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Physiological Events WILLIAM W. BUCK DODSON III MD MPH FACPM FASMA Col, ANG, MC, Physiological Events WILLIAM W. BUCK DODSON III MD MPH FACPM FASMA Col, ANG, MC, CFS Aerospace, Occupational, & Undersea Hyperbaric Medicine ANG Assistant to the 711 HPW Commander 711 th Human Performance Wing Wright-Patterson AFB, Ohio “Saving Lives – Our Calling”

Disclosures No Financial COIs Not DOD Policy – My Opinions if Differs Brands May Disclosures No Financial COIs Not DOD Policy – My Opinions if Differs Brands May Be Shown Non-FDA Usage may be Mentioned

Overview Physiological Events Reporting Treating Basic Life Support (BLS) + Advanced Cardiovascular LS (ACLS) Overview Physiological Events Reporting Treating Basic Life Support (BLS) + Advanced Cardiovascular LS (ACLS) 2015 Edition Neck Pain + Injury

Mishap Classification Classes per AFI 91 -204 12 FEB 2014 ; CORRECTIVE ACTIONS APPLIED Mishap Classification Classes per AFI 91 -204 12 FEB 2014 ; CORRECTIVE ACTIONS APPLIED ON 10 APRIL 2014 “SAFETY INVESTIGATIONS AND REPORTS” inc AFGui. Mem 2017 -01 19 Jan 2017: (Just need 1 Item on the lines below to be in that class) A: $2 M +, Death, Permanent Total Disability, Aircraft Destroyed B: $500 K-2 M, Permanent Partial Disability, Hospitalization of 3 or more Members C: $50 K-500 K, Permanent Change of Job, Loss of 1 or more Workdays D: $20 K-50 K, Recordable/Reportable Injury or Illness E: “Events”, Situations that do Not Fall into the Above Classes

Lead Resource “AVIATION SAFETY INVESTIGATIONS AND REPORTS” Air Force Manual (AFMAN) 91 -223 16 Lead Resource “AVIATION SAFETY INVESTIGATIONS AND REPORTS” Air Force Manual (AFMAN) 91 -223 16 MAY 2013, incorporating Change 1 dated 8 June 2016

“Events” 1. 3. 2 Class E Events In most cases, events do not require “Events” 1. 3. 2 Class E Events In most cases, events do not require reporting if they occur as described in the aircraft flight manuals and are expected responses to a crew’s actions or flight regime. For example, do not report the loss of pitot-static instrument indications if the loss is the result of crew failure to activate the pitot heat. If the circumstances of an event meet two or more criteria, such as an in-flight fire which results in a physiological episode, report event using following hierarchy: Physiological, Propulsion, Flight Control, Instrument, Miscellaneous, High Accident Potential (HAP), Hazardous Air Traffic Report (HATR), Controlled Movement Area (CMA) Violation, Bird/Wildlife Aircraft Strike Hazard (BASH). Note: Although Class E events do not require findings, A finding is required in order to input a recommendation into the Air Force Safety Automated System (AFSAS).

“Physiological Events” 1. 3. 2. 1. Physiological Events Report all flight-related aircrew abnormal physiological “Physiological Events” 1. 3. 2. 1. Physiological Events Report all flight-related aircrew abnormal physiological conditions not categorized as Class A-D mishaps as Class E Physiological events. Reportable events include: hypoxia, trapped gas disorders, G-induced loss of consciousness (GLOC), incapacitating hyperventilation, spatial disorientation, visual illusions resulting in unusual aircraft attitude, toxic smoke/fumes/liquid exposure resulting in aircrew or passenger symptoms (report exposures without symptoms as Class E Miscellaneous events), or Any condition that a qualified flight surgeon determines to be significant to the health of the aircrew member. Include accurate descriptions of symptoms in the event narrative and Ensure applicable human factors codes selected in AFSAS. (via Wing Safety Officer)

Flight Surgeon Duties Unlike Class A - D Mishaps, the documentation requirements are less Flight Surgeon Duties Unlike Class A - D Mishaps, the documentation requirements are less for Events. FS collects the usual patient care information such as History, Physical, Studies, Treatment that he and any other providers have produced. Wing Safety Officer will have an account in AFSAS and a portion of the FS collected information will be inputted by the SO and/or the FS. More documentation, studies, etc may be decided to be obtained by POCs such as the FS or others.

