The flight surgeon and psychiatry: interest and skills

Much of the flight surgeon's day-to-day clinical practice involves the use of psychiatric skills in the assessment and management of the problems of flyers and their families. Folklore holds that among nonpsychiatrists, the older, more experienced, nontrainee clinician is more interested in and knowledgeable about the psychiatric aspects of his practice. We studied this assumption in 170 flight surgeons who varied in age, experience, and whether or not they were presently in training or had already completed training in flight medicine. Measures of interest in psychiatry and self-assessed ability in seven areas of psychiatric skills and knowledge were obtained. Results indicate that age and experience are unrelated to interest in psychiatry, while being in training has a significant negative impact. Self-assessed ability is significantly related to training status, age, and experience. The flight surgeon's subjective assessment of needing further education was increased by being in a training status, but unaffected by age or experience.     

Psychiatric considerations in military aerospace medicine

Military aerospace medicine requires a psychiatric selection and certification process that determines not only the absence of significant mental disorders, but also the presence of positive qualities in the realms of motivation, ability and stability: not all normal people are fit to fly. Other issues of aerospace psychiatry involve maintenance of mental resilience and hardiness during a flying career, aeromedical decisions about when to remove from flight duties and when to return, criteria for waivers for psychiatric conditions, use of medications for treatment of psychiatric symptoms, questions of substance abuse, and research in such areas as genetics. This report reviews the basis for military aerospace psychiatry, primarily as practiced in the United States Air Force (USAF), and presents some of its underlying principles as they apply to clinical situations.     

Medico-psychological problems in guaranteeing flight safety today

At the present time flight safety can be provided only if aviation medicine requirements are taken into consideration. Maintenance of good health, high performance and professional longevity of the flight and ground crewmen requires that flight surgeons and aerospace medicine specialists revise their position and eliminate various shortcomings in their work. Those latter include: lack of data about correlations between health problems and decline of performance, risk factors and professional longevity; inadequate use of systemic analysis for evaluating man-machine interactions; low priority of the investigations needed to organize proper prophylaxis of diseases. The paper discusses proposals and suggestions with respect to the new types and methods of medical support of flight safety at the current and advanced levels of development of aviation technology.     

Human systems integration in remotely piloted aircraft operations

BACKGROUND: The role of humans in remotely piloted aircraft (RPAs) is qualitatively different from manned aviation, lessening the applicability of aerospace medicine human factors knowledge derived from traditional cockpits. Aerospace medicine practitioners should expect to be challenged in addressing RPA crewmember performance. METHODS: Human systems integration (HSI) provides a model for explaining human performance as a function of the domains of: human factors engineering; personnel; training; manpower; environment, safety, and occupational health (ESOH); habitability; and survivability. RPA crewmember performance is being particularly impacted by issues involving the domains of human factors engineering, personnel, training, manpower, ESOH, and habitability. RESULTS: Specific HSI challenges include: 1) changes in large RPA operator selection and training; 2) human factors engineering deficiencies in current RPA ground control station design and their impact on human error including considerations pertaining to multi-aircraft control; and 3) the combined impact of manpower shortfalls, shiftwork-related fatigue, and degraded crewmember effectiveness. Limited experience and available research makes it difficult to qualitatively or quantitatively predict the collective impact of these issues on RPA crewmember performance. CONCLUSION: Attending to HSI will be critical for the success of current and future RPA crewmembers. Aerospace medicine practitioners working with RPA crewmembers should gain first-hand knowledge of their task environment while the larger aerospace medicine community needs to address the limited information available on RPA-related aerospace medicine human factors. In the meantime, aeromedical decisions will need to be made based on what is known about other aerospace occupations, realizing this knowledge may have only partial applicability.     

Efforts to improve AME performance through CME and annual performance reports

Continuing medical education (CME) serves to maintain or increase the knowledge, interpretive proficiencies, and technical skills that a physician uses in his/her practice of medicine. Resulting improvement is frequently difficult to measure, particularly in aerospace medicine, but CME is required for relicensure and/or for medical society membership in 70% of states. The Civil Aeromedical Institute first received American Medical Association approval for Category I CME credit for attendance at FAA seminars in January 1973. We began preparing annual performance reports for each aviation medical examiner (AME) in 1979 to attempt to isolate the causes of, and to reduce, computer rejection of about one-fourth of all medical certification input because of omissions or procedural errors. A special analysis of 1983 AME performance data found that errors were significantly reduced with recent and frequent seminar attendance, larger volume of exams, and pilot and military flight surgeon experience.     

