ORIENTATION & AMNESIA TEST (GOAT) Error Points 1. 2. 3.

When were you born? (4) What is your name? (2) Where do you live? (4) (5) hospital Where are you now? (5) city (unnecessary to state name of hospital) On what date were you admitted to this hospital? (5) How did you get here? (5)

4.

What is the first event you can remember after the injury? (5) Can you describe in detail (e.g., date, time, companions) the first event you can recall after the injury? (5)

5.

Can you describe the last even you recall before the accident? (5) Can you describe in detail (e.g., date, time, companions) the first event you can recall before the injury? (5) (-1 for each ½ hour removed from correct What time is it now? time to maximum of -5) (-1 for each day removed from correct What day of the week is it? one) (-1 for each day removed from corWhat day of the month is it? rect date to maximum of -5) (-5 for each month removWhat is the month? ed from correct one to maximum of -15)

6. 7. 8. 9.

10. What is the year? one to maximum of -30)

(-10 for each year removed from correct Total Error Points Total Goat Score (100 total error points)

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U.S. Naval Flight Surgeon’s Manual

Date and time of first retrograde event reported by patient Duration of retrograde amnesia as calculated from dates of accident and first retrograde memory

. Duration of post-traumatic Date and time of first post traumatic memory amnesia as computed from date of accident and date of first anterograde event recalled

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Neurology APPENDIX 7-C Naval Aerospace Medical Institute Neurology Division, Code 24 Neurological Examination Form 1.

General: Head Spine Extremities

2.

Cranial nerves: Eyelid Visual Acuity Pupil Size Right...... Left. . . . . . .

in Light

in Dark

Light

Extraocular Muscles: ductions, Vestibulo ocular reflex, Amsler Field, finger count Visual Fields Fundoscopy Trigeminal motor Facial motor Taste Corneal Reflex Stennutory Reflex Gag Reflex Whispered Voice A.D. Rinne A.S. Rinne Weber Palate Position Sensation Phonation Tongue Trapezius Sternocleidomastoid

Bone < = > Air Bone < = > Air R = L

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Acc

Shape

U.S. Naval Flight Surgeon’s Manual 3.

Motor Muscle Status Strength Tone Character Tremor Gegenhalten

Tenderness, atrophy, fasiculations Drift mirroring

4.

Sensory LT PP Vibration Proprioception Temperature Sterognosis Graphesthesia Double Simultaneous Stimulation

5.

Cerebellum FTN HTS RAM Rebound

6.

Gait Regular Stress Tandem Station Standard Romberg Eyes Open/Eyes Closed Tandem Romberg Eyes Open/Eyes Closed Sharpened Romberg Eyes Open/Eyes Closed

7.

Cutaneous Reflexes Glabellar Snout Root Palmomental Jaw

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Neurology Abdominal Cremasteric 8.

9.

R Muscle Stretch Reflexes Pectorals. . . . . . . . . . . . . . . . . . . . . . . Deltoids . . . . . . . . . . . . . . . . . . . . . . . Biceps . . . . . . . . . . . . . . . . . . . . . . . . . Brachioradialis . . . . . . . . . . . . . . . . . Triceps . . . . . . . . . . . . . . . . . . . . . . . . Patellar . . . . . . . . . . . . . . . . . . . . . . . . Prepatellar . . . . . . . . . . . . . . . . . . . . . Adductor . . . . . . . . . . . . . . . . . . . . . . Crossed Adductor . . . . . . . . . . . . . . . Biceps femoris (hamstring) . . . . . . . Gastrocnemius (Achilles) . . . . . . . . . Hoffman . . . . . . . . . . . . . . . . . . . . . . Tromner . . . . . . . . . . . . . . . . . . . . . . . Finger Flexion . . . . . . . . . . . . . . . . . . Wartenberg . . . . . . . . . . . . . . . . . . . .

REFLEXES

L

+ more than other side - less than other side 0 Absent 1 Present with reinforcement 2 Present 3 Brisk/Transient Clonus 4 Increased/sustained clonus

NL = Normal NT = Not Tested

R

Plantar Responses Babinski . . . . . . . . . . . . . . . . . . . . . . . Chaddock.. . . . . . . . . . . . . . . . . . . . .

L + = extensor (abnormal) - = flexor (normal) Date

Neurology Division Head Patients Identification: Name: SSN: RANK: DUTY STATION:

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U.S. Naval Flight Surgeon’s Manual APPENDIX 7-D APPROACH TO NEW ONSET SEIZURES

1.

Quickly assess ABC’s, protect C-Spine if suspicion of trauma.

2.

Establish that the diagnosis of seizures is correct, statements of witnesses and EMT’s are essential. Pertinent history should include head trauma, alcohol or drug use, prior seizures.

3.

Physical examination including general exam for systemic derangement, infection, organ failure. Specific neurological evaluation should assess postictal confusion, focal neurological deficit.

4.

Assess for continued seizure activity, or failure of patient to regain consciousness (see Appendix 7-B. Status Epilepticus).

5.

Airway management: Oxygen by nasal cannula or face mask, nasal or oropharyngeal airway, blood pressure, cardiac, and respiratory monitor.

6.

Establish secure IV with 18 or 20 gauge needle, normal saline KVO (Dilantin precitates in glucose solutions).

7.

Laboratory Tests: a. STAT CBC, electrolytes including calcium and magnesium, EKG, UA, blood sugar.

8.

b.

CXR (R/O aspiration), cross table lateral C-spine if history of trauma.

c.

Medication screen: Aminophylline, Digoxin, Lithium, anticonvulsants.

d.

Drug screen: ETOH, amphetamines, cocaine, barbituates, PCP.

e.

Blood cultures, serum and urine Counter Immune Electrophoresis (CIE) antigens, if septic.

Cranial CT Scan: Noncontrast: R/O subarachnoid hemorrhage, contrast: R/O tumor/abscess

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Neurology 9.

Lumbar puncture: If meningeal signs and no focal neurological deficits. (Start IV antibiotics if meningitis is suspected)

10. Anticonvulsant therapy: Oral loading usually effective if not in Status Epilepticus, single idiopathic seizure may not require therapy 11. Frequent reassessment of patient’s clinical status.

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U.S. Naval Flight Surgeon’s Manual APPENDIX 7-E APPROACH TO STATUS EPILEPTICUS

1.

Quick assessment of general and neurological state, verify that unconsciousness persists.

2.

Maintain airway (chin lift/jaw thrust).

3.

Prevent aspiration by placing in semiprone (Fowler) position, clear secretions, insert airway or intubate, administer oxygen, insert NG tube.

4.

Start two secured IV lines, 18-20 gauge, normal saline KVO.

5.

Monitor vital signs frequently, cardiac/respiratory monitor.

6.

Laboratory tests, CT scan, and lumbar puncture (see Appendix 7-D, Approach to Seizures).

7.

TREATMENT OF STATUS EPILEPTICUS a.

Thiamine 100 mg IM.

b.

D50W - 1 AMP (50 ml) IV push.

c.

Narcan 1 amp IV/ ET tube.

d.

Valium 5-10 mg IV/ ET tube - Note: Only temporizing measure to control seizure to assist IV or ET tube insertion. Caution: Respiratory depressant, particularly with barbituates.

e.

DILANTIN (PHENYTOIN) Load: 15-20 MG/KG at 50 mg/min slow IV push on ECG monitor 4 Ampules of 250 mg/5 ml in 80 ml normal saline titrated over 20 minutes (set IMED at 300 ml/hour), observing closely for arrhythmia or hypotension. Maintenance dose: 100 mg slow IV push q8h to maintain therapeutic levels.

f.

If status epilepticus persists over 30 minutes: Phenobarital 15-20 MG/KG up to 100 mg/min, following closely for respiratory depression, hypotension, consider intubation.

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Neurology g.

By 45 minutes consider Paraldehyde 4% (5 ml in 5 ml mineral oil IM in buttocks (10 ml per side) or rectally, repeated every 30 minutes as necessary. Note: Very messy drug, smells funny, may melt plastic, and often not routinely available.

h.

Lidocaine 1MG/KG IV/ or via ET Tube as loading dose then 2-4 ug/minute IV, closely monitorying cardiac status.

i.

By 45-60 minutes if still in status, try general anesthesia.

j.

Electroencephalogram (EEG) as indicated.

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U.S. Naval Flight Surgeon’s Manual APPENDIX 7-F Naval Aerospace Medical Institute Neurology Division, Code 24 Syncope Test Battery

Requesting Physician: Clinical History:

HR ORTHOSTATIC TESTING Horizontal (Supine) . . . . . . . . . . . . . . . . . . . . . . . . . . . Vertical (Standing) . . . . . . . . . . . . . . . . . . . . . . . . . . . . Horizontal x 15 min then vertical . . . . . . . . . . . . . . . . Inverted head down . . . . . . . . . . . . . . . . . . . . . . . . . . . Squatting to standing. . . . . . . . . . . . . . . . . . . . . . . . . . UNILATERAL CAROTID MASSAGE (15 SEC) Left . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Right . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BILATERAL OCULAR PRESSURE (15 SEC) . . . . . . . BREATH HOLDING AT MAX INSPIRATION (60 SEC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VALSALVA MANEUVER (30 SEC). . . . . . . . . . . . . . . . HYPERVENTILATION (1-3 MIN) . . . . . . . . . . . . . . . . . HYPERVENTILATION (1 MIN) THEN BREATH HOLDING (15-SEC) . . . . . . . . . . . . . . . .

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BP

Symptoms Reproduce YES NO

Neurology COLD PRESSOR TEST (HAND IN O C FOR 1 MIN-) .

(

) (

)

POSITIVE PRESSURE BREATHING (1-3 MIN) . . . . .

(

) (

)

Date

Neurology Division Head Patients Identification: Name: SSN: RANK: DUTY STATION:

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U.S. Naval Flight Surgeon’s Manual APPENDIX 7-G Naval Aerospace Medical Institute Neurology Division, Code 24 Vestibular Function Testing Requesting Physician: Clinical History:

POSITIONAL TESTING Hallpike Maneuver Head Hanging Head Shaking Barany Chair Rotation FISTULA TESTING Tragus Compression Suction - Hennebert’s Sign Noise - Tullio’s Phenomenon Valsalva Swallowing POSTURAL TESTING Sharpened Romberg Quix Test Past Pointing GAIT TESTING Fukada Step Test Unterberger Step Test LABYRINTHINE TESTING Calories VISUAL TESTING Pursuit Saccades

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Neurology OKN VOR VOR Suppression NYSTAGMUS EVALUATION Type Direction Congugate Latency Fatigue/Habituation Fixation Effects Positional Changes Gaze Evoked Date

Signature & Title Patients Identification: Name: SSN: Rank: Duty Station:

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U.S. Naval Flight Surgeon’s Manual APPENDIX 7-H Naval Aerospace Medical Institute Neurology Division, Code 24 Spine and Nerve Evaluation NECK AND UPPER EXTREMITY EXAMINATION NECK

FLEXION ROTATION LEFT PARASPINAL MUSCLE SPASM

RANGE OF MOTION

EXTENSION LATERAL FLEXION RIGHT RIGHT

LEFT

SENSATION (- = DECREASED, NL = NORMAL, + = INCREASED) RIGHT

LEFT

PAIN OR OTHER SYMPTOMS AXIAL COMPRESSION SPURLINGS’ SIGN ADSON’S MANEUVER COSTOCLAVICULAR MANEUVER TINEL’S SIGN SPIRAL GROOVE LIGAMENT OF STRUTHER’S OLECRANON GROOVE CUBITAL TUNNEL CARPEL TUNNEL PHALEN’S SIGN FROMENT’S SIGN

C C C C C C C C T T

-

5 5 6 6 7 7 8 8 1 1

DERMATOME DERMATOME DERMATOME DERMATOME DERMATOME DERMATOME DERMATOME DERMATOME DERMATOME DERMATOME

PIN PRICK (PP) LIGHT TOUCH (LT) PIN PRICK (PP) LIGHT TOUCH (LT) PIN PRICK (PP) LIGHT TOUCH (LT) PIN PRICK (PP) LIGHT TOUCH (LT) PIN PRICK (PP) LIGHT TOUCH (LT)

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Neurology MUSCLE STRETCH REFLEXES RIGHT

LEFT

PECTORAL DELTOID BICEPS BRACHIORADIALIS TRICEPS HOFFMAN’S SIGN TROMNER’S SIGN FINGER FLEXION 0 1 2 3 4

PREPATELLAR PATELLAR KNEE ADDUCTOR CROSSED ADDUCTOR ANKLE (ACHILLES)

= = = = =

ABSENT PRESENT WITH REINFORCEMENT NORMAL TRANSIENT CLONUS SUSTAINED CLONUS

NECK AND UPPER EXTREMITY EXAMINATION (CONTINUED) RIGHT PLANTER SIGNS BABINSKI CHADDOCK

LEFT + = EXTENSOR (ABNORMAL) - = FLEXOR (NORMAL)

MOTOR FUNCTION 5 = NORMAL 4+ = SLIGHTLY LESS THAN NORMAL 4 = MODEST WEAKNESS 4- = MODERATE WEAKNESS (BETTER THAN JUST ANTI-GRAVITY) 3 = OVERCOMES GRAVITY (ANTI-GRAVITY) 2 = MOVES WITH GRAVITY REMOVED (PARALLEL TO GROUND) 1 = FLICKER OF MOVEMENT ONLY 0 = NO MOVEMENT

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U.S. Naval Flight Surgeon’s Manual LEFT

RIGHT SHOULDER SHOULDER SHOULDER SHOULDER EXTERNAL INTERNAL

ELEVATORS DEPRESSORS ABDUCTORS ADDUCTORS ROTATORS ROTATORS

ELBOW FLEXOR (SUPINATED) ELBOW FLEXOR (PRONATED) ELBOW EXTENSORS FOREARM PRONATORS FOREARM SUPINATORS WRIST EXTENSORS WRIST FLEXORS (ULNAR) WRIST FLEXORS (RADIAL) FINGER FINGER FINGER THUMB THUMB THUMB FINGER

FLEXORS (DISTAL) FLEXORS (PROXIMAL) EXTENSORS FLEXOR ABDUCTOR OPPOSER INTRINSICS

Date

Neurology Division Signature Patients Identification: Name: SSN: RANK: DUTY STATION:

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Neurology Naval Aerospace Medical Institute Neurology Division, Code 24 Spine and Nerve Evaluation BACK AND LOWER EXTREMITY EXAMINATION RANGE OF MOTION FLEXION ROTATION LATERAL FLEXION PARASPINAL MUSCLE SPASM RIGHT LEFT

LOW BACK

RIGHT

LEFT

BACK PAIN

EXTENSION

LEG PAIN

STRAIGHT LEG RAISING LESEQUE’S MANEUVER FEMORAL STRETCH MANEUVER PATRICK’S SIGN - FABERE EARLY /NAFZINGER’S SIGN RIGHT CAN PATIENT BEND AND TOUCH THIGH? CAN PATIENT BEND AND TOUCH KNEES? CAN PATIENT BEND AND TOUCH CALVES? CAN PATIENT BEND AND TOUCH ANKLES? CAN PATIENT BEND AND TOUCH TOES? CAN PATIENT TOE WALK? CAN PATIENT HOP ON ONE LEG?

