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NAVY MEDICINE March-April 1994 Surgeon General of the Navy NAVY MEDICINE Chief, BUMED VA DM Donald F. Hagen, MC, USN Vol. 85, No. 2 March-April1994 Deputy Surgeon General Deputy Chief, BUMED Department Rounds Chief, Medical Corps 1 Flag Officer Selectees RADM Richard I. Ridenour, MC, USN 3 Learning Survival at Naval Hospital Cherry Point Editor CPL D. C. Hottle, USMC Jan Kenneth Hennan 6 The "Miracle" of Flight 808 Assistant Editor CDR M T. Curran, DC, USNR Virginia M. Novinski 10 Naval Reserve Bolsters Navy Pilot ProgTam Editorial Assistant Nancy R. Keesee P. Antenucci NAVY MEDICINE, Vol. 85, No. 2, (ISSN 0895-8211 Features USPS 316-070) is published bimonthly by the Depart· 12 Strategic Planning and TQL at Doctrine Center ment of the Navy, Bureau of Meditine and Surgery (BUMED 09H), Washington, DC 20372-5300. Second· LCDR B. Johnson, MSC, USN tlass postage paid at Washington, DC, and additional mailing offites. POSTMASTER: Send address tbanges to NtwyMedl· 16 Malaria (Part1): Lessons From Somalia and General Slim cme tare Navy Publitations and Forms Directorate, AT IN: CDR JM Crutcher, MC, USNR Code 10363,5801 Tabor Avenue,Pbiladelphia,PA 19120. POLICY: Ntwy Med1cme is the offitial publication of LCDR T. W. Sharp, MC, USN the Navy Medical Department. his intended for Medical CDR MR. Wallace, MC, USN Department personnel and tont ams professional informa· lion relative to meditine, dentistry, and the allied health CAPT S.L. Hoffman, MC, USNR sciences. Opinions expressed are those of the authors and do not necessarily represent the official position of the Department of the Navy, the Bureau of Medicine and 20 Chronology-World War II Navy Medicine March-April1944 Swgery, or any other governmental department or agency. Trade names are used for identification only an do not J Mitchum represent an endorsement by the Department of the Navy D. Klubes or the Bureau of Medicine and Surgery. Although Ntwy Medicine may cite or extratt from directives, authority for action should be obtained from the cited referente. Professional DISTRIBUTION: Navy Med1cme is distributed to attive duty Medital Department personnel via the Stan· 24 Approach to Bleeding Disorders dard Navy Distribution List. The following distribution is authorized: one topy for eath Medical, Dental, Medical CDR JN Frame, MC, USN Service, and Nurse Corps officer; one copy for each I 0 enlisted Medical Department members. Requests to in· crease or decrease the number ofa llotted copies should be Notes and Announcements forwarded to Ntwy Medicine via the local command. 15 Naval Medical Research and Development Command Highlights NAVY MEDICINE is published from appropriated funds by authority of the BureauofMeditine and Surgery 28 Naval Health Sciences Education and Training Command Highlights in accordance with Navy Publications and Printing Regu· lations P-35. The Secretary of the Navy has determined that this publication is netessary in the transaction of A Look Back business required by Jaw of the Department of the Navy. Funds for printing this publicatico have been approved by 29 Navy Medicine 1958 the Navy Publications and Printing Polity Committee. Articles, letters, and addressthaages may be forwarded to the Editor, Ntwy Medicine. Department of the Navy, Bweau of Medicine and Surgery (BUMED 09H), Wash ington, DC 20372-5300. Telephone(Area Code 202) 653- COVER: Anopheles mosquito taking a blood meal, superimposed on a 1237, 653-1297; DSN 294-1237, 294-1297. Contribu malaria blood stage infection. Three P. ovale trophozoites are visible. tions from the field are welcome and will be published as spate permits, subject to editing and possible abridgment. Story on page 16. Photos by Dr. E. Rowton, Walter Reed Army Institute For sale by the Superintendent of Docwnents, U.S. of Research, Washington, DC, and LT Ellen Andersen, USN, Armed Government Printing Office, Washington, DC 20402. Forces Institute of Pathology. Digitized imagery by Moses Jackson, NAVMED P-5088 NSHS, Bethesda, MD. Department Rounds Flag Officer Selectees R ADM-selectee Joan M. and American Association for Coun Engel, NC, deputy director of seling and Development. Her deco the Navy Nurse Corps, is a rations include the Meritorious Ser native ofS t. Marys, P A. She is a 1961 vice Medal (4 awards), Navy Com graduate ofMercy Hospital School of mendation Medal (two awards), and Nursing, Buffalo, NY, and received a the National Defense Medal (two Bachelor of Education in Public awards). School Nursing from Clarion Univer sity, Clarion, PA, in 1969. CAPT RADM-selectee Jerry K. John Engel was Navy sponsored in 1981 to son, DC, dental officer of the Marine attend the University ofA labama, Bir Corps, was born in Waukesha, WI, on mingham, AL, earning a Master of 30 Jan 1945. After completing 2 Science in Nursing degree with a dual years of predental study at Carroll major in community health nursing College he went on to receive his and nursing administration. She has D.D.S. degree in 1969fromMarquette attended numerous