NAVAL OPERATIONAL MEDICINE INSTITUTE
1997 United
States Naval
Flight Surgeon
Handbook
(Back to Navy Index)
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Introduction
The flight surgeon and medical planning
Boards of flight surgeons
The waiver process
Aviator Evaluation Boards
Competency for duty exams
Aircraft mishap planning
Laser exposure
Toxicology
Burn Management
Management of decompression sickness
Aeromedical evacuation
Standard subject identification codes
Important phone numbers
Flight time requirements
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Introduction
Advice for reporting aboard your new duty station.
When reporting to your new duty station, you will be given the usual check in sheet, directing you to
appear at a number of different offices for administrative in-processing at your assigned squadron. Stop in
to introduce yourself to the X.O. and the C.O. There may be rare instances in which you will need to talk
privately with the C.O., but as a general rule the X.O. is the first point of contact for issues that need to be
brought to the attention of the command. In the interview, ask what they expect of you and listen carefully
to their advice and guidance. Brief them on the things you may be able to provide as the medical officer to
help them meet their requirements. Remember, you are now the advisor on all things medical to the
commanding officer, and he will need to know of your activities and progress in helping him meet his
mission requirements. From time to time, junior flight surgeons may be caught in a very dangerous trap.
As advisor to the aviation commander on medical issues which effect members of the squadron, the
procedure is simply one of resolution of that medical problem, followed by recommendations to the
commanding officer regarding disposition and/or flight status of that individual. But what if the medical
problem exists with the commanding officer himself? In these situations there exists the likelihood that
pressures may be brought to bear upon you to compromise your position of responsibility. Since medical
issues are involved, you are obliged to address them through the medical chain of command, and will
benefit from the advice and assistance of your senior flight surgeon. If you are the senior medical officer in
the area, you may seek help and advice from your TYCOM. Under NO CIRCUMSTANCES should you
bypass or go outside the squadron/group/wing chain of command, so your senior flight surgeon may be
the best person to extract you from a potentially difficult situation.
Meet the department heads and plan to work closely with the NATOPS and safety officers in your
aeromedical brief and safety activities. Tour the squadron spaces so that all personnel will get to know
who you are and what you are doing so that there are no surprises when you begin to make your rounds
unaccompanied. Ask to see the squadron mishap plan and become familiar with your particular duties and
responsibilities. Make sure you know the other members of the Aircraft Mishap Board (AMB) and attend its
meetings.
Make it a point to get acquainted with the senior enlisted man and the senior enlisted of each department.
They will be an extremely important link in the interaction between the enlisted personnel and yourself.
They all need to know that you are accessible to them at all times to help them with training and with their
medical concerns. They need to know that you are not just the "Officers’ Doc", but rather are there and
available to all members of the unit.
Obtain a copy of the "alpha roster" from the administrative department so that you can begin to put names,
faces and responsibilities together. If you have computer access or capability, consider developing a
tickler file for all squadron members immunizations, physical exam due dates, water survival
re-qualifications and the like, if such does not already exist.
Over the course of the next few weeks you will have become acquainted with a number of individuals from
other squadrons, group, wing, headquarters and various support units. Learn the organization, structure
and individuals well, for a good relationship is essential and guarantees their full cooperation when you
need it, as you most certainly will.
After completion of your administrative check-in, you will need to repeat the process by reporting to the
senior flight surgeon or senior medical officer, who will arrange for a briefing on your duties and
responsibilities while at the clinical facility where you will spend about 50% of your time, and introduce you
to other members of the staff.
Other key personnel you should meet as soon as possible include the leading petty officer (LPO) or
leading chief petty officer (LCPO) who will be directing all of the clinic's corpsmen and can give you a brief
on all enlisted personnel, with their special qualifications and assignments. Never allow yourself to come
between your senior enlisted man and his staff. These men are his responsibility and he must be able to
exercise his authority without interference. Need something done? Let him delegate those tasks to his
people and see to their completion.
Meet with your AVT in the Aviation Examination Room. This individual is a critical member of your team.
He needs to know your schedule and your thinking about each aeromedical issue that arises. He is a
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technician who is obligated to abide by strict rules. You have some discretionary powers as granted by the
Manual of the Medical Department, and he needs to know your reasoning when there appears to be
deviations from those rules. Let your AVT do the scheduling and control of your appointments which you
will refer from your squadron. Let him help keep you out of trouble. Since he is in a fixed facility, he is
more readily accessible for information regarding policy and physical qualification changes from NOMI and
BUMED.
Another key member is the training officer who can put you on the schedule for training of corpsmen and
otherwise take advantage of your specialized skills as well as adding you to local training events such as
BLS and ACLS to keep your requirements updated. Additionally, he can schedule you for C-4, Medical
Management of Chemical Casualties, Medical Effects of Nuclear Weapons and other training opportunities
to improve your skills and maintain continuing medical education requirements.
Learn the organization, structure and rules of the medical facility in which you will be working and the
chain of command. Then, follow that chain of command very carefully. Avoid going around the chain of
command at all costs. Brief your boss fully on your activities and any potential problems you become
aware of. Make it a point to prevent having him caught unaware of a situation of which you had prior
knowledge and failed to provide him a brief. He will be much more content with his lot in life, and your
success will be much more secure.
This is a good time to acquire the habit of maintaining a daily log of your activities, contacts and
conversations, whether by phone or in person. It is not uncommon that issues which seem insignificant at
the time, re-surface in unexpected and sometimes unpleasant ways. A carefully maintained daily log can
be a powerful defense against such an eventuality.
In all you do, remember that you are a naval officer, working with other naval officers and enlisted
personnel to achieve a common goal in service to your country. Your part is small in the grand scheme of
things, but very important to the common success. How you present yourself as a Naval officer is every bit
as critical to your credibility as are your medical skills. In fact, a careless appearance or attitude will almost
certainly be perceived as clear evidence of overall poor performance in all you do, both militarily as well as
medically. There are few other indicators by which they can judge.
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The Flight Surgeon and Medical Planning
Points of Contact:
 Host Facility in CONUS
 Navy Environmental and Preventive Medicine Units (See EPMU Chap.)
 Unit Supply Officer
 Unit Intelligence Officer
 Armed Forces Medical Intelligence Center (AFMIC)
Msg: DIRAFMICFTDETRICKMD
Ltr: ATTN:________________________
Fort Detrick
Frederick, MD 21701-5004
DSN Numbers:
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General Medical Intelligence
Information Services
AFMIC
Medical Intelligence Duty
Operations
343-7154
343-7214
343-7603 / 7511
343-7511
343-7574
General:
Whether planning for a CONUS training evolution or an overseas deployment, the line Commander must
have at his disposal all information which will potentially impact upon completion of the mission. The
medical department is often overlooked in the myriad of details surrounding pre-deployment planning, but
its role is not to be taken lightly. Consider for a moment that U.S non-combat losses have historically been
greater than combat losses in every conflict in which we have been involved. During WWII, 95% of
hospital admissions were non-combat related. This alone would seem to be adequate justification for you
to get involved as early as possible in deployment planning.
Deployment:
Deployments in CONUS will usually be to a fixed and established facility which can serve as a base of
operations. A few phone calls to establish contact with the medical department there may be all that is
required to find out what their capabilities are, and determine what additional arrangements you need to
make.
Deployments to remote locations or out of CONUS will require considerable planning and
preparation. Among the many questions to consider are:
 Climate/Temperatures/Precipitation
 Altitude and type of terrain
 Edible and poisonous plants
 Dangerous animals and snakes
 Availability and safety of water supplies
 Endemic diseases
 Vector control
 Current epidemics
 Host medical capabilities and availability
 Host scientific and technical capabilities, including NBC warfare
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Aeromedical evacuation routes and receiving facilities
Initial medical supply and re-supply
Status of Forces agreements
Decedent affairs
Once armed with all information necessary for you to begin preparations for departure, and as early as
possible, prepare a thorough briefing for the line Commander with assessment of risks, requirements, and
your plans to deal with casualties plus all preventive measures you wish to institute.
Further Responsibilities:
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Work with your PMU on rations/water/sanitation issues
Country hazard briefs for all hands
Immunization and dental completion for all hands
Corpsman Training
Buddy Aid Training all hands
Work with Chaplain and legal for personal affairs all hands
Aeromedical briefs as required for all aircrew
AFMIC Products:
Medical Capabilities Studies - Individual studies on foreign countries. Topics include environmental
health, diseases, public health services, military and civilian health care, medical personnel, materiel,
training and R&D.
Disease Occurrence Worldwide - A monthly summary, by region, of the diseases reported in foreign
countries.
Port Studies - Medical intelligence inputs on foreign ports, including water potability and sewage
treatment, public health, diseases and information on military and civilian health care facilities.
Foreign Medical Facilities Handbook - A summary of key hospitals in principal foreign cities throughout
the world.
Scientific and Technical Intelligence Studies - Studies on a wide variety of life science topics such as
foreign medical biotechnology, biological warfare capabilities, the biological effects of non-ionizing
electromagnetic radiation, chemical warfare agent antidotes, NBC warfare casualty management, blood
substitute R&D and hyperbaric medicine.
Special Studies - Initiative products on subjects of current interest.
Weekly Wire - A brief message format product which describes significant current medical situations in
foreign countries or foreign scientific and technical developments in the life sciences. U.S. Government
organizations which need this product should send a message or letter to AFMIC-SA/PS stating their
message address and point of contact, and specifying the level of security storage available at their
organization.
Quick Reaction Responses - Immediate responses to consumer questions on subjects of interest,
related to a variety of military medical or life science topics. Responses may consist of hard copy AFMIC
products or a summary of information available in AFMIC's files.
Foreign Medical and Materiel Studies - Evaluations of the characteristics and performance of foreign
medical material.
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Boards of Flight Surgeons
Local Boards of Flight Surgeons (LBFS)
Convening Authority:
Aviation Commander, or higher authority.
Membership:
The Local Board of Flight Surgeons will consist of at least three medical officers, one of whom must be a
flight surgeon. Other medical officers may be Board members as required or appropriate, particularly in
cases where an individual is being followed by a specialist. The senior Flight Surgeon is the senior
member of the Board.
 The use of medical specialists for consultation or appointment to the Board is encouraged.
Recommendations of the LBFS:
 Are made to the Aviation Commander for his consideration. He is not bound to heed any
recommendation.
 If the aircrewman is found medically unfit for flight, the reasons are to be clearly defined.
If the Local Board recommends that a waiver of physical standards is appropriate, then the senior member
of the board may issue an Aeromedical Clearance Notice pending final approval from BUPERS/CMC. The
decision of the board is binding until it is reviewed. If the local board’s decision is overturned, it is so on
the date of review and notification, not retroactive to the board's decision.
Reporting (LBFS):
LBFS reports are to be typed, explaining the decision of the board and discussion of the problems along
with:
 SF88
 SF93
 all relevant consultations
Board reports are to be forwarded to BUPERS/CMC via the convening authority and NOMI Code 42
(Physical Qualifications) within 10 working days of the board’s conclusion.
Remember that the LBFS is charged with the responsibility of determining the medical fitness of aircrew to
continue to fly. You are not granting a waiver, you are merely determining fitness to continue flying. If a
waiver is recommended, the Board may recommend that the aircrew continue to fly during the review
process and issue an up chit, but it is a very good idea to discuss this with NOMI Code 42 beforehand.
Special Boards of Flight Surgeons (SBFS)
Convening Authority:
Commanding Officer NOMI
Membership:
All active duty Naval Flight Surgeons on flight orders in the Pensacola area, as approved by the
Commanding Officer, NOMI.
Referral to a SBFS:
Requests for a SBFS may be made by the aviation Commanding Officer to the Commanding Officer NOMI,
preferably upon the recommendation of a LBFS. If approved by the Commanding Officer NOMI, a
recommendation will be made to BUPERS/CMC to order the member to NOMI for evaluation. The request
is sent via Immediate Superior in Command (ISIC) to NOMI Code 42 with:
 SF88
 SF93
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all appropriate consults and narrative summary.
NOMI Needs (for SBFS):
 The original package (reason for referral)
 Health record
 Natops Flight Training Jacket
 Aviation Qualification Jacket
The aircrewman reports to NOMI before 0800 on Monday, prior to the 1st or 3rd Friday of the month.
Reports of SBFS
Reports are made to BUPERS/CMC (through BUMED) by same day message.
Senior Board of Flight Surgeons
A Senior Board of Flight Surgeons at BUMED in Washington, D.C. is the final reviewing authority for all
aeromedical dispositions. This standing board consists of five members; the Assistant Chief for Fleet
Readiness and Support (Med-02), three senior flight surgeons and a senior line officer assigned by the
CNO. The board functions not only as the final authority for aeromedical disposition of cases, but also as
aeromedical policy advisor to the CNO and CMC. Final determinations of the board are submitted to CNO
or CMC within 5 working days after completion of the meeting.
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The Waiver Process
Point of Contact:
NOMI - Code 42
DSN: 922-4501 / 4502
Com: (850) 452-4501 / 4502
The waiver process is one which provides a mechanism for deviation from established standards as
published in the manual of the Medical Department when:
 The needs of the Navy require its consideration, and
 performance is not degraded due to the defect.
When considering your recommendation for an application for waiver, think about what the waiver is for,
and how any defect might affect his or her ability to perform the required tasks.
Physical defect - any condition, disorder or defect which may be of significance in determining a
person's ability to perform his or her duties. This includes all variations from "Normal", as
described in Chapter 15 of the Manual of the Medical Department. Each defect must be
commented upon on the SF88, physical exam form.
Disposition of Defects - The possible determinations to be listed in Block #74, Summary of Defects
and Diagnoses, are:
 Not considered disqualifying (NCD) - The defect will not affect performance and is within listed
standards. A waiver is not required.
 Considered disqualifying (CD) - Waiver recommended. - The defect is disqualifying by the
published standards, but is deemed not to interfere with the individual's performance.
 Considered disqualifying (CD) - Waiver not recommended. - The defect is disqualifying by the
published standards and is likely to adversely affect the safe performance of the individual's
duties.
Examples
1. NCD
Skin tags, Nevi etc.
Minimal scoliosis
2. CD, Waiver recommended
Defective visual acuity
Select maintenance medication
3. CD, Waiver not recommended
Diabetes Mellitus
Uncontrolled hypertension
Missing limbs or other important parts
Possible notations for block 77, SF88 include:
1st, the examinee is either:
 PQ and AA.
 NPQ but AA.
 NPQ and NAA.
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 PQ but NAA.
Temporarily Not Physically Qualified (TNPQ) is not an acceptable finding; the member should be
re-examined when the condition is resolved, and a determination of PQ/NPQ made.
2nd, (if applicable):
 Waiver may be recommended based on the needs of the Navy.
 Waiver not recommended.
e.g. Block #77:
-NPQ but AA, Waiver not recommended.
The flight surgeon should make his recommendation for waiver on the SF-88 ONLY, not by separate letter.
You may, however, submit an aeromedical summary or use a Local Board of Flight Surgeons to support
your recommendations.
Aviation Waivers
The Manual of the Medical Department urges the recommendation of waivers for those individuals who
have defects, but whose performance would be unaffected or minimally affected, and who could
reasonably be expected to complete a full service career without future performance degradation as a
result of that defect.
In Aviation:
Waivers are usually not granted to SNA's or SNFO's unless defects are minor and as of such nature as to
not jeopardize flight performance now or in the future.
Designated aircrew are frequently waived in order to preserve trained assests.
The waiver is recommended by the flight surgeon.
Requests for waiver are initiated by the member or the flight surgeon and submitted to
BUPERS/CMC/COMNAVCRUITCOM, via NOMI Code 42. The member's commanding officer is no longer
required to request the waiver.
BUPERS or CMC grants the waiver request, usually based on input from NOMI/BUMED.
No flight surgeon can grant waivers.
Practical Issues
Does the Aviator need a waiver?
 Anticipate problems before they develop.
 If it looks like a waiver will be required and you feel that you can recommend it, encourage action
by the member and his C.O.
 Keep the member and the C.O. informed of the status of the condition and the waiver process.
Do not delay in assembling a typed SF88 and 93, along with all consults and other data to support your
recommendation. Failure to do so may result in rejection of the package until additional information is
supplied, loss of flight currancy and flight pay by the aviator and loss of an aviator by the squadron as well
as a perception that the Flight Surgeon does not show any interest in his job.
 Remember, the member submits the waiver request, you only recommend.
 You may not grant a waiver. Neither can NOMI. Only BUPERS or CMC.
 There is no such thing as a "temporary waiver."
When doubt exists about the process or what current thinking is, the Physical Qualifications Department at
NOMI (Code 42) can provide help. They will consider all requests for waiver, but will only recommend one
if all medical questions have been answered completely and logically, and there is no reason to believe
that continued flight would be detrimental or dangerous to the individual or others.
The Final Package
1.
2.
3.
4.
The member's letter of request for waiver and C.O.’s endorsement.
Typed SF-88 and SF-93 with your recommendation for waiver.
Consults obtained (they must be legible).
All appropriate lab data.
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5. Aeromedical summary or LBFS proceedings if warranted to support your recommendation.
Routing is to CMC, BUPERS or COMNAVCRUITCOM via NOMI code 42.
All too often the waiver package may be lost if the medical and aviation commander's components are
mailed separately. It is probably a good idea to mail the entire package from medical to avoid this loss.
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Aviator Evaluation Boards
DEFINITIONS:
FNAEB - Field Naval Aviator Evaluation Board
FNFOEB - Field Naval Flight Officer Evaluation Board
FFPB - Field Flight Performance Board (for USMC Aviator and NFO's)
Purpose:
Flight performance boards are purely administrative in nature, and are designed to ensure that only those
officers who can safely and competently perform their aviation duties are so assigned. These boards are
not to be considered as either a forum for disciplinary or punitive action.
Aviation Designations:
The Chief, Bureau of Naval Personnel (BUPERS) confers aviation designations through the Chief of Naval
Education and Training (CNATRA) to Aviators and NFO's, and NOMI, for Flight Surgeons, SNAP's and
SNAEPS's. The right to wear the aviation designation insignia may be revoked by BUPERS, if such is
recommended by the Board. Aviation personnel assigned to flight billets are required to maintain all
physical exam, water survival, physiology training and minimum flight time requirements and in addition,
perform their aviation duties safely and competently.
Flight disqualifications, Medical:
2. NPQ because of illness or injury. May require temporary grounding, restriction to certain service
groups if an aviator and may necessitate waiver.
3. NAA in the Aeromedical sense, where the individual's ability to adjust to stressors in the aviation
environment has been unsuccessful or maladaptive.
These are strictly medical considerations for termination of flight status and are not grounds for
appearance before an evaluation board. In fact, the member must be found PQ and AA to appear before a
board to ensure that the question of his performance is not due to a medical condition. (This does not
preclude appearance while NPQ recovering from an illness or injury unrelated to performance questions).
Drug Abuse
Flight status and the right to wear the insignia are permanently revoked and the member processed in
accordance with SECNAVINST 1920.6.
Voluntary termination of Flight Status:
Any designated aviation personnel who voluntarily request termination from flight status must be:
 Immediately grounded
 Counselled that this will be considered permanent.
 Evaluated by a Flight Surgeon.
A formal request to terminate must be submitted in five days to the Commanding Officer, along with the