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LEFT

U.S. Naval Flight Surgeon’s Manual BACK AND LOWER EXTREMITY EXAMINATION (CONTINUED) CAN PATIENT HEEL WALK? CAN PATIENT DO DEEP KNEE BEND? IS THERE CALF ATROPHY? IS THERE TIBIALIS ANTERIOR ATROPHY? EXTENSOR DIGITORUM BREVIS ATROPHY? Patients Identification: Name: SSN: RANK: DUTY STATION: SENSATION (- = DECREASED, NL = NORMAL, + = INCREASED) RIGHT PIN PRICK (PP) L - 4 DERMATOME LIGHT TOUCH (LT) L - 4 DERMATOME PIN PRICK (PP) L - 5 DERMATOME LIGHT TOUCH (LT) L - 5 DERMATOME PIN PRICK (PP) S - 1 DERMATOME LIGHT TOUCH (LT) S - 1 DERMATOME MOTOR FUNCTION 5 = NORMAL 4+ = SLIGHTLY LESS THAN NORMAL 4 = MODEST WEAKNESS 4- = MODERATE WEAKNESS (BETTER THAN JUST ANTI-GRAVITY) 3 = OVERCOMES GRAVITY (ANTI-GRAVITY) 2 = MOVES WITH GRAVITY REMOVED (PARALLEL TO GROUND) 1 = FLICKER OF MOVEMENT ONLY 0 = NO MOVEMENT

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LEFT

Neurology LEFT

RIGHT HIP HIP

FLEXORS EXTENSORS

HIP ADDUCTORS HIP ABDUCTORS KNEE FLEXORS KNEE EXTENSORS ANKLE ANKLE ANKLE ANKLE

DORSIFLEXORS PLANTAR FLEXORS INVERTORS EVERTORS

GREAT TOE EXTENSOR TOE EXTENSORS TOE FLEXORS TOE INTRINSICS (SPREAD) MUSCLE STRETCH REFLEXES PREPATELLAR PATELLAR KNEE ADDUCTOR CROSSED ADDUCTOR ANKLE (ACHILLES)

0 1 2 3 4

Neurology Division Signature:

= = = = =

ABSENT PRESENT WITH REINFORCEMENT NORMAL TRANSIENT CLONUS SUSTAINED CLONUS Date

Patients Identification: Name: SSN: RANK: DUTY STATION:

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CHAPTER 8 OTORHINOLARYNGOLOGY Introduction Section I. Clinical ENT Otology Rhinology Examination of the Mouth and Pharynx Laryngology Section II. Audiology The Physics of Sound Measurement of Hearing Interpretation of Hearing Tests Section III. The Navy Hearing Conservation Program (HCP) Introduction Implementation of HCP Noise Measurement and Exposure Analysis Audiometry in the HCP Hearing Protectors References and Bibliography Appendix 8-A. Model Instruction for Establishing Noise Control and Hearing Conservation Program INTRODUCTION Otorhinolaryngology (Ear, Nose and Throat, or ENT) faces the same problems in military aviation medicine that are found in civilian medical practice, but the problems are compounded by (1) the exceptional environmental conditions of aviation, and (2) the fact that some of the symptoms experienced may degrade flight performance to the point that the safety of the aviator and his passengers may be threatened. The exceptional environmental conditions include rapid pressure changes, high ambient noise levels, and unusual linear and angular accelerations. These environmental conditions can elicit episodes of pain, vertigo, disequilibrium, and nausea. They may also introduce communication problems through temporary or permanent impairment of auditory function. In addition, these effects may be of sudden onset in apparently normal individuals.

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U.S. Naval Flight Surgeon’s Manual This chapter describes clinical ENT issues, audiology, and the Navy Hearing Conservation Program (HCP). Flight surgeons may find themselves at long distances from medical facilities when ENT problems arise, or they may have to care for patients until they can get an appointment at the nearest facility; therefore, this chapter is intended to assist the physician with common clinical problems. Due to the constant problem with acoustic trauma in aviation and aboard Navy ships, the evaluation and conservation of hearing is an important part of the flight surgeon’s responsibility. He is responsible, in part, for administering the Navy Hearing Conservation Program. The material in this chapter is closely allied with that presented in Chapter 3, Vestibular Function, which discusses illusions and disorientation effects which can result as the vestibular system reacts to the unique stresses of aviation. SECTION I: CLINICAL ENT Otology The Management of External Ear Problems Hematomas. Trauma to the auricle may cause hemorrhage beneath the perichondrium, most often on the superior lateral surface, resulting in a hematoma. Left untreated, the slow absorption of blood, loss of nourishment to the cartilage, and infection may lead to a deformed auricle or “cauliflower” ear. Management may take two forms. In the early stages, aspiration of the blood using sterile technique with a large 14- gauge needle is recommended by many physicians. A pressure dressing is then applied. For large, chronic, or recurrent hematomas, incision and drainage are recommended. The entire ear is prepared with Betadine, and under local Xylocaine anesthesia, a large curving incision is made through the skin of the scaphoid fossa following the curvature of the helix. The hematoma is then evacuated using sterile technique. In some chronic or recurrent cases, instead of blood there is only xanthochromic fluid. Some surgeons advise curettement of the cyst walls. A thin rubber drain is inserted the length of the hematoma sac and then withdrawn over the next two or three days. Fine nylon or silk interrupted sutures about one centimeter apart are used for closure of the incision, and a pressure dressing is applied. Through and through monofilament sutures tied over soft sponges for direct pressure are also effective.

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Otorhinolaryngology The flight surgeon is cautioned that aspiration of aural hematomas without meticulous attention to sterile technique is an invitation to disaster because of the excellent culture medium contained therein. Perichondritis and Chondritis of the Auricle. The spread of infection, most often after trauma, to the perichondrium results in a painful, hot cellulitis of the pinna with brawny edema. Aggressive systemic antibiotic therapy and warm, wet compresses are the treatment of choice, along with repeated cleaning of the wound. If chondritis develops, the infected area must be opened and drained with excision of infected cartilage. For these infections, cultures should be made for proper drug therapy. Lacerations. The basic principles of handling a laceration of the auricle are to avoid excessive debridement, approximate the cartilage with perichondrial sutures on both sides, use white silk or cotton for buried sutures on the thin lateral surface, and use good splinting with a pressure dressing. Even though a portion of the ear may look nonviable, it is usually best to clean, approximate, splint, and then wait for demarkation before final debridement. Through and through sutures tied lightly over cotton rolls, etc., may be used for splinting as well as the pressure dressing. Exposed cartilage or subcutaneous tissue should be covered with fine mesh gauze impregnated with an antibiotic ointment. Adequate antibiotic coverage is strongly recommended. Ear Dressing Procedure. The purpose of the dressing is to splint, protect, and absorb drainage from the ear with maximum comfort to the patient. It must also resist movement or displacement.

The bandage material most commonly used is a supportive pad behind the ear, a fluff dressing of loose gauze or mechanic’s waste, and a support covering of the dressing with material like Kling ( R ) or Kerlix(R) elastic or stretch gauze. First, two or three 4 x 4-inch pads are folded together in half, and then a “C” shape is cut out of the center that will fit behind and around the ear. Next, the entire ear is covered with two or three inches of fluff dressing or mechanic’s waste. If splinting of the pinna contours is important, as in lacerations, this can be accomplished by careful insertion of ointment-impregnated cotton in the grooves of the scaphoid fossa, canal meatus, and concha. The external bandage of an elastic or stretch gauze usually begins on the forehead and is always wrapped from the front to the back of the ear. To keep the dressing out of the patient’s eyes, two pieces of umbilical tape or thin gauze are laid vertically on both sides of the forehead. The stretch gauze is wrapped first across the center of the fluff, across the lower occiput, above the opposite

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U.S. Naval Flight Surgeon’s Manual ear, and then repeated below and above the first wrap, resulting in a football helmet-like appearance. The forehead tapes are now tied and tape strips applied to hold the gauze in position, using intermittent applications about six inches in length. Foreign Bodies in the External Canal. Anything that will fit has been found in the external auditory canal. Some of the foreign bodies are inert and cause no problems or symptoms, but most commonly they produce a canal blockage with a mild decrease in hearing, itching, infection, and drainage or even a cough, mediated through pressure on the twig of the tenth cranial nerve (Arnold’s nerve). Removal of round objects is most difficult, and it is best accomplished with a fine, blunt, right angle hook that can be inserted past and behind the object. Special cup or serrate jaw forceps can also be used. Hard, sharp, and large objects should be softened, if possible, and removed with care, protecting the canal from trauma and bleeding. Compressed strips of Gelfoam may be tried on sharp corners. Friable or adherent material may require loosening or dissolution before removal. Debrox (carbamide peroxide) works well in most cases. A fine stream of water, two percent acetic acid in water, or alcohol is used for irrigation and directed under direct vision and controlled pressure. Hydroscopic objects such as corn or peas may swell if saturated with water, therefore, alcohol irrigation or forcep/hook removal is recommended. Live insects should be killed rapidly by flooding of the canal with Lidocaine, alcohol, or oil and then removed with forceps. After the object has been removed, the canal should be suction-cleaned or wiped dry and eardrops or ointments applied for treatment of any possible tissue trauma or infection. External Otitis. The lining of the external auditory canal, including the outer surface of the tympanic membrane, is facial skin and, therefore, susceptible to the same infections as the face. The outer third, surrounded by an incomplete ring of cartilage, contains hairs and sebaceous and ceruminous glands. Infection may take place in any of these structures, most commonly as a furuncle. The fissures of Santorini in the floor of the external meatus cartilage may allow for spread of infection into the soft tissues of the periauricular region. Treatment of furuncles consists tion of topical antibiotic solution should be removed by suction or systemic antibiotics. Recurrent Betadine, or antibiotic ointment

of application of dry heat to the external ear and direct applicaor ointment to the inflamed area. If the furuncle points, the top needle to allow for drainage. Diffuse swelling or cellulitis require furuncles may be controlled by applications of Cresatin (R) , to the meatus region daily.

The most common causes of infections in the external auditory canal are maceration of the skin from water or other fluid drainage and trauma, often self-inflicted, when trying to scratch or

8-4

Otorhinolaryngology clean wax from the canal. The canal becomes inflamed and may begin to weep, and there may be mild pain on movement of the pinna. Predominant causative organisms are Sraphlococcus aureus and Pseudomonas. Progress of the inflammation leads to variable degrees of canal swelling, fever, severe pain, and occasionally trismus. Meticulous cleaning of the entire canal is the single, most important form of treatment. The canal should be gently suctioned and cleared of visible debris, and the inflamed tissue should be wiped with antibiotic drops or two percent acetic acid solution. Carbamide peroxide (Debrox) may be needed if there is hard or thick debris. Blind suction and wiping of diffusely swollen canals should be very gentle with attention to the direction of the canal and distance to the tympanic membrane (2.5 cm). A wet cotton canal wick about three- quarters to one inch long or the commercial wicks (i.e., Pope Oto-wick TM) are recommended for use in all cases with diffuse swelling of the canal. Burrow’s solution (1: 10) is an excellent astringent-type medication, but any of the antibiotic-cortisone aqueous otic preparations can be used on the wick. The cotton wick should be large enough to be snug and in contact with the inflamed tissues. It is kept wet and removed after 24 hours. Antibiotic drops themselves create debris, so the canal should be cleaned and a new wick inserted daily until the swelling has markedly resolved. A patient should never be given a bottle of drops and sent off on a course of self- treatment. Patients with adenopathy and cellulitis should be treated with systemic antibiotics, and the pain can be controlled with a strong anodyne. Otomycosis of the external canal constitutes less than five percent of all cases of external otitis, but it is commonly associated with long-term use of antibiotic drops and wet debris in the canal. The most common causative agents are Aspergillus species and Monilia. When the canal is not inflamed and the infection is mostly a saprophytic fungal growth, the cerumen, debris, and fungal growth are suctioned out followed by flushing of the canal with alcohol and thorough drying. When the canal is inflamed, gentle, meticulous suction is the first step in treatment. Mycostatin or Fungizone cream is applied for Candida infections. Aspergillus species may require treatment with two percent gentian violet in 55 percent alcohol, or one percent thymol solution in ethyl alcohol, or perhaps best of all, a 25 percent m-cresyl acetate (Cresatin) solution. In chronic otorhea, the underlying pathology must be controlled, or the fungus will return. The Middle Ear Anatomy. The part of the ear which is perhaps of greatest importance in aviation is the Eustachian tube. It is approximately 37 mm long and connects the middle ear with the nasopharynx. The lateral or tympanic third of the tube is bony, the medial or pharyngeal portion is cartilaginous. The course of the tube is forward, downward, and inward from the ear, opening

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U.S. Naval Flight Surgeon’s Manual into the nasopharynx about 15 mm lower than the tympanic opening in adults. It lies just posterior to the inferior nasal turbinate. The cartilaginous and bony portions meet at an obtuse angle in the narrowest portion of the tube. The osseous tympanic orifice is open, but the cartilaginous tube is a closed, slit- like cavity, It must be opened by acts of swallowing or yawning that contract the tensor and levator veli palatini muscles or by direct air pressure. Eustachian Tube Dysfunction. Edema or tissue hypertrophy in or about the Eustachian tube from infections, inflammations, or allergy is the most common cause of acute dysfunction. Chronic dysfunction is usually associated with anatomic abnormalities, such as scarring and chronic disease processes. With an acute, unexplained, unilateral dysfunction, especially in the older age group, one should always look diligently for tumor in the nasopharynx. Symptoms of Eustachian tube dysfunction are generally a fullness in the ear, mild intermittent discomfort or pain, and a mild decrease in hearing. The tympanic membrane shows some retraction with either a normal appearance or slight hyperemia of the vascular strip. The short process of the malleus is prominent or foreshortened, and the malleus may angle more posteriorly than usual. In chronic cases, there is a “dimple” or retraction of the pars flaccida. Tympanometry may indicate a chronic negative pressure. In the acute disease, treatment is directed toward control of any infection in the nasopharynx, and a decongestant with an antihistamine is recommended. Stubborn conditions, with no obvious etiology and no previous history, often respond to two weeks of nasal steroid insufflation and occasional politzerization. Cases that develop after an initial ear block or ear infection and resist other conservative treatment, occasionally respond to ventilation tube insertion for a minimum of three months. This can also be effective in some longstanding chronic cases. In children and selected resistent cases in adults, an adenoidectomy may be advisable, if hypertrophic or suspected of chronic infection. A silent or undiagnosed sinusitis can be associated with eustachian tube dysfunction. Direct Trauma. Direct trauma can occur from the increase in air or fluid pressure in the ear canal caused by a slap to the side of the head, falling off water skis, improper water entry during a dive, ear blocks while flying, ear squeeze during SCUBA, or improper irrigation of the ear canal. This may result in rupture of the tympanic membrane, laceration of the canal, and occasionally, ossicular disarticulation or subluxation of the stapes. There may be some bleeding, often marked tinnitus, and occasional vertigo and hearing loss, depending of the degree and location of the injury. Infection could result when foreign material, especially water, is forced into the middle ear through a ruptured tympanic membrane. Treatment should consist of suction clearing, oral antibiotic coverage for five to seven days, and a base line audiogram. Clean, small traumatic per-

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Otorhinolaryngology forations usually heal within three weeks, but the patient must avoid any significant barometric pressure changes as the perforation nears closure, and at no time should water or other fluids be allowed in the ear. Keep The Ear Dry! Never use ear drops, unless a true infection with puralent drainage develops and then use only the suspension preparations. Chronic Perforations of the Tympanic Membrane. Small, dry, central performations may be dosed by cauterizing the edge of the perforation with trichloroacetic acid. It can be left open or one may elect to place a small patch made from cigarette paper or other thin paper over the perforation. Usually the patch is moistened in antibiotic drops before application. Large perforations with a dry middle ear may be closed by a tissue graft if the Eustachian tube is functioning. Testing of this function is fairly accurate by tympanography. Poor or absent Eustachian tube function gives surgery a decreased chance of success. If the ossicles show fixation or if there is considerable scarring with adhesions, hearing might decrease somewhat further even though the perforation is closed, as a result of the poorer transmission of sound and the cancellation effect of sound striking both windows at the same time. A perforation, per se, which allows for equalization of pressure between the middle ear and the atmosphere does not affect flying. Sudden cold or hot air or water and loud noise may cause vertigo more easily in the perforated ear. Of course, water in a perforated ear usually leads to infection and drainage. Barotrauma. Aerotitis media occurs rather frequently in the aviation community and is directly related to the function of the Eustachian tube in equalizing the pressure between the atmosphere and the middle ear space. The tympanic end of the Eustachian tube is bony and usually open, whereas the pharyngeal end is cartilaginous, slit-like, and closed, acting like a one-way flutter valve. Opening of the Eustachian tube occurs with the contraction of the levator and tensor veli palatini muscles during acts of chewing, swallowing, or yawning. As one ascends to altitude, the outside pressure decreases, and the greater middle ear pressure forces open the “flutter valve”, pharyngeal end of the Eustachian tube every 400 to 500 feet to about 35,000 feet, and then every 100 feet thereafter. During descent, the collapsed, closed, pharyngeal end of the Eustachian tube prevents air from entering the tube. The increasing relative negative pressure in the middle ear further holds the soft tissues together, and muscular (active) opening of the Eustachian tube must be accomplished before the differential pressure reaches 80 or 90 mm Hg. Once this magnitude of differential pressure is established, muscular action cannot overcome the suction effect on the closed Eustachian tube, and the tube is said to be “locked”. This relative negative pressure not only retracts the tympanic membrane but pulls on the delicate mucosal lining, leading to effusion and hemorrhage. Pain may be severe, with nausea and occasionally vertigo. On rare occasions rupture of the tympanic membrane has been seen, and some aircrew-men have developed shock or syncope.