Decompression Sickness 1. 3. 2. 1. 1. Suspected DCS with symptoms that resolve on Decompression Sickness 1. 3. 2. 1. 1. Suspected DCS with symptoms that resolve on descent (with or without oxygen) or within 2 hours at ground level (with or without oxygen) with no recurrent symptoms and no (Other) medical treatment required is considered a Physiological Event. Other than above, confirmed aircrew or passenger DCS is considered a Mishap (usually will be a Class D Mishap), 1. 3. 2. 1. 2. Lab and/or Toxicological Test Results for involved personnel to be in the report only when determined necessary by the commander or flight surgeon. (GLOC events: include 72 -hour and 7 -day histories)

DCS treated w/ Hyperbaric Oxygen (HBO 2): Class A-D Mishap Possible DCS or DCS DCS treated w/ Hyperbaric Oxygen (HBO 2): Class A-D Mishap Possible DCS or DCS resolved w/ 100% O 2 within 2 hrs: Class E Physiological Event

Support If a Safety Officer is not readily available locally then contact: Air Force Support If a Safety Officer is not readily available locally then contact: Air Force Safety Center Human Factors Section Kirtland AFB, NM Aerospace Physiology Officers: (505) 853 -1117 DSN 263 (505) 846 -0880 DSN 246 Flight Surgeon: (505) 853 -4868 DSN 263 24/7 Command Post: (505) 846 -3777 DSN 246

Aviation DCS – USAF Approach Type I Aviation DCS: Joint, Skin 100% Oxygen* + Aviation DCS – USAF Approach Type I Aviation DCS: Joint, Skin 100% Oxygen* + Hydration (Improves w/in 60 min? Yes – 2 more hours; No – TT 5) Total Relief? YES *100% Oxygen: Aviator’s Mask – 1 st Choice Bi. PAP CPAP Nonrebreather Mask (> 15 L/min) Call USAF UHM (210) 292 -3483 (DSN 554) 24/7: -5990 NO Type II Aviation DCS: Neuro, Pulmonary, etc. TT 5 TT 6 Observe Total Relief w/in 10 min? NO Total Relief? NO YES Complete Treatment Table 5 & Observe YES Modified treatment regimens Complete TT 6 & Observe

Emergency Evacuation Hyperbaric Stretcher (EEHS) “Hyperlite” Transport Chamber m Emergency Evacuation Hyperbaric Stretcher (EEHS) “Hyperlite” Transport Chamber m

Monoplace Chamber Monoplace Chamber

Example of Multiplace Chambers Duke University 8 Chambers Interconnected By Airlocks Example of Multiplace Chambers Duke University 8 Chambers Interconnected By Airlocks

Approved HBO 2 Indications – UHMS “Life, Limb, Eyesight – All Saved” 1. 2. Approved HBO 2 Indications – UHMS “Life, Limb, Eyesight – All Saved” 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Air or Gas Embolism “AGE or DCI” (All - should have consultations) Decompression Sickness/Illness “DCS or DCI” (All) Clostridial Myositis/Myonecrosis – “Gas Gangrene” (All) Crush Injury/Compartment Syndrome (Some: esp if Ischemic Hypoxia) Carbon Monoxide (CO) Poisoning (Cardiac or Neuro S/S, or Hi COHb) Arterial Insufficiencies: 1) Cent Retinal Art Occlusion (If O 2 Fails) 2) Problem Wounds (Hypoxic-Diabetes, RA, Etc-Some) Exceptional Blood Loss Anemia (2* Religion-Some) Intracranial Abscess (Some: if Surgery/Abx Failing) Necrotizing Soft Tissue Infections (Some: as #8) Delayed Radiation Injury (Some; All Pre-Dental Proc) Idiopathic Sudden Sensorineural Hearing Loss (Some) Skin Grafts & Flaps (Some: If Failing) Acute Thermal Burns (Some: Face, Hands, Ft, Hi TBSA) Refractory Osteomyelitis (Failed 6 wks Abx+Surg)

Why Mechanisms Simplified: Pressure Effects with Arterial Gas Embolism (AGE), DCS: Makes Bubbles Smaller Why Mechanisms Simplified: Pressure Effects with Arterial Gas Embolism (AGE), DCS: Makes Bubbles Smaller Oxygen Effects with AGE, DCS: N 2 Leaves Faster Due to Better Gas Gradient with Infection: WBCs Are Released + Eat More; Toxic to Anaerobes with Wounds: Increased Capillary + Tissue Production with CO: Reduces Half-Life of Carboxyhemoglobin

