president’s column inside this issue - sousaffs · inside this issue news from sousaffs 6 ... col...

FLIGHTLINES | 1

With this, my first issue of

FlightLines as president, I

need to start off with some

“thank yous." However, keep

reading because this issue

is intentionally designed to

begin a controversial dialogue

that should help us discuss

and refine our management

of the Alcoholic Aviator.

Thank you to Romie

Richardson for leading this organization into a new mindset.

With our advances in member access and services, and the

amazing quality of our “journal,” society membership really is

a “must do” for every USAF flight doc. Thanks to the entire

executive team of the society for furthering this agenda – lots of

hours and lots of evenings have been devoted to this society. And

finally, thanks to you for choosing me to lead this group. I will

do everything I can to live up to the honor.

In this issue we will delve into the decades-old controversy

surrounding management of the alcoholic aviator. Over genera-

tions of aviators, each pilot and Flight Surgeon has known

someone whose career in the Air Force ended due to alcohol

VOL. 21, No. 2, Summer (July) 2005

Inside This IssueNews from SoUSAFFS 6

AsMA Recap 9

View from the Top 12

HQ Policies Update 13

RAM/AMP Report 14

Focus: Alcohol and the Aviator 16

From the Field 16

“AAA” - Mr. Bob Holliker 18

Help for the Pilot with Substance Abuse 20 From the Files: Aviator Stress 21 HIMS/EAP Program 22 Good News for Aviators 24

Monitoring Compliance 26

Aviation Movies 28

Guest Editorial 29

State of the Flight Surgeon: MDG/CC Survey 30

Fighter Speak 101 33

Readiness Review 34

Deciphering the UMD 36

International Corner 38

Intro to CHPPM 40

PHSD: CRAM and AF WEB HA 42

HMOC: Treating Decompression Sickness 44

Airmail/In Memory 45

The Last Word 46

President’s ColumnCol Chuck Fisher, USAF, MC, CFS

Alcohol and the Aviator

Society of USAF Flight Surgeonswww.sousaffs.org

FlightLines

2 | FLIGHTLINES

FlightLines Staffand Contributing Editors

Guest Editor LtCol(s) Kathleen JonesSenior Editor LtCol Jeanine CzechEditors LtCol Dana Windhorst, LtCol Cheryl LinnSenior Business Editor LtCol Peter KovatsBusiness Editor Capt Glen MacPhersonFrom the Top Col Dale TidabackHQ Updates Col(s) Mark MavityX-Files Maj Doug FilesGraduate Education Col Mike FarrellIG News Col Tom LunaDeployment Medicine LtCol Adanto D’AmorePopulation Health Support Col Alton Powell MSgt Susanna MiddletonFighterSpeak 101 Capt Sammy “The Bull” Galvagno Capt Thomas “Don Vito” Massa Capt Rich “Grover” Farley Photographer TSgt. Alfonso RamirezAlphagraphics Designer David Sanchez

FlightLines: Vision and MissionOur vision: FlightLines is the written forum for the Society of United States Air Force Flight Surgeons. We help facilitate top-to-bottom, bottom-to-top, and horizontal dialogue within the Flight Surgeon community.

Our mission: We provide a vehicle to pass the vector and tools to Flight Surgeons so they can do their jobs effectively and effi-ciently as current and future leaders within Team Aerospace.

misuse. We probably missed an equal or greater number,

though, who successfully hid their disease at least for a while.

Mr. Holliker, a recovered alcoholic pilot, correctly identifies

the civilian HIMS method of treatment, follow-up and return

as a successful model to emulate, postulating that fewer pilots

would be compelled to hide their disease if we embraced an open

support system like it. Maybe.

Management of the civilian alcoholic focuses on keeping alcohol

out of the cockpit in a relatively predictable scheduled environ-

ment, and in an environment where confidentiality is assured.

The military requires performance 24/7 in any environment, few

of which the pilot will control. Further the military pilot is an Air

Force officer first – meaning that we cannot permit the percep-

tion of a tacit endorsement of behavior that is incongruous with

officership. An alcoholic with an alcohol related incident is still

going to get the book thrown at him/her regardless of our best

intentions to return the pilot to work. Thus the civilian model

may work indeed, but is it applicable directly to the military?

Col Ireland discusses proposed and likely changes to AFI 48-123

that will change USAF management from punitive to supportive

in many ways. These changes, though, place additional burden

on the Flight Surgeon, commanders, and consultants to be espe-

cially attentive to the subtle signs of recidivism or relapse. Many

flight docs have not spent much time training in or with recov-

ering alcoholics, and to be an effective member of the treatment

team need to get smart quickly in that aspect of their medical

practice.

This issue, then, is written to open discussion and begin that

education process. The authors are all writing in their capacity as

members of the Society and practicing specialists. What is stated

in here is medical dialogue, NOT USAF policy or official guid-

ance. However, every member can have a role in formulating that

guidance and the training that follows by using this as a spring-

board for dialogue within their USAF chain of command. Grab

your colleagues and use this as the basis for a lunchtime confer-

ence – and reflect on just how great it is to be a USAF flight doc

able to genuinely team with your aviator patients!

In Errata: The very astute Capt Lee M. Nenortas, the Medical Control Center Team Chief at Grand Forks AFB, noted that in the Winter (February 2005) issue of FlightLines we published an error in the Deployment Medical Reporting section. According to AFI 10-206 (October 4, 2004) there is no longer a requirement for Section C of the MEDRED-C. We checked with our sources and found that Capt Nenortas is absolutely correct – thanks for the info!

“As I grow older, I pay less attention to what men say. I just watch what they do.”

-- Andrew Carnegie

FLIGHTLINES | 3

Inside This Issue

Kudos and many thanks to LtCol (sel) Kathleen “KitKat” Jones, RAM 2006, for acting as guest editor for this issue’s theme “Alcohol and the Aviator.” Kathleen did an awesome job of pulling together a bank of authors who shed light on the problem of alcohol abuse among aviators - from the first drink, to the Article 15, through treatment and waiver.

We start with a troubled Flight Doc - how to convince the impaired pilot to get help?

Mr. Bob Holliker, who shares his experiences with AMP classes, and the anonymous author of “Making Amends” show what goes on in the alcoholic’s mind.

Mr. Scott Hein tells us about Birds of a Feather, a AA support group oriented to pilots.

Mr. Dave Fredrickson gives us a look into how the airlines deal with this problem.

Dr. Quay Snyder discusses the importance and process of monitoring pilots who have a history of abuse but are cleared to return to flying.

And Col Bob Ireland gives us insight into military regs re: alcohol abuse and flying.

In addition:

Col William Nelson’s survey on how the Med Group commanders evaluate their Flight Docs - and how we can improve...

Col Pat “Goose” Storms cracks the secret code on the Unit Manning Document...

LtCol Bob D’Amore tells how to get a quick-and-dirty assessment of the Readiness Shop...

Squadron Leader “Nati” Nataraja tells us how they treat airsickness in the Indian Air Force...

Fighter Speak 101 - those fighter guys tell us how to evaluate a HUD tape, watching for signs of GLOC or inadequate AGSM...

Public Health Support Division tells us what we need to know about the CRAM(Cardiac Risk Assessment and Management) program, and gives us a look at thebrand-new Web Health Assessment Tool...

Info about CHPPM (US Army Center for Health Promotion and Preventative Medicine.) See their website and learn about opportunities for Risk Communication training...

...This, and much much more!

4 | FLIGHTLINES

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FLIGHT SURGEONS

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� Support training andprocedures development in U.S.

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All candidates must have a degree in medicine (D.O. or M.D.) with ABMS-recognized board certification or eligibility in aclinical specialty. Current (or ability to obtain) unrestricted Texas medical license, DEA and Texas DPS controlled substances

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Send inquiries and/or a detailed resume to:

email: [email protected]

*UTMB is an equal opportunity, affirmative actioninstitution which proudly values diversity.

Candidates of all backgrounds areencouraged to apply.

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6 | FLIGHTLINES

I’ve graduated from the RAM program and will be at Seymour-Johnson AFB by the time this goes to print, which means I need to introduce our new SoUSAFFS executive officer Maj Brian Pinkston. Feel free to email, call at all hours, or write to him voluminously regarding any concerns or thoughts you may have about your society. He has taken possession of the plethora of paraphernalia necessary to conduct SoUSAFFS business and is eager to assist all of you.

Seriously, it has been extremely rewarding to have served as the exec for the last two years. Over that time the society produced a landmark survey that continues to influence senior med corps leader-ship. FlightLines has become a highly valued resource, and our active membership has reached an all time high. Working with the quality leadership that makes up our society has been priceless and exceedingly rewarding. I say that as a shameless plug to encourage others to get involved with SoUSAFFS, AsMA, or ASAMS, because you’ll undoubt-edly get more from the experience than give. The relationships you build and knowledge you gain will make you a more effective and efficient aerospace medicine specialist. The time and effort you put in will pay generous dividends.

Speaking of work, the society has been busy crafting a business plan that now includes corporate sponsorship to ensure FlightLines can continue to be published in its larger format. Electronic voting for officers was successful this year, which is good because I was coerced into betting my career on it. And our SoUSAFFS annual awards program was extremely successful thanks to Lt Col Brian Hayes. If you have any questions about how to nominate any of your outstanding team aerospace members Lt Col Hayes ([email protected]) will enthusiastically assist you.As a parting thought I’ll pass along a concept that many of you will be familiar in the aviation environment but it’s essentially true of any profes-sion. I was on a T-1 ride this week where the instructor repeatedly had to bring our rapidly declining airspeed on short final to the attention of a somewhat frazzled student seated next to him. As our airspeed quickly fell below our intended safe approach speed toward a stall the instructor would correct the situation and discuss the importance of trend analysis

and of being five minutes ahead of the airplane with the student. He’d repeatedly say "Don’t let the airplane take you anywhere your brain hasn’t been already," and "Be five minutes ahead of your aircraft." I’d heard these concepts before, but as a newly minted RAM I kept hearing them in the context of "Don’t let the Med Group take you anywhere your brain hasn’t been already."

This proverb will have different implications depending on your posi-tion in the organization, but the truism is that as an aerospace medicine professional it’s your responsibility to have your brain ahead of the game regarding all things aeromedical. Be proactive, when it comes to major program changes do your homework, call another base or your MAJCOM for advice since most things have been done before, and always strive to stay five minutes ahead of your surroundings.

As I sign off from here in San Antonio I want to say thanks for the last two fantastic years, and I look forward to contributing in one form or another for many years to come. Who knows, maybe Maj Pinkston will let me have some fun shaking our fine members down for dues money at AsMA next year.

From the ExecMaj Chris Borchardt

RAM 2005

News From SoUSAFFS

Vice President/President Elect Richard Bachmann

Secretary Steven Hetrick

Board of Governors Randall Falk Cesario Ferrer Dale Tidaback

Congratulations to our newly elected SoUSAFFS Officers:

FLIGHTLINES | 7

News From SoUSAFFS

Society of USAF Flight Surgeons Annual Award Winners

9 May 2005Kansas City, Missouri

2004 MAJCOMFlight Surgeon

of the Year Winners

Air Combat Command

Major Robert R. York, Jr.

Air Education & Training Command

Capt Samuel M. Galvagno, Jr.

Air Force Materiel Command

Lt Col Ann L. Hoyniak-Becker

Air Force Reserve Command

Lt Col Keith R. Kulow

Air Force Special Operations Command

Lt Col Brandon D. Clint

Air Force Space Command

Major Christopher A. Walker

Air Mobility Command

Major Charles L. Bryant

Air National Guard

Lt Col Sidney T. Van Assche

Pacific Air Forces

Major Yuri F. McKee

United States Air Forces in Europe

Major Paige L. Neifert

2004 Malcom C. Grow Award Winner

Air Combat Command

Major Robert R. York, Jr.

2005 George E. Schafer AwardColonel (Ret) Romie N. Richardson

2004 MAJCOMOperational Flight Surgeon

Safety Award Winners

Air Combat Command

Major Walter M. Matthews


Major Keith W. Hunsaker

Air Force Special Operations Command

Major Jerry M. Cline

Air National Guard

Major Lisa K. Snyder

2004 Operational Flight Surgeon Safety Award Winner


Major Keith W. Hunsaker

2004 Olson-Wegner AwardsOutstanding Operational Aerospace

Medicine Airman of the YearSenior Airman Lawrence A. Whitmore

Outstanding Operational Aerospace Medicine NCO of the Year

Staff Sergeant Jessica F. Nuyt

Outstanding Operational Aerospace Medicine SNCO of the Year

Master Sergeant Rhonda J. Sharbini

2005 Julian E. Ward Memorial AwardMajor Kimberly R. Bradley

2004 Howard R. Unger AwardMajor Anthony P. Tvaryanas

8 | FLIGHTLINES

A great time was had by all Flight Surgeons and other members of Team Aerospace who attended the Annual Meeting of the Aerospace Medical Association (AsMA) in May, 2005. Highlights included listening to Dr. Joe Kittinger tell us the story of his historic skydiving feats. The SoUSAFFS luncheon was, as always, a great meal with great companions. We were treated to Dr. Charles Berry’s tales of earlier days as an AF Flight Doc, as well as Col Brian Hayes’ particular (or is that peculiar?) brand of humor as he introduced the winners of the many SoUSAFFS Awards (see p. 7 for names of the honorees.) Kelsey-Seybold treated us to a mighty fine buffet at the SoUSAFFS Social (thanks, Romie and Ms. Deb Mounts.) LtCol (now) Paul “VooDoo” Nelson was ambushed one evening as he was walking past the bar, silver oak leaves were pinned on his shoulders and he was forced to pay for a round of libations. Honors Night was a spectacular gala of gussied-up flight docs and happy award winners. Frankly, my favorite event was the last lecture, learning about the Ornithopter Project based at the University of Toronto’s Institute for Aerospace Studies. Those crazy Canadians...For those who could stay an extra day the B-2 tour was an outstanding look at a rarely seen weapon system.

News From SoUSAFFS

AsMA Recap

LtCol Jeanine “Wizard” Czech

Air Force Captain Joe Kittinger stepped from an open balloon gondola at 102,800 feet above

Tularose, New Mexico and set a world record for the highest altitude parachute jump ever made

from an aircraft.

Flapping like a mallard... No jet engine, no propeller. This ornithopter, designed by James DeLaurier and

researchers at the University of Toronto’s Institute for Aerospace Studies, is designed to fly by flapping its wings.

Credit: Institute of Aerospace Studies, University of Toronto

Dead Bugs Ortega and Drugs Robb at the SoUSAFFS social, AsMA 2005.

Our present leadership: Exec Maj Chris Borchardt, President Col Chuck Fisher, and Secretary Col Tim Jex trying to stay out of trouble.

FLIGHTLINES | 9

One of the highlights of AsMA week was watching as our very own VooDoo (now-LtCol Paul Nelson) had a surprise pinning-on by Maj Gen Bruce Green. Gen Green cornered VD in the bar and gave the oath, VD’s son provided the flag, VD’s wife Betsy and daughter pinned on the new jewelry, and VD paid the liquor tab. Congrats VooDoo, we’ll miss you here at FlightLines.

News From SoUSAFFS , con’t

10 | FLIGHTLINES

Following the AsMA meeting, several AF flight docs and family members traveled to Whiteman AFB to see the B2 up close and personal. Many thanks to Maj Rod Friend for arranging the trip, and Col Rich Bachmann for hosting the event. See more great photos at the SoUSAFFS Photo Gallery, http://www.sousaffs.org/photos.htm.

Here Dr. Chuck Berry is shown receiving the Academic Instructor of the Year Award at the recent USAFSAM RAM graduation. Dr. Berry was also the featured speaker at the SoUSAFFS luncheon during AsMA week, where he reminisced about his days as a USAF Flight Surgeon, before joining the NASA team. A memorable quote: “You haven’t led an exciting life until you’ve had your plane towed by a tuna boat through a storm off the coast of Central America.”

LtCol Lee Harvis zaps SoUSAFFS Vice Pres-Elect Col Richard Bachmann, on the Whiteman B-2 tour post-AsMA.

News From SoUSAFFS, con’t

FLIGHTLINES | 11

Finally.... New Flight Surgeon’s Checklist 7th Edition Published Jan 05

SoUSAFFS has joined the Brooks Heritage Foundation in a partnership to provide better service to our member-ship for mail/ phone orders for the Checklist and other Society items. Through this partnership we are able to accept credit cards, including unit IMPAC cards (no government travel cards) for payment and are able to take orders over the phone. The turnaround time for orders should be no greater than 4-6 weeks for delivery, usually with in 3 weeks. Mrs. Shelia Klein will have society items and wide variety of other aerospace medicine related items for sale at the gift shop at Hangar Nine during normal duty hours for those of you who visit Brooks. This will make the items conveniently available even when society officers are not available. Your patronage will do double duty, as a small portion of the proceeds of each mail order sale will be applied to the preservation of the history of aerospace medicine

through the Brooks Heritage Foundation.

Please see the Society website at http://www.sousaffs.org/ for more information about the checklist and other great items that Flight Surgeons just have to own! (Sorry, Toucan, no Breitling watches yet, maybe next year?)

It’s About Time...

Calling all Aerospace Medicine Leaders – Request for Teaching Resources

Craig S. Packard, LtCol, USAF, MC, SFSUSAFSAM/GE RAM ‘06

The diversity of skills and knowledge needed to practice in the aerospace medicine career field is enormous. If you doubt

this, just look at the METALS (mission essential tasks/activities for line support) list for Flight Surgeons. Ever since these

were first introduced in the RSVP (readiness skills verification plan), many of you in the field have been scrambling for good

teaching resources to address ongoing Flight Surgeon continuity training. There are several good resources out there but

they are spread out among various web sites or in some cases, not even in the public domain. Wouldn’t it be great if there

was one location where the “best of the best” resources and teaching aids were located and readily available? Over the next

year, I’m going to try to collect these resources in anticipation of developing such a continuity training site but I need your

help. Many of you may have personal lesson plans you developed locally. If you have access to a great powerpoint or other

teaching resource addressing one of our Flight Surgeon METALS, please send it (or the link to it, if available) to me at craig.

[email protected]. With your help, we can take Flight Surgeon continuity training to the next level. Thanks for your

support.

