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NAVY MEDICINE Vol. 84, No.3 May-June 1993 PDF

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NAVY MEDICINE May-June 1993 Surgeon General of the Navy NAVY MEDICINE Chief, BUMED VADM Donald F. Hagen, MC, USN Vol. 84, No.3 Deputy Surgeon General May-June 1993 Deputy Chief, BUMED Chief, Medical Corp8 Department Rounds RADM Robert W. Higgins, MC, USN I Branch Navy Hospital Adak to the Rescue HMCM(SW) C. Phillips, USN 3 Flag Officer Selectees Editor Jan Kenneth Herman 5 Commander Seventh Fleet Conducts First Medical Symposium LT J.E. Brooks, USN CDR N. Jones, USN Asllltant Editor Virginia M. Novinski Forum 8 The Cost of A voiding Risk Editorial ~nt CDR J.A. Brown, MC, USN Nancy R. Keesee 10 Navy Nurse Corps: 85 Years of Service Features 12 Corpsmen Scale Cliff to Rescue Accident Victim H. S. Samuelson NAVY MEDICINE. Vol. 84, No. 3, (ISSN 0885·8211 USPS 311..070) Ia publlahed blmonlhty by the ~ ol the 14 The Gospel on Leadership According to John NIIVY. BurMu ol MediCine and Surgery (BUMED OIH~ Waahlngton. DC 20372·5120. Sec:ond-clasa po.tage paid CAPT J.B. Cotton, MC, USNR W. ...l ngton. DC. and edcllll-maiNng olllc:ea. caPreO oS1T NMaAvSaTl EPRul:l lSlceanldlo -na a-nd Fcorhmaa e-leon N.. A-TrT llNe:d Cico/ndee 16 A Comparison of Navy and Civilian Health Habits 301, 5801 Tllbor AYMiue. PIIHaclelphla, PA 11120. M.A. Hoffman, Ph. D. POLICY: NMty AHdicine is the olllclal publication ol the V.S. Freeman, M.A., M. T. (A.S. C.P.), S.C. HIIVY MediCal Dapartment.llla inlllnded for Medical Depart LT C.L. Behmer, NC, USNR - periOIWiel and contalna prolaeionallnformation Nla llft 1o medicine. clentlatry, and the aiMed health IICienceaJ S. Kangas-Packett, M.S.N. Oplnlona exptWMCI are .,_ ol the aulhora and do noi T. M. Kaplan, M.S. N. -rlly rapNaalllllla official poalllon ol the Dapartment ol the Navy. lila BurMu of Medicine and Surgery, or any olllaroo-n....,... ~or agency. Trade nama. .r a 20 Chronology- World War II: Navy Medicine May-June 1943 uaec1 for iclanllflcation only and do notr .,-an anci«M J. Mitchum mant by the Dapa-of lila Navy or the BurMu of Medi cine and Surgery. Although N-r lledlcine may cite or axtrac1 from diractlvaa,.. ,a..u.nlllcoari.t y for action ahould ba Professional obtained lrom lila clled DISTRIBUnON: Navy lledlci,.la cllatributed to active clulj 26 Rapid Screening for Biological Threat Agents by the MediCal Daper1mant ,.._... ... via lila Standard Navy Dlatri Polymerase Chain Reaction butlon Uat. The following cllelrlbullon Ia aulllortzad: ona copy CDR J.R. Campbell, MSC, USN for each Medical. Danlal. Medlclll SeMca. and Nu-CorP'! o111car; ona copy for aach 10 anNIIed Medical Dapartment CDR S.E. Walz, MSC, USN lll8lllbara. 1'-quaata 1o inctaUe or clacr.a lila number ol CDR J.R. Crabbe, MSC, USN allolled coplaa lhoulcl ba for-.Md lo N•vyA Hdicinevi8111a CAPT W. W. Schultz, MSC. USN local command. NAVY MEDICINE Ia pullllahed from appropriated lunda authority olllla Bureau o1 Medicine and Surgery in accord Notes ance with Navy Publlcallona and Printing Ratulallona P-~ Tha s.c..wy olllla Navy haa determined lhallhia publica 7 Naval Medical Research and Development Command Highlights lion Ia -ry In lha tranuctlon ol bual-required 18w oflha Dapa-ollha Navy. Funda for prtnang IIIIa A Look Back publlcallon have bean approved by lha Navy Publlcallo111 and Prtntng Polley Commlltea. Mlclea. 1a1tera. and a--. 29 Navy Medicine 1919 c:hangM may ba lorW8rded 1o lha Eclllor. Navy lledlciMj Dapartmant of lha HI!VY. Bu..u o1 Medicine and Surgery (BUMED OIIH), Walhington, DC 20372-5120. T~ (Area Code 202) 153-1237, 153-1217; Aulovon 214-1237 214-1217. Contrtbutiona from lhallalclare walcoma and ba published aa apace parmita, aubjact 10 editing and poul COVER: HM3 James F. DeJanon examines a patient at Branch Medi bi8 abriclgmanl For ula by lila Superintendant of Documanta, U.S. cal Clinic, Marine Corps Recruit Depot, San Diego, CA. As the Hospi Gover~ Printing Olfica. Waahington, DC 20402. tal Corps celebrates its 95th anniversary, corpsmen continue a proud tradition of service to the Navy and Marine Corps. Story on page 12. NAVMED P-5018 Department Rounds Branch Navy Hospital Adak to the Rescue A t 0230 on 6 April 1993, the needed to land immediately. Attempts landed at Shemya AFB-325 miles duty officer at U.S. Branch by Branch