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Flight Surgeons Society of US Army Newsletter " Vol. 6, No. 1 - Spring 2005 Features: Election Results The long-awaited election was finally held in February 2004 at the Operational Aero- medical Problems Course at Moody Gardens in Galveston, Texas.

Congratulations to all of the new officers and governors!!! O FFICERS . President - LTC John Campbell Vice President - COL John Wing Secretary - MAJ Dana Thomas Treasurer - MAJ Justin Woodson B OARD OF G OVERNORS .

ARNG: LTC Mark Ivey USAR: LTC Andrew Bradbury APA: MAJ Jim Bean MAJ Jonathan Stabile COL Bill Statz CAPT Mark Tedesco LTC Shepard Stone 2004 Flight Surgeon Awards The Society presented the 2004 Flight Sur- geon and Aeromedical Physician Assistant awards at the annual OAP luncheon in Galveston last year. We never had the chance to announce them in the newsletter, so, while a little late, we 9d like to congratulate all the award winners one more time. The many highly competitive nominations for the 2005 awards have arrived.

Look for these to be presented at the OAP luncheon February, 16 2005. Congratulations to all!! (See page 3 for a full listing of the awardees.) "A WORD FROM THE PRESIDENT 1 " REFLECTIONS FROM ... more. less.

THE OUTGOING PRESIDENT3 "AERODYNAMICS FOR FLIGHT SURGEONS, PART I4 "EARLY PREVENTIVE MEDICINE6 "A BRIEF HISTORY OF ANCIENT FLIGHT11 "OBSERVATIONS FROM A MID- CAREER RAM12 "MOUNTAIN MEDICINE13 "THE AEROSPACE MEDICINE RESIDENCY PROGRAM15 Columns: "BUSINESS UPDATE (2004 ELECTIONS AND AWARDS)1 "AAMA CONSULT CORNER4 "NATIONAL GUARD UPDATE9 "SAFETY CENTER SURGEON 9S CORNER10 "USASAM FAQ17 A Word From the New President BY J OHN C AMPBELL , DO, MPH Hello, it has been a while since the last newsletter was published. A lot has happened and some significant changes have occurred. First, as the newly elected President, I would like to personally thank COL James McGhee for his five years as the President of the Society. Under his presidency, we have had five OAPs at various locations and with different organizations--all very successful. They gave all of us a chance to rekindle friendships, establish camaraderie and, of course, brief new updates and changes impacting our community. COL McGhee is now the Commander of USAARL and has turned over the responsibilities of the Consultant to the Surgeon General for Aviation Medicine to COL Joe Mckeon. Congratulations! Thanks for all you 9ve done, COL McGhee! (Continued on Page 2) Calender OAP!! Medicine in Challenging Environe- ments (M.I.C.E.) Galveston, TX Feb 15-18, 2005 AsMA Convention Kansas CityMay 8-12, 2005 FS Class 05-2 BeginsApril 11, 2005 FS Class 05-3 BeginsJuly 11, 2005 FS Class 06-1 BeginsOct 3, 2005 2 " Vol. 6, No. 1 - Spring 2005 (Continued From Page 1) All the activities over the past years have been done by a strong force of a few members and the hard work and dedication of USASAM. This is why I would like to declare this year the "Year of Members Involvement." The Society of US Army Flight Surgeons is maintained by the members, for the members. This means you! We need help. Some of the reason the newsletter and other society items have been sparse and irregular is the lack of interest and lack of participation by its members. Help us strengthen the society. I know they say never volunteer for anything, but we need volunteers to carry on the workload of the society. We need articles for the newsletters. These can be interesting mini-case studies, personal experiences, deployment issues, etc., each and every one of you has a great story/article. Write it down and email it to: dana.thomas@us.army.mil or justin.woodson@us.army.mil. On another note, as the new Dean of USASAM (19 March 2003), we have also been busy. We continue to graduate the best flight surgeons, APA's, flight medics, medical evacuation officers and aeromedical psychologists in the world. Also, as the Dean and President of the Society, we continue to search for better OAP conference sites and new and interesting topics. We will once again partner with the University of Texas- Medical Branch, Galveston, Texas. The conference will be 14-18 February 2005. The conference site-Moody Gardens, and the Galveston area offers a host of activities not to mention a great agenda of lectures and review topics. There will be 28+ CME hours and numerous hosted activities. Last year 9s conference was a great success and honored one of our greatest Aeromedicine leaders, MG (RET) Spurgeon Neel. MG Neel passed away 06 June 2003. His wife, Alice, was be in attendance to present the Flight Surgeon of the Year Award, the "Spurgeon Neel Award." I look forward to seeing everyone in Galveston in February. I had the privilege of deploying to Iraq in support of Operation Iraqi Freedom. I was a battalion flight surgeon for the 1/ 101st Attack Battalion/101st Aviation Brigade. I had to shake out some cob webs, but was able to revert back to the old flight surgeon course info (with updates) and provide the battalion an O- 5s view from the O-3s position. I was not alone in this situation; many other flight surgeons were called to fill PROFIS positions and performed exceptionally well. My experience helped me re-evaluate what we teach at the Flight Surgeon Course and confirmed the true need for flight surgeons and APAs at every aviation unit. The interactions and involvement with all the aviation operations is critical. We still need to be vocal and involved as special staff to the Commander. Get involved with the aviators, the crews and all the support personnel. Aviation is truly a team effort and if one team member is impaired, the entire mission could be compromised. Get out with each and every soldier, perform walk around inspections, have medications and SF 600s with you. Be proactive and be a combat multiplier for the aviation community. Train your medics, the combat life savers and educate the aviators; they all will appreciate you showing interest and being involved! Finally, I look forward to serving the Society and working with all the future officers and members. Again, thank you to all of our outgoing society officers (COL McGhee, LTC Joe McKeon, LTC Otto Boneta and all the Board of Governors). We could not have had a society without your hard work, dedication and commitment. Be involved, it is your society! LTC John Campbell serves as the Dean of the US Army School of Aviation Medicine 2004 Flight Surgeon Awards (Continued from page 1) S PURGEON N EEL F LIGHT S URGEON OF THE Y EAR . MAJ Thomas Hustead Brigade Surgeon, 101 Aviation 101st Airborne Division (Air Assault) R OLLIE H ARRISON A WARD . LTC Andre Pennardt Regimental Surgeon, 160th Special Operations Aviation Regiment T HEODORE L YSTER A WARD . MAJ John Hariadi Chief, Aviation Medicine and Physical Exams, USAAMC A EROMEDICAL P HYSICIAN A SSISTANT OF THE Y EAR . CPT Larry Carpenter 7-101 Aviation, 159th Aviation Brigade, 101st Airborne Division (Air Assault) R ESERVE C OMPONENT F LIGHT S UR - GEON OF THE Y EAR . LTC Mark Ivey Battalion Surgeon, 1/238th Avn Rgt A EROSPACE M EDICINE S PECIALIST OF THE Y EAR . MAJ Brian Smalley 159th Aviation Brigade, 101st Airborne Division (Air Assault) O UTSTANDING A EROMEDICAL A CHIEVEMENT A WARD . LTC Hyatt Keith Division Surgeon, 101st Airborne A EROMEDICAL O RDER OF M ERIT . COL Paul Edelen State Surgeon, Connecticut ARNG (ret) COL Robert Williams Vol. 6, No. 1 - Spring 2005 " 3 Reflections from the Outgoing President B Y J IM M C G HEE , MD, MPH I was elected president of our Society in 1999. Aviation medicine has made significant progress since that time and has weathered some significant storms. For example, the transition from a GMO based FS force to a residency- trained force contributed to a dramatic FS shortage. In 1999 we were able to fill only 114 of the 140 slots we had projected. We are now able to put 152 FSs in designated slots. The Aviation Medicine residency moved from the AF program to the Navy's, which is more attuned to Army needs, and the number of residency starts has increased from 2 or 3 per year to 5. Also, we not only have an Army faculty member at the residency