USAF School of Aerospace Medicine
FLIGHT SURGEON'S GUIDE
This book is a guide and reference for Air Force Flight Surgeons in the performance of their duties. It combines medical knowledge with engineering and aeronautical facts to provide basic information in the very specialized field of Aerospace Medicine. It also applies to the Air Reserve Forces and the Air National Guard.
TABLE OF CONTENTS
Chapter 1
Page
THE AEROSPACE MEDICINE PROGRAM
Introduction...... 1-1
The Aerospace Medicine Squadron...... 1-1
Flight/Missile Medicine...... 1-1
Squadron Medical Element...... 1-2
Health Promotion Flight...... 1-2
Public Health Flight...... 1-2
Medical Readiness Flight...... 1-2
Bioenvironmental Engineering Flight...... 1-2
Aerospace Physiology/ Physiological Training Flight...... 1-2
Aeromedical Staging Flight...... 1-3
Aerospace Medicine Squadron Leadership...... 1-3
Why Aerospace Medicine...... 1-3
Chapter 2
HIGH ALTITUDE RESPIRATORY PHYSIOLOGY
Introduction...... 2-1
The Atmosphere...... 2-1
Composition...... 2-1
Pressure...... 2-2
Temperature...... 2-3
Cosmic Radiation...... 2-3
Physical Meteorological Divisions of the Atmosphere...... 2-10
Measurement of Altitude...... 2-11
Physiological Divisions of the Atmosphere...... 2-12
The Gas Laws...... 2-13
Boyle's Law...... 2-14
Dalton's Law...... 2-14
Henry's Law...... 2-14
The Law of Gaseous Diffusion...... 2-14
Avigadro's Law...... 2-14
Charles' Law...... 2-15
Absolute Temperature...... 2-15
Physiology of Respiration...... 2-15
Introduction...... 2-15
Ventilation Phase of Respiration...... 2-16
Composition of Respired Air...... 2-18
Composition of Pulmonary Air...... 2-19
Blood Transport of Oxygen...... 2-22
Oxygen Dissociation Curve...... 2-23
Influence of the CO2 Partial Pressure...... 2-23
Influence of Temperature...... 2-24
Transport of Carbon Dioxide (CO2)...... 2-25
Summary of Transport Phase...... 2-26
Gas Exchange in the Tissues...... 2-26
Control of Respiration...... 2-29
Neural Control...... 2-29
Chemical Control of Respiration...... 2-31
Hypoxia...... 2-32
Classification of Hypoxia...... 2-33
Factors Influencing Hypoxia...... 2-34
Stages of Hypoxia...... 2-34
Time of Useful Consciousness...... 2-36
Symptoms of Hypoxia...... 2-36
Prophylaxis and Treatment of Hypoxic Hypoxia...... 2-37
Pressure Breathing...... 2-38
PPB and Counterpressure Garments...... 2-41
High Altitude Limits and Protection...... 2-35
Hyperventilation...... 2-48
Treatment of Hyperventilation...... 2-50
Oxygen Toxicity...... 2-51
Aircraft Pressurization and Decompression...... 2-51
Methods of Pressurization...... 2-51
Limits to Pressurization...... 2-52
Cabin Depressurization...... 2-52
Oxygen Equipment...... 2-55
Oxygen Storage Systems...... 2-55
Oxygen Delivery Systems...... 2-56
Oxygen Equipment Problems...... 2-58
PRICE Checklist...... 2-59
Chapter 3
EFFECTS OF DECREASED PRESSURE:
DECOMPRESSION SICKNESS
Introduction...... 3-1
History...... 3-1
Etiology of DCS...... 3-2
Bubble Effects on the Body...... 3-3
Mechanical Effects...... 3-3
Blood-bubble Interface Effects...... 3-4
Clinical Manifestations of Decompression Sickness...... 3-4
Type I DCS...... 3-4
Type II DCS...... 3-6
Factors Affecting DCS Incidence and Severity...... 3-8
Treatment of DCS...... 3-13
Initial Response During Flight...... 3-13