USAF Chamber San Antonio ‘ 06 Wilford Hall => BAMC, SAMMC ‘ 17 USAF Chamber San Antonio ‘ 06 Wilford Hall => BAMC, SAMMC ‘ 17

USAF San Antonio Multiplace Chamber USAF San Antonio Multiplace Chamber

Life, Limb, Eyesight – All Saved Questions (FSs to call USAF Hyperbarics STAT re Life, Limb, Eyesight – All Saved Questions (FSs to call USAF Hyperbarics STAT re Any Possible Cases) USAF Hyperbarics TX: (210) 292 - (DSN 554) 0700 -1600: x 3483 24/7: x 5990 If Above Not Reachable: Divers Alert Network (DAN) 24/7: 1 (919) 684 -9111

Basic Life Support (BLS) + Advanced Cardiovascular LS (ACLS) 2015 BLS Compressions are 1 Basic Life Support (BLS) + Advanced Cardiovascular LS (ACLS) 2015 BLS Compressions are 1 st at Rate 100 -120/minute 30: 2 2 -Rescuer 30: 2 Except Infant to Puberty 15: 2 ACLS q 5 year update recently released in 2015: # Meds Focused Upon Now Down To 4: Epinephrine: VFib, Asystole, Pulseless Electrical Activity (PEA) Amiodarone: VFib Adenosine: Tachycardia Atropine: Bradycardia Electricity if Unstable/Meds Fail: Cardioversion, Defibrillation, Pacing ETs not 1 st Choice for Ventilation unless Provider Current: Mask/Other Airways OK Capnography (CO 2 mm. Hg): Compressions: 10 -20 (if < 10, assess CPR technique) Ventilations: 35 -45 (if < 35, reduce volume or frequency; if > 45, increase)

High-G Aviator Neck Pain Disclosures No financial relationships of author and non- government entities High-G Aviator Neck Pain Disclosures No financial relationships of author and non- government entities in slides Some items mentioned may not be FDA approved, and some be in off-label usage The views expressed are those of the author and do not necessarily reflect the official policy or position of the Air Force, the Department of Defense, or the U. S. Government

High-G Aviator Neck Pain Preview Background Meetings Communication – Mtg Participants Actions: - Aircrew High-G Aviator Neck Pain Preview Background Meetings Communication – Mtg Participants Actions: - Aircrew Conditioning Programs (ACPs) - Devices - Research Trials + Studies - Other Communication – Field

High-G Aviator Neck Pain Background 1 History of Neck Pain and Potential Injury: - High-G Aviator Neck Pain Background 1 History of Neck Pain and Potential Injury: - High Gs: 1940 s - Ejection: 1950 s - Helmet Center of Gravity (CG) Moved Forward: - Night Vision Goggles: 1980 s (Detach) - Helmet Mounted Displays (HMDs): 2000 s (Non-Detach)

High-G Aviator Neck Pain Background 2 Helmet Center of Gravity Moved Forward: - HMDs: High-G Aviator Neck Pain Background 2 Helmet Center of Gravity Moved Forward: - HMDs: 2000 s (Non-Detachable) - Joint Helmet Mounted Cueing System (JHMCS): ~ 2003 - Joint Strike Fighter (JSF): ~ 2014

High-G Aviator Neck Pain Background 3 JHMCS: - Squadrons include F-15, F-16, F-18 (Navy/Marines) High-G Aviator Neck Pain Background 3 JHMCS: - Squadrons include F-15, F-16, F-18 (Navy/Marines) - Greater wt, forward CG vs. standard helmet - Many crew keep 2 helmets, limit JHMCS wear JSF: - JSF (USAF, Navy/Marines) - Combined wt/CG effects more vs. JHMCS - Crew wear only the JSF helmet at all times

High-G Aviator Neck Pain Meetings 1 Complaints about Neck Pain: - From pilots - High-G Aviator Neck Pain Meetings 1 Complaints about Neck Pain: - From pilots - From flight surgeons Queries about Neck Pain: - From USAF Major Commands (MAJCOMs) - From HQ AF + HQ Air National Guard (ANG) Duplication of Work at 711 HPW: - Answering same questions on emails + calls - Lesson from prior major taskings => Weekly Telecon Meetings