Throwing Down the Gauntlet

FlightLines extends sincere thanks to the generous anonymous donor who presented us with a gift of $100 to “keep up the good work.” The only thing we know about our donor is that he is a past president of SoUSAFFS, and he issues a challenge to all previous Society officers to match his gift. The competition is on!

12 | FLIGHTLINES

I am honored to have this opportunity to address my fellow Flight

Surgeons and all of Team Aerospace. For personal reasons I made the

difficult decision to retire this summer from the greatest organization in

not only the DoD but of all federal institutions…the AFMS. And as we

all know, the greatest place to be in the AFMS is in Aerospace

Medicine.

I would first like to thank the team of residents

that have done such an outstanding job with

FlightLines…I am continually impressed with

each edition. I also want to thank all of you

out there that I have had the privilege of

serving with over these last 21 years…I will

really miss all of the outstanding professionals

that make up our Team.

Over the last two years we have been trying hard

to re-emphasize/re-energize Team Aerospace and the

importance of Operational Medicine. Although inertia to

change things in the D.C. area is always challenging, I really feel we are

turning the corner. Col Materese and Col Tidabeck will be more than up

to the task to sustain and advance this trend as we head into the future.

With all the pressures to downsize, rightsize, jointsize, civilianize and

economize those of us in Aerospace Medicine must become the leading

force of the AFMS. This leads me to my new operational definition of

the famous P2R2 – Privileged, Professionals, Ready and Relevant.

Privilege: It is a privilege to directly support the warfighter and play a

critical role in Wing mission success. Whether it is Flight/Occ Medicine,

Public Health, Bioenvironmental Engineers, Aerospace Physiology,

Medical Readiness, Optometry or the HAWC, we are where the rubber

meets the road in support of operations.

Professional: We must continue to be true professionals in all we do as

we support the Line. We have gained their respect, proven our credibility

and the Line knows they cannot go to war without us. Sometimes you

only get one chance to make a first impression…

Ready: Not only must we be ready to go to war but it is up to Team

Aerospace to ensure total force readiness. This includes

all facets of Aerospace Medicine, and our job does

not stop when folks leave the base. Although

the health of all our beneficiaries is impor-

tant, our number one priority must always

be the warfighter. Human performance

enhancement/sustainment will continue

to be a critical element in future expedi-

tionary capabilities.

Relevant: Now, more than ever before, we

must continue to demonstrate our relevance

to the Line. Military essentiality is a term

being kicked around quite a bit by the Office of

the Secretary of Defense when they are looking for areas

to reduce the active duty. We are constantly being asked to prove why

certain jobs can only be filled by blue-suiters. If we do not remain

relevant to the Line, expeditionary, and uniquely different than the

civilian workforce we may slip in to the same struggles that some of our

“peacetime healthcare” blue-suiters find themselves in.

We must not grow stagnant or complacent as we step into the future.

We must continually push the envelope to improve our warfighting

capability for every airman in all occupations. By providing outstanding

operational healthcare and ever-advancing force health protection, we

will continue to be the “Tip of the Spear” for the AFMS.

Thanks again for all that you do and please continue to work together to

make Aerospace Medicine “the place to be” for the 21st century.

Leadership

The View From the TopCol Arne Hasselquist, USAF, MC, CFS Chief Aerospace Operations (SGOP)

FLIGHTLINES | 13

Revised Official Air Force Aircrew Approved Medication List, 14 Mar 05

This document is posted on the AF Knowledge Exchange (kx.afms.mil) under Physical Standards on the Aerospace Medicine web page.

Approved medications now include:

1. Etonogestrel/ethinyl estradiol vaginal ring (NuvaRing®) for contraception

2. Ramipril for second line treatment of hypertension

3. Hydroxychloroquine for treatment of non-rheumatoid arthritis

4. Mesalamine medications (Asacol®, Pentax®, and Rowasa®) for the treatment of inflammatory bowel disease.

Refer to the Official Aircrew medication list for restrictions, grounding requirements, and requirements for waiver submission.

A reduced (or no) grounding time is in effect for the following medi-cations:

5. Cromolyn (nasal) when underlying symptoms controlled

6. Steroids (nasal) when underlying symptoms controlled

7. Sucralfate when underlying symptoms controlled

8. Isoniazide reduced to 72 hours DNIF

9. Fexofenadine reduced to 72 hours DNIF

10. Loratadine reduced to 72 hours DNIF

11. Atorvastatin reduced to 5 days DNIF

12. Lovastatin reduced to 5 days DNIF

13. Pravastatin reduced to 5 days DNIF

14. Simvastatin reduced to 5 days DNIF

Refer to the Official Aircrew medication list for specifics.

Other medication changes include:

15. Testosterone therapy now requires a waiver for aviators

16. Antihypertensives require a minimum 7-day observation period after the last dose adjustment and documented blood pressure control prior to waiver submission.

Individual Aviator Medication Evaluations: Occasionally a medica-tion not on the Official Aircrew medication list may be particularly desir-able for general use in aviators. MAJCOM/SGPAs can submit requests for those medications they believe reasonable for use in an aviation envi-ronment to AFMSA/SGPA for consideration. For most systemic drugs, three years of post-marketing experience is needed. Refer to the policy memorandum for specifics.

HQ Policies Update

Lt Col Lane L. Wall, USAF, MC, SFSChief, Medical Standards Policy Application

Air Force Medical Support Agency

As we’ve all heard, recommendations from the Department of Defense regarding the Base Realignment and Closure plans for 2005 were published on May 13, 2005, and Brooks City-Base is on the list. As per DOD recommendations, USAFSAM is projected to move to Wright-Patterson Air Force Base.

Currently, senior personnel from the schoolhouse are involved in dialogue with MAJCOM and Airstaff leadership to determine costs and feasibility of the projected move. In July ’05 the civilian BRAC Commission will be visiting Brooks City-Base to evaluate and consider the economic impact of closing the base. The Commission must present its revised version of the list to President Bush by Sept. 8. Congress ultimately must approve the final list.

Stay tuned as decisions about the future of USAF Flight Medicine training continue to evolve.

BRAC Update

14 | FLIGHTLINES

Summer sees the advancement within the Residency of Aerospace Medicine of each class as newly graduated MPH students enter the year of Aerospace Medicine, second years divide between Preventive and Occupational Medicine tracks, and third years are sent off into the wide blue operational world. Below is a compendium of where these RAMs are from and where they are going.

Class of 2007Twenty-one students attended eight MPH programs by way of twenty different bases. Appearing below is an alphabetical list of the class members, the school of public health attended, and the position and base of the member prior to the MPH.

Capt Glenn Donnelly, UTSA, Chief of Flight Medicine Clinic, Dyess AFB, TX.

Maj Andrew Downes, UTSA, Aeromedical Flight Surgeon, 1st Canadian Air Division Headquarters, Winnipeg, Canada.

LtC Alfred Emmel, Harvard, Air Staff, Chief of Requirements and Modernization, Pentagon, Washington, D.C.

LtC Gail Fancher, Tulane University, Flight Medicine Flight Commander, Scott AFB.

Maj Michael Frey, UTSA, Brigade Flight Surgeon, 2nd Infantry Division, Camp Stanley, Korea.

LtC Mark Krautheim, USUHS, Flight Surgeon/Chief of Occupational Medicine, Peterson AFB, Colorado.

LtC Cheryl Linn, UTSA, Chief of Flight Medicine Clinic, Bolling AFB, Washington, D.C.

Maj Cheryl Lowry, Harvard, Flight Medicine Flight Commander, Lakenheath AFB, England.

Capt Glen MacPherson, Johns Hopkins, Flight Surgeon, Vance AFB, OK.

Col Fred Marks, University of Alabama at Birmingham, Flight Medicine Flight Commander, Maxwell AFB, Georgia.

Col Brian Masterson, UTSA, Chief of Informatics and Modernization at WHMC, Lackland AFB, Texas.

Maj Mark Nassir, UTSA, Flight Medicine Flight Commander, Edwards AFB, California.

LtC Eric Nelson, UTSA, Family Practice Residency Faculty, Clinic Chief, Medical Director, Andrews AFB, Virginia.

LtC Scott Norris, University of South Carolina, SGH, 437th Medical Group, Charleston AFB, South Carolina.

LtC Timothy Paulding, Harvard, Chief of Flight Medicine, Senior Validating Flight Surgeon for TPMRC Europe, 86th Aerovac Squadron, Ramstein AFB, Germany.

Maj Brian Pinkston, Johns Hopkins, Chief of Aerospace Medicine Guard Bureau, HQ Air National Guard, Andrews AFB, Virginia.

Col Chip Riggins, Tulane (1988), Regional Director for Department of State Health Services, State Air Surgeon for Air National Guard, Texas. Maj David Sarnow, University of Alabama in Birmingham, OSM Flight Commander, 353rd SOG, Kadena AB, Korea.

Maj Leigh Swanson, UTSA, Chief of Flight Medicine, Hurlburt Airfield, Florida.

Maj Lynn Vix, Tulane University, 16th OSS/OSM, Hurlburt Airfield, Florida. LtCol Dana Windhorst, University of North Carolina - Chapel Hill. Occupational Medicine residency completed at Duke University. Chief of Flight Medicine, Laughlin AFB.

Class of 2005The “drop” for the class of 2005 was rich and varied, scattering the class between the Orient, Europe, Canada, and throughout the lower 48.

Maj Christopher Borchardt, Aerospace Medicine, Occupational Medicine, Chief, Aeromedical Services, 4th Aeromedical/Dental Operational Squadron, Seymour-Johnson, North Carolina.

Maj Kimberly Bradley, Aerospace Medicine, Occupational Medicine, Chief, Aeromedical Services, Flight Commander, 319th Aeromedical Squadron, Grand Forks AFB, North Dakota.

Maj Stacey Branch, Aerospace Medicine, General Preventive Medicine, Chief, Aeromedical Services, 71st Medical Group, Vance AFB, Oklahoma.

LtC Donald Christensen, Aerospace Medicine, Squadron Commander, 22nd Aeromedical/Dental Operations Squadron, McConnell AFB, Kansas.

LtC Kevin Connolly, Aerospace Medicine, Occupational Medicine, Squadron Commander, 35th Aerospace Medicine Squadron, Misawa AB, Japan.

LtC Paul Doan, Aerospace Medicine, General Preventive Medicine, Chief, Aeromedical Services/Flight Commander, 2nd Medical Operations Squadron, Barksdale AFB, Louisiana.

LtC James Elliott, Aerospace Medicine, General Preventive Medicine, Chief, Aeromedical Services, Flight Commander, 95th Aerospace Medicine Squadron, Edwards AFB, California.

Maj Douglas Files, Aerospace Medicine, Occupational Medicine, Chief, Aeromedical Services, 47th Aeromedical/Dental Squadron, Laughlin AFB, Texas.

Maj Rodney Friend, Aerospace Medicine, General Preventive Medicine, Chief, Aeromedical Services, 509th Medical Operations Squadron, Whiteman AFB, Missouri.

RAM Report

FLIGHTLINES | 15

LtC Randy Guliuzza, Aerospace Medicine, Occupational Medicine, Chief, Aeromedical Services, Flight Commander, 28th Medical Operations Squadron, Ellsworth AFB, South Dakota.

LtC Lee Harvis, Aerospace Medicine, Occupational Medicine, Squadron Commander, 51st Aeromedical/Dental Squadron, Osan AB, Korea.

Maj Mical Kupke, Aerospace Medicine, General Preventive Medicine, Flight Commander, 38th Rescue Squadron, Moody AFB, Georgia.

Maj Scott McLeod, Aerospace Medicine, Division Surgeon, 1 Canadian Air Division, Winnipeg, Mannitoba, Canada.

LtC Paul Nelson, Aerospace Medicine, General Preventive Medicine, Chief, Aeromedical Services, Flight Commander, 14th Medical Operations Squadron, Columbus AFB, Mississippi.

Col William Nelson, Aerospace Medicine, SquadronCommander, 435th Aerospace Medicine Squadron, Ramstein AB, Germany.

Maj Mark Summers, Aerospace Medicine, Occupational Medicine, Chief, Aeromedical Services, Flight Commander, 5th Medical Group, Minot AFB, North Dakota.

Col Patrick Storms, Aerospace Medicine, General Preventive Medicine, Squadron Commander, 48th Aerospace Medical/Dental Squadron, RAF Lakenheath, UK.

LtC Eveline Yao, Aerospace Medicine, Flight Commander, 16th Operational Support Medical Flight, Hurlburt Field, Florida.

LtCol Joseph M Acosta

Maj Adam L Alpers

Maj Marc J A Brouwers

Capt Grady L Burleson Jr

Capt James M Byrne

Capt Chad J Carda

Maj Eleftherios Chatzellis

Capt Stephen E Chester

Maj Daniel E Cole

Maj Ritske Dreijer

Maj Maria A Duis

Capt Lisa A Durette

Maj William Harry

Maj James E Frame

Maj Renato A Geralde

Capt Bradley J Goad

Capt Sanjay A Gogate

Capt Theresa B Goodman

Capt Christopher M Grussendorf

Maj Richard L Horak II

Capt David L Huang

Maj Duncan G Hughes

Maj Ahmad Filza Ismail

Capt Gregory A Khanarthur

Maj Heini Keinanen

Maj Jocelyn A Kilgore

Maj Eric L Knight

Maj Craig A Manifold

Capt James F Martin

LtCol Antonio T Martinez-Luengo

Maj Saab Mestarihi

LtCol Patrick M Morgan

Capt Jason L. Musser

Maj Ramonito H Panal

LtCol Anthony M Propst

Capt Christopher R Schmelzer

LtCol Namfrel G Serran

Capt Deshawn K Stewart

Capt Joshua M Tobin

Maj Victor Albert Torano

Capt Emmanuel A Trigenis

Maj Anna C Van Riel Maj John P Vickery

Capt Alan J Williamson

Maj Kristan H Wusterhausen

Capt Noor Saadiah Zainal

Aerospace Medicine Primary

New Flight Docs

We are proud to introduce the newest Flight Surgeons. These physicians completed the Aerospace Medicine Primary course in Spring 2005. Welcome to Team Aerospace!

16 | FLIGHTLINES

Alcohol and the Aviator

Editors’ note: The following are excerpts of e-mailed communica-tion from a Flight Surgeon “in the field” to a mentor at USAFSAM (reprinted with permission from both individuals). These excerpts are in chronological order as the situation progressed over several months. Does this sound familiar to anyone? What would you have advised if you were the mentor? What would you have done if you were the flight doc?

“I’m in the middle of a disaster here at the squadron, and I often reflect back on the lecture you gave my AMP class because it sounds similar to the situation you were once in. I’ve just made a referral for an alcohol/mental health eval on one of our pilots who’s simultaneously caught up in a horrific command-directed investigation for misconduct. Not involving alcohol, but I’m sure it played a role. It was truly an awful, awful thing to sit down with this man whom I admire and respect and like very much and add this newest helping to his already-full plate of worries. It’s heart-wrenching to see him go down like this...”

“He views the referral as punitive, can’t see that it might provide some tools to help him out of this mess, denies any possibility of any kind of problem whatsoever (contrary to what family and friends and colleagues think), and just backs further and further into his corner.”

I’m in the middle of a disaster here at the squadron...It’s heart-wrenching to see him go down like this...

“So what happened with the friend you referred? Do you keep in contact? Did it turn out to be helpful for him? I just don’t think this guy is going to own up to anything or cooperate in any way. Was there anything that you did or said, looking back, that seemed particularly helpful?”

“Yeah, the [alcohol] eval didn’t exactly work out as I’d hoped. I’m not exactly sure why I thought it would, or anyone thinks it would. They really expect a pilot to go to that interview and corroborate all of the evidence of his alcoholism? “Well gee yes, you’re right, I guess my bizarrely irrational behavior, my daily half-liter of Jack Daniels and weekly binges to the point of unconsciousness, and my social isolation and depression ARE evidence of disease. You should ground me for 6 months and ruin my career.”

“My pilot lied his butt off and got away with all of it. Why did I waste my time talking to his colleagues, family and friends for hours on end? It was just “hearsay”. I begged for help…and didn’t get it. But then again, I’m not exactly sure WHAT would have helped. A 6-month out-patient treatment program? Doubt it. Maybe nothing would help anyway until he’s ready to ask for it. So for now, he’ll continue on in his self-destruc-tive and squadron-destructive way until the next event. At least now we have our concerns officially documented.”

They really expect a pilot to go to that interview and corroborate all of the evidence of his alcoholism?

“The attachments [to the last e-mail] were two of the faxes I sent to the [alcohol] evaluation team so they’d have the ‘hearsay’ evidence of

alcoholism… I was pretty stunned that they overlooked it all (“well, he didn’t own up to any of it (...DUH....) and we couldn’t prove it.”) and said they could find no evidence of alcohol abuse, dependence, or mental illness.”

“ My pilot is seriously ill and a magnificently talented and charming liar.” “Are there really alcoholic pilots in denial who ‘fess up during that two hour interview? I still don’t get it. I sure as hell won’t ever refer another aviator unless he tells me he’s ready to ask for help. This [alcohol] evalu-ation has made things worse: now the pilot’s delusion that he doesn’t have a problem has been legitimized; the other pilots who have watched him fall down drunk, sleep around, and completely destroy squadron morale will be even less apt to express concern about the next alcoholic (what’s the point? nothing comes of it); and the opportunity to leverage a sick man into recovery (though it probably wouldn’t have helped anyway) is gone. Really exasperating. Dismissal is sounding just fine these days-- I can spend my time making actual money in the ER and going to Little League games rather than wasting my time fretting over alcoholics in flight suits.”

From the Field: Alcohol Abuse DilemaAnonymous Flight Surgeon

John Belushi in the movie 1941.

FLIGHTLINES | 17

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18 | FLIGHTLINES

In the early 1980’s there were two almost identical incidents (that I can remember), where I flew drunk with absolutely no reservations at all. Both times were on the return legs to Randolph Field from cross-coun-tries to Shaw AFB, SC, in a T-38A. On the first trip I was the ‘seeing-eye’ Instructor Pilot (IP) for our Inspector General, a 1-star, and on the second flight, I was flying with the Command Flight Surgeon (who was also a pilot). Each time the guy I was flying with had an agenda of his own, and so did I – to ‘party’ and get drunk. And, on both occasions I drank until 0330 – 0400, and then subsequently took off at 0900 or so.

