Shipboard Injuries and Rehabilitation of United States Sailors

Shipboard Injuries and Rehabilitation of United States Sailors Kristin R. Hodapp, MS, PT, CSCS LCDR, MSC, USN

Presentation Overview Navy Medicine Assets n Role of Aircraft Carrier Medical Department n Role of Shipboard Physical Therapy n Physical Therapy Cases n

Navy Medicine Overview n Medical Treatment Facilities (MTFs): variable level of services depending on size. Typically, patients will be medically evacuated to the larger MTFs. – “The Big Three” n National Medical Center Bethesda n Naval Medical Center San Diego n Naval Hospital Portsmouth

Navy Medicine Overview n Forward deployed medical assets – Land based: Fleet Hospital – Shipboard: depends on mission/size of crew n Submarines n Cruisers/Destroyer or “small boys” n Amphibious Assault Ship n Hospital Ship n Aircraft Carriers

Cruiser/Destroyer Medical Staffing Medical staff: two junior hospital corpsmen and one Independent Duty Corpsmen. n Will MEDEVAC patients to either the amphibious ship or aircraft carrier depending on the Battlegroup assignment. n

Amphibious Assault Ship Medical Staffing Mission: to transport and deploy elements of a Marine landing force during amphibious assault operations via helicopter, amphibious vehicles, and/or landing craft. n Ship’s crew: 100+ officers and 1, 000+ enlisted. Marine detachment: 1, 900 n

Amphibious Assault Ship n n Largest dental component for any combat ship Medical: most extensive medical support of combat ship with 600 beds and 6 operating rooms.

Hospital Ships: USNS Comfort and Mercy USNS Mercy is west coast based. n USNS Comfort is east coast based. n Staff includes all major specialties, but will customize staffing depending on mission n

Hospital Ship Mission Provide afloat acute surgical care to the U. S. military that is flexible and uniquely adaptable to support expeditionary forces. n Secondary mission is to provide medical care for U. S. disaster relief and world-wide humanitarian operations. n

Hospital Ship Facts n n n Total Bed capacity: 1000 ICU beds: 80 Minimal care beds: 500 Recovery Beds: 20 Intermittent care beds: 400 Operating Rooms: 12 n Surgical Capabilities: – – – – – ENT Orthopedic OB/GYN Ophthalmic Dental and Maxillofacial General Urology Neurosurgery Plastic Cardiothoracic

Non-Surgical Capabilities Internal Medicine n Pediatrics n Dermatology n Respiratory Therapy n Physical Therapy n

Patient Transport n Patients primarily arrive either by helicopter or small boat

USNS Comfort Humanitarian Mission 4 month South American Tour • • Training Opportunity: CPR/BLS ACLS intubations

USNS Comfort Humanitarian Mission n Physical Therapy – Gait training – Ergonomics/Patient transport techniques to hospital staff – Burns/Wound Care – Splinting – Typical Sprains/Strains

Aircraft Carrier Medical Staffing Total Medical/Dental Staff: 97 n Staff: n – Senior Medical Officer (SMO) – General Medical Officer (GMO) – Nurse – Surgeon – Nurse Anesthetist – Physical Therapist

Aircraft Carrier Medical Staffing Clinical Psychologist n Physician Assistant n Radiation Health Officer (nuclear) n Medical Administration Officer (MAO) n Flight Surgeon (2 -3) n

Role of Aircraft Carrier Medical Department

USS RONALD REAGAN CVN-76 Peace Thru Strength motto n About 4. 5 acres of sovereign US territory n One of the most dangerous jobs: working on the Flight Deck. n

USS RONALD REAGAN (CVN-76) n n n Commissioned on 12 July 2003 Ship was built in Newport News, VA Homeport change “around the horn” cruise Maiden Deployment January-July 2007 Surge Deployment

USS RONALD REAGAN (CVN 76) n n Crew size: 5300+ As tall as the Empire State Building Over 80 aircraft attached to ship Can operate 24/7

