Академический Документы
Профессиональный Документы
Культура Документы
TRAINING
COURSE
Hospital Corpsman
NAVEDTRA 14295A
S/N 0504LP1094749
For content issues, contact the servicing Center of Excellence: Navy Medicine
Manpower, Personnel, Training and Education Command (NAVMED MPT&E);
(301) 295-4502, DSN: 295-4502 or RTM_Feedback@med.navy.mil.
This publication contains approved copyrighted material (©). In accordance, this manual is
only available for distribution through Department of Defense (DoD) restricted websites
(Navy Knowledge Online (NKO), Navy Advancement Center) and Naval Supply Systems
Command, Naval Logistics Library (NLL) (Hard Copy only).
PREFACE
This is a self-study course. By studying this course, you can improve your professional/military
knowledge, as well as prepare for the Navywide advancement-in-rate examination. It contains
subject matter about day-to-day occupational knowledge and skill requirements and includes text,
tables, and illustrations to help you understand the information. An additional important feature of
this course is its references to useful information to be found in other publications. The well-
prepared Sailor will take the time to look up the additional information.
Copyright material has been identified, approved and is listed below within this document.
Ansel, H.C. (2010). Pharmaceutical 21-NOV- 18 18-3, 18-24, 18-28, 18-29, Text & Figures
th
Calculations, (13 ed.) 2009 18-30, 18-31
Color Atlas of Common Oral Diseases (2nd ed.) 18-DEC- 8 8-13, 8-19, 8-20, 8-21 Figures
2009
Drug Facts & Comparisons, (2009). 4-DEC- 18 18-1 Text
2009
McCall & Tankersly, Phlebotomy Essentials (4th 14-DEC- 19 19-5, 19-7, 19-9, Text & Figures
ed.) 2009
Redford, Orthotics Etcetera, 9-DEC- 12 12-16, 12-17, 12-18, 12-19, 12- Text
(2nd ed.) 2009 20
McGraw-Hill
(2005). Current Medical Diagnosis and 2-DEC- 23 23-16, 23-17, 23-18, 23-19, 23- Text
Treatment (44th ed.). Lange Medical 2009 21, 23-22, 23-23, 23-24
Books/McGraw Hill, New York
Nursing School Entrance Exam Book 15-OCT- 6 6-61 Text
2009
North East Regional Board of Dental
Examiners, INC
www.NERB.org 2-OCT- 24 24-5, 24-6 Figures
2009
Quintessence
Terezhalmy, G. T., & Batizy, L. G. (Editors) 15-DEC- 24 24-16 Text
(1998). Urgent Care in the Dental Office: An 2009
Essential Handbook.
Seimens
Siemens Healthcare Diagnostics Inc. 19-JAN- 19 19-27 Figure & Text
2010
University of Illinois, McKinley Health
Center
University of Illinois. (2008). Using crutches. 15-DEC- 12 12-21 Text
Retrieved on August 21, 2009 2009
In this 2010 edition of the Hospital Corpsman NAVEDTRA 14295A, also referred to as, Rate
Training Manual (RTM) and/or Non-Resident Training Course (NRTC), the subject matter has
been revised, expanded, and brought up-to-date with the diverse medical aspects discussed in
various chapters and sections.
The Hospital Corpsman NAVEDTRA 14295A is intended to serve as a general guide and
reference manual for the Hospital Corpsmen of the U. S. Navy, especially those performing duty
independent of Medical Department Officers. It contains information and instructions
concerning the generalized duties based upon the most current occupational standards for the
Hospital Corps of the Navy. Hospital Corpsmen, particularly those in senior ranks, are urged to
make frequent references to other Navy publications for additional information and instructions
not contained within.
The principle subjects have been arranged in an organized manner ranging from the Heritage of
the Hospital Corps to Decedent Affairs. As these subjects are presented in condensed form,
readers should realize that the information contained in it must be supplemented by reference to
the standard textbooks and professional journals usually available in the medical libraries of
medical treatment facilities, ships, and various other stations.
The Bureau of Medicine and Surgery, Navy Medicine Support Command, and Navy Medicine,
Manpower, Personnel, Training and Education Command herewith expresses gratitude and
appreciation to the following members of the Medical Department, U.S. Navy for the time and
effort spent in preparing, reviewing, and revising the material for this manual:
Bureau of Medicine and Surgery Force Master Chief and Director of the Hospital Corps,
Bureau of Medicine and Surgery Force Master Chief’s Senior Enlisted Board of Advisors,
Bureau of Medicine and Surgery Historian, Specialty Leaders, Enlisted Technical Leaders,
Subject Matter Experts, and Academics and Governance Directorate (Navy Medicine
Manpower, Personnel, Training and Education Command) are acknowledged.
SCOPE OF RATING:
Hospital Corpsman (HM)
Assist health care providers in delivering medical care to armed
service personnel and their families. Supervises personnel in the
performance of clinical or ward duties; maintains health records;
instructs medical and non-medical personnel in general and emergency
medical care and in self-administration of medications. Administers
first aid; assists with physical examinations and makes basic
clinical assessments; assists in the transportation of the sick and
injured; maintains mechanical equipment; and conducts health
education training programs. They also perform medical
administrative and clerical functions. Additionally, completion of
Dental Assistant training allows Hospital Corpsman to perform diverse
duties in the prevention and treatment of oral disease, injury and
assist dental care professionals in providing quality dental care.
Hospital Corpsman also serve with the Marine Corps rendering
emergency and stabilization care in various combat environments while
also providing administrative and technical assistance to support the
mission and functions of operational units.
Sailor’s Creed
IV Trademarks.................................................................................................. AIV-1
INDEX
Index .......................................................................................................... Index-I
CHAPTER 1
1-1
early Hospital Corpsman was Hospital During World War II, a total of 15 Navy
Apprentice Robert Stanley. In 1900, Stanley enlisted men were awarded the Medal of Honor;
became the first of twenty-two Hospital of this number, seven were Hospital Corpsmen.
Corpsmen to be awarded the Medal of Honor. Members of the Hospital Corps received 820
major awards and citations (an honor of unique
SERVICE IN WORLD WAR I distinction since none of them bore arms). On
the summit of Mount Suribachi, Iwo Jima, along
In 1916, on the eve of America’s with six marines, Pharmacist Mate John Bradley
involvement in World War I, the Hospital Corps proudly participated in the raising of our flag.
saw further structural changes; it could be This scene has been reproduced thousands of
argued that these set the foundation for the times and is symbolized by the U.S. Marine
current system of rank structure used today. As Corps War Memorial.
part of this revision, the rates would be: Hospital
Apprentice; Hospital Second Class; Hospital At the end of the war, the Honorable James
First Class; Pharmacist Mates Third, Second, Forrestal, Secretary of the Navy, and later the
and First; and Chief Pharmacist Mate. All would first Secretary of Defense, paid honor to the
wear a red cross on their sleeve. By adding an Hospital Corps of the United States Navy for its
improved rank structure the Hospital Corps singular attainments during this conflict. His
allowed for a massive expansion of personnel words ring true today and tell so well the role of
which was needed for the war in France and for the Corpsman, not only in that conflict and the
the occupation of Haiti (1915-1934). conflicts that have followed, but also in times of
peace. Insofar, that can be determined; this is the
During World War I, the reputation of the first time in military history that a single corps
Hospital Corps, especially in the field with the has been commended by the Secretary of the
Marine Corps, was greatly enhanced by its many Navy.
achievements. Both the United States and France
cited many Hospital Corpsmen for valor and “Out of every 100 men of the United States Navy
performance of duty under fire. Fifteen Hospital and Marine Corps who were wounded in World
Corpsmen were killed in action, 2 died of War II, 97 recovered. That is a record not
wounds, and 146 were wounded or gassed. They equaled anywhere, anytime. Every individual
were the recipients of some 460 major awards who was thus saved from death, owes an
and citations, including 2 Medals of Honor, 55 everlasting debt to the Navy's Hospital Corps.
Navy Crosses, 31 Distinguished Service Medals, The Navy is indebted to the corps. The entire
2 U. S. Army Distinguished Service Medals, and nation is its debtor for thousands of citizens are
27 Letters of Commendation. living normal, constructive, happy and
productive lives who, but for the skill and toil of
WORLD WAR II AND THE YEARS the Hospital Corps, might be dead or
FOLLOWING disheartened by crippling invalidism. So, to the
200, 000 men and women of the Hospital Corps,
Women were first brought into the Hospital I say on behalf of the United States Navy: "Well
Corps during World War II. On 12 January Done. Well done, indeed!"
1944, the first Hospital Corps School for
Women Accepted for Volunteer Emergency On 02 April 1948, the nomenclature of the
Service (WAVES) was commissioned at the Hospital Corps’ ratings was changed to read:
U.S. Naval Hospital, National Naval Medical Hospital Recruit; Hospital Apprentice;
Center, Bethesda, Maryland. The first class Hospitalman; Hospital Corpsman Third Class;
consisted of 230 enlisted women. These women Hospital Corpsman Second Class; Hospital
served important functions at hospitals stateside Corpsman First Class; and Chief Hospital
allowing the Navy Medical Department to fulfill Corpsman. At this same time, the rating insignia
its wartime duties to the fullest. of the Hospital Corps was changed from the Red
Cross to the caduceus.
1-2
KOREA AND THE YEARS FOLLOWING Hospital corpsmen were present at sea and
ashore when the United States took military
As part of a United Nations force, Marines action in Grenada and during operation Desert
were committed to the Korean peninsula when Storm.
South Korea was invaded by its northern
neighbor in the summer of 1950. Within the SEPTEMBER 11TH
first year, Hospital Corpsmen had
participated in the dramatic landing at Inchon The attacks on the Pentagon and World
and the frigid retreat from the Chosin Trade Center on 11 September 2001 (9/11)
Reservoir. Although only one Marine division awoke the proverbial American “sleeping giant.”
was involved in the war between 1950 and 1953, In the days that followed the fall of the towers,
the Hospital Corps lost 108 killed in action. America relentlessly searched out terrorist
Disproportionate to their numbers was their havens across the world and neutralized them.
heroism. In Korea, Hospital Corpsmen earned As our focus shifted from hotspot to hotspot,
281 Bronze Star Medals, 113 Silver Star Medals, from Afghanistan to the Philippines, Hospital
and 23 Navy Crosses. All five enlisted Navy Corpsmen were there to support the mission.
Medals of Honor were awarded to Navy
Hospital Corpsmen serving with the Marines. As the mission of Navy Medicine changed,
so did its philosophy. On 27 September 2001,
VIETNAM AND THE YEARS by order of Navy Surgeon General Michael
FOLLOWING Cowan, new signal flags, “Charlie Papa:
Steaming to Assist” were flown above all Navy
With the escalation of the Vietnam conflict medical activities. As VADM Cowan
between 1963 and 1975, Hospital Corpsmen explained, “The men and women of Navy
were called to serve in Southeast Asia. They Medicine were among the first to respond,
served in Marine Corps and Navy air/ground providing aid to the injured at the Pentagon and
forces, naval support activity hospitals, hospital comfort and care for thousands of rescue
ships, Riverine Warfare ("Brown Water Navy"), workers who worked around the clock in the
and Navy ships on the "Gun Line" off the coast desperate race to find survivors beneath the
of South Vietnam and "Yankee Station" off the rubble that was the World Trade Center.
coast of North Vietnam. They served in [Similarly] we are no longer standing by to help
Cambodia and supported troops from Thailand. when a Sailor or Marine is sick or injured. We
Like their predecessors, they performed are out in front of the problem, providing
emergency treatment in all kinds of combat preventive care, promoting wellness, and
conditions. They were assigned to small medical anticipating crises before they occur.”
teams that provided care and health advice to
Vietnamese civilians. Some were assigned as GLOBAL WAR ON TERROR
medical advisors to Vietnamese military units. (GWOT)/OVERSEAS CONTINGENCY
Hospital Corpsmen truly felt the brunt of the OPERATIONS
Vietnam conflict. Six hundred twenty were
killed or mortally wounded and another 3,353 Afghanistan
were wounded in action.
The attacks of September 11th were traced to
Following the fall of Saigon in April 1975, Al Qaida, an ultra conservative Sunni Islamist
Hospital Corpsmen continued to serve in the terrorist organization and its leader Osama bin
many "hot spots" around the world. Fifteen Laden. Requiring a base of operations, Al Qaida
hospital corpsmen were killed in the line of duty had associated itself with the Taliban, the
when the Marine Barracks in Beirut, Lebanon, fundamentalist religious and political movement
was bombed and destroyed by terrorists. then in control of the remote and mountainous
Afghanistan. Following the Soviet withdrawal
from Afghanistan in 1989, the Taliban seized
1-3
control of this land in turmoil and fostered much As America continues to withdraw from Iraq
of Al Qaida’s extreme ideology. When the and as the responsibility for Afghanistan shifts
United States demanded that the Taliban give up from the Army to the Marine Corps, Hospital
Bin Laden and the other Al Qaida members Corpsmen are being deployed to Afghanistan in
operating in the country, the Taliban began to large numbers in support of national objectives.
actively protect and aid the terrorists in their Faced with an ongoing conflict, tomorrow’s
struggle against the West. Left with no other Corpsmen will be challenged with living up to
choice the United States, allied with the standards set by those who serve there today.
Afghanistan’s Northern Alliance and the local
Afghan resistance, began combat operations Iraq
against the Taliban on 07 October 2001.
When, in accordance with United Nations
Afghanistan’s landlocked location and Security Council Resolution 1441, American
hostile, arid landscape severely hindered any forces invaded Iraq on the 20 March 2003 to
traditional form of land based military remove Sadaam Hussein, the Corpsmen
campaign. As such the attacks began with an assigned to the 1st Marine Expeditionary Force (I
intensive air bombardment, which was MEF) were among the first Americans to cross
successful largely due to the aid of the Navy the border. During the assault the Marines and
SEALS who, along with other Special Forces Sailors of I MEF, in conjunction with the 3d
units, called in devastatingly accurate air strikes Infantry Division (3rd ID) and the 1st U.K.
in support of a renewed Northern Alliance Armored Division, drove over 300 miles into
ground offensive. SEAL Corpsmen, operating Iraq; the deepest penetrating ground operation in
hundreds of miles away from higher echelon Marine Corps history. As they had since Belleau
support, treated not only their own injured, but Wood, battalion Hospital Corpsmen served
also provided essential medical aid to their beside their Marines and rendered lifesaving
poorly trained and equipped Afghan allies. care even while the battle raged around them.
The 1st Medical Battalion, 1st Marine Logistics
In November, after flying over 372 miles by Group, as part of the historic assault, provided
helicopter from the USS Peleliu and the USS essential forward medical care to rapidly
Boxer in the North Arabian Sea, the Marines and advancing units.
Hospital Corpsmen landed in Afghanistan. The
Marines faced the daunting task of hunting down In March 2004, the 1st Medical Battalion
the Taliban in an operating area that had seen returned to Iraq, providing much needed relief to
almost continuous conflict since the time of the 82d Airborne Division Medical Units in the
Alexander the Great. Few since Alexander have Sunni Triangle. During Operation IRAQI
successfully managed to hold this troubled land. FREEDOM II, the Battalion conducted
operations in support of Marine units throughout
The austere and unforgiving mountainous Al Anbar Province, culminating in Operation
environment of Afghanistan is as much of an AL FAJR. This liberated the insurgent
enemy as the terrorists who hide in the many stronghold of Fallujah and enabled the first
caves and grottoes it provides. The lack of legitimate elections to occur in Iraq.
infrastructure prevents rapid evacuation of
casualties by land and its extreme elevation The Iraqi conflict gave Navy Medicine an
makes helicopter travel difficult. Corpsmen who opportunity to utilize the newly developed
had been trained to expect to be able to move Shock Trauma Platoon (STP) concept. Each
wounded Marines to higher echelon care within surgical company in the Medical Battalion had
hours of injury, were now often faced with the two STPs attached to them. The STP, a small,
very real prospect of stabilizing and maintaining mobile medical unit, was designed to advance
them for days. with assault units and support combat operations
from just behind the front lines. Between 17
February and 21 September 2004, STP 2, treated
1-4
141 combat casualties with a phenomenal 98% Chief Warrant Officer Four Brian Dix, the
survival rate allowing evacuation of its patients Director of the Marine Corps’ Drum and Bugle
to definitive care at higher echelon medical Corps, met HM3 Joe Worley. Badly wounded by
facilities. a rocket propelled grenade and six bullet wounds
during the battle of Fallujah, Iraq, “Doc” Worley
While most of the war in Iraq was conducted stunned the Marine Officer when he recalled that
by land forces, the contributions of Hospital harrowing day that proved so costly to him and
Corpsmen serving with the fleet cannot be his platoon. Thus inspired by the heroic actions
overlooked. The Tomahawk missile that opened of all Hospital Corpsmen which were so
the Iraqi conflict was launched from the USS exemplified by HM3 Worley, CWO4 Dix
Cheyenne, a submarine that could not have composed a military march entitled
sailed without her Independent Duty Corpsman appropriately “Corpsman Up!” to honor all the
(IDC). Hospital Corpsmen past and present. Such a
unique and moving tribute is a testament to the
An inescapable legacy of the Overseas bond we share with those whose lives we are
Contingency Operations in Iraq and Afghanistan entrusted and stands unequaled in military
are the thousands of Marines, Sailors, and medicine.
Soldiers returning with Traumatic Brain Injury
(TBI) as well as deeper psychological wounds CORPSMEN WITH THE FLEET
categorized as Post-Traumatic Stress Disorder
(PTSD). PTSD is nothing new. Over the course Even as the first tower fell in New York on
of 140 years of warfare, PTSD has been labeled 9/11, Hospital Corpsmen assigned to the
as nostalgia, neurasthenia, shell shock, and National Capitol Region rushed to make the
combat fatigue. Though medical professionals USNS Comfort ready for sea. Arriving on the
have long studied the symptomology and 14th, the Comfort provided much needed respite
treatment for PTSD, only recently, since 1980, to the thousands of rescue workers who searched
has it been acknowledged as a diagnosable in vain for survivors amid the rubble of the Twin
psychological disorder. Recent studies have Towers. During the initial phase of fighting in
revealed that as many as one in six returning Iraq, Corpsmen on the Comfort treated more
from combat operations in Iraq suffer from the than 650 casualties, many of them Iraqi
disorder with as many as 300, 000 returning civilians.
veterans from Iraq and Afghanistan. Combat
medical personnel are in the unique situation of While most of the attention given to sea
taking care of the psychologically wounded based medicine goes to the two hospital ships,
while also being exposed to the same stressors Mercy and Comfort, the unsung Hospital
that induce PTSD. Corpsmen assigned to the rest of the fleet
continue to prove their ability to support combat
Combat stressors and burnout are the operations anytime, anywhere. Even the
unfortunate and inevitable byproduct of hard- transport ships that carry Marine battalions to
fought wars and campaigns. However, our the fight bring with them the tools to save the
Sailors and Marines with war-induced lives of the men and women sent into harm’s
psychological trauma do not have to suffer in way. Each class of amphibious assault ship is
silence like many of their ancestral combat fitted out as well as most civilian hospitals,
veterans. The Navy Medical Department can bringing two to four fully functional operating
boast of some of the finest mental health care rooms, ICU beds, vast surgical wards, fully
providers who offer a wide array of treatment stocked pharmacies and even dental clinics to
for PTSD. every corner of the world where they are needed.
An interesting footnote to Hospital Corps In August 2009, the U.S. “Global War on
history occurred in 2004 when, while visiting Terror” in Afghanistan and Iraq was rebranded
wounded Marines at Bethesda Naval Hospital, the “Overseas Contingency Operations.” Despite
1-5
this name change, Hospital Corpsmen continue USS Bonhomme Richard, USS Abraham
to support ongoing operations serving where Lincoln, Carrier Air Wing Two, and the USNS
needed. Whether as a flight deck “HM” on a Mercy worked tirelessly to provide medical care
carrier supporting combat flight operations or an to survivors.
IDC aboard a destroyer conducting anti-piracy
patrols off the Horn of Africa, Navy Corpsmen Less than a year after the horror of the
have been, and always will be, in the vanguard tsunami, Americans were shocked by their own
of all naval activities. disaster. At 6:10 am on Monday, 29 August
2005, Hurricane Katrina made landfall. In less
SOFT POWER: A GLOBAL FORCE OF than 12 hours much of the city of New Orleans
GOOD lay in ruins underwater. The devastation
wrought by that “perfect storm” left much of the
As America moves into the new century, Gulf Coast reeling. Throughout these disasters,
more focus is placed upon “Soft Power,” i.e., the Hospital Corpsmen were among the first to
doctrine of using goodwill and cooperation to respond. Within days those assigned to ships
influence nations and peoples of the world. In were deployed ashore as members of response
an article entitled “International Neighborliness” teams. The hospital ship USNS Comfort arrived
published in Outlook magazine in January 1911, in New Orleans a week after the storm and
former president Theodore Roosevelt forecasted provided vital medical care to nearly 2,000
a global climate where fellow nations would survivors.
band together to help those who have been
struck by “terrible and overwhelming disaster.” During the first decade of the millennia
The Navy Medical Department has long been on Hospital Corpsmen deployed to Cambodia and
the forefront of what President Roosevelt called Sri Lanka to provide care to those with landmine
“acts of sincere disinterested friendliness.” For blast injuries; Djibouti to conduct an industrial
well over a hundred years, Navy medical health survey; Baghdad as part of the Coalition
personnel have exhibited diplomacy in the form Provisional Authority to assist in training the
of medical assistance to nations and peoples newly formed Iraqi Army in combat lifesaver
afflicted by natural disaster and poverty. skills; Zambia to conduct an HIV/AIDs research
project and provide HIV lectures to Zambian
Navy Corpsmen have played a pivotal role military personnel; Ghana to provide
in disaster relief operations. Following humanitarian aid, civic assistance, and medical
devastating earthquakes in San Francisco (1906) peacetime support; Honduras for a
and Messina, Sicily (1908), Hospital Corpsmen humanitarian support mission; and interestingly,
were among the first medical providers to Vietnam, Laos, and Cambodia with the Joint
partake in relief efforts. During the occupation POW/MIA Accounting Command (JPAC)
of Haiti (1915-1934), Navy physicians and providing medical support for those searching,
Hospital Corpsmen alike, traveled throughout recovering, and identifying the remains of
the country providing medical care to civilians American service members.
and spearheaded the creation of a Haitian public
health office (National d’Hygiene Publique). In the twenty-first century, the Navy
Medical Department continues to perform a
The Hospital Corps’ role in disaster relief wide range of humanitarian operations. These
and humanitarian campaigns continues through missions have evolved into complex,
the present. On 26 December 2004, a cooperative efforts with other government
magnitude-9 earthquake shook the Indian Ocean agencies and non-governmental organizations
just off the Indonesian coastal city of Banda (NGOs). One example was USNS Comfort’s
Aceh. Within hours the resulting tsunami 120-day humanitarian mission to South
devastated shorelines from Indonesia to South America, Central America, and the Caribbean in
Africa leaving at least 230,000 dead and 2007. During this mission the hospital ship
millions homeless. Navy medical teams from the visited 12 nations and personnel saw over
1-6
98,000 patients. However, the Navy was not Lakes, IL, and San Diego, CA, in 1948. Enlisted
alone in this effort. On board were personnel personnel could thus be procured by direct
from the Army, Air Force, Air National Guard, recruitment into the dental rating group; they no
Coast Guard, Canadian Defense Forces, U.S. longer were required to prepare themselves for
Public Health Service, and civilian NGOs (e.g., advancement in a rating group (i.e. Hospital
Operation SMILE, Project HOPE, USAID and Corpsman) that did not reflect their duties.
others). In 2008, this humanitarian effort was
countered in Pacific by USNS Mercy, whose 4- The Korean War marked the first time that
month deployment to the Republic of the Hospital Corpsmen wearing dental rating badges
Philippines, Vietnam, the Federated States of served in combat. Throughout this conflict,
Micronesia, Timor-Leste, and Papua New Navy Dental Technicians treated patients hand
Guinea served as a model for future “Pacific in hand with their medical counterparts both at
Partnership(s).” home, overseas, and most notably on the
frontlines. Wherever the Marines went, Dental
In 2009, USNS Comfort travelled to Central Technicians were there, generally assisting with
and South America on a 4-month humanitarian casualty care and treatment. The heroic
assistance operation called Continuing Promise. performance of Dentalman Thomas A.
During this effort, Navy medical personnel, in Christensen, Jr. was representative of the
partnership with other government and non- dedication and sacrifices of Dental Technicians.
government agencies, treated over 100,000 Christensen received the Navy Cross
patients, conducted 1,657 surgeries, and filled posthumously for valor demonstrated on 06
some 13, 238 prescriptions. The legacy of this November 1950 while treating casualties. Navy
and previous campaigns has strengthened U.S. Dental Technicians and Hospital Corpsmen were
relations with the developing nations while chief recipients of the 1,115 major combat
further defining what it means to serve in the awards given to Navy medical personnel in the
Navy Medical Department. Korean War.
1-7
mandated that the Army, Navy, and Air Force As the military becomes leaner and more
must co-locate all enlisted medical education specialized, the Hospital Corps must remain
and training programs to Fort Sam Houston, San flexible enough to meet any requirement asked
Antonio, TX. For the Navy, this will re-align all of them. Whether attached to a Marine Battalion
Corpsmen training programs except IDC and air in the mountains of Afghanistan, part of a ship’s
affiliated training programs. crew, or augmenting an Army unit in Iraq,
Hospital Corpsmen will continue to set the
For the Navy Hospital Corps, this tri-service standard for enlisted medical care far into this
integration marks the closing of another chapter century.
in its history. Since 1902, with the establishment
of the School of Instruction in Portsmouth, VA, HOSPITAL CORPSMEN AWARDS
the Navy has operated unique Hospital Corps
Schools to develop and teach new recruits how The Hospital Corps is the most decorated
to care for the sick and wounded aboard ship and branch of the United States Navy and has fought
ashore. Unlike the other service’s training on the front lines of every battle in United States
centers, which have traditionally focused history. Hospital Corpsman have served
training their medical personnel for specialized courageously on ships and valiantly on the
tasks, Naval Corps Schools use a broader brush. battlefields of every conflict, caring for injured
This jack-of-all-trades focus fostered the unique Sailors and Marines.
identity of the Hospital Corps by producing a
well rounded Sailor prepared to operate in all To date, there have been 22 Medal of Honor
expeditionary environments. recipients from the Hospital Corps; this is half of
all the Medal of Honor's awarded to the
Over the years, the Navy has operated Department of the Navy. There have been 174
Hospital Corps Training Schools in Bainbridge, Navy Crosses, 31 Distinguished Service Medals,
MD (1943-1957); Farragut, ID (1943-1945); 946 Silver Stars, and 1582 Bronze stars awarded
Great Lakes, IL (1913-1921; 1942 to 2011), to Hospital Corpsman since the establishment of
Newport, RI (1917-1921); Portsmouth, VA the Hospital Corps. Additionally, there have
(1902-1906; 1921 to 2011), San Diego, CA been 14 Naval Vessel's that have been named for
(1928-1932; 1935 to 2011); and San Francisco, Hospital Corpsman, and several hospitals and
CA (1917-1921). The three remaining clinics also bear the names of courageous
schools—Hospital Corps School Great Lakes, individuals that paid the ultimate sacrifice for
Naval School of Health Sciences Portsmouth, our country and our freedom.
VA, and Naval School of Health Sciences, San
Diego, CA, will be consolidated and co-located
with the 882nd Training Group of the Air Force,
and the Army’s Academy of Health Sciences.
1-8
HOSPITAL CORPSMEN WHO RECEIVED Korean War
THE MEDAL OF HONOR
• Hospital Corpsman Third Class Edward
C. Benfold, USN
Pre-World War I
• Hospital Corpsman Third Class William
• Hospital Apprentice Robert H. Stanley,
R. Charette, USN
USN (Boxer Rebellion)
• Hospitalman Richard D. Dewert, USN
• Hospital Apprentice First Class William
Zuiderveld, USN (Veracruz Incursion) • Hospitalman Francis C. Hammond,
USN
• Hospital Apprentice Fred H. McGuire,
USN (Philippine Insurrection) • Hospitalman John E. Kilmer, USN
• Hospital Steward William S. Shacklette,
USN (Boiler Explosion aboard USS Vietnam War
Bennington)
• Hospital Corpsman Second Class
Donald E. Ballard, USN
World War I
• Hospital Corpsman Third Class Wayne
• Pharmacist's Mate First Class John H. M. Caron, USN
Balch, USN
• Hospital Corpsman Third Class Robert
• Hospital Apprentice First Class David R. Ingram, USN
E. Hayden, USN
• Hospital Corpsman Second Class David
R. Ray, USN
World War II
• Hospital Apprentice First Class Robert
Eugene Bush, USN
• Pharmacist's Mate 2nd Class William D.
Halyburton, Jr., USNR
• Hospital Apprentice First Class Fred F.
Lester, USN
• Pharmacist's Mate First Class Francis J.
Pierce, USN
• Pharmacist's Mate Second Class George
E. Wahlen, USN
• Pharmacist's Mate Third Class Jack
Williams, USN
• Pharmacist's Mate First Class John H.
Willis, USN
1-9
CHAPTER 2
2-1
MEMORANDUM FOR THE RECORD permanent duty station, in this case NMCSD, the
readiness coordinator will see this up to date
A Memorandum for the Record is prepared information. There are gateways known as the
in accordance with (IAW) the SECNAVINST Central Data Repository (CDR) and Defense
5216.5 series, Department of the Navy Enrollment Eligibility Reporting System
Correspondence Manual, series for any event (DEERS) that allow SAMS and MRRS to
of historical or legal importance, or for which communicate and share information.
good judgment dictates that it should be
recorded. It provides a medium for recording SICK CALL TREATMENT LOG
special occurrences that might need to be
reconstructed in detail at a later time. The Sick Call Treatment Log is maintained
Memorandum for the Record may be drafted for in SAMS for each ship or activity. The log
any serious injury or death, patients who refuse contains each patient’s reporting date and time,
treatment or are noncompliant, or when name, rate, division, chief complaint, diagnosis,
recommendations to the command in regards to treatment, and disposition. The report is
the health and safety of the crew are not forwarded to the Commanding Officer on a daily
followed due to the Commanding Officer’s basis.
discretion.
TRAINING LOG
SHIPBOARD NON-TACTICAL
AUTOMATIC DATA PROCESS (SNAP) All lectures and training periods that are
AUTOMATED MEDICAL SYSTEM administered by the medical department should
(SAMS) be recorded in the training management module
of SAMS. The entries should include the date,
SAMS is an administrative management tool title of the lecture, division of personnel
that tracks the medical and dental readiness of attending, duration of the lecture, and the
Navy and Marine Corps operational units. number of Officers, Chiefs, and E-6 and below
SAMS enables health care providers to update attending.
patient medical information and record medical
encounters. Additionally SAMS is used to track The location may be a necessary item to put
supply inventory, log preventative medicine into the log book. For example, the Battle
inspections, report and receive radiation Dressing Station (BDS) is a designated location
exposure data, and manage medical training. for the treatment of casualties and is maintained
and managed by the medical department. It can
MEDICAL READINESS REPORTING be used to provide training to medical and non-
SYSTEM (MRRS) medical personnel. Additional BDS information
can be found in the COMANVSURFORINST
MRRS is an administrative management 6000.1 series, Shipboard Medical Procedures
tool that is used to track the medical and dental Manual.
readiness of every active duty and reserve Sailor
or Marine. It is an Internet based communication POTABLE WATER LOG
program that allows for health care providers to
update and manage a member’s readiness The purpose of the potable water log is to
regardless of the member’s permanent duty record the readings of daily residual chlorine or
station. For example, if is a member is stationed bromine levels and the weekly bacteriological
in Naval Medical Center San Diego (NMCSD) examinations required on potable water aboard
and goes on a weeklong evolution with a Marine ship and in the field. Records will be
Corps unit without the health record and maintained IAW the, Manual of Naval
receives an immunization, that Marine Corps Preventive Medicine, NAVMED P-5010,
unit has the ability to update this information chapter 6. Record the results using the SAMS
into MRRS. Once that member returns to the Environmental Management Module.
2-2
WORK CENTER PMS MANUAL DIRECTIVES ISSUANCE SYSTEM
2-3
Official Navy correspondence is usually required on all Navy and Marine Corps letters,
prepared and referred to as the standard naval messages, directives, forms, and reports. The
letter. The standard naval letter is used when extent of the HM’s knowledge of this
corresponding with certain agencies of the standardization system of subject identification
United States Government. Some civilian will determine the efficiency in being able to
companies dealing extensively with the Navy retrieve correspondence from the files.
may prepare correspondence using the standard
naval letter. Instructions for typing standard Numerical Subjects Grouping
naval letters are very precise and must be
followed to the last detail. All information to SSICs are divided into 13 major groups:
prepare naval correspondence can be found in
• 1000 series – Military Personnel
the SECNAVINST 5216.5 series, Department
of the Navy Correspondence Manual. • 2000 series – Telecommunications
2-4
These major groups are subdivided into important to maintain and dispose of records
primary, secondary, and tertiary (third-level) according to the guidance regardless of the type
subdivisions. Primary subjects are designated by of medium they exist on. Files in a digital
the last three digits of the code number, format which are easy to store should not be
secondary subjects by the last two digits, and kept indefinitely. If the HM is in doubt about
tertiary subjects by the last digit. For example: the disposal of certain records, superiors should
6421 be consulted to determine the course of action to
take.