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U.S. Naval Flight Surgeon’s Manual Otoscopic presentations vary greatly, but they can range from a retraction of the tympanic membrane with the classic backward displacement of the malleus, a prominent short process, and anterior and posterior folds, to hyperemia or hemorrhages in the tympanic membrane. There may also be varying amounts of serous and bloody fluid visible behind the membrane. Active treatment is directed toward equalization of pressure, relief of pain, and prevention or treatment of infections in the ear, Eustachian tube, or nasopharynx. In an aircraft or lowpressure chamber, descent should be stopped, and, if possible, there should be a return to a higher altitude where equalization can be attempted using the Valsalva maneuver or Politzer method. Descent should then be gradual, if possible. Middle ear inflation (politzerization) should be done especially if a negative pressure appears to remain on the ground and there is pain present. Caution should be exercised if there is an upper respiratory infection present. Oral decongestants may be helpful and are recommended, but the effect of antihistamines is questionable. In cases of thick effusion and poor Eustachian tube function or inability to Valsalva, daily or every other day politzerization or tubal insufflation may be in order. Persistent serous fluid may be removed by needle aspiration, but thick mucoid or organized blood must be removed by myringotomy if it has not cleared after two or three weeks of intensive therapy. Antibiotics are used only when infection is present in the upper respiratory region or develops during treatment. Delayed “Ear Block” 1. The Valsalva Maneuver. The procedure for self or mechanical inflation of the middle ear space is termed the Valsalva maneuver. It has been frequently observed in young student pilots and aircrewmen receiving earblocks in the low-pressure chamber or in flight during rapid descent, that they were unable to perform a proper Valsalva, frequently because they did not know the correct technique or were trying too hard. Several physiological conditions make the Valsalva maneuver more difficult. They are flexing the head or the chest, twisting the head to one side, pressure on the jugular vein, and being in the-prone position. The Valsalva maneuver requires the nose and mouth to be closed and the vocal cords open. Air pressure is then forced into the nose and nasopharynx forcing open the Eustachian tube and increasing the pressure in the middle ear space. This can be observed as a bulging of the tympanic membrane, especially in the posterior superior quadrant. The most frequently observed problems with the students were the fear that they would damage or rupture their eardrums, closing the vocal cords when they build up pressure like in the M-l maneuver, and straining so hard that marked venous congestion in the head further prevents opening of the Eustachian tube.

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Otorhinolaryngology Although it is possible to rupture the tympanic membrane when it is abnormally weak from previous disease, simple inflation done properly has little danger. Repeated overinflation does carry some risk and is discussed under politzerization and round window rupture. One of the best methods to prevent vocal cord closure is to instruct the patient or aircrewman to close his nose with his fingers and then attempt to blow his fingers off his nose, causing the nose to bulge from the pressure. The buildup of pressure should be rapid and sustained no longer than one to one and a half seconds to prevent the venous congestion that reduces the efficiency of the Eustachian tube function. Should the flight surgeon fail to see any movement of the tympanic membrane when he is evaluating the patient for Valsalva, he should then look for the small, quick retraction movement of the Toynbee maneuver, accomplished by closing the nose and swallowing. If a Toynbee is present and the aircrewman feels pressure in his ears during Valsalva, has no sign of ear disease, and no history of problems with pressure changes, he usually can be qualified for aviation. The best evaluation for candidates is, of course, the low-pressure chamber or an actual unpressurized flight with rapid descent. Difficulty with pressure equalization during SCUBA diving is often a poor prognosis for aviation. 2. Politzerization. Politzerization is the mechanical inflation of the middle ear usually required for treatment of acute ear and sinus blocks, chronic Eustachian tube dysfunction, or middle ear disease. To perform this procedure, one needs a source of pressure, either an air pump or rubber bag, with a one-way valve. For the air pump, it is most important to have variable control of the pressure and a pressure gauge, if possible. Most pressure/vacuum units in the Navy have a pressure gauge calibrated in pounds per square inch. If no gauge is present, the starting pressure should just be sufficient to blow off a lightly applied finger. When a pressure gauge is available, initial attempts should be done with ten pounds per square inch or less. To seal and deliver the pressure into the nose, an olive tip of metal, hard rubber, or glass is the most efficient. This tip may be attached to an atomizer if smoke or mist is desired for diagnostic or therapeutic reasons. If the patient has a very thin tympanic membrane, lower pressure must be tried first. An explanation to the patient is important to assure cooperation and prevent sudden movements that could injure the nose. The first attempt at politzerization should be done by inserting the olive tip into a nostril, getting a good seal but not striking the vestibule or septal walls. The opposite naris is occluded, and the patient is instructed to repeat K-K-K-K-K, loudly and sharply, as a one second burst of air is delivered. A characteristic soft palate flutter sound is heard if the procedure is performed correctly.

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U.S. Naval Flight Surgeon’s Manual If no results are obtained with this technique, the patient is instructed to swallow, and as the thyroid notch raises up, air pressure is again applied in the nose. For people who have trouble with a dry swallow, a sip of water may be given. In the low-pressure chamber, this method is most often used to get maximum opening of the Eustachian tube. It must be remembered that with the water technique, prolonged or high pressure might cause damage to the tympanic membrane with even a remote possibility of damage to the round window membrane and inner ear. As it is important to look at the patient’s tympanic membranes before inflation, it is equally as important to observe them afterwards to determine the extent or success of the procedure. A rubber Politzer bag is available in most drugstores and is useful with the swallow technique in children with serous otitis media or where a pressurized air supply is not available. The use of Eustachian tube catheterization is not recommended in any case. There have been cases of serious injury from improper catheterization. Acute Infections. When the tympanic membrane is intact, acute middle ear infections are direct extensions of infections in the nose and nasopharynx, frequently set up by improper blowing of the nose. Catarrhal otitis media produces blockage of the Eustachian tube and middle ear mucosa inflammation, without bacterial invasion. The patient usually develops a fullness or plugged feeling in the ear and may feel as if fluid is present. There is hyperemia of the vascular strip and annulus, and occasionally the entire tympanic membrane may be diffusely hyperemic. There is usually little or no hearing loss or tympanic membrane bulging. Treatment is directed toward relieving discomfort through decongestants and analgesics. Antibiotics are usually not indicated. Acute suppurative otitis media results when virulent bacteria invade the middle ear space, most frequently as a complication of a cold, influenza, measles, or scarlet fever. Mucopurulence is formed in the middle ear space, and all parts of the middle ear may be inflamed from the Eustachian tube to the mastoid air cells. Deep, sometimes throbbing pain, fever, and a mild to moderate hearing loss develop. Some people occasionally may have dizziness, nausea, or vomiting. Initial examination of the ear may show tympanic membrane hyperemia and slight bulging, especially in the para flaccida. As the process continues, the bulging and inflammation distort or obscure the normal landmarks on the tympanic membrane. Finally, an area of blanching develops that signals imminent perforation. With perforation, the patient’s pain is usually decreased, but drainage may be inadequate.

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Otorhinolaryngology Treatment should be initiated as soon as possible with an adequate dose of antibiotics, most often one of the penicillin groups. Medication should be continued for seven to ten days to assure complete eradication even in the mastoid cells. Antihistamine decongestant or plain decongestant medication by mouth is prescribed. Control of pain, hydration, and rest are also very important. If perforation appears to be imminent, it is wise to do a myringotomy (Figure 8-1) to assure adequate drainage and clear perforation that heals more rapidly. If the tympanic membrane ruptures spontaneously, suction cleaning should be done, and if the drainage area is inadequate, consideration should be given to enlarging it by myringotomy. The draining ear should be cleaned frequently to prevent chronic complications. Topical medication is only used in large perforations or when an external otitis is present or develops from the drainage.

Figure 8-1. Middle ear anatomy and myringotomy sites (A adapted from and B and C from Saunders & Paparella, 1968, published by permission of The C.V. Mosby Co.).

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U.S. Naval Flight Surgeon’s Manual In the management of a chronic draining ear, one has two objectives: First, attempt to control or clear the infection, and second, prevent formation of a cholesteatoma or mastoiditis that might lead to further destruction of hearing, labyrinthitis, meningitis, lateral sinus thrombosis, or brain abscess. The principles of treatment are meticulous cleaning of the canal perforation and middle ear, removal of granulation tissue, and control of the infection with both systemic and topical antibiotics. Neomycin-Cortisone suspension or Garamycin ophthalmic solutions may be introduced into the middle ear. One technique is to fill the canal with the solution and gently compress the tragus into the meatus while swallowing. If the otorrhea is not too heavy, antibiotic powders may be insufflated, or the older powder preparations, such as Sulzberger’s one percent iodine and one percent boric acid, are often effective. For thick drainage and debris, it may be necessary to irrigate with a one and a half or two percent acetic acid solution. The area should be suctioned clean and dry before using the antibiotic drops or powders to increase their effectiveness. The Inner Ear Anatomy. Situated medial to the middle ear entirely within the petrous portion of the temporal bone lies the inner ear. It is composed of dense, compact bone two to three millimeters thick, forming the osseous labyrinth. This is divided into semicircular canals, vestibule, and cochlea. Within the bony labyrinth is a membranous counterpart. The supporting fluid outside of the membranous labyrinth is perilymph. It is somewhat similar to cerebrospinal fluid and is high in sodium content. The fluid inside the membranous labyrinth, endolymph, has a high potassium content. The cochlea is a two and a half-turn coil about a central core called the modiolus, with the apex pointing anteriorly and laterally. There are three compartments. The first two, the scala vestibuli associated with the oval window and the scala tympani associated with the round window, contain perilymph and are joined at the apex of the cochlea through the helicotrema. The third or central compartment is the scala media or cochlea duct, containing endolymph. It contains the neural end organ of hearing, the organ of Corti, which rests on the thick basilar membrane that separates this compartment from the scala tympani. The delicate Reissner’s membrane separates the scala media from the scala vestibuli. The organ of Corti contains about 24,000 hair cells arranged throughout the cochlea as a single row of inner cells and from three to five rows of outer cells. Between them, they form a somewhat triangular tunnel of Corti that has its own slightly different fluid, Cortilymph. It is known that high frequency sounds stimulate the hair cells near the vestibule, and low frequency sounds stimulate those near the apex. The area of the promontory of basilar turn of the cochlea is stimulated by frequencies in the range of 3000 to 5000 Hz; it appears

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Otorhinolaryngology to be the most vulnerable to acoustic trauma, probably from the shearing force in the fluid so near the stapes footplate and the beginning curve in the scala. Trauma. Temporal bone fractures are, for the most part of two types. The longitudinal or middle fossa fracture that parallels the long axis of the petrous pyramid is usually due to forces applied to the temporoparietal region. The middle ear is always damaged. The. tympanic membrane is torn and bleeds. The labyrinthine capsule is usually spared, as is the facial nerve. Longitudinal temporal bone fractures are four times more frequent than the transverse variety. The transverse or posterior fossa fractures usually result from forces applied to the occipital or occipitomastoid region. There is essentially a fracture of the labyrinth that spares the middle ear. There may be hemotympanum, but rarely rupture of the tympanic membrane. Usually, there is both cochlear and vestibular function loss, and the facial nerve is damaged in the internal auditory meatus or horizontal portion. Only sterile ear instruments should be used for examination, and dry ear precautions must be taken. Initial treatment should include cranial checks, prophylactic antibiotics, and a complete neurological evaluation. The patient should be moved to the care of a neurosurgeon/otologist as soon as his condition permits. A baseline audiogram is valuable if the patient’s condition permits.

Barotrauma. In the past few years, an increasing number of cases of barotrauma to the inner ear have been reported from the diving community, and several cases of proven rupture of the round window membrane have been reported or evaluated at the Naval Aerospace Medical Institute (NAMI). These have been associated with overly aggressive use of the Valsalva maneuver to clear what the patient thought was an ear block. In reality, the problem was an over-inflated middle ear and distended tympanic membrane, which gives a similar blocked feeling, but usually has no pain. When the round window membrane ruptures, there may be variable degrees of tinnitus and persistent or positional vertigo, often with nausea and vomiting. Calorics are usually diminished on the involved side, and a sensorineural hearing loss, often across the board, is present with poor discrimination of words. A perilymph Fistula (PLF) may develop at the window also. The key to successful treatment is early suspicion and diagnosis by the flight surgeon and immediate repair by the otologist. Most complete recoveries have had repairs within 48 hours. The flight surgeon is reminded that a quick, simple tuning fork test will separate nerve loss from a conductive loss. Sudden Idiopathic Hearing Loss. Apoplectic onset of hearing loss is rare, but it is known to oc-

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U.S. Naval Flight Surgeon’s Manual cur. It is usually unilateral and often associated with transient vertigo and persistent tinnitus. Therapy must be instituted within 48 hours to be most effective. There have been three likely causes proposed: (1) occlusion of the internal auditory artery by spasm or thrombosis, (2) subclinical mumps, and (3) a single episode of Meniere’s resulting in permanent loss of cochlear function. A “shotgun” treatment regimen is most effective as follows: 1. Mandatory bed rest of seven to ten days. 2. Donnatal or tincture Belladonna q.i.d. 3. Nicotinic acid flushing q.i.d. 4. Histamine vasodilation using 2.75 mg of histamine in 200 ml of five percent dextrose in water I.V. at a rate to cause flushing, but not cause headache or significant drop in blood pressure. 5. Dextran, 500 cc per day (not with histamine). 6. Systemic steroids, such as prednisone 60 mg. daily x seven days, tapered to zero over another seven days. Hearing threshold and speech testing are done at regular intervals, initially q.o.d., then at bnger intervals in the ensuing weeks and months. Most patients have some residual hearing loss. Aviators must be considered on an individual basis for return to duty. This is mostly determined by the amount of hearing deficit, the completion of an extensive workup for tumor and neurological or other disease, and discontinuance of maintenance medication, such as histamine and nicotinic acid. Nystagmus The search for the presence or absence of spontaneous or positional nystagmus is an integral part of the otoneurological examination and the fitness for duty examination. Nystagmus is called right or left according to the direction of the rapid eye movement or quick component. When nystagmus is provoked only in the direction of the quick component, it is

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Otorhinolarnygology termed “first degree”. When nystagmus is also noted in forward gaze, it is “second degree”, and with nystagmus present in all directions of gaze, it is “third degree”. Nystagmus is further categorized as vertical, oblique (rare), horizontal, or rotatory. Proper evaluation calls for observation of the eyes in the right, left, upward, downward, and primary positions. If the patient is asked to look too far on lateral gaze, a few flicks of nystagmus are frequently seen and are a normal phenomenon of accommodation. After the test for spontaneous nystagmus, tests for positional nystagmus are carried out with the patient’s eyes in the straight ahead position. The method most often used is that of Cawthorne, Dix, and Hallpike. The patient is rapidly placed supine with the head hanging over the edge of the table, and the eyes are observed for 60 seconds. The patient is then raised up and then returned to the hyperextended position with the head in one direction, again for 60 seconds. The procedure is repeated in the opposite direction. Nystagmus, if present, should be immediately recorded as to type, direction, amplitude, and intensity. The position should be held until the nystagmus subsides; however, if it persists longer than 60 seconds, it is considered permanent. In older persons where vertebral artery occlusion may be the cause of the nystagmus and vertigo, one must use caution and good judgement to assure that the patient is not left in this position too long. Unidirectional nystagmus is usually of peripheral origin and occurs in the horizontal plane. The quick component is toward the uninvolved ear. Caloric response is usually hypoactive or absent. When caloric tests are normal, unidirectional nystagmus may be of central origin. The nystagmus is usually the strongest, and often only present, when gaze is directed toward the side of the quick component (first degree). The diagnostic characteristics of nystagmus are given in Tables 8-1 and 8-2.