Navy-sponsored University School ofDentistry. Ad leadership and management courses, CAPT Joan M. Engel, NC ditionally, he completed a rotating and was the first Navy Nurse Corps dental internship at Philadelphia Na officer to attend the Johnson & sponsored study groups. In 1990 she val Hospital in 1970 and earned an Johnson Wharton Fellows Program participated in the Navy Women's M.S. in fixed prosthodontics from the in Management for Nurses. Study Group to assess the status and University ofMissouri at Kansas City CAPT Engel has had a variety of evaluate the implementation and effi School ofDentistry in 1975. duty stations and assignments since cacy ofr ecommendations made in the Dr. Johnson was commissioned in entering the Nurse Corps as a lieu 1987 Report on Progress of Women the Navy Reserve 1925 Program in tenant in 1969. Clinical nursing as in the Navy. In 1990 she also served 1965 and commenced active duty signments include Naval Hospital, as chairperson oft he Ethnic Minority immediately upon graduation from Millington, TN; Branch Medical Study Group, a recruitment and re Clinic, lwakuni, Japan; Naval Hospi tention task force developed to exam tal, Charleston, SC; Branch Medical ine ethnic and minority issues within Clinic, LaMaddalena, Sardinia; and the Nurse Corps. In 1993 she served Naval Hospitals, Jacksonville, FL; as chairperson oft he Medical Depart Pensacola, FL; and Newport, RI. Ad ment Officers in Recruiting Process ministrative assignments include Bu Action Team, a model team with rep reau ofMedicine and Surgery, Wash resentation from the Bureau ofNaval ington, DC, where she was the first Personnel, Navy Recruiting Com junior Nurse Corps detailer; Naval mand, and Bureau of Medicine and Medical Command, Northeast Re Surgery. gion, Great Lakes, IL, where she was CAPT Engel is a Wharton fellow the first assistant chief of staff, logis and a member oft he American Nurses tics; and both Naval Inspector Gen Association, Pennsylvania Nurses eral, Washington, DC, and Medical Association, Association of Military Inspector General, Bureau of Medi Surgeons oft he United States, Ameri cine and Surgery, Washington, DC. can Association of Nurse Execu CAPT Engel has had the opportu tives, Navy Nurse Corps Association, nity to serve on a variety of Navy- Sigma Theta Tau, the Naval Institute, CAPT Jerry K. Johnson, DC March-April 1994 dental school. After completion of Ribbon, National Defense Service year peripheral vascular surgery fel his dental internship and being aug Medal, and Sea Service Deployment lowship. He stayed on in San Diego mented into the Regular Navy in 1970, Ribbon. as a staff vascular surgeon, and in he was assigned as assistant dental 1980 became head of the peripheral officer, Naval Station, Rota, Spain, RADM-selectee William R. vascular surgery division and fellow from 1970 to 1973. Completing his Rowley, MC, deputy assistant chief ship program director. fixed prosthetic residency program for health care operations, Bureau of From 1985 to 1988 Dr. Rowley in 1975, he was assigned as the Medicine and Surgery, was born in was chairman of the department of prosthodontist at Branch Dental Omaha, NB, but spent his childhood general surgery and residency pro Clinic, Quantico, VA, untill977. He in Owatonna, MN, where he gradu gram director. He also became direc then reported aboard the USS ated from high school in 1961. At tor of surgical services from 1987 to Yosemite (AD-19), homeported in tending the University ofMinnesota, 1988. In October 1988 he transferred Mayport, FL, as assistant dental of he received a B.A. degree in psychol to Naval Medical Command, South ficer. He was then assigned to the ogy in 1966 and a M.D. degree in west Region as assistant chiefo fs taff Naval Dental Clinic, San Diego, CA, 1970. He served a surgical internship for plans and operations. In the spring from 1979 to 1984. During his 5 years and first year of general surgery resi of 1989 he was assigned to 4 months at Naval Dental Clinic, San Diego, he dency at the University ofC alifornia, additional duty on a management as was a staff prosthodontist, developed San Diego, from 1970 to 1972. sistance team chartered by the Blue and was the director for 2 years oft he CAPT Rowley entered the Navy in Ribbon Panel on Navy medicine Navy's first Advanced Clinical Pro 1972 as shipboard medical officer on where he made assist visits to many gram in General Dentistry, and then USS Tripoli (LPH-1 0) which partici Navy hospitals. In September 1989 was selected as branch director oft he pated in minesweeping off the coast he was transferred to the National Fleet Anti-Submarine Warfare Branch ofVietnam following the end of hos Naval Medical Center in Bethesda, Dental Clinic. Reassigned in 1984 to tilities. In 1973 he was assigned to MD, as deputy commander. He be the 2nd Dental Battalion, 2nd Force Naval Regional Medical Center, came the commanding officer ofNa Service Support Group, Fleet Marine Philadelphia, PA, to complete gen val Hospital, Camp Pendleton, CA, in Force, Atlantic, Camp