When I say I flew drunk “with absolutely no reservations at all,” it is not from a position of arrogance or bravado – and I am certainly not proud of it. It is more from the consequences of my undiagnosed and untreated disease at the time – that of alcoholism. I am a drunk. And today, I intend to regress a bit (mentally), to share with you a little of ‘how I think’ in my alcoholic state. The brains of alcoholics are ‘wired’ a little differently than those of ‘normal folks.’ That’s not necessarily good, nor bad; it’s just the way it is. So all the briefings by commanders, flight safety guys and Flight Surgeons, the appeals to stop drinking from friends and wives, all are lost on alcoholics. I know, I had ‘em all and it still didn’t make a difference! For the two flights mentioned above I was serving as an ATC T-38 Flight Safety Officer at the time.

I was what is characterized as a ‘high-functioning’ alcoholic, until the bitter end. I made all my promotions on time, I never had a DUI, I always showed up for work (yeah, sometimes still ‘in the bag’) and I was a flying squadron commander at the end of my USAF career. I also completed all the Professional Military Educational courses along the way, and my Master’s degree as well. On the personal side, I was married, with two great kids. At the risk of vanity, I was charismatic, innovative, creative and funny as hell – the ‘life of the party.’ On the inside however, I was forever lonely, scared, uncertain, angry, and tormented; for I knew I was

a drunk! I have known there was something ‘not quite right’ with me since I was 8 or 9 years old. It was as if I never fit in anywhere, until I drank. Then I fit in everywhere!

So, knowing all this at the time, why didn’t I seek help? Well, I did, once – near the end of my career. Until then I was not able to because of a couple of reasons. First, our Air Force ‘culture,’ in and of itself – as it is. It’s just as simple as that. In spite of all the wonderful Air Force ‘programs and policies,’ with regard to alcohol use, I just did not trust ‘the System.’ (Alcoholics seem to have a natural hatred of ‘authority figures;’ I know, I did – and do even somewhat to this day.)

Let’s begin here by looking at the label for folks like me; the label for people struggling with alcohol given to us by the Air Force, and our society in general. The Air Force, yesterday and today, calls us ‘alcohol abusers!’ Stop and think about it here a second; do you seriously think I am going to go to anyone and fess up, “I am an alcohol abuser?” Gawd, the stigma associated with being an ‘abuser,’ of any kind within our society! And, to label myself as an ‘abuser?’ No way! While the term ‘alcohol abuse’ may carry an innocent connotation for what it is with ‘normal’ folks, for the alcoholic it’s tormenting because of everything else it brings with it: shame, stigma, fear, remorse, etc. In my mind I never ‘abused’ alcohol; I used it for what it is designed for – to help me get drunk – and make you go away! And, for many, many years, it very worked very well for me. I have always felt ‘alcohol abusers’ are people who leave a ½ glass of beer on the bar when they leave; or folks who order a glass of wine with dinner, and again, drink only a portion of it – through the whole meal! There are folks who can do that; and I don’t understand them… People who abandon a glass of wine, or let a perfectly good cold beer get warm, are ‘alcohol abusers’ in my mind. So the very labeling of the program, by ‘the System,’ fueled my fear for my career. Hell, my career progression was going just fine with my drinking; why screw it up? I never saw but one drunk leave for treatment and subse-quently recover his career.

In the culture of a flying squadron, there was a certain expectation to drink, yet not to be an alcoholic. If you aren’t afflicted with this disease that works ‘okay,’ but it didn’t for me. A lot of my buddies drank like I did for a while, then they all grew up and walked away from it. I never did – I never grew up, and I wasn’t able to walk away from it. To be labeled as an ‘alcohol abuser,’ would have been very ‘shameful’ for me within my squadron, as well as within the whole USAF community at large. So, I disguised my alcoholic behaviors as those of ‘the go-to-hell’ fighter pilot; the fun-loving ‘life of the party,’ with no cares at all in the world! And inside, I was dying.

The second dynamic that came into play with me, was one of denial and/or disillusionment. For a long time I denied my alcoholism. I didn’t want to be an alcoholic. I liked drinking, and wasn’t quite finished with it…

My disillusionment manifested itself in my attempts to minimize my drinking. I once mentioned my concern over my drinking to a dear, trusted friend; another pilot in my squadron. He pointed out how much ‘stress’ I was under at the time. Inspections, ‘time-line,’ promotion,

“AAA” – Alcohol, Aviators and Aviation MedicineLt. Col. R.F. Holliker Jr., USAF/Ret.

Alcohol and the Aviator, cont.

FLIGHTLINES | 19

career progression, what-ever. He further mentioned that I didn’t drink any more than anyone else in the unit at the time. There was no way he could have known of the nights I sat alone in my darkened living room; way into the night, drinking beer until I passed out, all the while listening to John Denver’s “Darcy Farrow,”…over and over again, wanting a bullet in my brain -- to end all my pain.

On another occasion, when the Wing Commander announced at a luncheon that I was to be the new Squadron Commander, I asked myself, “Would a Wing Commander make an alcoholic a Squadron Commander?” “Probably not,” I concluded, and that night I went over to the Auger Inn to celebrate my good fortune, and the fact that I was not an alcoholic – and I got drunk as hell! That’s how my brain ‘is wired’ folks…

About 11 months from retirement I sought out my Flight Surgeon one afternoon and sat down with him under a pecan tree at his house on Randolph Field, and expressed concern again about my drinking. I mentioned I was drinking about a six-pack a night, then really ‘cranking it off’ on the week-ends. (I was a daily drinker between binges…) I went on to tell him that I just wasn’t having any fun anymore in the Air Force. The ‘college boys’ were driving me nuts with their concerns over ‘appear-ances’ vs. the mission. I saw ‘careerism’ and ‘professionalism’ replacing ‘espirit-de-corps,’ and I resented it. The only place I found ‘relief’ was in Bud Light. The Air Force just wasn’t what it was anymore from when I signed up; and I was miserable. After an hour or so of talking that late August afternoon, Dr. John suggested I quit. With less than a year to go for my ‘twenty,’ and the airlines in a hiring posture, I submitted my retirement papers a short time later. Two years ago, as I was ‘playing the tapes’ in my mind of that August afternoon conversation, I wondered to myself if Dr. John meant ‘quit drinking.’ vs. quit the Air Force? Dooooo! It’s all about ‘how my brain is wired.’ It took about 10 years for me to make this connection; 10 years after I quit drinking.

Within flying squadrons, as well as everywhere else I suppose, there is a set of prevailing ‘protective’ attitudes with respect to confronting others with concern over their drinking. Oh, you might find a couple pilots lamenting about someone else’s drinking on occasion; most often in a form of mild ridicule. “It might ruin his/her career if I say anything,” or “He doesn’t drink any more than anyone else,” or “She ‘looked’ okay to me!” (I often heard, “Oh, that’s just Bob; isn’t he a riot!”) Then, after a ‘blessed event,’ whether it be an accident or incident, one can often hear, “I always knew he/she would get into trouble someday because of drinking,” or “I have known he has had a problem since our days at the Academy.” Well, from my perspective, if you have a ‘concern’ about someone’s drinking, and you don’t say anything, then you share in the responsibility of the ‘blessed event!’ I can tell you, with all candor; I was incapable of ‘taking care of myself’ when I was drinking! It seems there is more ‘honor’ in attending the funeral services for a fallen (drinking) pilot, than standing up and being accountable.

Conventional wisdom has it that the alcoholic will not seek help until he/she ‘hits bottom.’ Unless things have changed considerably in the Air Force, the alcoholic isn’t going to seek help from anyone, at any time. It’s going to require a substantial ‘culture change’ that isn’t going to occur overnight. The alcoholic today in the Air Force is either unable or unwilling to seek help, just as I was 20-30 years ago. Pretty sad, isn’t it. So, here is where you come in; here is where you engage and raise the alcoholic’s bottom! How do you do that? Simple; don’t carry him/her along once you suspect alcohol ‘dependency.’

First of all, get to know the people in your flying unit; gain their trust

and respect. Then remember, ‘I don’t think like you do; unless you’re an alcoholic.’ (Sorry, couldn’t help but toss that out…it’s my nature to screw with folks.) If you confront me directly with an accusation that I ‘abuse alcohol,’ in any way, shape or form – direct, indirect or subtle – I am going to dig my heals in and resist. My defenses will come up imme-diately! When I was drinking I always saw a Flight Surgeon as more threatening than a North Vietnamese gunner. The Flight Surgeon had the potential to ruin my career; the gunner was just going to kill me.

You don’t do me any favors by carrying me through ‘the System.’ Alcoholism never ‘gets better’ on its own. It’s a progressive, chronic and fatal disease. So, I would suggest beginning by expressing your concern, on an informal basis when you suspect alcohol dependency in someone. Keep your initial conversation confidential, and low-key; and own it yourself. “I am concerned with your drinking,” is a good approach, and back your statements with personal observations and/or collateral input. This kind of approach tells me you are concerned, but not threatening; at least at this point. And it also ‘puts me on notice.’

As the situation warrants, there comes the time to direct the individual to an alcohol assessment. What I am advocating here is to begin ‘the history.’ At some point in time, it will become obvious to everyone what the issue is; alcoholism. If the individual returns with an assessment of ‘non alcoholic,’ so be it. Again, he or she is ‘on notice.’

Just as the Cop doesn’t do me any favors, as an alcoholic, by ‘letting me go, this time’ after stopping me for a ‘suspected DUI,’ the Flight Doc doesn’t do me any favors by ignoring the warning signs of early stage alcoholism; elevated liver values, ‘stomach problems,’ sleep disorders, personal observations at squadron functions, collateral observations, etc. The ‘first call’ is the toughest; it gets simpler after that – kinda like learning to say ‘no’ as a parent.

Today, I enjoy a good life. In sobriety there is hope for me, whereas while I was drinking, I just didn’t care about anything or anyone. I am often asked, “Do you think you could have gotten sober had someone confronted you with your drinking while on active duty?” Tough one; don’t know. I can tell you however, when I was assessed ‘alcoholic’ by my airline and the FAA, I was given a choice – “Drink, or fly, but not both.” That made it real simple for me, and I understood it -- with great clarity. Initially my ‘motivation’ for not drinking was to continue my flying career (I suppose), but slowly, ever so slowly, I have come to realize that ‘flying’ isn’t my life; LIVING is! If flying were the only motivation I had for not drinking, what do you think I would do when I turned 60, with mandatory retirement from the airlines? And herein is the blessing that the ‘drink or fly’ policy has given me; a second chance at life.

Thank you for giving me the opportunity to pass on a few of my ‘lessons learned’ with respect to my alcoholism. I see my alcoholism as the greatest blessing I have ever been given; it has opened my eyes, and taught me so much. And, to keep what I have learned, I know I have to ‘give it away.’ Thank you….


20 | FLIGHTLINES


It seems like we are seeing it happen more and more frequently. The news program showing the pilots being escorted across the parking lot, hiding their faces, as the announcer tells us of yet another alcohol-related airline incident with airline pilots as the culprits. Is this a new trend or just a consequence of heightened awareness on the part of airline security screeners, managers and/or passengers?

Perhaps the question should be, “Why aren’t we seeing even more of these kinds of incidents?” After all, there is no reason to believe that airline pilots are any different from the general population in the United States when it comes to the percentage dependent on alcohol, gener-ally stated these days as around 10% or so. I believe the answer to this question is that pilots these days are well attuned to the extraordi-nary scrutiny being afforded to them and they subsequently plan their consumption of alcohol to be within the rules set out by the FAA (8 hours prior to duty) and the various airlines themselves (generally 12 hours before duty). However, what about those crewmembers who are unable to effectively control their consumption of alcohol? I’m talking about the true, alcohol-dependent airman—the pilot suffering from the disease of alcoholism.

The above is part of an article I wrote for the Flight Physician, a publica-tion of the Civil Aviation Medical Association in January of 2004, here reprinted with permission of the editor, Dr. David Bryman, D.O. His periodical is very similar to FlightLines, the publication of the Society of Flight Surgeons that you are reading now.

Having been asked my input for this issue of your publication, I jumped at the opportunity and want to basically present the same information I have previously done to the civilian Aviation Flight Examiners, knowing full well that we can easily place the military pilot in any kind of situation that the civilian commercial pilot could find himself.

So having said that, what do you, the USAF Flight Surgeon, have to be aware of? Depending on the alcohol-abuse education you received in medical school, plus the seminars and follow-on training you may have received about alcoholism in our society, do you have a game plan when you become aware of a military pilot sitting on your examination table who has an enlarged liver, high blood pressure, a suspect blood profile, and liver enzymes off the chart?

I am not here to comment or recommend the specific course of action you would take in this situation. I am just a layperson when it comes to the decisions of doctors. I may be familiar with some of the protocol or procedures the USAF follows to help a pilot who self discloses or is referred to rehab, but not all of it. I can, however, tell you of an orga-nization that you can refer your pilot to, should he want or need help, officially or unofficially. The organization I am referring to is Birds of a Feather International. Birds of a Feather is, basically, a self-help group for pilots and cockpit crewmembers that are active or inactive in the private, commercial or military fields of aviation. Its principles and tenets are based on a well-known organization that had its own start way back in 1935 in Akron, Ohio. Birds was formed in 1975 in response to the need for a meeting place for pilots where the subjects of addiction to alcohol or drugs might be discussed with impunity and anonymity. The cultural bias concerning these subjects has prevented many pilots in the past from seeking advice in this area. Birds of a Feather addresses, in an atmosphere of support, that its members are alcoholic themselves and have a means whereby

productive lives in their chosen profession can be maintained.Birds of a Feather has no loyalty or association with any branch of the military, any company, any Employee Assistance Program, treat-ment center, civilian or military medical program, the FAA or even the successful airline HIMS program. The fear of loss or limitation to a pilot’s career because of this misun-derstood disease has been a very real concern to pilots and the under-standing of those concerns to be found at Birds is priceless. The setting has contributed to the recovery of pilots, and the spirit of passing this philosophy on to others who also might benefit is the reason for Birds of a Feather. There are many “Nests” of Birds of a Feather across the U.S. and in a few European countries. These Nests hold weekly meetings that are attended by any pilot who would like support, whether he has been through rehab or not. In the cases where a major city does not have a regularly sched-uled meeting, there are “solo” Birds in those cities who are available to take calls to offer support. A convention is held each year for all the Nests where everyone gets together for fellowship, a business meeting, professional presentations, self-help support group meetings and a banquet. There is every reason to believe that any Air Force base could also have its own Birds of a Feather meeting. All it takes is a minimum of two pilots who have a serious desire to stop drinking and they are in business . . . the business of helping others who will join.

I feel honored and privileged to have been given the opportunity to tell you a little about Birds of a Feather International. There is more information available to you, much more than could be written in this article. I would like to refer you to our Web site (www.boaf.org) where you can find references, information and a complete history of BOAF to include how it impacted the beginnings of the airline HIMS program for returning rehabilitated airline pilots back to the cockpit. The site has information about Nests in cities worldwide, phone numbers of trusted individuals to contact who will always maintain strict anonymity with the person calling, plus information on how to subscribe to The Bird Word, our own quarterly newsletter with articles, letters, and information for the pilot interested in turning his life around from this debilitating disease.

My mission on writing this article would be complete if each Flight Surgeon reading this would at least place the Web site and the BirdWord address in a location in his office where he could refer a patient to them. You will find a “tear-out” page in this edition of Flightlines that you can put up in your office or keep on file. If just one military pilot would access the site, call for help, or subscribe to The Bird Word, then I believe my time spent writing this for you and the time you have spent reading it will have been worthwhile. Perhaps it may even prevent another pilot from the pain of seeing himself on CNN dodging the media because he had an alcohol-related incident while on duty and then having to suffer the unfortunate circumstances that occur afterwards.

The author is a former USAF pilot and is now a Captain for a major U.S. airline where he is involved with substance abuse recovery programs for pilots. He works closely with union committees and airline management and is familiar with Federal Aviation Administration procedures for returning pilots to the cockpit upon successful reha-bilitation from substance abuse. He has been associated with Birds of a Feather since 1990 and is a past International Secretary of that organization. He can be reached at: [email protected]

Help for the Pilot With Substance Abuse

A Primer for the Flight Surgeon

By: Scott L. Hein

FLIGHTLINES | 21

Editor’s note: As we discuss in depth the problem of alcoholism among aviators in this issue, we felt it was a good time to reprint this excellent article about mental health from 1994.

Dr. Ray King is currently a personnel research psychologist in charge of the Civil Service examination for the selection of Air Traffic Control Specialists at the Civil Aerospace Medical Institute in Oklahoma City. He also serves as an individually managed augmentee in the USAFR, attached to the 72nd Medical Group, Tinker AFB, OK.

Dr. Richard Rini is the director of the Indiana State University Student Counseling Center and the Student Health Promotions Program. By googling him we found an excellent powerpoint presentation that he had written on training for excellence in sports at http://www.aucccd.org/conference/2004Proceedings_files/Rini-Brief%20AUCCCD%20PRESENTATION.ppt

Dr. Chris Flynn is working as Deputy Director of Mental Health Services for the US Department of State. He’s posted in Washington, DC at this time--but expects to be heading PCS overseas in 2006.

Aviator StressCapt Richard Rini, Maj Chris Flynn, and Capt Ray King

When you consider aviation mishaps the inescapable truth is that many, if not most are human factors related. Stress-related performance changes (Alkov & Gaynor & Borowsky, 1985; P1-cane, 1990) are an area of aviator health that must concern the Flight Surgeon. This may be awkward, however, because you, the unit Flight Surgeon, might feel a lack of expertise on the topic. When distress is identified early in the dysfunctional aviator, intervention measures can help to improve stress coping (Senechal & Traweek, 1988). Consultation with your local mental health team is one avenue available for you when dealing with aviator stress and its impact on aviation safety (King & Lochridge. 1991).

Despite competitive selection and training programs, the aviator still is human and is vulnerable to performance decrements due to stress. Compartmentalization is the main psychological defense aviators use to focus their concentration of flying--while pushing unwanted thoughts out of conscious attention. Situational awareness is the capacity to process information from the total flight environment (Harman & Secrist, 1991). These skills are susceptible to disruption by cognitive overload, poor stress coping, and combat fatigue (Spick, 1988).