program, but at USUHS as well. Thus we finally have some exposure to this field for operationally oriented medical students. AAMA has improved dramatically with a decrease in FDME backlog from 9500 to <300 (as defined by being in house >30 days). By the time of the OAP, the backlog will practically be gone and the turn around time for FDMEs at AAMA will be measured in days, not weeks. APLs are constantly being rewritten and have become far more evidence based and rational. AAMA has made great strides in rebuilding the bridge to the LINE and to the field FSs. AERO, the automated flight surgeon's office, has matured and is proving to be everything it was designed to be. It has strong GO level endorsement. Plans are also in the works to make it even more comprehensive in its capability to include tracking up and down slips. USASAM has evolved to be a life long learning resource for FSs. The FS course continues to evolve and ensure what is taught is current and relevant. The web site and list server provide a mechanism to get new information to the field rapidly. The FS refresher course is evolving to provide an effective mechanism to refresh non-current FSs prior to deployment. The Society is in good shape as well. Its membership is the highest it has been in years and its finances continue to be very strong. It has served the membership by providing the Ultimate FS CD and other printable resources. It also produced the public relations / recruiting CD, which goes out to prospective FSs and to AMEDD recruiters. The icebreakers held at the flight surgeon primary course fosters comradery among our numbers as they join our community. Finally the Society recognizes the excellent achievements of members with annual awards. Our Society exists in large measure to fill in the gaps between necessary services for FSs in the field and what is provided by the AMEDD; and that work is by no means complete. There are still challenges in the area of recruitment and education, so the right people will become flight surgeons. We can do a better job preparing new flight surgeons for going into the field. The old Flight Surgeon Handbook, written by the Society in the 80s, had a check-list designed to help new flight surgeons arriving at a unit or hospital. It addressed how to educate a new boss about how FSs should be properly used and what they had to contribute to the organization. TRICARE metrics are here to stay and will only get worse. We need to equip FSs with tools to compete in that arena and hold their own. Workload accounting models are needed, so aviation medicine visits aren't wrapped up into primary care codes and flight medicine receives no credit. We need to be able to claim flight line visits as valuable patient interaction time. Staffing models are needed so we have adequate support staff too. Examples of job descriptions and successful SOPs need to be available for everyone. The documents exit, some people are being successful, but we need to be able to cross level those success stories more effectively. As I step down as Society President, I am confident that the Society and the specialty will continue to face the new challenges with courage and determination. We will doubtless continue to be a positive force in the AMEDD for years to come. Our new slate of officers will be strong, dynamic and enthusiastic. But, they will not be able to triumph in the future alone. They will need the support of the membership. As I have always said, our Society is an organization of Flight Surgeons dedicated to the success of Flight Surgeons. Pulling together, we can make that vision a reality. COL Jom McGhee serves as the Commander of the US Army Aeromedical Research Laboratory Ubi somnus delirium sedat, bonum. When sleep removes delirium, it is a favorable omen. -Hippocrates 4 " Vol. 6, No. 1 - Spring 2005 AAMA Consult Corner B Y D ANA T HOMAS , MD, MPH After years of promise, Beta-testing and name changing (formerly the Virtual Flight Surgeon's Office - VFSO), the US Army Aeromedical Activity has successfully rolled out its Aeromedical Electronic Resource Office (AERO): a system for performing paperless Flying Duty Medical Examinations. The initial product, available since late 2002, offered the then newly mandated DoD 2807 and 2808 templates for recording medical histories and physical examinations. Since then, AERO has developed other templates for the Interim or Abbreviated Health Screen (DA 4497) as well as an Aeromedical Summary feature. The most recent piece added this Spring is a secure messaging system with which providers may query each other or AAMA regarding process, policy or aeromedical disposition. With this product we are setting a new standard for secure health information management. The messaging system is not a robust e-mail account. It was designed for brief exchanges. i.e. a brief question, lab values, or dated consult. The purpose of developing AERO was to re-engineer the "paper and stubby pencil" system which was our heavily redundant and encumbered process of reviewing more than 24, 000 annual FDME and AMS. The average physical examination had a processing time of 150 days (from the date on the physical to the date received at AAMA was usually 90 days; then add another 60 days for AAMA to make a disposition and return it to the original facility.) Adding insult to injury, 40% of the time the FDME was returned as "disqualified" for inaccuracy or incompleteness. The beauty of AERO lies in its ability to self-check the patient's audiology, laboratory, visual and other health parameters automatically prior to submitting it to AAMA. In turn, this allows the flight surgeon to take the appropriate corrective action which may be repeat the test, complete an over-looked piece of the examination, or complete an Aeromedical Summary for a known disqualifying condition. The average physical is now processed in under a week, and most Aeromedical Summaries are completed within a month. The return rate on FDMES disqualified for inaccuracy or incompleteness is < 2%. AERO is a web-enabled, Oracle 9i database that melds with the future of the Army Medical Department, the Military Health System and the DoD's architectural infrastructure. The VAX/ VMS data that was historically stored on our aviation personnel for decades has been imported into this system from 1986 forward to enhance the Aeromedical Epidemiological Data Registry (AEDR). This is affords us the granularity to do evidence based medicine for Army Aviation. An AERO account may be requested by any military flight surgeon, aeromedical physicians assistant, clinic OIC or NCO who is involved in tracking and processing work between the aviation medicine clinic and AAMA. AAMA electronically communicates (via AERO) with the Active Duty and Guard Waiver Authorities for processing waivers and suspensions. An applicant must have an AKO account and must be involved in the processing of Army Aviation Personnel's physical examinations (i.e. need to know) to qualify for an account. For more information, download the application at https://vfso.rucker.amedd.army.mil. MAJ Dana Thomas serves as the Chief, Clincal Consultation for the US Army Aeromedical Activity PRACTICAL AERODYNAMICS FOR ARMY FLIGHT SURGEONS (Part 1 of 2) B Y ( UNKNOWN FS) Editorial Comment: This article was submitted some time back prior to the current editors. There was no name on the file.We apologise for the delay in publishing it. If the submitting author can drop the editor a brief e-mail, we 9d like to recognize you appropriately. Articles such as this add value to our newsletter. THANK YOU! This article is the first of two in a series. They are intended to provide a modicum of refresher training and, in a few instances, complement any single rotor helicopter aerodynamics knowledge you .may already possess. The primary focus is to ensure you are familiar with the aerodynamic concerns that are germane to pilots, and those that have the highest probability of contributing to aircraft accidents. Hopefully, upon completion of reading these articles you will be more conversant in pragmatic aerodynamics