Survey of USAF flight surgeons regarding clinical preventive services, using CHD as an indicator.

BACKGROUND: A recent Department of Defense study revealed that nonpharmacologic therapy is not well documented in medical records of individuals identified at risk for coronary heart disease (CHD). Exercise and weight control are often underemphasized relative to dietary and medication interventions, even in medical journal review articles on management of dyslipidemia. METHODS: A literature review of interventions consisting of exercise alone or with diet is presented. A brief survey was developed to assess the knowledge and beliefs of USAF flight surgeons regarding training received for, and delivery of, clinical preventive services. In addition, the respondents were given a scenario patient with high cholesterol to manage. RESULTS AND DISCUSSION: The literature review demonstrates the beneficial effect of exercise alone or with dietary interventions on reducing total cholesterol and increasing high-density lipoprotein (HDL). The survey reveals that USAF flight surgeons believe that more preventive medicine training is needed in the USAF flight surgeon course, graduate medical education, and medical school. Given a scenario patient with hypercholesterolemia, the flight surgeons believe that nonpharmacologic therapy with consults to the base Health and Wellness Center (HAWC), along with follow-up by the physician, is appropriate initial medical treatment rather than pharmacologic therapy. CONCLUSIONS: The primary treatment for prevention of CHD should be an organized exercise and diet program. This treatment is proven effective through clinical trials and is supported by the flight surgeon survey results. Additional benefits of an organized exercise and diet program include decreased obesity with its associated complications, decreased incidence of hypertension, decreased cancer risk, and decreased risk for diabetes mellitus.     

Paper-free flight surgeon's office

Integration of evolving technology into the flight surgeon's daily practice offers revolutionary opportunities to improve professional effectiveness. The productivity of those involved in the practice of aerospace medicine will be enhanced through the use of information systems, including word processors, communications equipment, graphics displays, and computers. The use of these systems will eliminate "paper work" and add efficiency to the flight surgeon's office environment. The practice of medicine is changing with increasing emphasis on credentialing, activity tracking, incident reporting, and occurrence screening. These quality assurance measures are being followed through data base management. The implications regarding medical records management, productivity indicators, continuing medical education, preventive medicine and direct patient care are great. The ability to communicate electronically leads to potential consultant networks, allowing real-time advice on complex cases regardless of geography. Military physicians should also be mindful of the command, control, communications, and intelligence advantages offered by these systems. Although microcomputers exist in most flight surgeons' offices and new technical applications are planned, integrators and champions are needed.     

Becoming a flight surgeon

This text is the inaugural lesson given by the Professor of Aeronautic Psychiatry and starts the training period for new flight surgeons in the French Air Force. Introducing the French Air Force Medicine Training Session, the author speaks about the psychological aspects in aviation medicine. Three points of pilots' psychology are developed: 1) the pilot's body as the source of intense sensations and as an object of important value; 2) the libidinal, narcissistic, and defensive aspects of the pilot's spirit; and 3) the pilot's environment with its characteristic relationships. These facts influence the medical approach and modify the physician-pilot relationship. The flight surgeon must pay attention and get ready for this specific practice.     

Inflight anxiety conditions presenting with "break-off" symptoms

The psychological dimension of disorientation is explored through two experienced pilots who developed inflight anxiety conditions. These were associated with "break-off" symptoms, which are inflight sensations of separation from the ground, the environment, and the aircraft. Following extensive psychiatric and medical evaluations, one aviator was diagnosed as having agoraphobia without panic disorder, and the other as having an otherwise unspecified anxiety disorder. These patient reports demonstrate the need for the clinical aerospace medicine specialist to investigate inflight anxiety conditions for underlying neuropsychiatric disorders. The reports also contrast some of the historical aeromedical concepts with modern psychiatric diagnostic nomenclature.     