• 6000 Medicine and Dentistry
o 6400 Special Fields OPERATIONAL MEDICAL AND
(Primary) DENTAL READINESS
6420 Submarine and Diving Medicine
(Secondary) LEARNING OBJECTIVE:
• 6421 Hyperbaric Treatment – Diving
Accidents (Tertiary) Identify the basic requirements of medical and
dental readiness.
• 6500 Research
• 6650 Operative Dentistry The mission of the medical and dental
departments is to provide care to sailors of navy
ships and units that they are assigned, and to
CLASSIFYING prevent and treat disease and injuries. The
senior dental and medical division officers
Classifying, as it is used here, is the process report to the Health Services department head
of determining the correct subject group or and the Commanding Officer on all matters
name-title codes under which correspondence affecting the health of the crew or deployable
should be filed and any subordinate subjects that unit. To accomplish the mission, medical and
should be cross-referenced. Classifying is dental personnel must keep themselves
typically accomplished by the originator. informed of planned operations and anticipate
Correspondence that has not been previously any possible demands placed upon them or the
classified a SSIC will need to be assigned upon members under their care. The Navy and Marine
receipt. Corps overall, must maintain the highest degree
of health and readiness in order to function as a
The proper method to subject-classify a fighting force.
document so that it can be readily identified and
found when needed is to read it carefully, MEDICAL READINESS
analyze it, and then select the SSIC that most
closely corresponds to the subject of the Assessing Individual Medical Readiness
document. (IMR) is a continuous process and must be
monitored and reported on a regular basis to
MANAGEMENT OF RECORDS provide service leaders and operational
commanders the ability to ensure a healthy
The Navy creates and uses records of many and fit fighting force.
different types, formats, and media to execute its
mission. The SECNAVINST 5210.8 series,
Department of the Navy Records Management
Program, provides guidance for records
maintenance, use, and disposition. The Records
Management Program is designed to retain
records that are needed to execute the mission
and dispose of records that have expired. It is
2-5
The requirements are outlined in the An individual who has been assigned a
SECNAVINST 6120.3 series, Periodic dental Class or 3 or 4 is likely to compromise
Health Assessment for Individual Medical combat effectiveness and potentially impact the
Readiness. IMR is composed of the following mission by experiencing a dental emergency.
six elements: Any member in Class 3 or 4 is considered non-
deployable and go to the head of the line for
• Individual Medical Equipment (glasses, gas
treatment prior to deployment.
mask inserts)
• Immunizations (TB Screening, Tetanus) DEPLOYMENT LIMITING CONDITIONS
• Readiness Laboratory Studies (DNA, G6PD) The assessment for future deployability
• Deployment Limiting Conditions includes a review of medical history and any
administrative issues. To be considered
• Periodic Health Assessment (PHA) deployable, the service member should NOT
• Dental Readiness be on limited duty or undergoing any type of
Physical Evaluation Board (PEB) or Medical
Evaluation Board (MEB).
PERIODIC HEALTH ASSESSMENT (PHA)
MEDICAL AND DENTAL SUPPORT
The PHA is used to review and correct any
TO THE FLEET MARINE FORCE
IMR deficiencies. For example, a member
needs an immunization, new pair of glasses, or (FMF)
a dental exam. It is also used to verify
compliance with the various elements of LEARNING OBJECTIVE:
Deployment Health Assessments. The PHA
provides the opportunity to assess changes in a Describe the medical and dental organization
member’s health on an annual basis that could of the Fleet Marine Force.
potentially impact the ability to perform
military duties and deploy worldwide. For the To understand the complexity of medical
PHA to be complete, all six elements must be and dental support to FMF, the HM must be
met and/or a continued plan of care received familiar with the overall organization. Medical
for any ongoing medical conditions. and dental personnel are not members of the
U.S. Marine Corps. They are detailed from the
DENTAL READINESS Navy and assigned to the FMF, which is a
balanced force of combined air and ground
The Fleet and Force Dental Officers ensure troops trained, organized, and equipped
that the Fleet is dental ready. A service primarily for offensive deployment. The FMF
member who is Class 1 or 2 is considered consists of a headquarters, a Marine Logistics
worldwide deployable. This means that no Group (MLG), and Marine divisions, brigades,
dental treatment is needed (Class 1) or an oral and aircraft wings.
condition, if not treated, does not have the
potential to become an emergency (Class 2) BATTALION AID STATION
within the next 12 months.
• Any oral condition that will result in an A battalion aid station (BAS) is used to
emergency condition within the next 12 provide direct support to company and platoon
months (Class 3) corpsman, and provide advanced trauma life
support under fire. The BAS of an infantry
• An individual who needs a dental exam or has battalion is the most forward deployed and most
oral conditions that are unknown (Class 4) mobile. It is normally comprised of two medical
officers and up to 65 HMs, depending on the
size of the battalion. A dental detachment would
2-6
also be assigned to the BAS to provide level 1, FMF DENTAL SUPPORT
2, and 3 dental care and dental health
maintenance with a focus on emergency care. A The mission of the FMF dental organization
specific number of medical and dental support is to ensure the combat effectiveness of the FMF
personnel are assigned to provide an interrelated by providing comprehensive dental services. By
network of health care support. assigning dental detachments to the task force,
battalion personnel maintain dental readiness
FMF MEDICAL SUPPORT during exercises, deployments, and combat
operations.
In general, Medical Department personnel
serving with FMF may be divided into two In an emergency environment, the dental
groups: battalion’s primary mission is emergency care to
ensure long term dental health maintenance.
• Combat personnel, providing medical and
Personnel from these detachments may also
initial first aid to prepare the casualty for
provide postoperative, ward, central sterilization,
further evacuation
and supply room support, and other medical
• Support personnel, providing surgical and support as determined to be appropriate by the
medical aid to those who need early medical battalion and surgical company
definitive care and cannot be further commanders.
evacuated.
Medical personnel are an integral part of the
FLEET HOSPITALS
combat unit to which they are assigned; they
train and live with their units. LEARNING OBJECTIVE:
All units comprising a FMF have Medical Describe the role and mission of Fleet
Department personnel organic to them. Hospitals and Expeditionary Medical
However, the majority of medical support comes Facilities.
from the medical battalion of the MLG. The
MLG is a composite grouping of functional units Fleet hospitals are used to provide medical
providing combat service support beyond the support during intense combat operations and in
organic capability of all elements of the FMF. lengthy low-intensity scenarios. Fleet hospitals
The medical battalion provides combat medical are transportable, capable of performing
support required for independently deployed advanced medical and surgical procedures, and
Marine Corps elements. The primary mission of deployable in a variety of operational scenarios.
the medical battalion is to provide: HMs deploy with Expeditionary Medical
• Casualty collection Facilities (EMF) with up to 500 beds, to be
organized and scaled to fit the requirements
• Emergency treatment identified by the Combatant Commander
• Temporary hospitalization (COCOM). Fleet hospitals are designed to be
used in operations greater than 60 days.
• Specialized surgery Moderately sophisticated care is provided, along
• Evacuation with resuscitative medical and surgical care.
2-7
ORGANIZATION MISSION
The internal organization of the fleet The mission of the NMCB medical and
hospital is similar to a shore-based military dental support is to ensure the combat
treatment facility (MTF). It consists of the effectiveness of the NMCB by providing the
command staff (Commanding Officer, Executive medical and dental needs of the Seabees.
Officer, and Command Master Chief) and five During contingency, disaster control, or mass
directorates: nursing services, medical services, casualty situations, NMCB dental personnel
surgical services, ancillary services, and augment with the medical effort under the
administrative services. direction of the cognizant authority.
2-8
Figure 2-1.—Enlisted Surface Figure 2-5.—Enlisted Submarine
Warfare Specialist Warfare Specialist
SUMMARY
i
Photographs provided by HM2 Timothy Hanna of
the Biomedical Photography Department of Navy
Medicine Support Command, Bethesda, MD.
2-9
CHAPTER 3
Hospital Corpsmen (HMs) are often the very PATIENT ELIGIBILITY FOR
first individual a beneficiary encounters upon HOSPITALIZATION AND
entering a military treatment facility (MTF), NON-FEDERAL CARE
outpatient or inpatient. In order to adequately
assist the beneficiary, HMs must be LEARNING OBJECTIVE:
knowledgeable and skilled in the administrative
affairs concerning outpatients and inpatients. Explain the policies and procedures for DEERS
and TRICARE.
This chapter will provide information on the
function of healthcare programs with which the
HM may be involved or responsible. It will Not all persons working for the federal
discuss the legal implications in medical care, government are eligible for treatment in a
including the various aspects of consent, medical treatment facility. The following
incident reports, and release or non-release of resources provide guidance regarding eligibility
medical information. Further, guidance verification by presentation of a valid
concerning the relationship and interaction with identification (ID) card and utilization of the
law enforcement personnel and the legal Defense Enrollment Eligibility Reporting
community will be outlined. System (DEERS).
3-1
• NAVMEDCOMINST 6320.3 series, Medical the DEERS verification process is outlined in
and Dental Care for Eligible Persons at Navy OPNAVINST 1750.2 series, Defense
Medical Department Facilities Enrollment Eligibility Reporting System.
• Resources Management Handbook, Eligibility
NAVMED P-5020
Patients who present for non-emergency
DEFENSE ENROLLMENT ELIGIBILITY treatment without a valid ID card but are in the
REPORTING SYSTEM (DEERS) DEERS database will not be provided medical
care without first signing a statement that they
DEERS is a computer-based enrollment and are eligible and giving the reason why a valid ID
eligibility verification system. It was developed card is not in their possession. If a valid ID card
to improve distribution and control of military is not provided within 30 calendar days, the
healthcare services including the projection and patient will be billed as a Civilian Humanitarian
allocation of costs for healthcare programs and Non-indigent IAW the Resources Management
to minimize fraudulent healthcare claims. Navy Handbook, NAVMED P-5020. Such billing
Medicine’s eligibility for care instruction, may be delayed if the commanding officer of the
NAVMEDCOMINST 6320.3 series, provides medical facility is convinced proof is delayed for
guidance as to who and under what reasons beyond the control of the patient or
circumstances members can receive medical and sponsor. In all cases where a patient presents
dental care at Navy Medical Department without an ID card and does not appear in the
facilities; the extent and conditions under which DEERS database, non-emergency care will be
such care may be provided; and the collection denied.
process to pay for that care.
REASONS FOR INELIGIBILITY.⎯
Family member enrollment is accomplished When a DEERS check is performed and the
for all seven uniformed services (i.e., Army, Air patient is found ineligible for any of the
Force, Marine Corps, Navy, Coast Guard, Public following reasons, routine non-emergent
Health Service, and National Oceanic & healthcare will be denied (except as noted later
Atmospheric Administration) by completing the in this section).
Uniformed Services Identification and Privilege
• Sponsor not enrolled in DEERS
Card application, DD 1172. When a new ID card
is obtained for the family member, the service • Family member not enrolled in DEERS
member’s DEERS data is updated online. If
problems exist within a patient’s database, active • Ineligible due to passed terminal (end)
duty personnel and their family members must eligibility date, i.e. child who ages out at 18
be referred to the sponsor’s personnel support years of age
detachment (PSD). Refer all other beneficiaries • Sponsor has separated from active duty
(e.g., retired personnel and their family
members) to the nearest PSD. • Spouse is divorced from sponsor and is not
entitled to benefits as a former spouse
Both DEERS and the ID card are utilized to • Family member child is married
establish eligibility for care. Initially the HM
will examine the beneficiary’s ID card. The • Secretary of the Navy Designee
beneficiary’s status (e.g., active or reservist; UNDER NO CIRCUMSTANCES WILL
service component, etc.) is depicted on the ID THE CLERK PERFORMING THE
card; also note the date of expiration. Next using ELIGIBILITY CHECK DENY THE
the online computer terminal, the HM will REQUESTED CARE. Only command-
perform an electronic DEERS check via CHCS; designated supervisory personnel can perform
this function.
3-2
DEERS ELIGIBILITY OVERRIDES.⎯ 8. Sponsor’s Duty Station is Outside the 50
The nine "DEERS eligibility overrides" are United States or has an APO/FPO
listed below. Unless otherwise stated, all Address⎯Family members whose sponsors
overrides must be supported by a valid ID card. are assigned outside the 50 United States or
to a duty station with an APO/FPO address
1. DD 1172⎯The patient presents an original
will not be denied care as long as the
or copy of the DD 1172 used for DEERS
sponsor is enrolled and eligible in DEERS.
enrollment. There are other specific items
required for verification, and current service 9. Survivors⎯When an eligibility check
directives must be checked. indicates that a deceased sponsor is not
enrolled in DEERS or the survivor is listed
2. All Other Family Members Recently
as the sponsor; the survivor will be treated
Becoming Eligible for Benefits⎯New
on the first visit and referred to the
mothers, babies, recent adoption, and
appropriate personnel support detachment
dependent parents.
(PSD) for correction of the DEERS
3. New Identification Card⎯Patients presenting database. For second and subsequent visits,
with a new valid ID card, issued within the the survivor will be required to follow the
previous 120 days, will not be denied care. procedure in item 1, above. While deceased,
the sponsor remains the sponsor in order to
4. Ineligible Due to ID Card Expiration⎯ facilitate eligibility for family members.
When the database shows a patient as
ineligible because of ID card expiration,
care may be rendered as long as the patient DEERS ELIGIBILITY EXCEPTIONS.⎯
has a new ID card issued within the previous The following beneficiaries are categorized as
120 days. After 120 days, follow the “DEERS Eligibility Exceptions.” Although
procedure in item 1, above. authorized care, they may not be authorized to
be enrolled in the DEERS system. These
5. Sponsors Entering Active Duty Status for
beneficiaries will NOT be denied care based
a Period of Greater than 30 Days⎯A upon a DEERS check.
copy of orders ordering a reservist or
guardsman to an active duty period of • Secretary of the Navy Designees⎯
greater than 30 days may be accepted for the Secretary of the Navy Designees will be
first 120 days of the active duty period. treated as indicated on their letter of
After that, follow the procedure in item 1 designation.
above.
• Foreign Military Personnel⎯These
6. Newborns⎯Newborns will not be denied personnel and their family members,
care for a period of 60 days. On the 61st day assigned through Personnel Exchange
the newborn will shift to TRICARE Programs or other means, are or may be
STANDARD if not enrolled in Prime. eligible. Eligible members may also include
Enrollment into Prime CANNOT occur o North Atlantic Treaty Organization
unless the newborn is put on the sponsor’s (NATO) military personnel and their
Page 2 and enrolled in DEERS. Newborns family members stationed in or passing
of Dependent Daughters must be approved through the United States
for Secretary of the Navy Designee or they
are not eligible for care. o Crew and passengers of visiting military
aircraft; and
7. Emergency Care⎯This is a medical
decision and shall be determined by criteria o Crews of ships of NATO nations that
established within the command. come into port
3-3
Other foreign military personnel may be enroll in the TRICARE Dental Plan as long as
eligible through Public Law or DoD agreements. the service member (active duty or reservist) has
As such, they will be treated IAW current at least 12 months remaining on active duty1.
service directives.
Patient Registration
Patients in other organizations, such as Red
Cross workers, Secret Service agents, Federal Patient Registration is an important part of
Aviation Administration personnel, and some the eligibility process either establishing it or
non-retiree veterans are also in this category of confirming it. Patient registration is usually
possible beneficiaries due to agreements. Ensure performed in outpatient medical records or in
current eligibility requirements are met for these admissions and dispositions.
personnel prior to treatment.
Priority of Care
TRICARE
Naval Dental Treatment Facilities (DTFs)
TRICARE is an enhancement of the Civilian and clinics will provide care to all eligible
Health and Medical Program of the Uniformed beneficiaries subject to the capabilities of the
Services (CHAMPUS). TRICARE is a medical professional staff and availability of space and
benefits program established to manage the care facilities.
services in military MTFs. Additionally, it
manages the cost sharing charges for medically In those instances when care cannot be
necessary civilian services and supplies required rendered to all eligible beneficiaries, care will be
in the diagnosis and treatment of illness or prioritized based on the criteria outlined in the
injury. TRICARE is utilized if the required following list without regard to the sponsoring
services are not available from the direct care uniformed service.
system of the Department of Defense treatment
facilities or designated MTFs/DTFs. Priority Categories
3-4
The rendering of emergency dental NAVY MEDICINE’S QUALITY
treatment to any person when such treatment is ASSURANCE PROGRAM
necessary affects the above priority
categorization, i.e. pediatric patient with an
LEARNING OBJECTIVE:
emergency will supersede an active duty person
awaiting a routine procedure.
Explain the philosophy of Navy Medicine’s
Quality Assurance Program.
ROUTINE DENTAL CARE.—Treatment
includes all the medical, surgical, and restorative
treatments of oral disease, injuries, and The Quality Assurance Program uses
deficiencies that come within the field of various sources of data to evaluate the degree of
dentistry. These services are reserved for active excellence and to make improvements as needed
duty members and reservists recalled to active for quality care. Quality assurance activities
duty beyond 30 days. Family members and reflect what patients and providers expect of
retirees are treated via the current TRICARE each other. Quality assurance activities are
Dental Plan or other dental insurance plan. highly valued by The Joint Commission (TJC)
Routine services are preventive and corrective and Medical Inspector General (MED IG).
which include:
Many of the principles, standards, and
• Dental examinations and oral health organizational requirements of The Joint
instruction (OHI) Commission (TJC) have been adopted and are
• Restoration of lost tooth structure contained in OPNAVINST 6320.7 series,
Health Care Quality Insurance Policies for
• Treatment of periodontal conditions Operating Forces. BUMEDINST 6010.13
• Surgical procedures series, Quality Assurance Program, lists the
required elements for process improvement
• Replacement of missing teeth essential to (quality assurance) programs of naval hospitals,
personal appearance, the performance of medical clinics, and dental clinics.
military duty, or the proper mastication of
food The delivery of quality health care has
always been a driving force in the operational
EMERGENCY DENTAL CARE.— and managed care of MTF’s and DTF’s. The
reatment is necessary to relieve pain, control Navy’s Health Care Relations Program
bleeding, and manage acute septic conditions or (BUMED Instruction 6300.10 series), provides
injuries to the oral-facial structures. Emergency general guidance to the establishment of this
dental care is authorized worldwide for program. The program has three parts, which are
personnel of all categories. Internal, External and Patient Relations.
3-5
PATIENT RELATIONS AND PATIENT CONTACT POINT PROGRAM
COMMAND PATIENT CONTACT
POINT PROGRAMS The Patient Contact Point Program, a subset
of the Patient Relations Program, ensures an
effective means of resolving such issues before
LEARNING OBJECTIVE: the patient departs the facility. All Navy
treatment facilities have this program which
Explain the philosophy of the Patient Relations allows patients to provide any complaints or
Program and the Patient Contact Point compliments relating to the treatment received.
Program.
PATIENT CONTACT REPRESENTATIVE
Navy healthcare professionals have long
understood the need for good communication Patient contact representatives are appointed
between the patient and the medical department in writing by the commanding officer and have
staff. The atmosphere in which care is given has their picture posted at the front desk or in the
a tremendous impact on the patient’s perception reception area visible to all patients. Patient
of the quality. The quality of medical and dental compliments and complaints are routed through
care rendered may be superb; however, the care the patient contact representative to the chain of
can be perceived by the patient to be command for action and incorporation into the
substandard due to poor interpersonal skills of command’s annual assessment for the Quality
those assigned to patient contact points (where Assurance (QA) Program. Follow BUMEDINST
the patient and healthcare professional meet). 6010.13 series and your clinic’s instruction for
Many complaints voiced by patients would not follow-up actions and reporting instructions.
occur if personnel consistently presented a
courteous and knowledgeable attitude that PATIENTS’ BILL OF RIGHTS AND
reflected a genuine concern for the patient. RESPONSIBILITIES
3-6
Figure 3-1.—Patient's Bill of Rights and Responsibilities
3-7
MEDICAL TREATMENT RECORDS If abuse is suspected by the HM there is a
moral and legal obligation to report the actual or
An essential part of the administrative duties suspected abuse to the chain of command and or
of a HM is preparing and maintaining the legal authorities as appropriate.
medical record with associated forms; guidance
is found in the Manual of the Medical DRUG AND ALCOHOL ABUSE
Department (MANMED) Chapter 16. Use of PREVENTION AND CONTROL
the term “medical records” includes records PROGRAM
maintained by both medical and dental treatment
facilities and to records in both paper and
automated (electronic) formats. LEARNING OBJECTIVE:
The purpose of the medical record (paper Explain policies and procedures pertaining to
and electronic) is to provide an individual the Drug and Alcohol Abuse Prevention and
chronological record of medical treatment Control Program.
afforded members of naval service. The record
has significant current and long-term medical- The policies governing the Alcohol and
legal value to the individual concerned, their Drug Abuse Prevention and Control Program
survivors, and the U. S. Government. Medical, encompass the Navy’s approach on eliminating
dental and occupational health examinations, alcohol and drug abuse. It provides methods of
evaluations and histories as well as evaluation of deterrence and prevention along with education
illness and subsequent treatments, are and treatment of individuals found guilty of
documented in this record. abuse or in need of substance abuse treatment.
3-8
PHYSICAL READINESS PROGRAM This section addresses some of the situations
that regularly occur and have legal
consequences, including the policy and
LEARNING OBJECTIVE:
instructions that apply to those situations. The
law is an inexact science subject to widely
Explain the policies and procedures pertaining
varying circumstances. The information in this
to the Physical Readiness Program.
chapter cannot substitute for the advice of an
attorney; consult with hospital or area Judge
The policies governing this program are Advocate General (JAG) Corps officers or Navy
outlined in OPNAVINST 6110.1 series, civil service lawyers on medical-legal issues.
Physical Readiness Program. Currently,
physical readiness testing is required for all CONSENT REQUIREMENTS FOR
personnel on a semi-annual basis. Testing, MEDICAL TREATMENT
education, and training information are provided
through a network of collateral duty command With limited exceptions, every person has
fitness coordinators. In addition to program the right not to be touched without giving
implementation, specific Medical Department permission first. Consent must be obtained
responsibilities include: before medical treatment is initiated. Failure to
• Providing technical assistance to BUPERS obtain consent may result in the healthcare
provider being responsible for medical
• Conducting lifestyle, fitness, and obesity malpractice and/or assault and battery upon the
research patient.
• Reviewing health status and granting
waivers for individuals unable to safely Informed Consent
participate in physical fitness testing and
training "Consent" in the medical setting refers to a
patient’s expressed or implied agreement to
• Assisting in the development of exercise submit to an examination or treatment.
prescriptions "Informed consent" requires that the healthcare
provider give the patient all the information
necessary for a knowledgeable decision. In order
LEGAL IMPLICATIONS IN MEDICAL to be considered “lawful consent” the patient
CARE must have made a knowledgeable decision with
full awareness of the consequences; without it
LEARNING OBJECTIVE: there is no lawful consent. The proposed
procedure must be described in lay terms for
Explain the policies and procedures pertaining patient understanding regarding the nature, the
to consent for medical treatment, incident risk, and the alternatives of what is proposed.
reports, and release of medical information. The higher the risk or the seriousness of the
consequences requires a greater duty to disclose.
There are few aspects of healthcare that do
not have legal implications. Every time a patient NOTE:
interacts with the staff of a medical or dental The duty to inform and explain rests with the
treatment facility, the potential for legal provider.
entanglement exists. Although the law has
THIS RESPONSIBILITY CANNOT BE
become more and more involved in the
DELEGATED.
operation of hospitals, the exercise of common
sense combined with knowledge of those
situations that require special care will protect
the hospital and its staff from most legal situations.
3-9
For common medical procedures that are power of attorney, or a general power of
considered simple and risk free, a provider is not attorney. This form is filed in the patient’s
required to explain consequences that are healthcare record and documented in the
generally understood to be remote. A electronic health record (i.e. CHCS/AHLTA) for
determination of what is simple and common quick retrieval in order to consult with the
should be made from the perspective of appropriate person on behalf of the patient.
appropriate medical standards.
Forms of Consent
Emergency Situations
Consent for medical treatment should be
Consent before treatment is not necessary obtained through an open discussion between
when treatment appears to be immediately the provider and patient during which the patient
required to prevent significant deterioration or expressly agrees to the procedure. The consent
aggravation of a patient’s condition. This applies should be documented by having the patient sign
especially in life-threatening situations when it appropriate forms and by the provider noting
is not possible to obtain a valid consent from the any important details of the discussion in the
patient or a person authorized to consent for the treatment record.
patient. The existence and scope of the
emergency should be adequately documented. In certain limited circumstances, the consent
When the patient is unable to give consent, the of an individual for simple medical treatment
appropriate course of treatment based upon a may be implied from the circumstances. Implied
qualified medical assessment of what a consent arises by reasonable inference from the
“reasonable person would expect” becomes the conduct of the patient or the individual
guiding principle for continued emergent care. authorized to consent for the patient. For
example, a patient who rolls up a sleeve when
Who May Consent told it is time to draw blood is providing implied
consent by this action. Reliance on this form of
The determination of who has authority to consent is strongly discouraged except in the
consent to medical treatment is based on an most routine, risk-free examinations and
evaluation of the competency of the patient. If procedures.
competent, the patient alone has the authority to
consent. Competency refers to the ability to Witness to Consent
understand the nature and consequences of one’s
decisions. In the absence of contrary evidence, it Any competent adult may witness the
is assumed that the patient presenting for patient’s consent. It is a conflict of interest to
treatment is competent. If the patient is have a staff member who is participating in the
incompetent, either by reason of statutory patient’s procedure to act as a witness; utilize a
incompetence (e.g., a minor) or by reason of a staff member of the hospital who is not
physical or mental impairment, the inquiry must participating in the procedure. It is not advisable
turn to whoever has the legal capacity to consent for a relative of the patient to act as a witness.
on behalf of the patient. Parents and guardians
will have the authority to consent for their minor Duration of Consent
children. In many states a husband or wife may
give consent for an incompetent spouse. It is the Consent is valid as long as there has been no
law of the state in which the hospital is located material change in the circumstances between
that controls the question of "substitute consent." the date that consent was given and the date of
the procedure. It is desirable that a new consent
There may be paperwork, called an advance be obtained if there is a significant time lapse
directive, that indicates who can provide (per command policy) or if the patient has been
informed consent for the patient. The form may discharged and readmitted due to postponement
be a healthcare surrogate designation, healthcare of the procedure.
3-10
INCIDENT REPORTS include the report in the patient’s treatment
record. The report should be limited to the facts
Incident reporting falls under Title 10 and must not contain conclusions. Reports
U.S.C. 1102, Confidentiality of Medical Quality should be addressed and forwarded directly to
Assurance Records. When an event occurs that the risk manager of the hospital. Guidance
harms an individual, illustrates a potential for concerning the Risk Management Program is
harm, or evidences serious dissatisfaction by found in BUMEDINST 6010.21 series.
patients, visitors, or staff, a risk-management
incident has taken place. Examples of such RELEASE OF MEDICAL INFORMATION
episodes include the following:
Two federal statutes, the Privacy Act and the
• A patient is helped out of bed by family
Freedom of Information Act (FOIA) combine to
despite directions to the contrary by staff
establish the criteria for collecting, maintaining,
members. The patient falls and is injured
and releasing medical treatment records.
• Excessive silver nitrate is put into the eyes
of a newborn impairing vision Freedom of Information Act (FOIA)
• The mother of the child complains about the FOIA governs the disclosure of documents
care that has been given to the child and maintained by government agencies. A written
informs a staff member that the issue will be request for Department of the Navy (DoN)
discussed with a lawyer records that refer to FOIA must be responded to
When a member of the staff becomes aware IAW the provisions of the Act. DoN will make
of an incident, there is a responsibility to make available to any person all documents provided
the hospital command aware of the situation. the requester reasonably describes the records
The mechanism for doing this is the quality care sought and promises to pay for reasonable
system. Quality Care Review (QCR) reports are search and photocopy costs. Each naval activity
designed to promptly document all is responsible for developing procedures for
circumstances surrounding an event, to alert the ensuring the prompt handling, retrieval, and
commanding officer, Command Risk Manager, review of requested records. The official having
and other involved administrators and clinicians responsibility for the records has 20 working
of a potential liability situation. It also days to respond to the requester.
establishes an information base to monitor and
evaluate the number and types of incidents that A naval record will be withheld only when it
take place in the facility. is exempt from disclosure under FOIA. One
basis for exempting a record from disclosure
QCRs by nature contain a great deal of applies to personnel, medical, and similar files.
information that would be of interest to persons The release of these files would constitute a
filing claims or lawsuits against the Navy for clearly unwarranted invasion of personal
alleged substandard medical care. The law privacy. This concern over clearly unwarranted
recognizes the need for hospitals to have a privacy intrusion is reflected in the provisions of
reliable means of discovering and correcting the Privacy Act while FOIA covers Protected
problems; most states have enacted laws that Health Information (PHI) outside the covered
make incident reports confidential. A person entity.
cannot obtain a copy of an incident report to
help in the legal action against the hospital. Privacy Act
QCRs lose their "protected" status if they The public’s concern over governmental
are misused or mishandled. It is important to functions led to the creation of FOIA. It became
treat these reports like all confidential obvious that a balance had to be made between
documents. All copies require the permission of the public’s right to know and the Government’s
the risk manager and the legal officer. Do not protected rights and interests. One of these
3-11
competing interests was the protection of an HEALTH INFORMATION PORTABILITY
individual’s personal right to privacy. In AND ACCOUNTABILILTY ACT
response to this need, the Privacy Act of 1974
was enacted. The Privacy Act establishes The Health Information Portability and
safeguards concerning the right to privacy by Accountability Act (HIPAA) was enacted into
regulating the collection, maintenance, use, and law in 1996. The overall goal is to provide
dissemination of personal information by federal safeguards for protected health information
agencies. (PHI) to ensure patient privacy is maintained.
The Privacy Rule addresses appropriate
The Privacy Act requires federal agencies to: disclosure of PHI while the Security Rule
addresses electronic disclosures.
• Permit an individual to know what records
pertaining to him or her are collected,
HIPAA Privacy Rule
maintained, used, or disseminated by the
agency
The HIPAA Privacy Rule creates business
• Permit an individual to prevent records processes to protect the use and disclosure of
pertaining to him or her and obtained by the protected health information (PHI). PHI is
agency for a particular purpose from being individually identifiable health information,
used or made available for another purpose including demographics, in paper, electronic, or
without the individual’s consent oral form. PHI is not limited to the documents
contained in the official medical record. The
• Permit an individual to gain access to
HIPAA Privacy Rule allows the use and
information pertaining to him or her in
disclosure of PHI for treatment, payment, and
federal agency records, have a copy made
health care operations without written
for all or any portion thereof, and correct or
authorization from the patient. Other uses and
amend such records
disclosures require permission. The compliance
• Collect, maintain, use, or disseminate any date for the HIPAA Privacy rule was April 14,
record of identifiable personal information 2003 and is guided by DODINST 6025.18
in a manner that ensures such action is for a series, DOD Health Information Privacy
necessary and useful purpose, that the Regulation.
information is current and accurate, and that
adequate safeguards are provided to prevent Required Uses and Disclosures
misuse of such information
By law, treatment facilities may disclose
• Permit exemptions from the requirements of health information to the patient unless it has
the Privacy Act only in those cases where been determined by a competent medical
there is specific statutory authority to do so authority that it would be harmful. Treatment
• Be subject to civil suits for any damages that facilities must also disclose health information
occur as a result of willful or intentional to the Secretary of the Department of Health and
violation of any individual’s rights under the Human Services (HHS) for investigations or
Privacy Act determinations of compliance with laws on the
protection of the patient’s health information.
In addition, any employee of an agency who
intentionally violates certain provisions of the
Privacy Act is subject to criminal prosecution
and fines.
3-12
TREATMENT.—Treatment facilities use setting forth which uses and disclosures are
and disclose protected health information to authorized. The Security Rule defines the
provide, coordinate, or manage the patient’s safeguards to protect that PHI. It is important to
health care with a third party. For example, the recognize that the Security Rule has greater
facility may disclose PHI, as necessary, to other limitations than the Privacy Rule, as the Security
military and or TRICARE contractors who are Rule only applies to PHI in electronic form.
providing care or consultation to patients. This
includes pharmacists who may be provided MEDICAL CONDITIONS AND LAW
information on other drugs the patient was ENFORCEMENT PERSONNEL
previously prescribed to identify potential
interactions. In emergencies, facilities will use
LEARNING OBJECTIVE:
and disclose PHI to provide urgent treatment.
Describe the policies and procedures
PAYMENT.—PHI will be used to obtain
pertaining to prisoner patients, victims of
payment for health care services. This includes
alleged sexual assault and rape, substance
certain activities the facility undertakes before it
abuse and control, probable-cause searches,
approves or pays for the health care services
and line-of-duty and misconduct investigations.
recommended. For example, obtaining approval
for a hospital stay might require that PHI be
disclosed to obtain approval for the hospital Some medical conditions will result in the
admission. involvement of law enforcement personnel.
Individuals who are injured while committing a
HEALTHCARE OPERATIONS.—PHI criminal offense; victims of abuse, neglect, or
may be disclosed to support the daily activities assault; impaired or injured as a result of drug
related to health care. These activities include, abuse; or injured as a result of a traffic accident
but are not limited to, quality assessment will often be the subject of an official
activities, investigations, oversight or staff investigation. The investigators will want to
performance reviews, training of medical question the patient or the healthcare providers
students, licensing, and communications. treating the patient. Authorities may request the
medical records of the patient as well as take the
HIPAA Security Rule patient into custody.