Lejeune, NC, eral surgery residency training. He August 1991. In July 1993 he trans he was the Company Commander of became a staff general surgeon there ferred to the Bureau of Medicine and the 22nd Dental Company from 1984 in January 1977. In July of that year Surgery, Washington, DC. to 1985, and Company Commander he transferred to the Naval Regional Dr. Rowley is an associate clinical of 2nd Dental Company and 2nd Ma Medical Center, San Diego, for a 1- professorofsurgeryatthe Uniformed rine Division staffd ental officer from Services UniversityoftheHealth Sci 1985to 1987. From 1987to 1990he ences, Bethesda, MD. He is a mem was the executive officer at Naval ber of the International Society of Dental Clinic, Norfolk, VA. From 28 Cardiovascular Surgery, Peripheral June 1990 to 13 July 1993 he was Vascular Surgery Society, Southern commanding officer of Naval Dental California Society of Vascular Sur Center, Orlando, FL. He assumed his gery, American College of Surgeons, present position 1 Aug 1993. Association of Military Surgeons of Dr. Johnson is a member of the the United States, American College American Dental Association, Ameri of Physician Executives, American can College ofProsthodontists, Omi College ofHealthcare Executives, and cron Kappa Upsilon Honorary Dental American Medical Association. Fraternity, and Association of Mili Dr. Rowley's awards include the tary Surgeons. His decorations in National Defense Medal with gold clude the Legion of Merit, Meritori star, Philippine Presidential Unit Ci ous Service Medal with two gold stars, tation, Navy Meritorious Unit Cita Navy Commendation Medal, Merito tion, Navy Commendation Medal, rious Unit Commendation, Navy "E" Meritorious Service Medal, and Le Ribbon, Navy Fleet Marine Force CAPT William R. Rowley, MC gion of Merit. 0 2 NAVY MEDICINE A Naval Academy midshipman checks his shoulder straps before a "punch-out" in a mechanical ejection seat trainer as HM2 Jeff Carter keeps a close watch. Learning Survival at Naval Hospital Cherry Point ether it's in a helicopter, or a high-speed jet reaction, aeromedical aspects of seat ejection, the effects ircraft, a matter ofm illiseconds can determine of high-gravity body stress and high-altitude oxygen fe and death for aircrews in the event of an deprivation, or hypoxia, all of which affect the brain's airborne mishap that requires an ejection or ditching. ability to react quickly. Each year, the 22 sailors who man Naval Hospital Cherry Hands-on applications during the physiology portion Point's Aviation Physiology and Water Survival Training include a static and dynamic seat ejection on a mechanical Department train thousands of first-time, or "indoc," and trainer for jet community students, and a high-altitude refresher aircrew members from all branches oft he mili ride in a hypobaric chamber, which all students are re tary to react to those crucial seconds not with panic, but quired to experience. with confidence. The chamber simulates ascent to various altitude lev That confidence is instilled in aircrews through an els, allowing students the opportunity to feel the effects of intensive series oflectures, demonstrations, and hands-on altitude compression on their bodies, such as inner-ear applications of the aspects of human physiology and and gastrointestinal pressure. Once at the maximum water survival procedures. Navy instructors teach stu designated height (25,000 feet for fleet jet, prop, and helo dents about how their bodies physically react to flight aircrew students), the oxygen masks worn on the trip up conditions, and how adverse physiological effects can are unattached for a maximum of 4 minutes, so that each weaken the link between man and machine. student can experience the effects of high-altitude hy The CNO-directed program was generated in response poxia. to problems encountered by Navy and Marine Corps Students not yet on flight status, or in a lower profile flight personnel confronted with survival in a water envi training level, such as Naval Academy midshipmen, "fly" ronment after an emergency, and represents the best at lower altitudes with full oxygen at all times. "lessons learned," said LT D.A. Ratcliff, NAW STP de On the water-training side of the house, students re partment head. ceive comprehensive survival training both in a class The two-part program is taught on varying levels, or room setting and in the air station's combat swimming profiles, tailored to the individual needs of the student. pool during the summer months. During the winter, the All profiles begin with physiology lessons concerning water training department "deploys" its pool classes each aviation stress factors, sensory physiology, night vision week to MCAS New River and Camp Lejeune, NC. March-April 1994 3 Coast Guard search and rescue helicopter crewmembers from Alexandria, VA, pre pare for a "crash" in the helo dunker. drop aid in teaching the students how to perform proper parachute water entries, drag and disentanglement egress procedures, and airborne helo rescues from the water. Students