Navy Hospital Adak to west of Adak in the Aleutian chain, Navy Hospital Adak received divert the airliner to Adak, where med with a staff of one medical officer and a phone call for help. It was from the ical capabilities are more readily avail three medics. They called Navy medi sole Air Force medical officer at able, were futile. The traumatic air cine, which was standing by, ready to Shemya Air Force Base, Shemya turbulence that injured more than half assist. Island, AK. A civilian Chinese airline the 265 passengers aboard had The 15-bed, 75-person Branch Navy was attempting an emergency landing. seriously damaged the aircraft, and the Hospital immediately initiated a total The pilot stated that he had many pilot was unsure of its airworthiness. staff recall. By 0410 everyone had seriously injured passengers and At 0355 the airliner and its injured arrived. Within an hour, a 12-member Left to right: HM1 Geoffrey Hughes, HM3 Jason Farlow, and LT Jeff McNeil prepare to place an IV into one of the victims of the Chinese airliner accident. May-June 1993 HM3 Dennis Matlock, LT Brian Smullen, and LCDR Chris Stokke check vital signs as HMC Robert Spindle looks on. medical team was identified for mobi lization to Shemya, contingency sup plies were gathered, and people and packages were loaded aboard a P-3 from VP-40's Fighting Marlins, an air squadron stationed at NAS Adak. Upon landing at Shemya, about an hour after takeoff, the team quickly assessed the situation and called for additional supplies and medical staff. Again, Branch Navy Hospital Adak was standing by to assist and answered the call. An additional 13 staff members and the urgently needed medical supplies were soon aloft in N AS Adak's C-130 transport and arrived at Shemya by 0900. The three medical officers, two nurse anesthetists, one Medical Ser vice Corps officer, and six hospital corpsmen of the Branch Navy Hospi tal's first team were joined by three Nurse Corps officers, another Medical Service Corps officer, one Army vet erinarian, one Army vet tech, and seven more hospital corpsmen. As Adak's teams arrived, they immediately joined the four on-site Air Force medical personnel in triag ing the 265 passengers, many of whom were very critically injured and were still inside the MD-11, a modified DC- 10 aircraft. Triage and immediate lifesaving using the P-3 that had brought the first treatment and medical evacuation of procedures took an hour and a half. Navy medical team to the scene. 89 critically and seriously injured pas Then medical evacuation could begin. By 1100, 15 additional patients had sengers. By 1500 the 60 less seriously Using an Air Force RC-135 that had been evacuated via a Coast Guard C- injured passengers had been evacuated been at Shemya at the time of the 130. Finally, at 1228, the last of the by an Air Force C-141. crisis, the first 27 critically injured pas seriously injured passengers were News service reports indicated one sengers were medevaced to Anchor evacuated off Shemya Island by NAS passenger died of his injuries. Without age. With them were Navy physicians, Adak's C-130, which carried 38 U.S. Branch Navy Hospital Adak's nurses, and corpsmen, who provided patients attended by 4 Navy medical rapid and capable response, the toll inflight medical care. At Shemya, personnel. would have been higher. o triage and treatment continued, and In the space of 8 hours, the Branch - Story by HMCM(SW) Clifford Phillips, the joint Navy-Army-Air Force medi Navy Hospital had mobilized 25 staff Command Master Chief, Director for Adminis cal team prepared and evacuated 10 personnel, moved more than 2 tons of tration, U.S. Branch Navy Hospital, Adak, AK. more critical patients to Anchorage, supply items, and provided lifesaving Photos by JOI Walter H. Panych. 