Multidirectional nystagmus is suggestive of central involvement (i.e., a lesion anywhere in the brain). Most often, however, it results from a posterior fossa lesion where the bulk of the vestibulocerebellar units are located. The quick component is usually permanent and toward the side of the lesion. True vertigo is less frequent, and ataxia may be evident in central lesions. Table 8-3 provides a listing of diagnostic criteria helpful in differentiating between central and peripheral vertigo. Drugs often produce characteristic nystagmus. Opium and Demerol produce a vertical downward nystagmus. Positional nystagmus is found with barbiturates and alcohol. Any patient who demonstrates a spontaneous positional nystagmus with no other abnormality of labyrinthine function should be checked for barbiturate ingestion. A most interesting and characteristic positional nystagmus is seen with alcohol intoxication. The nystagmus is typically in two phases and is often recorded as PAN (positional alcohol

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U.S. Naval Flight Surgeon’s Manual nystagmus) I and II. As little as 0.02 percent blood concentration may produce both phases. Phase I begins about 30 minutes after ingestion, as the blood alcohol peaks, and lasts approximately three and a half hours. The nystagmus is always in the direction of the gaze or toward the position of the head, for example, a right-beating nystagmus appears with right gaze, head turned to the right side or if the right of the patient’s head is down in the lateral position. There is a gradual diminution after the peak and an intermediate period of about 1.7 hours in which there is no nystagmus. Approximately five hours after the initial ingestion, PAN II begins, and the nystagmus is in the opposite direction of the gaze or lateral head position and persists for several hours after the blood alcohol level has disappeared. PAN II nystagmus is greatest when the “hangover” symptoms are greatest.

Table 8-1 Spontaneous Vestibular Nystagmus

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Otorhinolaryngology Table 8-2 Differences Between Peripheral and Central Positional Nystagmus

Table 8-3 Differentiation of Central from Peripheral Vertigo

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U.S. Naval Flight Surgeon’s Manual Diseases or Clinical Syndromes of Otological Origin The majority of cases of dizziness which the flight surgeon will see associated with disease or injury of the inner ear or eighth cranial nerve are acute labyrinthitis, epidemic vertigo, vestibular neuronitis, Meniere’s disease, acoustic neuroma, benign paroxysmal positional vertigo, and trauma. These must be differentiated from the many causes of dizziness or vertigo (Table 8-4). Labyrinthitis. Labyrinthitis has many classifications, but, in general, it is serous, diffuse, destructive, or toxic. Serous and diffuse destructive labyrinthitis are associated with otitis media, cholesteatoma, or ear surgery. When the disease is of the serous type, the vestibular and cochlear functions are depressed, with the vestibular symptoms usually preceding the cochlear depression by a few hours to several days. There is usually spontaneous nystagmus to the opposite ear, nausea and vomiting, true vertigo, ataxia, past-pointing, and loss of hearing. In patients with chronic ear disease, especially cholesteatoma, a fistula test should be performed by exerting pressure and then suction using a pneumo-otoscope. Production of nystagmus and vertigo indicates the presence of a labyrinthine fistula. An acute, initially severe, and sudden onset of symptoms may be associated with the erosion into the labyrinth; however, in cholesteatoma, the lining or sac protects the labyrinth, and only quick head movements or pressure applied in the canals cause vertigo in many cases. Patients who have had ear surgery or manipulation of the stapes may have all the usual findings, except nystagmus.

In isolated serous labyrinthitis, there is usually return of labyrinthine function over weeks or months. If any fistula is suspected or injury occurred in surgery, systemic antibiotics are indicated. With fistulas, there is often a permanent nerve-type hearing loss, and some patients have chronic positional vertigo. Suppurative labyrinthitis results in violent and sudden onset of vertigo, disturbed equilibrium, nystagmus, and vomiting. Cochlear and vestibular responses are lost. Complications such as meningitis or brain abscess lead to toxic symptoms of headache, malaise, and fever. Vigorous therapy with antibiotics and surgery must be instituted, and some small mortality can be expected even with treatment. For those who recover, there is usually no recovery of the cochlear or vestibular responses, and three to five weeks are required for compensation. Return to a flying status is not recommended, except in the mildest cases. It is often impossible to be sure of complete eradication of disease, and there is questionable compensation of loss of hearing and labyrinthine function and occasional residual ataxia.

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Otorhinolaryngology Table 8-4 Causes of Dizziness and/or Vertigo

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U.S. Naval Flight Surgeon’s Manual Toxic labyrinthitis is one of the most common types seen, and a great deal of disagreement remains about its classification. The etiology ranges from acute febrile diseases to toxic or chemical substances to idiopathic. The most common characteristic is whirling vertigo with gradual onset reaching a maximum in 24 to 48 hours, and at its height, there may be nausea and vomiting. There may be no cochlear or vestibular abnormalities in those cases associated with or following acute febrile illness, but when associated with drugs, either system may be affected. Usually there is recovery from vertigo in three to six weeks. Most commonly, toxic labyrinthitis is associated with pneumonia, cholecystitis, influenza, allergy, extreme fatigue, overindulgence in food or alcohol, and certain ototoxic drugs (Table 8-5). Palliative treatment with antivertiginous drugs (Table 8-6) and bed rest is helpful. The physician should always be aware of a missed or changing diagnosis with these patients. They should not be dismissed with the “they always get well” attitude.

Table 8-5 Ototoxic Drugs

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Otorhinolaryngology Table 8-6 Antivertiginous Drugs

Epidemic Vertigo. Although to a great extent this disease may be of central origin, it is important to differentiate if from other vertiginous conditions, and this can often only be done by exdusion. Characteristically, symptoms are acute onset of severe dizziness, nausea, vomiting, a slight fever, headache, and asthenia, with a duration of several weeks to months. Recovery, however, is usual. There is usually an epidemic character to the disease, and it is associated with either an upper respiratory infection or gastroenteritis. Caloric and audiological tests usually are normal, but spinal fluid may show some lymphocytic cells. Cases with gastrointestinal symptoms are more frequent in mid-January, and those with upper respiratory symptoms occur in the autumn. Laboratory tests are of little value.

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U.S. Naval Flight Surgeon’s Manual Treatment is supportive, with variable help from antivertiginous and antinausea drugs such as Dramamine, Vontrol, Torecan, and Tigan. These patients should be able to return to flying within one month after all symptoms have ceased. Vestibular Neuronitis. Vestibular neuronitis is characterized by an attack of sudden, debilitating vertigo, nausea, vomiting, and spontaneous nystagmus. In most cases, there appears to be an antecedent or concomitant infection in the upper respiratory tract, maxillary sinuses, or teeth. The cochlea is spared, but one or both of the labyrinths have abnormal calorics. Vestibular symptoms decrease somewhat after a few hours, but they remain fairly severe for the first week, slowly decreasing over the next four to eight weeks. About 70 percent of these patients have permanent, decreased caloric function. Management is directed toward supportive treatment of the symptoms and an aggressive workup to rule out other possible diagnoses. Vestibular neuronitis is a self-limiting disease, although return to work may require from three to twelve weeks. Generally, an aviator is permanently grounded for military flying because of the sudden debilitating nature of the attacks which can be recurrent even as long as four years after the initial attack. Meniere’s Disease. Although much disagreement persists as to whether this is a disease or a symptom complex, and its etiology is still unknown, there is usually the classical triad of episodic vertigo, tinnitus, and deafness. The average age of onset is 44 (Cawthorne & Hewlett, 1954), and it is predominantly unilateral, with only about ten percent of the patients having bilateral involvement. The onset of symptoms is insidious, usually with a sensation of dullness or fullness in the ear, and an initial fluctuation in hearing of 10 to 30 dB, usually in the low tones. The hearing improves somewhat between attacks, but it continues to deteriorate as time goes on. There may be increased sensitivity to sound, or music may sound distorted. Tinnitus, varying from a whistle to a roar, develops, followed by a turning or whirling vertigo that may lead to nausea, vomiting, and even prostration. Any head movement aggravates the condition, with the vertigo lasting several hours. Some patients can have fleeting attacks lasting several minutes, and still others have attacks lasting a week or longer and may take months to regain normal equilibrium. Besides the fluctuating hearing, spontaneous nystagmus, usually rotary and often directionchanging, and a direction-fixed, positional nystagmus are the most common findings. The caloric reaction is usually abnormal. Aside from the hearing loss, Meniere’s patients frequently have recruitment and diplacusis, low threshold discomfort, and low discrimination scores. Tone decay and a Type II Bekesy are present. A fairly reliable diagnostic test is the glycerin test, where a pa-

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Otorhinolaryngology tient ingests 1.5 gm/kg body weight of glycerol mixed with equal parts of normal saline and a few drops of lemon juice. Audiograms are taken immediately and at one, two, and three hours after ingestion. A positive test is said to be an improvement in hearing of 15 dB in any one frequency from 250 to 4000 Hz or 12 percent improvement in the discriminating score. There is no effective, long-term treatment for Meniere’s disease. For many years, some physicians have controlled their patients with a neutral-ash, salt-free diet, supplemented with diuretics. Shea (1975) recommends a regimen of bed rest, Valium, low salt, diuretics, and no smoking, plus inhalation of five percent carbon dioxide and 95 percent oxygen for 30 minutes q.i.d. and 2.75 mgm of histamine diphosphate in 250 cc of lactated Ringer’s solution I.V. b.i.d. Other drugs, given individually, that are reported to be effective for an acute attack are l/150 grain Atropine I.V., Valium 10 mgm I.V., and lnnovar, which must be administered in the hospital or by an anesthesiologist. Vasodilators, such as nicotinic acid, beta-pyridylcirbinol, Roniacol, or Arlidin, are usually ineffective in Meniere’s, as are the antivertiginous drugs. There have been several surgical treatments for Meniere’s with some success in a certain percentage of patients. These range from the endolymphatic shunt to destructive labyrinthotomy in the most severe, uncontrolled cases. Patients with a diagnosis of Meniere’s are permanently grounded, and only the patient with a rare surgical cure has ever been allowed to fly by the Federal Aviation Agency. Acoustic Neuroma. An acoustic neuroma is a fairly rare, extremely slow-growing neoplasm that originates on the vestibular portion of the eighth cranial nerve in the internal auditory canal. It constitutes about eight to ten percent of all brain tumors and is most common in the fourth and fifth decade of of life. Early diagnosis, which offers the best chance for a surgical cure and the least morbidity and mortality, is often based on a strong suspicion. Symptoms, often difficult to pinpoint but most often present, are steady, unilateral tinnitus, hearing loss, and a feeling of unsteadiness. Some patients have vague complaints of headache, local retroaural discomfort, and facial paresthesia or pain. A significant finding is speech discrimination much more severe than indicated by a pure-tone hearing test. Diagnostic evaluation should include a complete audiological examination of pure tone and speech, stapedial reflex, and acoustic reflex decay. Stenver’s and Town’s X-rays are valuable for an initial screen, but CAT scans or MRI are more often necessary. Typically, there is a sensorineural-type hearing loss with poor speech discrimination that is inconsistent with the puretone test, absence of recruitment or low small incremont sensitivity index (SISI) scores, pronounced tone decay, a type III or IV Bekesy tracing, reduced caloric response, widening of the internal auditory canal, decreased cornea1 sensitivity on the involved side, and decreased or absent stapedial reflex.

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U.S. Naval Plight Surgeon’s Manual Suspected cases, which are not diagnostic should be kept under the watchful eye of an otolaryngologist or neurologist and not dismissed or forgotten after the initial workup. Benign Puroxysmal Positional Vertigo. Benign paroxysmal positional vertigo must be differentiated from Meniere’s and eighth nerve tumors. In general, onset of nystagmus and vertigo occur when the head moves to a certain position. There usually is a latent period of several seconds, and the nystagmus fatigues with repeated testing. Most cases have normal calorics and audiological examinations. Symptoms abate in about eight weeks, but they may recur or even last for years. There is no treatment except avoidance of the position that creates the nystagmus and vertigo, as well as reassurance to the patient. Pilots should be grounded until all symptoms have disappeared, and each case must be considered on an individual basis. Rhinology Nasal and Sinus Physiology The primary functions of the nose are filtration, warming, and humidification of air; it also subserves the sense of smell, and it is the origin and recipient of numerous reflex areas. The sinuses have no primary function. Air filtration is accomplished by the vibrissae in the anterior nares and by mucus. Most of the mucous glands are in the nasal mucosa. The mucous blanket is moved by cilia toward the nasopharynx at the rate of five mm per minute. Although amazingly resistent to heat, cold, fumes, dust, and chemicals, the cilia are most vulnerable to drying from inspired dry air, such as central heating or 100 percent oxygen. Air flow during inspiration is directed over the turbinates to the roof of the nasal cavity and then into the nasopharynx. The air is warmed by heat transfer from the mucous membranes. During expiration, the air makes a loop before exiting the nose anteriorly, allowing for retention of the moisture in the air. The air flow volume is regulated by the changing size of the turbinates. Bacterial Diseases of the Nose Vestibulitis. An inflammation of the hair follicles in the nasal vestibule may cause chronic crusting and tenderness of the nasal tip or ala; it is often recurrent. Treatment consists of gentle deaning of the nasal vestibule and the application of topical antibiotic ointment, usually containing Neomycin, two or three times daily. Ophthalmic ointments work well, but treatment must be continued for two or three weeks after symptoms disappear to prevent recurrences.

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Otorhinolaryngology Furunculosis. Furunculosis of the vestibule is also common and usually associated with digital trauma and nose blowing. A crack in the skin allows the entrance of strep or staph organisms. Most infections localize, but occasionally they may become a spreading cellulitis. Squeezing or incising the area is dangerous, as it may cause spread to the cavernous sinus. Pain and systemic symptoms may be marked. Treatment consists of a “hands off” policy, adequate doses of appropriate antibiotics, hot, moist packs, and good analgesics. Rhinitis. Rhinitis can develop as a complication of an upper respiratory infection if symptoms last longer than seven to ten days. Thick yellow or greenish nasal drainage, fever, throat and ear pain, and productive cough suggest complications. Excessive blowing of the nose, which forces bacteria into the sinuses and Eustachian tube and traumatizes the sinus orifices, and severe coughing, which strips the cilia from the bronchial lining, are the most common causes. Treatment should place emphasis on maintaining good nasal and sinus drainage, good tissue hydration, and rest; antibiotics are used for bacterial infections or complications. The penicillins, erythromycin, or the tetracyclines, in order of preference, handle most complications, but cultures should be taken to provide help in resistant cases. In general, pilots or flight personnel should not fly with a cold. Even a slight amount of nasal congestion and tissue edema may be enough to interfere with pressure equalization of the sinuses and ears, leading to aerotitis, aerosinusitis, or barometric vertigo. The flight surgeon should strongly advise against self-medication and frequently reiterate the many predictable, immeasurable factors, such as level of awareness and performance, that may be affected by disease or medication. The flight surgeon must make individual judgements, depending of the aircraft, aircrewman’s job, type of flight, and medication, when deciding to ground flight personnel. Before personnel are allowed to return to flight status, a careful examination of the ears, nose, and throat should be made. Symptoms are often gone several days before the tissues return to normal and before essential functions return sufficiently to handle the many different and rapid environmental changes associated with flying. Diseases of the Nose and Sinuses Allergic Rhinitis. Allergic rhinitis, a very unpredictable and difficult problem in aviation, may be acute or chronic, seasonal or perennial. Common symptoms are nasal obstruction, clear rhinorrhea, sneezing, itching of the eyes, soft palate, and nose, and occasional associated headache, mostly frontal. Some cases of allergic rhinitis are similar to a cold, but they usually last only one or two days or else 10 days and are more frequent than viral upper respiratory infections.

