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ASM & FS (H.O.)

ASM & FS (H.O.). Rosalind Franklin University School of Medicine Med II Preventive Medicine Tues, 12 Apr 05, 1100-1200 Lecture by : Jesse Monestersky,DO,MS,MPH,DTM&H CAPT,MC,USNR(FS,HMO) Contact info : (W) 847-688-6712x5081 Email: jesse.monestersky@nhgl.med.navy.mil.

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ASM & FS (H.O.)

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  1. ASM & FS (H.O.) Rosalind Franklin University School of Medicine Med II Preventive Medicine Tues, 12 Apr 05, 1100-1200 Lecture by: Jesse Monestersky,DO,MS,MPH,DTM&H CAPT,MC,USNR(FS,HMO) Contact info: (W) 847-688-6712x5081 Email: jesse.monestersky@nhgl.med.navy.mil JH Monestersky

  2. Sobering stuff:Smoking craters in ground JH Monestersky

  3. Enabling Objectives • To gain familiarity with specialty of ASM & FS & their duties • To acquire understanding of key references & professional societies • To know training path of military & civilian FS, & training of ASM specialists • To acquire understanding of rigors of flight environment & potential killers JH Monestersky

  4. Orientation of Talk • Differences in civilian & military, commercial & general • Aviation medicine & space medicine alike but different • ASM/FS is just a subset of OEM, focusing on the aviator as a special category of worker; as hyperbarics with its focus on the diver is another special category of worker • ASM is a prevention specialty; central aspect of job is to prevent mishaps • Key job is personnel entry selection & retention • Determine safe to fly & fear of flying • Navy FS: PQ/NPQ, AA/NAA, NCD/CD • Hypobaric & aviation environment has unique physiology • Big part is HF (mishap investigation, aircrew coordination, instrument displays, personality, fitting in/not fitting in, go/no-go) • Focus is that of Navy FS & Navy RAM JH Monestersky

  5. Case Presentation • Should This Patient Use Supplemental Oxygen During Commercial Air Flight? • 65yo former smoker with stable COPD lives in a Midwestern city (20’ above S-L) & reports that he plans to fly to his daughter's wedding in CA. • No preceding hx of anemia, CAD, or CVA, & he is eucapnic. • Although he does not require supplemental oxygen currently, he asks whether you recommend his using oxygen while he is traveling aboard flight to wedding. • Table 1 (next slide) shows results of spirometry. • Is he at risk of hypobaric hypoxia & if so why? JH Monestersky

  6. Spirometry w/o pretest bronchodilator JH Monestersky

  7. ABPM Specialties & Professional Organizations • PM&PH (ACPM, APHA, ATPM) • OEM (ACOEM) • ASM (AsMA, IAASM) • CAQ: • HBOT (UHMS, ACHM) • MedTox (AACT, ACMT, SOT) JH Monestersky

  8. ASM/FS Professional Organizations • ASM: • AsMA • FS: • Military: Navy (SUSFS), Army (SUSAFS), AF (SUSAFFS) • Civilian : Civil Aviation Medical Association JH Monestersky

  9. Aerospace Medicine • Definition: • Branch of Preventive Medicine that deals with the clinical & preventive medical requirements of man in atmospheric flight & space. [AsMA: http://www.asma.org] JH Monestersky

  10. Standard References • Textbooks: • Aviation Medicine: • Dehart, RL; JR Davis: Fundamentals of Aerospace Medicine, 3rd Ed., Lippincott Williams & Wilkins, 2002 • Rayman, RB; JD Hastins, WB Kruyer, RA Levy: Clinical Aviation Medicine, 3rd Ed., Castle Connolly Graduate Medical Publishing, 2000 • Space Medicine: • Churchill, SE: Fundamentals of Space Life Sciences, Krieger Publishing Co., 1997 • Nicogossian, NE; C Leach-Huntoon, SL Pool: Space Physiology and Medicine, 3rd Ed., Lea & Fibiger, 1994 • Journals: • Aviation, Space, And Environmental Medicine (AsMA) JH Monestersky