The HIPAA Security Rule is designed to Under the Posse Comitatus Act, a federal
provide protection for individually identifiable statute enacted in 1956 (18 U.S.C. § 1385), it is
health information that is maintained, unlawful for the U.S. military to be used to
transmitted, or received in electronic form—not enforce or assist in the enforcement of federal or
just the information in standard transactions. All state civil laws. There are many exemptions to
covered entities were to be in compliance with this act, but the issue for healthcare providers is
the HIPAA Security Rule no later than April 20, settled by asking the following question:
2005. The safeguards in the HIPAA Security
Rule are divided into three categories: "Is the medical procedure being done on this
Administrative Safeguards, Physical Safeguards, patient for a legitimate medical reason, or is it
and Technical Safeguards. The guiding only being performed to assist civil law
instruction for HIPAA Security is DoD enforcement?"
8580.02-R series, DoD Health Information
Security Regulation. Provided there is a reasonable medical
justification for the procedure, the results of the
Security and privacy are linked in an effort procedure may be shared with civil law
to protect the privacy of health information. The enforcement officials under the circumstances
Privacy Rule sets standards for how protected covered below.
health information (PHI) should be controlled by
3-13
Cooperation with law enforcement officials, individual concerned has been issued. There are
to the extent possible, is required. Provided there circumstances in which delivery may be refused;
are no medical contraindications, patients who however, guidance should be sought from a
are suspected of having committed an offense or judge advocate of the Navy or Marine Corps
are presumed victims of criminal activity will be when delivery is to be denied.
made available to speak with investigators.
Access to medical treatment records is governed Normally, it is the responsibility of the
by the Privacy Act and FOIA. permanent command to take custody and control
of an active duty member suspected of
Records of patients may be made available committing an offense. If the member is an
to U.S. Navy investigators once they have unauthorized absentee (UA) and the command
established the need to know. This determination to which assigned is not in the same geographic
will be made by the hospital JAG or public area as the treatment facility, release of the
affairs officer (PAO). Other Department of patient should be coordinated with the nearest
Defense, federal, state, or local law enforcement Transient Personnel Unit (TPU) or Military
officers may have access to treatment records if Prisoner Escort Unit. Close liaison with the
access is necessary as part of a criminal member’s permanent command should be
investigation and there is no unwarranted established.
violation of the privacy rights of the individual
involved. Local health and social service In cases where delivery of an active duty
departments may be provided information from patient is requested by local civil authorities, and
the record. The same guidelines for accessing the treatment facility is located within the
treatment records apply to staff members' requesting jurisdiction or aboard a ship within
conversations with investigating officers. the territorial waters of such jurisdiction,
commanding officers are authorized to deliver
DELIVERY OF A PATIENT UNDER the patient when a proper warrant is presented.
WARRANT OF ARREST Whenever possible, a judge advocate of the
Navy or Marine Corps should be consulted
No patient may be released from treatment before delivery. If the treatment facility is
before it is medically reasonable to do so. Once located outside the jurisdiction requesting
it is determined that the individual can be delivery, only a General Courts-Martial
released without significant risk of harm, the authority (as defined by the Uniform Code of
following guidelines regarding release to law Military Justice, Manual for Courts-Martial and
enforcement authorities apply. Navy Regulations) is authorized to arrange for
delivery of such patient. Extradition, return
Non-active Duty Patients⎯ When a non- agreements, and other prerequisites to delivery
active duty patient is released from medical will have to be completed.
treatment, the facility no longer exercises any
degree of control, and normal legal processes When disciplinary proceedings involving
will occur. No official action by hospital military offenses are pending, the treatment
personnel is required before local authorities facility should obtain legal guidance from a
take custody of the released patient. There may judge advocate before delivering a patient to
be occasions, however, when law enforcement federal, state, or local authorities. When the
officials should be notified of an imminent commanding officer considers that extraordinary
release of a patient. circumstances exist which indicate that delivery
should be denied, then the Judge Advocate
Active Duty Patients⎯ The commanding General of the Navy must be notified of the
officer is authorized to deliver personnel to circumstances by message or phone.
federal law enforcement authorities who display
proper credentials and represent to the command
that a federal warrant for the arrest of the
3-14
PRISONER PATIENTS Military prisoners (those sentenced under
the Uniform Code of Military Justice) with
Prisoner patients fall into three categories of punitive discharges that have been executed but
eligible beneficiaries: the sentences have not expired are authorized
care. Individuals on appellate leave, awaiting
• Enemy prisoners of war and other detained
execution of a punitive discharge, are entitled to
personnel
care. Military prisoners with punitive discharges
• Non-military federal prisoners that have been executed and require
hospitalization beyond expiration of their
• Military prisoners sentences are not eligible for care; they may be
hospitalized as civilian humanitarian non-
Enemy Prisoners of War and Other Detained military indigents until disposition is made to
Personnel some other facility.
Enemy prisoners of war and other detained SEXUAL ASSAULT AND RAPE
personnel are entitled to all necessary care,
subject to the availability of care and facilities. Sexual assault and rape are criminal
offenses, often associated with serious physical
Non-military Federal Prisoners injury. The management of cases involving
sexual assault and rape must be a joint medical
Non-military federal prisoners are and legal function. A sexual assault investigation
authorized only emergency care. When such kit, supplied by the Naval Criminal Investigative
care is being provided, the institution to which Service (NCIS), is used to gather and preserve
the prisoner is sentenced must furnish security evidence of a crime. This kit includes step-by-
personnel to ensure custody of the prisoner and step procedures for examination of the patient
safety of others in the facility. Upon completion and a checklist of specimens to be collected.
of emergency care, arrangements will be made
to transfer these individuals to a non-military To safeguard and obtain evidence to be used
treatment facility or for return to the institution in legal proceedings, liaison among the naval
to which sentenced. treatment facility, military and civil investigative
agencies, and state and local agencies (such as
Military Prisoners Child and Spouse Protective Services) should be
established. Medical personnel are not to judge,
Status of Forces policy is to protect, to the defend, or prosecute the individuals involved.
maximum extent possible, the rights of U.S. NAVMEDCOMINST 6310.3 series,
personnel who may be subject to criminal trial Management of Alleged or Suspected Sexual
by foreign courts and imprisonment in foreign Assault and Rape Cases, provides guidance for
prisons. Active duty members are generally care, evaluation, and medico-legal
separated from the service until they have documentation of the alleged victim.
completed their term of imprisonment and
returned to the United States. During this
confinement, they will normally retain
healthcare benefits.
3-15
Treat the patient with respect and courtesy SUMMARY
and provide appropriate privacy. Careful
attention to psychological factors must be given Retaining high medical standards and
to lessen the impact of the incident. When a quality healthcare require a robust healthcare
minor is involved, the reaction of adults may be administration support structure. DEERS
more harmful than the actual assault itself. management and the determination of patient
Tactful questioning and use of appropriate eligibility are crucial components. There are
terminology are of extreme importance numerous health-related programs established to
throughout the history taking and examination. benefit and support eligible beneficiaries. Good
OPNAVINST 1752.1 series, Sexual Assault quality assurance creates better patient relations,
Victim Intervention (SAVI) Program, and thereby minimizing legal problems. Substance
SECNAVINST 5800.11 series, Victim and abuse and family advocacy programs identify
Witness Program, provide guidance for the care problems before they become unmanageable.
and support of alleged victims of sexual assault. The physical readiness program helps build a
healthier Sailor, thus eliminating needless
CHILD AND SPOUSE ABUSE AND patient visits.
NEGLECT
This chapter provided an overview of the
The nature of child and spouse abuse and HM’s responsibilities in the areas of
neglect requires a careful patient history and administrative and legal interaction with
physical examination by a medical provider to authorities. Legal cases are lost because of
identify or rule out past and present injuries. The failure to adhere to the proper administrative
policies and guidelines established by the Navy procedures. The HM must be aware of these
Family Advocacy Program must be followed. procedures and ensure that they are followed
This program was provided earlier in this precisely.
chapter and is outlined in SECNAVINST
1752.3 series and BUMEDINST 6320.70
series.
3-16
CHAPTER 4
MEDICAL RECORDS
INTRODUCTION PRIMARY AND SECONDARY
MEDICAL RECORDS
Navy and Marine Corps personnel and DoD
eligible beneficiaries utilize the U.S. Navy
LEARNING OBJECTIVE:
Medical Outpatient and Dental Treatment
Record (NAVMED 6150/21-30) as the official
Identify the types of primary and secondary
record jacket for the chronological
records, and the usage of each type.
documentation of medical and dental
evaluations, care, treatments and occupational
health. The medical and dental history stored in PRIMARY MEDICAL RECORDS
these color coded jackets assists medical
department personnel to provide care. The primary medical records are used for
the documentation of outpatient medical and
The health record has significant medico- dental care. A secondary medical record is
legal value to the patient, the healthcare established by a patient’s specialty healthcare
provider, the Medical Treatment Facility (MTF) provider and contains medical information
and Dental Treatment Facility (DTF) and the needed by that provider for a specific need.
U.S. Government. Also, various officials and Secondary medical records are maintained
boards (i.e., special duty boards and medical separate from the primary medical record.
boards) refer to information furnished by the
health record in determining physical fitness or The three major categories of primary
physical disability. Accurate and complete medical records are:
record entries and proper record maintenance are • Health records (HRECs)
of the utmost importance.
• Outpatient records (ORECs)
This chapter provides the fundamentals of o Dental records (DRECs) are part of
effective records’ management. Opening, filing, HRECs (active duty) and ORECs (retirees
verifying, and closing active duty and reserve and family members)
personnel medical and dental records, will be
outlined including the use of appropriate forms. • Inpatient records (IRECs)
Guidelines for record management are in
Chapter 16 of the Manual of the Medical Health Record
Department (MANMED P-117).
The HREC is a file of continuous care given
to active duty members and documents all
outpatient care provided during a member’s
career. While the HREC primarily documents
ambulatory (outpatient) care, copies of inpatient
narrative summaries and operative reports are
also placed in the HREC to provide continuity of
healthcare documentation.
4-1
Dental Records Secondary medical records include:
• Convenience records
The DREC is a file of continuous care given
to active duty and reserve members and their • Temporary records
families. It contains all documents of dental
care provided during a member’s career. • Ancillary records
The OREC is a file of continuous care that A convenience record contains excerpts
documents ambulatory treatment received by a from a patient’s primary record and is kept
person other than an active duty person, i.e. within the MTF by a treating clinic, service,
retiree and family members. department, or individual provider for increased
access to the information. When the convenience
Inpatient Record record’s purpose has been served, the
establishing clinic, service, department, or
The IREC is a medical file that documents provider purges the record from its file,
care provided to a patient assigned to a compares it to the primary medical record, and
designated inpatient bed at an MTF or ship. adds any medical documents that are not already
Summaries of inpatient care are placed into the in the primary medical record.
HREC (Active Duty) or OREC (non-active duty
personnel) to maintain continuity of care. Temporary Medical Record
4-2
The temporary dental record is maintained isolated duty locations). The Commanding
by the DTF providing the current course of Officer (CO) has ultimate responsibility for all
treatment. When the treatment is complete or medical records. Patients are not authorized to
when the patient returns to the location of the retain or maintain their original HREC, OREC,
permanent dental record, the patient may hand or dental record. In addition, the hand-carrying
carry the record or the custodian of the of medical records by unauthorized individuals
temporary record must forward it to the (e.g., spouses or siblings of the patient) without
custodian of the permanent record. written permission is prohibited.
4-3
Health records of civilian candidates OPENING HEALTH RECORDS FOR
selected for appointment to the Naval Academy RESERVISTS
will be prepared at the Naval Academy at the
time of appointment. Health records for civilian The Naval Reserve Personnel Center
applicants selected for officer candidate (NRPC), New Orleans, is the HREC custodian
programs should be opened upon enrollment in for inactive reserve personnel and is responsible
the program. for records' preparation and maintenance. When
inactive reservists are called to active duty and
OPENING HEALTH RECORDS FOR their HRECs have not been received by their
ACTIVE DUTY ENLISTED PERSONNEL duty station, a request for their records should be
initiated. Requests for Navy personnel are sent
The HREC is opened by the activity to NRPC. Marine Corps personnel requests are
executing the original enlistment contract in the sent to the Marine Corps Reserve Support
Navy or Marine Corps. An exception to this rule Center.
involves service members who are enlisted or
inducted and ordered to immediate active duty at For Navy and Marine Corps service
a recruit training facility. In this instance, the members who were discharged before 31
HREC (Fig. 4-1) will be opened by either the January 1994, requests should be sent to the
Naval Training Center (NTC) or Marine Corps National Personnel Records Center (NPRC) for
Recruit Depot, as appropriate. Copies of the record retrieval. For service members who were
service member’s DD 2807, Report of Medical discharged after 31 January 1994, requests for
History, and DD 2808, Report of Medical record retrieval are sent to the Department of
Examination are sent to the appropriate NTC or Veterans Affairs (VA). Addresses of each of
recruit depot, and added to other applicable these activities are listed in Chapter 16 of the
forms in the member’s records. MANMED.
Photograph provided by HM2 Timothy Hanna of the Biomedical Photography Department of Navy
Medicine Support Command, Bethesda, MD.
4-4
Figure 4-2.—Record (SSN)
PREPARING THE MEDICAL RECORD Each health record jacket has the second to
JACKETS: HREC, OREC, AND DREC the last digit of the social security number (SSN)
preprinted on it. The preprinted digit also
A new NAVMED 6150/21-30, U. S. Navy matches the last digit of the form number (e.g.,
Medical Outpatient and Dental Treatment the preprinted digit on NAVMED 6150/26 is 6).
Record, will be prepared when a record is The color of the treatment record jacket
opened or when the existing jacket has been corresponds to the preprinted digit. In preparing
damaged or is deteriorating to the point of a treatment record jacket, select a pre-numbered
illegibility. The old jacket will be destroyed NAVMED 6150/21-30 jacket by matching the
following replacement. second to the last number of the member’s SSN.
4-5
A “substitute” SSN should be created for PREPARING THE OUTSIDE FRONT
these members by assigning the numbers "9999" COVER
as the last four digits of the SSN and assigning
the first five digits in number sequence (e.g., Patient Name
first SSN 000-01-9999, the second SSN
000-02-9999). Place a piece of black Enter the member’s full name (last, first,
cellophane tape over the number that middle initial, in that order) in the upper-right
corresponds to the last digit of the SSN in each corner. Indicate no middle name by the
of the two number scales on the inside back abbreviation "NMN." If the member uses initials
cover of the HREC. instead of first or middle names, show this by
enclosing the initials in quotation marks (e.g.,
Family Member Prefix "J" "C”). Indicate titles, such as JR, SR, and III,
at the end of the name. The name may be
Enter the member’s family member prefix handwritten on the line provided or imprinted on
(FMP) code in the two diamonds preceding the a self-adhesive label and attached to the jacket in
SSN on the top of Part IV. Enter the FMP code the patient identification box.
of 20 for all Navy and Marine Corps active duty
members. Enter an FMP code of 00 for all Alert Box
foreign military personnel. See Table 4-1 for
more FMP codes. In the lower center area of the outside front
cover; indicate in the alert box whether the
Family Member Code member has drug sensitivities or allergies by
Sponsor 20 entering an "X" in the appropriate box. If there
Children 01-19 are no allergies or sensitivities, leave it blank. If
(First Child 01, Second allergies and or sensitivities are listed ensure that
Child 02, etc.)
all information is the same on the DREC and
Spouse 30
either the HREC (active duty) or OREC (non-
(First Spouse 30,
Second Spouse 31, etc.) active duty).
Mother, Stepmother 40-44
Father, Stepfather 45-49 Record Category
Mother-in-law 50-54
Father-in-law 55-59 Indicate the appropriate record category by
Other Authorized 60-69 entering an "X" in the appropriate box on the
Dependents outside front cover, just below the "Pencil
Beneficiary Authorized 90-95 Entries" block. Indicate whether the record will
by Statute be an Outpatient or Dental Treatment Record,
Civilian Emergencies 98 attach ½-inch red cellophane tape to the record
All Others 99 category block on the right edge of the inside
back cover of the jacket; indicating an active
Table 4-1.—Family Member Prefix
duty record.
4-6
Special Categories of Records Ship or MTF logos are permitted as long as
the necessary patient identifying information is
Identify the records of personnel assigned to not obscured.
special duty or medical surveillance programs
(e.g., Flight Status, Radiation Exposure, or the Preparing Part I (Inside Front Cover)
Asbestos Medical Surveillance Program) by
marking an "X" at the appropriate special Enter the following information in pencil on
category entry listed below the record category the inside front cover (Fig. 4-3) of the record
type. jacket. Recording the information in pencil
allows changes and updating throughout a
Identify flag officers and general officers by member’s career.
stamping or printing “FLAG OFFICER” or
• Date of arrival
"GENERAL OFFICER," as appropriate, on the
lower portion of the patient identification box. If • Projected rotation date
a patient identification label is used, print or
stamp the appropriate identification below the • Home address and telephone number
label. • Command UIC and telephone number
Pencil Entries
Preparing Part II (Front of Center Page)
Following the instructions on the front
cover, pencil in the appropriate title (i.e., grade IMPRINT OF DD 2005, PRIVACY ACT
or rate, if on active duty; preferred form of STATEMENT.—The imprint of DD 2005,
address, if retired or civilian), and include the Privacy Act Statement form is preprinted and
current command if active duty. located in front of the center page in the record
jacket. It must be signed and dated in black ink
Retired Year Tape Box by the patient, the parent, or the guardian must
sign if the patient is a minor (Fig. 4-4).
Leave the retired year tape box on the inside
back cover blank unless creating a record for a Preparing Part III (Back of Center Page)
retired service member.
DISCLOSURE ACCOUNTING
Bar Code Label Area RECORD.—The Disclosure Accounting
Record is preprinted and located on the back of
Some Navy treatment facilities have bar the center page of the record jacket. It is self-
coding capabilities. The bar code label indicates explanatory and will be filled out as needed.
the patient’s FMP, SSN, record type, and record Disclosure and release of information will be
volume number. Affix the label to the front of covered later in this chapter (Fig. 4-5).
the record jacket in the box to the right of the
alert box. If the bar code is part of the patient Preparing Part IV (Inside Back Cover)
identification label (such as the patient
identification label produced by the Composite The Forensic Examination form is
Health Care System (CHCS) computers), place preprinted and located on the inside back cover
this label in the patient identification box. of the record jacket, and should be completed if
the record is going to be used for dental care
Labels (Fig. 4-6).
4-7
Figure 4-3.—Part I - Inside Front Cover
4-8
Figure 4-4.—Part II – Front of Center Page
4-9
Figure 4-5.—Part III – Back of Center Page
4-10
Figure 4-6.—Part IV - Inside Back Cover
4-11
FILING HEALTH RECORDS Within each of these 100 sections, records
are filed in numerical sequence according to
their secondary numbers. The secondary number
LEARNING OBJECTIVE:
is the pair of digits immediately left of the
primary number.
Identify filing and tracking procedures for
health, outpatient, and dental records.
To make filing of records easier, they are
color-coded. The second to the last digit of the
RECORD FILING SYSTEM SSN is preprinted on the record jacket. The color
of the record jacket corresponds to the
The Navy Medical Department uses the preprinted digit as shown in Table 4-2.
Terminal Digit Filing System (TDFS) to file
health records. Records are filed according to
the terminal digits (last two numbers) of the Record Color Stock Form Number
service member’s social security number (SSN), Number
color coding of the record jacket, and use of a Orange NAVMED 6150/20
0105-LF-113-9700
block filing system.
Green NAVMED 6150/21
0105-LF-113-8700
To understand the TDFS filing system, the Yellow NAVMED 6150/22
SSN must be regarded in a specific manner. The 0105-LF-113-8800
nine digits of the SSN are divided into three Grey NAVMED 6150/23
number groups, reducing the chance of 0105-LF-113-9000
transposing numbers. In the TDFS system the Tan NAVMED 6150/24
SSN 123-45-6789 is visually grouped and read 0105-LF-113-9100
from right to left (instead of left to right), as Blue NAVMED 6150/25
follows: 0105-LF-113-9200
White NAVMED 6150/26
Primary Secondary Third 0105-LF-113-9300
Number Number Number Almond NAVMED 6150/27
0105-LF-113-9400
Pink NAVMED 6150/28
89 67 123-45 0105-LF-113-9500
Red NAVMED 6150/29
On the record jacket, the family member 0105-LF-113-9600
prefix (FMP) is added to the patient’s social
security number showing a beneficiary’s Table 4-2.—Record Color-Coding
relationship to the sponsor. For example, the
FMP for active duty personnel is 20, while the Centralized files having records based upon
FMP for a spouse is 30. more than 200 SSNs, or a file of more than 200
records, may need to use the TERTIARY (third)
Under the Terminal Digit Filing System, the NUMBER in filing. In a properly maintained
central files are divided into 100 approximately terminal-digit, color-coded and block-filing
equal sections. Each section is identified by a system, it is almost impossible to misfile a
maximum of 100 file guides bearing the 100 record. A record misfiled with respect to the left
primary numbers, 00 consecutively through 99. digit of its primary number (for example, a 45
Each of these 100 sections contains records that has been inserted among the 55s) will attract
whose last two digits correspond to the section’s attention because of its color difference. A
primary number. For example, every record with record jacket misfiled in respect to the right
the SSN ending in 56 is filed in section 56. primary number (for example, a 45 that has been
inserted among the 42s) causes a break in the
diagonal pattern formed by the blocking within a
color group.
4-12
Internal Charge out Control
4-13
Part I (Inside front cover): Record of Part II: Top Forms After a Patient is
Preventive Medicine and Occupational Deceased
Health
• Attestation sheet
• NAVMED 6150, Summary of care form
• DD 2604, Certificate of Death
(always top form)
• SF 503, Autopsy Protocol
• SF 601, Immunization Record
• SF 523, Authorization for Autopsy
• NAVMED 6000/2, Chronological record of
HIV Testing • SF 523A, Disposition of Body
• DD 771, Eyewear Prescription • SF 523B, Authorization for Tissue Donation
• NAVMED 6490/1, Visual Record
• NAVMED 6470/10, Record of Occupational Part II: Section B: Inpatient Care,
Exposure to Ionizing Radiation Ambulatory Surgeries, etc.
• NAVMED 6470/11, Record of Exposure to
Ionizing Radiation from Internally • NAVMED 6300/5, Inpatient Admission
Deposited Radionuclide Disposition Record
• DD 2215, Reference Audiogram • SF 502, Narrative Summary
• DD 2216, Hearing Conversation Data • SF 539, Abbreviated Medical Record
• NAVMED 6224/1, TB Contact converter • SF 509, Progress Notes
followup
• SF 516, Operation Report
• NAVMED 6260/5, Asbestos Medical
• SF 600, Chronological Record of Medical
Surveillance Program
Care
• DD 2493-1, Asbestos Exposure – Part I,
• SF 517, Anesthesia
Initial Medical Questionnaire
• SF 522, Request for Administration of
• DD 2493-1, Asbestos Exposure – Part II,
Anesthesia
Periodic Medical Questionnaire
• SF 233, Prenatal and Pregnancy Civilian
• OPNAV 5100/15, Medical Surveillance
Medical Care Notes
Questionnaire
• DD 602, Patient Evaluation Tag
Part II: Section A (Front of Center Page)
4-14
Part III (Back of Center Page) • Deoxyribonucleic Acid (DNA) Analysis
Sample Pouch
• NAVMED 1300/1, Medical and Dental
Overseas Screening Review for Active Duty Part IV (Inside of Back Cover)
and Dependents
• NAVPERS 1300/16, Report of Suitability • SF 217, Epilepsy Medical Report
for Overseas Assignment • SF 515, Tissue Examination
• NAVMED 6100/1, Medical Board Report • SF 519A, Radiographic Report
Cover Sheet
• SF 519B, Radiologic Consultation
• NAVMED 6100/2, Medical Board Request/Report
Statement of Patient
• SF 519, Medical Record-Radiographic
• NAVMED 6100/3, Medical Board Reports
Certificate
• SF 518, Blood or Blood Component
• NAVMED 6100/5, Abbreviated Temporary Transfusion
Limited Duty
• SF 520, Electrocardiogram Request
• SF 2824C, Physician Statement for
Employee Disability Retirement • SF 524, Radiation Therapy
• SF 47, Physical Fitness Inquiry for Motor • SF 525, Radiation Therapy Summary
Vehicle Operators • SF 526, Interstitial/Intercavity Therapy
• SF 78, Certificate of Medical Examination • SF 527, Group Muscle Strength, Join ROM,
• DD 2807, Report of Medical History Girth and Length Measurements
• DD 2808, Report of Medical Examination • SF 528, Muscle Function by Nerve
Distribution: Face, neck, and Upper
• NAVMED 6120/2, Officer Physical Extremity
Examination Special Questionnaire
• SF 529, Muscle Function by Nerve
• NAVMED 6120/3, Annual Certificate Distribution: Trunk and Lower Extremity
Physical Condition
• SF 53, Neurological Examination
• NAVMED 6150/4, Abstract of Service and
Medical History • SF 531, Anatomical Figure
• NAVJAG 5800/10, Injury Report • SF 541, Gynecologic Cytology
• NAVJAG Report • SF 545, Laboratory Report Display
• NAVPERS 1754/1, Exceptional Family • SF 546-557, Laboratory Reports
Member Program Application • SF 559, Allergen Extract Prescription- New
• DD 2569, Third Party Collection Program and Refill
• Living Will or Medical Power of Attorney • SF 560, Electroencephalogram Request and
History
• OPNAV 5211/9, Record of Disclosure,
Privacy Act 1974 • SF 511, Vital Signs Record
• DD 877, Request for Medical/Dental • SF 512, Plotting Chart
Records • SF 512A, Blood Pressure Plotting Chart
• DD 2005, Privacy Act Statement
4-15
VERIFICATION OF ACTIVE DUTY For dental records, document verification on
HEALTH AND DENTAL RECORDS the EZ603A and as they are verified at the time
of the annual exam there is no requirement to
blacken the verification year. The information
LEARNING OBJECTIVES:
on the inside of the jacket front cover should be
updated in pencil only for both records. This
Describe the requirements for record
information will be entered at the time of record
verification.
check-in (receipt) and will be kept current at all
times by erasing previous, outdated entries.
Describe the requirements for the
documentation of record verification.
PERMANENT CHANGE OF STATION
(PCS)
All records are verified annually by medical
and dental personnel having custody of them. At the time of a member’s PCS from a
Health records will be reviewed when service command, the medical and dental facilities that
members report and detach from their are responsible for the release of records will
commands, and at the time of any physical ensure the following steps are completed.
examinations. Guidance for PCS is found in MANMED,
Chapter 16.
Each record will be carefully reviewed and
any errors or discrepancies corrected. Items to 1. Verify medical and dental records.
be reviewed during any verification include: 2. If no health, outpatient, and or dental record
form placement, order of forms (chronological), exist, construct a new record following the
and completeness and accuracy of patient instructions in this chapter and MANMED.
identification data on the record jacket and on When re-constructing dental records have a
each piece of medical documentation. In dentist perform a T-2 dental examination.
addition, verify that the Privacy Act Statement
3. Ensure member has been processed for
has been signed, the DD 2766 (covered later in
transfer.
this chapter) is updated as necessary, operational
and occupational requirements updated, and 4. Complete record charge-out card.
currency of immunizations and accuracy of
5. Allow active duty members to hand carry
allergy documentation are complete.
their records, unless the facility or member’s
command determines it is not in the Navy’s
Upon completion of an annual medical
or member’s interest to do so. If the medical
record verification, the HM will make an entry
and dental records are not to be hand
on the SF 600 for medical records and black-out
carried, forward them via certified mail
the corresponding year block on the front leaf of
along with a DD Form 877, Request for
the jacket with a black felt-tip pen. With this
Medical/Dental Records Information, or
procedure, records that have not been verified
place medical and dental records in the
during the calendar year can be identified and
custody of authorized personnel.
the annual verification accomplished. The
annual verification section is located on the
right-hand side of the front cover of the record
jacket as a series of blocks numbered with the
years 1996 thru 2014. The year of verification
will be blackened out for health records once it
has been verified.
4-16
CLOSING HEALTH RECORDS A copy of the HREC is provided free of
charge to members requesting one upon their
release, discharge, or retirement.
LEARNING OBJECTIVE:
Missing or Missing-in-Action Members
Explain closing procedures for health records.
Whenever a member disappears and the
HEALTH RECORD CLOSURE available information is insufficient to warrant
an administrative determination of death, enter a
A member’s health records may be closed due summary of the relevant circumstances on the
the following circumstances: SF 600. Include circumstances about the
• Death or declared death presumed disappearance of the individual, status
(missing or missing in action), and supporting
• Discharge documentation. Close the record as would be
• Resignation done for members being discharged from the
service.
• Release from active duty
Desertion
• Retirement
• Transfer to the Fleet Reserve or release to When a member is officially declared a
inactive duty deserter, document the event fact on the SF 600,
EZ603A and the NAVMED 6150/4. Deliver
• Missing or missing in action (MIA; when
HREC and DREC to the member’s CO for
officially declared as such)
inclusion in and transmittal with the service
• Desertion (when officially declared as such) record for both Navy and Marine Corps
personnel.
• Disenrollment as an officer candidate or
midshipman When a deserter is apprehended or
When closing a HREC, ensure the record is surrenders, the CO of the activity having
in order, there are no loose papers, and all jurisdiction is required to submit a request for
identification data is consistent. Ensure all tests the member’s records to Bureau of Naval
(lab, x-ray, etc.) and their reports have been Personnel (BUPERS) or Commandant of the
printed out and placed in chronological order Marine Corps (CMC).
within the record. Record the closing entry on
the NAVMED 6150/4, Abstract of Service and Retirement
Medical History (Fig. 4-8). Include the date of
separation, title of servicing activity, and any When a member of the naval service is
explanatory circumstances. placed on the retired list or Fleet Reserve List,
close the HREC. Upon request of the retiring
Upon final discharge or death, send the member, a new medical record (OREC) is
complete and verified health and dental records established. A copy of the retiring member’s
to the command maintaining the member’s active duty HREC may be incorporated into a
service record (no later than the day following new NAVMED 6150/21-30 folder. Make an
separation) for inclusion in and transmittal with entry on an SF 600 in the HREC and in the new
the member’s service record. Make sure the OREC, stating the date the HREC was closed.
original of the separation physical examination Dental records should be verified and retired at
documents are included in the HREC before the same time, and forwarded to the National
delivery to the command maintaining the Personnel Records Center, Military Personnel
member’s service record, such as the PSD, PSA, Records, St. Louis, Missouri.
etc. In case of death, send a copy of the death
certificate along with the transmitted records.
4-17
Figure 4-8.—NAVMED 6150/4
4-18
Members separating from the service and • Sponsor’s branch of service (e.g., Army,
eligible for veteran’s benefits will be provided a Navy, or Air Force) and patient’s status
copy of their HREC on request. Members should (e.g., family member or retired)
be counseled to request a copy in the event they
Complete and accurate documentation of
may make a claim for veteran’s benefits in the
patient identification data is critical to ensure the
future. Always offer to send a copy of their
documents are placed in the correct patient’s
HREC to the regional VA office for them.
record. Three methods are currently used to
place patient identification on medical
HEALTH / OUTPATIENT RECORD documents:
FORMS
• Embossed medical card
LEARNING OBJECTIVE: • Automated forms
It is imperative that all forms documenting The HREC/OREC or any part of it should be
patient care contain adequate data to identify the duplicated whenever it becomes illegible or
patient and permit filing of the forms in the deteriorates to the point that it may endanger its
record. All forms documenting patient care and future use or value as a permanent record. The
filed in records will, at a minimum, contain the duplicate record or duplicate portion must
following data in the identification block: reproduce as closely to the original as possible.
When duplicating an entire health record, place
• Patient’s FMP and sponsor’s SSN the designation "DUPLICATE RECORD"
• Patient’s name (last, first, middle initial) prominently on the front of the jacket above the
wording OUTPATIENT MEDICAL RECORD.
4-19
When duplicating only part of the record, • Part 1 - Record of Preventive Medicine and
identify the individual forms by printing Occupational Health
"DUPLICATE” at the bottom of each form.
Enter the circumstances necessitating the • Part 2 - Record of Medical Care and Treat-
duplication and the date accomplished on an SF ment
600. If possible, microfiche all forms replaced • Part 3 - Physical Qualifications
for protection and preservation, and make the
envelope a permanent part of the medical record. • Part 4 - Record of Ancillary Studies,
On front of the envelope, record the member’s Inpatient Care, and miscellaneous forms
full name, FMP (family member prefix) and
SSN, date of birth, and list the original forms ADULT PREVENTIVE AND CHRONIC
contained in the envelope. CARE FLOW SHEET (DD 2766)
If microfilming is not available, place the The Adult Preventive and Chronic Care
original health forms (except forms Flow Sheet (Fig. 4-9) contains a summation of
contaminated with mold or mildew) inside a relevant problems and medications that
plain envelope for preservation and make them significantly affect the patient’s health status.
part of the permanent record. On the front of the Properly maintained, the DD Form 2766 form
envelope, record the member’s identifying data aids healthcare providers by allowing them
(same as microfiche envelope) and list the quick access to pertinent medical factors that
contents of the envelope. Mark the envelope may affect how they manage a patient’s medical
"ORIGINAL MEDICAL RECORDS care. This form is a permanent part of the HREC
PERMANENT" and file as the bottommost item or OREC. This form should be reviewed and
in part 2 of the 4-part record jacket. revised during the patient’s visit. The DD Form
2766 should also be reviewed during annual
Loose Forms verification and before HREC or OREC
transfers.