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U.S. Naval Flight Surgeon’s Manual Seasonal allergies are often caused by pollens from grasses, trees, or flowers and last two or three weeks. If a specific allergen is found, desensitization is often effective. After an allergy shot, a pilot is grounded for at least six hours. Perennial rhinitis can be quite variable with no pattern, or it may be nearly constant. Allergies may be caused by house dust, molds, dog dander, wool, feathers, tobacco pollutants, or food. Avoidance, if possible, is the best method of control; however, desensitization may be effective for dusts and molds. Examination of the nasal mucosa often reveals edema and pallor of the turbinates, especially the inferior turbinates and the anterior tips of the middle turbinates. The turbinates may be so engorged they appear purple. The posterior turbinate tips may protrude into the nasopharynx or become irregular and look like mulberries. Red or inflamed mucosa has also been noted, especially if the allergen is a pollutant. A basic allergy workup should include the following: 1. History - present, childhood, family. 2. Nasal smear for eosinophiles. 3. Sinus X-rays. 4. Complete blood count. 5. Thyroid function test. 6. Total protein and gamma globulin blood level. The basic treatment measures are as follows: 1. Take antihistamines, with or without decongestants. Alternating the antihistamine every two weeks is often effective. 2. Cover pillows and mattress with plastic. 3. Cover overstuffed furniture. 4. Eliminate wool from bedding. 5. Remove domestic animals from the house.

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Otorhinolaryngology 6. Air-condition the house. 7. Avoid milk and egg products; other foods can be eliminated, one at a time, a week apart. 8. Use nonallergenic cosmetics. Severe allergy attacks may require a short course of systemic steroids for control. Milder cases that create obstruction of the nasal airway and sinus orifices can often be helped by topical steroids in an aerosol form, such as Beclamethazone, Flunisolide or nasal cromolyn sodium. Nonallergic Rhinitis. Nonallergic rhinitis, often included under the term of vasomotor rhinitis, has as the most common symptoms chronic, intermittent, often alternating nasal stuffiness or obstruction, and postnasal drip. In the course of treatment, it is important to rule out allergies, to explain the physiology of the nose to the patient, and to prevent the overuse of nose drops or inhalers that may cause a rhinitis medicamentosa. Once rhinitis medicamentosa develops, it can only be cured by complete abstinence from nose drops. In about three weeks, the normal reflex activity should return. Septal deviations should be corrected if they are a factor in obstructions. Humidification of the house or bedroom, or the use of Proetz solution or ointments to prevent drying of the mucosa is often helpful. Thyroid function may be a factor in some cases; for borderline hypothyroid states, thyroid extract or Cytomel has been effective. Certain emotional states cause nasal symptoms, and they often respond when this problem has been explored or treated. Rhinitis of pregnancy usually responds to no treatment except delivery. Certain antihypertensive and birth control pills may cause nasal congestion; decrease or change in the drugs often improves or cures the problem. Topical steroids have been helpful in some cases. Polyps and Polypoid Degeneration. When the nasal mucosa, and in some cases the sinus mucosa, reacts to allergies or inflammation, edema develops due to increased capillary permeability and transudation of fluid into the cell and extracellular spaces. Air conditioners may contain much dust and mold, causing more trouble for a person with allergies to these substances. Electrostatic filters may do a better job, but may produce ozone which is toxic. If the first outlet is eight to ten feet from the unit, it is usually safe. Humidification is good for the dry nasal mucosa but it also increases the growth of molds in the house. The mucosa appears “waterlogged” or “intumescent”. Over a period gravity, this tissue may elongate to form nasal polyps, especially in meatus and maxillary sinus ostia. In some cases, the anterior tip of the remain edematous, and this condition is called polypoid degeneration, tissue may lose some of its cilia and is replaced with goblet cells.

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of time, with the help of the region of the middle middle turbinate may just rather than a polyp. The

U.S. Naval Flight Surgeon’s Manual Polyps and polypoid degeneration may obstruct the sinus ostia leading to acute and chronic sinus disease or sinu blocks and, therefore, should be removed when obstructive. Small, or single, nonobstructive polyps need not be removed unless they enlarge. Occasionally, polyps are found within the maxillary sinus; these polyps eventually move out of the sinus ostium and into the nasopharynx, where they expand in size. These polyps are called antrochoanal or choanal polyps, and their removal requires a Caldwell-Luc antrostomy to remove the base and prevent recurrence. Polyps in the maxillary sinuses are disqualifying for aviation candidates, as is nasal polyposis. A possible exception can be made for a single, small polyp on one side in an asymptomatic, nonallergic candidate. Recurrence of polyps after removal is common; this is especially true when the disease remains in the ethmoid sinuses. In some cases, the use of short courses of broad spectrum antibiotics and topical steroids may reduce the size of the polyps. A common dose schedule is two sprays in each nostril, twice daily for one week, then one spray in each nostril twice daily for four days, finishing with one spray daily in each nostril for the remainder of the week or longer, if desired. The use of topical steroids may be irritating to the mucosa; otherwise there are essentially no side effects. Epistaxis The majority of nosebleeds are caused by trauma and occur from the vascular plexus on the anterior septum, known as Kisselbach’s plexus or Little’s area. Common causes are air drying, violent sneezing or blowing the nose, and picking the nose. Severe bleeding, especially high anterior and posterior bleeding, occurs from the ethmoid artery, a branch of the internal carotid, and the sphenopalatine artery, a branch of the external carotid artery. In general, treatment of simple anterior bleeding should first be direct pressure, for at least five or ten minutes, against the anterior septum. Pledgets of cotton moistened in a vasoconstrictor, such as one percent Neo-Synephrine, one percent epinephrine, or one to four percent cocaine, along with pressure, are even more effective; large clots should be gently suctioned away. If bleeding is controlled, the bleeding site may be cauterized with 25 to 50 percent trichloroacetic acid, five percent chromic acid, or silver nitrate in a 50 percent solution or on a stick applicator. These solutions should be applied with a small, moist applicator under direct vision. Anterior bleeding sites not controlled by direct pressure or chemical cautery should be infiltrated with Xylocaine and epinephrine, using both the tissue wheal and the epinephrine effect for control. The site may then be cauterized by chemical or electrocautery; deep burns or cauterization of adjacent structures, such as the ala or vestibule, must be avoided. If the coagulated fluid and blood stick to the tip of the cautery and are pulled off with the coagulum, the bleeding may restart. In those cases where bleeding cannot be controlled, one might attempt cautery with a suction tip electrode; if this fails, the nose can be packed with Vaseline and antibiotic ointment impregnated

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Otorhinolaryngology in half-inch selvage gauze. It is best to pack both sides to prevent loss of the pack by shifting of the septal cartilage from a one-sided pressure. The pack should be left in place for at least 24 hours, but usually never more than 72 hours. All raw or cauterized surfaces should be lightly covered with an antibiotic ointment, and a small piece of compressed Gelfoam over the anterior septum further protects against air trauma. The ointment application should be repeated three or four times a day. Posterior bleeding, usually in the older age group, is a serious condition, and, if coupled with hypertension, it requires aggressive medical and rhinological management. The patient should be admitted to sickbay, sedated, and kept in a head- elevated position. After vasoconstrictor and topical anesthestic application to both nasal passages, an attempt can be made to control the posterior bleeding by the use of a specifically designed postnasal balloon, or a common, 15 cc-size Foley catheter. The balloon is checked before insertion, then it is passed along the floor of the nose, and when it is in the lower nasopharynx, the balloon is filled with about 5 cc of water. It is then drawn back up against the posterior choana and further filled to the point of tolerable discomfort to the patient. Anterior packing is inserted bilaterally with fixation of the catheter to the lip or against the packing, but never against the ala or septum to prevent pressure necrosis. The posterior pharynx is checked hourly for bleeding, and the hemoglobin and hematocrit are monitored according to the amount of oozing or bleeding; blood typing and cross matching are advisable. Blood coagulation studies are usually done, but it is unusual to see only nasal bleeding with abnormality of the clotting mechanism. A patient with a posterior nasal pack or balloon is never sent home. He should be closely monitored because of the possibility of a nasovagal reflex action when the nasopharynx is packed, that might lead to apnea or hypoxia. Uncontrolled bleeding of the ethmoidal arteries requires ligation in the orbit or, as a last resort, an internal carotid ligation. Uncontrolled sphenopalatine artery bleeding requires ligation through a transmaxillary sinus approach, or ligation of the external carotid in the neck. Barotrauma to Sinuses Aerosinusitis results when equalization of pressure between the sinus cavities and the atmosphere is prevented by obstruction of their orifices. There are numerous causes, but heading the list are the common cold and allergies. Other causes are anatomical defects, infection, and polyps. As an aviator goes to altitude, the outside pressure decreases, and discomfort may be felt in the obstructed sinus. It is usually not severe, however, and most often air forces its way out past the obstruction. When the aviator descends, the pressure in the obstructed sinus remains less than the surrounding pressure, creating a vacuum effect on the delicate, thin, mucosal lining and resulting

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U.S. Naval Flight Surgeon’s Manual in pain that is often severe. Some fluid may be drawn into the cavity, but the more serious complication is pulling away of the mucoperiosteum, with formation of a hematoma. Sinus blocks occur most often in the frontal sinus (70 percent), and the aviator must be grounded until the hematoma resolves, and the ostium is patent. This may require three weeks to three months. For this reason, anyone suspected of a sinus block should have sinus X-rays to determine the extent of injury and then should be followed at approximately three-week intervals, until clear. Treatment of the acute block is as follows: 1. Stop descent in aircraft or low-pressure chamber, if possible, and return to altitude for pain relief. 2. If available, spray the nasal passage with a vasoconstrictor nasal spray (nose drops). 3. Do the Valsalva maneuver or use the Politzer method. 4. Make a slow descent equalizing pressure with the above maneuvers. 5. Place patient on antihistamine-decongestant or decongestant therapy. 6. Take screening Water and Caldwell sinus X-rays. 7. If an upper respiratory infection is present, treat with antibiotics. 8. Control severe pain with Codeine or Percodan. 9. If a frontal sinus hematoma is present, ground the aviator for at least three weeks. With no apparent X-ray pathology, the aviator should be grounded for at least 72 hours, or until any nasal symptoms have been cleared. Recurrent trauma may result in mucocele formation, requiring a major surgical procedure and permanent grounding. Sinusitis The majority of acute sinusitis cases follows an acute upper respiratory infection, like the common cold, and they are often the result of improper nose blowing. Another cause, which may have a more rapid onset, is swimming or diving; occasionally, an upper molar tooth abcess breaks into the maxillary antrum. The extent and persistence of the infection depends on two major physiological principles, ventilation and drainage; the treatment is directed toward these prin-

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Otorhinolaryngology ciples. The most common bacterial causes are the Gram-positive cocci. Acute suppurative sinusitis usually has symptoms of nasal congestion and pressure or pain over the involved sinus. Toxicity is usually mild, except in cases of pansinusitis when the frontals or sphenoids are involved. Pus draining from the middle meatus or above the middle turbinate, pain and pressure over a maxillary or frontal sinus, and decreased transillumination may be sufficient to make a diagnosis. The X- ray is indispensable, however, in determining the extent of the disease, fluid levels, and response to medication, all of which may indicate the proper approach to treatment. Maxillary sinusitis, usually has the least toxicity, but a persistent fluid level or pain after 48 hours of adequate antibiotic therapy suggests the need for irrigation of the antrum, either through the canine fossa or through the thin, bony wall of the inferior meatus. The maxillary sinus mucosa has great reparative power; after removal of the pus by irrigation, it may clear within a few days. If the antral infection is dental in origin, it is useless to attempt a cure without treatment of the offending tooth. Ethmoid sinusitis is probably the most common infection. Due to the proximity of the ethmoid sinuses to the frontal and maxillary sinuses, ethmoid sinusitis either causes or is associated with the infections in those sinuses also. Ethmoid infections usually cause more inflammation and mucosal swelling. Pain may be near the root of the nose or frontal region. Edema of the lower lid is often present in children. Orbit involvement may result in painful eye movement due to a periostitis about the pulley of the superior oblique muscle or, in the case of rupture into the orbit, proptosis. Frontal sinusitis usually is associated with toxicity, frontal headache, often in mid-morning to late afternoon, tenderness to percussion over the sinus, or pressure on the floor in the supraorbital region; swelling of the upper eyelid may be highly suggestive. Treatment should be vigorous to prevent osteomyelitis of the skull or fistulas that lead to complications, such as soft tissue or sinus cavity abscesses, meningitis, brain abscess, and even death. Sphenoid sinusitis is uncommon, but it may result as a direct extension of infection in neighboring sinuses, nasal mucosa, or the nasopharynx. The symptoms are variable, but they may consist of a deep, boring, occipital or parietal headache with inability to concentrate, fever, malaise, and anorexia. Rupture or osteomyelitis from sphenoid infection leads to rapidly fatal meningitis or cavernous sinus thrombosis. Diagnosis can usually only be made by suspicion and X-rays, using proper contrast in the lateral and submental vertex positions; fluid levels will only be seen if the X-rays are taken in the upright position. These patients require high doses of intravenous antibiotics and emergency surgical intervention.

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U.S. Naval Flight Surgeon’s Manual

Since the cardinal principle of treatment in sinus infections is ventilation and drainage, the following treatment is suggested: 1. The nasal mucosa must be protected from drying. The patient must be kept hydrated, and, in some cases, use of a humidifier or vaporizer may help. 2. An oral decongestant may be used alone or with an antihistamine. Antihistamines may make secretions too thick or the mucosa too dry, so it is often helpful to use a mucousthinning medication, such as glycerial-guiacolate. 3. Antibiotics are given orally in adequate doses for at least seven days in most uncomplicated cases, but in pansinusitis or cases of moderate to severe toxicity, and especially in frontal or sphenoid involvement, intravenous antibiotics are necessary. Most organisms are sensitive to penicillin or erythromycin, but it is strongly recommended that a culture be taken from the turbinates and the meatuses. Be sure not to touch the nasal vestibule and hairs, as these areas may have different predominant organisms. The nasopharynx is another area from which to obtain a culture of prevalent sinus drainage. 4. Bed rest, hydration, and adequate pain medication are important in patients with toxicity. 5. Antral irrigation, either through the natural ostium or the canine fossa or inferior meatus puncture approach, is indicated for persistent pain or fluid levels after 48 hours of antibiotic therapy. Persistent swelling, and pain in the frontal sinus region, in spite of intense therapy, may signal the need for a frontal sinus drainage, usually done by trephine through the sinus floor. A rubber or plastic tube dram is sutured in place to allow irrigation and drainage until the natural ostium drainage is reestablished. 6. Daily mucosal shrinkage and gentle nasal suction cleaning may help promote drainage. 7. Local heat is often helpful, not only as comfort to the patient, but to increase the vitality of the mucosa. 8. Persistent or subacute ethmoid disease may respond to Proetz displacement irrigation, or Grossan nasal irrigation. 9. Acute sphenoid infection with toxic signs is an emergency life- threatening situation requiring immediate hospitalization and surgery, so one should always be alert to this disease, by itself or as a complication from the other sinuses.

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Otorhinolaryngology Neglected sinus infections or subacute disease leads to chronic irreversible changes in the sinus mucosa. With chronic purulent drainage or sinus blockage, one usually has to resort to surgery after conservative treatment fails. For the maxillary sinus, a Caldwell-Luc antrostomy or an intranasal antrostomy (antral window) is most often used. Removal of the ethmoid cells is most difficult and is done with an intranasal approach when polyps and persistent disease are present. Chronic sphenoid disease is not only rare, but most difficult to diagnose, because X-rays may be inconclusive and symptoms extremely variable. Chronic disease in the frontal sinus, be it osteomyelitis or mucocele formation, dictates a major surgical procedure through either a bicoronal incision flap approach or the osteoplastic eyebrow incision approach, with complete removal of the sinus mucosa and obliteration of the sinus, usually with fat. These surgical procedures and treatment may not result in relief of nasal symptoms or remove the tendency toward recurrent infection. A frontal sinus obliteration is usually disqualifying for most types of aviation. Antral cysts, which are frequently seen on the Waters X-ray as a smooth, rounded density in the lower aspect of the maxillary sinus, are benign, filled only with clear or xanthochromic fluid. They usually require no treatment, unless they fill the sinus, obstruct drainage, and lead to local symptoms of disease. Maxillary Sinus Irrigation-Inferior Meatus Puncture Anesthesia. 1. Spray mucosa initially with a vasoconstrictor. 2. For local anesthesia use four or five percent topical cocaine or 20 percent Benzocaine and two percent Xylocaine with Epinephrine 1:100,000 (dental carpule or equivalent). 3. Apply pledgets of cotton moistened with cocaine or Benzocaine (never sloppy wet) in the inferior meatus and on the inferior turbinate. After initial application, anesthetic on a wire applicator is placed against the lateral wall of the inferior meatus about one inch or 1.5 to 2.5 cm behind the anterior edge of the meatus for five minutes. 4. Insert a long (3 1/2 inch) needle into the inferior meatus until it strikes bone in the area of the intended puncture and infiltrate with local anesthetic. Equipment. 1. Straight three and a half inch, 18 gauge spinal needle or equivalent trocar with stylet.