2 NAVY MEDICINE Flag Officer Selectees R ADM-selecteeJamesHoward Association of Military Surgeons of tion, Sea Service Ribbon, and Over Black, MC, assistant chief of the United States; Association of seas Service Ribbon (with two bronze staff for fleet medical/ fleet Military Osteopathic Physicians and stars). surgeon on the staff of the Com Surgeons (past president I 982-1984); mander in Chief U.S. Pacific Fleet, Texas Osteopathic Medical Associa RADM-selectee Noel K. Dysart, Pearl Harbor, HI, was born in Camp tion; Society of U.S. Naval Flight MC, assistant chief for plans, analysis Hill, P A. He received his B.A. degree Surgeons; Aerospace Medical Asso and evaluation, Bureau of Medicine from Gettysburg College, Gettysburg, ciation; member, Joint Committee of and Surgery, is a native of east St. PA, and his D.O. degree from Phila Aviation Pathology (1977-1980); Louis, IL. He attended several colleges delphia College of Osteopathic Medi member, Naval Aviation Evaluation in Minnesota and received his B.A. cine, Philadelphia, P A. He completed Board at Chief of Naval Personnel degree from the University of Minne a rotating internship and an anesthesi (1977-1982); military representative, sota in 1967. ology residency at Fort Worth Osteo Alumni Board of the Philadelphia Following acceptance to medical pathic Hospital, Fort Worth, TX. College of Osteopathic Medicine; school, he was commissioned an Subsequently, Dr. Black entered pri member, Committee on Postdoctoral ensign in the Navy 1915 Early Com vate practice and served as a member Training of the A.O.A. (1984-1986), missioning Program in May 1966. He of the Admissions Committee and was San Diego Osteopathic Medical Asso received his medical degree from the appointed clinical instructor at the ciation; and delegate, A.O.A. House University of Minnesota on 10 June Texas College of Osteopathic Medi of Delegates on six occasions. 1970 and completed a straight pediat cine during 1973 and 1974. His military awards include the ric internship followed by I year of After being commissioned in the Legion of Merit (two awards), Meri pediatric residency at Children's Medical Corps, he completed a course torious Service Medal with gold star Orthopedic Hospital and the Univer in aerospace medicine at the Naval (two awards), Navy Commendation sity of Washington, Seattle, W A. Aerospace Medical Institute in Pen Medal, Meritorious Unit Commenda- He was assigned to the Naval Hospi sacola, FL, and was designated a flight tal, Bremerton, W A, as a pediatrician surgeon in March 1975. Subsequent in June 1973 and then moved to San duty assignments include: senior medi Diego, CA, for a final year of resi cal officer, USS Ranger (CV-61); dency and a 2-year assignment as a head, Aerospace Physical Examina staff pediatrician before moving to the tion Review Section, Bureau of Medi University of Minnesota for a 2-year cine and Surgery; assistant for medical fellowship in pediatric nephrology. officer distribution, Bureau of Medi Subsequently, he returned to San cine and Surgery; senior Medical Diego where he was assigned as a staff Corps assignment officer, Naval pediatric nephrologist with additional Military Personnel Command; region responsibilities as director of The Elec al healthcare coordinator, Naval tron Microscopy Laboratory in the Regional Medical Center, Oakland, Clinical Investigation Center. During CA; commanding officer, Naval Hos this tour, he was the operational medi pital, Oak Harbor, WA; commanding cine training coordinator and the officer, Naval Hospital, Yokosuka, director of interns. In 1982, he was Japan; and force medical officer, assigned to the Naval Health Sciences Naval Surface Force United States Education and Training Command as Pacific Fleet. director, Medical Corps Programs Dr. Black is affiliated with the and Clinical Investigations. Shortly American Osteopathic Association; CAPT James H. Black, MC thereafter, he transferred to the newly May-Jure 1993 3 dation Medal, and National Defense Medal with bronze star. RADM-selectee M. Eugene Fussell, MC, USNR, force medical officer, Reserve Naval Construction Force, Gulfport, MS, and reserve specialty advisor to the Surgeon General in orthopaedic surgery, Bureau of Medi cine and Surgery, is a native of Black shear, GA. He received his B.S. degree in chemistry from Morehouse College, Atlanta, GA, in 1959 and his doctorate degree from Meharry Medical Col lege, Nashville, TN, in 1964. While a freshman medical student, he was commissioned an ensign, United States Naval Reserve in the 1915 pro CAPT Noel K. Dysart, MC gram. He did three internships at U.S. CAPT M. Eugene Fussell, MC, USNR Naval Hospital, Bethesda, MD, in the created position of assistant for pro summers of 1961, 1962, and 1963. (Port Hueneme), and NR NAY fessional education, Office of the After completing a rotating intern HOSPCPEND. From 1987 to 1990, Director of Naval Medicine. After