When an aviator becomes “dis-stressed” and chooses an inadequate stress-coping strategy, compartmentalization may be lost and flight safety compromised. When Alkov reviewed over 700 Navy mishaps, he found that where pilot error was causal, the aviator more often than not was experiencing increased stress (Alkov, et al, 1985). Important factors included recent marital engagement, financial problems, and career decisions. Even positive events are stressful. Any change in life circum-stances, even positive events, has the potential to over-tax coping skills,

Consider the demands you faced upon the happy time of graduating from colleges moving, finding a job, juggling financial concerns, etc.

EXAMPLE: A pilot with 19 years of flight experience went to his Flight Surgeon about sleep problems. The Flight Surgeon checked with other aviators to assess this pilot's performance and found that his recent night flying skills had become “rusty” and possibly were the result of fatigue. After ruling out organic problems, the Flight Surgeon consulted with a local mental health provider. Further evaluation identified marital problems that were causing situational anxiety and insomnia. A focused mental health intervention addressed the pilot's concerns about his marriage. In the first week, his sleep improved and, after eight sessions, his anxiety symptoms had resolved. The pilot learned improved coping skills and flight safety was supported, with minimal time DNIF.

A good “rule of thumb” is to consider how an average person would be reacting to the level of stress the aviator is under. If most people would be “stressed out,’ you should have a heightened awareness of that aviator’s performance. The interaction of an aviator’ s poor stress coping style and novel stressors can create a “failing aviator” (Voge, 1989). This aviator becomes preoccupied with proving himself at all costs. Whether by overuse of alcohol, pushing too hard at work or in sports, or demon-strating ‘expertise’ in the aircraft by taking unnecessary risks; this aviator is at risk for suboptimal performance and possibly an aviation mishap.

In trying to refocus attention away from the stressors he is managing poorly, the failing aviator allows his emotions to interfere with his judgment. Your job is to recognize this type of problem and, as with any medical problem, focus appropriate care for an optimal outcome--balanced, well-compartmentalized aviator. Consider the alternative for the example aviator above, without help, his marital problems would have worsened--increasing the risk of a poor outcome (a mishap or a major psychiatric disorder) occurring.

The Neuropsychiatry Branch of the Aeromedical Consultation Service (ACS) supports specialized training for mental health providers who work with the Flight Surgeon remains the overall case manager for the flier. Only a Flight Surgeon can medically ground an aviator. The most productive relationships between Flight Surgeons and mental health providers are usually formed before an urgent need arises. In other words, optimal care for the aviator occurs when the Flight Surgeon understands the services mental health can, and cannot, offer. Make it a point to pursue a good working relationship with at least one local mental health provider.

Beyond the immediate needs of a single patient, mental health providers may make excellent Safety Day presenters with a little encouragement and guidance from the kindly Flight Surgeon.

Whenever you have questions about an aviator’s current mental health functioning, talk with your local mental health team to find interested providers. Working together we can optimize the outcome for aircrew members when stress threatens to disrupt an aviator’s ability to fly, fight, and win.

Ed Note: The NeuroPsych consultants at the Aeromedical Consult Service are an excellent resource - DSN 240-3537.


From the Files

22 | FLIGHTLINES

American Airlines HIMS/EAP program is the recognized benchmark for the successful restoration of aviators to active flight status following a clinical addiction diagnosis within the commercial aviation commu-nity. The pilots at American Airlines are represented by the Allied Pilots Association and the individual responsible for the HIMS/EAP Aeromedical oversight of their 13,500 + pilots is David Fredrickson. Dave is a pilot with American Airlines as well as a pilot in the USAFR and brings with him 23 years of experience in the field of addiction recovery.FLIGHTLINES recently caught up with Dave on his way to the USAF ADAPT conference in ST. Louis and used this opportunity to discuss the American Airlines HIMS/EAP model.

FLIGHTLINES: What does is HIMS / EAP stand for?Dave: HIMS stands for Human Intervention Motivation Study. Back in the 1970’s when a clinical diagnosis of addiction was permanently grounding to an aviator, it was virtually impossible to get direct funding to study the feasibility of rehabilitating pilots. Therefore, an alliance between the National Institute for Alcohol Abuse and Alcoholism [NIAAA] and the Air Line Pilots Association was formed to test a program for dealing with alcoholism among the airline pilot population. The name HIMS comes from that Congressional grant to NIAAA. Since the 1970’s HIMS alcohol study the majority of companies have expanded their employee programs under the heading of Employee Assistance Programs [EAP] to deal with a wide range of maladies not just alcoholism.

FLIGHTLINES: So, what is HIMS?Dave: HIMS is an industry-wide substance abuse program, specific to airline pilots, that coordinates the identification, treatment, intensive follow on care, monitoring and return to the cockpit of addicted aviators. HIMS is a cooperative effort between the FAA, companies and their pilot unions to work together to restore the pilot’s health while preserving their career and the tremendous investment the pilot represents.

FLIGHTLINES: Why does HIMS work?Dave: Well, in a word...cooperation. Everyone involved in the HIMS/EAP process recognizes that it’s in everyone’s best interest to spend the time and effort to help the affected pilot. The pilot is a huge resource and totally recoverable with the right treatment. The FAA realizes a benefit by ensuring chemically free pilots. The companies benefit by saving a huge investment and a valuable resource. The employee preserves their career and family while regaining their health. Hence, everybody wins.

FLIGHTLINES: So how did American get their HIMS program started?Dave:Well, we first had to change the culture of termination as the fix for an

addicted employee. We had to educate our leaders about addiction and get away from the stereotypes associated with alcohol/drug addiction. A major component of American’s program now is an acceptance of the problem – everyone understands that we are dealing with an addiction and that addiction is a treatable disease.

• It’s a chronic, permanent condition that is prone to relapse.

• It’s primary and exists independently from any other under-lying malady.

• It’s progressive and always gets worse if left unchecked.

• It’s contagious in that it produces dysfunctional coping behavior in others.

• Its primary symptom is denial. This makes the disease insidious because the individual has the perception that there is nothing wrong and therefore, nothing to fix.

• It’s completely treatable if the correct treatments are admin-istered.

FLIGHTLINES: Assume we have an addicted pilot, where do you begin?Dave:First, we have to start with identification. How do we know we have a pilot in trouble? Since pilots are such great “compartmentalizers” work is often the last place for the effects of addiction to show up. This can make it very tough to find the pilot in trouble. At American because we have an open system and don’t terminate, we get a tremendous amount of communication from fellow workers. If they know they can help without risking someone’s job they offer up invaluable data toward identifying afflicted pilots. We use supervisor reports, peer reports, increased sick leave usage, incident reports etc. to identify a potential problem. Second, once we have enough data to suspect there is a problem we have a meeting with the pilot to discuss options.

FLIGHTLINES: What are your options?Dave:It depends on the situation. If this is a first time event, a case of poor judgment with alcohol involved we will recommend they seek help through counseling to address the underlying cause of the behavior. If, it is more severe we might suggest going to Alcoholics Anonymous [AA] and Birds of a Feather (BOAF). When we offer this option we make it clear that this is their “one-time good deal” to find help. We let them know that if they aren’t successful in AA we will be entering them in HIMS. If they have had previous alcohol related events in the past (even if it was a DWI 20 years ago,) the only option we offer is HIMS. Also, if the FAA is aware of previous incidents, they can revoke the pilot’s medical and mandate HIMS.

A Highly Effective Model to Restore Pilots to FlightStatus Following Clinical Addiction Diagnosis

An Interview with Mr. Dave Fredrickson, American Airlines Chief Aerospace Operations (SGOP)


FLIGHTLINES | 23

FLIGHTLINES: What happens in HIMS?Dave:Well, by regulation we start out with a 28 day rehabilitation treatment. After rehab we use the aftercare report as a blueprint for the individu-al’s recovery. It will require aftercare meetings, group counseling and maybe intensive outpatient therapy. We also encourage intensive use of AA, we recommend 90 meeting in 90 days, getting a sponsor and active work on the 12 steps. As a minimum we like to have the pilot up to step 9 before they return to the cockpit and the stresses of flying again. We also help the pilot contact Birds of a Feather and then we have the monthly monitor meetings.

FLIGHTLINES: What is Birds of a Feather?Dave:It’s really pilots helping pilots. Because of the immediate loss of your medical with a diagnosis of addiction, there is a need for a specialized support group which is Birds of a Feather. BOAF is a sub-group within Alcoholics Anonymous and it’s a group made up solely of recovered pilots. There is no substitute for helping a pilot in trouble than a pilot who has already been down the path. And most recovered pilots will tell you “Birds” is the cornerstone of their recovery.

FLIGHTLINES: What are the “monthly monitor meetings” you mentioned?Dave:Monitoring is where we get together all the pilots in HIMS and meet to check up on their progress. Also at the meeting is the Chief Pilot, The flight doc, The EAP and a peer like myself. During the monitor meeting the pilots get to share about their recovery, their counseling, their aftercare, their home lives etc. After the monitor meeting we write up a joint report for each pilot as part of their FAA required re-certification paperwork.

FLIGHTLINES: How long does this process take?Dave:Well, it varies. We get most pilots back into the cockpit in 4-6 months. A lot depends on the individual and how well they respond to recovery. If they are “sick and tired of being sick and tired,” they make it through pretty quickly. If they are forced into HIMS, they tend to take longer. Also, if they are a “relapser,” they can take as long as 14 - 18 months to get past the FAA because we have to be sure they have achieved a stable recovery. Even after they return to flying we continue to monitor the pilots for at least 3-5 years.

FLIGHTLINES: 4-6 months seems like a long time, can’t you do it quicker than that?Dave:We could and some airlines do, the regulations allow for a quicker process but, we have found we get a much better product if we go a bit slower. Our goal is 100% recovery with no relapses and by going slower we get significantly higher recovery rates and move closer to our goal.

FLIGHTLINES: What is your recovery rate?Dave:We consistently achieve a 95% recovery rate through 3 years. After 3 years we can petition the FAA to release the pilot from monitoring and most of or pilots do get released by 5 years so it’s hard to get statistics beyond monitoring. In all cases, the FAA requires total abstinence

from alcohol for life once the pilot has been diagnosed so I’m sure the recovery rates are pretty consistent even after monitoring. I can also tell you this… the pilots who fail to get recovery die. Addiction is fatal and this is especially true for pilots. I’m not really sure why, maybe it’s something to do with a pilot’s persona but, our experience is that the pilots who fail to get recovery almost always limp off and die.

FLIGHTLINES: Do you think the Air Force could implement a HIMS type program and achieve recovery rates like you have?Dave:With pilots, Absolutely! I’m not sure about how effective you’d be if you try to apply HIMS to all careers but, with pilots I’m sure you could achieve what we have. We don’t nearly have the resources at American that you have in the USAF and we currently have 100+ pilots in the HIMS pipeline. With ADAPT and the command structure within the Air Force you already have most of what you’d need to start a HIMS type program. The only thing you are missing is monitoring and dupli-cating that would be a snap. The commanders are the same as the chief pilot, the Flight Surgeon is the same as the AME, The ADAPT is the same as the EAP and there are plenty of civilian pilot peers who could assist you until your program got up and running. The hardest part would be to change the Air Force culture. No offense but, the USAF is in the stone ages when it comes to recovery and they are currently destroying some of their most capable individuals because they haven’t learned how to rehabilitate them. About 40 % of the pilots we get in HIMS were identified with alcohol problems back in the military and unlike the military, instead of getting rid of them, we rehabilitate them and keep them as our best resources.

FLIGHTLINES: What about the cost?Dave:That’s the best part… We have consistently shown at least a $9 return for every dollar spent on HIMS. Last year at American, we saved the company 1.2 million and this year the numbers are even higher. Let’s look at how this would apply within the Air Force. What does the Air Force spend to train a Viper driver? Two million, three million? Whatever it costs it’s a bunch. What’s it worth to keep that kind of investment in the Air Force? Certainly more than just the initial invest-ment in training costs. What a difference it would make if you could keep that resource an extra 10 years because you rehabilitated them. Congress is constantly asking the military to do more with less and here’s a perfect chance to keep what we already have… HIMS is not only morally correct, it’s good business sense and the HIMS employees become some of our best because they understand that you not only saved their careers, you probably saved their lives and gave them their family’s back. How do you place a value on that? And remember, since it started, HIMS has returned over 3500 pilots to the cockpit.

FLIGHTLINES: Well, we’re just about out of time, any final thoughts?Dave:Yes, just this. As Flight Surgeons you are in tune with treating your patients and I’d encourage you to remember that there are numerous resources on the civilian side like AA and BOAF to help you in that endeavor. It is my hope that the time is finally right for the Air Force to adopt what we’ve had successfully on the civilian side for 30 years. There are dozens of people just like me who would gladly volunteer their expertise to help get the process going. If I can ever be of help to you please feel free to contact me at [email protected] or (214) [email protected]


24 | FLIGHTLINES

Col Bob Ireland is the Chief, Aerospace Psychiatry Function at the

Aeromedical Consultation Service at Brooks City Base. He is also the

Consultant to the Surgeon General for Psychiatry. In late June 2005, he

will become the Program Director, Mental Health Policy, at the Office of

the Secretary of Defense/Health Affairs.

In 1974, experts in the aviation industry and FAA convinced Congress

to fund the first credible and effective program to rehabilitate and safely

return alcoholic air transport pilots to flying. In the funding bill the

program was not titled as such due to the likely political tone of returning

alcoholic pilots to the cockpit. Rather, it was called the “Human

Intervention Motivation Study” or HIMS, an innocuous description that

did not raise eyebrows as it weaved its way through funding hearings.

This program resulted in a sharp rise in pilots reporting for treatment and

has sustained the highest sobriety rate of any professional group.

It is the very nature of alcoholism that those developing problems

with alcohol do not develop insight to appreciate them.

More than coincidently, the emphasis on human intervention and motiva-

tion captures the philosophy of the HIMS program. It is the very nature

of alcoholism that those developing problems with alcohol do not develop

insight to appreciate them. A “conscientious” drinker may stop drinking

just after appreciating the “buzz”, and before feeling “impaired”.

Due to predictable CNS changes (e.g. down-regulating GABA receptors),

the amount of alcohol required to get the “buzz” markedly increases over

time, yet the liver’s ability to clear the alcohol does not. This can result

in high alcohol levels (e.g. in a random screening) in those drinkers

who truly believe they did not consume much alcohol the night before.

Studies show airline pilots have difficulty estimating the time required

for alcohol levels to diminish, as do most folks.1

And so, alcoholic aviators, like others with alcohol problems, rarely

identify themselves and seek help due to lack of insight. The profes-

sional and financial penalties for identifying a significant alcohol

problem, even in those who develop insight into their difficulties with

alcohol, further erode any motivation to present for help. Thus—the “M”

for “Motivation” piece of HIMS.

The “Human Intervention” component of HIMS is where those who

work with and around the aviator come into play. Most often others must

intervene, as the alcoholic aviator is usually not motivated to change.

Before HIMS in 1974, and to a certain extent in the USAF today, the

“penalty box” has been the “solution” for alcoholic aviators. The theory

runs something like this: if punishment is made severe enough, the

problem of alcoholic aviators will go away as they will be motivated to

avoid the consequences of misusing alcohol.

The resulting end to civilian pilots’ careers before 1974 and the long

grounding period of USAF pilots (minimum 6 months) and no second-

waiver policy, likely caused some alcoholic aviators to go “underground.”

This was due both to the low motivation of the aviator to come forward

for help in this context, and also to the subtle undoing of the last layer of

public protection—the loss of human interventions to get aviators help.

Some peers, crew members, and even some Flight Surgeons were loath to

report aviators with an alcohol problem in order to “protect” their careers

and their families from financial impact. Even with social disasters,

DUIs, humorless buffoonery, public knowledge, and physical problems

only at a very high threshold for pathology were aviators finally referred

for evaluation. This, unfortunately, could still be true for some military

aviators.

The theory runs something like this: if punishment is made severe

enough, the problem of alcoholic aviators will go away as they will

be motivated to avoid the consequences of misusing alcohol.

The HIMS program, though, has changed the FAA special issuance

“climate” and potentially improved clinical treatment and utilization

of high value pilots. Identified alcoholic aviators who are successfully

treated may now receive special issuances (waivers) to continue their

careers. However, even so in one major airline, although the recidivism

rate was quite low, the average interval between initial waiver and falling

off the wagon was 3 years, corresponding with the end of their aftercare

program. These aviators tended to continue down the alcoholism disease

course until re-discovered an average of 8 years later reinforcing the need

for vigorous aftercare requirements.2

Currently in the USAF, after a minimum of 6 months grounding and

return to duty, most aviators receive no aftercare to assist them to

maintain sobriety—it’s sink or swim. On occasion, the Aeromedical

Consultation Service is asked to evaluate highly experienced aviators

who “busted” their waivers and continued to drink for years, even while

signing abstinence letters for waiver renewals. Unfortunately for them,

even after a successful 2nd rehab and subsequent years of sobriety, AFI

48-123 specifically prohibits 2nd waivers. Thus, USAF aviators with

an alcoholism waiver have little motivation to self-identify should their

problems recur, and a potentially lower likelihood of human intervention

to re-enter treatment as peers and Flight Surgeons conclude, “This time

it means they can never fly again, ever.”

Good News for Aviators Requiring Treatment for an Alcohol ProblemCol Bob Ireland


FLIGHTLINES | 25


The US Navy addressed this dilemma 3 years ago, breaking ranks with

sister services recognizing the 30-years of success the FAA and major

airlines have had with alcoholic aviators. These successes include:

—400% increase in the rate of pilots seeking treatment within 2 years

of starting the HIMS program; 92-95% of pilots returning to successful

careers; and 85% maintaining long-term abstinence, the highest in any

industry.3 These are felt to be related to lowering barriers for treatment,

and encouraging human interventions to assist problem-denying avia-

tors.

Many of the regulatory changes adopted by the Navy have been proposed

for inclusion in AFI 48-123. Motivation for treatment is encouraged by

reducing time in the “penalty box,” from 6 months after entering treat-

ment to 90 days after completing treatment, reducing DNIF periods to

as little as 3.5 months, depending upon how early rehab can be accom-

plished after identification. To do so, though, the entire treatment team,

including commander and Flight Surgeon, must be convinced of the

aviator’s low potential for recidivism.

Using the “HIMS approach” in the waiver phase, recidivism is addressed

by adding an effective aftercare program. For those who cannot remain

abstinent and require a 2nd rehab motivation for treatment may be

improved with the likelihood of a second, closely managed, waiver, and

recidivism may be reduced by increasing the observation period to1 or

more years before a repeat waiver can be considered. Human interven-

tions will be less threatening as aviators will continue to have a chance

to resume their flying careers after busting a waiver.