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U.S. Naval Flight Surgeon’s Manual 2. Sterile saline to which a small amount of Neo- Synephrine may be added. 3. One 30 to 50 cc syringe and one 5 cc syringe. 4. Plastic or rubber extension tubing. 5. Culture tube. Technique. 1. With the patient in a supine position and the head against a firm headrest, the puncture needle or trocar is inserted into the inferior meatus about two centimeters posterior to the edge of the inferior meatus and engaged in the thin bone of the lateral wall of this area. 2. The thumb is placed against the stylet and the needle is directed laterally in line with the outer canthus of the eye, using the fingers of the opposite hand to steady the needle. Pressure is slowly, but steadily, increased until the needle is felt to penetrate into the sinus. 3. The needle is pushed into the sinus until it strikes the lateral sinus wall and then withdrawn about one centimeter. If a low-lying cyst is present, the needle is directed as far inferior as possible just after penetration to puncture the cyst. 4. Direct observation of the drainage or aspiration with a small syringe may be diagnostic or produce a pure specimen for culture. Then place the patient in an upright position. 5. The large syringe and extension tubing filled with normal saline are inserted into the needle and aspiration is attempted. Air bubble or exudate indicates the needle is in the proper position. No aspiration may mean the needle is in the mucosa, plugged, or not in the sinus proper. 6. Irrigation is carried out with the patient leaning forward over a large basin with his mouth open, and gentle, but steady, pressure is applied to the syringe. 7. Instant, severe pain suggests the needle is in the mucosa; readjust the needle’s position and repeat. Intolerance to irrigation pressure dictates termination of the procedure and possible attempt at natural ostia irrigation. A slow buildup of pressure and occasionally pain is expected with an obstructed ostia, but it is usually tolerable or relieved as the sinus is irrigated.

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Otorhinolaryngology 8. Irrigation should be carried out until the washing is clear or, in the case of a clear irrigation, until at least three full syringes have been used. 9. The final irrigation should be made with the sinus ostia dependent. lnsufflation of air into the sinus has been associated with air embolism and should not be performed. 10. The needle is withdrawn with a smooth rapid movement and the nasal passage immediately inspected for retained pus or thick mucus. This material is aspired, being sure to include aspiration of the posterior floor and middle meatus. Maxillary Sinus Irrigation - Natural Sinus Ostia - not recommended Anesthesia. 1. Use Xylocaine 4 percent or Benzocaine 20 percent for local anesthesia. 2. Vasoconstrict the mucosa. 3. Apply anesthetic-moistened pledgets in and around the middle meatus. A long applicator containing anesthetic may also be inserted posteriorly against the area of the sphenopalatine nerve exit. Equipment. A maxillary sinus cannula plus the equipment used for the puncture technique are required. Technique. 1. A maxillary sinus cannula is inserted posteriorly into the middle meatus and slowly brought forward with the tip probing for the ostia in the hiatus semilunaris. When the cannula passes into the ostia, it should be anchored with tape to the nose or held in place by the physician. 2. Aspiration and irrigation are carried out in the same manner as for the needle irrigation. Ethmoid Sinus Irrigation The Proetz displacement technique can be used for irrigation of the frontal, sphenoid, and maxillary sinus as well as for the ethmoid sinus in nonacute disease.

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U.S. Naval Flight Surgeon’s Manual Equipment. 1. A controlled vacuum source. 2. Sterile 100 cc solution container. 3. Proetz vacuum apparatus (curved olive tip glass collection bottle). 4. Sterile bulb or other syringe, 20 cc or larger. 5. Sterile normal saline into which may be added Neo-Synephrine, not to exceed a total of 1/8 percent. Technique. 1. Place the patient supine, with head lowered over the edge of the table. 2. Instruct the patient to breathe only through the mouth and not to swallow or talk until instructed . 3. Pill the nose and nasopharynx with the solution through one nostril. 4. Insert the soft rubber or steel olive tip of the vacuum apparatus into one nostril, with no more than 180 mm Hg of vacuum. 5. Close the opposite nostril and have the patient say K-K-K-K-K-K-K-K. 6. Repeat the procedure several times in each side, or until purulent material is no longer present. 7. Stop immediately if the patient has severe pain, or if blood is noted in the irrigation fluid. 8. Give the patient a rest and allow him to sit up to drain out the nose several times during the procedure. Nasal Fractures Nasal fractures are common injuries which can usually be handled in the clinic or sickbay by the flight surgeon. There are basically three types: (1) a simple fracture of the nasal bones, most

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Otorhinolaryngology often just the tip, (2) lateral displacement of the nasal bones to one side, often as a green stick fracture on one side and impaction on the other, and (3) marked flattening of the nasal bridge with comminution of the bones or an accordian fracture displacement of the septum. Diagnosis of a displaced fracture can best be made by inspection, palpation, lateral X-ray of the nasal bones and comparison of the patient to his or her ID card or recent photo. Shortly after injury, when the airway is compromised, or before profuse swelling has occurred, reduction should be accomplished under local or general anesthesia. When the injury is very recent and the patient is still in a shock or “numb” like state, simple lateral displaced fractures can often be reduced without anesthesia by simple, quick, firm, thumb pressure on the convex side of the nose. When soft tissue swelling is marked, distorting the true alignment of the nasal bones, one may elect to wait four or five days for the swelling to recede before reduction. A compound fracture should be reduced within a few hours and then have a plastic-type laceration closure since reduction maneuvers usually tear out delicate sutures. Antibiotic coverage is recommended to prevent complications. Anesthesia Technique for Reduction of Nasal Fractures. 1. Shrink the nasal mucosa with one percent Neo-Synephrine. 2. Use fresh topical four percent Xylocaine, or 20 percent Benzocaine.. 3. Moisten long, thin, cotton pledgets with the anesthetic, squeeze out the excess, and insert them into the superior and middle aspects of the nasal passages. They should touch the septum and turbinate mucosa beneath the nasal bones where reduction instruments are inserted. The sphenopalatine and long nasopalatine nerves may be blocked by applying anesthetic on a long applicator to the area of the sphenoid rostrum. The area can be reached by inserting the applicator back past the posterior tip of the middle turbinate. The ethmoid nerves may be blocked by applying anesthetic on an applicator inserted superiorly just exterior to the middle turbinate tip. 4. Local anesthesia, using two percent Xylocaine with epinephrine (dental syringe carpule), is obtained by inserting a long dental needle into the nasal vestibule just above the upper lateral cartilage at the limen nasi. The needle is slid beneath the skin in the subcutaneous tissue but external to the nasal bones to the desired location. 5. Infiltration sites are the glabella for the superior trochlear nerve, the inner canthus region for the ethmoid and the infratrochlear nerves. A more lateral reinsertion of the needle to

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U.S. Naval Flight Surgeon’s Manual the infraorbital notch will block the infraorbital nerve. Following an initial wheal, the needle is slowly withdrawn while injecting a tract of anesthesia. Repeat on each side. A sublabial approach is also satisfactory. 6. Local anesthesia of the superior septum is obtained by injection of the septum just beneath the tip of the nasal bones and obtaining a “run” of the anesthesia beneath the mucoperichondrium. For the entire septum several anterior injections are required with the bevel toward the cartilage. Equipment for Nasal Fracture Reduction. 1. Elevator - Most often used is the Sayer elevator. Others are flat scalpel handles or the Salinger reduction instrument. 2. Bayonet forceps. 3. Gelfoam pledgets. 4. Half-inch Vaseline-impregnated gauze, minimum of two tubes. 5. Antibiotic ointment. 6. Rubber finger cot. (optional) 7. Quarter-inch regular or plastic tape. 8. Malleable metal nasal splint. Nasal Fracture Reduction Techniques. 1. Septal Fractures Only. a. Grasp the septum between two fingers, pull forward up, and side to side, using a thumb or finger of the opposite hand to unbuckle a concavity. b. The nose is then packed (beware of toxic shock syndrome) on both sides to maintain a good alignment alone or against a stint.

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Otorhinolaryngology c. Stints of dental wax or Teflon sheets can be used and held in position with through and through septal sutures. 2. Depressed Nasal Tip. a. Place a finger cot over the elevator and insert it in either nostril to just beneath the fracture. Using the fingers of the opposite hand to move and guide the fragment, lift the fragment with the elevator and slowly withdraw. b. Place compressed Gelfoam beneath the fracture site on both sides. Selvage gauze anterior packing, external taping, and a metal splint offer the best results. Packing should be removed in 24 hours. 3. Lateral Displaced or Comminuted Fracture. a. Measure the distance externally from the nostril to the glabella on the elevator. Insert the elevator the measured length into the most open side of the nose. b. With a steady lift of the elevator, move the fracture further to the deviated side. Then move the nasal bones across the midline an equal distance to the opposite side; return the fragments to the midline. Some bleeding is expected, but in the majority of cases, Gelfoam is all that is required for control, and it helps prevent adhesions that may occur superiorly. External taping and metal protection aid in maintaining alignment. Taping and Splinting Techniques. 1. Apply benzoin solution to the forehead, nose, and cheek areas. 2. If the nose is packed, the initial tape should run from one side to the other parallel with the dorsum across the packed nares. Do not pull tight, and allow for tissue swelling by cutting or pinching the tape at the tip. 3. Fixation of the nose is provided by an initial tape across the dorsum from cheek to cheek, then a crisscross taping from the forehead to the cheek on both sides. This may be weaved in with the dorsal tapes. If the nose is packed, be sure all of the tip is covered with tape to prevent swelling.

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U.S. Naval Flight Surgeon’s Manual 4. A malleable aluminum splint is placed over the nasal taping and held in place by similar crisscross taping. 5. For drainage, a folded two by two-inch pad taped across the lower lip allows the patient to breathe and eat without interference. Errors in Nasal Fracture Treatment. According to DeWeese and Saunders, the following common errors are associated with treatment of nasal fractures: 1. The doctor attempts to set a nose that was also fractured years previously, but the patient becomes aware of the old deformity only when the new trauma calls attention to it. (Check the patients ID card). 2. X-rays reveal no fracture when one is present altering the doctor’s clinical judgment. In reality, X-rays are of little practical value in management of nasal fractures. However, they are of great value in management of fractures of the zygoma and infraorbital sinus. 3. The doctor regards easy to reduce fractures too seriously, and severe fractures too lightly, leading to unnecessary anesthesia or poor reduction because of limited anesthesia. 4. The doctor waits longer than five or six days to reduce; thereafter, reduction may be difficult . 5. In addition, attempting to reduce a fracture in a grossly swollen nose may lead to insufficient reduction or poor alignment. Maxillary Fractures Maxillary fractures should always be suspected in direct trauma to the face when there is malocclusion or restriction of mandibular movement, flattening of the side of the face, a “black eye” which included ecchymosis and subconjunctival hemorrhage, anesthesia over the face supplied by the infraorbital nerve, or the more serious sign of diplopia. X-rays are extremely important in diagnosis, as well as postreduction evaluation. A full series should include the Waters, Caldwell, lateral, and submental vertex. Zygomatic arch fractures can be elevated under local anesthesia through a temporalis fascia approach or a buccal mucosa approach. All other fractures require more extensive open reduction, often with wire fixation or prosthetic support and protection requiring the assistance and training

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Otorhinolaryngology of an oral surgeon, otolaryngologist, or in the case of a true “blow out” fracture, an ophthalmologist. Examination of the Mouth and Pharynx This part of the ENT examination should be thorough and easy on the patient, but it is often most difficult and stressing, both for the physician and the patient. The following points and techniques are recommended. The patient should always be as comfortable as possible and in an upright position. Explanation and instructions to the patient before the procedure is started are absolutely necessary. The physician should reassure the patient and refrain from using uncomfortable words, such as gag, and from putting the mirror down the throat, or pulling the tongue. The patient should be encouraged to relax his tongue during the oral and pharyngeal examination and to breath through his mouth. If there is concern about disease transmission, the physician can wear a mask. The correct technique for using a tongue depressor is to insert the blade into the mouth without touching the tongue and then to press straight down on the anterior two-thirds of the tongue. Except for hypopharyngoscopy, the patient should not stick out his tongue because this raises and firms up the tongue, preventing good exposure of the tonsils and pharyngeal area. When warming a mirror, the physician should always test the back side of the mirror for proper warmth against his wrist or face so that the patient will not fear being burned. On introduction of the nasopharyngeal mirror, sizes zero, one, or two, it is helpful to slide the handle along the comer of the mouth and touch the patient’s face with the finger to steady the mirror. This also helps distract the patient’s thoughts about gagging. The nasopharyngeal mirror may be slipped into the nasopharynx alongside of the uvula and may even touch the tip, but touching the base of the tongue should be avoided. When holding the tongue for the laryngeal examination, the under surface should be wrapped with cotton gauze to protect it from the sharp edges of the teeth. The fingers can be steadied against the lower teeth and upper lip. If the patient sits up straight and brings his head and chin forward, the larynx is more fully visible. Fingers against the patient’s face steady the mirror (size 3, 4 or 5) as it is introduced into the mouth, without touching the tongue, toward the uvula and soft palate. Often the vocal cords can be seen without touching the soft palate, but if necessary, contact should be positive and firm, with little or no movement after contact is made. If a patient is unable to breathe through his mouth when requested, it may be necessary to have him hold his nose closed. These examinations should last only 10 to 15 seconds because of salivation, anxiety, and discomfort. For patients with hyperactive gag reflexes, mild mucosal anesthetics such as Chloraseptic or Benadryl Elixir can be tried first. Stronger anesthetic agents

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U.S. Naval Flight Surgeon’s Manual such as Cetacaine, one precent Tetracaine, four percent Xylocaine, or five percent cocaine may be necessary, but some are toxic and rapidly absorbed from the oral mucosa, so care must be exercised in the amount and rapidity with which they are applied. For extremely difficult cases, I.V. diazepam (Valium) of 2.5 to 5 mgm over a 90 second period of administration, gives an excellent effect for 15 to 20 minutes. Since apnea, caine reactions, or cardiac arrest are always a definite danger with these drugs, resuscitative equipment should be at hand. Common Oral Diseases Thrush. Since the advent of antibiotics, thrush, formerly seen chiefly in children, is now being seen in adults when the normal flora is altered. The usually white mucosal lesions are scraped for microscopic diagnosis of the characteristic yeast cells. Treatment of choice is usually with Mycostatin suspension, 1 cc (10,000 units). It is swished around in the mouth for a full five minutes daily, for seven or more days. All other antibiotics are stopped. A one percent Gentian Violet solution may also be applied b.i.d. to the lesions, but the messy staining properties of this solution have decreased its use. Herpetic Lesions. Fever blisters and cold sores caused by the herpes simplex virus begin with a vesicle that, unlike the aphthous ulcer, usually involves the gingiva; the vesicle breaks and forms an irregular ulcer. These lesions are most common after a febrile illness, trauma, actinic exposure, or stress. Treatment is symptomatic with nonirritating mouthwashes and oral irrigations; mild anesthetic ointments and solutions may be helpful. Benzoin and Orabase may protect or dry the vesicles and ulcers. Early application or Stoxil ointment or ether has been used, but the success rate is variable, and there is some suspicion of RNA alteration to a carcinogenic state. Corticosteroids are contraindicated. Aphthous Stomatitis. Recurrent canker sores are found most often as multiple, well-delineated shallow ulcers on the buccal and labial mucosa, tongue, soft palate (including tonsillar pillars), and pharynx; occasionally, there is only a single lesion. These yellow-gray, membrane-covered ulcers heal spontaneously in one to two weeks. There may be severe pain requiring topical and oral anesthetics for eating. Longer relief can often be obtained by cleaning the lesion off and applying Kenalog in Orabase, while it is still dry This may be repeated three or four times daily. Some physicians advocate the use of Tetracycline suspension, 250 mgm/per tsp., held in the mouth for at least two minutes and then swallowed, four times daily. Aphthous stomatitis should be differentiated from the herpetic gingival stomatitis by lack of bleb or vesicle formation or associated systemic disease, before cortisone treatment is started.