ship at George W. Hubbard Hospital, Dr. Fussell served as director, health serving as director, Medical Education Meharry Medical College, he was services, COMNAYREDRESCOM and Training (OP-939), Dr. Dysart called to active duty in June 1966. He Reg 19, San Diego, the largest RED reported to Naval Hospital, Roosevelt was assigned to the ADCOM Com COM in the nation. Roads, Puerto Rico, as executive mand at Great Lakes Naval Training During the Marine Corps Cold officer in July 1986. From June 1988 Center, Great Lakes, IL. Subse Winter '89 exercise in Norway, Dr. to June 1990, he served as executive quently, he was augmented to the Reg Fussell served as brigade surgeon. In officer of the Naval Health Sciences ular Navy and was assigned as a 1991 he was selected to work on an Education and Training Command. first-year resident in general surgery at elite group of naval officers to serve on Following a 2-year tour as command U.S. Naval Hospital, St. Albans, NY, OP-06 Innovative Naval Reserve ing officer, Naval Hospital, Groton, in June 1967. In 1968, he was assigned Workshop, Newport, Rl. CT, he assumed command of Naval to U.S. Naval Hospital, San Diego, In civilian life, Dr. Fussell partici Hospital, Jacksonville, FL, in June CA, as a second-year resident in ortho pates in several civic activities. He was I 992. In April 1993, Dr. Dysart paedic surgery. He completed his chief of staff at St. John's Regional reported to the Bureau of Medicine residency in I 970 and then served as Medical Center in Oxnard and now and Surgery. chief of orthopaedic surgery, U.S. serves on the board of directors of St. Dr. Dysart is certified by the Ameri Naval Hospital, Port Hueneme, CA, John's Pleasant Valley Hospital in can Board of Pediatrics and holds at the Construction Battalion Center. Camarillo, CA, and St. John's state licenses in Washington and Min He became board certified in ortho Regional Medical Center in Oxnard. nesota. He has authored or co paedic surgery in 1972 and in Sep He is a fellow of the American authored nine articles published in tember of that year, Dr. Fussell Academy of Orthopaedic Surgeons medical literature. He is a member of resigned his regular commission and and a diplomate of the American Alpha Omega Alpha, the American became a reservist. In addition, he Board of Orthopaedic Surgery. He is Academy of Pediatrics, American began private practice in Oxnard, CA. also a member of the National Medical Medical Association, American His first reserve assignment was Association, American Medical Asso Society of Nephrology, and Associa consultant to the commanding officer, ciation, and California Medical Asso tion of Military Surgeons of the U.S. Naval Hospital, Port Hueneme, ciation. United States. He is past alternate CA. He served in this capacity for 3 In addition, Dr. Fussell is a life chapter chairman and past president years and then became officer in member of the Naval Reserve Officer of the Uniformed Services Chapter charge, 1st MARDIV MED Detach Association, Reserve Officer Associa East of the American Academy of ment, Camp Pendleton, CA. Subse tion, Flying Physicians Association, Pediatrics. His awards include the quently, he became commanding and U.S. Naval Institute. His military Legion of Merit, Meritorious Service officer of NR NAYHOSP Unit Camp decorations include the Meritorious Medal with gold star, Navy Commen- Pendleton, NR NAYMEDCL 119 Service Medal. o 4 NAVY MEDICINE Commander Seventh Fleet Conducts First Medical Symposium M edical care throughout the for Surgeons General is a very signifi 62) and in the Seventh Fleet Flagship, world varies as much as the cant initiative. The fact that nations USS Blue Ridge (LCC-19); toured culture, customs, and the are sending such senior medical per Naval Hospital Yokosuka and Sagami foods it eats. For sailors and troops sonnel is indicative of the importance Army Contingency Hospital; and deployed overseas, finding this quality they attach to it, and we certainly con received briefings on the mission of care in unfamiliar parts of the globe cur," continued V ADM Wright. U.S. Seventh Fleet and the Navy's can be a life or death search. Attending Seventh Fleet's Western future outlook defined in". . . From In an effort to identify medical care Pacific Medical Symposium for Sur the Sea." facilities in the western Pacific