The role of aeronautical adaptability in the disqualification of a military flyer

INTRODUCTION: Possessing a stable personality plays a critical role in crew coordination, mission completion, and safety of flight in aviation. Presented is a naval flight officer whose personality traits were a threat to these key tenets and ultimately warranted removal from flight status. CASE REPORT: A naval flight officer was twice referred to Human Factors Boards (HFBs) after concerns were raised about her emotional stability in and out of the cockpit. Her history revealed multiple clinical presentations revealing personality characteristics that should have raised immediate concern about her aeronautical adaptability. Formal psychiatric evaluation after her second HFB confirmed the presence of personality traits incompatible with aviation duty, but not until she had served nearly 4 yrs. as an aviation officer. DISCUSSION: Aeronautical adaptability is a U.S. Naval term used to describe an individual's ability to work successfully in the aviation environment. Naval aviation personnel are considered not aeronautically adaptable/adapted if diagnosed with a "personality disorder or prominent personality traits that adversely affect flight safety, mission completion, or crew coordination". The Federal Aviation Administration, the U.S. Air Force, and the U.S. Army endorse similar concepts. Except for the U.S. Navy definition, aeronautical adaptability does not include formal DSM-IV-TR diagnoses, and, thus, flight surgeons and aviation medical examiners often make difficult aeromedical dispositions based on vague and subjective criteria. CONCLUSIONS: Determining aeronautical adaptability is not a simple, solitary process. It requires heightened suspicion, continual surveillance of suspect aviators, and collaboration from aviation medical professionals to ensure aviation safety.     

Development of a deployment course for graduating military internal medicine residents

Graduates of military internal medicine residency programs are required to have the necessary knowledge and skills to function as internists, military physicians, and military medical leaders. The global war on terrorism has increased the role internists are playing in combat theaters as they fill multiple different military medical positions including battalion, brigade, and division surgeons as well as physicians in echelon I, II, and III medical facilities. Along with general internists, internal medicine subspecialists, pediatricians, and family physicians also fill these roles. Although internal medicine training provides a broad-based knowledge to care for adults, it does not provide significant training in combat casualty care, detainee health care, or environmental health. To overcome many of these perceived shortfalls, we developed the 3-day deployment course for graduating internal medicine residents outlined in this article. Through a combination of didactic and hands-on training, militarily relevant medical knowledge and skills necessary to function at echelon I and II levels of care were provided. Residents uniformly accepted the course with measurable increase in their fund of knowledge at the completion of the course.     

Integrating emergency medicine residents into a well-established helicopter program

INTRODUCTION: The institution of an emergency medicine residency in a university-affiliated Level 1 trauma center in July 1993 provided a challenge to develop a curriculum and on-line learning experience for emergency medicine residents in a well-established helicopter program. The purpose of this study was to survey flight crew members, emergency medicine at tending physicians, and emergency medicine residents on the anticipated roles and educational experience of integrating the emergency medicine residents from a new emergency medicine residency into the flight crew of a well-established helicopter program. METHODS: A survey consisting of multiple choice, Likert scale, and open-ended questions was distributed to flight crew members (RN, RT, pilots, communication specialists, EM attendings, and EM residents [n=72]). RESULTS: 92% of surveys were returned. These surveys identified specific issues of concern and those areas believed to be of academic importance for the emergency medicine residents. CONCLUSIONS: The results of this study allowed for the creation and implementation of a progressive flight experience for EM residents that incorporates increasing responsibility on the flight crew as experience is gained.     

Theodor Benzinger, German pioneer in high altitude physiology research and altitude protection

Theodore Benzinger was a pilot-physician who performed pioneering research-often involving self-experimentation-in areas related to flight at high altitude during World War II. Of greatest historical interest to those of us in aerospace medicine is his work on the effects of rapid decompression and related oxygen equipment. Benzinger was born in Stuttgart, Germany, on 28th August 1905. He studied medicine and natural sciences at the universities of Tuebingen, Munich, and Berlin. From 1934 to 1944, Benzinger headed the aeromedical laboratory "EMed" in Rechlin, where he was instrumental in conducting studies related to stratospheric flight, including self-experimentation with rapid decompression up to 19,000 m (62,320 ft). His Rechlin experiments made an important contribution to understanding the physiology and life-support requirements for high-altitude aviation and later work under space-equivalent conditions. Following World War II, Benzinger joined the staff of the U.S. Army Air Force Aeromedical Center in Heidelberg. In 1947 he was recruited by "Operation Paperclip" to work at the U.S. Naval Medical Research Institute (NMRI) in Bethesda, MD, where he worked on various aspects of human physiology. He died as a U.S. citizen in Bethesda, MD, on 26th October 1999.     