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Otorhinolaryngology Pharyngitis Sicca or Chronic Dry Throat. The pharynx is usually dry, smooth, and shiny, with some yellow-green crusts. Treatment usually provides only temporary relief, but 50 percent potassium iodide, 10 gtt. in mild t.i.d., SSKI, 6 gtt, in half a glass of water t.i.d., or painting the throat with Mandel’s solution may be helpful. Occasionally, three to five grams of ammonium chloride t.i.d. also helps, but fluid and electrolyte balance must be watched. Pharyngeal Infection. It is sometimes difficult to determine if a pathogen is responsible for an infection in the nose or throat, or which pathogen is responsible. Many organisms such as Streptococcus veridans Neisseria, anaerobic streptococci, Staphylococcus albus, or yeast are always present and termed normal flora. Although a culture, which takes 24 to 48 hours to grow, may be helpful in treatment and should be obtained, it should be remembered that staphylococci can be obtained from 60 to 80 percent of the population, and beta-streptococci are often isolated from patients with a viral infection. Furthermore, pathogens may become established in the host and remain for months without causing disease. This is referred to as a carrier state. In treatment, the physician must make an intelligent “guess” about the etiology of the infection, using the most important clinical picture, a smear from the infected area for pus cells and predominant organisms, and then correlate this information with the bacteriological findings. Acute Tonsillitis. Acute bacterial tonsillitis or pharyngitis is most often caused by betahemolytic streptococci, Group A. It usually has a rather abrupt onset, with fever of 101° F+ and chills. The mucosa is grossly inflamed, with white or yellow exudate on the lymphoid follicles. If the exudative tonsillar tissue becomes necrotic, it is termed necrotizing tonsillitis. The antibiotic treatment of choice is penicillin, most often given orally, 250 mgm, q.i.d. An initial I.M. dose of 1.2 to 1.5 million units of procaine penicillin may be given to adults, to obtain a more rapid blood level. Therapy should be continued ten days. With toxic symptoms, the patient should be on bed rest and forced fluids. Hot throat irrigations hourly or at least four times daily, coupled with analgesics, such as Empirin Compound #3, Ascodeen - 30, or Tylenol #3, are necessary for both comfort and a more rapid recovery. Infection of the lingual tonsils at the base of the tongue, often not properly diagnosed without the aid of the laryngeal mirror, may cause considerable dysphagia. Besides the normal treatment for tonsillitis, the physician may need to add, by direct application, gargle or spray, soothing substances such as Chloraseptic solution, Mandel’s paint, or a topical anesthetic, such as Dyclone, 0.5 percent or 1 percent. Nasopharyngitis. Occasionally, a physician may see a patient who appears toxic and febrile, with pressure or pain in the ears, a severe headache, or retrobulbar pain. Usually, the oropharynx

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U.S. Naval Flight Surgeon’s Manual is somewhat inflamed, and there is occasionally neck stiffness or edema of the uvula. Examination of the nasopharynx with a mirror will make the diagnosis of nasopharyngitis with the discovery of exudate in upper reaches of the nasopharynx. Treatment with I.M/I.V. antibiotics initially, plus supportive treatment, is advocated. Viral Pharyngitis. Sore throat, lymphoid injection without exudate, general or posterior cervical adenopathy, and malaise are the usual symptoms of a viral pharyngitis; a normal white blood count with increase in the lymphocytes is often the blood picture. Tonsillitis that has a membranous exudate, marked lymphoid hypertrophy, often a negative throat culture, and does not respond to penicillin, should be evaluated for infectious mononucleosis. Diagnostic tests include white blood count, differential, and a mononucleosis spot test. In areas of frequent cases of gonorrhea, resistant or unusual cases of pharyngitis should be cultured, specifically for Neisseria gonococci. Thornwaldt's Disease. Physicians should be aware of a nasopharyngeal bursa or pouch that sometimes forms in the midline of the adenoid tissue and, when it becomes infected, produces occipital headaches and an irritating, purulent postnasal discharge; it can also be present after adenoidectomy. Diagnosis is made by ruling out sinus disease and visualization of the draining bursa with the nasopharyngeal mirror, or more clearly, the nasopharyngoscope, or Yankhauer scope. Treatment requires either electrocoagulation or surgical removal of the cyst or pouch. Peritonsillur Abscess. Known also as quinsy (sore throat), this abscess results when tonsillar infection spreads or breaks through posteriorly into the potential areolar space between the tonsil and the superior constrictor of the pharynx. Formation of the abscess results in displacement of the tonsil toward the midline, anteriorly and downward, with displacement of the uvula to the opposite side; it also causes fullness or cellulitis of the soft palate. There is a variable degree of trismus, pain referred to the neck or ear, variable adenopathy, and often the classic “potato” speech that results from the spasm or cellultis involving the pharyngeal muscularity. Treatment consists of high doses of systemic antibiotics for 10 to 14 days and incision and drainage (I & D) of the abscess immediately, if fluctuant, or as soon as fluctuance develops. If spontaneous drainage is noted from a necrotic site, gentle suction and blunt, careful widening of the opening assists in providing adequate drainage. Hot saline throat irrigations every few hours and adequate analgesics are necessary for the first few days. The I & D site should be reopened in 24 hours. Occasionally, a second or third reopening may be necessary if considerable pus continues to accumulate. Emergency tonsillectomies are performed by some physicians as a treatment for the abscess, but this should only be done by experienced hands because of the danger of

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Otorhinolaryngology bleeding or sepsis. It is advised that an elective tonsillectomy be considered in about six weeks, after the acute infection has subsided. Incision and Drainage of Peritonsillar Abscesses. 1. Equipment a. Long handle, curved Kelly forceps with smooth blunt tips. b. Suction machine with tonsil and/or nasal suction tips. c. Long knife handle with #15 blade. d. Large metal basin. e. Culture tube. 2. Anesthesia a. Premedication with I.M. Demerol/Vistaril or I.V. Valium is recommended. b. Topical Cetacaine, or four percent Xylocaine is helpful. c. Local infiltration at the incision site with dental two percent Xylocaine and epinephrine, 1:100,000, is often used, but some physicians are against infiltration into cellulitic tissue. 3. Procedure a. The best site for incision is at the point of intersection of a vertical line from the last molar tooth on the involved side and a horizontal line from the lower edge of the soft palate on the opposite, uninvolved side. The incision should be made from lateral toward the midline, about 1.5 to 2 cm long, just through the mucosa. b. The curved Kelly is introduced into the incision and spread, opening over the top, but never through, the tonsil. The tip is at first directed straight in, then slightly downward and medially.

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U.S. Naval Flight Surgeon’s Manual c. When the abscess cavity is opened, there is a sudden, often forceful, release of thick pus, for which both the physician and the patient should be prepared. d. With the patient leaning slightly forward, immediate, rapid, but gentle, suction is applied to the draining pus and incision site. e. The incision must be opened sufficiently. Bleeding is usually slight and clots form in five or ten minutes. A sterile nasal suction tip may be inserted into the incision site for better evacuation of the pus, but strong suction should not be applied, as this may create severe bleeding. f. Hot saline irrigations, three or four times per day, are recommended. One or two liters of saline are used for each irrigation. The solution can be used directly from a commercial container or mixed by the pharmacy. Murphy drip bottles, irrigation cans, or the solution bottles connected to I.V. tubing are placed eight to ten feet high. A small oral irrigation tip or glass or plastic eyedropper can be used to deliver a forceful, narrow stream. The solution should be as hot as tolerable without burning the oral tissue. g. An acceptable alternative to incision and drainage (I & D) is aspiration of the abscess by an 18 gauge needle attached to a 10 cc syringe. Laryngology There are four major functions of the larynx - airway, sphincter, protection, and phonation. As an airway, the vocal cords are constantly regulating the required air flow needed by the lungs and maintaining a proper resistance or back pressure. When we strain or lift with our arms and chest muscles, the vocal cords close, trapping air in the chest cavity, fixing the chest wall, and allowing for maximum efficiency in the lift. This function comes into play for the cough and for the effort in defecation. The larynx is said to be the “Watch Dog of the Lungs”. Through the sensory branches of the superior laryngeal nerve, foreign bodies, abnormal mucus, pus, or fluids are prevented from entering the trachea by the rapid closure of the cords, followed by coughing or by clearing of the throat.

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Otorhinolaryngology The vocal cords produce sound which is modified by the lips, teeth, tongue, and palate to form speech or singing tones. Diseases of tbe Larynx Hoarseness. Hoarseness is defined as roughness or discordance in the quality of the voice. It is apparent that it is a symptom and not a disease process in itself. Often, the first and only danger signal of serious disease, local or systemic, involves this area. Unfortunately, the degree of hoarseness presents no clue to the type of illness or its prognosis. A thorough examination is necessary in all cases to ascertain the exact cause and to prescribe the proper treatment. Generally, there are intrinsic lesions such as inflammation, benign or malignant neoplasms, allergies, and trauma. There may be disturbances in innervation, either central or peripheral. Hoarseness may be a manifestation of system disease, such as TB, syphilis, muscular dystrophy, arthritis, or endocrine disorders, and finally, psychosomatic involvements must be considered when all else has been eliminated. No more that two weeks should pass before an examination is made of the vocal cords. Acute Laryngitis. The chief symptoms of acute laryngitis are pain and hoarseness, and they may be secondary to an upper respiratory infection, most often viral, or hemophilus in children or streptococcus in adults. On laryngeal examination, the vocal cords and adjacent subglottic and arytenoid area are inflamed, and there may be various degrees of swelling. In most cases, treatment of the primary illness with appropriate antibiotics, cough suppressants, steam inhalation, elimination of irritants, especially tobacco and alcohol, and voice rest, is sufficient. Lozenges such as Cepacol, anesthetics, troche with benzocaine, or throat sprays such as Larylgan, may be soothing. Laryngitis from vocal trauma and noxious gases is best treated with voice rest and humidification. Thermal burns or caustic injury may require, in addition to other treatments, system steroids and tracheotomy. Chronic Laryngitis. Chronic laryngitis includes many different conditions and implies longstanding inflammatory changes in the mucosa, as might be expected from recurrent acute episodes, chronic improper use of voice (singers, speakers, and hucksters), and exposures to adverse conditions, such as dust and fumes. Smoking and alcohol have been shown to contribute, as well as TB, syphilis, and chronic sinusitis or bronchitis. Chronic laryngitis may take the form of small, bilateral vocal nodules or large polyps at the junction of the anterior and middle third of the vocal cords. Other forms are hypertrophic or hemorrhagic changes on the cord or dry thickening of the interarytenoid area. Vocal activities must be limited and rest encouraged. Surgical measures will occasionally become necessary. The flight surgeon should encourage the patient to keep well

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U.S. Naval Flight Surgeon’s Manual hydrated. Expectorant drugs, such as potassium iodide or guaifenesin chloride are advocated, as is the use of humidification. The flight surgeon should follow the patient closely by regular mirror laryngoscopy to assure early treatment should surgical pathology develop. Salivary Glands Calculi occur more frequently in the submaxillary duct and gland. A common sign may be painful swelling of the glands when the patient eats. Localization of the calculus can often be made by bimanual palpation of the gland or duct, along the floor of the mouth, and a dental X-ray of the floor of the mouth. If the calculus is in the duct, it can often be milked toward the papilla. Removal is facilitated, after local infiltration with Xylocaine, by cutting off the papilla to enlarge the orifice and then slitting along Wharton’s duct. Calculi in the proximal duct or gland may require excision of the gland if the obstruction cannot be relieved. Infection behind the obstruction usually responds to drainage but may require antibiotics as in sialadenitis. Acute Sialadenitis. The parotid is more often affected than the submaxillary gland, usually resulting from retrograde extension of the mouth infection and dehydration, especially in the elderly. The duct should be milked and a culture taken; however, the most common organism is often a penicillin- resistant, coagulase-positive staphylococcus. The empirical choice of antibiotics would be adequate doses of cephalothin or methicillin. Correction of the dehydration is essential, and X-ray of 400 to 600R may be helpful in the treatment of pain and swelling. In severe resistant cases, I & D of the gland may be lifesaving. Chronic Sialectasis. Recurrent infections or, occasionally, congenital anomalies lead to stasis of secretions and chronic dilation of the ducts and alveoli, which can be diagnosed by sialography. Long-term therapy with tetracycline is often helpful, but unresolved symptoms may necessitate excision of the affected gland. Auriculotemporal Syndrome. After parotidectomy or injury to the gland, the patient may experience gustatory sweating, called Frey’s Syndrome. Temporary relief might be obtained by Scopolamine, but more lasting results may require a tympanic neurectomy of Jacobson’s nerve and the chorda tympani nerve. Treatment with an antiperspirant may suffice.

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Otorhinolaryngology SECTION II: AUDIOLOGY The Physics of Sound Sound is a remarkable phenomenon. It enables us to communicate with each other, to learn new ideas, to influence others, and to enjoy life. It is intrinsically involved in human activity. Without it, we would withdraw socially; too much of it, and our sense of hearing would be dulled. The science of sound, acoustics, provides a basis for understanding hearing and communications. Sound can be described as a wave-like pressure fluctuation in air that conveys energy from the source outward in all directions. Sound can also be transmitted by fluid or solid media, but for simplicity, this discussion will consider only the air medium. Sound is also that which is perceived by people or the human brain, so it will be necessary to describe the dual nature of sound in terms of its physical and physiological characteristics (Table 8-7). Table 8-7 Parameters of Sound

The basic physical characteristics of sound are its frequency, intensity, and spectrum. Frequency, measured in hertz (Hz) or cycles per second (cps) is the number of positive or negative pressure fluctuations of a sound wave each second. Frequency largely determines pitch, although it is not quite a one-to-one relationship. The subjective term pitch comes from the musical vocabulary and is the relative lowness or highness of that attribute of sound relating to the frequencies of the musical scale. The gross frequency range of human hearing for young, healthy, and undiseased ears is from below 20 to over 20,000 hertz. The intensity of a sound is the term generally used to describe the amplitude component of a sound wave. Intensity is not actually measured; sound pressure is usually measured, and its level

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U.S. Naval Flight Surgeon’s Manual is related in decibels (dB) to an arbitrary reference pressure. Thus, the term sound pressure level (SPL) denotes the measured sound pressure and is defined according to the following equation: SPL = 20 log P/P0 dB, where P represents the measured rms pressure in Pascals (Pa), and PO is the reference pressure in Pascals. The decibel is, then, a dimensionless logarithmic unit. The reference pressure used by acousticians is 20 Pa (or 20 N/m2) and will be used throughout this chapter. All sound level meters will be calibrated to this reference pressure. Loudness is loosely related to intensity, depending somewhat upon frequency and spectrum. Much of the literature of psychoacoustics deals with the detailed description of this complex relationship. The basic curves (Figure 8-2) showing equal loudness versus frequency at different levels were originally developed by Fletcher and Munson in 1933. Sound level meters contain a set of frequency-weighting networks which correspond to different loudness levels. Thus, the A-weighted level, LA, corresponds to an equal loudness contour near threshold, the B-weighted level, LB, to a moderate loudness level (55 to 88 dB), and the C-weighted level, LC, is nearly “flat” or unweighted and corresponds to a loudness sensation above 85 dB. The useful amplitude range of human hearing is from 0 to 120 dB. The threshold of hearing is the minimum level of sound that evokes a response in at least 50 percent of the trials. Hearing sensitivity is the general term denoting the absolute hearing threshold of an individual. Hearing acuity is the just- noticeable-difference in a controlled change of frequency, intensity, or spectrum. Masking is the process by which the threshold of audibility of one sound is raised by the presence of another (masking) sound. The type of sound used most widely for hearing testing is a discrete frequency stimulus called a pure tone. Most sounds, however, are complex mixtures of various frequencies and intensities. In order to identify and to classify these complex sounds, a frequency analysis is obtained which, when graphed, results in a spectrum analysis curve. A sound spectrum may, for example, be composed of most audible frequencies and would be called broad-band or wide-band noise. A sound with a few closely related frequencies would obviously be called narrow band. Noise having all frequencies with equal energy is called white noise, and noise with a gradual decrease in amplitude of the higher frequencies is called pink noise. Musical sounds, when analyzed, produce line spectra since they are composed of fundamental frequencies and overtones or harmonic frequencies which are arithmetically related to the fundamental. The sensation of complex sounds is rather difficult to describe. We are probably able to distinguish complex sound patterns by repeated exposure, and we store auditory “images” and

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Otorhinolaryngology patterns of changing spectral and temporal components. The more the repetition, the finer is the ability to make subtle distinctions (e.g., the difference in the sound quality between a Stradivarius and a Guamerius violin).