When loose treatment forms are discovered,
every effort should be made to determine the The DD Form 2766 is divided into 4 pages:
present location of the record. If reasonable significant health problems, hospitalization/
search efforts do not locate the record, retain surgery, medical alert, medications, and health
loose forms for a period of 1 year. Upon maintenance (immunizations, deployment
expiration of the retention period, destroy the readiness, etc.).
forms locally according to paragraph six of the
standard identification code 6150 contained in Significant health problems section: Enter
SECNAVINST 5212.5 series, Navy and only significant medical conditions in this
Marine Corps Records Disposition Manual. section. Significant medical conditions include
chronic diseases (such as hypertension, diabetes,
Health/Outpatient Record Forms arthritis, etc.) and acute recurrent illnesses (such
as recurrent urinary tract infections, recurrent
When assembling a medical record, arrange otitis media, recurrent bronchitis, etc.)
the forms of the same type in chronological
order by date. The most current document • Hospitalization/surgery section:
should be placed on top, and the least current o Enter significant surgical conditions
documents below it. The HREC/OREC contains
dividers that partition the record into four parts. o Include all procedures requiring general
A sequential listing of medical forms to be filed or regional anesthesia and any procedures
in each section is provided in Table 4-3. The likely to have long-term effects on the
titles for each part of the HREC/OREC are as patient’s health status
follows:
4-20
Figure 4-9A.—DD Form 2766
4-21
Figure 4-9B.—DD Form 2766
4-22
Figure 4-9C.—DD Form 2766
4-23
Figure 4-9D.—DD Form 2766
4-24
CHRONOLOGICAL RECORD OF • SF 600s include the following information:
MEDICAL CARE (SF 600) complaints, duration of illness or injury,
physical findings, clinical course, results of
The Chronological Record of Medical Care, laboratory or other special examinations,
SF 600, provides a continuous comprehensive treatment (including operations), physical
record of a patient’s medical history (Fig. 4-10). fitness at the time of disposition, and
Use the SF 600 for all outpatient care and file in disposition. The subjective complaint,
the HREC or OREC. Record all visits, including observation, assessment, and plan (SOAP)
those that result in referrals to other MTFs. Each format may be used for entries as long as the
person making an entry on the SF 600 will sign required information is included.
the entry and include identification information
(full name, grade or rate, profession [e.g., MC,
Record each visit and the complaint
NC, etc.], and SSN), either hand printed, typed,
described, even if a member is returned to duty
or stamped.
without treatment. Document if a patient leaves
before being seen.
The SF 600 facilitates the evaluation of a
patient’s condition and reduces correspondence
necessary to obtain medical records. Appropriate Other SF 600 entries include the following:
use of the form eliminates unnecessary
• Imminent hospitalization
repetition of expensive diagnostic procedures
and serves as a permanent record of medical • Special procedures and therapy
evaluations and treatments.
• Sick call visit
Completing the SF 600 • Injuries or poisonings
• Entries made on the SF 600 can be • Line-of-duty inquiries
typewritten when practical. However, entries
normally are handwritten with black or blue- • Binnacle list and sick list
black ink pens. When initiating an SF 600, • Reservist check-in and check-out statements
patient identification data will be completed.
Type or stamp the date (DD/MM/YY) and
the name and address of the activity IMMINENT HOSPITALIZATION⎯
responsible for the entry. When a patient’s admission is imminent,
admission notes can be made on an SF 600.
• Use both sides of each SF 600. Preparation However, the use of the SF 509, Medical
of a new SF 600 is not necessary each time Record-Progress Report, is preferred. The SF
the person is seen in a different MTF. If only 509 form is routinely used for inpatient
a few entries are recorded on the SF 600 at admission notes and is filed in the patient’s
the time of a PCS, stamp the designation and IREC. Record referred or postponed inpatient
location of the receiving MTF below the last admissions on the SF 600.
entry and use the rest of the page to record
subsequent visits. If the back of the SF 600
is not going to be used, the back needs to be
crossed out and the words "No further
entries" printed in the middle of the form.
4-25
Figure 4-10.—SF 600
4-26
SICK CALL VISITS⎯ Whenever a Immunization Entries
member is evaluated at sick call, an entry will be
made on a SF 600 reflecting the complaints or The name of the medical officer or Senior
conditions presented, pertinent history, treatment Medical Department Representative (SMDR)
rendered, and disposition. administering the immunization, test, or
determining the nature of the sensitivity reaction
INJURY OR POISONING⎯ In the event should be typed or written on the DD Form
of injury or poisoning, record the duty status of 2766. Signatures are not required; however,
the member at the time of occurrence and the when signatures are used, make sure they are
circumstances of occurrence per the guidelines legible.
in BUMEDINST 6300.3 series, Inpatient Data
System. The medical officer or SMDR administering
the immunization is responsible for completing
LINE-OF-DUTY INQUIRIES⎯ When a entries in the appropriate sections of DD Form
member of the naval service incurs an injury that 2766. For smallpox, cholera, yellow fever and
might result in permanent disability or results in anthrax immunizations, record the
a physical inability to perform duty for a period manufacturer’s name and batch or lot number.
exceeding 24 hours, an entry will be made
concerning line-of-duty misconduct. Entries NOTE
include the time of injury, date, place, names of The specific protocol for recording anthrax
persons involved, and the circumstances immunizations is outlined in SECNAVINST
surrounding the injury. 6230.4 series, Department of the Navy (DoN)
Anthrax Vaccination Implementation Program
A line-of-duty inquiry is conducted to (AVIP).
establish whether the injuries sustained by the
patient are the result of misconduct on the part
of the member or others. Guidance on line-of- Type any hypersensitivity to drugs or
duty inquiries is located in the Manual of the chemicals under "Remarks and
Judge Advocate General (JAGMAN). Recommendations” in capital letters (e.g.,
HYPERSENSITIVITY TO ASPIRIN,
SERIOUSLY ILL/VERY SERIOUSLY HYPERSENSITIVE TO LIDOCAINE). This
ILL (SI/VSI) LIST⎯Place personnel whose entry is in addition to a similar entry required on
illness or injuries are severe on the SI/VSI List the EZ603 or EZ603A, current treatment form,
(as defined in MILPERSMAN 421-0100), make the SF 600 Special-Hypersensitivity form, and
appropriate notification, and document on the SF the NAVMED 6150/20 retained permanently in
600. the HREC or OREC.
4-27
INTERNATIONAL CERTIFICATES OF
VACCINATION (PHS-731)
4-28
ADJUNCT HEALTH RECORD FORMS Consultation Sheet (SF 513)
AND REPORTS
The SF 513 (Fig. 4-13) is used for
This section provides instruction for using outpatients who need to be referred to other
certain forms in the health record instead of healthcare providers or specialists, such as
transcribing their data to the Chronological gynecologists, internists, optometrists, etc. The
Record of Medical Care, SF 600. primary assessment and results of examinations
and tests will be entered onto the form. The
Narrative Summary (SF 502) patient remains the responsibility of the referring
provider until the specialist takes over the care.
The SF 502 (Fig. 4-12) is used to summarize In some cases, the specialist will perform an
clinical data relative to treatment received examination or procedure and refer the patient
during periods of hospitalization. The narrative back to the original provider for continued care.
summary will include all procedures and The original consultation form stays in the
diagnoses, and must match with information HREC.
listed on the Inpatient Admission/Disposition
Report (NAVMED 6300/5) and any information
listed in the operation report.
4-30
The DD Form 771 should be typewritten or Each dental care provider must indicate, in
computer printed whenever possible. This the dental treatment section of the EZ603A that
practice eliminates any errors by misreading an the questionnaire has been reviewed and updated
individual’s handwriting. Omission of any by the patient. Dentist must also annotate on the
information or entering erroneous information EZ603A in the “O” objective block, sections
will result in a delay at the fabricating facility or marked “HQ dated,” “Reviewed,” and “HQR
patients receiving an incorrect pair of Finding.”
eyeglasses, or both.
During annual dental exams, patients need
If the Corpsman cannot read what has been only to review, date, and sign the current
written on an eyewear prescription, contact the questionnaire if health status has not changed.
optometrist for clarification. In the case where Whenever a significant change in medical
the optometrist cannot be contacted, send a history or health status occurs, a new
photostatic copy of the prescription to the optical questionnaire must be filled out, dated, and
laboratory rather than transcribing information signed.
which is unclear. Make sure the copy of the
prescription is accompanied by a completed DD The initial and subsequent Dental HQRs are
Form 771. permanently maintained in the Dental Treatment
Record. For conditions that require medical
DENTAL RECORD FORMS clarification, use the SF 513 (Consultation
Sheet). Document the consultation on the
EZ603-Dental Exam Form and in the Summary
LEARNING OBJECTIVE:
of Pertinent Findings section of the NAVMED
6600/3. BUMED Instruction 6600.12 series
Describe the types and locations of dental
provides guidance for the Dental HQR.
record forms.
Part I (Inside Front Cover)
ARRANGEMENT OF FORMS
Forms will be filed in the inside front cover of
Front of Dental Record Jacket Center Page the dental record jacket as follows:
Forms will be filed in the front of the dental • Un-mounted radiographs in envelopes -
record jacket center page as covered in the Front
following paragraphs: • Sequential bitewing radiograph - Middle
4-31
Figure 4-15.—NAVMED 6600/3
4-32
Part III (Back of Center Page) • Narrative Summary, SF 502, Figure 4-12
(when related to dental treatment)
Place all Dental Exam Forms, EZ603s (Fig.
4-16) (Plan “P” side up) in reverse chronological • Consultation Sheet, SF 513, Figure 4-13
order, i.e. newest date on top, in this area. (when related to dental treatment)
• Doctor’s Progress Notes, SF 509, (when
related to dental treatment)
• Tissue Examination, SF 515 (Fig. 4-17) (if
required)
• Request for the Administration of
Anesthesia and for Performance of
Operations and Other Procedures, SF 522
(Fig. 4-18) (if required)
Figure 4-16.—EZ603
4-33
Figure 4-18.—SF 522
4-34
ADDITIONAL DENTAL FORMS Treatment facilities will take precautions to
avoid compromise of medical and dental
Under the following conditions, additional information during the movement and storage of
dental treatment forms are approved for medical records. This includes correspondence
inclusion in the dental record. concerning the medical records when protected
health information (PHI) is a part of the message
Other health care treatment forms (e.g., contents. Medical records will be handled by
Veterans Affairs, Office of Personnel only authorized medical service personnel.
Management, Compensation Act, Standard Records must be stored in a locked area, room,
Forms, optional forms, and civilian practitioner or file to ensure safekeeping, unless there is a
forms) may be incorporated in the dental record 24-hour watch in the record’s room. Refer to the
when considered necessary to document care MANMED Chapter 16 for detailed guidance.
and treatment. When feasible, attach the form to
the appropriate approved form (e.g., attach RECORD CUSTODY
summaries of reports from civilian practitioners
to validate the EZ603, EZ603A or old SF 603) Records are retained in the custody of the
in the proper sequential order. Those not medical officer and or dental officer on the ship,
attached to approved forms will be filed inside submarine, or aviation squadron to which the
the back cover of the dental record jacket behind member is assigned. For those platforms that do
the last authorized form listed above (e.g., SF not have medical/dental officers, the health
522). record may be placed in the custody of the
SMDR at the discretion of the CO. Examples of
SECURITY AND SAFEKEEPING OF SMDRs are Independent Duty Corpsman or
MEDICAL RECORDS Squadron Corpsman. When Medical Department
personnel are not assigned, the CO may assign
custody of the health records to the local
LEARNING OBJECTIVE:
representatives of the Medical and Dental
Departments who generally furnish medical and
Identify security and safekeeping procedures
dental support. The custody of the record by an
for medical records.
individual is never permitted.
Each treatment facility develops policies to Records are subject to inspection at any time
ensure that records are secure and patient’s by the CO, superiors in the chain of command,
privacy is protected. Security and safekeeping the fleet medical officer, or other authorized
are major concerns and responsibilities of staff inspectors. Records are for official use only and
handling medical records. The medical record adequate security and custodial care are
contains information that is personal, treated as required.
privileged information, and protected by the
Privacy Act of 1974. The Privacy Act permits There are many methods of providing
only the patients and their legal representatives adequate security and custodial control of
to obtain this information. Additional protection records. In general, records will be stored in a
is afforded under the HIPAA Privacy Rule. As manner making them inaccessible to the crew or
this is a federal law, there are fines and or general public. No records or record pages
imprisonment consequences depending upon the should be left unattended. This precaution helps
breach, utilization of the breached information, to prevent loss or misplacement of records, and
and the number of breaches for the person or the ensures that a command is compliant with
organization. federal and military regulations.
4-35
Medical Department personnel will maintain CROSS-SERVICING HEALTH RECORDS
a NAVMED 6150/7, Health Records Receipt,
File Charge-out, and Disposition Record for The HREC of a Navy or Marine Corps
each health, outpatient, and dental record in their member is normally serviced by personnel of the
custody. The completed charge out form must be Medical Department of the Navy. However, if a
retained in the file until the record is returned. Navy or Marine Corps member is performing an
Medical and dental officers or SMDRs are assignment with the Army or the Air Force, the
responsible for the completeness of required health record may be serviced by Army or Air
health record entries while the record remains in Force Medical Department personnel. This
their custody. management of the health record may be done if
the attendant service interposes no objection and
DISPOSING OF HEALTH RECORDS considers the procedure feasible. Reciprocal
DURING HOSPITALIZATION procedures for servicing the health records of
Army or Air Force personnel by personnel of the
When a patient is transferred to a treatment Medical Department of the Navy will be
facility, the HREC should accompany the maintained whenever feasible, and if requested
patient. If members are admitted to a military by authorized representatives of those services.
hospital while away from their command, their
HRECs should be forwarded as soon as possible RELEASING MEDICAL
to the hospital. If a discharged member is INFORMATION
directed to proceed home and await final action
on the recommended findings of a physical
LEARNING OBJECTIVE:
evaluation board, an entry to this effect will be
recorded in the HREC.
Identify guidelines for releasing medical
information.
If a member is admitted to a civilian hospital
for treatment involving brief periods of
hospitalization, the HREC should be retained by AUTHORITY
the activity until disposition is completed. The
HREC will then be forwarded to the cognizant The Surgeon General of the Navy is the
office of medical affairs or to the activity official responsible for administering and
designated by the Commandant of the Marine supervising the execution of SECNAVINST
Corps (CMC) for Marine Corps members. In 5211.5 series, Department of the Navy Privacy
instances where the parent activity retains the Act Program (PAP), as it pertains to the Health
HREC, a summary of the hospitalization will be Care Treatment Record System. Additionally,
entered on an SF 600 when the member returns the Office of the Surgeon General authorizes
to duty. requests for access and amendment to a naval
member’s treatment records.
When a member is hospitalized at a medical
facility of a foreign nation, an entry of this fact COs of Navy treatment facilities are
should be made in the HREC. The HREC should designated as local systems managers for
be retained on board and continued until the treatment records maintained and serviced
patient either returns to duty or is transferred to a within their activities. Local systems managers
U.S. military activity. Upon departure of the are authorized to release information from
medical facility, the HREC will be delivered to records located within the command if proper
the CO for inclusion in the member’s service credentials have been established. The
record for forwarding to the nearest U.S. requesting office or individual will be advised
embassy or consulate. that such information is private and must be
treated with confidentiality.
4-36
In all cases where information is disclosed, Release to the Individual Concerned
an entry will be made on OPNAV Form 5211/9,
Record of Disclosure-Privacy Act of 1974 to Release of healthcare information to the
include the date, nature and purpose of the individual concerned (patient) falls within the
disclosure, and the name and address of the purview of the Privacy Act and not the Freedom
person or agency receiving the information. of Information Act. When individuals request
Maintain a copy of any such disclosure requests. information from their medical record, it will be
Additionally, documentation of information released to them unless, in the opinion of the
released must also be noted in any required releasing authority, it might prove injurious to
electronic databases. their physical or mental health. In such an event,
the releasing authority will request authorization
GUIDELINES FOR RELEASING from the patients to send their medical
MEDICAL INFORMATION information to their personal physician.
This section will cover the policy for release Release to Representatives of the Individual
of record transcripts. The appropriate rule for Concerned
the release implemented depends upon the
intended recipient of the record transcript. Upon the written request from patients,
healthcare information will be released to their
Release to the Public authorized representatives. If an individual is
mentally incompetent, insane, or deceased, the
Information contained in treatment records NOK or legal representative must authorize the
of individuals having undergone medical or release in writing. NOK or legal representatives
dental examination or treatment is personal and must submit adequate proof that the member or
considered private and privileged in nature. former member has been declared mentally
Consequently, disclosure of such information to incompetent or insane, or furnish adequate proof
the public would constitute an unwarranted of death if such information is not on file. Legal
invasion of personal privacy. Such information representatives must also provide proof of
is exempt from release under the Freedom of appointment, such as a certified copy of a court
Information Act. order.
4-37
Releasing Medical Information to Federal Releasing Medical Information for Research
and State Agencies
COs of treatment facilities are authorized to
In honoring proper requests, the releasing release information from treatment records
authority should disclose only information located within the command to members of their
relative to the request as listed in the “Routine staff who are conducting research projects.
Uses" section of the Medical Treatment Records When possible, the names of parties involved
System, which is annually set forth in SECNAV should be deleted. Other requests from research
NOTE 5211, Systems of Personal Records groups should be forwarded to Bureau of
Authorized for Maintenance Under the Privacy Medicine and Surgery (BUMED) for guidance.
Act of 1974, 5 U.S.C. 552a (PL 93-579).
SUMMARY
In the following three instances agencies
may have a legitimate need for the information: The HM will be responsible for managing
medical and dental records. These records are
• Health care information is required to
vital tools in the healthcare delivery process. It is
process a governmental action involving an
of the utmost importance that the HM learns and
individual. The Veterans Administration and
follows the guidelines for establishing, handling,
the Bureau of Employees' Compensation
maintaining, and closing medical and dental
process claims in which the claimant’s
records. Well maintained treatment records
medical or dental history is relevant. If an
furnish healthcare providers with current
agency requests health care information
medical and dental data, enabling the provider to
solely for employment purposes, a written
give each patient timely and comprehensive
authorization is required from the individual
care. Confidential treatment of the patient’s PHI
concerned.
honors the patient’s privacy and is in keeping
• Health care information is required to treat with legal regulations.
an individual in the department’s custody.
(Federal and state hospitals and prisons may
need the medical or dental history of their
patients and inmates.)
• Release to federal or state courts or other
administrative bodies. The preceding
limitations are not intended to prevent
compliance with lawful court orders for
health records in connection with civil
litigation or criminal proceedings, or to
prevent release of information from health
records when required by law. If there are
doubts about the validity of record requests,
ask the Judge Advocate General (JAG) for
guidance.
4-38
CHAPTER 5
MEDICAL LOGISTICS
MEDICAL/DENTAL Without the proper amount of medical and
LOGISTICS HISTORY dental supplies and equipment at a command,
the medical and dental department’s operational
In 1850 the United States Navy established readiness to treat patients would be
the Naval Medical Supply Depot in Brooklyn, compromised. Proper planning, inventory, and
New York. In 1853, Congress authorized a maintenance are essential for the operation of
separate manufacturing laboratory that enabled it the medical and dental departments.
to "produce medical supplies for the Medical
Department of the Navy." In July 1952, the This chapter we will outline the proper
Naval Medical Supply Depot, Brooklyn was procedures to use in estimating, procuring, and
transferred to the Bureau of Supplies and accounting for supply needs and operating
Accounts. For the first time in 100 years the funds. The last section will cover equipment
Navy Medical Department was no longer technology & management and contingency
directly involved in centrally manufacturing, supply blocks.
warehousing, or distributing medical supplies.
All supplies would be controlled centrally with ORGANIZATIONAL STRUCTURE
other commodities by the Department of
Defense (DoD). The Chief, Bureau of Medicine and Surgery
(BUMED) established a standard organizational
The DoD centralized supply system has structure for Medical Logistics Departments at
served the Navy/Marine Corps Team and Navy all Naval Medical and Dental activities with
Medicine well. Due to budget and staffing logistics responsibilities.
constraints medical logisticians have continued
to seek more effective ways to procure, store and The key functional areas within the organization
issue medical/dental materiel. Today the local are:
Medical Logistics Department continues to • Purchasing and contracting
provide total logistic support to facilities,
utilizing all facets of the Defense Logistics • Materiel receipt, storage, and issue
Agency (DLA), Naval Supply Systems • Supply inventory management
Command (NAVSUP), and Naval Medical
Logistics Command (NAVMEDLOGCOM). • Equipment Management Division
• Biomedical Equipment Maintenance
INTEGRATED LOGISTICS SUPPORT
Division
Logistics encompasses the acquisition, • Central processing and distribution
accounting, sustainment, and disposition of
assets within the Department of the Navy. • Healthcare service contracting
NAVMEDLOGCOM works to ensure proper The Medical Logistics Department will
fiscal administration by directives, principles, administer the in-house supply programs for the
and policies prescribed by the Comptroller of the command. At some commands, additional
Navy, with the ultimate responsibility resting on functions such as Food Service or Linen
each Commanding Officer. A Hospital Management may also be assigned to Medical
Corpsman should become familiar with the rules Logistics.
and regulations that govern the supply process.
5-1
The Defense Logistics Agency (DLA), via Materiel Receipt, Storage, and Issue
the Federal Supply System, maintains
centralized inventory management and physical
• Warehouse/Storeroom/Receipt Control:
distribution of depot and vendor medical/dental
This division plans and directs operations
materiel to Naval MTFs/DTFs worldwide.
necessary to physically receive and control
incoming and outgoing supplies and
Materiel managers have various methods of
equipment for storage, direct turnover to the
access available to procure medical and dental
customer, or shipment to remote sites. This
materiel from government and commercial
division maintains records of incoming
sources. Because of rapid changes in medicine
receipts; prepares receipt documents;
and the demand for state-of-the-art materiel, the
prepares government bills of lading; and
DLA in cooperation with the Army, Navy, and
processes invoices for payment.
Air Force has established various innovative
forms of procurement to meet customer
demands. Most notable is the current Defense Supply Inventory Management
Supply Center Philadelphia’s (DSCP) Prime
Vendor Program and the International Merchant
• Stock Control: This division is responsible
Purchase Authorization Card (I.M.P.A.C.), also
for the inventory management aspect of the
known as the government-wide purchase card
materiel held in the warehouse or purchased
program.
for direct issue to a customer. Receipt and
issue documents are processed here.
KEY AREAS WITHIN MEDICAL
LOGISTICS DEPARTMENTS
Equipment Management and Biomedical
Purchasing and Contracting Equipment Repair Divisions
• Technical Review: This division screens all • Equipment Management: This division
requisitions to verify that items are available administers the command's property
from a mandatory government source of utilization and disposal program. Guidance
supply or assist in determining commercial on the acquisition, accounting, and survey of
sources of supply. This section maintains equipment is done here. It identifies and
vendor catalogs and Federal Supply accounts for plant property and minor
Schedule (FSS) information. medical and non-medical equipment within
the command’s control.
• Purchasing: In this division, commercial
procurement actions take place. The staff • Biomedical Equipment Maintenance
reviews purchase requests and determines (BIOMED): This division administers the
the type and method of procurement. medical/dental equipment preventive and
corrective maintenance programs. It also
oversees the following: equipment operation
training; repair parts inventory; operator
manual library; maintenance requests; and
equipment maintenance contracts.
5-2
Central Processing and Distribution NAVSUP P-409, MILSTRIP/ MILSTRAP
MANUAL
• Central Supply: This division plans and
The NAVSUP P-409 was published as a
directs operations necessary to order and
handy reference for personnel responsible for
receive materiel for working stock supplies,
originating and processing MILSTRIP/
or PAR levels, which are predetermined
MILSTRAP documents. This small booklet
stock levels maintained in the customer's
contains common definitions, coding structures,
working space based on established usage.
and abbreviated code definitions used on a day-
Most central supply areas issue supplies to
to-day basis.
authorized outpatients who have a
prescription for the materiel, i.e. dressings.
NAVMED P-5132, BUREAU OF MEDICINE
AND SURGERY EQUIPMENT
NAVSUP & NAVMEDLOGCOM MANAGEMENT MANUAL
MANUALS, PUBLICATIONS, AND
DIRECTIVES The P-5132 is available via the
NAVMEDLOGCOM homepage. It reiterates
Department of the Navy policy and provides
LEARNING OBJECTIVE: equipment management procedures to include
budgeting, funding, acquisition, use,
Explain the purpose and content of key supply maintenance, repair, redistribution, and disposal
manuals and instructions. of equipment.
INTRODUCTION TERMINOLOGY
Functioning well in Navy Logistics requires To effectively procure and account for
familiarization with the NAVSUP, materials, be familiar with terminology
www.navsup.navy.mil and NAVMEDLOGCOM commonly used in the supply system.
www.nmlc.med.navy.mil manuals, publications,
and directives. • Procurement: The act of obtaining materials
or services.
NAVAL SUPPLY SYSTEMS COMMAND • Contracting Authority: Refers to the dollar
(NAVSUP) MANUAL, NAVSUP P-485 limitation and acquisition methods the
command and purchasing agents are
The NAVSUP manual is designed to restricted to when placing government
institute standardized supply procedures and orders.
consists of the following three volumes:
• Commitment: When appropriated funds
• Volume I: Naval Supply Procedures, Afloat have been approved and set aside by the
• Volume II: Naval Supply Procedures, fiscal officer for acquisition of goods and/or
Supply Appendices services.
• Volume III: Naval Supply Procedures, • Obligation: When a qualified purchasing
Ashore agent enters into a contractual agreement
thereby obligating the Government with a
The Naval Supply Procedures, NAVSUP vendor for goods and/or services.
P-485, establishes policies for operating and
managing supply departments and activities. The
procedures contained in this publication are the
minimum essential for acceptable supply
management and are mandatory unless
specifically stated as optional.
5-3
• Unauthorized Commitment: When a • Federal Acquisition Regulation (FAR):
government representative, lacking the The primary regulation used by all Federal
authority to enter into a contract on behalf of Executive agencies in their acquisition of
the government, enters into an agreement supplies and services with appropriated
with a vendor for goods and/or services. funds.
This person may be liable for paying for
• Defense FAR Supplement (DFARS):
those goods and/or services.
Regulations providing supplemental
• Ratification: The process in which an guidance to the Federal Acquisition
unauthorized commitment is reviewed by Regulation for DoD activities.
designated personnel. Appropriate
• Navy Acquisition Procedures Supplement
contractual documentation is prepared and
(NAPS): A document providing guidance to
forwarded to the ratifying official to allow
the FAR and DFARS for Navy contracting
the vendor to be paid for goods and/or
personnel in acquiring goods and/or
services rendered.
services.
• Procurement Administrative Lead Time
• Competitive Threshold: Requisitions
(PALT): The time it takes for the
exceeding the current competitive threshold
Purchasing Agent to place an order against a
of $3000 must receive quotes from a
requisition. The PALT begins the day a
minimum of three vendors, unless a valid
valid requisition arrives in the procurement
sole source justification is provided.
office and continues to the time the order is
placed by the purchasing agent. • Separation of Functions: Controls
established to ensure the same person does
• Priority Designator: A two digit number
not initiate, award, and receive materiel. If
used by the customer to determine the
local circumstances make it impracticable
urgency of the requisitioned item.
for these functions to be performed by three
• Required Delivery Date (RDD): The date separate individuals, at a minimum, the
the materiel is required by the customer. same individual shall not be responsible for
the award and receipt of the materiel.
• Authorized Requisitioner: A person
designated in writing with signature • Requisition: An order from an activity that
authority to sign requisitions for supplies is requesting material or services from
and services, usually the Division Officer or another activity.
Department Head.
• Bulk Stock: Material in full, unbroken
• Micro-Purchase: An acquisition of containers available for future use.
authorized supplies or services that do not
• Consumable: Supplies that are consumed or
exceed the current competitive threshold of
disposed of after use.
$3000 (Micro-purchases are not required to
be placed with a small business vendor.) • Federal Supply Schedule (FSS): The
collection of multiple award contracts used
• Non-Procurement Official: A non-
by Federal agencies, U.S. territories, Indian
purchasing official who may place orders
tribes and other specified entities to
utilizing the Government-wide Commercial
purchase supplies and services from outside
Purchase Card for orders less than $3000
vendors.
and no more than a cumulative total of
$20,000 per year. • Controlled Equipage: Items of
equipage/equipment that require special
• SERVMART: A source for the purchase of
management control because the material is
non-medical administrative materiel,
essential for the mission or the protection of
including cleaning gear.
life, is relatively valuable, or easily
converted to personal use.
5-4
• Material: All supplies, repair parts, and FEDERAL SUPPLY CATALOG
equipage/equipment. SYSTEM
• Non-Consumable: Supplies and materials
that are not consumed or disposed of after LEARNING OBJECTIVES:
their use. Buildings and equipment are non-
consumable items. Explain the terms associated with the Federal
Supply System (FSS).
• Repair Part: Any item that has an
application and appears in an allowance Explain how to use the Federal Supply Catalog
parts list (APL), stock number sequence list (FSC).
(SNSL), integrated stock list (ISL), Naval
Ship Systems Command drawings, or a
manufacturer’s handbook. The Department of Defense Supply System
contains more than 4 million items; of this total
• Reserve Stock: Items on hand and available the Navy stocks more than 1 million items. To
for issue for a specific purpose, not for order supplies effectively from this system, a
general use (for example, decontamination basic understanding of the DOD supply system
supplies). terminology and structure is required. This
• Standard Stock: Material under the control includes the naming, description, classification,
of an inventory manager and identified by a and numbering of all items carried under
National Item Identification Number (NIIN). centralized control of the United States
Government. Only one identification number is
used for each item, from purchase to final disposal.
OPERATING BUDGETS
FEDERAL SUPPLY CLASSIFICATION
The operating budget is the annual budget SYSTEM
of an activity and is assigned by the Chief of
Naval Operations (CNO), Fiscal Management The Federal Supply Classification (FSC)
Division, to major claimants. Examples of a System is designed to permit the classification of
major claimant include BUMED and all items of supply used by the federal
Headquarters Marine Corps. Funds are government. Each item of supply will be
distributed as operating targets or OPTARs included in one FSC. The FSC is made up of 2
which are generally apportioned in four equal two-digit numeric codes: the federal supply
quarterly divisions that represent the maximum group and the federal supply class. The federal
amount that can be spent for each quarter of the supply group identifies, by title, the commodity
FY. This system prevents over expenditure of area covered by the classes within each group.
funds early in the fiscal year and helps prevent
financial problems at the end. Unused quarterly The following is an example of the 6500
funds may be carried over to the next quarter series Federal Supply Group and its classes used
simply by adding them to the new quarterly for the majority of the Medical, Dental, and
apportionment. At the end of the fourth quarter, Veterinary Equipment and Supplies:
all accounts are balanced and closed; new
expenditures are not authorized until • 6505 Drugs and Biologicals – (Note-Only
appropriated funds are made available for the items specifically formulated for human use
new fiscal year. are appropriate to this class.)
• 6508 Medicated Cosmetics and Toiletries
• 6509 Drugs and Biologicals, Veterinary Use
• 6510 Surgical Dressing Materials
5-5
• 6515 Medical and Surgical Instruments, SUPPLY MANAGEMENT
Equipment, and Supplies
Criteria for Maintaining Stock on Hand in
• 6520 Dental Instruments, Equipment, and the Warehouse or Storeroom
Supplies
• 6525 Imaging Equipment and Supplies: The cost of keeping stock on hand includes
Medical, Dental, Veterinary not just the initial cost of the item, but the
associated expense of storing, counting, and
• 6530 Hospital Furniture, Equipment, rotating the inventory. Each item added to the
Utensils, and Supplies inventory must meet certain criteria. In certain,
• 6532 Hospital and Surgical Clothing and exceptional cases, a command may decide that
Related Special Purpose Items an item must be available even if the need is
infrequent.
• 6540 Ophthalmic Instruments, Equipment,
and Supplies Normally, items are added to stock based
• 6545 Replenishable Field Medical Sets, upon the demand for the materiel. Each request
Kits, and Outfits for an item by a customer is counted as a
demand. The number of demands over a
• 6550 In Vitro Diagnostic Substances, specified period is the demand frequency, i.e., 4
Reagents, Test Kits and Sets per quarter. Demands are categorized as
recurring or non-recurring. A request for an item
NATIONAL STOCK NUMBERS that is continuously used is normally a recurring
demand. A non-recurring demand is generally
Every item in the FSC is identified by a 13- for an item that is needed infrequently or for an
digit stock number referred to as National Stock exceptionally large one-time request for an item
Number (NSN). The NSN for an item of supply normally used in smaller quantities. Three
consists of a four-digit federal supply recurring demands within one quarter are
classification (FSC group and class) and a nine- generally the minimum criteria for stocking an
digit national item identification number (NIIN). item in the warehouse.