High-G Aviator Neck Pain Meetings 2 “Helmet-Induced” Neck Pain Teleconferences: - Invitations to all High-G Aviator Neck Pain Meetings 2 “Helmet-Induced” Neck Pain Teleconferences: - Invitations to all sources of queries - Open meeting for all interested U. S. parties - Name changed to “High-G Aviator” NP Telecons (in recognition of additive other factors) Current Focus: - Mitigate / prevent pain from JSF, JHMCS helmets • • • Neck pain from muscle fatigue From constant contraction neck, upper back muscles Needed to keep the head level in the 1 G environment A large percentage of the duration of most flights Pain, from any source, can both distract a pilot from focusing on critical items at hand, as well as can cause pilot to avoid max Gs + certain maneuvers (both affecting mission performance + outcome)

High-G Aviator Neck Pain Meetings 3 Related Interest Items: • Neck strengthening to prevent High-G Aviator Neck Pain Meetings 3 Related Interest Items: • Neck strengthening to prevent injury (and injury pain) due to overangulation of the head, which can occur during high-G engagement portions of a flight due to lack of strength (or strength fatigue), which is needed to keep the head in an optimal position relative to the neck and body • Neck/back muscles already fatigued from holding the head level during the 1 G portion of the flight can potentially make neck injury more likely during the subsequent high-G portion of the flight

High-G Aviator Neck Pain Actions 1 ACPs include: - USAF Fighter ACP - Viper High-G Aviator Neck Pain Actions 1 ACPs include: - USAF Fighter ACP - Viper Neck Health & EXercise (NHEXS) Strategies ACP* - USAF/Physical Therapy ACP - RAF ACP - Fit For Flight. TM ACP - Neck. XTM ACP *Viper. NHEXS uses Iron Neck. TM

High-G Aviator Neck Pain Iron Neck. TM ACP Courtesy of Matt Schmit 1/30/17, Iron High-G Aviator Neck Pain Iron Neck. TM ACP Courtesy of Matt Schmit 1/30/17, Iron Neck Co. , iron-neck. com

High-G Aviator Neck Pain Neck. XTM ACP Courtesy of Patrick Houlahan 1/30/17, Neck. X High-G Aviator Neck Pain Neck. XTM ACP Courtesy of Patrick Houlahan 1/30/17, Neck. X LLC, neckxsystems. com

High-G Aviator Neck Pain Actions 2 Devices include: - Inflatable Support - Foam Wedge High-G Aviator Neck Pain Actions 2 Devices include: - Inflatable Support - Foam Wedge - Saunders. TM Portable Traction

High-G Aviator Neck Pain USAF Inflatable Support System Courtesy of William Dodson, personal photo High-G Aviator Neck Pain USAF Inflatable Support System Courtesy of William Dodson, personal photo

High-G Aviator Neck Pain Foam Wedge Chin Rest Courtesy of William Dodson, personal photos High-G Aviator Neck Pain Foam Wedge Chin Rest Courtesy of William Dodson, personal photos

High-G Aviator Neck Pain Saunders. TM Portable Traction Courtesy of Leda Buster, 1/30/17, DJO High-G Aviator Neck Pain Saunders. TM Portable Traction Courtesy of Leda Buster, 1/30/17, DJO LLC, djoglobal. com

High-G Aviator Neck Pain Actions 3 Potential research trials and studies include: - Prospective High-G Aviator Neck Pain Actions 3 Potential research trials and studies include: - Prospective Study - Neck. XTM Multicenter - Iron Neck. TM vs Neck. XTM - Portable Neck Traction

High-G Aviator Neck Pain Actions 4 Other: - Document Collection: Past Helmet R&D, ACPs, High-G Aviator Neck Pain Actions 4 Other: - Document Collection: Past Helmet R&D, ACPs, etc. - Writing: Research Funding Requirement Gaps - “Future Helmet” Design Discussions: USAF, Industry

High-G Aviator Neck Pain Guidance: Communication – Field - Short Term: - Slide Template High-G Aviator Neck Pain Guidance: Communication – Field - Short Term: - Slide Template for Sqdn Safety Meetings, Physiology Trng sent to AOPs, FSs (via A 3 to WG CCs and AOP Corp Chief) - Viper. NHEXS ACP, USAF PT ACP placed on KX https: //kx. afms. mil/kj/kx 12/HINP/Site. Pages/Home. aspx (or simply go to KX, use search term “Helmet”) - Long Term: - USAF Publications: putting neck specifics in Fighter ACP - USAF Curriculums: Initial, Renewal Physio Trng, Pilot Trng