also undergo multi place aircraft underwa ter egress procedures in 905 device, often known as the "dunk tank," "helo dunker," and "beer can." The device is designed to simulate escaping a multiseat helicopter fuselage after splashing into the water and rolling upside down, while sinking to a depth of 15 feet. The NAWSTPteam trains nearly a During water classes, trainees are Extended sea survival techniques thousand students each year in the first taught to identify survival gear are also discussed and practiced to physiology department, and nearly they will wear or have access to in prepare for the event of a downed 3,000 students each year in water sur flight, such as gravity suits, survival aircrew member who cannot be res vival and in the helicopter egress de vests, flotation and signaling devices, cued for an extended period. Priori vice. Students are individually graded and life rafts. ties-flotation, first aid, shelter, on each of the training events and Students also learn how each sur communication and food-are con must pass a final written examination vival aid functions and how they will sistently brought to the students' at at the end of the program to qualify employ it under a stressful survival tention by instructors as they attack for flight status. situation. Again, water survival con each training task. If a student cannot pass a require fidence is accomplished through rig Devices like the helicopter rescue ment, a conditionally qualified grade orous hands-on training. lift, parachute drag, and parachute is given and the student has 90 days to Water survival training begins with students treading water and drown proofing, or"dead-man" floating, in a combat pool, under the strict supervi sion of Navy corpsmen. Each indi vidual is tested on 2 minutes of each survival float, and on each survival swimming stroke in the pool, while clad in full combat flight equipment to include flight suit, survival vest, gloves, boots, and helmet. In addi tion, the students are tested on their - ability to deploy and inflate the sur --.;. ... vival vest's flotation unit bladders both manually and automatically while treading water. A Marine water survival student, wearing t 40 pounds of flight gear, struggles to stay afloat during a swimming test as a Navy corpsman keeps close watch. 4 NAVY MEDICINE complete the requirement for qualifi most important link in the chain be techniques when they complete the cation. In the event the student tween man and machine, no matter program. is completely unqualified, he is if that person is in a helicopter, prop, "They come here as aviators and grounded until a qualification can be or multimillion-dollar jet aircraft." we turn them into fish. They just obtained. Giordano added that there has been aren't prepared for things like the "Our goal is to have anyone who a 60- to 80-percent increase in ejec chamber and the helo dunker when sets foot in a military aircraft qualify tion and ditching survivability in the they arrive. We put them into those under our program," said LT Jim military aviation communities due to situations and they learn to handle Giordano, aviation physiologist and physiology and water survival train themselves," Giordano said. "After division officer for training and ing, and that his team is confident of our training, there won't be any sur hypobarics. "The human factor is the the students' knowledge of survival prises for them in the real situation if it happens. The knowledge will take over and it will come back without them even thinking twice about it. I've seen it happen more than once." 1st LT Bradley Close, USMC, an electronics countermeasures officer with Marine Tactical Electronic War fare Squadron-2, recently learned the truth of those statements, when his four-seat EA-6B Prowler aircraft splashed into the Neuse River. "An actual 'punch-out' from an aircraft is much more violent than can be simulated during training," he said. "When I ejected, the force of the wind knocked my helmet off and blew all the survival gear out of my vest pock ets. At the time, it was hard to think about survival procedures-they just came to me without thinking. The most important thing running through my mind was ifl was okay, and if my crew had made it out okay, too." Close added that it had been 2 years since he had attended a flight physiol ogy and water survival training class. "Training that will keep you alive in a situation like that is definitely worth remembering,"hesaid. D -Story and photos by CPL Daniel C. Hottle, USMC, Joint Public Affairs Office, 2nd Marine Aircraft Wing, MCAS Cherry Point, NC. Naval Academy midshipmen tighten their oxygen masks before ascending to 10,000 feet in the hypobaric chamber. March-April 1994 5 Photos courtesy of CDR Michael T. Curran, DC, USNR Co-pilot Captain Thomas Curran and sons the morning of ill-fated Flight 808 The "Miracle" of Flight 80S On 18 Aug 1993, a four neer, Second Officer David Rich As part of their normal, ongoing engine stretch DC-8 cargo mond. Instead of coming in for a program