Pulse oximetry: basic principles and applications in aerospace medicine

INTRODUCTION: Pulse oximeters are reliable, objective, and noninvasive monitors that have broad application in aerospace medicine. New technology enables pulse oximeters to perform well in adverse environments and measure additional parameters. Small, battery-powered devices can be used to monitor oxyhemoglobin saturation while in flight. THEORY OF OPERATION: Pulse oximeters use spectrophotometry to measure the ratio of oxyhemoglobin (Hbo2) to reduced hemoglobin (Hb) in arterial blood. This value is displayed as oxyhemoglobin saturation (Spo2). A plethysmographic waveform that resembles arterial waveform is also frequently displayed and may indicate relative changes in perfusion and blood volume. Loss and subsequent reappearance of this waveform during occlusion with a cuff has been used to measure systolic blood pressure during helicopter flight. APPLICATIONS: Accurate determination of oxygen saturation requires a high quality arterial signal and is limited by errors resulting from calibration, motion and vibration, and dyshemoglobinemias. Vasoconstriction may result in decreased pulse amplitude and also impair accurate measurement. Conventional fingertip probes may interfere with the performance of required duties, while helmets and other restrictive clothing can impede the use of sensors on the forehead or ear. Recently introduced devices answer some of these limitations and enable measurement of additional parameters. For example, new probe designs permit more freedom of movement and include a contactless camera and a sensor that fits around a finger like an ordinary ring. This article explains the theory of operation and limitations of pulse oximetry, offers an update on new technology, and discusses applications of this technology in aerospace medicine.     

Specialty competencies for residents in aerospace medicine.

BACKGROUND: The American College of Preventive Medicine (ACPM), with sponsorship from the Health Resources Administration (HRSA), has published core competencies that are common to all preventive medicine residencies-aerospace medicine (ASM), occupational medicine (OM), and general preventive medicine/public health (GPM/PH). Further development of specialty area competencies for ASM residents was addressed by a working group comprised of representatives from each of the four ASM residency programs. METHODS: Representatives from the U.S. Air Force School of Aerospace Medicine, Wright State University, University of Texas Medical Branch-Galveston, and the Naval Operational Medicine Institute convened to develop a set of broad competency statements for ASM residents that would encompass the breadth of ASM residency training as it is currently provided in the U.S. RESULTS: A listing of six ASM resident competencies, with supporting skill sets, are presented. In combination with the ACPM core competencies, the ASM resident competencies represent a refocusing of educational objectives on skills attainment. CONCLUSIONS: The ASM resident competencies identify the capabilities of graduating ASM residents as distinct from OM and GPM/PH residents. At the same time, they are broad enough to permit specific areas of emphasis (e.g., military, civil, or space) to be pursued within the various ASM residencies. This represents the first successful attempt to draft a consolidated statement of educational objectives that has universal acceptance and applicability across all U.S. aerospace medicine residencies.     

Assessment of simulated surgical skills in parabolic microgravity

BACKGROUND: During spaceflight crew health is paramount in the success of flight missions. The delivery of healthcare during flight requires crew readiness for medical and surgical response. METHODS: There were 20 participants who were evaluated for accurate performance of 4 basic laparoscopic surgical skills (clip applying, cutting, grasping, and suturing) during parabolic weightlessness using an inanimate workstation aboard the NASA KC-135 aircraft. RESULTS: Data indicate that motor skill performance decreased within the parabolic microgravity flight environment. Performance in parabolic microgravity flight included futile effort with an increase in number of tasks attempted and a decrease in tasks completed successfully. CONCLUSIONS: There is a decreased frequency of accurate task completion in parabolic microgravity flight, but it is not an obstacle to implementation of effective training for providing in-flight medical care. The data reveal that individuals perform basic laparoscopic surgical simulation with greater effort in microgravity following simulation training.     

New perspectives in the treatment of hypoxic and ischemic brain damage: effect of gangliosides

Aircrews operating at high G forces and altitudes may be exposed to both physiological and physical stresses capable of inducing brain hypoxia. A potential therapeutic tool for the treatment of flight personnel, monosialoganglioside (GM1) has been found to reduce deficits and enhance repair following CNS injury. A survey of experimental evidence concerning the effects of GM1 in the acute phase of CNS injury supports its proposed application for aerospace medicine.