Flight Surgeon Evaluation. This is then submitted to BUPERS, and the individual reassigned. No board is
required, and the right to wear the insignia is not in question.
Evaluation Boards:
After ruling out all the above issues that may remove an individual from flight status, one other remains,
the Evaluation Board.
This board is convened to evaluate the performance, motivation and behavior of an individual to determine
whether he can safely and competently continue in a flight status.
Convening Authority - immediate superior in command
Reasons to convene:
 faulty judgement
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violation of flight discipline
mishaps
minor incidents
failure to maintain currency requirements
lack of motivation
poor character traits
Board membership:
FNAEB & FFPB's
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Three Pilots - Senior member is senior to the aviator
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One flight surgeon.
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Three NFO's (or one NFO, two NA's)
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One flight surgeon
FNFOEB's
Proceedings:
Examinee is told of the reasons for the board.
Examinee is allowed to be present at all open sessions of the board, and present information, witnesses
and rebuttal.
Board members may not act as witnesses.
Medical evaluations of the examinee must be provided by a different flight surgeon from the one on the
board, unless there are no other Flight Surgeons in the area. In that case, the Flight Surgeon board
member may do both duties as long as the examinee waives this right in writing.
All of these principles are for the purpose of providing customary standards of fairness in administrative
proceedings.
Findings of the Board:
Type A. Continuation of Flight Status
1. At present duty assignment.
2. Transfer to another activity within the same administrative command.
3. Transfer to another activity.
4. Probationary status for a definite period with consequences for failure to meet the requirements of
probation.
Type B. Termination of Flight Status with:
1. Right to wear the insignia
2. Revocation of the right to wear the insignia. This is considered appropriate board action as a
result of acts which dishonor naval aviation or there has been willful and flagrant violation of
established rules, regulations and directives.
If evidence of illegal activities are uncovered during the proceedings, these issues may be referred to
other bodies for additional action.
The Flight Surgeon member of the board will be expected to attend all meetings of the board, provide
interpretation of all aeromedical aspects of the case, participate in all deliberations of the board and
provide any other assistance as required.
Reporting:
A formal report of the Boards findings is due to the first endorser in the chain of command within 20 days
of issuance of the convening order. There is little time to waste preparing the medical evaluation.
A number of documents are required in preparation of the report as outlined in PERSMAN and the ACTS
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Manuals, but the Flight Surgeon member shall see to presenting to the board the typed findings of the
examining Flight Surgeon, with any SF88's, SF93, consultations etc. Additionally, the Flight Surgeon
member's findings and opinions should include:
 age, family constellation and marital status,
 aviation background, study habits,
 past illnesses, social problems, failures, medications,
 life style, alcohol or drug use,
 major life changes (stressors), especially in the last year,
 coping mechanisms and effectiveness under stress,
 attitudes and motivation,
 continuity of training (delays, groundings, etc.),
 peer relationships,
 interests, hobbies,
 medical qualifications as per MANMED,
 your overall impression of the aviator as a person.
If the opinion of the board is not unanimous, a dissenting opinion may be submitted. There certainly have
been recommendations made which were less than completely fair due to domination of the proceedings
by the senior member, or the prevailing attitudes of the command at the time of the board. If you strongly
disagree with the results of the board, by all means write a dissenting opinion. Please recognize that this
does not give license to impune the integrity of the board, the command, the Navy or anything else. It is
your opportunity to bring to bear your special understanding of human behaviors and logic applied to the
aviation environment.
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Competence for Duty Examinations
Medical personnel are required to cooperate with (Military) law enforcement authorities as directed by
proper (Command) authority. They may be required to provide the results of an evaluation to the
Command without the consent of the patient.
For most competence for duty examinations, (properly documented) clinical observation is sufficient.
Drawing samples of body fluids for such purposes is discouraged. Samples drawn for medical purposes
may be used as evidence.
A service member may be ordered to provide body fluids for legal purposes, if a valid search warrant, or
Command authorization has been issued. It is the responsibility of the Command, not the Medical Officer,
to ensure the validity of the authorization. Refusal by the member to comply constitutes disobedience of a
lawful order. Use of force to obtain such samples may be determined unreasonable by a court martial, and
may expose the person giving the order, and the Medical Officer who carries it out, to criminal charges.
Observations should be documented on NAVMED 6120/1, Competence for Duty Examination form.
Pre-confinement Medical Examinations
References:
 SECNAVINST 1640.9B (Art. 7205)
 BUMEDINST 6320.11
Persons to be confined must be examined by qualified medical personnel prior to being accepted for
confinement. When the initial exam is performed by a Corpsman, the prisoner must be examined by a
physician or physician's assistant within 24 hours or on the next working day.
The examining official shall certify the prisoner "fit for confinement" on the confinement order (NAVPERS
1640/4).
The member is unfit for confinement if he has:
"... a serious physical injury or problem which requires immediate treatment, psychiatric disorders
which make the individual a threat to himself/herself or others, requires drugs or other intervention
to control his/her behavior, or is suspected to have suicidal ideation or behavior as specified in
BUMEDINST 6520.1. If persons ordered into confinement display irrational or inappropriate
behavior which is symptomatic of mental disturbance or of the effects of hallucinatory substances,
they shall be admitted to a hospital and be certified as ‘unfit for confinement’ until such time as
they are capable of participating in their legal defense..."
Document the exam on SF 600:
 Note any cuts, bruises, scars, unusual marks, or other physical injuries; any unusual behavior
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traits, gestures, or actions; and any physical limitations that would restrict participation in the
rigorous brig program.
Be meticulous; you may have to testify about your findings later.
Females require documentation of pregnancy test results on the confinement order.
Rule 315. Probable Cause Searches
(Excerpts from the Military Rules of Evidence Manual)
(a) General rule. Evidence obtained from searches requiring probable cause conducted in accordance
with this rule is admissible at trial when relevant and not otherwise inadmissible under these rules.
(b) Definitions. As used in these rules:
(1) Authorization to search. An "authorization to search" is an express permission, written or
oral, issued by competent military authority to search a person or an area for specified property or
evidence or for a specific person and to seize such property, evidence, or person. It may contain
an order directing subordinate personnel to conduct a search in a specified manner.
(2) Search Warrant. A "search warrant" is an express permission to search and seize issued by
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competent civilian authority.
(c) Power to authorize. Authorization to search pursuant to this rule may be granted by an impartial
individual in the following categories:
(1) Commander. A commander or other person serving in a position designated by the Secretary
concerned as either a position analogous to an officer in charge or a position of command, who
has control over the place where the property or person to be searched is situated or found, or, if
that place is not under military law or the law of war;
(2) Military judge. A military judge or magistrate if authorized under regulations prescribed by the
Secretary of Defense or the Secretary concerned.
(d) Exigencies. A search warrant or search authorization is not required under this rule for search based
upon probable cause when:
(1) Insufficient time. There is a reasonable belief that the delay necessary to obtain a search
warrant or search authorization would result in the removal, destruction, or concealment of the
property or evidence sought;
(2) Lack of communications. There is a reasonable military operational necessity that is
reasonably believed to prohibit or prevent communication with a person empowered to grant a
search warrant or authorization and there is a reasonable belief that the delay necessary to obtain
a search warrant or search authorization would result in the removal, destruction, or concealment
of the property or evidence sought.
Delegation of Authority
In 1984, subdivision (d)(2) in the original Rule, the provision permitting delegation of a commander's
search powers, was deleted in light of United States v. Kalscheuer, 11 M.J. 373 (C.M.A. 1981) (annotated
infra). The remaining provisions were then renumbered. The court impliedly invalidated 315(d)(2) when it
ruled that delegations to persons other than magistrates or judges do not meet Fourth Amendment
standards. Although there are now no provisions in the Rules of Evidence for delegating search authority,
the court's "admittedly imperfect" solution in Kalscheuer should normally suffice where the commander is
absent: the authority to search devolves to the subordinate who exercises command in the commander's
absence. Commanders may still delegate their authority to a military judge or magistrate.
The CDO is authorized to order a competency for duty exam including a urine for drug screen. He can no
longer authorize blood drawing or searches. E-4 shore patrol may not authorize searches.
15
Aircraft Mishap Planning
The Changing Role of the Armed Forces Institute of Pathology
Due to budget and manpower constraints, the Armed Forces Institute of Pathology (AFIP) will no longer be
able to dispatch a team of investigators to every fatal mishap. AFIP will continue to provide consultation
and laboratory support to medical investigators. They will also review Flight Surgeons' Reports (FSR),
Mishap Investigation Reports (MIR), and autopsy protocols. However, the collection and preservation of
medical evidence will fall to the on-scene investigators.
Historically, few Flight Surgeons investigate more than one fatal mishap in their careers. The vast majority
leave Flight Surgery at the end of their first tour for clinical specialties. These factors impair the
development of a "corporate memory" in the community. Aerospace Physiologists (AP), especially the
Aerospace Medical Safety Officers (AMSO) remain in the field for several tours and are likely to
investigate many mishaps. Their assistance and experience can be extremely helpful to the junior FS as
he approaches his first smoking hole.
The Flight Surgeon's Role in Aircraft Mishap Investigation
Although this section will focus on the responsibilities of the Flight Surgeon in mishap investigations, and
the resources available to assist him in meeting these responsibilities, several pre-mishap planning issues
will be addressed. Each Service has its own guidance regarding investigation of aircraft mishaps. These
are:
 OPNAVINST 3750.6Q The Naval Aviation Safety Program
 DA Pam 385-95 Aircraft Accident Investigation and Reporting
 AFP 127-1V1 US Air Force Guide to Mishap Investigations
 AFI 91-204 Safety Investigations and Reports
Familiarity with the entire Navy instruction is extremely important. It is especially important to have those
sections addressing your responsibilities readily available and to review them regularly; especially when
changes are issued. The senior flight surgeon at each facility should ensure that all new personnel are
oriented to their responsibilities, and that any local procedures are clarified.
Additionally, each facility is well advised to have a copy of the other Services procedures handy; you never
know when a stranger may "drop in" on you. As a Naval Flight Surgeon, the author was extremely
impressed and grateful when upon arrival to an AFB to investigate a USMC mishap, all required medical
evaluations, interviews, and biological sample required by the Navy instruction were presented in one neat
packet. The USAF Senior Flight Surgeon had provided his subordinate with excerpts from the Navy
instruction, outlining these requirements (which were subtly different from USAF procedures). Could your
facility do as well?
Reprinted from:
"The Role of the Flight Surgeon in Aircraft Mishap Investigation"; WRC Stewart; Navy Physiology
Supplement; 2nd - 3rd Qtr, 1988, Naval Air Systems Command, Washington, DC; presented to
1988 FAILSAFE Meeting, Yuma AZ.
Flight Surgeon participation in pre-mishap planning
Upon arriving at a new duty station, the FS should meet the persons with whom he will be working. The
"old hands" should aid him in this endeavor whenever possible. He should study the local mishap plans
with special attention to Medical Department responsibilities and participate in local mishap planning
meetings. This is where many "what if's" should be addressed.
SAR response and FS responsibilities must be clear to all involved. The FS must be familiar with the
emergency equipment he will have available, and the qualifications of support personnel to assist him.
Agreements with MTF's for care of casualties, and collection of biological samples must be addressed.
Very specific, brief instructions should be provided to those facilities, especially ER's and labs, where the
person on duty at the time of the mishap may be unfamiliar with the requirements. These must be readily
16
available to the duty personnel; a special folder for the duty desk with a covering checklist may be helpful.
Appendix 2 is an example of such an instruction for USN mishaps. These "go-by" notes must be reviewed
and updated, especially when Service instructions are modified.
Especially important is settling who has jurisdiction over remains of anyone killed in a mishap in your
operating area. Letters of agreement should be executed if possible so that all parties concerned know
what is expected of them. Many Medical Examiners will welcome assistance from the Aerospace
Pathologists from the Armed Forces Institute of Pathology (AFIP). Some may be happy to relinquish
jurisdiction outright, while others will permit varying degrees of participation by AFIP or other military
pathologists. The Medical Examiner may wish to retain certain "sensitive" cases. However, liaison and
establishment of rapport before a mishap is more likely to produce co-operation than unprofessional
haggling over the remains at the mishap site. The local Judge Advocate General Officer can assist you in
researching this issue and drafting any agreement. Most states take a dim view of "body snatching", so
prior resolution of this issue is very important.
Identification of fatalities and notification of next of kin will require the efforts of many persons. Avoidance
of errors is critical for obvious reasons, but so is prompt resolution of the question. Dentists and law
enforcement agencies such as Naval Investigative Service or the Provost Martial Office may have useful
expertise in identification. The Decedent Affairs Officer can assist with notification of next of kin. Clear
delineation of the responsibilities and authority of those involved can prevent confusion during such an
event.
Since you will want to make photographs of the mishap site, liaison with the base photo activity is
recommended. These professionals can probably provide better quality photos than you can take on your
own. However, they will need to be shown what you want photographed, and what the picture is supposed
to demonstrate. Also, remember that the photographer will likely be unaccustomed to the proximity of
dead bodies, so be sensitive to his reaction.
Pictures should also be taken during the autopsy. If no medical photographer is available, ask the
photographer to shoot color strips for each roll, and bracket the exposure for each shot. Begin with the
remains before removing the flight gear, then the exposed body. Ask the pathologist conducting the
autopsy to point out all significant findings, and make pictures whenever possible. If no photographer is
available, shoot your own. Use prudence, but don't be stingy with the film - it's the cheapest part of the
investigation! Take any shots you might reasonably need and extras of critical items. Contact sheets of
each roll can be made quickly and can help you decide which shots you want printed.
Aerial views of the mishap site can usually be obtained from a helo. An extra circle of the site on the way
in or out will allow the photographer to get the shots you need. Additional aerial photos with infra-red film
thru a #12 yellow filter can often provide information not visible on standard photos. The photo facility can
obtain and store this film for you until needed. AFIP can assist with interpretation of the infra-red photos.
Post-mishap considerations:
Care of casualties takes priority over collection of evidence. However, proper prior planning can maximize
efficiency of both. Although the injured require prompt evacuation for treatment, obvious fatalities (eg,
decapitated, incinerated, etc.) need not be removed from the wreckage immediately, unless additional fire,
explosions or other damage is likely.
Accident reconstruction will be easier if the position of the fatally injured is documented. Pictures can be
valuable, but notes can be of great help in interpreting them, especially if the quality is less than ideal.
Engineers can help survey the crash site and make accurate drawings of the location of wreckage and
bodies.
Flight gear should be left on the bodies until the postmortem. This permits corelation of injuries, damage to
flight gear, and trace evidence from the aircraft to reconstruct the crash. Explosive devices (flares, ejection
seats, etc.) should be "safed" before removing the fatalities. If there will be a delay before autopsy, the
remains should be refrigerated, not frozen.
AFIP assistance must be requested; it is not automatic for all fatal mishaps. Check OPNAVINST 3750.6 to
determine how to get them launched to you. Remember they will be limited to working with the physical
evidence that you collect and protect. Avoid disturbing such evidence to the greatest degree possible.
Inform the CO of the severity of the injuries ASAP. As soon as fatalities are identified, execute previously
agreed upon responsibilities to allow notification of next of kin. Allow survivors to speak with family as
soon as practical, but caution them to avoid discussing injuries of other crewmembers or starting rumors.
Histories of the events preceeding a mishap are routinely collected by the FS examining survivors.
17
Statements should be obtained from aircrew, support personnel, and witnesses as soon as possible. Tape
recording is preferred, but a written outline should be made if a recorder is not available. In the case of
fatalities, family, friends, and co-workers are interviewed. The art of such interviews is beyond the scope of
this paper. However, a FS who gains the respect of the interviewees prior to the mishap is more likely to
receive co-operation from surviving aircrew, squadron mates, or next of kin.
Although most Flight Surgeons receive little to no formal training in ergonomics, dynamic cockpit workload
evaluation, or system safety engineering, they are expected to be the human factors expert for the AMB.
Even the "medical" factors in a mishap may require specialist knowledge of such esoterica as the effect of
presbyopia on accomodation time of the night myope in low illumination conditions. Each Service has its
own experts in aviation life support systems (ALSS), who can compliment the FS medical knowledge. In
the Navy, Aerospace Physiologist AMSO's are far more experienced in this area than most FS. Their
assistance can enhance the quality of the investigation and report. USAF Safety and Inspection Center
and the Army Safety Center also have ALSS experts. Additionally, these experts know experts in related
fields such as ejection seats, parachutes, etc. If you have a question whether any such factors might have
contributed to the accident or injuries, timely contact may be able to resolve the issue. The FS should
ensure that design flaws that aggravate injury or impede safe egress are appropriately addressed.
Perhaps the most under utilized resources are the Aerospace Medical Specialist Senior FS who can assist
the new guy by helping him organize the available information, focus his investigation, and request other
"specialists" to assist as necessary. Collecting and analyzing all this data, and evaluating the effect on the
Aviator's cockpit performance at the time of the mishap is a bit much to expect of a first tour Flight
Surgeon who may also be grieving the loss of a friend and squadron mate. Several recent MIR's reflect
the inexperience of the AMB Flight Surgeon. Providing him with a more experienced colleague, who has
participated in several investigations can produce a better investigation and report.
Two questions frequently asked about a fatal mishap are, "what killed him ?" and "was it potentially
survivable ?" Mishap survivability is a complex subject, but can be approached systematically. Survival
depends on several factors for which the acronym "CREEP" has been coined:
Crash forces
There are several technics for the determination of crash forces. Some involve mathmatical modeling,
other are based on autopsy findings. AFIP and the Safety Center can assist in determining whether the
crash forces were in the potentially survivable range. Many Aerospace Medicine Specialists, and AMSO's
attend a 2 week course in this subject as part of their training. If this is a pertinent part of any mishap
investigation, especially those near the edge of the survivability envelope, don't hesitate to ask for
assistance.
 Container; refers to the integrity of the airframe during and after a crash.
 Restraint systems; failure in an otherwise survivable mishap is certainly worth reporting.
 Environment; includes occupiable space, intrusion of objects into this space, in-flight fire, fumes,
etc.
 Energy absorbtion; stroking seats, deformation of the aircraft, etc. which decreases the creash
forces applied to the occupant.
 Post-crash factors; fire, blocked exits, or drowning which may kill persons surviving the crash
itself.
Depending on the condition of the remains, autopsy may be able to determine the cause of death, and
relate the findings to the evidence in the wreckage. If there is any question whether an autopsy might be
illuminating, telephone (or message) consultation with AFIP should be accomplished. Although the
pathologist can rarely work miracles with 8 ounces of incinerated tissue, in appropriate circumstances, an
autopsy can be most helpful in reconstructing what happened. The investigating FS should attend the
postmortem if possible. If the autopsy is not performed by AFIP, the FS should ensure that the following
specimens are obtained at autopsy whenever possible:
 Whole body X-rays
 Blood (note source)
- 2 large red top tubes
- 2 large purple top tubes
 Urine 50 ml.
18