Figure 8-2. Free-field equal-loudness contours for pure tones (observer facing source) determined by Robinson and Dadson. Piano Keyboard helps identify the frequency scale. Only the fundamental frequency of each piano key is indicated (Peterson & Gross, 1972, published by permission of GenRad, Inc.).

The graph in Figure 8-3 is a composite which brings together various levels of hearing and tolerance throughout the audible range of hearing. The sound pressure level scale extends from below 0 dB to over 160 dB SPL and has as its reference 20 Pa. The minimum audible field (MAF) curve is the absolute threshold of hearing versus frequency and is the same as the 0 dB loudness curve in Figure 8-2. This curve is also very nearly 0 dB on the audiometer. Notice that the ear is less sensitive between 3000 and 4000 Hz. Below 18-20 Hz, we feel rather than hear the vibrations

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U.S. Naval Flight Surgeon’s Manual in the infrasonic range. Above 20,000 Hz, we sense a sort of pressure for sound in the ultrasonic range. The speech area ranges from 80 to 100 Hz to around 10,000 Hz and from about 40 dB to 80 dB SPL. Telephone and aircraft radio systems, however, are designed to transmit mainly the frequency range from 300 to 3000 Hz. At levels around 120 dB SPL, many individuals find that they can no longer tolerate the noise and will try to get away from it or seek hearing protection. Note that this is 30 dB above the lower level for the damage risk criteria (DRC) for the Navy Hearing Conservation Program (Section III) based upon an eight-hour workday. At 130 to 140 dB SPL, many people describe sensations of pain or tickle in their ear canals. A 160 dB SPL, tissue damage has been observed in deaf subjects, viz., a bruising of the capillaries of the tympanic membrane particularly around its periphery and near the manubrium of the malleus.

Figure 8-3. Thresholds of hearing and tolerance (adapted from Peterson & Gross, 1972, published by permission of GenRad, Inc.)

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Otorhinolaryngology Measurement of Hearing

Introduction An individual having a significant hearing deficit may be identified through a simple audiogram done during a physical examination or as a part of the Hearing Conservation Program (HCP). After this identification, a more detailed clinical evaluation is warranted. The clinical measurement of hearing and the interpretation of findings resulting from such measurements has become progressively more sophisticated since the end of World War II. A whole new professional field involving measurement, diagnosis, and rehabilitative aspects of hearing impairments has arisen since that time. The field is called audiology. Civilian audiologists are employed at the Navy’s two Aural Rehabilitation Centers at Oakland, California and Portsmouth, Virginia. Military and civilian audiologists are now on the staffs of many naval hospitals serving in Otolaryngology and Occupational Health and Preventive Medicine Departments. Increasing availability of clinical audiology services in the Navy means that the flight surgeon will see more and more clinical audiology reports in medical records. For this reason, the flight surgeon must understand the basic concepts of hearing measurement and interpretation to take full advantage of the more detailed information contained in the audiologists’ reports. Basically, there are four reasons for obtaining hearing measurements (audiometry): (1) to aid in medical diagnosis of an existing problem, (2) to plan a rehabilitation program, (3) physical evaluation for admission or retention in a particular program or task area, and (4) for hearing conservation purposes. The first area mentioned above is the topic of this discussion. Background The term decibel (dB) is routinely used in reporting the results of hearing testing. When used for this purpose, the dB is always referenced to a value called audiometric “zero”, which represents statistical averages of hearing threshold levels of young adults with no history of aural pathology. The current standard is ANSI (American National Standards Institute) S3.6-1969. An earlier standard, on which many hearing tests on older personnel might be based, is ASA (American Standards Association) Z24.5-1951. The newer standard was adopted because it more accurately reflects the hearing of people today and is in substantial agreement with the IS0 (Inter-

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U.S. Naval Flight Surgeon’s Manual national Organization for Standardization) R389-1964 recommendation. The ASA, ISO, and ANSI average minimum audible pressure curves are shown in Figure 8-4. Note that the values are plotted in dB Sound Pressure Level by frequency. The numeric values for each date point and the difference between the two standards are shown immediately above the graph. All of the ANSI threshold values are smaller (lower SPL) than their corresponding ASA values. This is a result of better subject selection, better electro-acoustic equipment, and better sound isolating booths for testing. The term audiometric “zero” is applied to each of these values. For example, the average hearing threshold level (HTL) at 1,000 Hz for the ANSI standard is 7.0 dB SPL; this is audiometric “zero” for that frequency. The same holds true for 6,000 Hz for the ANSI standard, where audiometric “zero” would be equal to 15.5 dB SPL. It is this way of specifying audiometric “zero” that permits the use of a straight line for “zero” on the graphic-type audiogram form (Figure 8-5). All Navy audiometers are now calibrated to the ANSI-1969 standard.

If both ASA and ANSI audiograms appeared in the medical record of an individual whose hearing has not changed, it would seem that hearing has gotten worse. This is due to the different audiometric “zero” standards and not to any organic change in HTLs. To convert the ASA audiometric findings to ANSI, one would add the difference values in Figure 8-4 to produce an audiogram directly comparable to the ANSI findings. The flight surgeon should be alert to this occurrence so that inappropriate referrals are not made. Another type of report format found in the medical record is the tabular audiogram (Figure 8-6). This is simply the numeric presentation of HTLs by frequency. One also frequently finds a graph-type audiogram card in the medical record produced by self-recording audiometers (Figure 8-7). These audiograms are very often done as part of the hearing conservation monitoring program. A self-recording card should not be left in the record. The HTLs should be transposed to a serial, tabular form which should be a permanent part of the medical record. This greatly facilitates comparisons of current and previous audiometric results. Most frequently, testing done at naval hospitals would be reported in the graph format (Figure 8-5).

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Page 8-55.

Figure 8-4. Audiometer reference threshold pressures for TDH-39 earphone sound pressures re: .0002 microbar as measured in NBS-9A coupler.

U.S. Naval Flight Surgeon’s Manual

Figure 8-5. Graphic audiogram form. 8-56

Otorhinolaryngology

Figure 8-6. Tabular audiogram form.

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U.S. Naval Flight Surgeon’s Manual

Figure 8-7. Audiogram card produced by self-recording audiometers. The instrument used for more advanced hearing testing is a clinical or diagnostic audiometer. It very often is a two-channel unit and combines pure tone and speech audiometry in a single cabinet. The two-channel capability permits the presentation of a different stimulus to each ear simultaneously or “mixing” two stimuli for presentation to the same ear, etc. There are many potential combinations. In the latter case above, one may want to “mix” speech and noise to present to one ear. The two stimulus levels (amplitudes) can be controlled independently, so that a positive or negative signal-to-noise (S/N) ratio can be created. This is often done in testing speech discrimination ability. Presenting speech and noise together makes the test much more realistic than presenting speech in quiet. Clinical units also have provisions for microphone, tape, phono, or internal oscillator input for pure tones. These inputs are fed through an attenuator and amplifier and then to the output transducer which would be an earphone or bone conduction vibrator, but it could be one or even two speakers. Clinical testing is conducted with the patient seated in a sound- treated room with the examiner in an adjacent room. The examiner can operate the equipment, whose output is cabled through the sound room wall, and can observe the patient through a window. The noise level inside an audiometric test booth is critical and is specified in ANSI S3.1, 1977. The subject responds, in the case of pure tone testing, by either pressing a button, which triggers a response light on the audiometer, or simply by raising his hand or finger. For speech audiometry, the subject responds by writing or checking off the word identified or by repeating the word aloud after the examiner. There is provision for two-way communication between the patient and examiner.

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Otorhinolaryngology Basic Hearing Tests Pure-Tone Audiometry. The most common and also the most elementary test is done with pure tones. The patient is asked to respond whenever he hears a tone, regardless of the loudness of the signal. The lowest amplitude at which the patient responds at a particular frequency is called the hearing level (HL). HL’s are determined at octave frequencies from 250 to 8000 Hz and at the half- octave frequencies of 3000 and 6000 Hz. Each continuous tone is presented for a period not exceeding one second. Intermittent (pulse) tones are also frequently used, especially in patients where tinnitus is present. There will be several tone presentations at a particular frequency before the HL is recorded on the audiogram (Figures 8-5 and 8-6). In general, pure-tone HL’s are determined for both air conduction (earphones) and bone conduction (vibrator) stimuli. Masking noise is used when one ear needs to be isolated from the other in order to get a correct threshold measurement for the test ear. Masking noise is generated within the audiometer and can consist of a broad or narrow-frequency band. Narrow band noise is most efficient for masking pure-tones. In a situation where one ear of the patient is “dead”, incorrect information would be obtained for the nonfunctional ear if masking were not used for the good ear. By air conduction measurement, the nonfunctional ear would yield HL’s around 50 to 60 dB. This is due to a phenomenon called “crossover”. Even though the signal is presented at the nonfunctional ear, it is heard by the good ear primarily by direct energy transmission through the head from the vibrating earphone cushion. The head creates about a 50 to 60 dB “barrier” between ears. If proper masking noise is applied to the good ear in the case mentioned, then a correct determination of a profound hearing loss would be made. An electromechanical vibrator is placed on the mastoid process for bone conduction (BC) testing. The threshold determination procedure is identical to that of air conduction (AC) testing. Since it requires more energy to drive a mechanical vibrator than an earphone, the maximum hearing loss that can be measured for BC is less than for AC, (e.g., 70 dB for BC and 100 for AC). Care should be taken to place the vibrator on the mastoid without contacting the pinna. This is to ensure that responses at low frequencies are auditory and not tactile in nature. Masking of the contralateral ear is done more frequently in BC than in AC. This is because interaural attenuation, while about 50 to 60 dB for AC, is practically nonexistent (0 to 5 dB) for BC. In the previous example of the “dead” ear, a BC measurement without proper contralateral masking would have shown normal BC hearing in the nonfunctional ear due to the low (0 to 5 dB) crossover levels. Speech Audiometry. Another aspect of the basic hearing test battery is speech audiometry. The purpose here is to discover two things. First, it is necessary to determine the amplitude at which

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U.S. Naval Flight Surgeon’s Manual the patient can repeat back approximately 50 percent of the two-syllable words presented to him. This measure is referred to as the speech reception threshold (SRT). There are six word lists, each list being a different scrambling of the same 36 words. The most widely used form is CID Auditory Test W-l. Secondly, the percentage of 50 single-syllable words the patient can correctly repeat back is determined. This test is called the “PB score” or “PB Max” and is a measure of speech intelligibility. The term “PB” stands for “phonetically-balanced”. When these word lists (24 lists with 50 words each, and 200 words in the corpus) were developed in the late 1940’s, it was believed that the phonemes in each 50-word list had to have the same proportionate frequency of occurrence as that in everyday English, in order for the test to be valid. This was later shown to be unnecessary, but the terminology “PB” still remains today.

Figure 8-8. These typical word intelligibility curves demonstrate the relationship between word discrimination and amplitude (Davis & Silverman, 1970).

A graph demonstrating the relationship between word discrimination and amplitude (SPL) is shown in Figure 8-8. the various curves shown are called articulation curves or performance intensity (PI) functions. The PB words, the most widely used form being CID Auditory Test W-22, are presented at a level of 40 dB above the SRT in routine use. Since this represents a suprathreshold presentation, masking noise is almost always used in the contralateral ear. It is at this amplitude or sensation level (SL) that most patients would achieve maximum performance. However, there are instances where this is not the case. So, ideally, a performance intensity function would be generated by presenting the monosyllabic word lists at a variety of sensation levels. A phenomenon called roll-over is demonstrated in Figure 18-8 by the abnormal curve. Roll-over

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Otorhinolaryngology is characterized by a worsening of discrimination as loudness is increased. This finding is characteristic of retrocochlear disorders (e.g., acoustic neuroma) and to a lesser extent Meneire’s syndrome. Often speech discrimination testing is done in a noise background. A variety of word lists and test formats are used for this purpose. The basic concept behind this is to provide a more realistic environment in the measurement of speech discrimination. It is a rare occasion, particularly in the naval environment, when the listening environment is absolutely quiet. There are several considerations for discrimination in noise testing. Probably the most important, single consideration is the signal to noise ratio (S/N) employed in the test. S/N ratio is expressed in dB, and the figure represents the number of dB the signal (speech in this case) is above or below the level of the noise. If the S/N is minus 4 dB, this would mean that the average speech level is 4 dB below the noise level. Typical S/N levels used in discrimination testing that would be reflective of typical naval aviation noise environments would range from 0 to +4 dB S/N. Threshold Tone Decay Tests. Another component of the basic test battery is the threshold tone-decay test (TDT). This is a pure-tone, supra-threshold test. It is usually done at 4,000 Hz first, and, if positive, the test frequency is dropped by octaves until 500 Hz is tested. The tone is presented at 5 dB SL for one minute. If the patient can hear the tone for the entire period at the same level, the test is negative. If the level of the tone has to be raised by 20 or more dB above the starting level, the test is positive. The TDT is a measure of auditory adaptation and is considered a screening test for retrocochlear pathoiogy. If the test is positive, other, more detailed, tests would be done in order to help establish the reason for the abnormal adaptation and the site of the lesion. The Suprathreshold Adaptation Test (STAT) is also frequently used. The test is positive if a high level (e.g., 100 dB) tone cannot be heard over a 60 second period. Advanced Tests in Differential Diagnosis Short Increment Sensitivity Index (SISI). This is a pure-tone test presented at 25 dB SL that measures amplitude discrimination ability. The result is expressed in terms of percent correct identification out of twenty, one-Db increments, added to a reference pure-tone level. A high percent correct response is indicative of a cochlear pathology. Alternate Binaural Loudness Balance Test (ABLB). This is one of two direct tests of a phenomenon called recruitment. Recruitment is an abnormal growth of loudness in which soft sounds are not heard while loud sounds are perceived to be as loud as in a normal ear. The presence of recruitment narrows the dynamic range of hearing significantly and is characteristic of a cochlear (sensory) pathology. In order to do this test, it is necessary for hearing to be within

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U.S. Naval Flight Surgeon’s Manual normal limits in the contralateral ear at the same frequency at which the test is being done in the poorer ear. Bekesy Audiomerry. Bekesy audiometry is an advanced site-of-lesion test and is a special form of the more routine, self-recording audiometry procedure. The patient is asked to track his puretone threshold by means of a response button, first for a pulsing tone and then for a continuous tone. Either a discrete frequency or continuous frequency tracing can be generated. The audiograms are traced on the same graph. The audiogram is then categorized according to the relationship between the pulsed and continuous tracings. There are five recognized types of Bekesy audiograms. Each type is supportive of a particular pathology and will be discussed in the section on interpretation of findings. Auditory Brainstem Response (ABR) Audiometry. ABR audiometry and electrocochleography (EChocG) are two relatively new objective hearing tests. Both are electrophysiological measures of auditory function. These are noninvasive techniques that involve computer averaging of the auditory system’s electrical response to clicks or tone pips. Either of these tests could be used in cases of functional (nonorganic) hearing loss or psychogenic problems. The ABR is particularly useful in cases of suspected brainstem lesions. The flight surgeon should have little contact with these test types. Lengthened Off Time (LOT) Test. The LOT test is also used where malingering is suspected. This is basically a Bekesy test with the pe