Thus, following the lead of the HIMS program and the FAA, the proposed

AFI language defines a 4-year aftercare program with follow-up by the

Flight Surgeon, ADAPT, mental health professional, and an approved

recovery program like AA (e.g. Birds of a Feather). AA can be accom-

plished via several modalities while deployed, either with a deployed

group, by phone or internet chats (most Navy ships have AA meetings).

The proposed aftercare program elements are described in Table 1.

Major airlines require regular contacts with both a supervisory company

pilot and recovering pilot-mentor. The AF, though, will urge voluntary

ongoing contact with a recovering pilot or aviation-career mentor to

reduce chances of recidivism. It turns out there is a host of recovering

pilot-mentor resources (e.g. active Birds of a Feather participants) quietly

ready to help recovering active duty or reserve pilots in communities

around most Air Force bases (www.boaf.org).

Flight Surgeons play a pivotal role managing the threshold for

evaluating and assuring the quality of treatment for alcohol-related

problems in aviators.

With the assistance of ADAPT, the role of the Flight Surgeon in aftercare

will include: documenting work performance, peer-family-marital rela-

tionships, psychosocial stressors, attitude toward recovery, abstinence

and AA attendance. An anticipated major benefit of AF transitioning

to the “HIMS model” is the recovery of several pilots who have previ-

ously “busted” their alcoholism waivers and subsequently successfully

achieved recovery. Those with >1-2 years of sobriety should be carefully

assessed for waiver consideration and return to flying, implementing a

stage of aftercare appropriate to their stage of recovery.

Flight Surgeons play a pivotal role managing the threshold for evaluating

and assuring the quality of treatment for alcohol-related problems in

aviators. Avoiding punitive prolonged groundings beyond a reasonable

safe interval for rehab and observation enhances motivation for treat-

ment. Implementing aftercare enhances long-term sobriety. Holding

out the option for flying again after busting a waiver, albeit after a longer

observation period, minimizes the human tendency to avoid intervening

on behalf of a failing aviator for whom complete recovery remains a

reasonable expectation.

Air Force Flight Surgeons who keep their threshold very high for evalu-

ating and treating potentially alcoholic aviators, may not see any prob-

lems with this position during their AF careers. However, such Flight

Surgeons who have kept in touch with their aviator friends over the years

and into their retirements are more prone to experience the agony of

watching or hearing about some of them undoing their airline careers and

family life as alcohol begins to play too great a role in their lives. Like

they say about other professions, any kid can do flight medicine--with

20 years experience!

REFERENCES:

1 Widders R, Harris D. 1997. Pilots’ knowledge of the relationship

between alcohol consumption and levels of blood alcohol concentration.

Aviat Space Environ Med. 68: 531-7.

2 Major (USAF Reserve)) Dave Fredrickson, airline pilot and Human

Intervention Motivation Study /Employee Assistance Program (HIMS/

EAP) for a major airline.

3 Flight Safety Foundation 2003; Reproduced with permission. Flight

Safety Foundation & National Business Aircraft Association Corporate

Aviation Safety Seminar Proceedings 2003 by Quay Snyder, MD,

MSPH—found on web 3 Jul 03 @ http://www.aviationmedicine.com/

indexaboutus.htm.

Professional/Meetings First Year Second/Third Year Fourth Year

Flight Surgeon Monthly Quarterly Annually

ADAPT Monthly Monthly N/A

Psychiatrist/Psychologist/Social Wkr Annually Annually N/A

Organized Alcohol Recovery Program 3x weekly 1x weekly Recommended not required

Table 1. Post-treatment Aftercare Requirements

26 | FLIGHTLINES

Safely returning a sober, healthy pilot to flying duties is the goal of

aviation substance abuse programs. Comprehensive, cooperative and

compassionate monitoring optimizes the opportunity for sustained

sobriety and peak performance.

The FAA HIMS (Human Intervention and Monitoring Study) Program

is the most successful substance abuse recovery program in existence.

Monitoring is critical to this success.

Official Monitors

The FAA requires at least two non-medical and one medical monitor

before considering reinstatement of a medical certificate. The monitors

include:

1) Peer pilot monitor

2) Company supervisor monitor.

3) Independent medical sponsor.

Non-Medical Monitors

The peer pilot sponsor is frequently designated by the pilot union. In

non-unionized organizations, a trusted volunteer willing to participate

for 3 or more years is acceptable. The company sponsor is a volunteer

with supervisory responsibilities over the pilot.

The FAA requires monthly meetings with both sponsors. The sponsors

must report monthly on the progress of the pilot’s continued sobriety.

The pilot is responsible for insuring reports are forwarded monthly to

the medical sponsor.

Independent Medical Sponsor

The independent medical sponsor (IMS) is an FAA Senior Aviation

Medical Examiner who has attended the HIMS training seminar and

who, ideally, has experience in addiction medicine. The IMS watches

for evidence of alcohol use, receives reports from sponsors, makes quar-

terly reports to the FAA, and directs no-notice alcohol testing during the

monitoring period.

The IMS receives all reports from the pilot’s treatment, aftercare, and

sponsors. This information, along with personal observations, is used

to assemble an aeromedical summary requesting the FAA reinstate the

medical certificate. The IMS receives quarterly reports from the after-

care supervisor (medical professional). Following recertification, the

IMS submits reports to the FAA annually. If reports aren’t submitted,

or are unfavorable, the pilot’s Special Issuance medical certificate is

revoked.

FAA Medical Certification (Special Issuance)

Pre-Certification

Psychiatric and Psychological Assessment

The pilot must undergo complete assessment by an FAA-approved

psychiatrist-psychologist team no earlier than 60 days after the initial

sobriety date, but possibly much later.

One purpose of this assessment is to determine if alcohol has compro-

mised intellectual function necessary for safe flight. Many pilots want

to rush this assessment, which is detrimental since the toxic effects of

alcohol improve gradually. The longer a pilot waits after the sobriety

date, the better the chances for favorable results.

The second purpose of psychological assessment is determining if

the pilot is making progress towards, and is committed to, sustained

recovery. The psychiatrist assesses plans, resources for continuing

support, and tools available for difficult times ahead. While no assess-

ment is foolproof, psychiatrists experienced in addiction medicine and

aviation are capable of identifying pilots who simply “check the boxes”.

Patience and serenity are good markers for commitment to sustained

recovery.

Clinical Assessment

If the psychological assessment is favorable, the IMS will conduct a

physical examination before petitioning the FAA for reinstatement of

the medical certificate through Special Issuance. The IMS compiles an

aeromedical summary outlining a detailed history of the disease, route to

evaluation, treatment program, aftercare program, employment circum-

stances, sponsors, and recovery. This summary and all medical records

are forwarded to the Federal Air Surgeon’s office in Washington DC for

psychiatric review.

Certification Authority Assessment

The FAA psychiatrist reviews records prior to making recommendations

to the Federal Air Surgeon and Aeromedical Certification Division.

Often the psychiatrist speaks with the pilot, independent psychiatrist,

people involved in the treatment and aftercare program, and the IMS.

Monitoring - Comprehensive, Cooperative and CompassionateKeys to Sustained Sobriety

Quay Snyder MD, MPH


FLIGHTLINES | 27

In favorable cases, the FAA sends a Special Issuance letter and medical

certificate to the pilot.

Upon receipt of the medical certificate and SIA letter, the pilot returns

to the company for reinstatement to flight duties or training with no

restrictions. The timeline from intervention to medical certification may

be as short as 4 months, although usually is longer. Without the spon-

sored alcohol program, a pilot may remain grounded for a minimum of

2 years documented sobriety.

Post Certification

Abstinence

The SIA letter will specify periodic requirements to maintain medical

certification. The prime requirement is total, sustained abstinence

from all alcohol and alcohol- containing compounds for the duration

of the medical certificate, i.e., for an entire career.

Aftercare

Additional requirements include regular participation in a continuing

care (aftercare) program. An aftercare program is a group meeting

supervised by someone trained in substance abuse recovery. Pilots

generally attend at least 2 meetings monthly, and are responsible for

having the supervisor submit quarterly reports to the IMS.

12-Step Programs

Participation in a 12-step program is required for a pilot holding a

Special Issuance medical certificate. Even after release from the Special

Issuance requirement, pilots are expected to regularly attend 12-Step

meetings. The usual minimum attendance for airline pilots is 12-15

meetings monthly. Because an essential element of AA is anonymity,

reports from AA sponsors are not mandatory for FAA Special Issuance.

Non-Random Testing

The IMS may direct no-notice, non-random alcohol testing to validate

abstinence, in addition to the DOT random testing program. Some IMSs

will have pilots obtain pagers and require completion of testing within

hours of being paged. Laboratory testing for serum markers indicative

of possible alcohol use are also available.

Reports

The pilot is responsible for forwarding peer and supervisor reports to the

IMS monthly. Aftercare program summaries are forwarded quarterly.

Continued favorable reports from all persons involved are necessary for

maintaining the SIA and medical certificate.

Psychiatric Assessment

Annually, the pilot will obtain assessments from the psychiatrist who

did the pre-certification assessment. This is independent validation of

commitment to sustained sobriety and active participation in a 12-Step

recovery program. Reports are sent first to the IMS, then to the FAA.

Monitoring Duration

Monitoring continues for at least 3 years, but may continue longer if risk

factors for relapse exist. Some pilots have been monitored for over 15

years.

If satisfied a pilot has made excellent progress in recovery and is at low

risk for recurrence, the FAA may discontinue monitoring and the require-

ment for the SIA. The pilot would then resume regular medical exams,

but must always report the diagnosis of abuse/dependence on the medical

application. The FAA will continue to require sustained, total absti-

nence as long as the pilot holds a medical certificate, even though the

monitoring has been discontinued.

Relapse

Relapses occur, although the rate among pilots going through the FAA

mandated program is under 15% over a career. This rate is far lower than

any other program in the country and is a direct result of the involved

monitoring approach. Relapse rates for alcoholics completing initial

treatment and only participating in a 12-Step program without additional

monitoring are approximately 90%.

The FAA will allow a pilot who has relapsed to re-enter treatment with

opportunity for reinstatement of the medical certificate and SIA. Pilots

recertified after relapse undergo extended monitoring periods. Second

relapses generally receive unfavorable reviews by the FAA, effectively

ending a pilot’s flying career.

Enhancing Health and Safety, Protecting Careers and Investment

Aviation safety is the overriding concern when evaluating pilots with

any disease. Alcoholism is a treatable disease, and success rates treating

it equal or exceed secondary and tertiary treatment rates for most other

diseases. An alcoholic pilot in active recovery enhances aviation safety

with improved cognitive function, better CRM, and better physical

health.

The aviation industry benefits when the disease isn’t hidden by alco-

holics and their peers (including Flight Surgeons) for fear of costing a

career. Significant investments of time, money and resources are lost

with early career termination. A program of monitored alcohol recovery

preserves those investments. The result is a productive, healthy, safe

pilot performing well within the organization.


28 | FLIGHTLINES

Editors’ note: Many thanks to Dr. Richard Jennings of the University of Texas Medical Branch at Galveston Aviation Medicine Center for this list of films depicting pilots and Flight Surgeons wrestling with aeromedical issues since the days before the “talkies.” We plan to make this a regular feature in FlightLines.

The Pilot (1979) The Pilot starred and was directed by aviation enthusiast Cliff Robertson and released in 1979. It is also known as Danger in the Skies. Frank Converse, Dana Andrews, Gordon McCrea, Milo O’Shea, and Ed Binns appeared. The story follows the disintegrating personal world of an excellent pilot with a love of flying, and unfortunately, alcohol. His marriage is disintegrating, and he feels trapped in his airline job due to financial constraints when the type of flying he prefers is aerial appli-

cation and aerobatics.

Robertson as Captain Mike Hagen is aware of his drinking problem but continues to fly by concealing the alcohol use and by hiding a flask in the aircraft lavatory for use during flights. His regular first officer is aware of the drinking, but defers to his seniority and widely known expertise as the “perfect pilot” and avoids turning him in to the airline or FAA. He does approach Mike’s west coast mistress to intervene. A bar scene with other drunks indicates the depth of his problems. When the unexpected lack of alcohol during a flight leads to a near accident, he seeks help from his personal physician, who refers him to an unusual psychiatrist, played by O’Shea. The interaction with the psychiatrist is interesting because Hagen says that he does not want to quit drinking but “control it.” The psychiatrist permits him to fly and offers tranquilizers to use if needed. An astute flight attendant warns the airline operations department that she suspects that Hagen is drinking during flights. While the airline doubts the flight attendant, a check pilot is assigned to investigate. When Hagen has alcohol withdrawal during and after a flight associated with DTs, the psychiatrist correctly admits he was wrong in allowing him to fly while drinking.

Finally, a crash unrelated to the alcohol occurs during take-off due to fire in two engines of the DC-8. The back-up alcohol flask that he carried was discovered, and his airline career ends with his admission that “I have a problem.” Later, he resumes the type of flying that he loved from his earlier years. Other aeromedical scenes include emergency egress down aircraft inflatable slides and deployment of emergency oxygen equip-ment during an out-of-control decent secondary to midair turbulence.

Cliff Robertson was a natural for the role of a pilot since he has loved aviation since he was a young teen exchanging free work at the local airport for plane rides. He has owned multiple airplanes from gliders to war birds. He has been particularly active in the Experimental Aircraft Association and won the EAA’s Freedom of Flight Award and chaired the Young Eagles program. He starred in other aviation movies including the 633 Squadron and Return to Earth as Buzz Aldrin. He also appeared

in Midway.

Other movies that deal with alcohol use among aviators include:

Ace of Aces (1933) Sculptor who doesn’t want to have any part of World War I is shamed by his girlfriend into joining the Army. He becomes a fighter pilot, and undergoes a complete personality change. Richard Dix, Ralph Bellamy.

Cannonball Run (1981) Totally mindless chase comedy. Pilot lands on Main Street to buy beer. Burt Reynolds, Dom Deluise, Roger Moore, Dean Martin, Sammy Davis Jr., Jamie Farr, Adrienne Barbeau.

Fate is the Hunter (1964) Based on the book by Ernest T. Gann. An airline investigator is sent to uncover the facts surrounding a fatal plane crash and tries to clear the name of the dead pilot, who turns out to have been an Air Force friend of the investigator’s. Glenn Ford, Suzanne Pleshette, Wally Cox, Jane Russell, Nancy Kwan.

Flight Lieutenant (1942) A disgraced pilot deter-mines to regain the respect of both his son, now a test pilot for the Army, and the men he once flew with. Pat O’Brien, Glenn Ford, Lloyd Bridges. Flying Leathernecks (1941) Action-packed war film utilizing actual battle footage to create a tense drama. Two US Marine fighter pilots try to fight their own personal battles, while still banding together to fight the war. Flight Surgeon prescribes alcohol. Flag waving at its finest with John Wayne.

A Gathering of Eagles (1963) Rock Hudson plays an Air Force Colonel who has just been re-assigned as a cold war B-52 commander who must shape up his men to pass a grueling inspection that the previous commander had failed, and had been fired for. He is also recently married, and as a tough commanding officer doing whatever he has to do to shape his men up, his wife sees a side to him that she hadn’t seen before.

Lilac Time (1928) In this silent drama a member of Britain’s Royal Flying Corps falls in love with a French farm girl as his Corps constructs an Air Dome during WWI. Binge drinking before air battle, drinking in cockpit before battle. Gary Cooper.

Night Flight (1933) A must for aviation enthusiasts, based on Antoine de St. Expury’s experiences as a flyer, and later, a manager, with Aeropostale, the pioneering French Air Mail line later merged into Air France. Using Buenos Aires as a center, Aeropostale developed South American airoutes south to Patagonia, to the oil fields near Tierra del Fuego. Pilot drinking in cockpit. John Barrymore, Helen Hayes, Clark Gable.

1941 (1979) Steven Spielberg’s 1941 is a big-budget zany comedy detailing the hilarious panic that gripped Los Angeles after the Japanese attack on Pearl Harbor. As explosions burst forth and air-raid sirens scream, John Belushi, Tim Matheson, and Treat Williams are part of the Army Air Corps reacting to the news of war with a somewhat energetic craziness. The film suffered from critical venom upon its initial release but has since become a cult fave.

Aviation Movies – Aviators and Alcohol


FLIGHTLINES | 29

It may not feel like it most days, but there are quite a few “no brainer” diagnoses, treatments, and aeromedical decisions to be made in Flight Medicine. “Geez Major, I’m pretty sure your arm shouldn’t be bent backwards like that. How about a cast and some ground time to work on your ACSC?”, or “Hey Lt., you actually do need something resembling color vision to fly in this Air Force. That whole ‘cross into the blue’ business….it’s just a figure of speech.”

Unfortunately alcoholism does not meet criteria for a “no brainer” diag-nosis. Aside from the obvious pitfalls to identification of alcoholism in any patient who doesn’t want to get “caught,” we in Flight Medicine have to face our daily balancing acts. We are physicians, we are officers, and we are aircrew. Some of us are owned by a medical group, while others belong to a flying squadron. We all want to fit into the flying squadron and we all want to practice the best medicine possible.

It is so easy to pontificate on the right thing to do. It is far more difficult to be the flight doc out in the field who has to do the right thing for a patient on Friday morning, then show up for a squadron function that afternoon and face that patient as a flyer in the midst of his/her peers. And folks, there are consequences to any action we take. Confronting an aviator with your concerns may, at worst, lead to your alienation from that individual and/or the squadron. At best, that aviator has a second chance at life. However, the consequences from our failure to act are so much greater, even if the individual is never involved in any alcohol-related mishap. If you need a reminder of those consequences, please take a moment to re-read the pilot stories in this edition.

What follows are some of my observations based on the articles you’ve read in this issue of Flightlines. Make of them what you will, but I offer them up for your consideration.

• The pilot personality is one that can very successfully allow an alcoholic pilot to elude detection. These folks have high IQs and generally fantastic coping mechanisms. They also fear losing their flying career. In some cases, as we’ve read, they fear this loss more than the loss of life. Alcoholic pilots won’t look like the “wino on the street”. In general, they will still function better than much of the rest of our society. That doesn’t mean there isn’t a problem, it just means the problem is harder to find and the pilot will be highly motivated to keep it that way. (FYI – The doctor’s personality is remarkably similar….)