and will have a greater understanding of what aerodynamic questions you should Vol. 6, No. 1 - Spring 2005 " 5 ask if participating in a mishap investigation. The primary references used in writing these articles are TC 1-212 (Aircrew Training Manual, Utility Helicopter, UH-60) dated 28 SEP 1992, and FM 1- 203 (Fundamentals of Flight) dated OCT 1998. TC 1-212, Chapter 8 specifies items which rated crewmembers must perform or demonstrate knowledge of when being evaluated. A portion of the oral examination includes the following aerodynamic subject areas: retreating blade stall, dynamic rollover, and settling with power. Each of these aerodynamically induced events can result in significant aircraft controllability problems, damage, injuries and deaths. Each is readily avoidable and easily recovered from if caught early enough and appropriate pilot actions are taken. This newsletter's article will address retreating blade stall; a subsequent newsletter will cover dynamic rollover and settling with power. Retreating blade stall occurs when the dissymmetry of lift between the advancing and retreating portions ofthe rotor disc (determined via relative wind) becomes so large that the retreating blade exceeds its critical angle of attack (stalls) in a failed effort to balance the increasing lift created by the advancing blade (see Figures 6-36 C and 6-37). In single rotor aircraft in which the main rotor turns counterclockwise the aircraft experiences substantial vibrations and may pitch up and to the left due to the rotor disc's unbalanced lift and gyroscopic precession (aerodynamic effects occur 90 degrees after the input actually takes place). The following conditions tend to precipitate retreating blade stall: high forward airspeeds, high gross weights, low rotor RPM (remember the lift equation in which velocity squared is the greatest factor in determining lift?), high density altitude, steep or abrupt turns, and turbulent air. Pilots can preclude or terminate retreating blade stall by reducing airspeed, decreasing power demands on the main rotor via collective reduction, avoiding or ceasing maneuvers which place the aircraft in severe attitudes, increasing main rotor RPM, and maintaining the aircraft in trim. In normal peacetime settings and flight environs, retreating blade stall is seldom an accident producer because of its effective and relatively benign warning signs of vibration and uncommanded pitching of the aircraft; the pilots' natural reactions are to slow down and dampen out whatever maneuvers they may be executing. However, in combat or other emergency settings, a crew's demand for airspeed may be so essential and rapid that uncontrollability or damage to the aircraft could occur before the warning signs are fully recognized. If you have further questions concerning retreating blade stall, sit down with your local IP, and he or she will be glad to provide any additional detail. Good health and good flying. 6 " Vol. 6, No. 1 - Spring 2005 Early Preventive Medicine and the United States Sanitary Commission B Y D ANA T HOMAS . MD, MPH Between 15 April 1861 and 30 June 1865 nigh twenty four hundred battles comprised the American Civil War. Neither North nor South were capable of alleviating the epic suffering of the wounded. It was a rifleman's war: 94% of all wounds were attributed to bullets; 5.5% were attributed to artillery; and 0.4% were from sabres and bayonets. Based on wound ballistics and the less than enlightened practice of medicine at the time, Civil War medicine is most often remembered by legions of non- sterile, brutally simple amputations. Lack of medical knowledge rendered medical personnel hapless in the face of infection and disease. The real killers were bacteria, often unwittingly transmitted by doctors who, as yet unaware of the "germ theory," routinely performed surgery with unclean hands and unsterilized instruments on unwashed operating tables. The Civil War was fought before the advent of preventive medicine, prior to the publication and acceptance of Koch's Postulates(1890). By any standard, progress was limited in the prevention of disease: this is fully explained by the fact that bacteriology and its twin, modern hygiene, were yet unborn." Disease casualties were enormous, both in the Union and Confederate Forces. However, one U.S. Agency, the Sanitary Commission, stood up in 1861 and down in 1866, served as a secret weapon for the Union Army to combat these epidemics. Even with limited medical knowledge of the period, the Commission's common sense oversight turned the odds in favor of the North maintaining their fighting strength. The morbidity and mortality rates from disease and battle are well summarized in Louis Duncan's Seaman Prize essay. The following quotation is a brief yet detailed summary which provides a pertinent backdrop for further discussion: "During the American Civil War, the average strength of the Union armies was 806,755 officers and men. The total number of deaths was 359,528; 67,058 were killed in battle and 43,012 died of wounds; giving a total of 110,070 from battle casualties; equivalent to a rate of 33 per 1000 per annum. The number dying of disease is estimated at 224,586, or 65 per 1000 per annum. The death rate due to DNBI in the regular troops was 32; in the white volunteers 55; and in the Negro troops 133 per 1,000 yearly. Of the wounded 14.6% died, which was the average rate at that time. About two-thirds as many died of wounds as were killed in battle. Twice as many men died of disease as from battle wounds. In addition to the deaths named there were 24,877 from accidents, injuries and unknown causes. More than 250,000 were discharged for disability and 200,000 deserted." Despite those staggering numbers of disease-non-battle injury (DNBI), there were individuals and processes which created trends of improvement within the Army Medical Department that must be recognized. At the beginning of the war the North had only sixteen army hospitals and ninety-eight medical officers; it had no nursing corps or provisions for ambulances. The South had even fewer resources. Key contributions to preventive medicine included increased organizational proficiency; the establishment of a model system of ambulance corps and field hospitals; improvements in the care of the sick and wounded. Slower to improve were the areas of sanitation and military hygiene . By 1865, the two sides had built 204 general hospitals with a total bed capacity of 137,000. Both sides fought disease hard, though less effectively, as they fought each other. The bane of illness amongst the soldiers were common diseases, magnified by the crowded conditions and poor hygiene. Acute and chronic diarrhea and dysentery occurred with more frequency and produced more sickness and mortality than any other form of disease. In the period covered by the statistics, 1 May 1861 to 30 June 1865, there were 1,739,135 reported cases of diarrhea and dysentery and 44, 558 deaths. Medical officers had no knowledge of what caused this diarrhea and assumed that it was due to a single disease. It seems probable that Entamoeba histolytica, Shigella, Giardia, Salmonella and Campylobacter were afflicting the soldiers of 1861- 1865. However, lacking the staining and culture techniques available a few decades later, physicians were unable to compile records that would enable the modern scientist to positively identify the agents of these epidemics of dysentery. Of note is the fact that in the first year of the war only 1 in 178 dysentery patients died, however, by June 1865, when long campaigns, disease and deprivation had weakened the soldiers, 1 in 29 was failing to survive. Occasionally, there were outbreaks of typhoid fever. Without knowing exactly why, military experts had long realized that filth, especially when large numbers of men were grouped together was associated with disease. The control measures employed were the usual ones of cleanliness, disposal of wastes and excreta, policing of camps and some attempts to purify water or to secure clean sources. Smallpox was present during the Civil