Medical Management...... 3-13
Aeromedical Disposition Following DCS...... 3-15
Chapter 4
EFFECTS OF ACCELERATION
Introduction...... 4-1
Basic Principles...... 4-1
Speed and Velocity...... 4-1
Acceleration...... 4-1
Basic Physiological Effects of Acceleration...... 4-2
Cardiovascular System Effects...... 4-4
Respiratory Effects...... 4-6
Central Nervous System Effects...... 4-7
Renal System Effects...... 4-7
Musculoskeletal Effects...... 4-7
G Tolerance...... 4-7
G-induced Loss of Consciousness...... 4-9
Sensory Effects of Acceleration...... 4-12
Basic Neurophysiology...... 4-12
Illusions...... 4-15
Spatial Disorientation...... 4-19
Motion Sickness...... 4-21
Vibration...... 4-23
Chapter 5
THERMAL STRESS
Introduction...... 5-1
Heat Transfer and Thermal Balance...... 5-2
Measurement of the Thermal Environment...... 5-3
Effect of Clothing...... 5-4
Human Thermoregulation...... 5-5
Heat Stress Effects...... 5-8
General...... 5-8
Exercise in Hot Environments...... 5-9
Heat Effects on Mental Performance...... 5-10
Interaction with Other Environmental Factors...... 5-10
Pathophysiology of Heat Stress...... 5-11
Prevention of Heat Injury...... 5-12
Evaluating Heat Stress Problems...... 5-17
Cold Stress Effects...... 5-17
General...... 5-17
Moderate Cold and Protective Clothing...... 5-17
Non-freezing Injury...... 5-18
Freezing Injury (Frostbite)...... 5-18
Systemic Hypothermia...... 5-19
Chapter 6
OTOLARYNGOLOGIC ASPECTS OF AEROSPACE MEDICINE
Introduction...... 6-1
Mechanical Effects of Barometric Pressure Changes...... 6-2
General...... 6-2
Barotitis...... 6-3
External barotitis...... 6-8
Barosinusitis...... 6-8
Alternobaric vertigo...... 6-13
Other Vertiginous Entities...... 6-14
General...... 6-14
Inner ear conditions...... 6-16
Aeromedical implication of vertigo...... 6-19
Miscellaneous ENT Conditions...... 6-19
Ear...... 6-18
Nose...... 6-23
Paranasal sinuses...... 6-26
Larynx...... 6-28
Facial nerve paralysis...... 6-29
Equipment...... 6-29
Chapter 7
NOISE, AUDIOMETRY, AND COMMUNICATION
Introduction...... 7-1
Auditory Signals and Noise...... 7-1
Sound, Noise, and Signal...... 7-1
Types of Auditory Signal...... 7-2
Noise as a Human Factor...... 7-3
AEROSPACE SYSTEM NOISE...... 7-3
Acoustics - The Physics of Sound...... 7-3
Sound Pressure Measurement...... 7-5
Sources and Characteristics of Aerospace System Noise...... 7-6
THE EFFECTS OF NOISE ON MAN...... 7-7
Communication Effects...... 7-7
Noise Induced Injury...... 7-8
Other Effects of Noise...... 7-9
AUDIOLOGY - TESTING HEARING...... 7-9
Pure Tone Threshold...... 7-9
Speech Audiometry...... 7-12
Tympanometry...... 7-13
Auditory Brainstem Response...... 7-15
NOISE PROTECTION...... 7-16
Workplace Hazardous Noise...... 7-16
Parameters of Hazardous Noise Exposure...... 7-17
Noise Protection...... 7-18
The USAF Hearing Conservation Program...... 7-19
Chapter 8
OPHTHALMOLOGY AND SPECIAL PROBLEMS OF THE EYE
Introduction...... 8-1
General Effects of Altitude...... 8-1
Visual Effects of Hypoxia...... 8-1
Effects of Glare at High Altitudes ...... 8-2
Effect of Space Myopia (Empty Visual Field)...... 8-3
Sunlight and its Effect on the Eyes...... 8-3
Brightness of the Field of View...... 8-5
Spectacles and Ophthalmic Filters...... 8-6