Aircraft Carrier Medical Capability n n Basic Laboratory services Basic Radiology services – – – Radiographs Ultrasound Unable to have MRI onboard due to the constant motion on ship and metal in ship

Aircraft Carrier Medical Capabilities Able to manufacture eye glasses n Basic casting and splinting n Pharmacy technician n

USS RONALD REAGAN CVN-76 Medical resources are primarily located in the main medical spaces (2 nd deck below the Hangar Bay). n During flight operations, special manning of the Flight Deck Battle Dressing Station (BDS) required. n Flight Deck BDS have special communications with Main Medical. n

USS RONALD REAGAN CVN 76 Medical is staffed 24/7 even when in port. n Duty Medical staff in-port: one officer and minimum of four corpsmen n Duty Medical Staff while deployed: minimum of eight corpsmen, 2 officers, and one MD. n

Shipboard 911: Medical Emergency Over the 1 -MC announce location of casualty n Medical response team launched and main medical sets up triage room. n Communications via radio. n Response team consists of: n n 3 corpsmen n One Independent Duty Corpsmen

Shipboard Medical Emergency Response n n Underway, all medical staff required to report to main medical to set up. Approximately two minute transit time to anywhere in ship. Right of way with ladder wells and passageways All crew members are stretcher bearer and BLS certified. Ship minimum of 90% compliance.

Reasons for Actual Medical Emergency n n n Chest pain/MI Electrical Burns Smoke Inhalation Heat Stress Fall – down ladder – Flight deck n n n Stroke Drug Overdose Steam Burn Syncope Ramp strike with pilot ejection Man Overboard

Emergency Medical Training n All crew members are to be BLS and stretcher bearer certified – Three types of stretchers – Reeves sleeve only one safe for ladder transport n Unique transportation challenges: – Island of ship – Main engineering spaces

Emergency Patient Transport

Mass Casualty Definition Five or more injuries that taxes medical resources n Most likely scenarios: n – Flight Deck accident n Called Mass Casualty by the Air Boss – Main space fire – Hangar bay explosion

Mass Casualty n n n Dental officers serve as the initial triage officers to sort casualties on flight deck Senior Medical Officer (SMO) and surgeon divide casualties based on acuity. “Pods” set up to manage up to 10 patients. Staffed by 2 -3 corpsmen and IDC, PA, or MD

Mass Casualty Ancillary services role with walking wounded (PT and Psychologist) n Goal to clear all patients off of flight deck in 15 minutes and to resume operations n

Mass Casualty n n n Goal to then clear hangar bay Overflow area is the mess decks Role of other staff: – – – Chaplains Dental after initial triage Admin with patient tracking – Supply – Mess decks staff n n n Blood bank initiated by either the SMO or surgeon Communication with Commanding Officer Primary goal is to “Fight the ship”

Mass Casualty

Mass Casualty Training Required to do a Mass Casualty Drill once a quarter. n Once a year, the ship will be graded by an independent training team. n Mass Casualty training is the surgeon’s responsibility n

Related Occupational Health Issues n n Low Back Pain/Injuries tracked by Safety department. Multiple medical surveillance programs – – – Radiation Fuels Heavy Metals Hearing TB STD

Shipboard Physical Therapy

Physical Therapy On average, 60% of sick call was for a musculoskeletal reason. n Prior to Physical Therapists onboard, over 20 MEDEVACS/deployment with an average cost of over $70, 000 with the additional loss of staffing. n Since PTs onboard, average of two MEDEVACs per deployment and average cost of less than $7, 000. n

Shipboard Physical Therapy Neuromuscular expert n Casting/splinting skills n Evaluation, treatment, and management for a return to duty n Manual therapy skills n Health Promotions Officer n

Neuromuscular Screener Role of Physical Therapists as a Physician Extender. n Additional training in evaluation and therapeutic management. n Credentials n