  11. Hx of Profession • Origins of specialty, to develop & then apply physical qualifications for flight duty. • Driven by high losses of life due to physically unqualified pilots. JH Monestersky

  12. ASM/FS Jobs • Within ASM realm: • Government: • DoD & PHS • USA, USN, USAF, USCG • FAA • CAMI staff, Regional FS, Federal Air Surgeon • NASA • Space FS • Private sector: • Airline corporate offices • AME • Universities • Related disciplines: • OEM JH Monestersky

  13. Aerospace Medicine: Future • Continuing space shuttle flights, International Space Station, Commercial Space Flights, massive increases in domestic & international PAX, plans for permanent inhabitation of space. • Will require competent aerospace medicine support. JH Monestersky

  14. Approach to ASM/FS • At S-L: medical practitioner has a focus on abnormal physiology in a normal environment. • At altitude: medical practitioner has a focus on normal physiology in an abnormal environment. • FS takes care of aviator, a physiologically normal individual who works in hostile environment of flight. • The FS is natural interface between practice of medicine, science of safety & profession of aviation. JH Monestersky

  15. Some principles • Atmosphere (up to 600mi): • Troposphere: 0-8 miles (0-40,000’); weather • *Stratosphere: 9-28mi (45,000-150,000’); ozone, commercial jet travel • Mesosphere: 30-50mi (160,000-260,000’); middle atmosphere • *Thermosphere: 55-372mi; space shuttle travel • Exosphere: 600-1200mi; merges with planetary gases • Gas laws • Boyle’s Law: P1 V1 = P2 V2 • *Dalton’s Law: PT = P1 + P2 + ..... + Pn • Calculations: • PT=PN2+PO2+PAr+PCO2 • At S-L: PT=.79(760mm)+.21(760)+.03(760); 760mm=600.4+159.5 • At 10,000’: 199= .79(199)+.21(199); 157.2+41.8 • Importance: • %O2 does not change with altitude • It is ambient pO2 and pO2 in the lung that is important not %O2 • pO2 of atmosphere decreases with increasing altitude & decreasing pressure • Henry’s Law: p = K'cc • Charles’ Law: P1 V1 = T1 P2 V2   T2 • General Gas Law: P1V1 = P2V2 T2 T2 JH Monestersky

  16. Basics • Altitude & blood-O2 saturation: • SL: 95-98% • 10,000’: 90% • 14,000’: 84% (thought, memory, judgment impaired; peripheral vision affected; hands shake) • 16,000’: 77% (incapable of controlling aircraft & may lose consciousness) • 18,000 feet’: LOC, could occur in 15-30min • >18,000’: Effects in terms of time of useful consciousness • Time of Useful Consciousness: Altitude (ft)TUC w/o O2 40,000 15sec 35.000 20sec 30,000 30sec 28,000 1min 26,000 2min 24,000 3min 22,000 6min 20,000 10min 15,000 Indefinite JH Monestersky

  17. O2/Counter-pressure in Non-Pressurized Aircraft • From SL-10,000’: ambient air. • From 10,000’: O2 by mask at increasing concentrations up to an altitude of 20,000’ • From 20,000-40,000’: 100 %O2 • ≥40,000’: (+) pressurized O2 • ≥50,000 ft: (+) pressure O2 + pressure suits JH Monestersky

  18. Duties of Military FS • 50% clinical (primary care, occupational medicine) • 50% squadron duties: • Become a qualified aircrewman • HF boards & councils • Advisor/counselor • Family doc for squadron families • Fly with squadron (minimum =/>4hrs/mo) to interact with them in their environment • Aeromedical training briefs • Know aviators & support crew • Annual physicals • Process waivers • Down chits & Up chits • Special boards of flight surgeons • Research • Mishap investigations • Aviation safety JH Monestersky

  19. A brief picture show… JH Monestersky

  20. “Airplanes are interesting toys but of no military value.” Great moments in forecasting! [Marechal Ferdinand Foch, Professor of Strategy, Ecole Superieure de Guerre (Higher School of War), 1919] JH Monestersky