Basic Issues...... 8-6
Colored Filters...... 8-8
Neutral Filters...... 8-8
Reflecting Filters...... 8-8
Polarizing Filters...... 8-8
Transmission...... 8-9
Glare...... 8-9
Color Perception...... 8-9
Visual Acuity...... 8-10
Sunsensor Lenses...... 8-11
Selection of a Sunglass for US Air Force Use...... 8-11
Goggles or Visors...... 8-12
OTHER LIGHT HAZARDS...... 8-13
Nuclear...... 8-13
Laser...... 8-14
VISUAL PROBLEMS OF HIGH SPEED/ACCELERATION...... 8-17
Introduction...... 8-17
Effect of Slanting Optical Surfaces...... 8-20
Visual Effects Produced by Shock Waves...... 8-20
Vibration...... 8-20
Effects of Acceleration on the Eye...... 8-21
Lag in Visual Perception...... 8-19
NIGHT VISION...... 8-24
Introduction...... 8-24
Mesopic Vision...... 8-25
Brightness Thresholds...... 8-25
Central Blind Spot at Night...... 8-25
Dark Adaptation...... 8-28
Photochromatic Interval...... 8-28
Operational Aspects of Night Vision...... 8-29
Night Vision Devices (NVD)...... 8-32
OCULAR DISEASES OF THE EYE...... 8-32
Glaucoma...... 8-32
Contact lenses...... 8-34
VISUAL ILLUSIONS...... 8-35
Introduction...... 8-35
Runway Aerial Perspective...... 8-35
Visual Autokinesis...... 8-36
Linear and Angular Vection...... 8-36
The Black Hole Approach...... 8-36
Sloping Cloud Decks...... 8-36
Lean-on-the-Sun Illusion...... 8-37
False Horizon...... 8-37
OPTICAL PRINCIPLES...... 8-37
Chapter 9
AEROSPACE PSYCHIATRY AND PSYCHOLOGY
Introduction...... 9-1
Psychiatric Disorders...... 9-2
Aircrew Selection...... 9-3
The Pilot Personality...... 9-5
Aerospace Clinical Psychology Program...... 9-8
Circadian Rhythm in Aviation...... 9-8
Stress and Fatigue...... 9-10
Airsickness...... 9-12
Fear of Flying...... 9-14
Aircrew Briefings...... 9-15
Combat Fatigue...... 9-16
Survival and Prisoner of War Considerations...... 9-19
Psychiatric Aspects of Mishaps and Disasters...... 9-20
Chapter 10
ISSUES IN INTERNAL MEDICINE
Introduction...... 10-1
Cardiovascular Problems...... 10-1
Asymptomatic Coronary Artery Disease (CAD)...... 10-1
Valvular Heart Disease...... 10-3
Hypertrophic Cardiomyopathy...... 10-6
Dysrhythmias...... 10-6
Hypertension...... 10-9
Metabolic Problems...... 10-10
Diabetes Mellitus and Glucose Intolerance...... 10-10
Hyperlipidemia...... 10-10
Pulmonary Problems...... 10-11
Chronic obstructive pulmonary disease (COPD)...... 10-12
Reactive airway disease...... 10-12
Sarcoidosis...... 10-12
Gastrointestinal and Genitourinary...... 10-13
Gastrointestinal Hemorrhage...... 10-13
Renal Stones...... 10-13
Aeromedical Management of Neoplasms...... 10-14
Actions to take at the Time of Diagnosis...... 10-14
Obtaining a Waiver - Returning the Cured...... 10-15
After the Waiver...... 10-16
Chapter 11
AEROSPACE NEUROLOGY
Introduction...... 11-1
Review of Conditions...... 11-1
Cerebrovascular disease...... 11-1
Intracranial tumors...... 11-3
Head Injury...... 11-3
Extrapyramidal and Movement Disorders...... 11-5
Demyelinating Conditions...... 11-6
Intellectual Disturbances...... 11-7 Dementias...... 11-8
Spinal Cord Syndromes...... 11-9
Peripheral Nerves...... 11-9
Seizure Disorders...... 11-11
Loss of Consciousness...... 11-12
Infections...... 11-12
Migraines...... 11-13
Vertigo and Air Sickness...... 11-16
Chapter 12
AEROSPACE DENTISTRY
Introduction...... 12-1