Casting/Splinting Physical Therapy AMMAL (supplies) include materials and prefabricated splints n Training n Fracture management n

Return to Full Duty Over 90% of patients returned to full duty within two weeks. n Manual therapy n Light duty recommendations n Patient education n Barriers to return to full duty n

Barriers to Return to Full Duty Psychosocial n Crutches n Splints n Casts n Operational Tempo n Patient Compliance n

Psychosocial Factors n n n Depression Anxiety Stress Fatigue Work Center Dynamics

Shipboard Physical Therapy n Top Diagnoses: - Sacroiliac Dysfunction and Low Back Pain Patellofemoral Syndrome Plantar Fasciitis Shoulder Impingement Neck Pain

Shipboard Physical Therapy Direct Access clinic n On deployment, clinic averaged 456 patient encounters per month. n 40% of patients were Air Wing (ship’s company approximately 3500 vs. Air wing 1700). n

Factors that influence the effectiveness of PT Boots n Steel decks n Low ceilings n Poor work center ergonomics n People not screened for certain job requirements (handling lines, etc) n Fatigue/Poor sleep hygiene n Drills and work center hours n

Unique Shipboard Jobs

Shipboard Physical Therapy Role of manual therapy n Patient and supervisor education n Prevention programs n

Role of Manual Therapy Key in the treatment of LBP and SI pain n Evidence based n 45% of all PT patients required manual therapy. n

Patient and Supervisor Education Crucial in compliance with program and successful rehabilitation. n Fine balance between mission and patient goals n Use of light duty recommendations n – Work restrictions for max of 30 -day intervals and may be extended for three months

Prevention Programs Basic Weight-lifting gym program and core stabilization program n Back and Knee Schools n Running clinic n Health Promotion programs n

Deployment, Physical Therapy and Psychology 32% of all Physical Therapy patients also seen by Clinical Psychologist. n Of those patients, 21% were diagnosed with depression. n About 15% of all Physical Therapy patients had chronic pain. n

Physical Therapy Cases

Physical Therapy Cases 19 y/o Seaman (Deck Department) with sudden onset of right hand weakness n Was using sandpaper to prep steel for painting the ceiling n NSAIDs, light duty, wrist and hand bracing n Radial Nerve Palsy n EMG n

Physical Therapy Cases 52 y/o active duty male with left UE and LE pain and weakness n Social h/x: occasional cigar and ETOH use n 60 pounds overweight n Significant medical h/x: HTN and high cholesterol n Family h/x: MI, hypertension n MEDEVAC for suspected CVA n

Physical Therapy Cases 36 y/o AD male n Basketball injury with “pop” n + Thompson, Absent Achilles reflex n Watershed Achilles tendon rupture n Blue water operations n Casted in plantar flexed position before MEDEVAC. n

Physical Therapy Cases n n n 39 y/o pilot with right chest/UE pain MOI: Bench pressing with sudden weakness Main complaints: unable to do pushups, open and close watertight doors. Notable muscle defect insertion pectoralis major with associated weakness and deformity Pectoralis Major insertion complete tear Sling, ice, and ortho consult

$Physical Therapy Cases n n n 22 y/o AD male s/p maxilla fracture (hit$

Physical Therapy Cases n n n 22 y/o AD male s/p maxilla fracture (hit in face with bat) Pain 8/10 with HA. No dizziness. Exam: significant restriction 75% all cervical motions. Passive range of motion limited due to significant guarding. TTP C 3 -4 spinous processes. MRI while in port. Infectious Disease admission for epidural abscess.

Physical Therapy Cases 32 y/o AD EOD technician with neck pain, weakness, numbness & tingling. n MVA: unrestrained driver and ejected with head strike. Initially seen in civilian ER and released. n Abnormal AROM. TTP C 3, C 4, and C 5 spinous processes. n MEDEVAC for fracture with subluxation of C 3, C 4, and C 6. n

Questions? Thank you for your time and attention.