  21. JH Monestersky

  22. Educational Opportunities • Take an elective at FAA/CAMI • If HPSP student, take an elective at Ft. Ruckers, NAS Pensacola, Brooks SAM • Consider a career in the military as a FS • Think about FAA/CAMI training for FAA/AME • Consider RAM as 2nd residency • Consider learning to fly • Even consider Astronaut Corps! JH Monestersky

  23. ASM Training Programs • Military: • USAF: SAM (Brooks-City Base, San Antonio) • USA/USN: NAMI (NAS Pensacola) • Civilian: • UTMB (Galveston) • WSU (Dayton OH) JH Monestersky

  24. FS Training • Military: • USN: NAMI (6mos) • USA: Ft. Rucker (2mos) • USAF: Brooks-City Base (2mos) • Civilian: • FAA/CAMI: AME (1wk) • FS →→→ RAM JH Monestersky

  25. NAMI SFS Training: Water Survival Training • Survival swimming • 1-mile swim in flight suit • Full flight equipment swims • Devices: Helo dunkers, HEEDs, parachute drag, life raft JH Monestersky

  26. Brooks City-BaseTraining Centrifuge: • Test vehicle for developing & assessing effectiveness of experimental aircrew G-protection equipment & methods • Indoctrination & training of aeromedical & aerospace personnel in use of protective techniques • Familiarity with high rate of G onset (6 G/sec) , as well as sustained high G levels 8-9 G); profiles simulate newer high performance jet aircraft • Thousands have had this training JH Monestersky

  27. ABPM Training Programs • Minimums: • ACGME approved internship (PG-1) • MPH (PGY-2) • Practicum (PGY-3) • Required/Recommended (editorial remark): • Clinical specialty (IM, FP, EM, Peds) • Taking ABPM certification exam in ASM leads to B/C in specialty of ASM JH Monestersky

  28. USG Agencies • FAA (http://www.faa.gov): • Created by Federal Aviation Act of 1958; became part of DOT in 1967. • Regulates civil aviation to promote safety (inc., medical). • Encourages new aviation technology. • Operates system of ATC & navigation for civil & military aircraft. • Research in aircraft noise control & environmental effects of civil aviation. • Regulation of US commercial space transportation. • NTSB (http://www.ntsb.gov): • Since 1967, independent Federal agency charged by Congress with investigating all civil aviation accidents in US & significant accidents in other modes of transportation (railroad, highway, marine, pipeline) & issuing safety recommendations aimed at preventing future accidents. • Authority derived from Title 49 of the United States Code, Chapter 11. • NTSB serves as court of appeals for any airman, mechanic or mariner whenever certificate action is taken by FAA or USCG Commandant, or when civil penalties are assessed by FAA. • NTSB has investigated >124,000 aviation accidents & >10,000 surface transportation accidents. JH Monestersky

  29. Recommended Movies • The Great Santini (1979) • Officer & A Gentleman (1982) • The Right Stuff (1983) • Top Gun (1986) • Apollo 13 (1995) • Space Cowboys (2000) JH Monestersky

  30. Military Aviation JH Monestersky

  31. Potential Bad Stuff in Military Aviation Environment • Hypoxia • Hypothermia • Explosive cabin decompression (=/<1sec) vs. rapid decompression (1-12sec) vs. slow decompression • Barotrauma • Sudden incapitation [medical (e.g., AMI)] • G-forces (G-LOC) • Altitude DCS • Spatial disorientation & disorientation (mismatch of visual, vestibular, somatosensory cues; experienced aviators not immune) • In flight mechanical emergencies (e.g., hydraulics) • In-flight refueling • Stuff hitting you • SAMs, dogfights, bird strikes, FOD • Ejection • Drowning • Mishaps →Mishap Board → ?Career (Locally done wit NSC oversight) JH Monestersky

  32. Causes of Mishaps • Most accidents are HF not mechanical failure • Specific human factor causes: • Poor or marginal weather • Night flying • High task loading • Breakdown in crew coordination or scan in single piloted aircraft • Spatial disorientation • Loss of situational awareness • Distraction • Violations of SOPs/Regulations • G-LOC episode JH Monestersky