and to geons General were senior medical Commander in Chief Pacific Fleet exchange medical information and officers from Indonesia, Malaysia, Surgeon, CAPT James H. Black and expertise, Commander, U.S. Seventh Philippines, Thailand, and Japan. In Japan Maritime Self-Defense Force Fleet recently held its first-ever addition to the opportunity to ex Surgeon General, RADM Hiromichi Western Pacific Medical Symposium change professional information and Oiwa also attended the symposium for Surgeons General from regional background on each nations' medical and made remarks to the multina- nations on 6-8 April 1993. service, symposium attendees toured tiona! force surgeons general. "It was another step in the growing shipboard medical facilities in the air CAPT M. Hollis Tanksley, Seventh cooperation between the United States craft carrier USS Independence (CV- Fleet Surgeon, says he initiated the and the nations of the Asia-Pacific region. I think a Jot of goodwill came from sharing ideas and concerns," said VADM Tim Wright, Commander, U.S. Seventh Fleet. One of the greatest concerns for the Seventh Fleet is identifying medical facilities within its 52-million-square mile area of responsibility which can be accessed in a medical evacuation or contingency situation. Although all U.S. Navy ships have trained medical personnel and facilities, shipboard capabilities can only, in most cases, stabilize patients with serious injuries and illnesses until they can be trans ported to modern hospitals for defini tive treatment. "We sometimes have to rely on the indigenous facilities (of some coun tries) as some of our ships transit through, particularly the combatants and smaller ships which don't have USS Independence's senior medical officer, CDR Dennis extensive medical capabilities. The Deakins, shows the aircraft carrier's medical facilities to Western Pacific Medical Symposium senior medical personnel. May-June 1993 5 \J f' z "' ::::> ~ 0 0 0. , ~ ;;;: a: 0 () ~ B 0 &~~~~~~~~~~~~~~~~~- Surgeons General from Malaysia, Indonesia, Thailand, Japan, and the United States gather In the operating room of USS Blue Ridge. conference because it was apparent to Charron, organizing and hosting a ing sailor prompt medical attention. him, during visits to nations in the medical symposium at the U.S. Navy's Because the Seventh Fleet flagship western Pacific with the Fleet Com forward-deployed base in Yokosuka, visited Madras, India, several months mander, that the U.S. Navy's medical Japan, required a little more advance earlier and medical facilities within role and responsibility in that area was planning than just compiling a sched India were explored by CAPT not well understood. Additionally, the ule of events. Obtaining the required Tanksley during that visit, it was deter medical capabilities of those nations country clearance for the multina mined that quality treatment was were not well known to the U.S. Navy, tional medical officers required liaison available in the area. explained CAPT Tanksley, and a with the Japan Maritime Self-Defense "We had to medevac that person common ground was needed. With Force, Commander U.S. Forces ashore and because we were familiar that goal in mind, the first Western Japan, and Commander, Naval with the nearby medical facilities, we Pacific Medical Symposium was or Forces Japan. were able to get her to a hospital where chestrated. "No small share of the credit goes to she underwent surgery, did very well, "To have interoperability, you have our Japanese hosts who have been and is now fully recovered," recalled to have a beginning point and I hope very gracious and took an active role VADM Wright. this symposium is the first step. This in the presentations," stated V ADM Seventh Fleet's first-ever Western gives us the opportunity to start or Wright. Pacific Medical Symposium for Sur continue a dialogue with those nations The importance of understanding geons General has opened the door for we interact with," said CAPT the medical capabilities in regions further discussions to understand the Tanksley. where soldiers, sailors, airmen, and medical care facilities and practices in CAPT Tanksley hopes that more marines operate is vital to force sub the region where the Seventh Fleet medical symposia will be conducted in stainability and survivability. This was operates. With a