Vitreous
CSF
Other tissues (liver, lung, brain, etc) as available.
The pathologist may brief Board members, if they are available, and will submit a report, but participation
by the FS will allow him to answer other question raised by Board members later. AFIP conducts an
Aerospace Pathology course annually.
In addition to the exceptional in-house laboratory services, AFIP can tap the resources of several other
agencies. When appropriate, the FBI or the Bureau of Alcohol, Tobacco, and Firearms can assist with
identification, or when hijacking, sabotage, or other explosion is a possibility. NTSB has computer
capability to reconstruct a 3-D projection of the flight path from radar tapes. The more tracking stations
providing data, the better the output. They can also provide assistance in evaluating crash forces as
described above. Some of the Service research labs can provide assistance in answering specific
questions. Simulators may offer insights into what the pilot was experiencing prior to the crash and direct
the investigation along fruitful lines (e.g. disorientation, GLOC). Re-flying the mission profile (with
appropriate safety checks) may be similarly helpful. In summary, when considering the mishap scenario,
think of evidence which would support or reject a hypothesis; try to imagine or ask experienced
investgators how such evidence might be obtained; and consult with the Board to determine whether that
line of investigation is likely to be fruitful. If the answer is "yes", ask for assistance.
Pre-mishap Planning Checklist




OPNAVINST 3750.6Q The Naval Aviation Safety Program reviewed
NAVSAFECEN Flight Surgeon's Pocket Checklist (FS-PCL) reviewed
Local mishap plan reviewed
Local civilian Medical Examiner/Coroner contacted:
 Jurisdiction addressed, and MOU reviewed by JAG

Instructions for other Services available and reviewed
 DA Pam 385-95 Aircraft Accident Investigation and Reporting
 AFP 127-1V1 US Air Force Guide to Mishap Investigations
 AFI 91-204 Safety Investigations and Reports

Liaison with key personnel:
 Station CO, XO, OpsO, SafetyO
 Wing CO, XO, OpsO, SafetyO
 Squadron CO, XO, OpsO, SafetyO
 Aerospace Medical Safety Officer (AMSO)
 Public Affairs Officer (PAO)
 SAR personnel
 Crash & Salvage/Fire Department
 Explosive Ordinance Disposal (EOD)
 Aircrew equipment specialists
 Medical Treatment Facility CO/OIC
19
 Medical colleagues (Medical staff meeting)
 Medical support personnel
 Photographer - Infrared film & #12 yellow filter for aerial photos.
 Local civil engineers (site survey capabilities)

Brief instructions provided to supporting facilities:
 ER
 Drawing of samples
 Handling of flight gear
 Lab
 Drawing & handling of samples
 Morgue
 AFIP autopsy protocol
 Total body X-rays
 Handling of samples for toxicology
 Photo
 Infrared and color film for on-site photos
 Photos of autopsy
 Special handling required by OPNAVINST 3750.6Q
 Others as required

SAR equipment inventoried & inspected
 Personnel trained in use

Flight Surgeon's Pocket Checklist in mishap investigation kit

Mishap investigation equipment inventoried regularly;(See FS-PCL for recommended
contents.)

Identification of fatalities; support personnel identified
 Dental
 MP's
 Others
20

Notification of next of kin; policy reviewed and roles identified
 Decedent Affairs Officer
 Casualty Assistance Care Officer (CACO)
 CO appointed Command representative
 Chaplain