  33. Survival Equipment • Ejection seat • Helmet • OBOGS, O2 canister • Parachute • SV2 survival vest • Flotation device • Radio • Flares • Life raft • Water • Knife • Rescue helicopter JH Monestersky

  34. Military Aviator Training • Flight training • Aviation & quals (carrier, night, NVG) • Navigation • Weapons systems • NATOPPS • Aviation physiology • Altitude chamber • Water survival • Ejection seat & parachute • Simulator (stationary, dynamic) • Centrifuge (MSDD, High speed) • Ground survival • SERE school • ASO school • Note: NFS training parallels NA/NFO training JH Monestersky

  35. Aviation Fun Stuff to Do • Museums: • Visit the many private & government museums • Army, Navy, AF, NASA • Air shows: • EAA (Experimental Aircraft Association), Oshkosh WI; July • International Paris Air Show; July • Blue Angels (USN), Thunderbirds (USAF), Snowbirds (Canadian AF) • Learn to fly! JH Monestersky

  36. Core Knowledge in ASM • Clinical: • ENT, ophthalmology, aviation psychiatry, military OEM, aviation pathology, IM, neurology • Related disciplines: • Aviation safety, aviation physiology, human factors engineering, survival equipment, aeronautical engineering & physics JH Monestersky

  37. Civil Aviation • Interesting accident statistics: • 1-2 commercial airline accidents/yr in USA, yet 55% of adults state USG not doing enough to make air travel as safe as possible (FAA) • 35,890 flights take off & land every day in USA uneventfully • Odds of being in an airline accident are extremely low; more likely to die on way to & from the airport on highway than on a flight • USA, aviation accident rate (per 100,000hrs flown)= general aviation 8/100,000 vs. commercial air carriers <1/4/100,000hrs. • Military aviation accident rate >> civilian aviation (different missions) • Crashes: 51% on final approach & landing; 17% on takeoff, initial climb, climb; few along flight path • US doing great vs. other countries operating sudden death airlines JH Monestersky

  38. Civil Aviation Medicine • Medical involvement: • Aviation physicians great job as not a single accident in commercial aviation attributable to sudden medical incapitation in flight • FAA designated AME’s=5,072 [military/federal-8%, international (93 countries)-8%, domestic-84%]. AME’s who are pilots=2,354 (46%). • FAA/CAMI Aeromedical Certification processes 1,799 flight physicals/day; 37,476/month; with a turn-around time of 3-4 wks JH Monestersky

  39. PAX Issues • Economy class DVT • Infectious diseases due to air recirculation • Pregnancy • COPD/Heart Dx (can request supplemental O2) • Alcohol & abusive PAX • Terrorism • In-flight medical emergencies • Obesity & seat fit • Child safety (safety seats) JH Monestersky

  40. Staff Health Concerns • Gamma radiation • 49-95% air recirculation • Airport malaria (baggage handlers) • Chronic dyssynchrony syndrome/ jet lag • Job stresses • Annual physicals • IAQ (particulates, gaseous; ) • Related stressors of low RH, hypoxia, vibration, noise, motion sickness, fatigue • Endemic diseases & food sanitation • Aviator mandatory retirement age 60yo • Financial (airline solvency, pension plans, wages) JH Monestersky

  41. World of FAA AME • Those who require physical: • Airline transport pilots • Commercial pilots • Private pilots • Recreational pilots • Flight engineers • Flight navigators • Air Traffic Controllers • Those who do not require physicals: • Flight attendants • Mechanics • Dispatchers • Repairmen • Free balloon pilots • Glider pilots • Ultra-light pilots • AME’s adhere to FAA Regulations for aeromedical certification JH Monestersky

  42. FAA Medical • In business of assuring safety • Highest levels set for commercial operations, esp., PAX safety • Private pilots are allowed to assume some risk, & their passengers to assume some risk; more special issuances (waivers) tolerated • Fairness in certifications • Recent changes: • Upgraded medical kits, AED • Some current issues: • Commercial orbital & suborbital aircrew & PAX • UAV pilots • Note crashes investigated by NTSB not FAA JH Monestersky