Dental Classification...... 12-1
DENTAL WARTIME READINESS...... 12-3
ODONTALGIA...... 12-3
Barodontalgia...... 12-3
Acute Periapical Abscess...... 12-5
Periodontal Disease and Soft Tissue Pathology...... 12-7
Periodontal Disease...... 12-7
Soft Tissue Pathology...... 12-10
Problems Involving Tooth Structure...... 12-13
Dental Caries...... 12-13
Tooth Fracture...... 12-16
Tooth Avulsion...... 12-19
Gingival Abrasion...... 12-19
Local Anesthesia...... 12-20
Armamentarium...... 12-21
Maxillary Area...... 12-21
Mandibular Area...... 12-23
TOOTH EXTRACTION...... 12-25
Post Extraction Complications...... 12-25
FACIAL FRACTURES...... 12-26
Diagnosis...... 12-27
Temporary Stabilization...... 12-27
Emergency Release...... 12-30
Evacuation...... 12-31
Dislocation of the Mandible...... 12-32
DENTAL IDENTIFICATION...... 12-34
Terminology...... 12-35
The Post-mortem Dental Examination...... 12-38
ATTACHMENT 1 -Dental Fly Away Kit...... 12-46
Chapter 13
DRUGS AND THE FLIER
Introduction...... 13-1
Adverse Reactions of Prescription Drugs...... 13-1
Antibiotics...... 13-3 Antimalarials...... 13-4
Antihistamines and Decongestants...... 13-4
Cardiovascular and Antihypertensive Drugs...... 13-5
Ocular Drugs...... 13-6
Antiemetics...... 13-6
Oral Contraceptives...... 13-6
Pyridostigmine bromide...... 13-7
Medication Use In Aviators...... 13-7
General...... 13-7
Allowable Medication Without Waiver...... 13-8
Medications Requiring Waiver...... 13-9
Self-Medication...... 13-10
Drugs of Abuse...... 13-10
Caffeine...... 13-10
Tobacco...... 13-10
Alcohol...... 13-11
Conclusion........ 13-11
Chapter 14
HEALTH, FITNESS, AND NUTRITION
Introduction...... 14-1
Operational Stress...... 14-1
Self-Imposed Stress...... 14-1
Physical Fitness...... 14-2
Anaerobic (Muscular) Conditioning...... 14-2
Aerobic Conditioning...... 14-2
Physical Fitness and G Tolerance...... 14-3
Nutrition...... 14-5
Basic Nutrition...... 14-5
Special Nutritional Considerations...... 14-6
Flight Feeding...... 14-7
Preflight Feeding...... 14-8
Inflight Feeding...... 14-8
Postflight Feeding...... 14-10
Between Meal Snacks...... 14-10
Feeding of Patients...... 14-10
Survival Feeding...... 14-10
Deployment...... 14-11
Sleep and Sustained Operations...... 14-13
Sleep Structure...... 14-14
Napping Strategies...... 14-14
The Short Nap...... 14-15
The Long Nap...... 14-15
Normal Sleep...... 14-15
Sleep Debt and Disorders...... 14-15
Circadian Disruption...... 14-16
Transmeridian Travel...... 14-16
Shiftwork...... 14-16
Crew Rest...... 14-17
Health Promotion/ Intervention Programs...... 14-20
Health and Wellness Centers...... 14-20
Clinical Preventive Medicine...... 14-24
Obesity...... 14-24
The Problem...... 14-24
Weight Control and the Flier...... 14-24
Air Force Weight Program...... 14-25
Determination of Caloric Needs...... 14-25
Weight Loss Diets and Flying Safety...... 14-27
Smoking...... 14-27
The Problem...... 14-27
Smoking and the Flier...... 14-28
Quitting...... 14-28
Stress...... 14-28
Coronary Artery Disease...... 14-29
Risk Factors...... 14-29
High Density Lipoprotein (HDL) Cholesterol...... 14-30
Exercise...... 14-32
Smoking...... 14-32
Obesity...... 14-33
Serum Triglycerides...... 14-33
Behavioral Risk Factors...... 14-33
ATTACHMENT I. High Intensity Muscular Conditioning...... 14-42