The NIIN consists of a two-digit national
codification bureau (NCB) code and an The number of demands alone, however, is
additional seven digits that identify each NSN not the only criteria to consider. The cost of the
item in the Federal Supply Distribution System. item and its availability (how long it takes to
The National Item Identification Number is a bring it into the command) are also considered.
nine-digit number that identifies each item of An expensive item that can be purchased and
supply used by the Department of Defense. received in a short period of time is not a good
Although the NIIN is part of the NSN, it is used candidate for stock since buying enough to keep
independently to identify an item within a on hand to meet the customer's requirements
classification. Unlike the FSC, the NIIN is would be very expensive. Additional item to
assigned serially, without regard for the name, consider is the shelf-life or expiration date.
description, or classification of the item.
Stockage Levels
An example NSN is:
Once the decision has been made to stock
6515 -00- 123-4567 the item, a determination must be made as to
| | | how much of the item to keep and when to
FSC NCB NIIN reorder. Automated software programs will
calculate the stockage levels based upon the
projected monthly usage. A change to any of the
factors listed below will result in a change in the
overall projected inventory.
5-6
Levels of Supply • Safety Level: This measurement indicates
the quantity of an item, over and above the
There will be control over the level or operating level, that should be maintained to
quantity of supplies kept by departments. ensure that operations will continue if
Without controls, policy changes or poor replenishment supplies are not received on
ordering procedures may result in some items time, or if there is an unpredictably heavy
being in short supply, while other items are demand for supplies, generally 14 days of
stockpiled in quantities that would not be supply.
consumed for several years.
• Stockage Objective: This measurement
Supply Level Terminology indicates the minimum quantity of a stock
item that is required to support current
Supply levels are expressed in one of two operations. It is the sum of the operating
ways: numerical terms and months of usage. level and the safety level.
Numerical is expressed as the total amount of • Requisitioning Objective: This
supplies on hand. “Months of Usage” is the most measurement indicates the maximum
common and best method to use in accounting quantity of a stock item that should be kept
for the amount of items used. on hand and on order to support operations.
It is the sum of the operating and safety
In expressing the supply level of any stock levels (a.k.a. stockage objective) and the
item, four measurements are used: operating quantity of an item that will be consumed in
level, safety level, storage objective, and the interval between the submission of a
requisitioning objective. requisition and the arrival of the supplies.
• Operating Level: This measurement Figure 5-1 illustrates the relationship
indicates the quantity of materiel required to between the various levels of supply.
sustain operations during the interval
between arrival of successive replenishment
shipments, normally seven days of supply.
The operating level should be based upon
the length of the replenishment cycle.
5-7
Usage Data
BUMED-CONTROLLED INVENTORY
ITEMS
5-8
PROFESSIONAL BOOKS AND description of the item(s). It can also be used to
PUBLICATIONS document purchase card transactions, as well as
provide documentation to ship materiel between
The listing of all books and publications that activities. As a requisitioning document, use this
are required to be maintained at an activity can form to procure GSA contract items such as
be found in NAVMEDCOMINST 5600.1 medical books, journals, and standard and
series, Procedures for Review of Naval Medical nonstandard BUMED-controlled items requiring
Command Publications, and NAVMEDCOM- local purchase action (Fig. 5-6).
INST 6820.1 series, Professional Reference
Materials and Publications. GSA periodically
makes open-ended contracts that cover the
procurement of books. All professional books
and publications are procured using a credit card
purchase under the provisions of these contracts.
5-9
Figure 5-5.—DD 1348-6
5-10
DD Form 1155 (Order for Supplies and 3. All requisitions must obtain "Availability of
Services)—This form is an official purchase Funds" certification. This will be automated
order document and is required whenever an with both DMLSS and SAMS. For hard
open market order is placed with a vendor. It is copy requests and specialized high cost
usually completed by the purchasing staff and requests, this certification must be
includes all ordering information (Fig. 5-7). specifically obtained.
4. Certain requisitions require approval by
designated approving officers prior to
submission to the Medical Logistics
Department. (i.e. Management Information
Department (MID) approval for computer
items).
5. All purchase requests must be technically
reviewed and screened. Supplies and
services must be described in a generic
manner to encourage maximum competition
and eliminate features restrictive to one
supplier.
6. Once the requisition has been technically
reviewed and items are determined not to be
available from mandatory or other than open
market sources, the requisition document is
ready for procurement action.
SOURCES OF SUPPLY
5-11
4. National Industries for the Blind and INVENTORY MANAGEMENT
Severely Handicapped (NIBINISH) -
Commands are required to purchase
LEARNING OBJECTIVES:
commonly used supplies from certain non-
profit organizations employing blind or
Explain specific characteristics of each type of
severely handicapped persons. Technical
supply inventory.
review and procurement personnel should be
aware of the supplies and services available
Explain how inventories are to be conducted.
from these institutions and utilize them to
the fullest extent.
Explain procedures for inventory
5. General Services Administration (GSA) reconciliation.
Federal Supply Schedule (FSS) Contracts -
There are contracts established by GSA and OVERVIEW
Veterans Affairs (VA) with commercial
firms to provide supplies and services at Inventory, or stock on hand, is both a
stated prices for given periods of time. valuable management asset and a considerable
When placing orders under a FSS, financial investment. The official inventory is
purchasing agents do not seek further managed by the Medical Logistics Department.
competition nor make a separate
determination of fair and reasonable pricing. This section uses various terms to refer to
Commonly used medical and non-medical inventory control procedures. NAVSUP P-485
items can be obtained from Federal Supply provides definitions for all the terms used in
Schedules. inventory control.
6. Defense Personnel Support Center (DPSC)
Shared Procurement Program for Equipment Inventories
Items - These are long term requirements
contracts established by DPSC for state-of- An accurate physical inventory is a
the-art equipment items at a significantly prerequisite to efficient inventory control. The
reduced price. Some items are mandatory primary objective of a physical inventory is to
and require a waiver from ensure the on-hand inventory balance reflects
NAVMEDLOGCOM to locally purchase the automated stock records. Inventories are
items other than the mandatory Shared initiated by the Inventory Management or Stock
Procurement item. Control section.
7. DoD Prime Vendor Requirements Contract - Inventory Management Goals
DPSC and the VA have established
contracts with both pharmaceutical and The goal is to have the right item, at
medical/surgical commercial vendors to be sufficient quantity, at the best price, and when
the prime supplier for medical treatment the customer wants it. The most successful
facilities in a geographical area. If the Prime initiative to streamline medical/dental logistics is
Vendor does not carry an item required by the Prime Vendor program. This response time
the treatment facility, Medical Logistics may allows users to order only the quantities needed
request a Distribution and Pricing and reduce the amount of money, human
Agreement (DAPA) be initiated with the resources, and storage space devoted to
vendor for that item. The Prime Vendor maintaining larger quantities of materiel.
shortens the logistics pipeline by utilizing
electronic ordering methods which enables
delivery of ordered materiel within 24 hours.
5-12
INVENTORY PROCEDURES Controlled Substances
TYPES OF INVENTORIES
Spot Inventory
There are several types of inventories, each
Unscheduled type of physical inventory
with a specific purpose. These types of
verifying existence of a specific item. It is
inventory are controlled substances, bulkhead-
conducted when a requisition is returned
to-bulkhead, specific commodity, special
showing the item is not in stock but the stock
material, spot, velocity, random sampling,
records indicate the item is on hand. A spot
departmental, and war.
inventory is conducted when directed by higher
authority or when a specific item has been found
to be defective.
5-13
Location Surveys SAFETY
During spot check inventories the location All materiel must be stored in a clean and
accuracy should also be verified. Location orderly manner, maximizing space and
surveys can be done as a separate action if productivity, and ensuring an accurate inventory.
desired. The goal is to have 98% of the actual The storage area must be kept clean. Aisles
stock locations match the recorded location in should be wide enough (generally 1.5 times the
the inventory management system. width of the largest cart or vehicle used) to
permit easy passage by materiel handling
Velocity Inventory equipment and must remain clear.
Required on items with a relatively high Use chocks behind vehicle tires when
turnover rate. It is based on the premise that the loading or unloading to prevent movement of the
faster an item moves the greater the room for vehicle; especially important when the loading
error. ramp is on a slope or a forklift is used to unload
the vehicle.
Random Sampling Inventory
Stack boxes evenly with labels facing the
Part of the annual scheduled inventory front. All containers marked with "UP" should
program. It is done to measure the stock record be stored accordingly. Items should be stored off
accuracy for a segment of material on hand. the floor; pallets may be used for this purpose.
Sprinkler heads must be unobstructed. Boxes
Department Inventory must be stored 18 inches below the sprinkler
heads.
Inventories held in departments or clinics
are not carried on the Medical Logistics Storeroom personnel working in the
inventory records, but represent a considerable warehouse should wear safety shoes for personal
investment and are a valuable asset to the protection.
command. The goal is to keep enough stock on
hand to meet routine and peak demands while Issuing
holding the financial investment to the
minimum. The act of pulling stock from the shelves to
fill a customer's requisition. The supplies and
War Reserves their documents are placed on a cart or in a
distribution area before they are delivered to or
Known as War Reserve Materiel picked up by the customer.
Requirements or Mobilization Requirements, it
is those activities that have an expanded mission MATERIAL RECEIPT, CUSTODY, AND
during wartime will also have materiel STOWAGE
requirements identified to support the expanded
mission. War reserve materiel is counted as part Once the supplies are received, they must be
of the inventory so that stock can be rotated, but identified, checked, and distributed to the
it cannot be issued for routine operations. appropriate storeroom or department, and
Release of war reserve materiel assets in support documentation as to their receipt, custody and
of operational requirements is governed by stowage must be completed.
OPNAVINST 4080.1 series.
5-14
Material Receipt Types of Documents Used in the Receiving
Process
In the receipt of government-owned
materials, responsibility for receipts takes on an Some forms used for ordering supplies will
added importance because of the many types of be used in the receiving process. Order for
material receipts and the required accountability. Supplies or Services/Request for Quotations
(DD Form 1155) Request for Contractual
Receipt Documentation Procurement (NAVCOMPT Form 2276), and
Materiel Inspection and Receiving Report (DD
There are several types of receipt papers. Form 250) are used for inspection and
The most commonly encountered receipt is the acceptance of locally procured items. Upon
DoD Single Line Item Release/Receipt receipt of a shipment, the appropriate purchase
Document, DD Form 1348 (Fig. 5-4). Regardless of order/contract will be pulled and verified with
the type of receipt document, the end-use the receiving document.
receiver must:
Prompt receipt processing is essential in
• Date the document upon receipt
certification of the invoice. Once the invoice is
• Circle the quantity accepted verified against the shipment received, the
paperwork should be processed promptly to
• Sign the document to indicate receipt ensure payment is made and no interest is
charged. Refer to your local policy for
Receiving Procedures distribution of invoice copies (Fig. 5-8).
5-15
Receiving Process UNIT OF ISSUE.—Describes how an item
is packaged for sale by the distributor. Some
items are issued in boxes, bottles, packages, or
1. Is it yours?
tubes. Often a product will be sold by the box or
a. Verify that the shipment is for the package with smaller boxes, tubes, or bottles
command. Each command has a unique, inside. The unit of measure is the smallest
six- character Unit Identifier Code (UIC) internal package (one Band-Aid out of a box of
assigned for the purpose of identification. 100); if your activity issues materiel by the unit
This UIC is the first part of the document of measure, it will account for the materiel by
number. both the unit of issue (the way it is packaged for
b. Verify the serial number assigned to track sale by the distributor) and the unit of measure
it. (the smallest distribution quantity). Sometimes
the outside of the container will be marked with
c. If the shipment does not belong to the a two (2) character code to identify the unit of
command and the delivery truck is still issue of the materiel inside.
there, bring it to the driver's attention.
d. If the shipment was received by mail or Example: 12 BT.
the delivery vehicle has left, consult the
local SOP for guidance on misdirected
shipments. d. Check the quantity. Make sure the
quantity received is the same as the
e. If the materiel is for your command,
quantity printed on the shipping
begin the check-in process.
document. When the quantity received
2. Damage matches the quantity printed on the
shipping document, annotate verification
a. One of the first checks is a visual
on the document. This can be done by
inspection for damage: dented, crushed,
circling or placing a check next to the
or liquid stained. Follow local policies to
quantity field, or writing in the quantity
report damaged containers. If the
received. If the quantities do not match,
containers are in good condition, proceed
be sure to clearly mark the discrepancy.
with the check-in.
One way to do this is, using a red pen:
3. Compare Shipping Document to the
Actual Item Received • Line through the incorrect quantity printed
a. The shipper prepares a document to in the quantity field of the shipping
identify what is included in the shipment. document
Shipping documents are found in a • Write the actual quantity received next to
plastic envelope on the outside of the the quantity field
exterior pack or container. Sometimes the
document is placed inside the container. • Circle the actual quantity received
There may be one packing slip for
several items or a separate document for
each requisition in the shipment.
b. Check the stock or catalog number. Make
sure the stock or catalog number printed
on the box is the same as the stock or
catalog number on the shipping document.
c. Check the unit of issue. The unit of issue
on the item or container should match the
unit of issue on the shipping document.
5-16
4. Stock or Direct Turn Over (DTO) 7. Signing the Document
a. Stocked items are stored in the a. After verification actions are completed,
warehouse until a customer orders them. the receiving document should be signed
These items are routinely used (another and dated to signify completion of the
term is "demand supported"); they are check- in process.
kept on hand to meet the needs of
b. Make sure the signature is legible!
customers.
8. Marking the Boxes
b. Direct Turn Over items are items ordered
by a customer that are to be issued a. DTO materiel should be marked with the
directly to that customer. customer's name or identification number
and then placed in a distribution area.
5. Expiration Dated Material
b. The materiel will be delivered to the
a. Materiel that deteriorates over time is has
customer who will sign the receiving
expiration date or shelf life. The
report or the receiving section notifies the
manufacturer prints the expiration date
customer that materiel is ready for pick-
on the exterior pack and on the unit pack.
up and signature.
The abbreviation EXP is often used for
expiration date. c. The document signed by the customer
will become the official file copy.
b. Routine shipments received by the
activity should have at least six (6) 9. Forwarding Documents
months of shelf life left at the time they a. Shipments can be received as one item or
are received. In some cases, when a high a truckload. It is important to maintain
priority requisition is submitted, materiel control of all the receipt documents.
with a life expectancy of less than six
months may be shipped with the b. As the check-in for each document is
expectation that it will be used completed, set the document aside where
immediately. it will not be confused with other
paperwork.
c. Check the date and mark any materiel
that has less than six months life c. For some commercial shipments, interest
remaining. is charged if the receipt is not processed
and the bill paid in a timely manner.
6. Equipment
d. Once the entire check-in process is
a. Check in equipment using steps 1-2 and complete, the receipts are forwarded to
following policies. the stock control section and entered into
b. Accountable equipment must have a the automated inventory management
property tag before being issued to the system.
customer.
c. All medical and dental equipment is
inspected by the biomedical equipment
department/division.
d. Equipment check-in procedures are
discussed in the biomedical equipment &
technology management section.
5-17
Report of Discrepancy (ROD) • Damage caused prior to shipment (damage
to interior contents)
The Report of Discrepancy (ROD), SF 364
(Fig. 5-9), is the method by which activities • Incorrect item pulled and shipped (be sure
report shipping type (issue) discrepancies and the item received is actually a discrepancy
packaging discrepancies on the part of the and not a substitute item)
shipper. It is filed with the DoD Supply System • Item is not identifiable -missing paperwork,
when a shipping type (item or packaging) etc.
discrepancy is found. The report serves two
purposes: the customer is provided an exchange NOTE:
of items or financial reimbursement and the Some packaging discrepancies are: improper
shipper is made aware that a physical packing, marking, unit of issue, or preservation
distribution problem exists. Discrepancies are method (i.e. refrigerated or frozen).
most often discovered during the receiving
process; review the information in NAVMED
MATERIAL STORAGE
P-5132 and follow local procedures.
Location
Storerooms/Supply Lockers
GENERAL.—When in charge of a
storeroom the HM is also responsible for
maintaining cleanliness and organization of the
space and custody of the key(s). Proper
temperatures should be monitored to avoid
deterioration of products. Rotation of the stock
and using products before the expiration date are
critical to patient care.
SHIPBOARD.—Rust is an ever-present
Figure 5-9.—SF 364 enemy and constant vigilance is required to keep
it under control. Rust spots should be chipped,
wire brushed or sanded, primed, and spot
Shipping-type (issue) discrepancies are: painted. Tighten loose bolts promptly to prevent
possible damage to the storeroom or its contents.
• Excess or shortage in quantity; if the
Examine pipes, valves, electrical systems,
quantity is short, look for a suffix code after
watertight fittings, and fire-fighting equipment
the document number that identifies this as a
daily, and report any defect to the supply officer.
partial shipment rather than a shortage
5-18
Before getting underway into open seas, • Shelving by Stock Number Sequence:
thoroughly inspect and secure storerooms to Used in small storage areas such as the vault
prevent stores from shifting due to the ships and cage.
motion. Lash bulk stores to bulkheads,
stanchions, or battens, and secure the fronts of • Creating a New Location: Sometimes there
open bins and shelves to prevent stores from is no room on the shelf for the new materiel.
falling out on the deck. Even when a location is empty, it is still
reserved while waiting for another shipment
Areas of the Warehouse of the materiel shown on the label or
placard. Do not remove the placard or cross
Depending upon the size of the warehouse, out the existing label on an empty location.
separate, distinct areas may be established: Create additional storage spaces/locations
per local policy and document the new
• Administration: The space within the location.
warehouse used for clerical or management
functions.
Stock Rotation
• Receiving: Where incoming shipments are
checked-in and data about the shipment is To prevent deterioration of items, the oldest
recorded. Materiel should remain in the products should always be issued first. This is
receiving area until the check-in process is the FIFO (first in, first out) method. This is
complete. After the physical check-in is especially important when managing items
complete, the receipt information is entered marked with a shelf life code or expiration date.
into the automated medical inventory Non-expiration dated materiel is rotated by
system. manufactured (MFR) date. This date can be
found on the outside of the exterior pack or on
• Storing: The act of putting materiel into a
the item.
specific area of the warehouse. The majority
of the warehouse floor space is devoted to
In the bulk area, items are rotated from top
storage. Following are specific areas of
to bottom; in other areas, materiel is pulled from
storage.
front to back. For example: a box with an
• Bulk: Contains large boxes stored on box expiration date of 06/2011 will be placed on top,
pallets or racks such as solutions, toilet or in front of, a box with an expiration date of
paper, and plastic urinals. 11/2012. A box with a manufacture date of
04/2012 will be placed on top, or in front of
• Bin/Small Item/Loose: Contains surgical another box with a manufacture date of 07/2014.
instruments, dental materiel, and other small
items. An active shelf life management program
• Cage: Provides storage, under lock and key, identifies stock that will expire prior to being
for items that have some potential for abuse used. A monthly surveillance check should be
or are likely to be pilfered such as needles performed to verify the rotation of stock
and syringes. Access to this area is limited. procedure is being implemented.
• Vault: Provides secure storage for Shelf-Life Material
controlled substances (i.e. morphine and
codeine). These items have a high abuse or Shelf-life material is subject to deterioration.
pilferage potential thus federal law requires These items are assigned a shelf-life code listed
them to be stored in an approved, secure in the Navy Management Data List (NAVSUP
enclosure. It may be a freestanding vault of Publication 4100).
750 pounds or more or it may be built into
the warehouse. Access to this area is
restricted.
5-19
SPECIAL STOWAGE OF ITEMS Treatment Facility is guided by BUMED
instructions to develop, implement, and maintain
a written hazard communication program. This
LEARNING OBJECTIVE:
includes labeling, Material Safety Data Sheets
(MSDS), and employee training.
Identify hazardous materials and how they are
labeled.
Labeling and MSDS
This section will cover the classifications of Products considered hazardous should come
material and discuss storage requirements for from the manufacturer with a label identifying
special types of material. The Naval Ships the chemicals and containing an appropriate
Technical Manual (NSTM) and the Hazardous hazard warning. MSDSs provide information on
Materials Information System (HMIS) outline the hazards of potentially harmful materiel and
the requirements for shipboard stowage of precautions for using such materiel safely.
dangerous materials and lists the materials under OSHA regulations require all employers,
each classification. including health facilities, to keep MSDSs on
file for each hazardous chemical used. By law,
HAZARDOUS MATERIALS chemical manufacturers, suppliers, and
distributors are required to supply MSDSs with
Hazardous material includes all types of their initial shipments of hazardous chemicals.
compressed gases and materials that present a An up-to-date file of these sheets must be
fire hazard or are otherwise dangerous. Paint and maintained and available to all employees.
oil constitute the bulk of material in this
category. Paint and flammable liquid storerooms Materiel Safety Data Sheets (MSDS)
are normally provided with alarm and CO2
smothering systems that can be activated by These are maintained in the working area of
automatic temperature-sensitive devices inside the warehouse. All personnel must be able to
storerooms and by manual controls outside locate the MSDS and understand each section as
storerooms. These storerooms are located, when they provide specific information.
practical, below the full-load water line, near
either end of the vessel, but not adjacent to a Hazardous Technical Information Services
magazine. They are equipped with watertight (HTIS): HTIS is located at Defense Supply
doors. Center, Richmond and maintains a data base of
Materiel Safety Data Sheets. The helpline
The Occupational Safety & Health telephone number is 1-800-848-4847 or DSN
Administration (OSHA) establishes regulations 695-5168 and is staffed from 0730-1700 EST.
regarding the rights of employees to know the
potential dangers associated with hazardous General Precautions for Handling Materials
chemicals in the workplace. The goal is to
reduce the risk of injury or illness caused by By knowing the general precautions and
hazardous’ chemicals in the workplace. following manufacturer’s instructions when
handling materials, the HM can easily prevent
Accomplishing this goal requires hazardous situations or accidents. Use only
information and communication; therefore, proper cleanup procedures. HMs must dispose of
OSHA issued The Hazard Communication all hazardous chemicals according to the MSDS
Standard. This standard helps protect the instructions, applicable local, state, and federal
Corpsman’s right to work in a safe and healthy regulations.
environment. It requires the HM to not only be
informed about hazardous chemicals in the
workplace, but also to be trained to work safely
with these materials. Each Medical and Dental
5-20
For protection, avoid skin contact with Toxic Vapors
chemicals and minimize chemical vapor in the
air whenever possible. Wear the appropriate Toxic vapors can be generated when mixing
protective eyewear, gloves, and a mask in order impression and denture materials and various
to protect from injury. medical materials. Using adhesive, solvents,
acids, chemical sterilizer agents; mixing
Never leave chemical bottles open. If left radiographic processing solutions; and mixing
open, vapors can escape into the air and some disinfectant agents can emit toxic vapors.
chemicals can be easily spilled when bottles are Besides the danger from the vapors, direct
left open. Do not use a flame near flammable contact with many materials, such as etchant
chemicals. Eating, smoking, or drinking is acids, radiographic solutions, endodontic
prohibited in areas where chemicals are used. materials, or bleaching agents can cause
Eating can cause chemicals to be ingested and chemical burns of the skin or eyes.
smoking can cause chemicals to ignite or
explode. Proper ventilation can eliminate Chemical Storage
hazards associated with most gases and
chemicals. Storage rooms must be properly Proper storage of chemicals is critical for
furnished and maintained. safety and guidance is located in MSDSs. The
type of container and cabinet, security, and
GAS AND CHEMICAL HAZARDS proximity to other chemicals, materials, heat, or
open flame are areas that need consideration and
A variety of gases and chemicals are used or control.
produced in medical and dental facilities. It is
important to be aware of the hazards and to take Flammable Liquids
the necessary precautions.
Many items used in medicine and dentistry
Gases are flammable. Solvents such as acetone and
alcohol are examples. When using flammable
Ensure proper labeling, storage, and use of liquids, always have adequate ventilation, never
compressed gases, such as oxygen, nitrogen, and use where sparks or flames are present, and have
propane, according to published standards. The a fire extinguisher available. Store flammable
use of nitrous oxide conscious sedation requires liquids and bulk quantities in tightly covered
special training and the use of Personal containers in an approved flammable storage
Protective Equipment (PPE) by personnel during locker.
the administration of the gas.
Flammable Storage
Stow compressed gases on the weather deck,
or properly mounted in a shock resistant bracket, An enclosed area containing items that must
and securely fastened in a vertical position. be kept away from sparks or open flames. If the
Protect the cylinder valves from accumulations command is using a flammable locker, it must
of dust, ice and snow, and screen the cylinders remain locked. Keep a fire extinguisher nearby.
from direct rays of the sun. NAVSUP P-485 Acetone, methanol, paint, and isopropyl
contains more specific information concerning (rubbing) alcohol are examples of items stored
handling compressed gas cylinders. in this area.
5-21
Alcohol Gypsum Products
Stowed in a locked container in the paint Gypsum Products include dental plaster and
and flammable liquid storeroom, to which only stone which are considered hazards because of
the supply officer (or other officer designated in the dust particles circulated. It is important to
writing by the commanding officer) has the key minimize exposure to the dust during handling,
or combination. as it may cause respiratory problems.
Corrosive Storage can be a special, separate Radiographic Chemicals are used to process
room, or more commonly, a lockable storage radiographs. Radiographic solutions and
container used to store acids. Because of the chemicals should be stored in tightly covered
potential danger in handling acids, there should containers in a cool, dark place.
be a shower or eyewash station nearby. This
storage area must have a way to contain spills. SUSPENDED OR “J” STOCK
This is accomplished by a brim around the area
or containers under the bottles or boxes within Suspended or “J” stock is used to store
the locker. The area should be well ventilated to material unsuitable for issue. Suspended stock
remove any vapors. must be separated from other storage areas and
the area clearly marked to eliminate confusion
Acid with serviceable or “good” stock. Damaged,
expired or material temporarily suspended from
Unless classified as safe material, is stowed use by medical material recall notices is held in
in an acid locker. Acid lockers are leak-proof this area.
and lead-lined boxes, chests, or lockers
specifically designed for stowing bottles or Suspended material that is normally kept in
containers of acid. a special storage area for security or temperature
control reasons will stay in that special storage
Acid Etchants area while suspended. The stock must be clearly
marked as “SUSPENDED” to avoid accidental
Acid Etchants come as solutions and gels issue of the item. One way to do this is to tape
are used for acid etch techniques used in sealants off the shelf where suspended stock is held.
or composites. Always wear protective
applicable PPE to avoid skin contact. Always REPAIR PARTS
handle acid-soaked items with forceps or gloves.
If spills occur, use a commercial acid spill kit. Repair parts should be stored in their
original containers.
Organic Chemicals
MEDICAL WASTE
Organic Chemicals include alcohols,
ketones, esters, solvents, and monomers, such as Medical and dental departments generate
methyl acrylate. After each use, clean the and accumulate large amounts of medical waste.
outside surfaces of the containers to prevent Medical and dental departments will cooperate
residual material from contacting the next user. fully with other departments (supply, safety,
etc.) to establish and enforce appropriate
command policy involved in disposal of plastic
materials and medical waste. Treatment facilities
have designated areas to store medical waste.
5-22
BIOMEDICAL EQUIPMENT Heritage Assets
TECHNOLOGY & MANAGEMENT
Recognized to be of historical or natural
significance; cultural, educational, or artistic
LEARNING OBJECTIVE:
importance; or possess significant architectural
characteristics. Located in museums or
Explain the responsibilities and accountability
registered with the Naval Historical Center or
required for management of equipment.
the Marine Corps Museums Branch; expected to
be preserved indefinitely.
TERMINOLOGY AND DEFINITIONS
Stewardship Land
Defense Medical Logistics Standard Support
(DMLSS) Land not acquired for, or in connection with
General (PP&E).
Centrally-managed automated system for
use by logistics personnel to procure, maintain, General PP&E
and dispose of consumables and equipment.
Medical/Dental Equipment—devices used in Divided into two sub-categories: Real
medical/dental diagnosis, therapy, and treatment property (i.e., land, building, and structures), and
of injury or disease. Personal Property, defined below.
5-23
Categories of Personal Property include Medical & Dental Equipment with Patient
Capitalized, Minor, and Sub-minor. Data
Capitalized Personal Property must meet The Health Insurance Portability and
all of the following criteria: Accountability Act of 1996 (HIPAA) Privacy
Rule provides federal protections for protected
• Has an acquisition cost, book value, or when
health information held by covered entities and
applicable, an estimated fair market value
gives patients’ rights with respect to that
equal to or greater than $250,000.
information. HMs are mandated to secure any
• Has an estimated recovery period equal to or equipment within the department, that may be
greater than 24 months. contain patient data (Name, SSN, diagnosis,
pictures, etc.) and stored on some type of media
• Is not intended for sale in the ordinary (Hard drives, Floppy Disk, etc.).
course of operations.
• Has been acquired or constructed with the EQUIPMENT MANAGEMENT PROGRAM
intention of being used or available to be
used by DoN in its operations. Equipment Manager
Minor Personal Property has an The Command's Equipment Manager,
acquisition cost greater than $5,000 and less appointed by the Commanding Officer, has
than $250,000, or has an acquisition cost greater primary responsibility for comprehensive
than $250,000 but does not meet all the management of medical equipment within a
capitalization “criteria.” treatment facility. Comprehensive management
includes planning, procuring, receiving, property
Sub-Minor Personal Property is any asset accounting, installation, inventory, replacement,
that has an acquisition cost of $5,000 or less. and disposal of equipment. Planning will
precede all equipment acquisition.
Tracking of Equipment Data in an MTF/DTF
Equipment Manager's Responsibilities
All equipment is processed through the
Equipment Management Division. The Scheduling, supervising and coordinating
equipment is safety tested, assigned an procedures to ensure complete and accurate
equipment control number, and added to the physical inventories are some of the duties.
Defense Medical Logistics Standard Support Equipment managers process equipment custody
(DMLSS) System. The customer ordering the transfers between departments and maintain
equipment is notified of the equipment receipt documentation to support transfers between
after these steps are completed. departments and outside activities. Property
Accountability and acceptance of equipment records kept by the equipment manager should
should be documented on the purchase order by reflect the current location and who has custody
the signature of an authorized individual within of the item of equipment. The Equipment
the receiving department. Records should be Manager plays a key role in the Equipment
maintained to adequately identify the location Program Review Committee (EPRC).
and person responsible for each item of
equipment at any time. A custodian and sub-
custodian will be assigned to each equipment
item in the inventory.
5-24
Role of the Equipment Program Review Refer to the NAVMED P-5132 for
Committee (EPRC) additional references for obtaining special
approvals.
This committee provides oversight of scarce
equipment resources in the most cost effective After preparing a purchase request, the fiscal
manner possible. The program allows department will ensure funds are available. After
conservation of resources while enabling quality funds availability certification is obtained, the
health care delivery. The committee should meet purchase request is ready for procurement.
at least semi-annually to formulate and prioritize
minor equipment requirements and to establish Funding for Minor Equipment and
priorities for investment equipment. Investment Equipment
5-25
Safe Medical Devices Act (SMDA) of 1990 Defense Personnel Support Center (DPSC)
serves as the single Department of Defense
The SMDA of 1990 established a mandatory (DOD) focal point for processing of medical and
requirement for treatment facilities to report all dental materiel/equipment complaints. Below is
incidents that reasonably suggest there is a a summarization of equipment conditions that
probability that a medical/dental device has would require a report to be completed and
caused or contributed to the death, serious forwarded to DPSC.
injury, or serious illness of a patient. Internal
controls and reporting mechanisms must be Inventories and Inspections
established to ensure the Head, Biomedical
Engineering, the Equipment Manager, and BUMED activities are responsible for
Command Safety Manager are notified of any completing two different types of inventories. A
incident to ensure the equipment is removed Master Equipment Inventory conducted annually
from service and thoroughly checked. A SF-380, and a Triennial Inventory to be conducted every
Reporting and Processing Medical Materiel third year. The Equipment Manager is
Complaints/Quality Improvement Report, is responsible for setting up procedures to follow
prepared and submitted to the Defense Personnel when conducting physical inventories.
Support Center (DPSC) per the timelines
outlined in the Reporting Unsatisfactory NAVMED P-5132 contains instructions as
Equipment section. to the necessary data to be recorded for each
item during an inventory, along with submission
Reporting Unsatisfactory Equipment requirements. The collected data from the
physical inventory will be used to update the
When a piece of equipment is received or current inventory in DMLSS.
used and found to be unsatisfactory or presents a
hazard to the patient or operator, the below Biomedical Equipment Maintenance Division
reports are to be completed. Classifications of (BIOMED)
complaints are grouped in three classes and are
as follows: The BIOMED division serves as a resource
for questions and to provide preventive and
• Type I: Materiel determined to be harmful
corrective maintenance. It is staffed by specially
or defective to the extent that use may or has
trained Bio-Medical Equipment Technicians
caused serious illness or death.
(BMET). The HM must be familiar with the
• Type II: Materiel, other than equipment, equipment in the treatment facility in order to be
suspected of being harmful, deteriorated, or effective in daily clinical operations.
otherwise unsuitable for use. Basic Expectations:
• Type III: Equipment determined to be • Recognize the major components of each
unsatisfactory because of malfunction, piece of equipment
design deficiency, defect, faulty materiel,
• Perform routine user maintenance on
workmanship, or performance. Equipment
equipment (Level I Maintenance)
may be used unless the item presents a
possible direct hazard (i.e., electrical shock, The first rule for operating and performing
sharp edges, or other safety hazards). user maintenance on equipment is to carefully
read the manufacturer’s instructions. Copies of
Report Type I complaints immediately.
this literature should be in the LPO/LCPO’s
Type II and III complaints are to be reported as
office or BIOMED.
soon as possible but not later than 10 days from
the date of the incident.