List of Key phone numbers and points of contact
 Safety Center (Duty Officer) DSN 564-3520 COM (757) 444-3520
 AFIP (Medical Examiner) DSN 662-2626 COM (301) 319-0000
 Local Medical Examiner/Coroner
 Wing
 TYCOM
MEDICAL AND LABORATORY PROCEDURES REQUIRED POST-MISHAP
1. Physical Examinations.
While the responsibility for performing the required physical examination lies with the first "Flight Surgeon"
to examine the survivors and victims, an initial examination should be conducted by the first member of
the medical department to contact the survivors/victims according to the following order of preference:
a. U.S. Naval Flight Surgeon
b. Other service flight surgeon
c. Physician
d. Senior Independent Duty Hospital Corpsman
e. Other Hospital Corpsman
 NOTE: These examinations shall be performed on all flight crewmembers, and on passengers and
flight support personnel (e.g. controllers, LSO, line handlers) as appropriate.
2. Radiographs (X-Rays).
Radiographs (x-rays) shall be performed as clinically indicated. After all ejections, bailouts, and crashes
with or without suspected back injuries, full spinal x-rays are required.
3. Biological Samples.
While biological/laboratory samples are required only for Class A and B mishaps, and those Class C
mishaps which are investigated by a Flight Surgeon, the exact class of the mishap is frequently not known
until it is too late to obtain meaningful laboratory samples. For this reason, the following rule of thumb
should be used: obtain laboratory samples any time there is damage of any extent to an aircraft or other
government property, or any time someone is injured in association with flight operations. Samples which
are later determined to be superfluous may be discarded.
 WARNING: Clean venopuncture site with Betadine solution, NOT ALCOHOL SWAB which can
give false positive for blood alcohol!
a. SAMPLES
Sufficient blood and urine shall be drawn from each member of the flight crew and from support
personnel such as handlers, controllers, or LSO's, who may have been involved in the mishap, for
the determination of:
1. Blood alcohol - 2 gray topped tubes (fluoride)
21
2. Lactic aid - 2 gray topped tubes (fluoride)
3. CBC & differential - 2 lavender topped tubes
(Make 4-5 smears on glass slides with Wright's stain ASAP)
4. Carbon monoxide - lavender topped tubes
5. Glucose - 1 red topped tube
6. Drug levels - 2 red topped tubes
7. Misc. (extra) - 2 red topped and 2 green topped tubes (heparin)
b. HANDLING PROCEDURES:
1. Blood alcohol - refrigerate only - DO NOT CENTRIFUGE
2. Lactic acid - centrifuge ASAP - remove and freeze plasma ASAP
3. CBC - refrigerate only - DO NOT CENTRIFUGE OR FREEZE
4. Carbon monoxide - refrigerate only - DO NOT CENTRIFUGE
5. Glucose - centrifuge ASAP - remove and freeze plasma ASAP
6. Drug levels - centrifuge, remove and freeze plasma
7. Misc. - refrigerate only
The above samples should be labeled with NAME, SSN, DATE, AND TIME COLLECTED and turned over to
the flight surgeon for submission to appropriate laboratories. A legal chain of custody is not required, but
samples should be secure from damage or tampering.
4. Other:
a. Identify and preserve all flight gear, helmets, LPA, etc.
b. Have all aircrew begin writing a detailed 72 hour history as soon as practicable; include meals,
rest, activities, etc
c. Recovered bodies or body parts should be placed in body bags and refrigerated; DO NOT
REMOVE FLIGHT GEAR OR CLOTHING.
d. Aircrew should not return to flight duty until examined and cleared by a Naval Flight Surgeon.
They may be transported by air (as pax or patients) if necessary.
22
Laser Exposure
Points of Contact
 Unit Intelligence Officer/Safety Officer
 Armed Forces Medical Intelligence Center
 NOMI Ophthalmology, DSN: 922-3938 / 4558
Definition:
LASER - Light Amplification by Stimulated Emission of Radiation
General:
Lasers are of military usefulness by all nations for range finding, target designation and tracking. They
may also be used as weapons for harassment and physical injury of opposing forces. They may be
disruptive of operations by:
 Obscuring dim lights, such as Heads Up Displays
 Causing glare and interference with dark adaptation and target acquisition
 Causing damage to canopies, cameras and weapons
 Causing temporary or permanent eye damage
Laser Physics:
If energy is applied to a substance causing electrons to jump from the basal to the excited state, the same
amount of energy is released as electrons return to the basal state. If that energy is released as light, the
light will be of the wavelength (color) characteristic for that substance and the energy required to excite it.
Thus, only a single wavelength is produced when an electron in a given molecule returns to its basal state.
If that light is collimated by mirrors into a unidirectional beam, it will tend to retain its energy until
dissipated by distance through the atmosphere, each wavelength absorbed by the atmosphere at different
rates. So, some wavelengths will retain their energy and focus over greater distances than others. How
intense the laser beam is depends upon the energy applied to excite the electrons (and therefore that
released) and the excitability of the substance used. Therefore, a ruby laser is not necessarily stronger or
more energetic than a neodymium laser, but the wavelengths produced have quite different properties.
Each LASER will function at a discrete frequency (depending on the substance used), some of which are
in the visible range, some not. Some LASER substances have more than one energy level capability on
excitation, and therefore may radiate at more than one discrete frequency if different energy levels are
applied.
Optical Media:
Atmospheric conditions will have an effect on LASER beams by diffusion or absorption by water vapor,
smoke, etc., again depending on wavelength. Generally all LASER beams widen at least a small amount
with distance. Unfortunately, the human eye has the capability of concentrating the LASER beam by a
factor of about 100,000 times and focusing it on the retina. The temperature at the point of focus at the
retina may be in the neighborhood of 1000 degrees, causing coagulation and destruction of that small
area or, if a blood vessel is involved, a rupture of that vessel and hemorrhage into the vitreous with
subsequent loss of vision. Or, since there are no pain fibers in the retina, damage may go undetected until
it is discovered that there is a loss of some portion of the visual field. It is also worth noting that LASER
beams may be reflected off mirror-like surfaces and picked up by the eye, losing some energy in
transmission, but still dangerous. Skin burns are quite unlikely given the powers used and distances on
the battlefield, and since skin does not concentrate the beam as the eye does.
The cornea will not allow all wavelengths to pass through, but acts somewhat like a filter. Wavelengths
above 1300 nm (far infrared) are absorbed by the cornea and lens and may produce damage to these
structures while the retina is undamaged. Thus, visible and near infrared LASERs may cause damage to
the retina while far infrared LASERs cause damage to the cornea and lens structures ultimately leading to
corneal scarring and cataract formation.
23
......Retinal Damage.................|...Corneal Damage......
|
UV Visible Light Infrared | Far Infrared
|
100nm.....400nm...........700nm......|..........110,000nm
|
|
||||||
Ar H-N R G N CO2
(Argon He-Neon Ruby Gallium Neodymium CO2)
LASER Eye Protection
Just as with any other optical media, filters may be employed to absorb LASER light before it reaches the
eye to cause damage. Unfortunately, if one were to filter out all the LASER wavelengths available, the
result would be a filter which no one would be able to see through. The compromise is to filter out those
frequencies most likely to be used in LASER operations, leaving as much usable visible spectrum as
possible. Two examples of LASER protective goggles are shown with their absorption spectra.
UV Visible Light Infrared | Far Infrared
|
100nm.......400nm............700nm......…....|.....110,000nm
_________________________________|______________
|||||||
Ar H-N R G N | CO2
|
EEK-3/P.......................xxxxx.........|..................
|
LG-Bxxxxx.....................xxxxxxxxxx....|......xxxxxxxx....
........Retinal Damage...............................Corneal...
Note that while the EEK-3/P would only block the Neodymium wavelength, but the aircraft canopy would
block the far infrared and provide some additional protection. The LG-B goggle provides protection against
several wavelengths, but would also block out considerable amounts of visible violet and blue-green
wavelengths, degrading normal vision and particularly night vision. Unfortunately, there are literally
hundreds of different LASERs with different wavelengths available.
The Practicalities of LASER Protection
When operating in the neighborhood (5 mi) of U.S. deployed neodymium LASERs, eye protection at the
1040 nm wavelength is needed to prevent eye damage from this invisible wavelength device. This does
not help much when confronted by opposing forces who may use different wavelength devices or multiple
devices. The fact is that there is no good way to predict what might be used. We do know that there have
been a number of incidents reported in which the Soviets have practiced their target designation on our
aircraft and ships.
At this time the recommendations are to use protection against neodymium when that is the one most
likely to be used, and LG-Bs when unknown frequency LASERs are the potential threat. At night, there is
24
greater threat of eye damage due to enlarged pupillary opening, and so LASER protection is
recommended when operating within 10 miles of suspected systems.
It is also recommended that people not fixate on a target with LASER use potential, but rather to one side
of it. The rational for that is to minimize the possibility of central retinal burn and complete visual loss.
Obviously, when LASERs are being used around friendly forces, they cannot be trained on ships, aircraft
or uncleared ground.
It is very important that LASER exposure incidents be evaluated and reported in order to gather as much
data as possible in an attempt to determine wavelengths being used, allowing use of appropriate
protection.
Laser Incidents
The flight surgeon should be alert to the possibility of laser incidents which may be encountered. A high
index of suspicion is necessary because laser damage may be produced without any particular immediate
awareness of the event by the patient. Any such events need to be evaluated and reported.
QUESTIONS FOLLOWING POTENTIAL EXPOSURE TO LASERS
6. What did the patient describe as the initial event which caused him/her to seek care. How long
ago did incident occur?
7. Was the patient wearing any type of goggles, sunglasses or other eye protection during this
incident? Identify if possible.
8. Was there a flash of light? Have the patient describe the light to the best of his/her ability...color,
intensity, continuous or pulsed source, number of pulses observed (if any)? etc.
9. Was the patient's vision disrupted or disturbed during or after the sighting? Any flashblindness or
afterimage? Have patient describe to the best of his ability. If there was an after image what color
was it or the surrounding background when the patient tried to see through it? Was the color of the
image the same if the patient closed his eyes? (Positive vs. Negative after image)
10. Is there any lingering visual problem?
a. visual acuity
b. visual field defects - define limits
c.
color defects
d. photophobia/photopsia
6. Gross physiological defects? Describe and diagram to the best of your ability.
7. Slit lamp defects? Describe and diagram to the best of your ability.
a. fluorescein - corneal lesions or anterior chamber abnormalities.
8. Ophthalmoscopic defects? Describe and diagram to the best of your ability.
a. vitreous
b. retina
c.
hemorrhage/hole/windows
d. edema
PLEASE QUALIFY AND QUANTIFY THE ABOVE TO THE BEST OF YOUR ABILITY.
DESCRIBE ANY OTHER OBSERVATIONS YOU FEEL MAY BE PERTINENT TO THE LIGHT
INCIDENT BASED ON YOUR EXAMINATION, TESTING, TREATMENT, AND INTERACTION
WITH THE PATIENT.
9. What is the estimated distance from the source taking into account slant angle and altitude?
10. . Was the light directed at the patient? Did it follow the platform or did the patient move through
the beam of light?
11. Is the patient aware of any others exposed to the light? Have they been examined by the flight
25
surgeon?
12. Were any evasive maneuvers attempted by the individual? Describe please.
NOTIFY YOUR INTELLIGENCE OFFICER OF YOUR FINDINGS.
FORWARD MEDICAL INFORMATION TO DIRAFMIC FT. DETRICK MD//AFMIC-SA
26
TOXICOLOGY
Points of Contact:
Industrial Hygiene (IH) consultation can be obtained from:
 Naval Hospitals - contact the one supporting your command
 USMC Fleet Service Support Groups (FSSG) have IH's assigned
If these sources are unavailable, or unable to meet your needs, contact the nearest Navy Environmental
Preventive Medicine Unit (EPMU).
 EPMU - 2, Naval Station, Norfolk, VA. 23511-6288
Com: (757) 444-7671 DSN: 564-7671
 EPMU - 5, Naval Station, Box 143 San Diego, CA 92136-5143
Com: (619) 556-7070 DSN: 526-7070
 EPMU - 6, Box 112 Pearl Harbor, HI 96860-5040
Com: (808) 471-9505 DSN: 471-9505*
 EPMU - 7, PSC 824 Box 2760 FPOAE 09623-2760 (Sigonella, Italy)
Com: 39-95-56-4099 DSN: 624-4099*
* Call your local DSN operator to see if applicable geographical area voice codes are required.
Message address: NAVENPRVNTMEDU - TWO, NORFOLK, VA (etc)
Toxicologic Evaluation
Toxicity usually depends upon the dose and the duration of exposure. Simultaneous and consecutive
exposure to more than one chemical may result in additive, synergistic, or potentiated effects. Likewise,
chemical antagonism, functional antagonism, competitive antagonism, and noncompetitive antagonism
may be factors to consider.
Toxicologic evaluation involves several concepts which must be defined. Risk denotes the probability
(expected frequency) that a chemical will produce undesirable effects under specified conditions. NEL (no
effect level) is the maximum dose that has not induced any sign of toxicity in the most susceptible species
of animals tested and using the most sensitive indicator of toxicity (not applied to carcinogens). There is
no threshold defined for carcinogens because cancer cells can be induced by a single change in the
cellular genetic material and they are self-replicating. The dose-response relationship is graphically
displayed by plotting the frequency of an event vs. the dose on a log scale, which results in a
sigmoid-shaped curve. The portion of this curve between 16-84% response is nearly linear and represents
one standard deviation each direction from the mean.
The LD50 is also utilized to classify the toxicity of substances, as demonstrated in the following:
Category LD50
Supertoxic ..........................................…..5mg/kg
Extremely toxic.........................................5-50 mg/kg
Highly toxic........................................…...50-500 mg/kg
Moderately toxic.......................................0.5-5 g/kg
Slightly toxic........................................…….5-15 g/kg
Practically non-toxic...............................……..15 g/kg
Duration and frequency of exposure are also important parameters:
 acute exposure - an exposure of 24 hours or less.
 subacute exposure - repeated exposure over one month.
 subchronic exposure - exposure occurring over 1-3 months.
 chronic exposure - over 3 months.
Toxic substances may be excreted as the parent chemicals, as metabolites, or as conjugates. Generally,
when xenobiotic metabolism (biologically active but nutritionally valueless) results in more polar chemicals,
27
they are more readily excreted by the kidneys. However, in some cases, the metabolite is more toxic
(termed bioactivation).
Conjugation reactions are of several types, including glucuronide formation, sulfate conjugation,
methylation, acetylation, amino acid conjugation, and glutathione conjugation. Glucuronide formation is
the most common and important.
Adipose tissue presents a storage depot for lipid-soluble substances.
Major Routes of Exposure
Inhalation -- the most important in industry.
Ingestion -- most important in civilian exposure, least important in industry.
Percutaneous -- rare and seldom serious.
Types of Hazardous Substance Exposure Controls
1. Substitution. This implies using a less hazardous material, however, the substituted material seldom
works either as well or as cheaply. Substitution is the best type of control.
2. Engineering controls. This involves placing a permanent barrier between man and the hazard. It can be
simple or it can be very expensive. Engineering controls are the next best type of control.
3. Personal protective devices. These are self-donned temporary barriers. They often work well, however,
a sizeable number of workers simply cannot be relied upon to use the devices.
4. Administrative controls. This entails setting limits, or educating those who may be exposed. Although
important, it is the most difficult of the controls to enforce and should not be relied upon routinely.
GLOSSARY
PEL - Permissive Exposure Limit -- The maximum permissible concentration of a toxic substance
(averaged over eight hours) to which an employee may be exposed, by directive. A legal limit that takes
into account both chronic and acute effects.
TLV - Threshold Limit Value -- A time weighted average exposure over an eight hour day, five day week,
from which no acute ill effects occur. Excursions above the TLV are permitted if properly compensated
with appropriate times below the TLV. This is a practical limit developed by industry prior to OSHA which
takes into account only acute effects and contains a generous safety factor.
TLV-C - Threshold Limit Value - Ceiling -- a value not to be exceeded even briefly.
STEL - Short Term Exposure Limit -- A legal fifteen minute time limited exposure which may not be
exceeded.
OSHA - Occupational Safety and Health Administration -- A Federal Bureau and a political organization
empowered to enforce Federal Safety Standards. It was organized in 1970.
NIOSH - National Institute of Occupational Safety and Health -- Responsible for research, development
and publishing of standards. This is a scientific organization.
ACGIH - American Conference of Governmental Industrial Hygienists.
Carcinogenesis - The ability to induce malignant neoplasm. Harms a single individual. Effects this
generation.
Mutagenesis - The ability to change genetic material. Harms the succeeding generations.
Teratogenesis - The ability to cause birth defects by direct effects on the fetus. Harms the next generation.