ATTACHMENT II. Major Nutrients And Diet Analysis...... 14-63
ATTACHMENT III. Microbiology of Flight Meals ...... 14-65
ATTACHMENT IV. Possible "Gas Formers"...... 14-66
ATTACHMENT V. Caffeine Content of Foods and Drugs...... 14-67
ATTACHMENT VI. Caffeine Content of Soft Drinks...... 14-68
ATTACHMENT VII. Put Prevention Into Practice (PPIP)...... 14-69
Chapter 15
AVIATION PATHOLOGY
Introduction...... 15-1
Purpose...... 15-1
Background...... 15-1
Aircraft Mishap Investigation...... 15-1
Pathology Support...... 15-3
Aircraft Mishap Investigation Readiness...... 15-3
Preparation...... 15-3
Photographic Kit...... 15-4
Investigation Kit...... 15-5
Basic Procedures...... 15-6
Response Phase...... 15-6
Crash Scene Phase...... 15-6
Administration Phase...... 15-8
External Examination Phase...... 15-10
Pre-Crash History Phase...... 15-11
Identification Phase...... 15-11
Autopsy Phase...... 15-12
Radiographic Phase...... 15-12
Conclusion Phase...... 15-13
Injury Analysis...... 15-13
Introduction...... 15-13
Traumatic Injuries...... 15-13
Environmental Factors...... 15-17
Hypoxia...... 15-17
Decompression Sickness...... 15-17
Fire...... 15-18
Water (Drowning)...... 15-19
Toxins.......... 15-20
Carbon Monoxide/Smoking/Combustion Products...... 15-20
Alcohol and Drugs...... 15-21
Pre-existing Disease...... 15-22
Laboratory Tests...... 15-23
Specimens...... 15-23
Blood Carboxyhemoglobin...... 15-23
Blood Alcohol/ Volatiles...... 15-23
Drug Screen...... 15-24
Supplemental Local Laboratory Studies...... 15-24
Serology...... 15-25
Lactic Acid...... 15-25
Collection/Submission of Specimens...... 15-25
Aircrew Fatalities...... 15-25
Aircrew Survivors...... 15-25
SUBMISSION OF SPECIMENS...... 15-26
Aircrew Fatalities...... 15-26
AFIP Laboratory TELEPHONE Information...... 15-29
Surviving Aircrew...... 15-29
Forms, Documents, and Paperwork...... 15-29
REPORTS REQUIRED...... 15-30
Autopsy Report...... 15-30
AF Form 711gA...... 15-30
Chapter 16
FLIGHT SURGEON IN FLIGHT SAFETY
Introduction...... 16-1
USAF Program...... 16-1
Local Programs...... 16-2
Flight Safety...... 16-2
Flying Safety Participation...... 16-3
Mishap Investigation...... 16-4
Physiological Incidents...... 16-4
Aircraft Mishap Investigation...... 16-4
Pre-response preparation, Response, Post Response
Safety Investigation Board...... 16-7
The Formal Report...... 16-10
Accident Investigation Board...... 16-11
Chapter 17
EMERGENCY EGRESS FROM AIRCRAFT
Introduction...... 17-1
Escape Systems...... 17-1
Ejection Seat Operation...... 17-1
Current Air Force Ejection Seats...... 17-2
Ejection Events...... 17-7
Pre-ejection...... 17-7
Primary Acceleration...... 17-8
Forces of Windblast...... 17-8
Parachute Descent and Landing...... 17-9
Pattern of Ejection Injuries...... 17-9
Future of Escape Systems...... 17-11
Chapter 18
UNIQUE MISSIONS
Introduction...... 18-1
Combat Search and Rescue...... 18-1
Military Assistance to Safety and Traffic...... 18-3
Concerns of Special Operations Forces and Low Intensity Conflict 18-3
Parachuting...... 18-3
Hot Refueling...... 18-4
Night Vision Goggles...... 18-4
Other Issues...... 18-5
Manned Space Flight Support Office...... 18-5
History and Structure of DDMS...... 18-5
Emergency Medical Services System...... 18-6