5-26
Preventive maintenance for all • Level III: Consists of maintenance
medical/dental equipment is a part of the requiring complete overhaul of the
Equipment Management Program. A HM may equipment item and is considered depot-
be tasked with assisting the BMET with locating level maintenance or equipment
equipment that belongs to the department. manufacturer service center level
maintenance. At command discretion,
Maintenance Levels performance of Level III is permitted. Level
III maintenance will usually result in
Proper care and use by the equipment extension of service life and should be
operator, combined with regularly scheduled documented in the appropriate service
maintenance, ensure maximum reliability and history.
prolongs the useful life of equipment. BIOMED
is responsible for performing or coordinating, NOTE:
and recording preventive maintenance on all If a contractor is responsible for Level II or
medical and dental equipment. Preventive Level III maintenance, only approved personnel
maintenance will be performed on all may coordinate Level II and III maintenance
medical/dental equipment utilizing a risk-based with the contractor assigned.
management program. NAVMEDLOGCOM is
the technical manager for this program and Services coordinated by unapproved personnel
provides training and technical guidance. All may result in a voided warranty, voided contract,
newly acquired equipment will be safety and or an unauthorized commitment.
checked by a BMET before leaving the
equipment management division.
5-27
MAINTENANCE WORK ORDERS redistributed within the command to other
departments, must be requested using a
The Medical/Dental Maintenance Work memorandum of transfer to the Equipment
Order (NAVMED 6700/4) shown in Figure 5- Manager. Property records will be updated to
10, or DMLSS work orders are used to reflect a change in custodian.
determine workload and assign priorities.
BMETs receiving equipment not properly PROPERTY SURVEYS
functioning will complete the top section of the
NAVMED 6700/4. Depending upon the A property survey (or investigation) is the
BIOMED departmental workload and procedure used when Navy property or Defense
availability of loaner equipment, they may Logistics Agency material is lost, damaged, or
assign a functioning piece of equipment on a loan destroyed and must be completed in a timely
basis until the equipment repairs are completed. manner. The purpose of a survey is to determine
responsibility for the loss and to determine the
actual loss to the United States Government. The
forms discussed in the following paragraphs are
used in connection with survey procedures.
5-28
Figure 5-11.—DD 200
5-29
Authorized Medical/Dental Allowance List SUMMARY
(AMAL/ADAL)
This chapter identified Naval Supply
The AMAL/ADAL is the minimum amount publications; introduced the Federal Supply
of medical/dental material to be maintained by Catalog System; outlined procedures used to
an operational platform or on order at any given estimate supply needs, procure supplies and
time. Revisions are based on changes to the material; and outlined procedures to account for
Federal Supply System, professional supplies and operating funds. Supply
recommendations, and Type Commanders. The management affects the availability of supplies
amount of material as noted in an AMAL/ADAL when most needed (deployment or emergency)
is designated by NAVMEDLOGCOM for each thus application of the principles and procedures
specific operational platform and area covered. outlined will ensure operational readiness and
Submit recommendations for changes to the mission satisfaction.
AMALs/ADALs to NAVMEDLOGCOM where
it will be reviewed and approved through the
TYCOM.
5-30
CHAPTER 6
LEARNING OBJECTIVE:
6-1
To aid in understanding the location of Other commonly used anatomical terms
anatomical structures, a standard body position include the following:
called the anatomical position is used as the
• Anterior or Ventral: Toward the front, or
point of reference. This anatomical position is
along the belly side of the body
assumed when the body stands erect with the
arms hanging at the sides and the palms of the • Posterior or Dorsal: Toward the back, or
hands turned forward (Fig. 6-2). along the vertebral side of the body
• Medial: Near or toward the mid-sagittal
plane of the body
• Lateral: Away from the mid-sagittal plane
of the body
• Internal: Inside
• External: Outside
• Proximal: Nearest to the point of origin or
towards the trunk
• Distal: Away from the point of origin or
away from the trunk
• Superior: Toward the top of the body or
above
• Caudal: Toward the lower end of the body
• Inferior: Toward the bottom of the body or
below
• Supine: Lying position of the body, face up
• Prone: Lying position of the body, face
down
• Lateral recumbent: Lying position of the
body, on either side
• Peripheral: The outward part or surface of a
structure
6-2
CHARACTERISTICS OF LIVING ORGANELLE LEVEL
MATTER2
Organelle level: Organelles consist of
chemical structures organized within larger
LEARNING OBJECTIVE:
units (cells) to perform a specific function. It
is within a cell and allows the cell to live;
Identify the characteristics of living matter.
without it the cell is unable to live.
In man, some of the characteristic Tissue level: Tissues are a group of many
functions necessary for survival include similar cells that all develop together from the
digestion, metabolism, and homeostasis. same part of an embryo and all perform a
Digestion involves the physical and chemical certain function. Tissues are the “fabric” of
breakdown of food into its simplest forms. the body. Epithelial and muscular are
Metabolism is the process of absorption, examples.
storage, and use of these foods for body
growth, maintenance, and repair. Homeostasis ORGAN LEVEL
is the body's self-regulated control of its
internal environment. It allows the organism to Organ level: Organs are more complex
maintain a state of constancy or equilibrium, in than tissue. An organ is defined as a structure
spite of vast changes in the external made up of several different kinds of tissues
environment. arranged so that, together, they can perform a
special function. Each organ is unique in
The human body is broken down into shape, size, appearance and placement in the
various levels of organization, the chemical, body. The heart, lungs, spleen, and liver are
organelle, cellular, tissue, organ, organ examples of some of the organs found in the
system, and the organism levels. human body.
The chemical level is the beginning level System level: Systems are the most
of the organization of the body. There are complex of the organizational units of the
more than 100 different chemical building body. The system level of organization
blocks of nature called atoms (tiny spheres of involves varying numbers of kinds of organs
matter so small they are invisible). Every arranged so that, together, they can perform
living thing in the universe, including the complex functions for the body. There are 11
human body, is composed of atoms. major systems that make up the human body:
integumentary, skeletal, muscular, nervous,
endocrine, circulatory, lymphatic,
respiratory, digestive, urinary, and
reproductive.
6-3
ORGANISM LEVEL Cells are composed largely of a gel-like
substance, called cytoplasm, upon which
Organism level: Organisms, such as the depend all the vital functions of nutrition,
human body, are a collection of interactive secretion, growth, circulation, reproduction,
parts that are capable of surviving in hostile excitability, and movement. The cytoplasm is a
environments, with the ability to reproduce gelatinous substance surrounding the nucleus
and repair damaged parts. and is contained by the plasma membrane. The
cytoplasm is made of various organelles and
THE CELL molecules suspended in a watery fluid called
cytosol, or intracellular fluid (Fig. 6-3).
LEARNING OBJECTIVE:
The simplest living organism consists of a
single cell. The amoeba is a unicellular
Identify the characteristics of living matter.
animal. The single cell of a one-celled organism
must be able to carry on all processes necessary
The cell is the smallest and most numerous for life. This cell is called a simple or
structural unit that possesses and exhibits the undifferentiated cell, one that has not
basic characteristics of living matter. A typical acquired distinguishing characteristics.
cell is made up of the plasma membrane, the
nucleus, and the cytoplasm. Each cell is In multi-cellular organisms, cells vary in
surrounded by a membrane called the plasma size, shape, and number of nuclei. When
membrane which is a selectively permeable. It stained, the various cell structures can be more
controls the exchange of materials between the readily recognized under a microscope. Many
cell and its environment by physical and cells are highly specialized to perform special
chemical means. Gases (such as oxygen) and functions (e.g., muscle cells which contract
solids (such as proteins, carbohydrates, and and epithelial cells which protect the skin).
mineral salts) pass through the plasma
membrane through a process known as
diffusion; a process during which elements
achieve equilibrium by moving from an area
of higher concentration to an area of lower
concentration.
6-4
Figure 6-3.—Typical, or composite, cell. An Artist’s interpretation of cell structure. Note, too, the
innumerable dots bordering the endoplasmic reticulum. These are ribosomes, the cell’s "protein
factories."
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-5
TISSUES also forms the lining of the digestive,
respiratory, and urinary tracts; blood and lymph
vessels; serous cavities (cavities which have no
LEARNING OBJECTIVE:
communication with the outside of the body, and
whose lining membrane secretes a serous
Identify the types of tissues in the human body
fluid), such as the peritoneum or pericardium;
and their functions.
and tubules (small tubes which convey fluids)
of certain secretory glands, such as the liver and
Tissues are groups of specialized cells kidneys. Epithelial tissues are classified
similar in structure and function. They are according to their shape, arrangement, and the
classified into four main groups: epithelial, function of their cells. For example, epithelial
connective, muscular, and nervous. tissues that are composed of single layers of
cells are called "simple,” while cells with
EPITHELIAL TISSUE many layers are said to be "stratified" The
following paragraphs will discuss the three
The lining tissue of the body is called categories of epithelial tissue: columnar,
epithelium. It forms the outer covering of the squamous, and cuboidal (Fig. 6-4).
body known as the free surface of the skin. It
Figure 6-4.—Classification of epithelial tissues. The tissues are classified according to the shape and
arrangement of cells. The color scheme of these drawings is based on a common staining technique
used by histologists called hematoxylin and eosin (H&E) staining. H&E staining usually renders the
cytoplasm pink and the chromatin inside the nucleus a purplish color. The cellular membranes,
including the plasma membrane and nuclear envelope, do not generally pick up any stain and are
thus transparent.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-6
Columnar Epithelial Tissue Squamous Epithelial Tissue
Epithelial cells of this type are elongated, Squamous epithelial tissue is composed of
longer than they are wide. Columnar tissue is thin plate-like or scale-like cells forming a
composed of a single layer of cells whose mosaic pattern (Fig. 6-4). This tissue is found
nuclei are located at the same level as the in the tympanic membrane (eardrum) as a
nuclei in their neighboring cells (Figs. 6-4 and single layer of cells, or in the free skin surface in
6-5). These cells can be located in the linings of multiple layers. Squamous tissue is the main
the uterus, in various organs of the digestive protective tissue of the body.
system, and in the passages of the respiratory
system. Cuboidal Epithelial Tissue
In the digestive system, the chief function The cells of cuboidal tissue are cubical in
of columnar tissue is the secretion of digestive shape (Fig. 6-4) and are found in the more
fluids and the absorption of nutrients from highly specialized organs of the body, such as
digested foods. In certain areas (such as the the ovary and the kidney. In the kidneys,
nostrils, bronchial tubes, and trachea), this cuboidal tissue functions in the secretion and
tissue has a crown of microscopic hair like absorption of fluids.
processes known as cilia. These cilia provide
motion to move secretions and other matter
along the surfaces from which they extend. CONNECTIVE TISSUE
They also act as a barrier by preventing foreign
matter from entering these cavities. This is the supporting tissue of the various
structures of the body. It has many variations and
is the most widespread tissue of the body.
Connective tissue is highly vascular, surrounds
other cells, encases internal organs, sheathes
muscles, wraps bones, encloses joints, and
provides the supporting framework of the body.
Structures of connective tissue differ widely,
ranging from delicate tissue-paper membranes
to rigid bones.
6-7
Areolar Connective Tissue MUSCULAR TISSUE
Areolar tissue consists of a meshwork of Muscular tissue provides for all body
thin fibers that interlace in all directions, giving movement. Contracting muscles cause body
the tissue both elasticity and tensile strength. parts to move. The three types of muscle tissue
This type of connective tissue is extensively are skeletal, smooth, and cardiac.
distributed throughout the body, and its chief
function is to bind parts of the body together. Skeletal Muscle Tissue
Areolar tissue allows a considerable amount of
movement to take place because of its Skeletal (voluntary) muscle fiber is striated,
elasticity. It is found between muscles and as or striped, and is under the control of the
an outside covering for blood vessels and individual's will (Fig. 6-6). For this reason, it is
nerves. The areolar tissue layer connects the often called "voluntary" muscle tissue. Skeletal
blood vessels and nerves to the surrounding muscle tissues are usually attached to bones.
structures. When muscle fibers are stimulated by an action
of a nerve fiber, the fibers contract and relax.
Adipose Connective Tissue This interaction between muscle and nervous
fibers produces movement.
Adipose tissue is "fatty tissue." The adipose
cell at first appears star-shaped. When the cell
begins to store fat in its cytoplasm, it enlarges
losing its star shape as the nucleus is pushed to
one side (Fig. 6-5). When this process occurs to
many cells, the other cell types are crowded out
and adipose tissue is formed. Adipose tissue is
found beneath skin, between muscles, and
around joints and various organs of the body.
Adipose tissue acts as a reservoir for energy-
producing foods; helps to reduce body heat loss
(because of its poor heat conductivity); and
serves as support for various organs and fragile
structures, such as the kidneys, blood vessels,
and nerves. Figure 6-6.—Skeletal muscle. Note the striations
of the muscle cell fibers in longitudinal section.
Osseous Connective Tissue (Dennis Strete.)
This type of tissue, known as "bone tissue" Image reprinted with permission from: Thibedeau, G.
is dense fibrous connective tissue that forms A., & Patton, K. T. (2006). Anatomy & Physiology
tendons, ligaments, cartilage, and bones. These (6th ed.). St. Louis: Elsevier Health Sciences.
tissues form the supporting framework of the
body.
6-8
Smooth Muscle Tissue hollow organs, such as the stomach, intestines,
blood vessels, and urinary bladder. Smooth
These muscle fibers are smooth, or non- muscle tissues are responsible for the
striated, and are not under the control of the movement of food through the digestive
individual's will (Fig 6-7). For this reason, this system, constricting blood vessels, and
type of muscle tissue is called "involuntary.” emptying the bladder.
Smooth muscle tissue is found in the walls of
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006). Anatomy & Physiology
(6th ed.). St. Louis: Elsevier Health Sciences.
6-9
Cardiac Muscle Tissue NERVE TISSUE
The cardiac muscle cells are striated and are Nerve tissue is the most complex tissue in
joined end to end, resulting in a complex the body. It is the substance of the brain, spinal
network of interlocking cells (Fig.6-8). cord, and nerves. Nerve tissue requires more
Cardiac muscles are involuntary muscles and oxygen and nutrients than any other body
are located only in the heart. These tissues are tissue. The basic cell of the nerve tissue is the
responsible for pumping blood through the neuron (Fig. 6-9). This highly specialized cell
heart chambers and into certain blood vessels. receives stimuli from and conducts impulses
to all parts of the body.
6-10
THE INTEGUMENTARY SYSTEM Dermis
6-11
NAILS.—The nails are composed of horny SWEAT GLANDS.—Sweat glands are
epidermal scales and are found on the dorsal found in almost every part of the skin (Fig. 6-
surfaces of the fingers and toes. They protect the 10). They are a control mechanism to reduce
many sensitive nerve endings at the ends of the body's heat by evaporating water from its
these digits. New formation of a nail will surface. The perspiration secreted is a
occur in the epithelium of the nail bed. As it is combination of water, salts, amino acids, and
formed, the whole nail moves forward urea. Normally, about one liter of this fluid is
becoming longer. excreted daily. However, the amount varies
with atmospheric temperature and humidity and
HAIR.—Hair is an epithelial structure the amount of exercise. When the outside
found on almost every part of the surface of the temperature is high, or upon exercise, the
body (Fig. 6-10). Its color depends on the type glands secrete large amounts of perspiration to
of melanin present. The hair has two cool the body through evaporation. When
components: the root below the surface and the evaporation does not remove all the sweat that
shaft projecting above the skin. The root is has been excreted, the sweat collects in beads
embedded in a pit-like depression called the on the surface of t h e s k i n .
hair follicle. Hair grows as a result of the
division of the cells of the root. A small CERUMINOUS GLANDS.—Ceruminous
muscle, known as the arrector (Fig. 6-10), glands are modified sweat glands found only
fastens to the side of the follicle and is in the auditory canal. They secrete a yellow
responsible for the gooseflesh appearance waxy substance called cerumen that protects
(goose bumps) of the skin as a reaction to cold the eardrum.
or fear. Each hair follicle is associated with
two or more sebaceous glands.
6-12
Figure 6-10.—Diagram of skin structure. A, Thick skin, found on surfaces of the palms and soles of the feet.
B, Thin skin, found on most surface areas of the body. In each diagram, the epidermis is raised at one corner
to reveal the papillae of the dermis
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006). Anatomy & Physiology (6th ed.).
St. Louis: Elsevier Health Sciences.
6-13
THE SKELETAL SYSTEM At the ends of the long bones is a smooth,
glossy tissue that forms the joint surfaces. This
tissue is called articular cartilage because it
LEARNING OBJECTIVE:
articulates (or joins) with, fits into, or moves
in contact with similar surfaces of other bones.
Identify the parts of bone and their functions.
The thin outer membrane surrounding the
bone is called the periosteum. An important
The skeleton, the bony framework of the body, function of the periosteum is to supply
is composed of 206 bones (Figures 6-11A-C). It nourishment to the bone. Capillaries and blood
supports and gives shape to the body; protects vessels run through the periosteum and dip
vital organs; and provides sites of attachment into the bone surface, supplying it with blood
for tendons, muscles, and ligaments. The and nutrients. The periosteum is the pain center
skeletal bones are joined members that make of the bone.
muscle movement possible. It is important to
understand the relationship of the bones and
muscles as they work together to provide
support and movement for the human body.
ANATOMY OF BONES
6-14
Figure 6-11.—Skeleton. B, Posterior view. C, Lateral view
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-15
and fixed in one position. The bones of the
face are a complex framework that helps to
form facial features, the upper jaw (maxilla)
and lower jaw (mandible). With the exception
of the mandible and the bones of the inner ear,
all skull bones are joined together firmly along
seams. The seams where they join are known
as sutures. The bones of the skull are classified
as either cranial or facial bones.
6-16
Figure 6-13.—Anterior view of the skull. (Courtesy Vidic B, Suarez FR: Photographic atlas of the human
body, St Louis, 1984, Mosby.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006). Anatomy & Physiology (6th ed.).
St. Louis: Elsevier Health Sciences.
Ethmoid Bone. The ethmoid bone is Sphenoid Bone. The sphenoid bone is
situated in front of the sphenoid bone in the posterior to the ethmoid bone providing for the
front part of the cranium (Fig. 6-13). Through front base of the cranium and forming the floor
small openings in this bone pass nerves to the and sides of the orbits (Fig. 6-13).
roof of the mouth that are responsible for sense
of smell.
6-17
BONES OF THE FACE.—The facial The maxillary bones form the upper jaw,
skeleton consists of 14 stationary bones and a the anterior roof of the mouth, the floors of the
mobile lower jawbone (mandible). These 14 orbits, and the sides and floor of the nasal
bones form the basic shape of the face, and are cavity. The small holes on each side of the
responsible for providing attachments for nasal opening are called the infraorbital
muscles that make the jaw move and control foramina (sin g. foramen). The maxillary
facial expressions. Figures 6-13 and 6-14 show bones contain large cavities called maxillary
the bones of the face. sinuses.
Figure 6-14.—Skull viewed from the right side. (Courtesy Vidic B, Suarez FR: Photographic atlas of
the human body, St Louis, 1984, Mosby.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006). Anatomy & Physiology
(6th ed.). St. Louis: Elsevier Health Sciences.
6-18
The palatine bones are L-shaped bones Coronoid process—Located anterior of the
located behind the maxillary bones. They form condyle, and provides attachment for the
the posterior section of the hard palate and the temporal’s muscle, which helps lift the
floor of the nasal cavity. mandible to close the mouth.
The zygomatic bones are responsible for Other important anatomical landmarks of
the prominence of the cheeks. The zygomatic the mandible that the HM should be able to
bones serve as part of the posterior section of the recognize are as follows:
hard palate and the floor of the nasal cavity.
Alveolar process—Supports the teeth of
The lacrimal bones provide a pathway for the mandibular arch.
a tube that carries tears from the eye to the
nasal cavity. The lacrimal bone is a thin, scale- Mental protuberance—Also referred to as
like structure located in the medial wall of the chin and is located at the midline of the
each orbit. mandible.
The nasal bones have cartilaginous tissues Mental foramen—Located on the facial
attached to them. These tissues contribute surfaces of the mandible on both the right and
significantly to the shape of the nose. The nasal left sides, just below the second premolars. This
bones are long, thin, and nearly rectangular in opening contains the mental nerve and blood
shape. They lie side by side and are fused vessels.
together to form the bridge of the nose. Body—The heavy, horizontal portion of the
mandible below the mental foramen extending
The inferior nasal conchae are curved, to the angle.
fragile, scroll-shaped bones that lie in the
lateral walls of the nasal cavity. They provide Angle—Juncture where the body of the
support for mucous membranes within the mandible meets with the ramus.
nasal cavity.
Mandibular foramen—Located near the
The vomer bone is connected to the center of each ramus on the medial side (inside),
ethmoid bone, and together they form the nasal through this opening passes blood vessels and
septum (the wall separating the two nasal the interior alveolus nerve, which supply the
cavities). roots of the mandibular teeth. This is a common
area where the dental officer will inject
The mandible is horseshoe-shaped, with an anesthetic to block the nerve impulses and make
upward sloping portion at each end called the the teeth on that side insensitive (numb).
ramus. The rami are divided into two different
processes: BONES OF THE EAR
Condyloid process—Also called mandibular In each middle ear (Fig. 6-15) and located
condyle, located posterior on the ramus and in the auditory ossicles are three small bones
forms the head of the mandible. It is knuckle- named the malleus (hammer), incus (anvil), and
shaped, and articulates in the glenoid fossa of stapes (stirrup). Their function is to transmit
the temporal bone to form the temporal and amplify vibrations to the ear drum and
mandibular joint. inner ear.
6-19
Figure 6-15.—The ear. External, middle, and inner ear. (Anatomical structures are not drawn to scale.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
The vertebral column consists of 24 There are seven cervical vertebrae in the
movable or true vertebrae, the sacrum, and the neck. The first is called the atlas and resembles
coccyx or tail bone (Fig. 6-16). The vertebrae a bony ring. It supports the head. The second
protect the spinal cord and the nerves that is the highly specialized axis. It has a bony
branch out from the spinal cord. Each vertebra prominence that fits into the ring of the atlas,
has an anterior portion, called the body, which is thus permitting the head to rotate from side to
the large solid segment of the bone. This side. The atlas and the axis are the only named
vertebral body supports not only the spinal vertebrae; all others are numbered (Fig. 6-16).
cord but other structures of the body as well. At Each cervical vertebra has a transverse (or
the bottom of the spinal column are the sacrum intervertebral) foramen (Fig. 6-16A) to allow
and the coccyx. Many of the main muscles are passage of nerves, the vertebral artery, and a
attached to the vertebrae. vein. The seventh cervical vertebra has a
prominent projection that can easily be felt at
The vertebral foramen is a hole directly the bottom of the neck. This landmark makes it
behind the body of the vertebrae that forms the possible for physicians to count and identify the
passage for the spinal cord. The vertebral vertebrae above and below it.
projections are for the attachments of muscles
and ligaments and for facilitating movement Thoracic
of one vertebra over another. The spinal
column is divided into five regions in the There are 12 vertebrae in the thoracic
following order: cervical (neck), thoracic region. The thoracic vertebrae articulate with
(chest), lumbar (lower back), and sacral and the posterior portion of the 12 ribs to form the
coccygeal (pelvis). posterior wall of the thoracic region (chest) or
rib cage.
6-20
Figure 6-16.—The vertebral column. A, Right lateral view. B, Anterior view. C, Posterior view. The photo
inset shows a midline sagittal magnetic resonance image (MRI) of the vertebral column.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
Lumbar THORAX
There are five lumbar vertebrae. Located This cone-shaped bony cage is about as
in the small of the back, these vertebrae are the wide as it is deep (Fig. 6-17). The thorax is
larger and stronger segments of the vertebral formed by 12 ribs on each side and articulates
column. posteriorly with the thoracic vertebrae. The
first set of ribs are attached to the
Sacrum manubrium, a flat irregular bone atop the
sternum. The first seven pairs of ribs are called
The sacrum is the triangular bone true ribs. The remaining five pairs are called
immediately below the lumbar vertebrae. It is false ribs. They are called false ribs because
composed of five separate vertebrae that their cartilages do not reach the sternum
gradually fuse together between 18 and 30 directly. The eighth, ninth, and tenth ribs are
years of age. The sacrum is connected on each united by their cartilages and joined to the rib
side with the hip bone and with the coccyx to above. The last two rib pairs, also known as
form the posterior wall of the pelvis. floating ribs, have no cartilaginous
attachments to the sternum. The sternum is an
elongated flat bone, forming the middle portion
of the upper half of the chest wall in front. The
xiphoid process, located at the inferior aspect
of the sternum.
6-21
Figure 6-17.—Thoracic cage. Note the costal cartilages and their articulations with the body of the
sternum.
The upper extremity consists of the bones Scapula. The scapula is a triangular bone
of the shoulder, arm, forearm, wrist, and hand. that lies in the upper part of the back on both
sides, between the second and seventh ribs,
Clavicle. The clavicle (commonly called forming the posterior portion of the pectoral
the “collar bone”) lies nearly horizontally above girdle (Fig. 6-18). Its lateral corner forms part of
the first rib and is shaped like a flat letter S. The the shoulder joint, articulating with the
clavicle is a thin brace bone that fractures easily. humerus.
Its inner end is round and attached to the
sternum; its outer end is flattened and fixed to
the scapula.
6-22
Figure 6-18.—Right scapula. A, Anterior view. B, Posterior view. C, Lateral view. D, Posterior view showing
articulation of the right scapula with the clavicle. (The inset shows the relative position of the right scapula
within the entire skeleton.) (D: Courtesy Vidic B, Suarez FR: Photographic atlas of the human body, St Louis,
1984, Mosby.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-23
Humerus. The humerus is the longest bone
of the upper extremity and is often called the
arm bone (Fig. 6-19). It articulates with the
pectoral girdle to form the shoulder joint, and
with the bones of the forearm to form the
elbow. Its anatomical portions include a head
(a rounded portion that fits into a recess of the
scapula) called the glenoid fossa; the shaft,
which is the main part of the humerus; and the
distal end, which includes the prominence
(called an epicondyle) and theses surfaces
articulate with the bones of the forearm.
6-24
Figure 6-20.—Bones of the hand and wrist. A, Dorsal view of the right hand and wrist. B, Palmar view of the
right hand and wrist. (Courtesy Vidic B, Suarez FR: Photographic atlas of the human body, St Louis, 1984,
Mosby.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
The ilium forms the outer prominence of The crest of the ilium is used in making
the hip bone (the crest of the ilium, referred to anatomical and surgical measurements (e.g.,
as the iliac crest, provides an anatomical location of the appendix, which is
landmark above the ilium); the ischium forms approximately halfway between the crest of the
the hard lower part; and the pubis forms the ilium and the umbilicus).
front part of the pelvis.
Femur. The femur, or thigh bone, is the
Symphysi Pubis. The area where the two longest bone in the body (Fig. 6-22). The
pubic bones meet is called the symphysis pubis proximal end is rounded and has a head
and is often used in anatomical measurements. supported by a constricted neck that fits into the
The largest foramen, or opening, is located in acetabulum. Two processes called the greater
the hip bone, between the ischium and the and lesser trochanters are at the proximal end
pubis, and is called the obturator foramen for the attachment of muscles.
(Fig. 6-21).
6-26
The neck of the femur, located between the Patella. The patella is a small oval-shaped
head and the trochanters, is the site on the femur bone overlying the knee joint. It is enclosed
most frequently fractured. At the distal end are within the tendon of the quadriceps muscle of
two bony prominences, called the lateral and the thigh. Bones like the patella that develop
medial condyles, which articulate with the within a tendon are known as sesamoid bones
tibia and the patella. (Fig. 6-22D).
Figure 6-22.—Bones of the thigh and leg. A, Right femur, anterior surface. B, Right femur, posterior view. C,
Right tibia and fibula, anterior surface. D, Anterior aspect of the right knee skeleton. E, Right tibia and
fibula, posterior aspect. (The inset shows the relative position of the bones of the thigh and leg within the
entire skeleton.) (D-E: Courtesy Vidic B, Suarez FR: Photographic atlas of the human body, St Louis, 1984,
Mosby.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-27
Tibia. The tibia, or shin bone, is the larger Tarsus. The tarsus, or ankle, is formed by
of the two leg bones and lies at the medial side. seven tarsal bones: medial cuneiform,
The proximal end articulates with the femur intermediate cuneiform, lateral cuneiform,
and the fibula. Its distal end articulates with the cuboid, navicular, talus, and calcaneus. The
talus (one of the foot bones) and the fibula strongest of these is the heel bone, or the
(Fig. 6-22C). A prominence easily felt on the calcaneus (Fig. 6-23).
inner aspect of the ankle is called the medial
malleolus. Metatarsus. The sole and instep of the
foot is called the metatarsus and is made up of
Fibula. The fibula, the smaller of the two five metatarsal bones (Fig. 6-23). They are
leg bones, is located on the lateral side of the similar in arrangement to the metacarpals of
leg, parallel to the tibia (Fig. 6-22C). The the hand.
prominence at the distal end forms the outer
ankle and is known as the lateral malleolus. Phalanges. The phalanges are the bones of
the toes and are similar in number, structure,
and arrangement to the bones of the fingers
(Fig. 6-23).
Figure 6-23.—The foot. A, Bones of the right foot viewed from above. The tarsal bones consist of the
cuneiforms, navicular, talus, cuboid, and calcaneus. B, Posterior aspect of the right ankle skeleton and
inferior aspect of the right foot skeleton. C, X-ray film of the left foot showing prominent sesamoid bones
(arrows) near the distal end (head) of the first metatarsal bone of the great toe. (B: Courtesy Vidic B, Suarez
FR: Photographic atlas of the human body, St Louis, 1984, Mosby.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-28
JOINTS Immovable (synarthroses)
Wherever two or more bones meet a joint In slightly movable joints, the bones are
is formed. A joint binds various parts of the held together by broad flattened disks of
skeletal system together and enables body cartilage and ligaments (e.g., vertebrae and
parts to move in response to skeletal muscle symphysis pubis).
contractions.
JOINT CLASSIFICATIONS
6-29
Freely movable (diarthroses) The whole joint is enclosed in a watertight sac
or membrane containing a small amount of
Most joints in the body are freely movable lubricating fluid. This lubrication enables the
joints. The joint consists of the joint capsule, joint to work with little friction. Ligaments
articular cartilage, synovial membrane, and (cords or sheets of connective tissue) reach
synovial (joint) cavity. There are six across the joints from one bone to another and
classifications of freely movable joints: ball-in- keep the bone stable. When ligaments are torn,
socket, condyloid, gliding, hinge, pivot, and the injury is called a sprain. When bones are out
saddle joints (Fig. 6-25). These joints have of place, it is called a dislocation. When bones
much more complex structures than the are chipped or broken, the injury is called a
immovable and slightly movable joints. The fracture.
ends of the bones in this type of joint are
covered with a smooth layer of cartilage.
Figure 6-25.—Types of synovial joints. Uniaxial: A, hinge, and B, pivot. Biaxial: C, saddle, and D, condyloid.
Multiaxial: E, ball and socket, and F, gliding.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-30
TYPES OF JOINT MOVEMENTS Other Types of Movement
6-31
Table 6-2.—Synovial Joints.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-32
TEMPORAL MANDIBULAR JOINT MUSCLES
6-33
MUSCLE CONTRACTION TONICITY
6-34
MUSCLE TISSUES Cardiac
There are three types of muscle tissue: The cardiac muscle tissue forms the bulk
skeletal, smooth, and cardiac. Each is of the walls and septa (or partitions) of the
designed to perform a specific function. heart, as well as the origins of the large blood
vessels. The fibers of the cardiac muscle differ
Skeletal from those of the skeletal and smooth muscles
in that they are shorter and branch into a
Skeletal, or striated, muscle tissues are complicated network (Fig. 6-8). The cardiac
attached to the bones and give shape to the muscle has the most abundant blood supply of
body. They are responsible for allowing body any muscle in the body, receiving twice the
movement. This type of muscle is sometimes blood flow of the highly vascular skeletal
referred to as striated because of the striped muscles. Cardiac muscles contract to pump
appearance of the muscle fibers under a blood out of the heart and through the
microscope (Figs. 6-27 and 6-28). They are also cardiovascular system. Interference with the
called voluntary muscles because they are blood supply to the heart can result in a heart
under the control of a person’s conscious will. attack.
Smooth, or non-striated, muscle tissues are In the following section, the location,
found in the walls of the stomach, intestines, actions, origins, and insertions of some of the
urinary bladder, and blood vessels, as well as major skeletal muscles are covered. In Figures
in the duct glands and in the skin. Under a 6-27 and 6-28 the superficial skeletal muscles
microscope, the smooth muscle fiber lacks the are illustrated. Also note, the names of some of
striped appearance of other muscle tissue. This the muscles provides clues to their location,
tissue is also called involuntary muscle shape, and number of attachments.
because it is not under conscious control.