War, but at no time could it be considered a prevalent disease among white troops. A total of 12,236 cases with 4,717 deaths were reported. Sporadic cases occurred in all commands. Isolation and vaccination were recognized as efficient means of protection, but often the troops were not adequately vaccinated. Measles caused 67,763 cases and 4,246 deaths in white troops. Most of the mortality was due to secondary pulmonary infections, chiefly pneumonia. There were recurrent waves of measles involving the susceptible persons through the successive additions to the strength of the command. There was little or no yellow Vol. 6, No. 1 - Spring 2005 " 7 fever among the troops, a result attributed to active measures of sanitation and the strict quarantine regulations imposed by the military government of all main ports in the South. Malaria was prevalent in the Atlantic and southern coastal regions, and although not usually fatal, it posed a major threat to the Army's Health. The usual methods of attempted prevention employed were avoidance of the vicinity of swamps and marshes as campsites; avoidance to noxious airs of night, when feasible; avoidance of chilling and great fatigue, when not in battle, etc& One breakthrough in medical thought came as a result of Charles Tripler's interest in disease prevention. Tripler was selected to serve as medical director to Major General George McClellan in August 1861. Although he had been serving in the Medical Department since 1830, prior to the war he had been lecturing on the subject of military medicine, thereby making the problems intrinsic to caring for sick and wounded soldiers fresh in his mind. Based on earlier reports of effectiveness by British seamen stationed in tropical, malarious regions of West Africa, a new therapy was introduced: quinine sulphate. The drug was customarily given by mouth in alcoholic solution - 3 grains in a gill of whiskey per day to each soldier in a malarious region- an alcoholic bitters that became the soldiers' favorite medicine -one that they did not spit out! The deliberate introduction of chemo prophylaxis against malaria, by oral administration of quinine sulphate, marked the development of a new principle in military preventive medicine in the United States Army, certainly one of the most valuable lessons from the Civil War. Diseases of respiratory organs (acute catarrh, bronchitis, and pneumonia, both primary lobar and bronchopneumonia secondary to measles) were important causes of ineffectiveness and mortality among the soldiers. As usual for armies in the field, fighting during fall, winter and early spring, many thousands of cases of respiratory disease occurred, especially during the first years of the war. Other "camp diseases" included outbreaks of jaundice, apparently due to infectious hepatitis, which were numerous, incapacitating , but not highly fatal. Among white troops there were no fewer than 71,691 cases of probable infectious hepatitis. Scurvy was also prevalent amongst the troops, but often not listed as an isolated disease because the average soldier was afflicted by scurvy in conjunction with other infections, fevers or diarrhea. Scurvy develops secondary to a Vitamin C deficiency. Fresh fruits or vegetables become difficult for an army on the move to supply, and "Billy Yank" was always the last in the supply chain. One solution came through the Army's attempt to compress and desiccate vegetables such as carrots and potatoes. These were poorly received by the troops, who called them "desecrated." Lastly, venereal diseases, chiefly syphilis and gonorrhea were more frequent at the beginning and close of the war than in the intermediate years. Almost 24,000 cases of venereal disease appeared in the Union Army during the first year of the war, although the author of one journal article noted that very few patients came from commands where lieutenants were "vigilant and sober." When not drinking or gambling, some men escaped the tedium of daily army life by enjoying "horizontal refreshments," as visiting prostitutes became known. Thousands of prostitutes thronged the cities in the war Flight Surgeon PT? ...check again. Bunikis 8 " Vol. 6, No. 1 - Spring 2005 zones and clustered about the camps. By 1862, for instance, Washington, D.C., had 450 bordellos and at least 7,500 full-time prostitutes; Richmond, as the center of prostitution in the Confederacy, had about an equal number. Venereal disease among soldiers was prevalent and largely uncontrolled. About eight percent of the soldiers in the Union army were treated for venereal disease during the war and a great many cases were unreported; figures for the Confederacy are unavailable, but assumed to be about equal in proportion. With the invention of penicillin more than 70 years away, treating venereal disease with herbs and minerals such as pokeweed, elderberries, mercury, and zinc sulfate may have eased symptoms but did nothing to cure the disease. The control measures applied were mainly reporting of contacts of infected soldiers, treatment of diseased prostitutes, and licensing of prostitutes. At the onset of the Civil War the Army Medical Department was rife with administrative problems. Due to the seniority system, the department's initial responses to the Civil War were directed by old codgers "paralyzed by routine habits acquired in long dealing with an army of ten or fifteen thousand and utterly unequal to their present work." Accustomed to handling the health problems of small and relatively isolated posts, old-time Army surgeons had never been called upon to develop plans for evacuation, hospitalizing and caring for vast numbers of wounded and sick or for preventing disease in camps with populations of thousands. Prior to the Civil War it was common for an Army Surgeon in wartime to command line troops as well as serve as a medical officer. The professional demands on medical officers during the Civil War would prove too onerous to permit them to play part-time active military roles as well. The care of thousands of patients, both sick and wounded, and the management of the various stages of their evacuation from battlefield to the hospital that completed their care would soon no longer allow a surgeon general to ride at his general's side or permit a medical officer the challenge of commanding a unit in battle. The Civil War's first two Surgeon Generals (Lawson, who died after fifty years in the Army and twenty-five as Surgeon General and his aging successor Finley, who had little to recommend him for so high a post except his forty years in the Army) were unable to accept the fact that their years of experience had taught them little that would be of value in the current crisis, and on occasion stood in the way of others more willing to innovate. One of the most progressive organizations founded during this otherwise staid time was the United States Sanitary Commission (USSC). In the spring of 1861 a group of upper class women from New York in alliance with the Women's Central Association for Relief and a group of highly influential gentlemen met in New York City. This meeting was the beginnings of what was to be known as the U.S. Sanitary Commission, whose roots came initially from the work done by the British Sanitary Commission during the Crimean War, a few years earlier. It was Florence Nightingale's work in the Crimea which opened the door for women who sought to contribute to military healing in the wars that followed. On June 18, 1861 President Lincoln signed a bill making the USSC an official agency. At first the President gave the Commission only limited powers of inspection and advice on medical, surgical and sanitary matters in camps and hospitals, and in connection with certain non-medical military activities in the Army. Despite the reluctance of men in general and often blatant defiance from physicians, surgeons, the military and the Federal government the work of the Sanitary Commission went on. Women tirelessly canvassed neighborhoods for donations, worked as nurses, organized diet kitchens in the camps, ran hospital ships, knitted socks