  43. Space Medicine JH Monestersky

  44. Space Medicine • Crews undergo intense selection & training (simulators, neutral buoyancy lab, hypo/hyperbaric chambers, KC-135, NASA jets) • Flight medicine responsible for astronaut health (on ground) • Medical OPS responsible for mission support & medical contingency • Crew FS is lead medical flight controller in Mission Control Ctr (real time physiologic monitoring, private medical consultation • Life in microgravity (1/106 of earth) & weightless environment • Health problems, inc., skeletal mineral loss, muscle atrophy, delayed wound healing, psych, radiation • Challenges inc., nutrition, life support systems, behavioral, cognitive, vertigo, acute dx, DCS • On landing, post-flight astronaut rehab (post-flight orthostasis, weakened) • Risks of failure are enormous (to individual, mission, program) • Lots of close calls; space exploration inherently risky • ISS carries EMD, advanced life support pack, 103 Rx; no physician • International cooperation – KSC & JSC, Gargarin Cosmonaut Training Ctr in Star City Russia, ESA JH Monestersky

  45. Concluding Remarks • I hope that you enjoyed your exposure to an unusual side of medicine & unique medical specialty. • Aviation environment is an inhospitable environment. • You can play a role in making it safer for aviation professionals & the flying public. • Regardless of specialty you chose, ask your pts if they are aviation personnel, as some underlying conditions & meds are incompatible with safety of flight. • Remember some blue water Navy wisdom: There are more planes in the ocean than there are submarines in the sky JH Monestersky

  46. Discussion & Questions JH Monestersky

  47. Aviation Humor THE 25 RULES OF FLYING: 1. Every takeoff is optional. Every landing is mandatory. 2. If you push the stick forward, the houses get bigger. If you pull The stick back, they get smaller. That is, unless you keep pulling the stick all the way back, then they get bigger again. 3. Flying isn't dangerous. Crashing is what's dangerous.   4. It's always better to be down here wishing you were up there than up there wishing you were down here.   5. The ONLY time you have too much fuel is when you're on fire.   6. The propeller is just a big fan in front of the plane used to keep The pilot cool. When it stops, you can actually watch the pilot start sweating.   7. When in doubt, hold on to your altitude. No one has ever collided With the sky.   8. A 'good' landing is one from which you can walk away. A 'great' Landing is one after which they can use the plane again. 9. Learn from the mistakes of others. You won't live long enough to make all of them yourself. 10. You know you've landed with the wheels up if it takes full power to taxi to the ramp.   11. The probability of survival is inversely proportional to the angle Of arrival. Large angle of arrival, small probability of survival and vice versa.   12. In the ongoing battle between objects made of aluminum going Hundreds of miles per hour and the ground going zero miles per hour, the ground has yet to lose. 13. Good judgment comes from experience. Unfortunately, the experience usually comes from bad judgment. 14. It's always a good idea to keep the pointy end going forward as much as possible 15. Remember, gravity is not just a good idea. It's the law. And it's Not subject to appeal. 16. Keep looking around. There's always something you've missed. 17. The three most useless things to a pilot are the altitude above you, runway behind you, and a tenth of a second ago. 18. Helicopters can't fly; they're just so ugly the earth repels them. 19. Never let an aircraft take you somewhere your brain didn't get to Five minutes earlier. 20. Stay out of clouds. The silver lining everyone keeps talking about might be another airplane going in the opposite direction. Reliable sources also report that mountains have been known to hide out in clouds. 21. Always try to keep the number of landings you make equal to the Number of take offs you've made. 22. There are three simple rules for making a smooth landing. Unfortunately no one knows what they are. 23. You start with a bag full of luck and an empty bag of experience. The trick is to fill the bag of experience before you empty the bag of luck. 24. If all you can see out of the window is ground that's going round And round and all you can hear is commotion coming from the passenger compartment, things are not at all as they should be. AND FINALLY, 25. When in doubt, take AMTRAK. They may crash more, but they don't have to fall before they do! JH Monestersky

  48. Notes/Questions ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ JH Monestersky

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