6-35
Figure 6-27.—Anterior View of Superficial Skeletal Figure 6-28.—Posterior View of Superficial
Muscles Skeletal Muscles
6-36
MUSCLES OF THE HEAD of the mouth express surprise, sadness, anger,
fear, and pain. Table 6-3 lists the muscles of
The muscles of the head can be classified facial expression and Figure 6-27 illustrates
into two groups, muscles of facial expression these muscles.
and muscles of mastication. How muscles work
and function depends on the action of each MUSCLES OF MASTICATION
muscle (movement), the type of joint it is
associated with, and the way the muscle is Mastication is defined as the process of
attached on either side of the joint. Muscles are chewing food in preparation for swallowing and
usually attached to two places: one end being digestion. Four pairs of muscles in the mandible
joined to an immovable or fixed portion, and make chewing movements possible. These
the other end being joined to a movable portion muscles can be grouped into two different
on the other side of a joint. The immovable functions. The first group includes three pairs of
portion is called the origin of the muscle, and muscles that elevate the mandible to close the
the movable portion is called the insertion. mouth as in biting down. The last group includes
When muscles of the head contract, the insertion one pair that can depress the mandible (open the
end is pulled toward the origin. mouth), make grinding actions side to side, and
can make the mandible go forward in a
MUSCLES OF FACIAL EXPRESSION protruding motion. Table 6-4 lists the muscles of
mastication and Figure 6-27 illustrates these
The muscles underneath the skin of the face muscles.
are responsible for helping communicate
feelings through facial expression. The muscles
LIPS
6-38
Surface (Dorsal Aspect) Tongue and Digestion
On the surface of the tongue are rough The tongue is an important muscle in the
projections called papillae. They provide the chewing process. It crushes food against the
tongue with friction in handling food and also palate; it deposits food between the chewing
act as taste buds. surfaces of the teeth for mastication; it transfers
food from one area of the mouth to another; it
Taste Buds mixes food with saliva, which assists in the
digestive process; assists in swallowing; and
The four types of taste sensations are cleans the mouth of residue.
sweet, sour, bitter, and salty-all resulting from
stimulation of the taste buds. Most are located MYLOHYOID AND GENIOHYOID
on the tongue and the roof of the mouth. Figure
6-31 illustrates taste buds of the tongue. The mylohyoid muscles anatomically and
functionally form the floor of the mouth (Fig.
6-30). They elevate the tongue and depress the
mandible. Their origin is the mandible and
insertion is the upper border of the hyoid bone.
The geniohyoid muscles are found next to each
other, on each side of the midline, directly on
top of the mylohyoid muscle, and have the
same origin and function as the mylohyoid
muscle.
6-39
PALATE TEETH
The palate (Fig. 6-32) forms the roof of the The teeth are located in the alveolar process
mouth and is divided into two sections: of the maxillae and the mandible. They serve
important functions of tearing and masticating
• Hard palate: This section is formed by the
food, assisting in swallowing, speaking, and in
palatine process of the maxillary bones and
appearance. The health of the teeth affects the
is located in the anterior portion of the roof
health of the entire body.
of the mouth. It has irregular ridges or folds
behind the central incisors called rugae.
SALIVARY GLANDS
• Soft palate: This section forms a soft
muscular arch in the posterior part of the The functions of the three major salivary
palate. The uvula is located on the back glands are to keep the lining of the mouth moist
portion of the soft palate. When swallowing, and to bond with food particles creating a
the uvula is drawn upward and backward by lubricant effect that assists in the swallowing
the muscles of the soft palate. This process process of food. They act as a cleaning agent to
blocks the opening between the nasal cavity wash away food particles that accumulate in the
and pharynx, not allowing food to enter the mouth and on the teeth. Figure 6-33 illustrates
nasal cavity. The soft palate must function the salivary glands.
properly to allow good speech quality.
The salivary glands produce two to three
Located in the posterior part of the mouth,
pints of saliva daily, which greatly aids in the
on both sides of the tongue, are two masses of
digestion process. Enzymes are present in
lymphatic tissue called the palatine tonsils. They
saliva; they act on food, and start the
assist the body to protect against infections.
breakdown process. In dentistry, knowing
exactly where the saliva glands and ducts
(openings) are located is important in keeping
the mouth dry during certain dental procedures.
Table 6-5 lists the three major salivary glands.
6-40
Gland Location Duct Description
Sublingual On each side underneath Multiple separate ducts Smallest of salivary glands, secretes,
the tongue, in the floor of thick stringy mucus.
the mouth
Submandibular Posterior portion of Opens under the tongue, Walnut sized. Secretes watery fluid
mandible, lingual to close to the frenulum with some mucus. More viscous (thick)
mandibular incisors than parotid secretion.
Parotid Inside cheek, opposite Parotid ducts go through Largest of salivary glands. Secretes
maxillary second molar the buccinator muscles and clear watery fluid.
enter the mouth opposite
maxillary second molars
The mastication process includes the biting The temporalis muscle is a fan-shaped
and tearing of food into manageable pieces. muscle located on the side of the skull, above
This usually involves using the incisors and and in front of the ear. This muscle's fibers
cuspid teeth. The grinding of food is usually assist in raising the jaw and pass downward
performed by the molars and premolars. During beneath the zygomatic arch to the mandible
the mastication process, food is moistened and (Fig. 6-27). The temporalis muscle's origin is
mixed with saliva. the temporal bone. It is inserted in the coronoid
process (a prominence of bone) of the
Deglutition is the swallowing of food and mandible.
involves a complex and coordinated process. It
is divided into three phases; the first phase of Sternocleidomastoid
swallowing is voluntarily; phases two and three
are involuntary. The sternocleidomastoid muscles are
located on both sides of the neck. Acting
• Phase One: The collection and swallowing
individually, these muscles rotate the head left
of masticated food.
or right (Figs. 6-27 and 6-28). Acting together,
• Phase Two: Passage of food through the they bend the head forward toward the chest.
pharynx into the beginning of the The sternocleidomastoid muscle originates in
esophagus. the sternum and clavicle and is inserted in the
mastoid process of the temporal bone. When
• Phase Three: The passage of food into the this muscle becomes damaged, the result is a
stomach. common condition known as a “stiff neck.”
6-41
Trapezius Triceps Brachii
The trapezius muscles are a broad, The triceps brachii is the primary extensor
trapezium-shaped pair of muscles on the upper of the forearm (the antagonist of the biceps
back, which raise or lower the shoulders (Figs. brachii) (Fig. 6-28). It originates at two points on
6-27 and 6-28). They cover approximately one- the humerus and one on the scapula. These three
third of the back. They originate in a large area heads join to form the large muscle on the
which includes the 12 thoracic vertebrae, the posterior surface of the upper arm. The point of
seventh cervical vertebra, and the occipital insertion is the olecranon process of the ulna.
bone. They have their insertion in the clavicle
and scapula. Latissimus Dorsi
6-42
Quadriceps Sartorius
The quadriceps is a group of four muscles The sartorius is the longest muscle in the
that make up the anterior portion of the thigh. body. It extends diagonally across the front of
The four muscles of this group are the rectus the thigh from its origin at the ilium, down to
femoris that originates at the ilium; and the its insertion near the tuberosity of the tibia
vastus (v.) lateralis, v. medialis, v. (Fig. 6-28). Its function is to flex the thigh and
intermedius (not shown), that originate along rotate it laterally, and to flex the leg and rotate
the femur (Fig. 6-27). All four are inserted it slightly medially.
into the tuberosity of the tibia through a
tendon passing over the knee joint. The Gastrocnemius and Soleus
quadriceps serves as a strong extensor of the
leg at the knee and flexes the thigh. The gastrocnemius and soleus (together
Additionally located in the quadriceps area is commonly called the calf muscles) extend the
the adductor longus that adducts, rotates, and foot at the ankle (Figs. 6-27 and 6-28). The
flexes the thigh. gastrocnemius originates at two points on the
femur; the soleus originates at the head of the
Biceps Femoris fibula and the medial border of the tibia. Both
are inserted in a common tendon called the
The biceps femoris (often called the calcaneus, or Achilles tendon.
hamstring muscle) originates at the tuberosity
of the ischium (the lowest portion of the Tibialis Anterior
innominate or coxal bone, part of the pelvic
girdle) and the middle third of the femur (Fig. The tibialis anterior originates at the upper
6-28). It is inserted on the head of the fibula half of the tibia and inserts at the first
and the lateral condyle of the tibia. It acts, metatarsal and cuneiform bones (Fig. 6-27). It
along with other related muscles, to flex the flexes the foot.
leg at the knee and to extend the thigh at the
hip joint. Diaphragm
6-43
THE CIRCULATORY SYSTEM Plasma
BLOOD
6-44
RED BLOOD CELLS.—Red blood cells Red blood cells live only about 100 to 120
(RBC), or erythrocytes, are small, biconcave, days in the body. There are several reasons for
non-nucleated disks, formed in the red bone their short life span. These delicate cells have
marrow (Fig. 6-35). Blood of the average man to withstand constant knocking around as they
contains 5 million red cells per cubic millimeter. are pumped into the arteries by the heart. These
Women have fewer red cells, 4.5 million per cells travel through blood vessels at high speed,
cubic millimeter. Emotional stress, strenuous bumping into other cells, bouncing off the
exercise, high altitudes, and some diseases may walls of arteries and veins, and squeezing
cause an increase in the number of RBCs. through narrow passages. They must adjust to
continual pressure changes. The spleen is the
During the development of the red blood gravey ard where old, worn out cells are
cell, a substance called hemoglobin is removed from the blood stream. Fragments of
combined with it. Hemoglobin is the key of the red blood cells are found in the spleen and
red cell's ability to carry oxygen and carbon other body tissues.
dioxide. The main function of erythrocytes is
the transportation of respiratory gases. The red WHITE BLOOD CELLS. — W h i t e
cells deliver oxygen to the body tissues, blood cells (WBC), or leukocytes, are almost
holding some oxygen in reserve for an colorless, nucleated cells originating in the
emergency. Carbon dioxide is picked up by bone marrow and in certain lymphoid tissues
the same cells and discharged via the lungs. of the body (Fig. 6-35). There is only one
white cell to every 600 red cells. Normal
The color of the red blood cell is determined WBC count is 6,000 to 8,000 per cubic
by the hemoglobin content. Bright red (arterial) millimeter. The number of white cells may be
blood is due to the combination of oxygen and 15,000 to 20,000 or higher during infection.
hemoglobin. Dark red (venous) blood is the
result of hemoglobin combining with carbon
dioxide.
Figure 6-35.—The formed elements of blood. Red blood cells (erythrocytes), white blood cells
(leukocytes), and platelets (thrombocytes) constitute the formed elements of blood.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-45
Leukocytes are important for the protection Other necessary elements for blood
of the body against disease. Leukocytes can clotting are calcium salts; a substance called
squeeze between the cells that form blood cell prothrombin, which is formed in the liver;
walls. This movement, called diapedesis, blood platelets; and various factors necessary
permits them to leave the blood stream for the completion of the successive steps in the
through the capillary wall and attack coagulation process.
pathogenic bacteria. They can travel anywhere
in the body and are often n a m e d t h e Once the fibrin plug is formed, it quickly
wandering cells. They protect the body tissues enmeshes red and white blood cells and draws
by engulfing disease-bearing bacteria and them tightly together. Blood serum, a
foreign matter, a process called phagocytosis. yellowish clear liquid, is squeezed out of the clot
When white cells are undermanned, more are as the mass shrinks. Formation of the clot
produced, causing an increase in their number closes the wound, preventing blood loss. A clot
and a condition known as leukocytosis. also serves as a network for the growth of new
Another way WBC's protect the body from tissues in the process of healing. Normal clotting
disease is by producing bacteriolysins that time is 3 to 5 minutes, but if any of the
dissolve the foreign bacteria. The secondary substances necessary for clotting are absent,
function of WBCs is to aid in blood clotting. severe bleeding will occur.
6-46
Heart Composition However, the walls of the ventricles, which
comprise the bulk of the heart, are thick and
The heart is enclosed in a membranous muscular. The wall of the left ventricle is
sac, the pericardium. The smooth surfaces of considerably thicker than that of the right
the heart and pericardium are lubricated by a because more force is required to pump the
serous secretion called pericardial fluid. The blood into distant or outlying locations of the
inner surface of the heart is lined with a circulatory system than into the lungs located
delicate serous membrane, the endocardium, only a short distance from the heart.
similar to and continuous with that of the inner
lining of blood vessels. Heart Functions
The interior of the heart (Fig. 6-36) is The heart acts as four interrelated pumps.
divided into two parts by a wall called the The right atrium receives deoxygenated blood
interventricular septum. In each half is an from the body via the superior and inferior
upper chamber, the atrium, which receives vena cava. It pumps the deoxygenated blood
blood from the veins, and a lower chamber, the through the tricuspid valve to the right
ventricle, which receives blood from the atrium ventricle. The right ventricle pumps the blood
and pumps it out into the arteries. The openings past the pulmonary valve through the
between the chambers on each side of the pulmonary artery to the lungs, where it is
heart are separated by flaps of tissue that act as oxygenated. The left atrium receives the
valves to prevent backward flow of blood. The oxygenated blood from the lungs through four
valve on the right has three flaps, or cusps, and pulmonary veins and pumps it to the left
is called the tricuspid valve. The valve on the ventricle past the mitral valve. The left
left has two flaps and is called the mitral, or ventricle pumps the blood to all areas of the
bicuspid, valve. The outlets of the ventricles body via the aortic valve and the aorta.
are supplied with similar valves. In the right
ventricle, the pulmonary valve is at the origin The heart's constant contracting and
of the pulmonary artery. In the left ventricle, relaxing forces blood into the arteries. Each
the aortic valve is at the origin of the aorta. contraction is followed by limited relaxation
See Figure 6-36 for valve locations. or dilation. Cardiac muscle never completely
relaxes: It always maintains a degree of tone.
The heart muscle, the myocardium, is Contraction of the heart is called systole or
striated like the skeletal muscles of the body, "the period of work." Relaxation of the heart is
but involuntary in action, like the smooth called diastole or "the period of rest." A
muscles. The walls of the atria are thin with complete cardiac cycle is the time from onset of
relatively little muscle fiber because the blood one contraction, or heart beat, to the onset of
flows from the atria to the ventricles under low the next.
pressure.
6-47
Figure 6-36.—Chambers and valves of the heart. A, During atrial contraction cardiac muscle in the atrial
wall contracts, forcing blood through the atrioventricular (AV) valves and into the ventricles. Bottom
illustration shows superior view of all four valves, with semilunar (SL) valves closed and AV valves open. B,
During ventricular contraction that follows, the AV valves close and the blood is forced out of the ventricles
through the SL valves and into the arteries. Bottom illustration shows superior view of SL valves open and
AV valves closed.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-48
Cardiac Cycle This same cardiac impulse continues to
travel to another group of specialized tissues
The cardiac cycle is coordinated by called the atrioventricular (AV) node. The
specialized tissues that initiate and distribute AV node is located in the floor of the right
electrical (cardiac) impulses (Fig. 6-37). The atrium near the septum that separates the atria.
contractions of the heart are stimulated and The cardiac impulse to the AV node is slowed
maintained by the sinoatrial (SA) node, down by junctional fibers. The junctional
commonly called the pacemaker of the heart. fibers conduct the cardiac impulse to the AV
The SA node is an elongated mass of node; however, these fibers are very small in
specialized muscle tissue located in the upper diameter, causing the impulse to be delayed.
part of the right atrium. The SA node sets off This slow arrival of the impulse to the AV node
cardiac impulses, causing both atria to contract allows time for the atria to empty and the
simultaneously. The normal heart rate, or ventricles to fill with blood.
number of contractions, is about 80 beats per
minute.
Figure 6-37.—Conduction system of the heart. Specialized cardiac muscle cells (boldface type) in the wall of
the heart rapidly initiate or conduct an electrical impulse throughout the myocardium. Both the sketch of the
conduction system (A) and the flowchart (B) show the origin and path of conduction. The signal is initiated by
the SA node (pacemaker) and spreads to the rest of the right atrial myocardium directly, to the left atrial
myocardium by way of a bundle of interatrial conducting fibers, and to the AV node by way of three
internodal bundles. The AV node then initiates a signal that is conducted through the ventricular
myocardium by way of the AV bundle (of His) and subendocardial branches (Purkinje fibers).
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-49
Once the cardiac impulse reaches the far BLOOD VESSELS
side of the AV node, it quickly passes through
a group of large fibers which make up the AV Blood vessels form a closed circuit of
bundle (also called the bundle of His). The AV tubes that transport blood between the heart
bundle starts at the upper part of the and body cells. The several types of blood
interventricular septum and divides into right vessels include arteries, arterioles, capillaries,
and left branches. About halfway down the venules, and veins.
interventricular septum, the right and left
branches terminate into Purkinje fibers. The Blood Vessel Classifications
Purkinje fibers spread from the
interventricular septum into the papillary The blood vessels of the body fall into
muscles, which project inward from the three classifications:
ventricular walls. As the cardiac impulse
• Arteries and Arterioles: Distributors
passes through the Purkinje fibers, these fibers
in turn stimulate the cardiac muscle of the • Capillaries: Exchangers
ventricles. This stimulation of the cardiac
muscles causes the walls of the ventricles to • Veins and Venules: Collectors
contract with a twisting motion. This action
squeezes the blood out of the ventricular Arteries and Arterioles
chambers and forces it into the arteries. This is
the conclusion of one cardiac cycle. Arteries are elastic tubes constructed to
withstand high pressure. They carry blood away
Blood Pressure from the heart to all parts of the body. The
smallest branches of the arteries are called
Blood pressure is the pressure the blood arterioles. The walls of arteries and arterioles
exerts on the walls of the arteries. The highest consist of layers of endothelium, smooth
pressure is called systolic pressure, because it is muscle, and connective tissue. The smooth
caused when the heart is in systole, or muscles of arteries and arterioles constrict and
contraction. A certain amount of blood pressure dilate in response to electrical impulses
is maintained in the arteries even when the received from the autonomic nervous system.
heart is relaxed. This pressure is the diastolic
pressure, because it is present during diastole, Capillaries
or relaxation of the heart. The difference
between systolic and diastolic pressure is At the end of the arterioles is a system of
known as pulse pressure. minute vessels that vary in structure, but which
are spoken of collectively as capillaries. It is
Normal blood pressure can vary from these capillaries that the tissues of the
considerably with an individual's age, weight, body are fed. There are approximately 60,000
and general condition. For young adults, 120 miles of capillaries in the body. As the blood
systolic 80 diastolic is the average normal passes through the capillaries, it releases
blood pressure, women have lower blood oxygen and nutritive substances to the tissues
pressure than men. and takes up various waste products to be
carried away by venules. Venules continue
from capillaries and merge to form veins.
6-50
Veins and Venules
ARTERIES OF THE HEAD, NECK,
Veins and venules form the venous AND BRAIN.—The carotid arteries divide
system. The venous system is comprised of into internal and external branches. The
vessels that collect blood from the capillaries external supplies the muscle and skin of the
and carry it back to the heart. Veins begin as face and the internal supplies the brain and the
tiny venules formed from the capillaries. eyes.
Joining together as tiny rivulets, veins connect
and form a small stream. The force of muscles ARTERIES OF THE UPPER
contracting adjacent to veins aids in the EXTREMITIES.—The subclavian arteries
forward propulsion of blood on its return to the are so named because they run underneath the
heart. Valves, spaced frequently along the clavicle. They supply the upper extremities,
larger veins, prevent the backflow of blood. branching off to the back, chest, neck, and brain
The walls of veins are similar to arteries, but through the spinal column (Fig. 6-38).
are thinner and contain less muscle and elastic
tissue. The large artery going to the arm is called
the axillary. The axillary artery becomes the
Arterial System brachial artery as it travels down the arm and
divides into the ulnar and radial arteries. The
Arterial circulation is responsible for radial artery is the artery at the wrist that is felt
taking freshly oxygenated blood from the heart when taking the patient’s pulse (Fig. 6-38).
to the cells of the body (Fig. 6-38). To take this
oxygenated blood from the heart to the entire ARTERIES OF THE ABDOMEN.—In the
body, the arterial system begins with the abdomen, the aorta gives off branches to the
contraction of blood from the left ventricle abdominal viscera, including the stomach, liver,
into the aorta and its branches. spleen, kidneys, and intestines. The aorta later
divides into the left and right common iliacs,
AORTA.—The aorta, largest artery in the which supply the lower extremities (Fig. 6-
body, is a large tube-like structure arising 38).
from the left ventricle of the heart. It arches
upward over the left lung and then down along ARTERIES OF THE LOWER
the spinal column through the thorax and the EXTREMITIES.—The left and right
abdomen, where it divides and sends arteries common iliacs, upon entering the thigh,
down both legs (Fig. 6-38). become the femoral arteries. At the knee, this
same vessel is named the popliteal artery
KEY BRANCHES OF THE AORTA.— (Fig. 6-38).
Key arterial branches of the aorta are the
coronary, innominate (brachiocephalic), left
common carotid, and left subclavian. The
coronary arteries are branches of what is called
the ascending aorta. The coronary arteries
supply the heart with blood. There are three
large arteries that arise from the aorta as it
arches over the left lung. First is the
innominate artery, which divides into the
right subclavian artery to supply the right arm,
and the right common carotid to supply the
right side of the head. The second branch is
the left common carotid, which supplies the
left side of the head. The third branch is the
left subclavian, which supplies the left arm.
6-51
Figure 6-38.—Principal arteries of the body.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-52
Venous System • The systemic system is divided into the
deep and superficial veins. The superficial
Venous circulation is responsible for veins lie immediately under the skin,
returning the blood to the heart after exchanges draining the skin and superficial structures.
of gases, nutrients, and wastes have occurred The deep veins, usually located in the
between the blood and body cells (Fig. 6-39). muscle or deeper layers, drain the large
To return this blood to the heart for muscle masses and various other organs.
reoxygenation, the venous system begins with Deep veins commonly lie close to the large
the merging of capillaries into venules, venules arteries that supply the various organs of the
into small veins, and small veins into larger body and typically have the same name as
veins. The blood vessel paths of the venous the artery they accompany.
system are difficult to follow, unlike the
arterial system. However, the larger veins are
VEINS OF THE HEAD, NECK, AND
commonly located parallel to the course taken
BRAIN.—The superficial veins of the head
by their counterpart in the arterial system. For
unite to form the external jugular veins. The
instance, the renal vein parallels the renal
external jugular veins drain blood from the
artery; the common iliac vein parallels the
scalp, face, and neck, and finally empty into
common iliac artery, and so forth.
the subclavian veins.
THREE PRINCIPAL VENOUS
The veins draining the brain and internal
SYSTEMS.—The three principal venous
facial structures are the internal jugular
systems in the body are the pulmonary, portal,
veins. These combine with the subclavian
and systemic.
veins to form the innominate veins, which
• The pulmonary system is composed of empty into the superior vena cava (Fig. 6-39).
four vessels, two from each lung, which
empty into the left atrium. These are the
only veins in the body that carry freshly
oxygenated blood.
• The portal system consists of the veins
that drain venous blood from the abdominal
part of the digestive tract the spleen,
pancreas, and gallbladder, but not the lower
rectum and deliver it to the liver. There, it
is distributed by a set of venous capillaries.
The blood in the portal system conveys
absorbed substances from the intestinal tract
to the liver for storage, alteration, or
detoxification. From the liver the blood
flows through the hepatic vein to the inferior
vena cava.
6-53
VEINS OF THE UPPER EXTREM- VEINS OF THE LOWER EXTREM-
ITIES.—The veins of the upper extremities TIES.—In the lower extremities (Fig. 6-39)
begin at the hand and extend upward. A vein of a similar system drains the superficial areas.
great interest is the median cubital, which The great saphenous vein originates on the
crosses the anterior surface of the elbow. It is inner aspect of the foot and extends up the
the vein most commonly used for venipuncture. inside of the leg and thigh to join the femoral
Also found in this area are the basilic and vein in the upper thigh. The great saphenous
cephalic veins, which extend from the midarm vein is used for intravenous injections at the
to the shoulder. ankle.
The deep veins of the upper arm unite to The veins from the lower extremities unite
form the axillary vein, which unites with the to form the femoral vein in the thigh, which
superficial veins to form the subclavian vein. becomes the external iliac vein in the groin.
This vein later unites with other veins to form Higher in this region, external iliac unites the
the innominate and eventually, after union with internal iliac (hypogastric) vein from the
still more veins, the superior vena cava (Fig. 6-39). lower pelvic region to form the common iliac
veins. The right and left common iliac veins
VEINS OF THE ABDOMEN AND unite to form the inferior vena cava.
THORACIC REGION.—The veins from the
abdominal organs, with the exception of those
of the portal system, empty directly or
indirectly into the inferior vena cava, while
those of the thoracic region eventually empty
into the superior vena cava (Fig. 6-39).
6-54
Figure 6-39.—Principal veins of the body.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-55
THE LYMPHATIC SYSTEM PATHWAYS OF THE LYMPHATIC
SYSTEM
LEARNING OBJECTIVE:
The lymphatic pathway begins with
lymphatic capillaries. These small tubes merge
Identify the parts of the lymphatic system and
to form lymphatic vessels, and the lymphatic
their function.
vessels in turn lead to larger vessels that join
with the veins in the thorax.
All tissues of the body are continuously
bathed in interstitial fluid. This fluid is formed Lymphatic Capillaries
by leakage of blood plasma through minute
pores of the capillaries. There is a continual Lymphatic capillaries are closed-ended
interchange of fluids of the blood and tissue tubes of microscopic size (Fig. 6-40). They
spaces with a free interchange of nutrients and extend into interstitial spaces, forming
other dissolved substances. Most of the tissue complex networks that parallel blood capillary
fluid returns to the circulatory system by networks. The lymphatic capillary wall
means of capillaries, which feed into larger consists of a single layer of squamous
veins. Large protein molecules that have epithelial cells. This thin wall makes it
escaped from the arterial capillaries cannot possible for interstitial fluid to enter the
reenter the circulation through the small pores lymphatic capillary. Once the interstitial fluid
of the capillaries. However, these large enters the lymphatic capillaries, the fluid is
molecules, as well as white blood cells, dead called lymph.
cells, bacterial debris, infected substances, and
larger particulate matter, can pass through the
larger pores of the lymphatic capillaries and,
thus, enter the lymphatic circulatory system
with the remainder of the tissue fluid.
6-56
Figure 6-40.—Circulation plan of lymphatic fluid. This diagram outlines the general scheme for
lymphatic circulation. Fluids from the systemic and pulmonary capillaries leave the bloodstream and
enter the interstitial space, thus becoming part of the IF (interstitial fluid). The IF also exchanges
materials with the surrounding tissues. Often, because less fluid is returned to the blood capillary
than had left it, IF pressure increases—causing IF to flow into the lymphatic capillary. The fluid is
then called lymph (lymphatic fluid) and is carried through one or more lymph nodes and finally to
large lymphatic ducts. The lymph enters a subclavian vein, where it is returned to the systemic blood
plasma. Thus fluid circulates through blood vessels, tissues, and lymphatic vessels in a sort of "open
circulation."
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-57
Lymphatic Vessels Like a vein, the lymphatic vessel has
valves to prevent backflow of lymph. The
Lymphatic vessels are formed from the larger lymphatic vessels lead to specialized
merging of lymphatic capillaries. Lymphatic organs called lymph nodes. After leaving these
vessels, also known simply as lymphatics, are structures, the vessels merge to form still larger
similar to veins in structure. The vessel walls are lymphatic trunks (Fig. 6-41).
composed of three layers: an inner layer of
endothelial tissue, a middle layer of smooth
muscle and elastic fibers, and an outer layer of
connective tissue.
Figure 6-41.—Structure of a typical lymphatic capillary. Notice that interstitial fluid enters through
clefts between overlapping endothelial cells that form the wall of the vessel. Valves ensure one-way
flow of lymph out of the tissue. Small fibers anchor the wall of the lymphatic capillary to the
surrounding ECM (extracellular matrix) and cells, thus holding it open to allow entry of fluids and
small particles.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-58
Lymphatic Trunks and Ducts Lymphatic trunks from the upper half of
the right side of the body converge to form the
Lymphatic trunks drain lymph from large right lymphatic duct, which empties into the
regions in the body. The lymphatic trunks are right subclavian vein. Drainage from the
usually named after the region they serve, such remainder of the body is by way of the thoracic
as the subclavian trunk that drains the arm. duct, which empties into the left subclavian
There are many lymphatic trunks throughout vein.
the body. These lymphatic trunks then join one
of two collecting ducts, the thoracic duct or
the right lymphatic duct (Fig. 6-42).
Figure 6-42.—Lymphatic drainage. The right lymphatic duct drains lymph from the upper right
quadrant (dark blue) of the body into the right subclavian vein. The thoracic duct drains lymph from
the rest of the body (green) into the left subclavian vein. The lymphatic fluid is thus returned to the
systemic blood just before entering the heart.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-59
LYMPH NODES abdominal cavity, and thoracic cavity. Lymph
nodes vary in size and act as filters to remove
Lymph nodes, which are frequently called bacteria and particles from the lymph stream.
glands but are not true glands, are small bean- Lymph nodes produce lymphocytes, which
shaped bodies of lymphatic tissue found in help defend the body against harmful foreign
groups of two to fifteen along the course of particles, such as bacteria, cells, and viruses.
the lymph vessels (Fig. 6-43). Major locations Lymph nodes also contain macrophages,
of lymph nodes are in the following regions: which engulf and destroy foreign substances,
cervical, axillary, inguinal, pelvic cavity, damaged cells, and cellular debris.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-60
IMMUNE SYSTEM The memorization and production of
antibodies is called active immunity. In passive
immunity the antibodies have been obtained
LEARNING OBJECTIVE:
from outside the body, either from another
animal or person.
Identify how the immune system works.
A number of cells are involved in combating
“First, it is important to recognize that cells, the invasion of viruses and bacteria. B cells have
viruses, and other particles have unique antigen receptors and antibodies, and they work
molecules and groups of molecules on their to fight off bacteria. B cells can form plasma
surfaces that can be used to identify them. These cells and memory cells. The plasma cells
molecular markers visible to the immune system produce antibodies that bind to antigens,
are called antigens. Human cells have unique whereas the memory B cells form new plasma
cell markers embedded in our plasma cells if the bacteria enter the body again. T cells
membranes that identify each of our cells as are responsible for recognizing nonself cells. On
self—that is, belonging to us as an individual. engagement with nonself cells, they produce
Foreign cells or particles have nonself molecules killer T cells and memory T cells. The killer T
that serve as recognition markers for our cells have the task of binding to cells that have
immune system. The ability of our immune been infected by viruses. The memory T cells
system to attack abnormal or foreign cells but are ready to produce more killer T cells if the
spare our own normal cells is called self- virus enters the body again. In both cases,
tolerance2.” bacterial and viral infections, helper T cells are
available to recognize the antigens that have
“The body takes a number of measures to been ingested and displayed by macrophages3.”
prevent infection. The body’s primary defenses
against infection include the skin, tears, stomach THE NERVOUS SYSTEM
acid, urine, sweat, mucus, and saliva. By having
this range of both physical and chemical
LEARNING OBJECTIVES:
defenses, the body is able to defend against a
range of pathogens.
Identify the components and function of a
neuron.
Secondary defenses bring about
inflammation. The swelling, redness, and
Identify the process of impulse transmission.
warmth of the infected area cause the body to
call in macrophages and neutrophils to
Identify the components and functions of
consume the bacteria [see chap 10 for more
the central and peripheral nervous systems.
details]. If the pathogen is a virus, interferon
(interferon proteins interfere with the ability of
viruses to cause diseases) is produced so that The activity of widely diverse cells, tissues,
other cells in that region of the body can block and organs of the body must be monitored,
the virus from attacking any healthy cells. regulated, and coordinated to effectively
support human life. The interaction of the
The body’s third line of defense is the way nervous and endocrine systems provides the
the body remembers specific pathogens and their needed control through communication.
structures. If the pathogen enters the body again,
the body’s response will be much quicker than The nervous system is specifically adapted
the first time the pathogen invaded the body. to the rapid transmission of impulses from one
Antibodies, specific to each pathogen, are ready area of the body to another. On the other hand,
to respond should this occur. the endocrine system, working at a far slower
pace, maintains body metabolism at a fairly
constant level.
6-61
This section will cover the study of the glia There are five major types of Glia cells,
and neuron, the two main types of cells of the Astrocytes, Microglia, Ependymal cells,
nervous system. It will discuss the Oligodendrocytes, and Scwhann cells. The
components and functions of the different first four types of glia are located in the CNS
categories of the nervous system: the central and the Scwhann cells are located in the PNS.
nervous system (CNS) and the peripheral Astrocytes help feed the brain and make up
nervous system (PNS). Another division of the the Blood Brain Barrier. Microglia enlarge,
nervous system is the autonomic nervous engulf, and destroy microorganisms and
system (ANS), which is further subdivided cellular debris. Ependymal cells have two
into the sympathetic and parasympathetic functions in the CNS; they help produce the
nervous systems (Fig. 6-44). fluid and some have cilia that help move the
fluid around. The Oligodendrocytes produce
GLIA the fatty myelin sheath around the nerve fibers
in the CNS.
Glia cells do not usually conduct
information themselves but support the
functions of the neurons in various ways.
Unlike neurons, glia cells retain their capacity
for cell division throughout adulthood. This
characteristic gives them the ability to replace
themselves and it makes them susceptible to
abnormalities of cell division – such as cancer.