Vapor - The gaseous phase of a material which is mostly solid or liquid at room temperature (e.g.
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gasoline).
Aerosol - A dispersion of particles, either solid or liquid, of microscopic, size in a gaseous medium.
Mist - An aerosol of suspended liquid droplets (e.g. fog).
Fume - An aerosol of solid particles (0.1 microns or less) generated from condensation from a gaseous
state, usually after volatilization from metals (as a cutting torch on lead).
Smoke - An aerosol of carbon particles (0.1 microns or less) of very small size mixed with droplets of
various things.
Dust - An aerosol of solid particles of 0.1 to 5.0 microns (eg.
talc).
Toxic - An inherent capacity to produce illness or injury when in physical contact with a living cell. Toxicity
does not necessarily imply hazard.
Hazardous -- For purposes of discussion, a substance which is toxic, exposure is reasonably likely, and
harmful effects are likely.
Threshold Value -- The level below which there is no effect. This involves determining exactly when
"approaching zero" is replaced by "zero." Very difficult to define, much less determine.
Voids -- Voids are "unused" spaces aboard a ship that are closed and not ventilated for months at a time.
Rust formation consumes available oxygen. They may be entered safely with a source of supplied air or
generated oxygen. An organic vapor mask or a bandanna over the nose and mouth is not adequate.
Toxic Substances
A major difficulty in the study of toxicology is that there are too many toxicants. The following are
substances that you may encounter while you are practicing aviation medicine:
Hydrocarbons -- General Notes
Hydrocarbons are divided into two general classes, aliphatic and aromatic. Aromatic compounds contain a
benzene ring. Aliphatics are everything else. Saturated compounds are "saturated" with hydrogen and
contain no carbon to carbon double or triple bonds. Alkenes have double bonds, alkynes have triple bonds.
Solvents are composed predominantly of hydrocarbons, thus their importance in aviation. Solvents are
substances capable of dissolving another substance (solute) to form a uniformly dispersed mixture
(solution). Solvents are either polar or non-polar. Hydrocarbon solvents are generally non-polar.
Exposure to solvents occurs primarily through inhalation of vapors or through skin contact. The very short
chain gases, methane (C1), ethane (C2), propane (C3), and butane (C4), are biologically inert and
non-toxic. They may serve as simple asphyxiants as they will not support life. They have no significant
narcotic effects as straight chain compounds. The rules change with other than the straight chain isomers.
Cyclopropane is an excellent anesthetic, but it is explosive. The C5 through C8 straight chain compounds
are powerful narcotics. Above C8 are weak narcotics. Above C18 are solids. These are broad
generalizations. Gasoline is C5-C15 with a few aromatics. Cyclic and unsaturated compounds tend to be
more narcotic.
The most common acute effect of hydorcarbons in the workplace is not a loss of consciousness, but
instead, a prenarcotic syndrome of mild incoordination and general malaise shading gradually into more
severe symptoms. Many organic solvents have the potential upon acute high level vapor exposure to
cause narcosis and death. Disorientation, euphoria, giddiness, confusion, progressing to unconsciousness,
paralysis, convulsion, and death from respiratory or cardiovascular arrest are typically observed. In the
majority of subjects, recovery from CNS effects is rapid and complete following removal from exposure.
One must also remember fire and explosion are common hazards associated with use of solvents.
Aspiration of any of these organic fuels can cause chemical pneumonitis. No common organic fuels can
29
be considered pure. All are mixtures defined by certain physical parameters such as specific gravity,
boiling point, or viscosity. As a general rule, the more volatile, the more toxic as well as the more
hazardous. Usually the compounds are excreted rapidly, but some have long term effects. Chronic
exposure to Benzene may cause leukemia. Benzene more commonly causes bone marrow depression.
Carbon disulfide may cause psychosis and peripheral neuropathy of sensory nerves. Vinyl chloride may
cause hemangiosarcoma of the liver although polyvinyl chloride is harmless. Aromatic nitro and amino
compounds cause production of methemoglobin, which interferes with normal oxygen transport.
Solvents are used in dry-cleaning agents, drying compounds, degreasers, and liquid extractions.
JP4-JP5
Chemical nature -- JP4 is 65% kerosene and 35% gasoline. JP5 is kerosene.
Method of absorption -- primarily by inhalation, although superficial cutaneous is also common. Ingestion
is rare.
Associated clinical syndrome -- In high concentrations, may cause headache, nausea, confusion,
drowsiness, convulsions, coma, and finally death. Skin exposure lends to defatting and dermatitis.
Prolonged skin exposure can lead to second degree burns. Ingestion lends to chemical pneumonia.
Association with USN -- these are jet engine fuels.
Ethylene glycol
Chemical nature -- a low molecular weight alcohol.
Method of absorption -- not an inhalation hazard unless heated. Accidental or purposeful ingestion.
Associated clinical syndrome -- In cases of fatal poisonings, symptoms include those of typical alcoholic
intoxication followed by coma, pulmonary edema, and death within 72 hours. In non-fatal cases, acute
tubular necrosis with anuria occurs within 24 hours. 100cc may be fatal. Liver alcohol dehydrogenase
metabolizes ethylene glycol to oxalic acid, which is the likely cause of the metabolic acidosis and
subsequent nephrotoxicity.
Treatment -- Ethyl alcohol is a better substrate for alcohol dehydrogenase, which accounts for its use as
therapy in massive ingestion. The oral loading dose is 0.6 gm of 50% ethanol per kg body weight. Hourly
oral maintenance doses of 109 mg of 20% ethanol per kg body weight should be administered, along with
rapid initiation of hemodialysis.
Association with USN -- antifreeze, hydraulic fluids, condensers, and heat exchangers.
Triorthocresyl phosphate - TOCP
Chemical nature -- an aromatic ester with three benzene rings.
Method of absorption -- ingestion. This compound occurs as a contaminant in some other product. It is
never produced deliberately.
Associated clinical syndrome -- basically an ascending paralysis.
Association with USN -- This was found in small amounts in green hydraulic fluid. Approximately one
gallon of this hydraulic fluid would have to be ingested before a toxic dose of TOCP would be absorbed.
There has never been a documented case of TOCP toxicity in the Navy.
The new hydraulic fluids have small amounts of TOCP.
Benzene
Chemical nature -- the basic unsaturated resonating ring compound. This is the basis of all aromatic
compounds.
Method of absorption -- rapidly absorbed via inhalation of vapor and distributed throughout body, tending
to concentrate in tissues with high fat content. Measurement of total urinary phenols gives the most
specific indication of exposure.
Associated clinical syndrome -- Acute exposure to high concentrations results in CNS depression with
headache, nausea, dizziness, convulsions, coma, and death. Contact with broken skin may result in
erythema, blistering, or dry, scaly dermatitis. Benzene is best known for its chronic effects; aplastic anemia,
preleukemia, and acute myelocytic and monocytic leukemia.
Association with USN -- extensive use as a solvent. May contaminate gasoline, paint remover, degreasers,
and kerosene.
An extremely valuable compound of mild toxicity except for its ability to cause leukemia. Also recently
found in illegal cocaine.
30
Toluene
Chemical nature -- a benzene ring with an attached methyl group.
Method of absorption -- inhalation - formally common with glue sniffers.
Associated clinical syndrome -- an irritant to the eyes, respiratory tract, and skin. A CNS toxicant which
may produce exhilaration, inebriation, headache, extreme lassitude and in high concentration, collapse,
coma, and death. Abuse (sniffing) produces hyperchloremic acidosis, renal tubular acidosis, weakness,
hypokalemia, and hypophosphatemia.
Association with USN -- a solvent for parts and coatings. It is also a component of motor and aviation
fuels.
Carbon Tetrachloride
Chemical nature -- an absolutely superb solvent and degreaser of metal. Previously used as a fire
extinguishing agent.
Method of absorption -- inhalation, percutaneous.
Associated clinical syndrome -- chronic exposure causes liver damage with destruction of hepatocytes. It
is also a potent liver carcinogen.
Association with USN -- very common in the past, but now outlawed.
An excellent solvent. A good fire extinguisher (heat and carbon tet form compounds which use up
available oxygen forming among other things, phosgene).
History of use as a delouser and vermifuge. It is not now used due to severe immediate plus delayed
toxicity.
Trichloroethylene - TCE
Chemical nature -- quite volatile.
Method of absorption -- inhalation.
Associated clinical syndrome -- a CNS depressant with symptoms of headache, dizziness, vertigo,
tremors, sleepiness, fatigue, and blurred vision. Intoxication is similar to alcohol. There have been many
sudden deaths from ventricular fibrillation from users of this compound. TCE is hepatotoxic and probably a
hepatocarcinogen.
Association with USN -- the principal solvent in vapor degreasing. This was the "safe" substitute for carbon
tetrachloride. It is used as a dry-cleaning solvent and metal degreaser in certain shipboard shops with
specific venting.
Summary -- A liquid which is almost as good a cleaner as carbon tetrachloride, has similar qualitative, but
much less quantitative effects. It is safer than carbon tetrachloride, but more dangerous than
perchlorethylene and methyl chloroform.
Tetrachloroethylene
Chemical nature -- another chlorinated hydrocarbon. It is also known as perchloroethylene.
Method of absorption -- inhalation and percutaneous.
Associated clinical syndrome -- a narcotic. Also a hepatoxin and inducer of liver cancer.
Association with USN -- used only in drycleaning plants.
Of the three, this is safer than trichloroethylene and much safer than carbon tetrachloride. It is more
dangerous than methyl chloroform or freon.
Freon
Chemical nature -- trichloro-triflouro-ethane (many possible isomers).
Method of absorption -- inhalation.
Associated clinical syndrome -- when inhaled, it is a mild CNS depressant. It is also a skin defatter.
Association with USN -- very common refrigerant and solvent. A very safe solvent. The major toxic effect
occurs with deliberate abuse causing simple hypoxia due to displacement of oxygen in the breathing gas.
Methyl ethyl ketone - MEK
Chemical nature -- much like acetone, but less volatile.
Method of absorption -- rapidly absorbed through the skin, then rapid excretion through expired air.
Associated clinical syndrome -- inhalation may cause narcosis. Skin contact causes marked defatting and
31
a dermatitis.
Association with USN -- solvents or resins, lacquers, paints, oils, pigments, dyes, and polymers. Very
common in shore facilities, not used on ships.
Methyl chloroform
Chemical nature -- a carbon with three chlorines and a methyl group.
Method of absorption -- inhalation.
Associated clinical syndrome -- can cause narcosis, but practically this is seldom seen. Causes dizziness,
incoordination, drowsiness, increased reaction time, unconsciousness, and death.
Association with USN -- used on ships and ashore as a solvent and degreaser.
One of the least toxic of the chlorinated solvent chemicals.
Carbon monoxide
Chemical nature -- a product of incomplete combustion of carbon compounds.
Method of absorption -- inhalation.
Associated clinical syndrome -- well-known competitive hemoglobin binder, also less well known as a
direct cellular toxin at the electron-transport level. Causes both anemic and histotoxic hypoxia.
COHb level Symptoms
10-20%...................................headache
20-30%......nausea, weakness, occasional vomiting
35-45%......clouding of sensorium, collapse, coma
over 50%....................................death
Treatment -- hyperbaric oxygen.
Association with USN -- common in internal combustion engine exhaust and in cigarette smoke. Very
small amounts in jet exhaust.
A classic killer: ubiquitous, silent, deadly. A colorless, odorless, tasteless gas. It associates 210 times more
readily with hemoglobin than oxygen. It has a four hour half-life in air, and a forty minute half-life in oxygen
at one standard atmosphere and about half that at sixty feet in the hyperbaric chamber. The treatment of
choice is hyperbaric oxygen.
Chlorobromo methane (CBM)
Method of absorption -- inhalation, skin absorption.
Associated clinical syndrome -- Pyrolysis resultant compounds are phosgene, HCl, HBr, and CO with their
related syndromes. Phosgene becomes HCl in the lungs and causes severe pulmonary edema.
Association with USN -- aircraft engine fire extinguisher for internal combustion engines.
OTTO fuel
Chemical nature -- 1,2 propylene glycol dinitrate -- a nitrated ester plus oxidizer.
Method of absorption -- inhalation or percutaneous absorption. Product is extremely volatile and TLV's can
readily be exceeded.
Associated clinical syndrome -- vascular effects, starting with headache, occur after inhalation.
Methemoglobinemia is seen with chronic inhalation exposure. Ingestion can cause circulatory collapse
and death.
Association with USN -- this is a torpedo fuel; torpedos are not only submarine items, we also can drop
them from aircraft.
Halon
Chemical nature -- a generic term meaning halogenated hydrocarbon. Halon 1301 is in use in the Navy. It
is a gas. Generally, those compounds containing fluorine tend to be less toxic, whereas those with
bromine or iodine are more toxic than those hydrocarbons containing chlorine.
Method of absorption -- inhalation.
Associated clinical syndrome -- CNS depressants. Cardiac arrhythmias may result, and the myocardium is
sensitized to epinephrine.
Association with USN -- in new ships, halon is utilized to flood spaces to stop fire. Harmless, if breathed
for only a few minutes.
32
Hydrazine
Chemical nature -- N2H4.
Method of absorption -- inhalation, skin contact.
Associated clinical syndrome -- inhalation leads to pulmonary edema. Skin contact causes severe burns.
Association with USN -- a missile fuel. Also found in the space shuttle and the F-16.
A very toxic and hazardous compound used as a fuel.
Isocyanate
Chemical nature -- toluene-2,4-diisocyanate - TDI.
Method of absorption -- inhalation of paint vapor and mist.
Associated clinical syndrome -- asthma like syndrome, due to prior sensitization. Repeat exposure of even
tiny amounts to a sensitized person can cause symptoms.
Association with USN -- polyurethane paints are common in the Navy. It is the standard aircraft paint.
Isocyanates are the monomers of polyurethane paint. The cured (polymerized) paint is harmless.
Hydraulic fluid, red (aircraft)
Chemical nature -- petroleum based and inflammable. Contains traces of TOCP. When burned, liberates
phosgene.
Phosgene hydrolyzes to becomes HCl in the lungs.
Method of absorption -- inhalation; skin contact.
Associated clinical syndrome -- skin contact for prolonged period can cause dermatitis. Phosgene is a war
gas causing pneumonitis and severe pulmonary edema.
Association with USN -- in aircraft hydraulic lines. Inhalation of mist possible when line breaks under
pressure. Mild toxicity except when burned. A very minor hazard.
Hydraulic fluid, green (shipboard)
Chemical nature -- this is a green synthetic based fluid that does not burn easily. It is called cellulube,
although that is an obsolete brand name.
Method of absorption -- inhalation, skin contact, ingestion.
Associated clinical syndrome -- causes a mild dermatitis on contact. Ingestion is sometimes deadly, more
because of the hydrocarbon effects than the TOCP. Approximately one gallon of this fluid would have to be
consumed in order to receive a toxic dose of TOCP.
Association with USN -- deck edge elevators. A large amount of this substance is in the piping of the
elevators. TOCP is a contaminant and the new "cellulube" has much less of it. The problem is going away.
Sometimes the new cellulube is blue in color, which confuses the issue somewhat.
A fairly non-toxic material found shipboard that has received attention far out of proportion to its
importance.
Plastics
Chemical nature -- burns to CO, HCl, HF, HCN, H2S,SO2.
Method of absorption -- inhalation.
Associated clinical syndrome -- this is a black, choking, toxic smoke that quickly incapacitates.
Association with USN -- interior of passenger aircraft contain much plastic; largely cosmetic interior
appointments which become deadly in a fire.
Methyl alcohol
Chemical nature -- CH3OH.
Method of absorption -- ingestion.
Associated clinical syndrome -- disturbances of vision and metabolic acidosis. High exposure results in
headache, vertigo, unsteady gait, weakness, nausea, vomiting, inebriation. Optic neuritis, with indistinct
vision, changes in color perception, and blindness as common symptoms.
Treatment -- ethyl alcohol, because of its greater affinity for ADH (alcohol dehydrogenase). Drinking
methyl alcohol may cause permanent blindness.
Association with USN -- deicing fluid. Also a solvent in paint, stains, varnishes, cements, dyes, and inks.
33
It is a relatively minor hazard, since most people are aware of the dangers of wood alcohol.
Deicing fluids
Chemical nature -- methyl, ethyl, isopropyl alcohols.
Method of absorption -- deliberate ingestion.
Associated clinical syndrome -- intoxication (drunkeness) with methanol effects.
Association with USN -- used on aircraft windshields and props.
Organophosphates
Method of absorption -- inhalation or through intact skin and eyes.
Associated clinical syndrome -- Organophosphates inhibit the enzyme cholinesterase and the toxic effects
are related to the resulting increase in endogenous acetylcholine at the synaptic sites. Monitoring enzyme
activity not only can serve as a measure of acute toxicity, but also can be used to monitor occupational
exposure (remove from exposure if enzyme activity decreases 25% from preexposure levels). The time of
onset of symptoms after toxic exposure can be very rapid, but rarely longer than a few hours. If the patient
is still alive after 24 hours, survival is likely. Recovery, when it occurs, is usually rapid and complete.
Early symptoms are pupillary constriction, chest tightness, headache. More severe exposure produces
coughing, wheezing, and increased bronchial secretions. Weakness and fatigability lead to twitching and
fasiculations and eventual respiratory paralysis. CNS symptoms include anxiety, restlessness and
irritability.