of training, the base crash jet from American Interna landing on a straight-in approach for and fire crews were on the scene for tional Airways, Flight 808, was on its runway 28, the plane was coming in what was to be just another normal final approach to runway 10 at for landing on the much more diffi landing. Instead, it was time to put all Guantanamo Naval Base, Cuba. The cult runway I 0. Unfortunately, at their training into immediate prac plane was inbound fromNorfo1k, VA, 1654 hours, with the plane in a steep tice. Within 12 minutes from the with a cargo of mail and supplies. right hand bank and within the final moment of the accident, crash and On board the aircraft were three seconds of its flight prior to landing, fire truck crews were pullingthecriti crewmembers, Pilot-in-Command, something went wrong and the plane cally injured crewmembers from the CAPT James Chappo; Co-pilot, CAPT crashed, cartwheeled, broke apart, and cockpit of the plane. Fortunately, Thomas R. Curran; and Flight Engi- burned. due to the severity of the crash im- 6 NAVY MEDICINE pact, the cockpit broke away from the main body of the airplane and rolled clear of the fire engulfing the wings and fuselage. Luckily also, when the cockpit stopped rolling it cleared a minefield, by a mere 50 yards. The crewmembers of the plane were all still alive, but all were criti cally injured. With the severity of their injuries, the time necessary to get them to the primary treatment facility became absolutely critical. If the crash occurred at any other air field, the severity of the crash would probably have been fatal for the three men. Fortunately, one of the Navy helicopters was fired-up and avail able to fly the injured to the base hospital immediately after their re moval from the cockpit. With word of the emergency, the entire base was mobilized for mass casualty care. The hospital medical staff, the dental clinic staff, chap lains, all participated in the rapidly developing emergency. The Marine Corps Barracks was called upon for voluntary blood donations. The co-pilot, Thomas Curran, was brought conscious into the emergency treatment area. Large facial skull lacerations and a depressed skull frac ture were immediately apparent. Most immediately threatening, however, were the multiple severe compound fractures of his left femur, left and right tibia and fibula, shattered right knee, and his shattered left and right ankles. Less immediately pressing were the fractures in both left and The wreckage of Flight 808 right wrists, lumbar vertebrae, and floor of the right orbit. was fortunately at the Guantanamo and right wrist. Medication was able By 1930 hours, all his fractures had airfield and received emergency Cuba to stabilize his heart function and he been stabilized, dressings had been overflight perm iss ion. This enabled a was the second memberofthecrewto placed over the lacerations and he 45-minute saving on the flight to Mi be medevaced to Miami. was the first of the injured crewmen ami, a flight which took them directly Second Officer David Richmond outbound from Guantanamo Bay for over Havana. was in extremely critical condition the flight to Ryder Trauma Center at The pilot, James Chappo, had se when he was brought into the emer Jackson Memorial Hospital in Mi verechest compression injuries, along gency treatment area. It had taken the ami, FL. A Coast Guard medevac jet with fractures to his lumbar vertebrae longest time to remove him from the March-April 1994 7 Right and below: Captain Curran re covers at Atlanta's Meadowbrook Hospital. wreckage oft he cockpit since he had been pinned beneath heavy equipment. He had received such severe compres sion injury to his heart that it was not functioning properly. Trauma to his face was so severe that virtually every facial bone had been fractured. In addition, he had a severe compound fracture to his left leg and a fractured shoulder. Basic stabilization and transport would not suffice for Richmond. In order to have any chance for survival, he required immediate emergency surgery at Guantanamo Hospital. Medical and Dental Corps personnel composed the operating room staff. Even though Richmond "coded" during the II hours oft horacic and abdominal surgery, he was able to be revived and the surgery was successfully completed. Finally, at 0430 the next morning, he was determined to be stable enough to attempt the medevac flight to Miami. The estimate was that he had only a 5 or 10 percent chance of surviving the flight. Once the three injured crewmen arrived at Ryder Trauma Center in Miami, the scene was just as active as it had been at Guantanamo. All three crewmen survived their 2-hour medevac flights and were again undergoing emergency surgery. Fortunately for Richmond, the thoracic and abdominal surgery had been performed so well at the Navy Hospital in Guantanamo that no further surgery to those areas was required. The first 96 hours were the most critical and all the men remained stable to that point, even though they remained unconscious. 8 NAVY MEDICINE