• The alcoholic brain is just “wired” differently than that of the non-alcoholic. Remember the bumper sticker “I’m not an alcoholic, I’m a drunk. Alcoholics go to meetings.” The alcoholic will take inaction or lack of consequences to

mean that there is no problem with their drinking. In their minds, no diagnosis means no problem.

• “Fly or drink…Drink or fly”. Most alcoholics entering treatment do so with the imprint of someone else’s boot on their ass. Admitting they have a problem may be the first step in recovery, but don’t wait for them to hit rock bottom. Begin the process of identification now.

• Alcoholism is a disease, which is prone to recidivism. When a patient is diagnosed with hypertension we treat the disease process until the blood pressure is under control, and screen for evidence of recurrence. This patient may now be normotensive with treatment, but is he/she is still considered a “hypertensive.” Should elevated pressure readings reoccur, we do not consider the patient to be bad or weak…he/she is hypertensive! In fact, we had some expectation that such an event might happen. Otherwise, why screen? We need to be reminded frequently that alco-holism is a disease, not the sign of a bad or weak person. However, once an alcoholic, always an alcoholic….treated (recovering). This disease is prone to recidivism and should be screened for such an occurrence.

• Follow-on care is necessary for sobriety. Hypothyroidism requires levothyroxin. Hyperlipidemia responds well to a statin. Alcoholism requires peer support. Let me say that again: alcoholism requires peer support. The doctor, the spouse, the coworker, and the counselor do not understand the life of a pilot who is also a recovering alcoholic. The individual who will best understand and demand account-ability is another recovering pilot. After all, birds of a feather…..

• Random alcohol screening is used for all Department of Transportation employees. Commercial pilots who are entered into treatment expect increased random screening…and their companies do not disappoint in this matter! We do random drug testing. Perhaps we should begin to look at screening for a substance that is used more frequently, by more individuals, and in greater quantities?

• Prevention, prevention, prevention.

There are no easy answers, but I hope this issue of Flightlines has given you some insight into the problem, some helpful information in dealing with the problem, and the knowledge that you are not out there on your own.

Guest Editorial Lt Col (Sel) Kathleen Jones


30 | FLIGHTLINES

A small cohort of current MDG commanders and officers selected to assume MDG command recently voiced constructive criticism of, and cogent recommendations to improve the competence of Air Force Flight Surgeons. Subsequently a survey of Air Force Medical Group commanders was completed to obtain further evaluations of Flight Surgeon effectiveness as well as recommendations for improvement. A questionnaire containing questions pertaining to respondent demo-graphics, MDG/CC satisfaction with Flight Surgeon performance, and recommendations for improving Flight Surgeon performance was mailed to the current commanders of USAF Medical Groups during January 2005. Responses from 58 returned questionnaires were combined for aggregate analysis. This article provides Air Force Flight Surgeons a review and analysis of the survey results.

Demographic Information

The responses presented in this article represent the assessment of Medical Group commanders who lead 4 medical centers, 15 hospitals, and 39 clinics. 28 of the MDG/CCs who provided recommendations for improving Flight Surgeon performance have completed the Aerospace Medicine Primary Course, 21 commanders have completed one or more operational Flight Surgeon tours, and 12 of the MDG/CCs have completed the Residency in Aerospace Medicine.

MDG/CC Assessment of Flight Surgeons’ Performance

84% of Medical Group commanders state that Flight Surgeons fulfill their expectations.

73% of MDG/CCs rate Flight Surgeons’ clinical skills as equal to those of other AF physicians, 5% of group commanders rate FS clinical skills as better than other AF physicians.

MDG commanders rate Flight Surgeons’ communication skills better than their clinical skills. 16 % of group commanders rate FS communi-cation skills as better than other AF physicians, 74% of MDG/CCs rate Flight Surgeons’ communication skills as equal to those of other AF physicians.

MDG commanders rate Flight Surgeons’ leadership skills better than their communication and clinical skills. 24 % of group commanders rate FS leadership skills as better than other AF physicians, 61% of MDG/CCs rate Flight Surgeons’ leadership skills as equal to those of other AF physicians.

MDG/CC Assessment of Flight Surgeon Oversight of Aerospace Medicine Programs

In general, Medical Group commanders state that Flight Surgeons are able to provide effective oversight of immunizations, Flight Medicine, and Public Health aerospace medicine programs. Increasing percentages of group commanders indicate that Flight Surgeons provide inadequate oversight of Occupational Medicine, health promotions, Optometry, Bioenvironmental Engineering and Readiness Programs.

MDG/CC Recommendations to Enhance Flight Surgeon PerformanceWilliam E Nelson, Col, USAF, MC, SFS

State of the Flight Surgeon

FLIGHTLINES | 31

Flight Surgeons Ability to Provide Effective Oversight (cont.)

State of the Flight Surgeon, cont.

32 | FLIGHTLINES

• Enhance Readiness Skills

Improve Communication

• Enhance communication with MDG and line leadership

• Act as an interface between the Clinic and Flight Squadrons

• SMEs keep the AMDS/CC informed of line support issues that can be resolved or improved with increased MTF support

• Expand communications with other AF physicians and MDG personnel concerning aeromedical standards and other Flight Medicine issues

Enhance Patient Care

• Energize patient care

• Ensure Continuity of health care – be available for your patients

• Focus on flyers and their families - think “what do they need?”

Be Leaders

• Provide clear and strong leadership across all team aero-space functions

• Enhance your management skills

• Get out in front! Lead the Medical Group in medical stan-dards compliance and Readiness

Additional comments that the Medical Group commanders made regarding areas for Flight Surgeons to improve their service included:

• Decrease turn around time for waivers, MEBs

• Become familiar with the AFMS Business Plan and imple-ment the aerospace medicine components successfully

Summary

Air Force Flight Surgeons are fulfilling the expectations of 84% of 58 Medical Group commanders who lead AF clinics, hospitals, and medical centers. The top two ways MDG/CCs recommend Flight Surgeons improve their service are to improve clinical skills and to be a MDG team player. MDG/CCs assess Readiness as the program area for which Flight Surgeons most need to improve their ability to provide oversight.

MDG/CC Recommendations For Improving Flight Surgeon Performance

The Medical Group Commanders were asked to list the top two ways Flight Surgeons should improve the service they provide. Their replies were categorized for analysis.

The two areas the commanders most frequently listed were to improve clinical skills and to be a MDG team player. Other frequently listed ways that commanders stated Flight Surgeons should improve the service they provide (in order of frequency from more frequent to less frequent mention) were: engage with Flying Squadrons/Wing, increase knowl-edge of aerospace medicine programs, improve communication, enhance patient care, and be leaders.

Examples of comments that MDG commanders noted concerning improving Flight Surgeon services are listed below by subject area:

Improve Clinical Skills

• Obtain advanced clinical training to augment FS skills

• Establish a solid clinical base to establish credibility

Be a MDG Team Player

• Engage in MDG activities

• Remain a full up member of the medical staff

• Emphasize commonalities with clinicians; participate on MDG committees

• It’s not MDG or Flying Squadron but MDG AND Flying Squadron

Engage with Flying Squadrons/Wing

• Stay heavily involved at the squadron level; solidify bond with Flying Squadrons

• Attend Flyers' training and meetings: squadron, wing, social

• Be proactively engaged with all aspects of the wing mission to enhance safety and performance

• Place more emphasis on operational safety

Increase Knowledge of Aerospace Medicine Programs

• Know Aerospace Medicine AFIs and H S I checklists and implement them

• Increase understanding of population health, Occupational Health, and Public Health

State of the Flight Surgeon, cont.

FLIGHTLINES | 33

Editor’s note: We are sad to announce that this will be the last article from Sammy the Bull for a while – Sammy will be leaving Flight Med to learn to pass gas in Mass(achusetts) as a resident in the Anesthesiology program at Harvard. We are confident that in a few years we’ll be hearing from Sammy again, when he has a billet on a CCATT team.

We’d also like to welcome Capt. Rich “Grover” Farley to the Fighter Speak team!

Fighter Speak: The HUD ReviewCapt Tom “Vito” Massa

Capt (Dr.) Sammy “The Bull” GalvagnoCapt Rich “Grover” Farley

56th TRSLuke AFB, AZ

In the last column of Fighter Speak, we discussed basic fighter maneuvers (BFM) and terminology. In this column, we will discuss the essentials of performing an effective Anti-G Straining Maneuver (AGSM) Heads Up Display (HUD) review (see Figure 1). The essentials presented here are derived from the numerous HUD reviews performed weekly at the 56th Fighter Wing for F-16s but the principles can be applied to other fighter aircraft as well.

Purpose: Evaluate Potential for GLOC

The purpose of performing a HUD review is to identify breakdowns in the AGSM that occur during periods of high task saturation and stressful in-flight situations. BFM, ACM (Aerial Combat Maneuvers), and SAT (Surface Attack) sorties are typically when problems occur. A HUD review should be an objective assessment.

AGSM Breathing Component Assessment (Look, Listen, Evaluate)

The reviewer should look closely at the HUD tape while listening. Air exchanges can be timed with a stopwatch. The HUD tape review should include all high +Gz engagements during the flight, not just the G-exercise (Gx). Standard verbiage that precedes the Gx includes a variation of the following statement: “Check cameras on, hot mike, standby for Gx.” The reviewer must listen carefully for a preparatory inhalation in conjunction with aircraft lift vector movement followed by brief air exchanges every 2.5-3 seconds (quick, crisp exhalations against a closed glottis). Each air exchange should last no more than 1 second. The AGSM should be continued during G unloading, not just during maximal +Gz.

Fighter Speak 101

Signs of GLOC or Blackout

In cases where GLOC is questionable, a careful HUD review may be deci-sive. There are several indicators of GLOC including the following:

Pilot: Late AGSM followed by dumping of air, lack of air exchanges, incapacitation at reduced +Gz, snoring, silence, cognitive decrement (missed radio calls, inappropriate communication, etc.). Additional performance indicators can be derived from the aircraft’s fuel status. For instance, BINGO fuel may indicate increased aircraft performance (increased thrust-to-weight ratio) although there can be a decline in human performance due to end-of-sortie fatigue.

Aircraft: Reduced +Gz at incapacitation (on G meter), attitude changes (nose low acceleration, increased airspeed with loss of altitude, any aircraft position change not commensurate with briefed profile).

Life Support Equipment: By listening for positive airflow, one can determine if the pilot’s oxygen equipment is working. At +4Gz, positive pressure is delivered in aircraft with COMBAT EDGE (F-16).

References

AFPAM 11-419AFI 11-404All Fighter MDS 11-2 Vol 1 Series

In future columns, the workup for GLOC and physiological incidents will be discussed.

SIGNING OFF FROM FIGHTER COUNTRY!

Your paesani and the crazy Irishman, Sammy the Bull, Vito, and Grover

Capt Tom “Vito” Massa

Capt (Dr.) Sammy “The Bull” Galvagno Capt Rich “Grover”

Farley

34 | FLIGHTLINES

As you settle in to your new base, you as the new SGP or Flight Surgeon

need to know how to rapidly assess programs and sections, and identify

problem areas to drill down to. Readiness is Job 1, and a high visibility

area that our MDG/CCs have identified as a place where the Flight

Surgeon community can really help out. Here are some fast steps that

can give you a warm fuzzy (or a cold chill) early.

Remember that you can learn a lot by just walking in and observing the

office during your in-processing appointments. I recommend that as you

in process, walk through the first seven steps. Set up a time to do the last

three steps later as you get established.

1) Curb Appeal: Look at the shop…first impressions matter.

- When you walk into the office or work area, does it look like a place

where the folks who work there like their job?

- Do you think they have ever deployed? (readiness mementos, pictures,

etc on the wall?)

- Do they have labeled binders with current plans in them?

- Do they have a SIPRNET/STU phone in the area? Maps, charts and

other contingency/disaster stuff on the walls?

2) Attitude and Enthusiasm:

- Are they in BDUs or Blues?

- How do they respond when you ask them questions?

- Does the staff act as if they like their job?

- Are they happy to tell you about what they do or do they run the other

way when they see you coming?

Spot Check the Readiness ShopLtCol Adanto R. D’Amore

Readiness Review

- Are they excited to tell you about the next/last exercise, or the next

formal course or deployment, or do they tell you about their new/civilian

job (shoe-clerk or otherwise).

3) SORTS (Status of Resources and Training System)/ART (Air

Expeditionary Force Reporting Tool)/DOC (Designed Operational

Capabilities) Statement: These reports are the best place to go to see a

snapshot of the unit, and are what the higher headquarters sees. ART is

classified and provides a detailed analysis of each Unit Type Code (UTC)

assigned to your facility.

- Ask to see what the most current DOC statement/SORTS report.

(Assuming your security clearance is UTD)

- Remember, SORTS is not a report card; it is an honest assessment on

the unit capability.

- What are the percentages, and why are they that way?

- What problems does the readiness team see in various areas?

- What do they need you to do to help them?

4) Plans: Look at the Medical Contingency Response Plan (MCRP) and

other supported plans.

- Can they find them or are they “around here somewhere?”

- When was the last rewrite and full review? Is there documentation of

periodic reviews?

- Look at the supported pubs. Are the dates current? Are they all there?

- What are the plans, taskings, and MOUs in support of the civilian

community? Are these current? Very important as we have a lot more

contact with the civilian communities than we used to.

- Are there any assumptions in the plans that the readiness folks are

concerned about that are unrealistic?

5) Mobility Processing: This is where the rubber hits the road.

Remember, some discrepancies matter and some don’t (this is why you

get paid on the line), but when you’ve got time to prepare you should

have none.

- Ask to see the after action report for the last couple of mobility

processing’s, Operational Readiness Inspection (ORI) or Health Services

Inspection (HSI) reports.

- Look at any discrepancies. Were they unavoidable or should they have

been caught well before the processing line?

6) Security access/letters: Who has access to all of the classified stuff,

whether to log on to SIPRNET (Secret Internet Protocol Router Network,

aka the “High Side”) or to pick up classified messages?

- Are all of the letters up-to-date? How often do they check to make sure

they stay current?

- Are you on the list? If not, how do you fix this ASAP?

Flag on top of control tower at Bagram AB, November ‘02. Tents in background is the Army Combat Support

Hospital (CSH) and mountains are the Hindu Kush.

FLIGHTLINES | 35

7) War Readiness Materials (WRM): ask the MRO to introduce you to

the loggie who is in charge of WRM. Tell him you’d like to actually look

at the WRM. (be prepared, this may surprise him…)

- How does it look? Palletized and ready to go, or in piles in the

corners?

- D&D (dated and deteriorate-able) items identified and ready to be

added to go out the door?

- If it ain’t 100%, what are the missing items? (Are you missing pencil

erasers or tent poles and the electrical buss?)

Later on, when time permits:

8) Exercise: Does the WRM really work?

- Who owns the WRM materials? How much is at your base? (Some are

line and some medical.)

- Tell your SMEs you want to take their equipment off-line, exercise it,

and make sure it all works. (You want to make sure everyone knows what

to do with all of this stuff, too.)

- Schedule this as soon as ops tempo and regs permit, but at least annu-

ally.

9) Solicit Honest Feedback from the Line. This is a great place for

the Flight Surgeon to make his money, and give feedback to the MRO

and staff.

- When you fly, swing by the squadrons and talk to the UDMs.

- How do they think the last mobility processing line went?

- Are there problems that your Medical Readiness shop didn’t tell you

about?

10) Go over the last full self-inspection.

- Ask the shop to go over the most recent one and review the results.

- If it was a long, long time ago, ask them why.

- Have they tracked and fixed the discrepancies?

- Do they have solid plans and timelines to address and fix OPEN

discrepancies?

Here’s a great list that LtCol Kelli Thomas passed on to me from a very

smart MSC Officer who worked with her at Brooks came up with. She

calls them the “Things Bosses Oughta Know”

1. Be a readiness advocate. This is the biggest thing you can do. Back

up the words that “Readiness is Number One.” Have unannounced bag

drags…make sure people leave TDY and leave contact info. Speak regu-

larly with the readiness shop to hear about any base issues and help them

work the kinks out of the system.

2. AEF 101: Learn the ins and outs of the AEF cycle: what bucket(s) the

MTF is in, which drives what training should be attended. One frustra-

tion I’ve had is that MDG/CC’s often just want their bottom line to read

100%, but that often requires that I train people outside their bucket. The

MDG/CC’s and the AEF/CC’s expectations should be aligned; unfortu-

nately, too often they are not.

3. SORTS/ART/MRDSS/LOGMOD: Understand what these reports

are, what their limitations are, and what their intent is- they are meant to

show the current status, not how the CC wants them to be.

4. Understand training requirements in AFI 41-106. Do not duplicate

efforts.

5. Understand the deployment process. It is all in the base’s Installation

Deployment Plan (IDP) and associated checklists, so familiarize yourself

with them. The Medical Annex is your guide; as a Flight Surgeon or

AMDS/CC you are responsible for the medical portion of the mobility

line, e.g. immunizations, medical/dental/life skills clearances, etc. For

example, know where the DCUs/PPE are coming from.

6. Know where your people are! Know who is deployed and where,

and who is tasked to deploy? If it takes the Readiness shop putting a

map of the AOR in the office and putting pins in the spots where Airmen

are, that’s fine.

7. Know what UTCs are assigned to your MTF.

8. Coordinate any potential UMD changes. The Readiness shop needs

to know so they can coordinate with the MAJCOM. For example, don’t

just delete your 48As without letting readiness know.

9. Get good people to the Readiness Shop. Don’t make this a home

for the homeless. Readiness seems to only get visibility when things go

wrong, but avoid the temptation to let it be the “reject shop.”

10. Get your Readiness Shop the right training. Make sure that your

Airmen are set up to succeed.

11. Understand the requirements for the unit. Talk to the Readiness

Shop, and learn what they need, from training to mobility folders. Be

aware of where their efforts are going.

12. Hook the Readiness Shop up with the Systems Flight. Make sure

that you are using the electrons well, and you have current, comprehen-

sive data bases to work with.

Of course what is most important to me as a Readiness Officer is to work

for a Commander who listens and leads by example. The MDG/CC does

not necessarily need to have a background in Readiness. It is far more

important to me that he has a commitment to officership and leadership,

period.

Readiness Review, cont.