Treatment -- atropine 1-2 mg every 15-30 minutes until tachycardia, flushing and dry mouth occur (does
not reverse phosphorylation of cholinesterase, but blocks effect of acetylcholine). 2-PAM (Protopam
Chloride) will reverse the inhibition of the enzyme if given early enough before aging process occurs
(given as 1 gm slowly and repeated in one hour prn).
For monitoring workers, both RBC and plasma cholinesterase should be measured. Plasma
cholinesterase decreases earlier, and returns more promptly. RBC cholinesterase decreases less readily
and has a slower return (however, is more representative of functional cholinesterase). Baseline levels are
very important because of variability.
Parathion
Chemical nature -- complex organophosphate.
Method of absorption -- ingestion, inhalation.
Associated clinical syndrome -- this is the insecticidal equivalent of a war nerve gas. It is a cholinesterase
inhibitor like the other organophosphates.
Parathion is deadly and has caused many times the number of deaths caused by DDT. However, it does
not persist in the environment and does not bioconcentrate.
DDT
Chemical nature -- a halogenated hydrocarbon.
Method of absorption -- usually ingestion, by humans. This chemical bioconcentrates.
Associated clinical syndrome -- hyperesthesia of mouth and face early, followed by paresthesia, tremor,
confusion, malaise, headaches, fatigue, and delayed vomiting. Convulsions occur only in severe
poisoning.
Association with USN -- no longer used. EPA cancelled its use for all crops in 1972, and all except
emergency cases in 1973; primarily of historical interest.
Beryllium
A hard, light, easily machined, useful metal.
Method of absorption -- inhalation of the dust.
Associated clinical syndrome -- pulmonary and systemic granulomatous disease requiring exposure over
months to years. There is a possible long latent period (suspected cancer inducer). Exertional dyspnea is
the most common symptom of chronic disease. Cough, fatigue, weight loss, chest pain, and arthralgia
may occur. It is difficult to differentiate from other pulmonary disease.
Treatment -- cessation of further exposure. Possibly steroids.
Association with USN -- brakedrums of S3 and F14. Used brakes are the dangerous ones. The aircraft
brake shop is the locus of the hazard.
34
Modern technology has produced new uses of berrylium in nuclear reactors, electronic equipment,
guidance and navigation systems, rocket parts, and heat shields.
Cadmium
An elemental metal.
Method of absorption -- inhalation of fumes. Typically, acetylene cutting of metal plated with cadmium.
Associated clinical syndrome -- symptom-free period followed in 4-10 hours with dyspnea, cough, chest
tightness, chest pain and burning. Metal fume fever is shaking, chills, and myalgia. This can progress to
pulmonary edema 24-48 hours after exposure. Chronically, cadmium can cause pulmonary fibrosis, liver
and kidney damage, and cancer of the lung and the prostate. This is probably the most harmful fume.
Treatment -- remove from exposure; chelation therapy may produce renal damage by increasing the renal
concentration of cadmium.
Association with USN -- electroplating, stabilizer in plastics, component in nickel-cadmium batteries.A
common, useful metal with extremely dangerous fumes. Most toxicity is caused by not knowing the
Cadmium is there.
Chromium
A metal with trivalent and hexavalent ions.
Method of absorption -- inhalation of fumes and cutaneously.
Associated clinical syndrome -- cough, wheezing, pain on inspiration, fever, weight loss, and possible
chemical pneumonitis. This is a trace element required for health. Only the hexavalent form is dangerous
and causes both skin ulcers and respiratory ulcers. It may be a carcinogen with a long latent period.
Treatment -- calcium EDTA for skin ulcers.
Association with USN -- chrome plating and as a paint primer (corrosion resistance); a common ion found
in rework facilities which causes severe ulcers which are slow to heal.
Lead
A very malleable, heavy, and much-used metal.
Method of absorption -- inhalation of dust or lead oxide fumes or ingestion. Dust comes from sanding of
lead-based paint. Fumes come from gas cutting of metal. Ingestion from any number of ways.
Associated clinical syndrome -- Lead poisoning is essentially a chronic disease caused by the gradual
accumulation of a significant body burden. One of the most important sites of the toxic action of lead is the
inhibition of the heme biosynthetic pathway. Blood lead levels are measured for assessing acute exposure.
Accumulation of zinc protoporphyrin (ZPP) is used effectively as a diagnostic test for lead exposure (a
measure of the biological effect of lead averaged over a 3-month interval). CNS symptoms include
convulsions, delirium, coma, headache, dizziness, sleep disturbances, memory deficit and changes in
personality. Progressive renal disease is possible. Some of the most frequent symptoms are GI; including
nausea, anorexia, weight loss, epigastric discomfort, dyspepsia, and abdominal cramps (lead colic). The
"lead caper": Colic, Arthralgia, Polyneuritis, Encephalopathy, Red blood cell stippling and anemia.
Treatment -- discontinue exposure. Calcium EDTA.
Association with USN -- lead-based paint is very common and sanding can cause airborne exposure.
Finished lead products are safe in normal use. Heating, grinding, spraying, burning may result in emission
of biologically active forms of lead. Consideration of lead exposure is important in the demolition of ships
because of lead-based paint.
Nickel
An elemental metal of little toxicity as the metal, but with many toxic compounds. Ni is a trace element
needed for life. Nickel carbonyl - Ni(CO)4 - is especially bad for cancer induction.
Method of absorption -- inhalation of the compounds (primarily in nickel refinery workers).
Associated clinical syndrome -- Gas wielding nickel-plated materials may result in metal fume fever.
Ni(CO)4 produces immediate non-specific symptoms which soon disappear. Severe respiratory distress
develops hours or days after exposure as a result of chemical pneumonitis. Death is usually the result of
interstitial pneumonitis. Cancer of the respiratory tract, including nasal cavity, sinus cavities, and lungs
may occur.
Association with USN -- Cigarette smoke has nickel carbonyl. A lot of nickel-plating is done in industry. All
chrome plating has nickel under it. Also found in nickel cadmium batteries.
35
Mercury
An elemental metal liquid at room temperature and fairly nontoxic as the metal. Vapor is toxic and some
compounds are real problems.
Method of absorption -- inhalation.
Associated clinical syndrome -- The CNS is generally the target of acute exposure, whereas, the kidney is
the target of chronic exposure. Chronic exposure produces the classical triad: erethism, tremor, and
gingivitis. Tremor is one of the earliest and most characteristic expressions of Hg toxicity. In the CNS,
erethism is described as nervousness, irritability, tendency to resent being observed, timidity, and bursts of
quick temper of unusual degree for the individual affected. Hg in the urine is a good index of exposure, but
not toxicity. Urinary Hg levels remain an important indicator of body burden, particularly when followed
over time.
Treatment -- Although penicillamine is preferred, dimercaprol (BAL) may be useful. Polythiol resin has
been used for the reduction of intestinal absorption of methyl Hg.
Association with USN -- used by dentists. Recent media attention has been given to mercury levels
detectable in the mouths of patients with mercury containing amalgams, and its potential for damage to
patients. No final determination or recommendations have yet been made.
Methyl mercury is another bioconcentrator.
Metal fume fever
Caused by the fumes from non-ferrous metal welding.
Method of absorption -- inhalation; remember what fumes are.
Associated clinical syndrome -- typical of a flu syndrome with fever, c
36
BURN MANAGEMENT
Point of Contact:
U.S. Army Institute for Surgical Research (ISR)
Brooke Army Medical Center
DSN:
429-2876/2604/0501
Com: (210) 916-2876/2604/0501 or 1-800-222-BURN
Message Address: CDR USAISR FT SAM HOUSTON TX
First Aid at Scene:
1. Stop the burning process and remove the patient to a safe area.
2. Place patient in a supine position and initiate CPR if indicated. The same general principles of
cardiopulmonary resuscitation apply, and are a priority.
3. Cover patient (clean sheet &/or "space blanket").
4. If 30 min. to ER, start large bore (16 ga.) IV with Lactated Ringer's solution (LR).
5. Oxygen; intubate if necessary. Carbon monoxide poisoning is the most frequent cause of death in the
first hours after a fire.
Notes:
* Rapidly remove burning clothing.
* Electrical burns: Ensure patient is clear of electrical source prior to rescue.
* Chemical burns: Remove soaked clothing, and irrigate with copious amounts of water ASAP.
* Ensure that the patient and the medical team are completely clear of the fire area for their protection and
to avoid interference in fire fighting efforts.
ER/Medical Department Treatment:
1. Re-assess ABC's of BLS. FLUID RESUSCITATION is of great concern.
2. Oxygen, NG tube & foley for all serious burns. Intubation if indicated.
3. Assess extent and severity of burns. (Rule of 9's or mapping; patients hand = 1% body surface).
4. IV analgesics titrated to reduce pain to tolerable levels during initial cleaning and debridement.
5. Gently clean and debride wounds; cover wounds with Silvadene or Sulfamylon. Keep patient warm;
clean and re-cover wounds daily.
6. Evaluate the eyes using fluorescein.
Special Situations
1. Electrical Burns:
* Cutaneous lesions may be misleadingly small (tip of the iceberg) in the face of serious deep tissue
damage.
* Watch for myoglobinuria and treat promptly. Give 25 grams of mannitol IV and add 12.5 grams (1 amp)
to subsequent liters of fluid. Alkalinization of the urine with sodium bicarb will increase excretion (1 amp in
a liter of LR). Use of any diuretic makes urine output an invalid estimator of circulatory status.
* May cause tetanic contractions leading to fractures of the vertebrae and falls may lead to other injuries.
* May impair circulation; monitor pulses closely. Escharotomy, as with any circumferential burn may be
needed. However, a fasciotomy maybe required due to deep muscle injury.
37
2.Chemical Burns:
* Alkali powder (lime): brush the powder from the skin before lavage is begun.
* Phenol: instead of lavage and in any case after lavage as well, the skin should be washed with a solvent
such as polyethylene glycol, propylene glycol (anti-freeze), or glycerol to remove residual phenol.
* White phosphorous: must be kept moist to prevent ignition of the retained phosphorous particles. Wash
the involved area with an 0.5% or 1.0% solution of copper sulfate. This will cause the formation of a
blue-black film of cupric phosphide on the surface of the retained particles. Debride the particles and keep
them moist or you will have another fire.
3.Closed Space Fires:
* May have inhalation injuries. Look for facial burns, singed nasal hair or eyebrows, oropharyngeal burns,
carbonaceous sputum, hoarseness and stridor, etc.
* Intubate early for inhalation injuries.
* Evaluate for carbon monoxide and toxic gas inhalation. Don't forget re-evaluation for delayed effects.
Fluid Resuscitation:
First 24 hours post-burn:
* 2-4 ml of LR / kg body weight / % body surface burned.
* infuse 1/2 calculated dose within first 8 hours post-burn; second half over next 16 hours.
* adjust IV rate to maintain urine output at 30-50 ml/hr in adults.
* make decreasing adjustments of IV rate gradually (10% increments q 1hr).
* use of diuretics make urine output an invalid measure of circulatory status.
Second 24 hours:
* 5% albumin in LR @ 0.5 ml / kg / %burn (200 cc of salt-poor albumin placed in 800 cc of LR).
PLUS:
* D5W (or 1/4 Normal saline (1/4 NS) primarily for children) to yield same hourly infusion rate as the first
24 hours.
* Adjust D5W or the 1/4 NS rate, not the 5% albumin soln., in order to maintain urine output 30-50 ml/hr.
General Considerations:
1. ALL medications must be given IV during the resuscitation because of the dramatic changes in capillary
permeability. Otherwise, the patient can receive an overdose when fluid mobilization occurs.
2. Sodium shifts can cause serious hyponatremia. The rate of fall of serum sodium levels is very important,
especially in young patients. Serum sodium must be carefully monitored when giving large volumes of IV
fluids.
3. Transfusion is indicated for hematocrit under 30. Packed RBC's are preferred.
4. Insulin infusion may be instituted for serum glucose over 200mg%.
5. Histamine (H2) blockers and antacids should be used to keep the gastric pH at 7.0.
Aeromedical Evacuation:
1. Patient must be accompanied by a physician or nurse.
2. 2 IV lines, sewn in place; NG tube; foley. (Balloons filled with water, not air).
3. Intubate if airway is a concern.
4. Chest X-ray to evaluate placement of lines and tubes, and rule out pneumothorax. Insert a chest tube if
indicated.
5. Apply Silvadene to burns, and cover patient with "space blanket".
6. Cardiac monitor & ACLS meds.
7. Notify the Burn Center if a ventilator is required.
* NOTE: Foley & ET tube cuffs should be filled with WATER not air.
Criteria for Burn Center Referral:
* Burns over 25% body surface area (BSA).
* Partial thickness (second degree) burns over 20% BSA.
* Full thickness (third degree) burns over 10% BSA.
38
* Burns involving face, hands, eyes, feet, or perineum.
* Burns associated with significant fractures or other major trauma.
* High voltage electrical burns.
* Inhalation injury.
* Pre-existing disease.
* Very young and very old.
39
MANAGEMENT OF DECOMPRESSION SICKNESS
24 Hour Points of Contact:
 Experimental Diving Unit, Panama City, FL
DSN: 436-4351 Com: (850) 234-4351
 Naval Medical Research Institute (NMRI) Bethesda, MD
DSN: 295-1839/5875 Com: (306) 295-1839/5875
General
Aviation DCS may occur in flight in unpressurized or depressurized aircraft, altitude chamber operations
and high altitude high opening parachute operations. DCS does not generally occur with exposure to
altitudes below 18,000 feet. Aviators are generally protected from DCS by maintaining cabin altitudes at
lower levels by cabin pressurization, by use of pressure suits, by pre-oxygenation to reduce total body
nitrogen or a combination of these measures. Currently, the largest numbers of DCS cases seen in Naval
Aviation operations involve low pressure chamber activities at the rate of about 1 case per 1000 chamber
exposures.
Effects of bubble formation
There are two pathophysiologic effects attributed to the formation of nitrogen bubbles with altitude
exposure (or upon decompression from diving):
 A direct mechanical effect of the bubble in distortion of tissue or in vascular obstruction, causing
pain, ischemia, infarction or dysfunction.
 Tissue-bubble interface activity resulting in denaturation of proteins, platelet aggregation and other
biochemical mechanisms causing tissue damage and release of pain mediating substances.
Because these bubbles may form at different locations, there may be multifocal lesions without
necessarily following dermatomal or anatomic distributions.
Once bubbles are formed, they expand as dissolved gases continue to come out of solution. Carbon
dioxide is highly diffusible and contributes to bubble enlargement, especially if formed in excess by
vigorous exercise. For this reason, DCS patients should be kept at rest.
Clinical syndromes of DCS
Type I DCS
Limb pain (musculoskeletal symptoms)
The most common presenting symptom, accounting for 60-70% of altitude related cases
and 80-90% of diving cases. Pain usually begins gradually and is poorly localized, but
increases in intensity and localizes with time as a throbbing ache. Guarding may be seen.
If the painful area is accessible, inflation of a blood pressure cuff over the site may relieve
the pain and help distinguish it from pain of ischemia or nerve entrapment which would be
made worse by such pressure. Sharp, shooting or encircling pain, migratory pain and
tingling or burning trunk pains arise from CNS involvement and should be considered
Type II DCS and treated accordingly.
Cutaneous bends
The skin is often affected during and after the decompression event. There are two
distinct manifestations; The most common symptom is a transient, multifocal itching, often
associated with a scarlatiniform rash, and is not an indication of development of serious
sequelae. Itching or crawling sensations usually occur in hyperbaric chamber dives and
do not require recompression as a rule. Cutis Marmorata results from venous obstruction
and vasospasm and presents as confluent rings of pallor, surrounded by areas of
cyanosis which blanche to the touch. This may be the harbinger of more serious forms of
DCS and should be treated by recompression.
40
Lymphatic bends
Rare. Recompression usually provides prompt relief of pain, but swelling of lymphatic
tissue may persist after treatment.
Type II DCS
The most severe form of DCS, and may present as neurological, cardiorespiratory or inner ear symptoms,
pain or shock. There may be concurrent Type I symptoms in 30-40% of cases. About 10-15 of all altitude
DCS cases will be type II.
Early Type II DCS symptoms may seem inconsequential. Fatigue is a very common and early symptom,
progressing to weakness, dyscoordination and other difficulties. Many symptoms of Type II DCS are the
same as those of arterial gas embolism (AGE), although AGE presents very early, usually within 10
minutes after exposure. Treatment of AGE is also appropriate for DCS.
Unexplained fatigue
This should always alert the examiner to the possibility of DCS.
Neurological symptoms
These may occur at any level of the CNS. There may be paresthesias, numbness or
weakness. Symptoms are usually mild and confined to one extremity.
Spinal cord DCS may present with numbness, weakness and paralysis or urinary
dysfunction, and occurs in about 10% of Type II altitude DCS cases.
Cerebral DCS is the most common of Type II DCS. Fatigue is a very common symptom.
There may be confusion, odd behavior and personality changes. Headache, tremor,
hemiplegia, hemisensory losses and scotomata may also occur. These signs and
symptoms may range from mild and seemingly inconsequential to fulminant and life
threatening.
Inner ear DCS may mimic round or oval window rupture with vertigo, tinnitus and hearing
loss.
Bilateral pain involving the trunk or hips should be considered Type II DCS.
The occurrence of any neurological symptom after a dive or flight should be considered a
symptom of Type II DCS or AGE.
Cardiopulmonary symptoms
Symptoms of congestion of pulmonary circulation, the "chokes", are the result of
intravascular bubbling, and account for 5-10% of altitude DCS. They are:

burning substernal pain, worse with inspiration

cough

dyspnea
If not treated promptly, the result may be circulatory collapse and death.
Special considerations
Flight after diving
OPNAVINST 3710.7 prohibits flight or low pressure chamber exposure within 24 hours of a
41
SCUBA or compressed air dive or high pressure chamber run. This may be reduced to 12 hours
for urgent operational requirements provided there are no symptoms following the dive and the
subject is examined and cleared by a flight surgeon.
Diving at altitude
This refers to dives at elevations, such as in mountain lakes and may be a factor in increasing risk
for DCS. U.S. Navy dives above 2300 ft. MSL require CNO approval.
Other factors increasing the risk of DCS
 Prior DCS
 Occupation. Incidence in chamber inside observers increased.
 Age. 3 times higher in 40-45 year old group than 19-25.
 Sex. Females 2 times as likely, and may relate to menses as well.
 Exercise. Individuals undergoing exposures to altitudes above 18,000 ft. should avoid strenuous
activities for 12 hours before and 3-6 hrs. after exposure.
 Injuries
 Cold temperatures
 High body fat appears to be a factor
 High C02 environments predispose individuals due to high solubilities
 Hypoxia
 Alcohol, dehydration and fatigue may be associated
 Atrial septal defects have been implicated
Pulmonary overinflation syndromes
These are due to trapping of gas in the lung with ascent, producing rupture of alveoli and resulting in:
 Arterial gas embolism (AGE)
 Pneumothorax
 Mediastinal emphysema
 Subcutaneous emphysema
 Pneumopericardium (rare)
These may occur as a result of breath holding on ascent or because of localized pulmonary obstructions
secondary to disease processes. Sudden changes in depth while in shallow water can be far more
hazardous than equivalent depth changes in deep water. Improper ascent from just a few feet can cause
POE syndromes.
Arterial gas embolism (AGE)
Produced by entry of gas emboli into the arterial circulation.
Susceptible organs are the heart and the CNS, in of which bubble emboli are responsible for life
threatening symptoms.
Symptoms of AGE usually occur within a minute or two after surfacing.
Unconsciousness upon, or within 10 minutes of surfacing after breathing compressed air including HEEDS
bottles must be assumed to be AGE and treated immediately.
CHARACTERISTICS OF AGE:
 Sudden, dramatic onset within seconds or minutes of surfacing
 Chest pain may be noted on ascent
 Weakness, paralysis, large areas of abnormal sensation, visual disturbances and convulsions
may occur.
 Coughing of blood may be present
If symptoms of AGE are present and resolve spontaneously, they may recur later with increased severity.
Therefor, symptoms of AGE should be treated promptly even if they have spontaneously resolved.
AGE vs DCS
Not always easy to distinguish the difference between the two.
42
AGE treatment is more lengthy than that of DCS.
If in doubt, err on the side of treatment for AGE, which is always adequate for DCS.
Treatment
General
Treatment tables are time/pressure profiles applied in recompression therapy, and bear numbers which
have been assigned as they were developed and so do not necessarily follow a logical sequence. You
should be familiar with treatment tables 5,6,6A,4 and 7.
Two basic types of treatment tables:
 AIR. Breathing air mixtures only. Since nitrogen is present and being absorbed, the benefit is
from the compression only. Lengthy tables and gradual ascents are required.
 100% 02. Helps in wash out of nitrogen as well as prevention of further absorption. This permits a
more rapid ascent and therefore shorter tables and less risk. Short, air breathing breaks are
included in the tables to prevent oxygen toxicity.
Treatment table 5
For Type I DCS only - 2 hrs. 15 min. total time
Pressure is at 60 FSW (ft. sea water) for 2 oxygen periods, gradual ascent to 30 FSW, and 1
period at this depth.
Treatment table 6
For Type I DCS which fails to respond with relief of pain within 10 minutes on TT-5.
For Type II DCS (except inner ear DCS) 4 hrs 45 min. total time.
Similar to TT-5 except that times at 60 FSW and 30 FSW are increased if clinically indicated.
Extensions of 2 periods at 60 FSW and 2 periods at 30 FSW may be used if indicated.
Treatment table 6A
For treatment of:

AGE

Inner ear DCS
This is like a TT-6 except that the patient is taken to 165 FSW for 30 min. on air to compress
intra-arterial bubbles maximally. At this depth, oxygen cannot be used because of toxicity. After
this period of deep recompression, the patient is brought slowly to 60 FSW and treatment follows
a TT-6 with oxygen.
Treatment table 4
Used for serious cases in which symptoms are refractory to treatment at the 60 FSW level,
requiring further compression to 165 FSW for longer periods. This table takes 38 hrs. 11 min.
because of the extended time at depth and resultant nitrogen saturation. (Unable to use oxygen
until return to 60 FSW)
Treatment table 7
For life threatening DCS unresponsive to treatment. Maximizes the 60 FSW treatment time. This
is at least 12 hrs at 60 FSW. Very gradual ascent over 36 hrs. There is no limit on the time at 60
FSW.
Other indications for hyperbaric therapy
 Cyanide or carbon monoxide poisoning
43




Smoke inhalation
Gas gangrene
Iatrogenic gas embolism
All other non-diving indications require prior approval of BUMED.
Triage and referral of altitude DCS cases
Type I DCS
If symptoms appear at altitude and resolve on descent, use 100% 02 for two hrs and observe for
recurrence. If none, light duty only and ground for 1 week. Warn the patient to return promptly if
symptoms recur for hyperbaric therapy.
If symptoms develop at altitude and persist, or develop after flight, place the patient on 100% 0 2
while arranging evacuation or recompression. If evacuation is delayed and symptoms resolve,
leave on oxygen for 24 hrs. Then, place the patient on limited duty for 1 week, and no physical
training for 72 hrs. Recurrence must be treated by hyperbaric therapy.
Current U. S. Navy diving medicine protocols are to treat all patients referred for altitude DCS
regardless of whether or not symptoms have resolved.
Type II DCS
All must be recompressed urgently or evacuated promptly for treatment.
Aeromedical evacuation of DCS cases
 Contact receiving facility prior to transport
 Medevac aircraft should be pressurized to altitudes of 500 ft. or less.
 Place patient on 100% 02
 Place patient in supine position (unless unconscious) , neutral head position and uncrossed




extremities for transport.
Do not allow patient to sleep in order to monitor mental status.
IV of N.S. or Ringers Lactate.
Inflatable cuffs should be filled with WATER rather than air.
Dexamethasone is controversial, but may be given 10 mg. IV if indicated.
Aeromedical disposition
 Type I patients grounded 1 week.
 Type II patients grounded 1 month.
 Flight surgeon should conduct a fitness to continue exam.
 Gas embolism should be worked up for pulmonary bullae and other causes of pulmonary




overinflation syndrome and cardiac work up for septal defects.
Persistent neurologic sequelae of DCS or AGE are disqualifying.
Type II DCS or recurrent Type I DCS is disqualifying, but designated personnel may be
considered for waiver.
Single Type I DCS is disqualifying but may be considered for waiver in designated and
non-designated personnel.
Waiver requests are forwarded to NAMI code 42 for consideration by the Hyperbaric Medicine
Committee.
44
AEROMEDICAL EVACUATION
Points of Contact:
 Global Patient Movement Requirement Center (GPMRC)
Scott AFB, IL
DSN: 576-6161/6162/6262 Com: (618) 256-6161/6162/6262
 Navy Liaison Officer
DSN: 576-4938/4939 Com: (618) 256-4938/4939
 Theater Patient Movement Requirement Center (TPMRC)

Europe (UECOM)
Ramstein Air Base, Kaiserslautern, Germany
DSN: 480-8040/8041/8042/8043* Fax 480-8045*

Pacific (PACOM)
Yokota, Japan
DSN: 225-4700*
*Call your local DSN operator to see if applicable geographical area voice codes are required.
DOD Policy
It is DOD policy that the movement of patients of the armed forces, in both peace and war, be
accomplished by airlift when airlift is available, when conditions permit and if not medically contraindicated.
The policy further states that this mission will be carried out by units specifically assigned that task except
when urgent medical requirements dictate otherwise. In that case, any suitable aircraft may be pressed
into service.
General
Aeromedical evacuations from the field, from aboard ship and from in-garrison facilities are frequently of
sufficient urgency that local aircraft assets are used in order to transfer a patient to the nearest available
medical facility suitable to that patient's needs. In cases requiring higher levels of care, where immediate
danger to life and limb are not urgent considerations or where considerable distances are involved, the
Worldwide Aeromedical Evacuation system is used. Or, it may be that urgent cases may require removal
from a remote site using local aircraft assets and a link up with the aeromedical evacuation system at
some location for further transport. The Navy overseas component commander is responsible for
providing aeromedical evacuation over routes solely of interest to the Navy and where the facilities of the
Worldwide Aeromedical Evacuation System cannot provide this service. Thus, a burn case requiring
evacuation from the middle of the Mediterranean would require use of Navy assets for transportation to
some land-based U.S. facility in Sicily or Italy where the patient can then be entered into the worldwide
aeromedical evacuation system.
Caution
Aeromedical evacuation is a very helpful tool, but DOD policy should not be interpreted as an absolute
requirement. You may be called upon for advice or to accompany a medical evacuation requested by a
non-flight surgeon medical officer. In some cases, evacuation by air may not be in the best interests of the
patient or may cause harm.
One must also bear in mind that an aviator will press a mission further than he otherwise would if he
believes lives are at stake, and he must so assume when an aeromedical evacuation is requested. He
may, therefore, launch in bad weather or other than ideal circumstances. It is incumbent upon the flight
surgeon to evaluate all factors, and if an aeromedical evacuation seems ill advised, to present that opinion
to the attending physician and through the medical chain of command if necessary. Clearly, these opinions
must be presented in the most diplomatic and informed of methods. When presented with carefully
reasoned objectives based on patient interests and safety, most physicians will look at alternative methods
of transportation. Entry into the Worldwide Aeromedical Evacuation system is a bit more tightly controlled
and run by people who do this every day. That system has a series of checks which prevent such
45
problems.
Organization of the Worldwide Aeromedical Evacuation System
Patient Evacuation System (2 components)
11. Medical Regulation (DOD)
The Armed Services Medical Regulating Office (ASMRO) is a tri-service organization which
processes requests from medical facilities for evacuation of individuals to facilities able to provide
higher levels of care, and then arranges movement to those facilities after having balanced
requirements with current capabilities. This office handles cases from overseas and within
CONUS during war and peace. Regulation of patients to be transported within the overseas area
is not an ASMRO function, but is rather the mission of the Unified Commander of that theater of
operations who has a Joint Medical Regulating Office (JMRO) which arranges for movement.
There are two JMROs, one located at Frankfurt, Germany for the European theater, and one at Ft.
Smith, Hawaii covering the Pacific theater of operations.
12. Patient Movement
This is the charter of the U.S. Air Force Military Airlift Command (MAC), 375th Aeromedical Airlift
Wing. The 375th has four Aeromedical Evacuation Squadrons (AESs):

57th AES, Scott AFB, IL - Largely administrative and scheduling.

1st AES, Pope AFB, NC - The tactical evac squadron in combat
situations.

9th AES, Yokota AFB, Japan.

2nd AES, Rhein-Main AFB, Germany.
There are Dets of AESs as well at various turn around points and receiving facilities in the U.S.
and the Pacific which provide support.
How it Works
The flight surgeon elects to medevac a patient. The nearest U.S. medical facility does not have the
capability to handle the case but does have a large airport available. The flight surgeon prepares the
patient for transport while the staging medical facility contacts the ASMRO (JMRO in European and Pacific
theaters) with the request for movement of the patient. ASMRO (or JMRO) matches the patients
requirements with the capabilities of higher level facilities for that day and then contacts the cognizant AES
for movement to the final destination. Each case is regulated individually except during wartime, when
large numbers of casualties may dictate regulation and transport on the basis of injury categories such as
neurology injury, orthopedics, burn or other.
Airframes in Use:
 C-130 used by 1st AES primarily in the tactical role. 74 litters, 94 ambulatory.
 C-9A Nightingale (specific configuration). 30 litters (40 wartime) 40 ambulatory.
 C-141 (multi-purpose configuration). 103 litters, 168 ambulatory.
Medical Crews on Board:
 2flight nurses.
 3 aeromedical evacuation technicians.
 May be augmented as required.
No medical officer is aboard. The medical crew relies on the orders and diagnosis of the originating
medical officer.
46
Patient classification (based on condition and ability to egress in an emergency)
Class 1 (Psychiatric)
 1A - Severe psychiatric
a) litter
b) hospital attire
c) sedated
d) restrained

1B - Intermediate psychiatric
a) litter
b) sedated
c) restraints available

1C - Moderate psychiatric
a) in uniform
b) ambulatory
Class 2 (Litter)
 2A - Immobile
a) litter
b) hospital attire
c) cannot egress

2B - Mobile
a) litter
b) hospital attire
c) can egress
Class 3 (Ambulatory)
 3A - Non psych, non substance abuse going for treatment.
 3B - Recovered patients returning home.
 3C - Drug/substance abuse patients going for treatment
Class 4 (Infants)
 4A - Infant/child under 3 in bassinett/car seat
 4B - Recovered infant/child requiring seat
 4C - Infant in incubator
 4D - Under 3 on a litter
 4E - Outpatient under 3
Class 5 (Outpatients)
 5A - Ambulatory, non psych/substance abuse going for treatment.
 5B - Ambulatory, psych/substance abuse going for treatment.
 5C - Psychiatric outpatient going for treatment/evaluations.
 5D - On litter for comfort/safety going for treatment.
 5E - Returning on litter for comfort/safety.
 5F - All other returning outpatients.
47
Class 6 (Attendants)
 6A - Medical attendant
 6B - Non-medical attendant
Movement Precedence:
1. Urgent - move immediately
Indication - to save life/limb/eyesight or prevent complications of serious illness.
Requires - Doctor to doctor referral.
*Validation by surgeon at Wing or designated overseas flight surgeon.
2. Priority - move within 24 hrs
Requires - Doctor to doctor referral.
*Validation as with Urgent.
3. Routine - move within 72 hrs
Routine flight.
GPMRC locates a bed for the patient.
4. Special - Inflight care exceeds usual capabilities
Requires special equipment/teams/expertise/limit stops/RON.
Your Responsibilities for Patient Preparation:
2. DD form 602 - (Patient evacuation tag) Legible, with primary and secondary diagnoses, orders
and treatments.
3. Narrative summary.
4. Patient x-rays, records.
5. Medications: CONUS Travel - 3 day supply, Overseas Travel - 5 day supply.
6. Special Diets.
7. IV fluids, supplies, etc.
Special considerations:
1. Physicians
 Originating M.D. is responsible for care until patient reaches destination hospital.
 Medical crew may request flight surgeon evaluation.
 Death in flight.
 Do not resuscitate orders (DNR).
2. Patient
 Cardiac --10 days post MI, 5 days complication free.
 Anemia -- Hb/Hct 8.5/30 -- May need continuous 02.
 Chest tubes -- HeimlichValve -- XR to assure lung expansion.
 Infectious Disease -- Usually not accepted -- Special precautions -- Isolation is possible.
 Immobilized Jaw --Aspiration protection --Quick release mechanism (Rubber retaining bands with
scissors attached to the patient).
 Tracheotomy -- Change 24-48 hrs prior to flight.
48