solid foundation the future to explore deeper areas of most apparent during a recent medical established, quality medical care for the medical profession dealing with evacuation of a woman sailor aboard U.S. sailors, marines, airmen, and equipment, infectious diseases, USS Cape Cod who suffered from an soldiers is quickly becoming avail medevac procedures, and possibly acute appendicitis. With the ship able- wherever they operate. o combined medical exercises. steaming toward the Persian Gulf and -LT James E. Brooks and CDR Norris According to Assistant Seventh the nearest land being India, quick Jones, Commander Seventh Fleet Public Fleet Surgeon's, HMCS William decisions were required to get the ail- Affairs Office. 6 NAVY MEDICINE Naval Medical Research and Development Command Highlights Bethesda, MD • New Submarine Rescue Manual equivalent" model development by NAMRL a series of The Naval Submarine Medical Research Laboratory irradiation tests will measure specific absorption rates (NSMRL) provided undersea medical officers and sub (a measure of energy absorption within the human marine crew rescue teams with a valuable resource, the body}. Reliable RFR protective suits are products that Pressurized Submarine Rescue Manual (NSMRL have been long-awaited and anticipated by industries Report No. 1178, 22 June 1992), to assist in rescuing that use radiofrequency technology. The principal survivors of a disabled submarine. NSMRL scientists investigator for NAMRL will be Dr. Richard G. Olsen, conducted extensive pulmonary oxygen toxicity and Head, Bioengineering Division. For more information decompression research to establish the safe procedures contact CDR J.R. Beddard, MSC, NMRDC Research outlined in the manual. Various methods of safe decom Area Manager for Fleet Occupational Health, DSN pression from 132 fsw were explored and researchers 295-0885 or Commerical 301-295-0885. developed decompression tables for air, nitrox, and * * * trimix gas mixtures. Further work on decompressing with a trimix gas led to a 1.5 day decrease in decompres sion time when compared to standard saturation rates. • Genetics of Motion Sickness The manual reviews concepts of pressure, hypoxia, Motion sickness and disorientation are significant oper hyperoxia, and atmosphere contamination. Factors ational concerns for the Navy and Marine Corps. Cur affecting the decision of a crew to either escape to the rent studies have documented an unacceptably high surface or await rescue are examined. Included are incidence of motion sickness in aircrew and shipboard algorithms (decision trees) which when incorporated personnel. Studies also have recognized that, in the with decompression procedures could be useful under a underwater environment, sensory conflicts, body fluid variety of rescue scenarios. The information in the redistribution, and nitrogen narcosis make Navy divers manual represents a synthesis of material from many highly susceptible to motion sickness. Researchers at sources. The manual is intended to supplement the the Naval Health Research Center, San Diego, CA; the Submarine Rescue Manual ATP 57 and the Search and Wayne State University School of Medicine, Detroit, Rescue Instructions ATP IO(d), Chapter 8. For more Ml; and the University of Michigan Medical School, information contact CDR B. Schibly, MC, NMRDC Ann Arbor, MI, are investigating a new approach to the Research Area Manager for Submarine and Diving problem of motion sickness. They are focusing on the Medicine, DSN 295-0879 or Commercial301-295-0879. cellular and molecular physiology of gene expression to determine if a predisposition to motion sickness is an * * * inherited trait. Genetic differences in the complement of receptors on autonomic neurons of the central and • Radiofrequency Radiation peripheral nervous system could explain the differences Protective Suits in an individual's susceptibility to motion sickness. Pre The Naval Aerospace Medical Research Laboratory liminary findings suggest that a genetic polymorphism (NAMRL), Pensacola, FL, has entered into a Coopera of the alpha-2 adrenergic receptor (encoded by chromo tive Research and Development Agreement (CRDA) some 10) is associated with development of motion with Maxwell Safety Products, Ltd., of Smithtown, sickness. This approach can also be used to understand NY. This