DoD Medical Response Requirements...... 18-8
Overview...... 18-8
Concept of Operation...... 18-8
Manning...... 18-9
Training Requirements...... 18-9
Medical Equipment and Configuration...... 18-10
Medical Operations and Coordination...... 18-11
Medical Condition Codes...... 18-14
Mission Profiles...... 18-15
Launch...... 18-15
Return to Launch Site...... 18-17
Transoceanic Abort Landing...... 18-17
Abort Once Around...... 18-18
Nominal Mission Progression...... 18-20
Nominal End of Mission Landing...... 18-20
Contingency Response Modes...... 18-20
Launch Pad Modes...... 18-20
Landing Modes...... 18-21
Flight Modes...... 18-21
Egress Condition Red...... 18-21
Toxicological Hazards...... 18-21
Command, Control, and Communications...... 18-23
Chapter 19
GLOBAL AEROMEDICAL EVACUATION
Concept of Operations...... 19-1 General...... 19-1
Contingency Operations...... 19-1
Organizational Roles and Missions...... 19-2
Expanded AE Capabilities...... 19-3
The Aeromedical Evacuation Program...... 19-3
Aeromedical Evacuation Organization...... 19-4
Aeromedical Evacuation program Responsibilities...... 19-5
Aeromedical Evacuation System Components...... 19-6
Aeromedical Evacuation Administrative Authority...... 19-10
Continental US Operations - The CONUS System...... 19-10
Overseas to CONUS Operations - (Intertheater Systems)...... 19-11
Theater Systems...... 19-12
Casualty Staging...... 19-13
Administration...... 19-14
Patient Classification...... 19-14
Patient Categories...... 19-15
Aeromedical Evacuation Equipment...... 19-15
Flight Certified Medical Equipment...... 19-16
Defense Medical Regulating Information System (DMRIS)...... 19-17
Automated Patient Evacuation System (APES)...... 19-18
Do Not Resuscitate (DNR)...... 19-18
Aircraft...... 19-18
Airlift Resources...... 19-18
Aircraft Availability...... 19-18
C-9A, C-141B, C-130B,E,H, C-21A, C-12F ...... 19-19
Civil Reserve Fleet (CRAF) ...... 19-23
Clinical Aeromedical Evacuation Issues...... 19-24
Preparing Patients for AE...... 19-24
Diagnoses and Clinical Issues...... 19-24
Alcohol or Drug Abuse...... 19-24
Anemia...... 19-24
Burns...... 19-25
Cardiac Patients...... 19-25
Decompression Sickness Patients...... 19-25
Chapter 20
THE MILITARY PUBLIC HEALTH PROGRAM
Introduction...... 20-1
General...... 20-1
Public Health Responsibilities...... 20-2
Epidemiology...... 20-2
Communicable Disease Program...... 20-2
TB, STDs, HIV, and other reportable diseases
Medical Entomology...... 20-3
Food Safety Program...... 20-3
Public Facility Sanitation...... 20-3
Occupational Health Program...... 20-4
Environmental Health Assessment/ Education...... 20-4
Immunizations...... 20-4
Disaster Response...... 20-5
Medical Intelligence...... 20-5
Consultation Services...... 20-5
Summary...... 20-5
Chapter 21
OCCUPATIONAL MEDICINE
Introduction...... 21-1
Staff and Responsibilities...... 21-1
The Bioenvironmental Engineer Program...... 21-1
Occupational Health, Environmental Protection, and Health Physics
The Public Health Officer...... 21-4
Occupational Physical Exams, HAZCOM, Fetal Protection, Hearing
Conservation, Occupational Illness/ Injury Reporting
The Physical Examination Section...... 21-5
The Flight Surgeon...... 21-5
Regulating Agencies...... 21-6
OSHA...... 21-7