and gloves, sewed blankets and uniforms, baked food and organized Sanitary Fairs that raised millions of dollars worth of goods and funds for the Federal Army. Members of seven thousand local chapters raised nearly five million dollars in cash and about fifteen million dollars in supplies for the commission, the largest of the private relief organizations to emerge during the war. The more tangible assistance that the Sanitary Commission offered the sick and wounded included care of prisoners of war, ranging from providing papers, pens and voluntary scriveners to write letters for those unable to do so, to securing and supplying donations of mosquito netting, sheets, wine and spirits to establishing a hospital directory by means of which relatives could determine the location of any individual patient. The USSC urged more exacting physical exams for recruits, the creation of a nurse corps, and increased rank of members of the Medical Department. They outlined a system of triage to be used for determining the order in which patients were treated during and after battle and recommended specific instruments and supplies a surgeon should take into the field. Sanitary agents were granted more authority over time, becoming a pseudo-military operating agency. Among its ideals and policies was the establishment and conduct of a "preventive service" in and for the Army. From the preventive medicine point of view, the most important division in the Commission's organization was its Camp Inspection Service. Throughout the war, the Commission recognized that prevention was far more effective than relief. The Sanitary Commissions findings in 1861 triggered the re-organization for the US Army Medical Department. Congress was influenced considerably by depositions made by the USSC and passed the Act of 16 April 1862 which reorganized the Medical Department. Specific to this act was the increase in rank (to general officer grade) for the Surgeon General and a strengthened administrative position for the Medical Department in the Army, as well as eight (later increased to sixteen) Medical Inspectors charged with the duty of supervision over every sanitary matter that affected the health of the troops. The USSC was extremely instrumental in implementing a change of guard, after the retirement of Surgeon General Finley on 14 April 1862, Vol. 6, No. 1 - Spring 2005 " 9 essentially dictating the appointment of 1st LT Alexander Hammond as Surgeon General on 25 April 1862 (much to the disgruntlement of the old regime.) Also through the Commission's influence, Surgeon Jonathan Letterman was appointed by General McClellan as medical director of the Army of the Potomac. Both Hammond and Letterman were men of superior ability and their appointments had the direct result of immediate improvement on the future development of preventive medicine in the Army. One final, precedent setting contribution made by the U. S. Sanitary Commission was a series of prepared monographs, military medical and surgical essays, which were written by distinguished American physicians and surgeons based on their Civil War experience. These were published by the Commission and issued to both medical and line officers. A number of these specifically addressed preventive medicine and included: (1) Military Hygiene and Therapeutics, (2) Control and Prevention of Infectious Diseases, (3) Quinine as a Prophylactic against Malarious Diseases, (4) Scurvy. (5) Rules for Preserving the Health of Soldiers and (6) pamphlets on various communicable disease, including venereal diseases. Seventeen of these pamphlets were arranged in a more permanent form and published by the Surgeon General. These individual monographs were well received and in great demand. These pamphlets are a historical landmark, for they initiated a special technique of public health education which has developed into enormous proportion and remains one of the standard procedures in civilian health education in America. From the military experience it can be said that this procedure is equally valuable in the practice of preventive medicine for the Army. REFERENCES 1. Naythons, Matthew: The Face of Mercy. Random House, Inc., New York, 1993. 2. Duncan, Louis C.: cSeaman Prize Essay. The Comparative Mortality of Disease and Battle Injuries in the Historic Wars of the World. d J. Mil. Service Institute of the U.S. 54: pp 167-168, 1914. 3. Woodward, Joseph J.: The Medical History of the War of the Rebellion (1861-1865). Medical History. Washington: Government Printing Office, 1879, pt II, vol. I. 4. Gillett, Mary C.: The Army Medical Department (1818-1865). Center of Military History. United States Army, Washington, DC., 1987. 5. Smart, Charles: The Medical and Surgical History of the War of the Rebellion (1861-65). Medical His- tory. Washington: Government Printing Office, 1888, pt III, vol. I. 6. Bayne-Jones, Stanhope: The Evolu- tion of Preventive Medicine in the U.S. Army, 1607-1939. OTSG, Department of the Army, 1968. 7. Hammond, William A. (editor): Mili- tary Medical and Surgical Essays Prepared for the United States Sanitary Commission. Philadl- phia: J.B. Lippincott & Co., 1864. 8. Smillie, Wilson G.: The United States Sanitary Commission and the Civil War. In Public Health: Its Promise for the Future. New York: The Macmillan Co., 1955. MAJ Dana Thomas serves as the Chief, Clincal Consultation for the US Army Aeromedical Activity NATIONAL GUARD B Y J OHN W ING , MD, MPH Greetings to fellow National Guard Flight Surgeons from Ft. (it's nice to be in the middle of nowhere) Indiantown Gap, PA. As you are all well aware, the Army National Guard Flight Surgeon community is in a period of unprecedented activity. Many of you have already been deployed, and most of the rest of you are in the barrel. There is no question that this level of participation has had a profound impact on many of your practices, and your dedication and sacrifice has been noticed and is much appreciated. We have had several of our brethren deployed in their primary specialties, rather than as 61N's, and the attendant shortage of flight docs will bring many additional "opportunities" for the rest of us. Add to this the one acronym that needs no more comment- BOG! Sadly, this war can't last forever, and we will have to look forward to returning to weekend drills and AT at home station (ha!). Truly, the Guard isn't what it used to be and we can look forward to an exciting future. The up-side to all this is that the National Guard has more than proven its mettle, and we need to take our rightful place as equals to the AC. We'll know we're getting there when we see brand new Blackhawks at the Flight Facility. There's lots to discuss and by no means limited to this newsletter. We've got a new Guard Surgeon, COL Craig Urbauer, who had the job a while back and someone who will continue to excel. He's a RAM, so we know we have a sympathetic ear at NGB. The WAATS also has a new AGR flight doc. His name is MAJ Doug Little, Family Practice type, who has had a wealth of experience as an Active Duty Air Force Flight Surgeon for Davis Monthan AFB, Tucson. In regards to more mundane news, the whole spectrum of soldier readiness and preparing for deployments has revealed a host of challenges with our aging population- MODS/MEDPROS issues, SRP's, dental, profiles, dental again, incomplete medical records, dental 10 " Vol. 6, No. 1 - Spring 2005 again, MMRB's- and we need to have those of you who have successfully met these challenges to share your technique with us. To this end please make every effort to attend the Galveston OAP for your annual CME trip. It's a nice break away from the winter cold and will be a chance for the two-way interaction we need to improve our Aviation Medicine programs- home station as well as operational. This year's conference has a registration fee, so be sure to add that to your orders. We can anticipate the usual half-day National Guard breakout, or more if there is the demand. Contact me with any and all suggestions- lessons learned from deployments, ARMS results, FDME issues, etc. are all worth discussing. See