36 | FLIGHTLINES

Many Flight Surgeons occupy positions that require a working knowl-edge of the Unit Manpower Document (UMD). Flight Surgeons func-tioning as Flight Commanders, SGPs, or Squadron Commanders will need to have a thorough understanding of the UMD to complete any tasks relating to manpower, such as anticipating and filling vacancies.

A large part of reading the UMD is just knowing what the acronyms stand for. I’ve included a list of some acronyms you’ll likely come across, and some comments for your info. Many of these codes are of more interest to your resource management office than to you, and I’ve identified those you won’t need to spend brain bytes on. POS: Position number. Each manpower authorization is associated with a unique position number. Only one member can occupy a given position number at a time. “Double booking” (assigning two members against the same position number) is not allowed. When engaging AFPC in an assignment fill request, be ready to tell them which valid, unencum-bered authorization you wish for them to fill. AFSC: Air Force Specialty Code. This code signifies the career field specialty of the member in question. 48X represents aerospace medicine, 44X represents non-surgical medical specialties and 45X represents surgical specialties. 48A is a RAM, 48R is a residency trained (non-RAM) Flight Surgeon, and 48G is a general medical officer (GMO) Flight Surgeon. Prefixes include:C: Command qualified: earned after a year on G-series orders (though you’ll be given it when you assume command). You continue to hold this prefix on the AFSC in which you earned it unless you do something to make yourself non-command qualified.M: Board certified: earned when you are board-certified in the AFSC in questionT: Teaching position: earned after a year in a teaching staff position (though you’ll be given it when you take on the position). You continue to hold this prefix on the AFSC in which you earned it unless you do something to make yourself non-teaching qualified.Suffixes include:1: for residents and physicians in the first year post residency training. You’ll often see people granted “3” suffixes upon arrival at base. While this isn’t strictly allowed, it does make the system run smoother.3: for fully qualified physicians (whether or not they are board certi-fied)4: for physicians at a headquarters staff or equivalentThe regulation dealing with officer AFSCs is AFMAN 36-2105. SEI: Special Experience Identifier: Allows subdivision of skills within an AFSC (example: IDMTs). Granted by AFPC. GRD: Rank RGR: Required grade for the position in question. Can usually assign

Flight Surgeon Continuing Education

Deciphering the UMDCol Pat “Goose” Storms, RAM 2005

up or down two grade levels (Capt OK in a Lt Col position), but must involve the Colonels group if you wish to put an O6 in a non-O6 slot, or a non-O6 in an O6 slot. MNT: Manpower Type Code: Describes whether or not a give position has a wartime requirement, and whether or not it is funded:AN: authorized (funded) with NO wartime requirementAY: authorized (funded) with a wartime requirementPN: Unfunded with NO wartime requirementPY: Unfunded with a wartime requirement API: Aircrew Position Indicator (previously RPI). Flight Surgeon = API 5 PEC: Program Element Code (Not something you’ll be routinely involved with): Related to programmed cost data (people, facilities, equipment). DTY: Authorized Duty Title: Special codes for specific titles (Not something you’ll be routinely involved with):063: Chief113: Commander326: Supervisor CEC: Civilian Employment Group Category: Coded as follows:10: GS (General Schedule: salaried workers)20: WG (Wage Grade: hourly workers)30/40: Foreign nationals SAR: Security Access Requirement1: Secret2: TS3: TS/SCI PRP: Personnel Reliability Program status SCI: Sensitive Compartment Information MSI: Manpower Standard Implementation (Not something you’ll be routinely involved with): identifies the type of manpower standard under which the authorization was approved. CRK: Command Manpower Remarks (Not something you’ll be routinely involved with): identifies unique characteristics not defined by other data codes (all are specific codes) NUM: (Not something you’ll be routinely involved with): Identifies the number of codes found in the CRK1 and CRK2 columns RMK: Force Manpower Remarks (Not something you’ll be routinely

FLIGHTLINES | 37

involved with):CR7: Civilian/Military reductionRED: Civilian Reduction with impact MAC: Major Command Identity: a two-digit code that identifies the MAJCOM PAS: Personnel Accounting System: 4-digit code that identifies the unit to which the manpower authorization belongs UNIT: Unit assigned ILC: Installation Location Code: identifies a particular location (usually a base) SCC: Installation State Country Code: identifies the state or country in which the unit is located SUB (Not something you’ll be routinely involved with): Subcommand Identity: denotes various reporting units PAL2, PAL3, PAL4 (Not something you’ll be routinely involved with): Servicing Personnel Accounting Levels: allows “lumping” of units into MAJCOM-determined bundles CBP (Not something you’ll be routinely involved with): Designates where the servicing MPF is located

CCP (Not something you’ll be routinely involved with): Designates the

location of the servicing Central Civilian Personnel Office (CCPO)

MET (Not something you’ll be routinely involved with): Designates the

location of the servicing Manpower Quality Office

Identity: Identifies the query file selected for the report: Active Duty,

Reserve, Guard, IMA, NPP (non-permanent party)

PPN (Not something you’ll be routinely involved with): Parent PAS

Number: identifies the unit directly above the identified unit

Parent Unit: identifies parent unit’s number, kind, type

OSC: Organization Structure Codes: identifies the internal organiza-

tional structure of a unit

CC: Command

CCQ: Command support

FAC: Functional Account Code: 6-digit codes that identify functions

down to the basic work center

1XXXXX: Command and Command Support

5XXXXX: Medical

2005 AAMIMO Class with Capt Morin: L to R: LT “Panos” Kousoulis (Greece), Maj Hsin Chu (Taiwan), “Some Reeely Old & Uuuugly Grumpy Guy (Twilight Zone),” “Some Colorblind

Guy in a Blue (?!?) Flight Suit (Smurfland),” Sqdrn Ldr “Nati” Nataraja (India), Maj Bierthe Henriksen (Denmark), Sqdrn Ldr

Lalith Jayaweera (Sri Lanka), Maj Chun-Cheng Liu (Taiwan), LTC “Ullie” Naschold (Germany). Editorial comments courtesy of Col

Hadley “The Iguana” Reed.

Naval Flight Surgeon, RAM and Astronaut Capt. Lee Morin pres-ents Col Courtney Scott with USAFSAM patch, which had been

flown on the 2002 Space Shuttle mission. Capt Morin spent the day at Brooks City Base sharing his experiences with USAFSAM staff

and students. Also present is Navy Captain Matt Waack.

Flight SurgeonContinuing Education, cont.

38 | FLIGHTLINES

Editor’s note: We are proud to introduce our newest feature, in which we will highlight the international members of Team Aerospace. The author of this article was a member of this year’s AAMIMO (Advanced Aerospace Medicine For International Medical Officers) Class at USAFSAM, and the proud recipient of the “Propwash Award,”given annually to an outstanding member of the class. Congratulations, Nati!

IntroductionMotion Sickness is a response to real or apparent motion to which a person is not adapted. When the provocative motion environment is flying in aircraft, the sickness is named as airsickness. Although a person suffering from airsickness exhibits symptoms and signs of a bodily disturbance, these are not abnormal, but are a result of a built-in response caused by exposure to abnormal motion environment for a sufficient length of time. It is the stimulus that is abnormal and not the person.

The main symptom of airsickness is nausea and the main signs are pallor, sweating and vomiting. The other responses like apathy, general discom-fort, head ache, stomach awareness, increased salivation, and prostration appear at varying degrees.

EtiologyThe etiology of airsickness has not been fully established. Currently the most accepted explanation for causation is the theory of sensory conflict, indicating some degree of sustained de-synchronization at the level of the comparator in the brain. In addition, there is a psychological component to the causation of airsickness. Anxiety develops due to feel-ings of discomfort or nausea brought about by provocative maneuvers or when exposed to unfamiliar mode of travel. This is due to the arousal that typically develops when one is exposed to situations that are known to be threatening or uncomfortable. In some individuals, the sickness could be primarily psychological and have no relation to flight profile; nausea and vomiting are common reactions to stressful situations in certain personality types.

IncidenceThe incidence of airsickness is extremely variable, depending on the circumstances. Only persons with lack of functional vestibular system are not susceptible to it. The incidence of airsickness in the Indian Air Force (IAF) is between 30 and 40%, which is comparable with those seen in the other major Air Forces of the world. Most of the trainees get adapted to motion stimuli leaving about 9% who have persistent airsick-ness and do not adapt spontaneously to aviation. They require interven-tion and are referred to No.2 Aero Medical Training Centre (AMTC) located at the Air Force Academy, Hyderabad.

Management of Airsickness in IAFIAF uses a combination of counseling, physical exercise, ‘Yogic’ exercise and desensitization on Barany’s chair. This is followed by gradual expo-sure to straight and level flying. A trainee pilot is said to be successfully

desensitized when he does not have any episodes of vomiting or other features of airsickness.

Yogic ExerciseYoga is an ancient Indian science that aims at maintaining good health, mental peace and concentration. The Benefits of yoga are due to its effect on the autonomic nervous system reducing the sympathetic activity. The Yogic exercise schedulecomprises:

(a) Suryanamaskar: Salutation to the sun

(b) Pranayama: Controlled breathing

(c) Padmasana: Lotus position

(d) Kapal Bhati: Diaphragmatic breathing Sarvangasana: All part pose

(e) Savasana: Corpse position (complete relaxation)

The Schedule followed was a total period of 45 minutes thrice a week till completion of basic flying training.

Physical Exercise Training This training consists of exercises that produce cross-coupled vestibular stimulation. The benefits of this program are: (a) It does not depend on any complex equipment for ground based desensitization; (b) It does not depend on expensive in flight desensitization; (c) It blends with flying training and there is no requirement of setting a specialized centre; (d) By practice of this exercise the trainee can maintain the habituation even with a long break in flying; (e) Boosts confidence in an individual and removes the feeling of inferiority as the individual is able to overcome the embarrassment of airsickness by the simple exercises. The schedule has four sets of exercises shown in Appendix A.

In a study by Kumar BKU et al a total of 142 trainee pilots (133 male, 9 female) were subjected to Yogic exercises at AF A. The authors have reported a reduction of 47.78% (males 48.59%, females 19.43%) in the incidence of airsickness among these trainee pilots. “Wash-out” rates were nil. In another study by Sood S, a total number of 281 cadets took part in the study. The regime followed in the study was three vertigo inducing exercises and one yogic posture, the Sarvangasana. Among these cadets, the incidence of airsickness reported was 18.5%. Suspension rates were nil as comparedto 4.6% in the control group where no preventive measures were used.

Approach to Pilot with AirsicknessThe Aerospace Medicine Specialist plays an active role in prevention and management of airsickness in trainee pilots. On arrival of the trainees to the academy they are educated about the problem of airsickness, the magnitude of the problem and spontaneous recovery with habituation to stimulus (flying). They are advised to visit the doctor without any hesita-tion for consultation in case of severe or recurrent symptoms.

International Corner

Management of Air Sickness Among the Undergraduate Pilots in Indian Air Force

Squadron Leader Marur Sriniv NatarajaAAMIMO 2005

FLIGHTLINES | 39

Typically during the initial 2-3 episodes of airsickness the instructors try to alleviate the anxiety by counseling. If the trainee is still suffering from airsickness, he is referred to AMTC for intervention. At AMTC, the trainee is physically examined to rule out any pathological cause of airsickness. He is informed of the treatment protocol, the expectations for him to succeed and then introduced to combination of Physical Exercise Therapy (PET) and yogic exercise. From the second day onwards, he is exposed to Barany’s chair for simulating the Coriolis sensation, progres-sively increasing the number of rotations from 5 rpm up to 25 rpm. His progress is monitored and counseling done on daily basis. By seventh day he is usually fit to go back for flying.

After successful completion of the desensitization therapy, the trainee is exposed to straight and level flying with gentle maneuvers only. Feedback about his performance and recurrence of airsickness symptoms are obtained from the instructors.

On recurrence of symptoms the trainee is reports back to AMTC where he is subjected to another week of desensitization therapy. If the symp-toms persist beyond this time he is referred to Institute of Aerospace Medicine (lAM), Bangalore for further evaluation. In the absence of any pathological cause and persistence of symptoms the disposition of the trainee pilot is administrative.

Appendix-A

VESTIBULAR DESENSITIZING EXERCISES USED IN THE MANAGEMENT OF AIRSICKNESS IN INDIAN AIR FORCE

No 1.Stand upright with one arm up, face up, and rotate five times slowly. At the end if the head is brought forward, a sense of vertigo is experienced for 15 to 25 seconds. The exercise is repeated thrice clockwise and thrice counterclockwise at an interval of 30-60 seconds. The schedule is progressively increased to 20 repetitions. The vertigo reduces in intensity and duration.

No2Stand erect with hands close to side. Bend forward at waist so upper trunk and head faces the ground. Rotate as the first exercise. The schedule is progressively increased to 20 repetitions. The vertigo reduces in intensity and duration.

No.3Stand erect and rotate head over the shoulder clockwise and anticlock-wise, then walk forward for 20 steps.

No.4 (a)Lie down on the floor with your legs together and your hands, palms down, by your sides. Inhaling, push down, by your sides. Inhaling, push down on your hands and raise your legs straight up above you.

No.4 (b)Lift your hips off the floor and bring your legs up, over and beyond your head, at an angle of about 45 degrees.

No.4 (c)Exhaling, bend your arms and support your body, holding as near the shoulders as possible, thumbs around the front of the body, fingers around the back. Push your back up, lift your legs. Now straighten your spine and bring the legs up to a vertical position. Keep your feet relaxed. To come down from the pose perform the procedure in the opposite direction till resting the feet on the ground.

International Corner, cont.

40 | FLIGHTLINES

Intro to CHPPM

USACHPPM

USACHPPM offers military health and environmental products. For up-to-date information on traditional and emerging diseases, deployment health care solutions and products, health hazard assessments, risk communication and more, visit and bookmark the Web site of the U.S. Army Center for Health Promotion and Preventive Medicine http://chppm-www.apgea.army.mil/ What is the U.S. Army Center for Health Promotion and Preventive Medicine?The US Army Center for Health Promotion and Preventive Medicine (USACHPPM) is a major subordinate command of the US Army Medical Command. With more than 1,000 professionals on staff, we are here to support you. Our staff includes chemists, physicists, engineers, physicians, optometrists, epidemiologists, audiologists, nurses, industrial hygienists, toxicologists, entomologists, and many others as well as sub-specialties within these professions.How do I access USACHPPM information? Online, go to http://chppm-www.apgea.army.mil/ for access to USACHPPM’s array of relevant health and environmental products and services.What will I find there that will make me more effective in my mission?Publications and health information products and resources – A listing can be found at http://chppm-www.apgea.army.mil/USACHPPM%20Technical%20Guide%20276.htmNote: Ultimate Preventive Medicine CD, Technical Guide 276 is being updated. The current stock has been depleted. The updated version will be available in August 2005. Look for it on our Web site home page http://chppm-www.apgea.army.mil/ under Hot Topics as soon as it becomes available. When I find what I need on the Web site, what’s the next step?For products you can download and adapt to your service and locations, including Medical Threat Briefings, Staying Healthy Guides, posters and much more, go to http://chppm-www.apgea.army.mil/dcsops/Health.aspxHow can I get products that can’t be downloaded?Much of the information on USACHPPM’s Web site can be ordered at “Order Health Information Products” http://chppm-www.apgea.army.mil/hio_public/orders.aspx. Or click the home page listings, “A to Z Resource Guide” or “Request USACHPPM Services.” What’s available from USACHPPM that I can’t get from the CDC or WHO?Assessments of environmental conditions and diseases adapted to your needs in the military health care profession. You must use your secure connec-tion to access the site, http://usachppm1.army.smil.mil, or email contact [email protected] should I contact if I still can’t find what I need?Make use of USACHPPM links below for materials, services, or answers to questions not covered by the Web site.

• Health and environmental information and products http://chppm-www.apgea.army.mil/contactus/Wemail.asp

• Public Affairs http://chppm-www.apgea.army.mil/contactus/PAOemail.asp

FLIGHTLINES | 41

“Promise that you’re not going to ground me, Doc.” “Have you taken the anthrax vaccine?” “Why won’t you test me for DU?”

How would you answer questions like this when they come from an Airman that is angry, upset, or scared? The Health Risk Communication Program at the U.S. Army Center for Health Promotion and Preventive Medicine offers training to help you communicate in these situations. We offer you concrete tools and proven techniques that work—not group hugs. Our interactive workshops steer you away from pitfalls, help you counteract mistrust, and effectively address controversy. Our regularly scheduled workshops are free to military, DoD civilians, and DoD contractors. We can also work with you to develop a workshop geared toward your issue or project. Go to http://chppm-www.apgea.army.mil/risk/ to sign up today. Contact Jennifer Lynch at 410-436-8147 or [email protected] for more information.

Introductory Risk Communication

16-18 August 2005, Fort Lewis, WA18-20 October 2005, Landstuhl, Germany

Advanced Risk Communication Please note: At least 1-day of risk communication training is required prior to taking this workshop.

26-28 July 2005, San Antonio, TX25-27 October 2005, Landstuhl, Germany

Conflict Management

21 October 2005, Landstuhl, Germany

More training courses for FY06 will be added soon. Check our website http://chppm-www.apgea.army.mil/risk/

Risk Communication Training

42 | FLIGHTLINES

Population Health Support Division

The Cardiovascular Risk Assessment and Management (CRAM) Project, which began 1 Jan 04, focuses on the primary prevention of coronary heart disease (CHD) including the early identification, assessment and management of CHD risk factors in Airmen. The use of CRAM mate-rials is not mandatory, but assists the SGP in assuring that all active duty Air Force (ADAF) undergo a cardiovascular risk assessment during their PHA, which is a mandated responsibility for the SGP per section 1.17 of AFI 10-248, AF Fitness Program. CRAM is comprised of three main elements: 1. MTF education on the risk factors and initial assessment of CHD risk in ADAF (with CME available for physicians), 2. A CHD toolkit with summarized clinical practice guidelines and example SF 600 overprints, and 3. A computer-generated 10-year risk estimate for developing CHD (using Framingham methodology) in PIMR.

The educational activity is available via teleconference and video tele-conference (both free), or in-person (MTFs must pay TDY costs). Please use the POCs listed at the bottom of this section if you’d like to arrange an educational session.