C-SpineFracture -- Stryker frame -- Collins traction.
Pregnancy -- OB records. Medical officer with labor patient or if on Ritodrine.
TB -- New: on litter with mask. Over 2 wks: chemotherapy no precautions.
Casts -- Dry 48- 72 hrs. Bi-Valve all casts.
Post-op -- 5 days post major surgery, and must be stable.
49
Department of the Navy
Standard Subject Identification Codes
(SSIC)
SSIC's are designed to meet the needs of the entire Navy Department for a single standard subject
scheme to be used for classifying (numbering), arranging and filing, and referencing various types of Navy
and Marine Corps documents by subject matter. This is required on all Navy and Marine Corps letters,
instructional forms and other official documents.
 SSIC's provide for a convenient numerical classification outline consisting of 14 major numerical
series.
(1) May be broken into primary, secondary, and tertiary subjects.
(2) A number to be assigned to any and all subject matters.
 Correspondence files are always in SSIC order. This is universal among Navy and Marine Corps.
 Correspondence files are always renewed at the beginning of each new calendar year.
 Classified Documents will always have their SSIC numbers prefixed by a certain number of zeroes.
a. Confidential documents' SSIC numbers are prefixed by 1 zero (I.E., CO1530)
b. Secret documents' SSIC numbers are prefixed by 2 zeros (I.E., S001530)
c. Top secret documents' SSIC numbers are prefixed by 3 zeros (I.E., TS0001530)
The 14 major subject groups are designated by either a 4 or 5 digit number:
1000-1999 Military Personnel
Includes subjects relating solely to the administration of military personnel. Civilian personnel
subjects are included in the 12000 series. General personnel subjects relating to both civilian and
military personnel are included in the 5000 series.
2000-2999 Telecommunications
Includes subjects relating to general communication matters and to communication systems and
equipment.
3000-3999 Operations and Readiness
Includes subjects relating to such matters as operational plans, fleetoperations, operational
training and readiness, warfare techniques, operational intelligence, research and development,
geophysical and hydrographic support.
4000-4999 Logistics
Includes subjects relating to the logistical support of the Navy and Marine Corps, including
procurement, supply control, property redistribution and disposal, travel and transportation,
maintenance, construction and conversion, production and mobilization planning, and foreign
military assistance.
5000-5999 General Administration and Management
Includes subjects relating to the administration, organization, and management of the Department
of the Navy , including general personnel matters concerning both civilian and military personnel,
records management programs, security, external and internal relations, audiovisual management,
law and legal matters, office services, office automation, and publication and printing matters.
6000-6999 Medicine and Dentistry
Includes subjects relating to medical matters such as physical fitness, general medicine, special
or preventive medicine, dentistry, medical equipment and supplies.
7000-7999 Financial Management
Includes subjects relating to the financial administration of the Department of the Navy, including
budgeting, disbursing, accounting, auditing, contract auditing, industrial and other special
50
financing matters, and statistical reporting.
8000-8999 Ordnance Material
Includes subjects relating to all types of ordnance material and weapons, including ammunition
and explosives, guided missiles of all types, nuclear weapons, fire control and optics, combat
vehicles, underwater ordnance materials, and miscellaneous ordnance equipment.
9000-9999 Ships Design and Material
Includes subjects relating to such matters as the design and characteristics of ships, and to ships
material and equipment.
10000-10999 General Material
Includes subjects relating to general categories of materials not included in the specialized
material groups. It includes audiovisual/graphic arts/photographic/television/video equipment and
accessories, general machinery and tools, personnel (materials), and miscellaneous categories.
11000-11999 Facilities and Activities Ashore
Includes subjects relating to ashore structures and facilities, fleet facilities, transportation facilities,
heavy equipment, utilities and services, and other similar subjects.
12000-12999 Civilian Personnel
Includes subjects relating solely to the administration of civilian personnel. Military personnel
subjects are included in the 1000 series. General personnel subjects relating to both civilian and
military personnel are included in the 5000 series.
13000-13999 Aeronautical and Astronautical Material
Includes subjects relating to aeronautical and astronautical material, including parts, accessories,
and instruments; special devices; armament; aerological equipment, weapons systems, types of
aircraft; and astronautic vehicles.
16000-16999 Coast Guard Missions
Includes subjects relating solely to administration and mission of the Coast Guard. NOT TO BE
USED BY NAVY OR MARINE CORPS ACTIVITIES.
When looking for a specific instruction, you should use NAVPUBINST 5215.1 (Consolidated Subject
Index). This publication includes: The Alphabetical Listing, Numerical Listing, Cancellation Listing, and the
DOD Implementation Listing. A listing of instructions issued by Washington, DC Headquarters
Organizations is issued twice each year. This numerically indexed, subject-categorized compilation will aid
in identifying active naval instructions applicable to addressee's programs or subject matter interests.
51
REFERENCE TELEPHONE NUMBERS
TYCOMS
AIRLANT Force Medical Officer
AIRPAC Force Medical Officer
FMFLANT Force Surgeon
FMFPAC Force Surgeon
DSN
8
DSN
8
DSN
4
DSN
0*
564-702
735-114
836-168
477-866
*Call your local DSN operator to see if applicable geographical area voice codes are required.
Naval Operational Medicine Institute (NOMI)
Commercial (850) 452-XXXX
DSN 922-XXXX
Commanding Officer
Accounting Division
Management Support
Command Master Chief
Data Analysis Department (Code 14)
Psychiatry Department (Code 21)
Otorhinolaryngology Department (Code 22)
Ophthalmology Department (Code 23)
Internal Medicine Department (Code 24)
Special Studies Department (Code 25)
Physical Exams Department (Code 26)
Training Directorate (Code 03)
Library
Aviation Physiology Training Dept. (Code 81)
Safety/Survival (NASTP) (Code 06)
Physical Qualifications Directorate (Code 42)
Operational Psychology Department (Code 41)
4554 / 4555 / 3679
4655 / 8143
8155 / 8144
4154
2171 / 2444
4238 / 3974
2657 / 3938
4558 / 3938
4349 / 4293
2157 / 8645 / 4672
2257 / 2258 / 9343 / 9344
2741 / 4659 / 2457 / 2458
2256 / 3517
2141 / 2142 / 2143
2681 / 4705
4501 / 4502 / 8744
2544 / 2516 / 2187
Naval Safety Center
Commercial (757) 444-XXXX
Commanding Officer
Administration
DSN
564-XXXX
7005
3520
52
Duty Officer
A/C Mishap Reports
Fax
Aviation Safety Dir.
A/C Operations Specialist
Air Operations
Air Traffic Control
Aeromedical Division
FSR
Physiology
Human Factors Engineering
A/C Mishap Investigators
3520
2929
7205
7225
7285
7281
7282
7228
7268
7230
7231
7240
Navy Environmental and Preventive Medicine Units
EPMU No. 2
Naval Station
Norfolk,VA 23511-6288
Com: (757) 444-7671
DSN: 564-7671
EPMU No. 5
Naval Station
Box143
San Diego, CA 92136-5143
Com: (619) 556-7070
DSN: 526-7070
EPMU No. 6
Box112
Pearl Harbor, HI 96860-5040
Com: (808) 471-9505
DSN: 471-9505*
EPMU No. 7
(Sigonella, Italy)
PSC 824 Box 2780
Com 39-95-56-4099
FPO AE 09623-2760
DSN: 624-4099*
*Call your local DSN operator to see if applicable
geographical area voice codes are required.
Navy Disease Vector Ecology and Control Center
Naval Air Station Jacksonville
Com
53
Jacksonville, FL 33212-0043
(904)542-2424
DSN 942-2424
Com
(360)315-4450
DSN 322-4450
Naval Submarine Base Bangor
Bangor, WA 98370-7405
Navy Environmental Health Center
2510 Walmer Avenue
Norfolk,VA 23513-2617
Com: (757) 363-5402
DSN: 864-5402
Armed Forces Medical Intelligence Command (AFMIC)
Com: (301) 619-7511 DSN: 343-7511
BUPERS
Selection Board
Officer Promotion
Head, Officer Separations Branch
MC Detailer
Officer Records
Fiche
Subspecialty Code Assignment
DSN: 224-3105
Com: (703) 614-3105
DSN: 224-2725
Com: (703) 601-2725
DSN: 224-3674
Com: (703) 614-3674
DSN: 225-7960/7961
Com: (703)695-7960
DSN: 224-1315
(Com: (202) 685-1770
for corrections)
DSN: 224-1315
(see MC Career Plans)
54
BUMED
Chief, Medical Corps
(Code 00MC)
Deputy Chief, Medical Corps
(Code 00MCB)
MC Career Plans Officer
(Code 00MCB4)
Aerospace Medicine
(Code 23)
Deputy Dir., Aerospace Medicine
(Code 23B)
Preventive Medicine & Occup. Health
(Code 24)
Medical Boards
(Code 311A)
Medical Dept. Special Pays Program Mgr.
(Code 525)
Assistant Special Pays
(Code 525A)
Assistant Special Pays
(Code 525B)
Deputy for Marine Corps Medical Matters
(Code 093M)
Deputy Director, Medical Programs
(Code 093M1)
DSN 762-3070
DSN 762-3063
DSN 762-3069
DSN 762-3453
DSN 762-3451
DSN 762-3500
DSN 762-3143
DSN 762-3362
DSN 762-3363
DSN 762-3364
Com (703) 614-4478
Com (703) 614-4478
Research & Development Command
R&D (CODE 026)
DSN: 295-0287
United States Air Force School of Aviation Medicine (USAFSAM)
Brooks AFB, San Antonio, TX
Com: (210) 536-1110 / 3500
DSN: 240-1110 / 3500
United States Air Force Aeromedical Research Lab (USAFAMRL)
Wright-Patterson AFB, OH
Com: (513) 225-4549
DSN: 785-4549
United States Army School of Aviation Medicine (USASAM)
55
Ft. Rucker, AL
Com: (334) 255-7409 / 7467
DSN: 558-7409 / 7467
United States Army Aeromedical Research Lab (USAARL)
Ft. Rucker, AL
Com: (334) 225-6920
DSN: 558-6920
Available Lines of Communication for ALSS Problems
Three Regional Coordinators:
OIC East Region, ASTC
Norfolk, VA
DSN: 564-3720 / 1329
Fax: (DSN) 565-9284
OIC Central Region, ASTC
Pensacola,FL
Com: (850) 452-3301 / 2102
DSN: 922-3301 / 2102
Fax: (850) 452-3404
OIC West Region, ASTC
Miramar, CA
DSN: 577-4159
Fax: (DSN) 577-6359
Federal Aviation Administration (FAA) Regional Flight Surgeons
Alaska
Central
(IA, KS, MO, NE)
Eastern
(DE, DC, MD, NJ, NY, PA, VA, WV)
Great Lakes
(IL, IN, MN, MI, OH, WS, ND, SD)
New England
(CN, ME, MA, NH, RI, VT)
Northwest Mtn
(ID, OR, WA, CO, MT, UT, WY)
(902)271-5431
(816)426-5096
(800)832-6421
(718)553-3304
(800)322-2180
(847)294-7491
(781)238-7300
(425)227-2300
(800)233-5811
56
Southern
(AL, FL, GE, KT, MS, NC, SC, TN, P. Rico, Virg. Isl.)
Southwest
(AR, LA, NM, OK, TX)
Western-Pacific
(AZ, CA, NV, HI, Guam, Am. Samoa,
Marshall Isl., Wake Isl.)
(404)305-6150
(817)222-5300
(310)725-3750
(800)471-6736
Civil Aviation Medical Institute (CAMI)
Oklahoma City, OK 73125
Chief, Aeromedical Certification Branch
Chief, Airman Certification Branch
Civilian Aircraft Accidents
(405) 954-4419 / 4821
(405) 954-3261
(405) 954-4173
Important Websites
NOMI
BUMED
DOD
NEDS
http://www.nomi.navy.mil/
http://support1.med.navy.mil/bumed/
http://www.dlaps.hq.dla.mil/websites.htm
http://www.dodssp.daps.mil/usndirs.htm
57
FLIGHT TIME REQUIREMENTS
As a designated Naval Flight Surgeon, you are required to maintain a current Aviation Medical
Examination, current physiology training requirements and a minimum of 48 hours of flight time per year.
Failure to maintain any of these requirements will result in loss of eligibility for flight pay, recoupment of
payments made for which you are not eligibile, and possible loss of designation.
Definitions:
1. Authorized Aircrew
Those personnel under orders to flight status who have met the requirements as outlined above. Your
orders should reflect assignment to a 2102 billet, indicating an authorized flight billet.
2. Creditable flight time.
a. Pilot time - time creditable as first pilot in control of the aircraft and copilot who is assisting the
pilot in control.
b. Special crew time - time not creditable as pilot or copilot, but serving as a member of the
authorized crew.
3. NAVFLIRS (Naval Flight Record Subsystem)
This new reporting system is the compiled source of individual flight data on Navy aircrew. Information
gathered through this system is used for a number of purposes including flight safety analysis, flight
qualification minimums and flight hour budgeting. Each aircrew member receives a monthly Individual
Flight Activity Report (IFAR) which lists a summary of your flight time for that month. Errors should be
corrected within 3 days of receipt of your IFAR either by your NATOPS officer, or by contacting the logs
and records clerk at the squadron with which you flew that mission.
4. Naval Aircraft Flight Record (Yellowsheet) OPNAV 3710/4.
This is the primary source of all flight data for Navy aircraft and aircrew. This form is sent to NAVSAFCEN,
where data is transfered to the NAVFLIRS and the IFARs.
5.Flight Readiness Evaluation Data System (FREDS).
This is the USMC equivalent of the Naval Aircraft Flight Record (also called the yellowsheet by USMC).
This is not compatible with IFARS and is not sent to NAVSAFCEN, but rather to Quantico, VA for the
Marine Corps System.
IFARS and FREDS constitute a data bank for valuable information regarding flight safety analysis, but also
to determine aircrew compliance with established minimum standards as previously noted.
If you fly with the Marine Corps, no entries will be sent to NAVSAFCEN. If you fly with the Navy in other
than your own squadron, there is little incentive for the squadron file clerk to transfer your data to the
submission form since you are not in that squadron Do not be surprised if your monthly IFAR needs
correction.
To save yourself considerable trouble, you would be well advised to:
 Get your name on each yellow sheet.
 Obtain a signed Record of Completed Flight Time (OPNAV 3760/37) and maintain them for your
entire career. (Also known as a transmittal form).
 Enter flight time in your Naval Aviator Log book, preferably verified periodically by your NATOPS
officer.
These will help you back up corrections of IFARS and substantiate the DOD Aviation requirements.
Your log book should be kept forever. Auditors have been known to try to recoup money even if you are
retired or in the civilian community. There is no statute of limitations for recoupment.
58
Annual Flight Requirements:
OPNAVINST 3710.7 outlines your minimum flight requirements for special crew as:
 Semi-annual - 24 hours
 Annual - 48 hours
These are the requirements to meet currency of flight qualifications only. For purposes of eligibility for
flight pay, the DOD PAYMANUAL is the document the auditors will use.
 The DOD flight pay manual requirement is - 4 hours per month, and is based on the fiscal year.
 "Banking" of flight time - hours flown in the preceeding five months, not already used to qualify for
flight pay may be used against the monthly four hour requirement.
 Catching up - you have three months to catch up if you fall behind on your monthly requirement.
In other words, if you have not flown at all in October and November (1st quarter) you must fly 12
hours in December to meet minimums. If you fly only 10 hours, you lose two months of flight pay,
not one, because the pay manual says you must fly 12 hours, but does not break it down by
month once you fall behind, and the "three month requirement" starts with the first month you fail
to meet your requirements. Since you failed to meet your requirement by the 3rd month, this
becomes the first month of your three month requirement and you lost two.
Flying while in a leave status:
Flight time thus acquired will count toward flight currency requirements but not for pay purposes.
Simulator time:
Flight time logged in a simulator may be used to fulfill up to 50% of annual flight proficiency requirements,
but it does not apply for pay purposes.
Summary of requirements for special crew:
 Annual Flight Physical Exam.
 Annual Flight Minimums.
 NAPTP (Physiology training) - every four years.
 NAWSTP (Water Survival) - every four years.
 Emergency Egress Training - annually.
Flight Surgeon Flying Policy:
You are only authorized to fly operationally when under DIFOPS Orders, assigned to 2102 billet or
enrolled in the Aerospace Medicine Residency Program.
You may fly in actual control of any dual controlled aircraft in all phases of flight if a NATOPS qualified pilot
is occupying the other cockpit seat (CNO Msg 252228Z May 78).
59