you in Galveston. COL John Wing serves as the Senior Flight Surgeon for the EAATS and can be reached at: john.wing@pa.ngb.army.mil 717-861-9175 Safety Center Surgeon 9s Corner B Y J OE M C K EON , MD, MPH Greetings from the US Army Safety Center, at Mother Rucker. I wanted to quickly add a note from the safety perspective, now that I've spent two and a half years at the Safety Center, and become a bit of a safety "disciple." The role of the flight doc in aviation safety cannot be over stressed. Everything we do, as aviation medicine practitioners, is related to the safe flight of our aircrew and the Warriors they transport. If we are not thinking accident prevention, we might as well be outsourced, like much of the rest of patient care these days. Face it, You, the flight doc, put the "military" in military medicine as far as your patients are concerned. Why else have the AMEDD? This may sound a bit parochial, but flight surgeons and aeromedical PA's are critical in today's Army; we must be there for our aviators. It is imperative that you understand their mission, their stressors, their fears, their joys. Your aviators love what they do, and odds are, if you are reading this newsletter, you love what you do as well. So how you can better do what you love to do? Spend time with your aircrew. Talk to them. Give them an opportunity to ask questions. Just today I got an e-mail from an aviator asking about a complementary and alternative medicine approach to lipid lowering. I had to read up on it before I could provide a cogent response, but I feel I benefited from the drill, and he benefited from my counsel. We've got to keep the dialogue open to know what they are thinking and how we can help them be more discerning with their health and risk management. A failure to communicate will not benefit anyone. Today's Army is endeavoring to do more with less, and our aviation assets, as well as our medical assets, are being stretched thin. Odds are, many of you have been, and/or will be deployed in the near future. Think prevention! Push hydration, exercise, smoking cessation. Wear your protective gear, and wear it properly. Set the example for the Soldiers you serve. Read. Write. Capture your experiences and send them back to MAJ Woodson and the Society 9s newsletter. Life is too short to make all the mistakes, so share your experiences with others. You've got more to offer than you might realize. Be a safety "disciple." Be safe. Make it home. COL Joe McKeon serves as the Command Surgeon at the US Army Safety Center and as the Consultant to the Surgeon General for Aviation Medicine Vol. 6, No. 1 - Spring 2005 " 11 A brief history of Ancient Flight B Y R ON K ING , MD, MPH Man has been preoccupied with flight at least as long as history has been recorded. There are in existence prehistoric cave paintings that show winged figures and what appears to be some type of airborne craft, while the gods of Egyptian mythology were winged - and so were the bulls of the ancient Assyrians and the horses of Greek myth. In those far-away days, flight was always connected to the supernatural. Gods could fly but humans could not. Sooner or later, however, man came to the realization that he too wanted to fly. The earliest story relating to human flight is that of Daedalus and Icarus, who escaped from prison using wings manufactured from birds feathers held together with beeswax. Daedalus, the father of the pair, made good his escape - but his son, not as wise, flew too high and fell to his death when the sun melted the wax (first recorded instance of structural failure in flight?) Of course, this particular tale is myth. It illustrates, however, how man's thinking had progressed. No longer was the realm of flight limited to birds, gods and mythical creatures. Man was beginning to believe that he, too, could get off the ground and soar in the air. Mythical flight was not limited to the Mediterranean civilizations, by the way - in 2200 B.C. the Chinese emperor Shin supposedly leapt from a high tower wearing two large straw hats, and landed safely. Other accounts believe that the Shin was imprisoned in this tower and actually used a kite-like apparatus (hang-glider?) to escape! About 700 years later, the Persian king Kai Kawus allegedly flew across the sky in a chariot powered by eagles. Alexander the Great explored the heavens in a wicker basket drawn along by griffins. Steering was accomplished by the unique and ingenious method of suspending food just in front of the mouths of the ravenous beasts, either to the left or right depending upon which direction Alexander wished to travel in. Then, English legend tells us of the mythical King Bladud, reportedly the father of King Lear and founder of the city of Bath, who fell to his death after trying to fly with a pair of wings made of chicken feathers strapped to his back (picture to the right.) His launching point was atop Trinavantum's (modern day London) Temple of Apollo in 863 B.C. and his fatal attempt was criticized by many (first accident review board?) because his wings were made of feathers from an essentially a flightless bird! The first recorded flight attempt by a human which can be believed dates back to Spain in 852. A Muslim holy man, Armen Firman, made an unsuccessful attempt to fly with wings attached to his shoulders. Others report that it was actually just a huge voluminous cloak and he hoped it would billow out and allow him to float gently to the ground. It did not, and he was fortunate to survive. A different technique was tried just a few years and miles away, in the Andalusians. A physician named Abbas ibn- Firmas tried to fly using wings (the first flight surgeon?) He covered himself with feathers, attached wings and, according to eyewitness accounts, flew for some distance (picture to the left.) Trying to land like a bird he lost his balance and stability and crashed to the ground, severely injuring his back. He attributed his failure to not having a tail. 200 Years later a monk by the name of Aelmer, who had been obsessed with the Daedalus story, broke both his legs when he jumped from the roof and tried to fly with wings made of feathers and wax. For stability he had attached the wings to his hands and feet. This did not present a problem as he stood on the edge of the abbey tower but it is not recorded when it dawned on the monk that this did not provide anything to land with. Officially, Aelmer also attributed his failure to the lack of tail feathers, which he believed would have given him more stability. He was, however, lamed by the first attempt and was never able to try again. An unknown Saracen man became the first recorded air fatality when, in about 12 " Vol. 6, No. 1 - Spring 2005 the year 1050, he made a flight attempt in Constantinople (now Istanbul) and plummeted to his death. In 1503, mathematician Giovanni Battista Danti, of Perugia, jumped into the air with a pair of wings and broke his leg when he fell onto the dome of a church. Four years later another Italian, who had moved to Scotland and taken the name John Damian, jumped off the walls of Stirling Castle and ended up the same way - one broken leg. Yet another Italian, a clockmaker named Bolori, leapt from the top of Troyes Cathedral and was killed when his wings failed to have the desired effect. For the next several centuries, attempts at flight by jumping, with or without wings, occurred throughout Europe and Asia. For the most part they were brave but dismal failures, often resulting in injury and death. Franz Reichelt, perhaps one of the last of the "birdmen," attempted a flight off the Eiffel Tower in Paris in 1912. His parachute-like suit failed and he plummeted some 190 feet to his death in five seconds (picture on the right.) We've come a long way and I will be happy to make this a series on historical aviation firsts if there is an interest. (Special thanks to Geoff and Laura Rout for their historical assistance.) LTC King is currently serving as our exchange Aeromedical Research Officer with the British Army. Observations from a Mid-Career RAM B Y O TTO B ONETA , MD, MPH