action is taken under the authority of the the variations in human responses to other physical Federal Technology transfer Act of 20 Oct 1986, as stresses in the operational environment, such as a pre amended. Under CRDA, Maxwell and the Bioengi disposition to heatstroke or gravity-induced loss of neering Division of NAMRL will work together to consciousness. For more information contact Ms. perform highly specialized tests regarding the effective Christine Eisemann, NMRDC Associate Director for ness of NAPTEXTM radiofrequency radiation (RFR) Research Management, DSN 295-0882 or Commercial protective suits. Using the uniquely valuable "human- 301-295-0882. May-June 1993 7 Forum The Cost of Avoiding Risk CDR James A. Brown, MC, USN isk is inherent to the clinical practice of med quietly translated to not surgically intervening with R icine. Every surgical intervention, prescribed out the promise of a predictably safe outcome. Fear medication, and many diagnostic studies en stalked the corridors of naval hospitals, shadowed by tail potential hazards. The possibility of errors of a perceived need for perfection, which led to indeci omission and commission exists whenever patients siveness and professional stagnation. Consequently, are evaluated and treated, even when the caregiver is complicated cases were sent elsewhere at greater attentive, highly trained, and conscientious. Physi expense to the patient and taxpayer, often for less cians constantly weigh the risk/ benefit ratio in liter than or, at best, equal quality of care. Meanwhile, ally hundreds of daily decisions. The same is true for Navy surgeons' skills atrophied and many qualified those in leadership positions, where numerous com surgeons left active service to practice the full realm peting interests must be considered in every manage of their specialty in the civilian sector where they were ment decision. Effectiveness is dependent upon good most welcome. judgment and decisiveness. Although risks must be Another costly attempt to eliminate risk is the minimized, they cannot be completely eliminated. To implementation of restrictive policies after a single demand such is unrealistic. bad outcome. Certainly every complication should be "Cast out fear!" is one of the basic tenants of total carefully scrutinized for lessons learned, and policies quality leadership (TQL), today's management phi to minimize risk should be developed. But extreme losophy endorsed by Navy leadership in both line and cases rarely make good policies, and the zeal to pre medical communities. It means to sweep away the vent recurrent complications often results in limita fear of failure. Yet, this concept requires some clarifi tions upon the entire community in which the cation. The fear of failure is not necessarily a bad complication occurred. Nonphysician health care thing; it shields one from the capricious pursuit of providers are particularly vulnerable to such restric foolish or dangerous acts, and motivates when irre tions. Consequently, policies such as the following sponsibility or sloth beckon. But the fear from which might be put into effect: independent duty hospital we need to be free is that which stifles creativity and corpsmen are not allowed to see dependents, physi moral courage simply because risk is involved. cian assistants are forbidden to order a particular In the mid-1980's well-trained Navy surgeons were medication, nurse midwives are prohibited from encouraged to refer many patients who needed high ordering obstetrical ultrasounds without an obstetri risk operations to CHAMPUS (Civilian Health and cian's approval, or certified registered nurse anesthe Medical Program of the Uniformed Services) be tists are denied the opportunity to perform pediatric cause to incur a bad outcome, regardless of the ap anesthesia. While designed to reduce risk, such poli propriateness of the care rendered, was to place one's cies only reduce availability of patient care and in professional future in jeopardy. Or, more often, hibit professional satisfaction. In spite of adequate though not usually spoken, it was to jeopardize the training, a provider may be prohibited from practic commanding officer's professional future, which ing safely those skills that were arduously obtained. 8 NAVY MEDICINE

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