The toolkit condenses the most current evidence-based guidelines on the assessment and initial management of the CHD risk factors, including

HTN, dyslipidemia and diabetes. The toolkit also contains information designed to help clinicians regarding with tobacco cessation, dietary and exercise recommendations, aspirin use, and information on abdominal circumference and CHD. Now it can all be accessed on the Knowledge Exchange at https://kx.afms.mil/cram/. A zipped file containing all the information can also be e-mailed by the POCs if you have difficulties accessing the web page.

The 10-year CHD risk estimate calculation can streamline essential portions of the risk assessment process by saving you from lengthy chart review or hand-calculating the estimates! It is calculated by Population Health Support Division (PHSD) informatics staff for all ADAF with available risk factor data monthly; the scores and risk factors are refreshed in PIMR at the end of each month. This data is available in the individual Military “People” screens by clicking the “CPS/CHD” menu button or by generating a CHD report of all ADAF assigned to the MTF in the “Reports” section of PIMR. A Quick Guide to Navigating the Coronary Heart Disease (CHD) Data in PIMR is also available on the web page https://kx.afms.mil/cram/ or through the POCs below .

SGPs, Flight Surgeons, and all MTF staff interested in obtaining more information on CRAM materials or to schedule a CRAM educational activity should contact the following PHSD personnel: Lt Col Daniel Burnett, MD, MPH at DSN 240-2363, [email protected] or Dr. Celan Alo, MD, MPH at DSN 240-6513, [email protected].

Cardiovascular Risk Assessment and Management (CRAM) Project

FLIGHTLINES | 43

Population Health Support Division

Why use an automated, internet, self-report tool for health assessments?

The patient has much of the information needed by medical staff to provide efficient, high quality care. Health information of military interest and certain evidenced-based clinical preventive services, recom-mended by the U.S. Preventive Services Task Force can be accomplished by presenting standard questions to a patient using a computer, which can then be scored, interpreted, and reported, allowing for targeted inter-ventions to beneficiaries with the greatest needs and potential benefit.

“Traditional history taking by physicians is time-consuming not only for collecting information but also for documenting it... The number of questions a clinician needs to remember in an ideal interview is large… A computer always asks every question it is programmed to ask… Computer interviews can be done at the patient’s pace… Computer interviewing is effective for obtaining personal information that many people find difficult to discuss face-to-face…”

*John Bachman, The Patient-Computer Interview: A Neglected Tool That Can Aid the

Clinician. Mayo Clinic Proceedings; Jan 2003: 78: 67-78

Would you like to know more about your patients; but, don’t have the time?

The AFMS owns an automated, internet, self-report tool that is ready NOW for your use, it’s called the Air Force Web-based Health Assessment (AF WEB HA). Try it out by going to our training site:

http://www.intellicahealth.com/afwebhatraining. Login as by using one of the patient Username and Password provided below. Complete the questions (averages 16 minutes) your personal patient feedback is immediately available. Login as a PCM or Technician and see the tools available to manage your patients.

Go to the AF WEB HA Training Website: http://www.intellicahealth.com/afwebhatraining

(Information provided is for training purposes only and is not real)

You don’t just get the patient’s responses as with most currently available health assessments. This application also scores, interprets and gives you reports in four different formats: Patient (letter format), Healthcare Team (SF 600 format), Provider Bulleted and a Patient Response.

Want to know more? Please contact Mr. Bill Kenyon at DSN: 240-6511 or email: [email protected].

Access Level Position / Patient SSN Username Password

Level 4, PCE Primary Care Manager pflight O&2ods7e09 Level 4, PCE Technician tflight 6u09zuz@2ZLevel 5, Patient 30/100000000 janedoe !6Kf9j17mkLevel 5, Patient 20/500000000 jzapata ke9@3il2K1

Computerized Patient History

44 | FLIGHTLINES

An F-15C pilot is flying a mission, cruising at an altitude at FL 250, when he experiences a rapid decompression. He immediately develops right elbow pain, goes on 100% oxygen, and declares an in-flight emer-gency. After landing his aircraft, he is met on the flight line by the Flight Surgeon. His elbow pain persists and 3 hours elapse before he is trans-ferred to the nearest hyperbaric chamber. What is the recommended treatment for this pilot?

“Preparation is Key” are words to live by for any Flight Surgeon, RAM, or other profes-sional. Is your office prepared to respond to patients with decompression sickness (DCS)? The following discourse might help you be prepared, or at the very least, make sure your office is ready to manage such patients. Why are we writing about this subject? We are seeing a trend in the field of incorrect recognition and treatment of basic DCS cases. The purpose of this article is to share information regarding the proper recognition and treatment of patients with DCS.

If you encounter a patient with symptoms of DCS such as joint pain, you will want to make sure your patient is placed on 100% oxygen (via a tight-fitting aviator’s mask) during your evaluation and in preparation for transportation, if required. Sometimes, surface level O2 (SLO2) alone will be the recommended treatment for altitude induced joint pain only or skin DCS. To utilize SLO2 as the only treatment, the patient’s pain must be reported inside the chamber or within 2 hours of exiting. SLO2 is not recommended as the only treatment for other types of DCS including the presence of paresthesia and other neurological symptoms (such as central nervous system DCS and the chokes).

SLO2 must be delivered by a tight-fitting aviators mask or anesthesia mask. Treatment is considered successful if symptoms resolve after 2 hours of SLO2. Continue this treatment for at least one hour after all symptoms have resolved, with a minimum of 2 hours (even if resolved on descent) and up to a maximum of 3 hours. If the symptoms worsen or recur, you must begin an USAF treatment table (TT) 5 or TT-6 imme-diately. Additionally, if there is no improvement in symptoms within 30-60 minutes while breathing SLO2, then the patient should receive a USAF TT-5/TT-6.

A good history of the present illness and physical examination will form the basis for which treatment table will be utilized. A USAF TT-5 may be considered for “altitude-induced DCS joint pain only” if the symp-toms have presented within 6 hours of the hypobaric exposure. However, a USAF TT-5 is not recommended for diving DCS because the symptom recurrence rate is over 30%. For any patients presenting with neuro-

logical symptoms or if the “altitude-induced DCS joint pain” is greater than 6 hours in duration, a USAF TT-6 is mandatory. (See Table 1.)

For clarification, both tables utilize a 60 feet of sea water depth equiva-lent. The main difference between the two treatments is the length of the

treatment. USAF TT-5 is only 140 minutes long, while the total elapsed time for a USAF TT-6 is

285 minutes. Ensure you provide post-hyperbaric treat-

ment instructions for DCS patients. These instructions should include no strenuous phys-ical activity, no excessive alcohol intake, and no flying, diving, or altitude exposure for 72 hours. Patients should maintain good hydration.

Inform the patient to anticipate delayed ear pain. This pain may occur because excess oxygen trapped in the middle ear is later

reabsorbed, leaving a partial vacuum. It is called middle-ear oxygen absorption syndrome, or Draeger ear. The patient should plan to stay in the local area

for at least 24 hours. In addition, make arrangements for follow-up the next day.

To prevent future cases of DCS, always inves-tigate the causes of any DCS case. Common

factors leading to DCS include malfunctioning oxygen regulators and trainees that disregard our recom-

mendation to avoid strenuous exercise for 24 hours after an altitude chamber flight. Other risk factors include exposure to

temperature extremes, age older than 40 years, obesity, dehydration, recent physical injury, and repetitive exposures to decompression.

Please visit our website (http://wwwsam.brooks.af.mil/hyper/Guide.htm) where you will find additional information regarding treatment equip-ment and guidelines. There are references on how to build an adapter for CRU-60 and CRU-94 masks, Operating Instruction templates in MS Word on the evaluation and treatment of DCS, guidelines for the admin-istration of surface level oxygen, and instructions and diagrams on how to use the USAF treatment tables.

According to the soon-to-be-released revised edition of AFI 48-112, any Flight Surgeon caring for a patient with suspected DCS will coordinate their patients’ complete care course in consultation with our staff. Our Undersea and Hyperbaric Medicine Fellows and staff providers are on call to answer your questions 24 hours a day. We can be reached at DSN 240-3281 (210 536-3281) during duty hours and DSN 240-3278 (210 536-3278, or LEO-FAST) for after duty hours. We encourage you to contact us for further information or clarification.

From The USAF HMOC

Treatment of Decompression Sickness

Patrick J. Kearney, Lt Col, USAF, MC, SFSFellow, Undersea and Hyperbaric Medicine

James R. Little, Col, USAF, MC, CFSDirector, Undersea and Hyperbaric

Medicine Fellowship

Timothy A. Hursh, Lt Col, USAF, MC, CFSChief of Medicine Branch, Undersea and

Hyperbaric Medicine Fellowship

FLIGHTLINES | 45

Just a quick note to everyone who helped look for W.A.S.P. Marie Michell’s next of kin. Marie’s brother Roy has been located in VA. I talked to him for over an hour last night and he proved to be a wealth of information. Roy maintained contact with Marie’s husband and told me he passed away in 1989. Roy was a Navy aviation cadet during WWII and made many visits to his sister during the war. After her death her friends told him what happened the day of her death. Roy told me she was not scheduled to fly that day. The W.A.S.P that was scheduled had a toothache and bowed out at the last minute and Marie jumped at the chance to take her spot. Thanks for all your help.

Yours,David Schurhammer

Gill Reza of the L.A.Times published Marie’s story on May 30, 2005; the article is available through the archive services of the paper.

For further information about Marie and the WASP program, the following book is now available at your local bookstore: “FLYING HIGHER” by Wanda Langley

AIRMAIL

Richard D. “Hap” Hansen, 76, a Flight Surgeon and Brigadier General who served in the United States Air Force for 30 years died July 7, 2005. Gen. Hansen, originally from Indiana, received a B.S. degree, cum laude, from Indiana University in 1951, an M.D. degree from the Indiana University School of Medicine in 1954, and an MPH degree, cum laude, from the Harvard University School of Public Health in 1958. After entering the Air Force as a 1st Lt. in June 1954, Gen. Hansen completed an internship at Letterman Army Hospital in San Francisco in July 1955. A residency in Aerospace Medicine was completed after study and service at the School of Aerospace Medicine, Brooks Air Force Base, Texas, Wright Patterson Air Force Base, Ohio, and Minot Air Force Base, North Dakota. Gen. Hansen also served at The Air Force Academy, Colorado, with the Military Advisory Assistance Group in Taipei, Taiwan, as Hospital Commander at Luke Air Force Base, Ariz., and as the Director of Education at The School of Aerospace Medicine. Prior to his last assignment as the U.S. Forces in Europe Command Surgeon General, he served as the Tactical Air Command Surgeon General and the Air Force Military Personnel Surgeon General. Gen. Hansen took an active part in the United States Space Program, serving first as a medical controller on the tracking ship positioned in

the Indian Ocean, then at Cape Canaveral, Fla., and as medical flight controller in Corpus Christi, Texas for the Mercury first manned orbital flight. While assigned to Tan Son Nhut Air Base, Republic of Vietnam, he flew more than 70 combat missions and was the last Air

Force physician to leave Vietnam at the end of the war in March 1973. Gen. Hansen was a member of Alpha Omega Alpha, diplomat of the American Board of Preventive Medicine in Aerospace Medicine, a past president of the USAF Flight Surgeons, a past president and fellow of the Aerospace Medical Association, and author of a number of professional publi-cations in the field of Aerospace Medicine. Gen. Hansen held a private pilot’s rating for both single engine planes and gliders. He had more than 2,500 flying hours, including 400 in single engine jet aircraft. His mili-tary decorations and awards include the Air Force Distinguished Service Medal, Legion of Merit with three oak leaf clusters, Meritorious Service Medal, Air Force Commendation Medal, Presidential Unit Citation Emblem, Air Force Outstanding Unit Award Ribbon with ‘V’ device and four oak leaf clusters, as well as several awards from the Republic of Vietnam including the Air Service Medal and the Gallantry Cross. After retiring from the Air Force in 1984, Gen. Hansen attended the College of William and Mary taking Fine Arts

classes. He then held the position of Medical Director at the NASA Langley Clinic until l998.

In Memory

46 | FLIGHTLINES

First things first: Many thanks to Maj Gen Green, Col (Ret) Richardson, and now Col Fisher as Society Presidents

(past and current), and to Jeanine, Kerry, and Pete as Co-Editors. Their vector and support has made my tenure with

FlightLines the highlight of my RAM experience. Additionally, their free reign to try new things (and sometimes

bust the budget) allowed us the opportunity to learn from so many Aerospace Medicine professionals and bottle just

a few of the exciting things going on in the field. Thank you!

Jeanine has stepped up as the new Senior Editor this year, and she and her staff have some fantastic ideas that will take us to the next level for

FlightLines. I am confident that they will produce the most useful newsletter ever, including both hardcopy and soon to be electronic format. At

Jeanine’s suggestion, I will continue to be involved coordinating the new “Editor’s Emeritus” board including inputs from all of the past Editors, from

Lt Gen Taylor and Col (Ret) Heinrichs to the present.

Until then, I’m off to Columbus AFB and a real no-kiddin’ RAM job at a UPT base, no less. It’s a bit intimidating realizing the rich heritage of RAMs

who have come before, but with 3 years of the best training, much of it from my classmates and friends in the Class of 2005, I’m confident that we

will all be ready for business.

Hope to see you from the mighty Thunder Tweet soon,

Until then, Check Six,

v/r vd

LtCol Paul "VooDoo" Nelson

The Last Word

I can’t believe it’s been a year since Choc and I began working on FlightLines - it’s truly been one of the best

learning experiences of the RAM, so far. For a year I’ve been listening to Voodoo’s rambling cell phone messages

coming at all hours with every kind of crazy idea. Exasperating, but his vision and creativity have been the driving

force behind the growth of FlightLines - not only in size, but (most importantly) in depth. Voodoo, you’re my

mentor.

Now, plans for the upcoming year. First, we want to continue publishing a professional-quality valuable newsletter,

on time and on budget. Each issue will be focused thematically, yet incorporate articles covering a wide range of

aeromedical topics from our Contributing Editors. The positive reviews we’ve received have been heart-warming and energizing - we’re ready to keep

working hard to deliver a valuable product to our readership.

In the “State of the Flight Surgeon” survey, completed by Col Bill Nelson and published in this issue, MDG group commanders recommend that we

Flight Surgeons increase our knowledge of all Aerospace Medicine programs, that we become more familiar with the responsibilities and capabilities of

the other members of Team Aerospace. At FlightLines we will help with this effort, in each issue we will include articles that highlight Public Health,

Occupational Medicine, Readiness, the BEEs, and other Aerospace Medicine functions.

Soon we will inaugurate the FlightLines Website, a platform for information better distributed in an interactive electronic format. One possibility is the

development of Bulletin Boards for each RAM class, where we can meet up with old friends electronically and share news. We’re not yet sure what

we should include on the website...what do you think? email us and let us know.

It’s going to be a great year!

Wiz

LtCol Jeanine "Wizard" Czech

Editorial Page

FLIGHTLINES | 47

FlightLines team in transition

From L to R: Incoming Senior Editor LtCol Jeanine “Wizard” Czech RAM 2006, incoming Business Editor Capt Glen MacPherson RAM 2007, incoming Editor LtCol Dana “Windsock” Windhorst RAM 2007, Senior Business Editor LtCol Pete “Choc” Kovats RAM 2006, incoming Editor LtCol Cheryl Linn RAM 2007, outgoing Senior Editor Paul “VooDoo” Nelson RAM 2005. Elvis is standing in for incoming Website Editor Maj David Sarnow RAM 2007.

Last year, the FlightLines editors worked to stabilize the content and quality of the FlightLines newsletter, and

have developed a proposed vector for the future. With guidance from the BOG, we expanded publication to use

FlightLines to help advocate for an effective Team Aerospace at the MDG/CC level with distribution expanded to all

MDG/CCs and SGPs. In addition, we used it to actively recruit medical students, AMP graduates, and non-members

from the field.

As many of you know, we increased the size of the publication from 12-20 pages to an average of 45 pages and delivered a timely, quarterly product.

This produced significant cost increases which to this point the SoUSAFFS BOG has been able to subsidize. However, this level is not sustainable

next year without cost containment measures, many of which have been already undertaken, revenue or subsidy enhancement, or some combination

of the two. Options were presented to the BOG in May 2005 at the recent AsMA conference in Kansas City, to continue to maintain the current level

of quality and content.

It was agreed upon to continue our current course with regard to publication and to continue to solicit advertising to help offset the above deficit in

production cost. Currently, we have 5 advertisers, with our latest one to be seen in this issue from UTMB. We would like to thank all of our sponsors

for their continued support and belief in this product.

All of us here at FlightLines would like to thank everyone for your continued support of this publication and hope to continue to expand and further

enhance this well received product for many years to come. Please do not hesitate to contact me if you would like detailed information about our

budget, or have any questions regarding this or any other concerns or comments at [email protected]

Keep ‘em Flying!

Choc

LtCol Pete "Choc" Kovats

Comments? Suggestions? Ideas? Complaints?

Let us know what you think!

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[email protected]

Society of USAF Box 35387Brooks City-Base, TX 78235-5387

ADDRESS SERVICE REQUESTED

PRSRT STD

U.S. POSTAGE PAID

PERMIT NO. 244

SAN ANTONIO, TX

Please complete the applicable items on this form, detach and mail with a check for $15/yr to the Society at Box 35387, Brooks City-Base, TX 78235-5387. Checks should be made payable to: The Society of USAF Flight Surgeons. Credit card payments, as well as address changes, can be made on-line at www.sousaffs.org. Dues are effective from 1 Jan -31 Dec of the calendar year. Life membership is available for $150 — you must also be a life member of AsMA.

Name/Rank: _______________________________ Service (circle): AF AFRES ANG RET INTL

Complete Mailing Address: ___________________________________________________________________

E-mail Address: ____________________________________________________________________________

Aerospace Medical Association membership paid through (month/year or life): __________________________

THE FOLLOWING INFORMATION IS REQUIRED OF NEW MEMBERS ONLY

Medical school and year graduated _____________________________________________________________Internship/Residency and year completed: ________________________________________________________Aerospace Medicine Primary Course place and year graduated: ______________________________________

In order to become a member of the Society, we may need to verify your information. Do we have your permission to verify the above information? YES NO (circle one and sign/date below)

Signature: _______________________________________________________ Date: ____________________

Membership is open to all Flight Surgeons in good standing who are members of our parent organization, the Aerospace Medical Association (AsMA.) Society by-laws define the classes of membership. For more information, see the Society Website at www.sousaffs.org.

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