Aviation Medicine in the Army began a renaissance a few years ago under the guidance of COL McGhee. The DoD would be more inclined to use the word ctransformation d but I believe this was truly a rebirth and not just a change or adaptation. If I were a little more histrionic I would use the old "Phoenix rising from the ashes" analogy but I'll refrain from such melodramatics. I have been a flight surgeon for almost 12 years and I honestly believe our specialty is healthier today than at any other time in those 12 years. Thank you, COL McGhee for your vision and leadership. I am very proud to have worked closely with COL McGhee during this period. During this time I had the privilege of running the flight surgeon course for three years and I have just completed the hyperbaric fellowship and three years as staff on our residency program in Pensacola. I say privilege because during this time I have seen and trained hundreds of new flight surgeons and RAMs. The quality of the students / residents never ceases to amaze me. I can't wait for this new generation of Flight Surgeons and RAMs to "mature" and fill the key positions in Army Aviation Medicine and take over the leadership of our specialty. Things are really looking good; we have some stellar folks! USASAM has really been the pointy end of the spear in this rebirth. Perhaps the biggest challenge in a large-scale transformation is educating the masses so that they all can work together. In Aviation Medicine this starts with primary training in the flight surgeon course and the Aviation Medicine NCOIC course, continues with refresher training and updates such as the OAP, and for an Army Flight Surgeon it may culminate with residency training in Aerospace Medicine. I am lucky to have been involved in all these phases of training during these exciting times. Though I have not been directly involved in training Flight Medics and Aeromedical Evacuation Officers, USASAM is on the cutting edge here as well. 1SG Litteral of USASAM spearheaded a team of NCOs and revolutionized the way in which we train our Flight Medics. Revolutionize is not even close to hyperbole, it's an accurate assessment. The development of USASAM's UH-60 cabin simulators equipped with state of the art human patient simulators is a quantum leap in the training of Flight Medics. The aeromedical Officer's Evac Course continues to be one of the best doctrine- based courses in the AMEDD. The addition of an Army Flight Nurse to USASAM added immensely to both of these courses as well as the Flight Surgeon course. I would be remiss if I did not mention the Aeromedical Psychology course and CPT Kratz. It remains a one-of-a-kind DoD course that adds a most valuable player on our aviation medicine team. If you are passionate about aviation medicine, there is no better place to be than on the USASAM team. AAMA has also experienced a period of great success. As this newsletter is compiled, they will undergo their Vol. 6, No. 1 - Spring 2005 " 13 greatest test. LTC Ruiz is at Ft. Lewis, Washington field testing the Virtual Flight Surgeon's Office (VSFO). This will put us ever so closer to Army-wide fielding in the near future. The VFSO coupled with other initiatives at AAMA should tremendously streamline our administrative process and make the job of the flight surgeon in the field that much easier. These changes at AAMA must be carefully coordinated with USASAM in order to ensure that our students are trained in the state of the art. It all gets back to training. As for the future, I am very excited. COL McGhee and USASAM remain very forward thinking. Currently, my crystal ball is limited to the specialty of aerospace medicine but I see great and exciting challenges. Our partnership with the University of Texas Medical Branch at Galveston continues to grow -- the potential is huge. UTMB is working on two level four biological containment labs and we are exploring expanding other training opportunities at UTMB beyond the MPH. Our ties with UTMB have opened doors for us at NASA and we are exploring Army Medicine's future role at NASA as well as Space Command. This year, the commanding officer of the Test Pilot School at Pax River will be an Army officer! As jointness spreads across the DoD, we need to stand ready to play jointly. Our partnerships with the Navy, UTMB and other agencies place Army Aviation Medicine in a unique position to capitalize on these opportunities. I would like to close by thanking all of you the fine work you do every day. When you look good, we all look good. Keep up the good work and keep us informed of what you need. We are here to serve you, the flight surgeon in the field. As for me, "I'm just happy to be here and proud to serve". Mountain Medicine B Y A LEX T RUESDELL , MD March, April and May 2002&..Operations Anaconda, Snipe, and Torii. Soldiers, Sailors, Airmen, and Marines from the US, Canada, and Great Britain fought pitched battles against Al- Qaida and Taliban forces in the mountains of Afghanistan. At the same altitude, thousands of miles away in the Pyrenees, I joined 50 physician mountaineers from 12 countries in a multinational Mountain Rescue and Mountain Medicine exercise-and pondered the significance of my training. Aviation medicine, as a subset of preventive medicine, focuses in part on improving medical readiness by mitigating physical stresses on the soldier created by the high-altitude environment. It is the flight surgeon's job to advise commanders-to become expert on operational issues, recommend preventive measures, and understand how to diagnose and treat environmental injury and illness. As flight surgeons we also have a professional interest in hypobaric (and thus high-altitude and mountain) medicine. For centuries, the world's armies have waged war in the cold and at altitude. And while our Army has extensive experience with cold-weather injuries-from Valley Forge to the Korean Peninsula-the War in Afghanistan marks this nation's first-ever high-altitude battles. The US Army has no previous experience fighting in high mountainous terrain. For medical planners, much of the current knowledge was gained from the experiences of other nations, many of which-such as the Soviets in Afghanistan-have successfully waged war at altitudes above 10000 feet. Most recently, during Operation Anaconda, soldiers from the 10th Mountain Division and other units struck from an altitude of 5000 feet at Bagram towards the mountains around Shah-e- Kot, fighting at altitudes as high as 12000 feet, in cold, snowy conditions, to root out Al-Qaida and Taliban fighters. Of a reported 70 injured troops, at least 10 were diagnosed with acute mountain sickness or other forms of altitude illness. A handful of others demonstrated symptoms even at the lower altitudes of Bagram. Such facts demonstrate the importance of developing familiarity with high-altitude and mountain medicine in the AMEDD. Mountain medicine focuses on care under harsh environmental extremes-such as mountainous terrain, high-altitude, and cold weather. Few of us are ever exposed to these topics during the course of our medical training. Yet, for flight surgeons supporting units operating and training in harsh mountainous climates, such knowledge is critical to troop survival and mission success. By all accounts the Army has transitioned to a more CONUS-based rapid-deployment force-prepared to travel anywhere, anytime, to support any contingency. Thus, soldiers and their surgeons must be prepared for an array of environmental hazards. Although there is a host of literature available to the recreational mountaineer physician, little of it is directly applicable to the military community. Unlike civilian professionals, military physicians are faced with a patient population undergoing compulsory rapid ascents-what I will call "forced acclimatization." Insertion of soldiers into high- altitude without adequate physiologic adaptation results in a wide-spectrum of cerebral and pulmonary syndromes-high- altitude illness-due to hypobaric hypoxia. In fact, various studies demonstrate that as many as 45% of individuals rapidly ascending to altitudes over 5000 feet may develop some symptoms of altitude illness. 14 " Vol. 6, No. 1 - Spring 2005 The most common altitude illnesses with which the military physician should be familiar include acute mountain sickness (AMS), high altitude pulmonary edema (HAPE), and high altitude cerebral edema (HACE). Other altitude conditions include high-altitude retinopathy, peripheral edema, venous stasis, high-altitude pharyngitis and bronchitis, and UV keratitis (snow blindness). Additionally, the military physician has to concern himself with other common risks of mountain operations-cold weather injuries, dehydration, and trauma (munitions- related and due to falls, rockslides, and avalanches). Although the exact process of AMS is unknown, cerebral edema is believed to be the major contributing factor. Diagnostic symptoms include headache, fatigue or weakness, nausea, vomiting, or anorexia, dizziness or lightheadedness, and difficulty sleeping. While management in the civilian environment involves rest, halting ascent (or descending), supplemental oxygen, and the use of portable hyperbaric chambers, the military situation is different. Military ascents are often rapid and forced, loads are heavy, and there is little opportunity for staged climbs or adequate acclimatization. More significantly, the tactical situation often prohibits descent. In this situation, AMS can best be treated with the administration of acetazolamide-a respiratory stimulant which reduces cerebral hypoxia-and/or dexamethasone. Various placebo- controlled studies with both of these agents demonstrate significant symptom reduction within 12-24 hours. These medications can also be supplemented by antiemetics to treat nausea and vomiting and low doses of furosemide to counteract peripheral edema. Preferable to treatment, particularly for the military mountaineer, is prophylaxis. Both acetazolamide and/or dexamethasone (both starting 1 day prior to descent and continuing for 2 days at altitude) can be used to prophylax AMS during rapid ascents. A new prophylactic drug of interest is Ginko Biloba-starting 5 days prior to ascent and continuing at altitude. Although research is limited, preliminary results have been favorable. Recent double-blind, placebo- controlled studies demonstrated a dramatic decrease in both the incidence and severity of symptoms during rapid ascent from 5000 feet to 14000 feet. HAPE, another common altitude ailment, is a noncardiogenic pulmonary edema associated with pulmonary hypertension and elevated capillary pressure. Symptoms include dyspnea at rest, cough, weakness or decreased exercise performance, and chest tightness or congestion-and are exacerbated by cold. Signs include central cyanosis, rales, tachypnea, and tachycardia. Whenever possible, HAPE is treated by warming, descent (or portable hyperbaric chamber), and supplemental oxygen. When these treatments are not feasible, nifedipine-a pulmonary vasodilator-can be used instead to reduce pulmonary artery pressure. Finally, while equivocal, recent studies indicate a potential role for inhaled beta-agonists in HAPE prevention and treatment. HACE, an end-stage of AMS, is defined as the onset of ataxia and/or altered consciousness in the setting of AMS or HAPE. As with AMS and HAPE, it is best treated with descent-or temporizing measures to include oxygen, acetazolamide, dexamethasone, and hyperbaric therapy. AMS, HAPE, and HACE all represent a spectrum of high-altitude pathology. Significantly, the vast majority of individuals suffering from HAPE and HACE generally first demonstrate recognizable symptoms of AMS. As a physician caring for soldiers at altitude it is therefore essential to screen troops and educate leaders in the early recognition and prevention of these altitude illnesses. And so, while traveling through the majestic Pyrenees mountain range, our soldiers in Afghanistan were never far from my mind. As a member of the International Society of Mountain Medicine (ISMM), I joined 50 physicians from 4 continents in traversing the Pyrenees-on skis (with and without skins and ski crampons), snowshoes, and crampons. We shared knowledge of mountain medicine and conducted various practical exercises on mountain rescue and the treatment of cold-weather, high-altitude, and traumatic mountain injuries while moving from refuge to refuge along the mountain range. And next year, I intend to accompany another group to the Makalu region of Nepal (to altitudes of 20000+ feet) to conduct studies on high-altitude physiology and adaptation. For any flight surgeon with an interest in mountaineering and mountain medicine, I wholeheartedly recommend membership in the ISMM. For who knows when the Army may next need our high-altitude medical skills. R ECOMMENDED R EADING : USARIEM Technical Note 93-4 Medical Aspects of Cold Weather Operations USARIEM Technical Note 94-2 Medical Problems in High Mountain Environments Current Concepts: High-Altitude Illness. Hacket, PH, N Engl J Med 2001; 345:107-114 http://www.high-altitude-medicine.com http://hypothermia.org CPT Alex Truesdell, MC, FS currently serves as Battalion Flight Surgeon for the 1st Military Intelligence Battalion in Wiesbaden, Germany and Lecce, Italy. (alex.truesdell@us.army.mil) Vol. 6, No. 1 - Spring 2005 " 15 What is the Haley Award? B Y D ANA T HOMAS , MD, MPH The Haley Award is a literary award presented annually to the best and most useful publication to the Army flight surgeon. This award was founded in recognition of Joseph L. Haley's lifelong contribution to the aeromedical safety literature. The award recognizes the best published work with relevance to the practice of rotary-wing aviation medicine. Eligible works may be written by anyone and may be published in any forum or medium, as long as the average Aerospace Medical Association (AsMA) member can obtain a copy if he or she so desired. The Award committee will consider the following three main characteristics when selecting the winning publication. a)Information: The winning publication will contain high quality information of particular value to the AsMA membership. For example, it might fill a void in rotary-wing aviation medicine research, or might detail personal experiences of great value to the Army flight surgeon in the field. b)Method: Whether a basic science paper or a collection of amusing stories, the winning publication will display attention to excellence in method. A winning scientific paper will display commitment to scientific excellence (e.g. appropriate statistics, defensible conclusions, etc...) while a wining historical essay would be based on reliable sources that are well referenced. c)Presentation: Consideration will be given to the author's attention to detail in writing style, graphics quality and general eye appeal. In selecting a winner, the committee is, in effect, recommending a work to the AsMA memebership, so the winner should be readable and polished. The Haley Award is presented at the US Army Aviation Medical Association (AVMA) luncheon. AVMA is the Army's branch of the Aerospace Medical Association (AsMA). AsMA is the largest most-representative professional organization in the fields of aviation, space and environmental medicine. This year's annual scientific meeting will be held in Kansas City, Missouri - May 8-12, 2005. We encourage those interested in attending our specialty's annual international Aerospace Medicine Meeting or nominating any particularly useful literature to contact the AVMA Secretary, Dana Thomas, MAJ MC FS at (334) 255- 7575 or dana.thomas1@us.army.mil. MAJ Dana Thomas serves as the secretary and treasurer of the Army Aviation Medicine Association Have you thought about the Aerospace Medicine Residency? B Y J OHN A LBANO , MD, MPH The Residency in Aerospace Medicine, a subspecialty of Preventive Medicine, consists of four years of graduate medical education (GME), comprised of an internship year, an academic year (Master 9s Degree in Public Health), a practicum year, and an advanced clinical year. The PGY-1 is an internshi

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