Figure 6-44.—Organizational plan of the nervous system. Diagram summarizes the scheme used by most
neurobiologists in studying the nervous system. Both the somatic nervous system (SNS) and the autonomic
nervous system (ANS) include components in the CNS and PNS. Somatic sensory pathways conduct
information toward integrators in the CNS, and somatic motor pathways conduct information toward
somatic effectors. In the ANS, visceral sensory pathways conduct information toward CNS integrators,
whereas the sympathetic and parasympathetic pathways conduct information toward autonomic effectors.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-62
THE NEURON
6-63
Figure 6-46.—Development of the myelin sheath. A Schwann cell (neurolemmocyte) migrates to a neuron and
wraps around an axon. The Schwann cell's cytoplasm is pushed to the outer layer, leaving a dense
multilayered covering of plasma membrane around the axon. Because the plasma membrane of the Schwann
cell is mostly the phospholipid myelin, the dense wrapping around the axon is called a myelin sheath. The
outer layer of cytoplasm is called the neurilemma. The extensions of oligodendrocytes also wrap around axons
to form a myelin sheath.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-64
CENTRAL NERVOUS SYSTEM
Brain
6-65
MENINGES. The outer surface of the
brain and spinal cord is covered with three
layers of membranes called the meninges. The
dura mater is the strong outer layer; the
arachnoid membrane is the delicate middle
layer; and the pia mater is the vascular inner-
most layer that adheres to the surface of the
brain and spinal cord. Inflammation of the
meninges is called meningitis. The type of
meningitis contracted depends upon whether
the brain, spinal cord, or both are affected, as
well as whether it is caused by viruses,
bacteria, protozoa, yeasts, or fungi.
CEREBROSPINAL FLUID.—Cerebrospinal
fluid is formed by a plexus, or network, of
blood vessels in the central ventricles of the
brain. It is a clear, watery solution similar to
blood plasma. The total quantity of spinal fluid
bathing the spinal cord is about 75 ml. This
fluid is constantly being produced and
reabsorbed. It circulates over the surface of the
brain and spinal cord and serves as a supportive
protective cushion as well as a means of
exchange for nutrients and waste materials. It
monitors for changes in the internal
environment.
Spinal Cord
Figure 6-48.—The central nervous system. Details
of both the brain and the spinal cord are easily
The spinal cord is continuous with the seen in this Figure.
medulla oblongata and extends from the
foramen magnum, through the atlas, to the Image reprinted with permission from: Thibedeau, G.
lower border of the first lumbar vertebra, where A., & Patton, K. T. (2006). Anatomy & Physiology
it tapers to a point (Fig. 6-48). The spinal cord (6th ed.). St. Louis: Elsevier Health Sciences.
is surrounded by the bony walls of the
vertebral canal. Ensheathed in the three
protective meninges and surrounded by fatty
tissue and blood vessels, the spinal cord does
not completely fill the vertebral canal, nor does
it extend the full length of it. The nerve matter
is shaped roughly like the letter H. It establishes
sensory communication between the brain and
the spinal nerves, conducting sensory impulses
from the body parts.
6-66
The spinal cord may be thought of as an
electric cable containing many wires (nerves)
that connect parts of the body with each other
and with the brain. Sensations received by a
sensory nerve are brought to the spinal cord,
and the impulse is transferred either to the brain
or to a motor nerve. The majority of impulses
go to the brain for action. However, a system
exists for quickly handling emergency
situations. It is called the reflex arc (Fig. 6-49).
6-67
PERIPHERAL NERVOUS SYSTEM While the cranial nerves are numbered in a
specific order, the spinal nerves are merely
The peripheral nervous system (PNS) numbered according to where they emerge
consists of the nerves that branch out from the from the spinal cord. Cranial and spinal nerves
CNS and connects it to the other parts of the carry both voluntary and involuntary impulses.
body. The PNS includes 12 pairs of cranial
nerves (Fig. 6-51) and 31 pairs of spinal nerves
(Fig. 6-52).
Figure 6-51.—Cranial nerves. Ventral surface of the brain showing attachment of the cranial nerves.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-68
Figure 6-52.—Spinal nerves. Each of 31 pairs of spinal nerves exits the spinal cavity from the intervertebral
foramina. The names of the vertebrae are given on the left and the names of the corresponding spinal nerves
on the right. Note that after leaving the spinal cavity, many of the spinal nerves interconnect to form
networks called plexuses. The inset shows a dissection of the cervical region, showing a posterior view of
cervical spinal nerves exiting intervertebral foramina on the right side. (Courtesy Vidic B, Suarez RF:
Photographic atlas of the human body, St Louis, 1984, Mosby.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-69
Cranial Nerves Some Hops or I-Olfactory, II-Optic, III-
Oculomotor, IV-Trochlear, V-Trigeminal, VI-
The 12 pairs of cranial nerves (Table 6-6) Abducens, VII-Facial, VIII-Vestibulocochlear
are sensory, motor, or mixed (sensory and (Auditory), IX-Glossopharyngeal, X-Vagus, XI-
motor). The following saying helps in the Spinal (Accessory), and XII-Hypoglossal (Fig.
memorization of the nerves: On Old Olympus 6-51). The figure below shows the 12 cranial
Tower Tops A Famous Vocal German Viewed nerves and parts of the body they service.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-70
“The cranial nerves are the 12 pairs of 7. Facial: The Facial Nerve controls the face
nerves emerging from the cranial cavity through muscles. It stimulates the scalp, forehead,
various openings in the skull. Beginning with eyelids, muscles of facial expression,
the most anterior (front) on the brain stem, they cheeks, and jaw. Symmetry of the
are appointed Roman numerals. An isolated nasolabial folds (lines from nose to outside
cranial nerve lesion is an unusual finding in corners of the mouth) should be observed.
decompression sickness or gas embolism, but
8. Acoustic: The Acoustic Nerve controls
deficits occasionally occur.
hearing and balance.
1. Olfactory: The olfactory nerve provides the
9. Glossopharyngeal: The Glossopharyngeal
sense of smell.
Nerves transmit sensation from the upper
2. Optic: The optic nerve is for vision. It mouth and throat area. It supplies the
functions in the recognition of light and sensory component of the gag reflex and
shade and in the perception of objects. constriction of the pharyngeal wall when
Blurring of vision, loss of vision, spots in saying “aah.”
the visual field or peripheral vision loss
10. Vagus: The Vagus Nerve has many
(tunnel vision) are also indicative of nerve
functions, including control of the roof of
involvement.
the mouth, vocal cords, and tone of the
3. Oculomotor, 4. Trochlear, 5. Abducens: voice; hoarseness may also indicate vagus
These three nerves control eye movements nerve involvement.
in the six directions (fields) and eye
11. Spinal Accessory: The Spinal Accessory
movement towards the tip of the nose
Nerve controls the turning of the head from
(giving a “crossed-eyed” look). The
side to side and shoulder shrug against
oculomotor nerve is responsible for
resistance.
movement of the pupils.
12. Hypoglossal: The Hypoglossal Nerve
6. Trigeminal: The Trigeminal Nerve
governs the muscle activity of the tongue.
governs sensation of the forehead and face
An injury to one of the hypoglossal nerves
and the clenching of the jaw. It also
causes the tongue to twist to that side when
supplies the muscle of the ear (tensor
stuck out of the mouth4.”
tympani) necessary for normal hearing.
6-71
Spinal Nerves AUTONOMIC NERVOUS SYSTEM
There are 31 pairs of spinal nerves that The autonomic nervous system (ANS) is
originate from the spinal cord. Although spinal the portion of the PNS that functions
nerves are not named individually, they are independently, automatically, and
grouped according to the level from which they continuously, without conscious effort. It helps
arise, and each nerve is numbered in sequence. to regulate the smooth muscles, cardiac muscle,
Thus, there are 8 pairs of cervical nerves, 12 digestive tract, blood vessels, sweat and
pairs of thoracic nerves, 5 pairs of lumbar digestive glands, and certain endocrine glands.
nerves, 5 pairs of sacral nerves, and 1 pair of The autonomic nervous system is not directly
coccygeal nerves (Fig. 6-53). under the control of the brain but usually works
in harmony with the nerves that are under the
Spinal nerves (mixed) send fibers to brain's control. The autonomic nervous system
sensory surfaces and muscles of the trunk and includes two subdivisions (the sympathetic and
extremities. Nerve fibers are also sent to parasympathetic nervous systems) that act
involuntary smooth muscles and glands of the together.
gastrointestinal tract, urogenital system, and
cardiovascular system. The sympathetic nervous system's primary
concern is to prepare the body for energy-
expending, stressful, or emergency situations,
also known as fight or flight. On the other
hand, the parasympathetic nervous system is
most active under routine, restful situations.
The parasympathetic system also
counterbalances the effects of the sympathetic
system, and restores the body to a resting state.
For example, during an emergency the body's
heart and respiration rate increases. After the
emergency, the parasympathetic system will
decrease heart and respiration rate to normal.
The sympathetic and parasympathetic systems
work together to preserve a harmonious
balance of body functions and activities.
6-72
THE SENSORY SYSTEM SIGHT
SMELL
6-73
Structure of the Eye Both chambers of the anterior cavity are filled
with a clear, watery fluid called aqueous
Approximately five-sixths of the eyeball humor. Aqueous humor helps to give the
lies recessed in the orbit, protected by a bony cornea its curved shape (Fig. 6-55). The
socket. Only the small anterior surface of the aqueous humor drains out of the anterior
eyeball is exposed. The eye is not a solid chamber at the same rate it enters the posterior
sphere but contains a large interior cavity that is chamber. When there is a pressure increase
divided into two cavities, anterior and posterior. inside the eye, and the level exceeds 25 mm
The anterior cavity is further subdivided into hg, damage will occur and may cause
anterior and posterior chambers (Fig. 6-55). blindness; this condition is called glaucoma.
Figure 6-55.—Eye Structure Horizontal section through the eyeball. The eye is viewed from above.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-74
The posterior cavity of the eye is larger MIDDLE LAYER.—The middle layer of
than the anterior cavity, occupying the entire the eye is the choroid. It is a highly vascular,
space posterior to the lens to include suspensory pigmented tissue that provides nourishment to
ligaments and ciliary body. The posterior cavity the inner structures. Continuous with the
contains a substance, with the consistency choroid is the ciliary body. The ciliary body
similar to soft gelatin, called vitreous humor. is formed by a thickening of the choroid and
Vitreous humor and aqueous humor help fits like a collar into the area between the retina
maintain sufficient pressure inside the eye to and iris. Attached to the ciliary body are the
prevent the eyeball from collapsing (Figs. 6-55 suspensory ligaments, which blend with the
and 6-56). elastic capsule of the lens and holds it in place
(Fig. 6-56).
The eyeball is composed of three layers;
sclera, choroid, and retina (Fig. 6-56). Iris.—The iris is continuous with the ciliary
body. It is a circular, pigmented muscular
structure that gives color to the eye. The iris
separates the anterior cavity into anterior and
posterior chambers. The opening in the iris is
called the pupil. The amount of light entering
the pupil is regulated through the constriction
of radial and circular muscles in the iris. When
strong light is flashed into the eye, the circular
muscle fibers of the iris contract, reducing the
size of the pupil decreasing the amount of light.
If the light is dim, the pupil dilates to allow as
much of the light in as possible. The size and
reaction of the pupils of the eyes are an
important diagnostic tool.
6-75
INNER LAYER.—The inner layer of the Vision Process
eye is the retina (Fig. 6-57). It contains layers
of nerve cells, rods, and cones, which are the The vision process begins with rays of light
receptors of the sense of vision. The retina is from an object passing through the cornea. The
continuous with the optic nerve, entering the image is then received by the lens, by way of
back of the globe carrying visual impulses the iris. Leaving the lens, the image falls on the
received by the rods and cones to the brain. The rods and cones in the retina. The image is then
area where the optic nerve enters the eyeball sent by the optic nerve to the brain for
contains no rods and cones and is called the interpretation (Fig. 6-58). Note the image
optic disc (blind spot). received by the retina is upside down, but the
brain turns it right-side up.
REFRACTION.—Deflection or bending
of light rays results when light passes through
substances of varying densities in the eye
(cornea, aqueous humor, lens, and vitreous
humor). The deflection of light in the eye is
refraction.
Figure 6-57.—Opthalmoscope View of the Eye
ACCOMMODATION. —Accommodation
is the process by which the lens increases or
Rods.— Rods respond to low intensities of decreases its curvature to refract light rays into
light and are responsible for night vision. They focus on the fovea centralis.
are located in all areas of the retina, except in
the small depression called the fovea centralis, CONVERGENCE.—The movement of the
where light entering the eye is focused, and has globes toward the midline causes a viewed
the clearest vision. If a person looks slightly object to come into focus on corresponding
to the side (where most of the cones are at) it points of the two retinas. This process
will be clearer at night. produces clear, three-dimensional vision.
6-76
HEARING The auricle collects sound waves from the
environments that are conducted by the
The ear is the primary organ of hearing and external auditory canal (about 3cm long) to the
the sense organ for balance. Its major parts are eardrum. The lining of the external auditory
illustrated in Figure 6-59. The ear is divided canal contains glands that secrete a wax-like
into three parts: the external, middle, and inner substance called cerumen. Cerumen aids in
ear. protecting the eardrum against foreign bodies
and microorganisms.
External Ear
The tympanic membrane, or eardrum, is
The external (outer) ear is composed of two an oval sheet of fibrous epithelial tissue that
parts, the auricle and the external auditory stretches across the inner end of the external
canal (see Fig. 6-15). The auricle, or pinna, is auditory canal (Fig. 6-59). The eardrum
a cartilaginous structure located on each side of separates the outer and middle ear. Sound
the head. waves cause the eardrum to vibrate, and this
vibration transfers the sounds from the external
environment to the auditory ossicles.
Figure 6-59.—Effect of sound waves on cochlear structures. A, Sound waves strike the tympanic membrane
and cause it to vibrate. This causes the membrane of the oval window to vibrate, which causes the perilymph
in the bony labyrinth of the cochlea and the endolymph in the membranous labyrinth of the cochlea, or
cochlear duct, to move. This movement of endolymph causes the basilar (spiral) membrane to vibrate, which
in turn stimulates hair cells on the organ of Corti (spiral organ) to transmit nerve impulses along the cranial
nerve. Eventually, nerve impulses reach the auditory cortex and are interpreted as sound. B, High-frequency
(high-pitch) waves stimulate hair cells nearer the stapes (oval window) and low-frequency (low-pitch) waves
stimulate hair cells nearer the distal end of the cochlea. The location of peak stimulation of the hair cells
allows the brain to interpret the pitch of the sound. (B: Adapted from Guyton A, Hall J: Textbook of medical
physiology, ed 11, Philadelphia, 2006, Saunders.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-77
Middle Ear The cells protruding from the organ of
Corti are stimulated by the ripples to convert
The middle ear is a cavity in the temporal these mechanical vibrations into nerve
bone, lined with epithelium. It contains three impulses, and these impulses are relayed
auditory ossicles the malleus (hammer), the through the vestibulocochlear (8th cranial)
incus (anvil), and the stapes (stirrup) which nerve to the auditory area of the cortex in the
transmit vibrations from the tympanic temporal lobe of the brain. There they are
membrane to the fluid in the inner ear (Fig. 6- interpreted as the sounds a person hears (Fig.
59). The malleus is attached to the inner surface 6-59).
of the eardrum and connects with the incus,
which in turn connects with the stapes. The The vestibule constitutes the central
base of the stapes is attached to the oval section of the bony labyrinth. The bony
window, the membrane-covered opening of labyrinth opens to the oval window as well as
the inner ear. These tiny bones, which span the the three semicircular canals which are
middle ear, are suspended from bony walls by situated at right angles to each other (Fig. 6-60).
ligaments. This arrangement provides the Movement of the endolymph within the canals,
mechanical means for transmitting sound caused by general body movements, stimulates
vibrations to the inner ear. nerve endings, which report these changes in
body position to the brain, which in turn uses
The eustachian tube, or auditory tube, the information to maintain equilibrium.
connects the middle ear with the nasopharynx.
It is lined with a mucous membrane and is The sense of organs located in the utricle
about 36 mm long. Its function is to equalize and saccule function in static equilibrium, a
internal and external air pressure. For example, function needed to sense the position of the
while riding an elevator in a tall building, a head relative to gravity or sense acceleration
person may experience a feeling of pressure in or deceleration of the body. “The sense organs
the ear. This condition is usually relieved by associated with semicircular ducts function in
swallowing, which opens the eustachian tube dynamic equilibrium – a function needed to
and allows the pressurized air to escape and maintain balance when the head or body itself
equalize with the area of lower pressure. Divers is rotated or suddenly moved.”
who ascend too fast to allow pressure to adjust
may experience rupture of their eardrums. The The round window is another membrane-
eustachian tube can also provide a pathway for covered opening of the inner ear. It is the
infection of the middle ear. opening for the auditory tube.
Inner Ear
6-78
Figure 6-60.—The inner ear. A, The bony labyrinth (bone colored) is the hard outer wall of the entire
inner ear and includes semicircular canals, vestibule, and cochlea. Within the bony labyrinth is the
membranous labyrinth (purple), which is surrounded by perilymph and filled with endolymph. Each
ampulla in the vestibule contains a crista ampullaris that detects changes in head position and sends
sensory impulses through the vestibular nerve to the brain. B, The inset shows a section of the
membranous cochlea. Hair cells in the organ of Corti (spiral organ) detect sound and send the
information through the cochlear nerve. The vestibular and cochlear nerves join to form the eighth
cranial nerve.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-79
TOUCH TYPES LOCATIONS SENSES
6-80
Cells that are affected by the hormone are
referred to as target organ cells. Endocrine
glands secrete hormones directly into the blood,
because they have no duct system. The glands of
this system are often called ductless glands
unlike exocrine glands that secrete their products
into ducts.
6-81
Figure 6-62.—Pituitary hormones. Some of the major hormones of the adenohypophysis and
neurohypophysis and their principal target organs.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
The pituitary is a small, pea-sized gland The anterior pituitary gland plays the more
located at the base of the brain in the sella important role in influencing body functions.
turcica, the Turkish saddle-shape depression of The five main secretions produced by the
the sphenoid bone. The pituitary is connnected anterior pituitary gland have a broad and
to the hypothalamus by the stalk called significant range of effects.
infundibulum. (Fig. 6-61). It is often called the
master gland of the body as it influences many SOMATOTROPHS.—Somatotropin, the
other endocrine glands. Although the pituitary growth hormone, influences body growth and
looks like just one gland, it actually consists of development. During the growth years, an
two separate glands, the anterior pituitary overproduction of somatotropin causes
gland and the posterior pituitary gland (Fig. 6-62). Giantism, while the lack of it causes Dwarfism.
An overproduction after the growth years
causes acromegaly, which is characterized by
the development of abnormally large hands,
feet, and jaw.
6-82
THYROTROPHS.—Thyrotropin, or the PINEAL GLAND
thyroid-stimulating hormone (TSH), influences
the growth, development, and secreting The pineal gland, or pineal body, is a tiny
activities of the thyroid gland. structure resembling a pine nut located on the
dorsal aspect of the brain’s diencephalons
GONADOTROPHS.—Gonadotropin region. It produces small amounts of different
influences the gonads and is essential for the hormones with melatonin being the main one.
normal development and functioning of both It is known as the biological clock; melantonin
male and female reproductive systems. levels rise when sunlight is absent triggering
sleepiness.
CORTICOTROPHS.—The
adrenocorticotropin hormone (ACTH) acts THYROID GLAND
primarily on the adrenal cortex (the outer portion
of the adrenal glands), stimulating its growth The thyroid gland, shaped like a butterfly,
and its secretion of corticosteroids. lies in the anterior part of the neck, below the
Corticosteroid hormones affect every cell in the larynx (Figs. 6-63 and 6-64). It consists of two
body. lobes, one on each side of the upper trachea,
connected by a strip of tissue called the
LACTOTROPHS.—Prolactin, (PRL): isthmus. The thyroid secretes the iodine
“during pregnancy, a high level of PRL containing hormone thyroxin (TSH), which
promotes the development of the breasts in controls the rate of cell metabolism. Excessive
anticipation of milk secretion. At the birth of an secretion of thyroxin raises the metabolic rate
infant, PRL in the mother stimulates the and causes hyperthyroidism. This condition is
mammary glands to begin milk secretion2.” characterized by a fast pulse rate, dizziness,
increased basal metabolism, profuse sweating,
Posterior Pituitary Gland tremors, nervousness, and a tremendous
appetite coupled with weight loss.
The posterior pituitary gland stores two
hormones, antidiuretic hormone (ADH) and Iodine is essential for the formation of
oxytocin. thyroxin. Simple goiter, a diffuse and painless
enlargement of the thyroid gland, was
ANTIDIURETIC.—The ADH hormone, common in areas of the United States where
promotes the conservation of water by the the iodine content of the soil and water was
kidney. ADH stimulates contraction of inadequate. In simple goiter, the gland
muscles in the wall of small arteries thus enlarges to compensate for the lack of iodine.
increasing blood pressure by retaining fluids To prevent formation of a simple goiter,
in the vasculature. When ADH is not produced iodine-containing foods, such as vegetables,
in adequate amounts, the daily urine volume iodized salt, and seafood, should be eaten.
increases to 10 and 15 liters instead of the
normal 1.5 liters. This condition is known as A condition known as hypothyroidism is
diabetes insipidus. caused by an insufficient secretion of thyroxin.
The patient exhibits a decrease in basal
OXYTOCIN.—Oxytocin stimulates metabolism, and sweating is almost absent.
contraction of the muscles of the uterus, There may be a weight gain and constant
particularly during delivery of a baby. It also fatigue. The heart rate may be slow, and a
plays an important role in the secretion of milk simple goiter may form. There may also be
in the mammary glands of nursing mothers. personality changes characterized by slow,
lethargic mental functioning. Hypothyroidism
during childhood can lead to the development
of cretinism. Cretinism is a condition characterized
by retarded mental and physical development.
6-83
Figure 6-63.—Thyroid gland. A, In this drawing, the relationship of the thyroid to the larynx (voice
box) and to the trachea is easily seen. B, In this photo of a dissected cadaver, the location of the
thyroid relative to the carotid arteries and jugular veins is seen. (B: From Jacob S: Atlas of human
anatomy, Edinburgh, 2002, Churchill Livingstone.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
Figure 6-64.—Parathyroid gland. A, In this drawing from a posterior view, note the relationship of the
parathyroid glands to each other, to the thyroid gland, to the larynx (voice box), and to the trachea. B, Photo
of a cadaver dissection (also from a posterior view) showing several parathyroid glands on the posterior
surface of the lateral lobes of an isolated thyroid gland. (B: From Abrahams P, Marks S, Hutchings R:
McMinn's color atlas of human anatomy, ed 3, Philadelphia, 2003, Mosby.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-84
PARATHYROID GLANDS ADRENAL GLANDS
Parathyroid glands are four small round The adrenal glands are located on the
bodies located just posterior to the thyroid superior surface of each kidney, fitting like a
gland (Fig. 6-64). Their hormone, cap (Fig. 6-65). They consist of an outer
parathormone (PTH), regulates the calcium portion, the cortex, and an inner portion, the
and phosphorus content of the blood and medulla.
bones. The amount of calcium is important in
certain tissue activities, such as bone Adrenal Cortex
formation, coagulation of blood, maintenance
of normal muscular excitability, and milk Specialized cells in the outer layer of the
production in the nursing mother. Diminished adrenal cortex produce three types of steroid
function or removal of the parathyroid glands hormones that are of vital importance.
results in a low calcium level in the blood. In
extreme cases death may occur, preceded by MINERALOCORTICOIDS.—
strong contraction of the muscles (tetany) and Mineralocorticoids are regulators of fluid and
convulsions. electrolyte balance. Sometimes called salt and
water hormones because they regulate the
Hyperparathyroidism, an excess of excretion and absorption of sodium, chlorine,
parathyroid hormone in the blood, causes potassium, and water. In humans, aldosterone
calcium levels in the blood to become elevated is the only physiologically important
by the withdrawal of calcium from the bones, mineralcorticoid. Its primary function is the
leaving the skeleton demineralized and subject maintenance of sodium homeostasis in the
to spontaneous fractures. The excess calcium blood. Aldosterone accomplishes this by
may be deposited as stones in the kidneys. increasing sodium reabsorption in the kidneys.
Figure 6-65.—Structure of the adrenal gland. The zona glomerulosa of the cortex secretes aldosterone. The
zona fasciculata secretes abundant amounts of glucocorticoids, chiefly cortisol. The zona reticularis secretes
minute amounts of sex hormones and glucocorticoids. A portion of the medulla is visible at lower right at the
bottom of the drawing.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-85
GLUCOCORTICOIDS.—Glucocorticoids PANCREAS
are essential to metabolism. They increase
certain liver functions and have an anti- The pancreas contains exocrine and
inflammatory effect. Clinically, they are used endocrine tissues. The exocrine tissue secretes
to suppress inflammatory reactions, to promote digestive juice through a duct to the small
healing, to treat rheumatoid arthritis, and intestine, while the endocrine tissue releases
maintain normal blood pressure. One of the hormones into body fluids. The endocrine
main glucocorticoids secreted in significant portion of the pancreas consists of cells
amounts is cortisol. arranged in groups, called islands (islets) of
Langerhans. The islands (islets) of
GONADOCORTICOIDS.—The adrenal Langerhans contain three types of endocrine
cortex also produces sex hormones, some with cells: alpha, beta, and delta. The alpha cells
male characteristics (androgens), others with secrete the hormone glucagon. Glucagon
female characteristics (estrogens). These causes a temporary rise in blood sugar levels.
hormones appear in different concentrations in The beta cells secrete insulin, which is essential
both men and women. for carbohydrate metabolism. Insulin lowers
blood sugar levels by increasing tissue
Adrenal Medulla utilization of glucose and stimulating the
formation and storage of glycogen in the liver.
The adrenal medulla secretes epinephrine Together, glucagon and insulin act to regulate
(adrenalin) in the presence of emotional sugar metabolism in the body. Delta cells
crises, hypoglycemia (low blood sugar), or produce the hormone somatostatin.
low blood pressure. Epinephrine causes Somatostatin helps regulate carbohydrates by
powerful contractions of many arterioles inhibiting the secretion of glucagon.
(especially in the skin, mucous membranes,
and kidneys), but it dilates other arterioles (such When the islet cells are destroyed or stop
as those of the coronary system, skeletal functioning, the sugar absorbed from the
muscles, and lungs). Heart rate, respiration intestine remains in the blood and excess
rate and depth, blood pressure, blood sugar sugar is excreted by the kidneys into the
levels, and metabolism are all increased by urine. This condition is called diabetes
epinephrine. It stimulates the production of mellitus, or sugar diabetes. Insulin, a
other adrenal cortical hormones. synthetic hormone, is given to patients
having this disease as part of their ongoing
Norepinephrine is produced in the treatment.
adrenal medulla and a chemical precursor to
epinephrine. Its effects are similar to those of
epinephrine, but its action differs.
6-86
GONADS (TESTES AND OVARIES) Male Secondary Sex Characteristics
The male gonad is the testis (pl. testes), • Increased muscle growth, broadening of
and the existence of the testes is the primary the shoulder and narrowing of the waist
male sex characteristic (Fig. 6-66). The testes • Thickening and strengthening of the bones
produce and secrete the male hormone
testosterone, which influences the The male accessory sex organs include
development and maintenance of the male two groups of organs: the internal sex organs
accessory sex organs and the secondary sex and the external sex organs. See section titled
characteristics. "Male Reproductive System” for more
information on the male accessory sex organs.
Ovaries
6-87
Female Secondary Sex Characteristics: THE RESPIRATORY SYSTEM
Estrogen Influenced
LEARNING OBJECTIVES:
• Development of the breasts and the ductile
system of the mammary glands within the Identify the parts, location, and function of
breasts each part of the respiratory system.
• Increased quantities of fatty (or adipose) Describe the process of respiration.
tissue in the subcutaneous layer, especially
in the breasts, thighs, and buttocks
Respiration is the exchange of oxygen and
• Increased vascularization of the skin carbon dioxide between the atmosphere and
Female accessory sex organs are also the cells of the body. There are two phases of
divided into internal and external accessory sex respiration:
organs. See section titled "Female Reproductive • Physical, or mechanical respiration
System” for more information on the female (external respiration) involves the motion
accessory sex organs. of the diaphragm and rib cage. The
musculoskeletal action, which resembles
PLACENTA that of a bellows, causes air to be inhaled or
exhaled
“The placenta, the tissue that forms on
the lining of the uterus as an interface • Physiological respiration (internal
between the circulatory systems of the respiration) involves an exchange of gases,
mother and developing child, serves as a oxygen and carbon dioxide, at two points in
temporary endocrine gland. The placenta the body. The first is the transfer that
produces the human chorionic occurs in the lungs between the incoming
gonadotropin (HCG).” This hormone is high oxygen and the carbon dioxide present in
during the first 3 months of pregnancy to tell the capillaries of the lungs (external
the female’s gonads to maintain the uterine respiration). The second transfer occurs
lining instead of falling away as in when oxygen brought into the body
menstruation. HCG is the hormone used for replaces carbon dioxide build up in the
early pregnancy tests. cellular tissue (internal respiration)
Oxygen and carbon dioxide exchange in
THYMUS equal volumes; however, certain physiological
conditions may throw this balance off. For
The thymus is a gland located in the example, heavy smokers will find that the
mediastinum just beneath the sternum. It is ability of their lungs to exchange gases is
large in children and atrophies as they impaired, leading to shortness of breath and
become adults, once they reach old age it fatigue during even slight physical exertion.
becomes a vestige of fat and fibrous tissue. It This debilitating situation is the direct result
has a critical role in the immune system, of their inability to draw a sufficient amount of
thought to stimulate the production of T cells. oxygen into the body to replace the carbon
dioxide build-up resulting in fatigue. Another
GASTRIC MUCOSA example, hyperventilation brings too much
oxygen into the body, overloading the system
The hormone Ghrelin produced by the with oxygen, and depleting the carbon dioxide
endocrine cells in the gastric mucosa needed for balance.
stimulates the hypothalamus to boost
appetite, slow metabolism and fat burning,
and may play an important role in obesity.
6-88
ANATOMY OF THE RESPIRATORY The sequence of air through the nose is
SYSTEM anterior nares; vestibule; inferior, middle, and
superior meatuses (simultaneously); and
Air enters the nasal chambers and the posterior nares (Fig-6-68). The nasal and oral
mouth, then passes through the pharynx, larynx, cavities are separated by the palate. The anterior,
trachea, and bronchi into the bronchioles. Each rigid portion is called the hard palate, and the
bronchiole is surrounded by a cluster of alveoli posterior fleshy part is called the soft palate. The
(Fig. 6-67). mouth and nose serve as secondary respiratory
structures.
Nasal Cavity
Figure 6-67.—Structural plan of the respiratory system. The inset shows the alveolar sacs where the
interchange of oxygen and carbon dioxide takes place through the walls of the grapelike alveoli.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-89
Figure 6-68.—Upper respiratory tract. In this midsagittal section through the upper respiratory tract, the
nasal septum has been removed to reveal the turbinates (nasal conchae) of the lateral wall of the nasal
cavity. The three divisions of the pharynx (nasopharynx, oropharynx, and laryngopharynx) are also
visible.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
Pharynx Epiglottis
The pharynx, or throat, serves both the The epiglottis is a lid-like, leaf-shaped
respiratory and digestive systems and aids in cartilaginous structure that covers the entrance
speech. It has a mucous membrane lining that to the larynx and separates it from the pharynx.
traps microscopic particles in the air and aids It acts as a trap door to deflect food particles
in adjusting temperature and humidifying and liquids from entering the larynx and
inspired (inhaled) air. The pharynx connects trachea.
with the mouth and nasal chambers
posteriorly. According to its location, the
pharynx is referred to as the nasopharynx
(posterior to the nasal chambers), the
oropharynx (posterior to the mouth), or the
laryngopharynx (posterior to the pharynx).
6-90
Larynx
6-91
Trachea Bronchioles
The trachea, or windpipe, begins at the The bronchioles are much smaller than the
lower end of the larynx and terminates by bronchi and lack supporting rings of cartilage.
dividing into the right and left bronchi. It is a They terminate at the alveoli.
long tube about 11 cm composed of 16 to 20 C-
shaped cartilaginous rings, incomplete on the Alveoli
posterior surface, embedded in a fibrous
membrane, that support its walls, preventing The alveoli are thin, microscopic air sacs
their collapse (Fig. 6-70). within the lungs (Fig. 6-71). They are in direct
contact with the pulmonary capillaries. It is
The trachea has a ciliated mucous here that oxygen exchanges with carbon dioxide
membrane lining that entraps dust and foreign by means of a diffusion process through the
material. It also propels secretions and alveolar and capillary cell walls. The lungs are
exudates from the lungs to the pharynx, where cone-shaped organs that lie in the thoracic
they can be expectorated or swallowed. cavity. Each lung contains thousands of alveoli
with their capillaries. The right lung is larger
Bronchi than the left lung and is divided into superior,
middle, and inferior lobes. The left lung has
The trachea splits into two primary two lobes, the superior and the inferior (Fig.
bronchi, the right being larger and more 6-72).
vertical than the left; this is where they enter
the lungs. This explains why more foreign
objects get lodged on the right side. Once
entering the lungs they immediately divide
into smaller branches to carry air to each lung
and further divide into the bronchioles.
Figure 6-70.—Cross section of the trachea. The inset at the top shows from where the section was cut. The
scanning electron micrograph shows details of the mucous coat, the tip of a cartilage ring, and the adventitia
that form the wall of the trachea (×300). (From Erlandsen SL, Magney J: Color atlas of histology, St Louis,
1992, Mosby.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-92
Figure 6-71.—Alveoli. A, Respiratory bronchioles subdivide to form tiny tubes called alveolar ducts,
which end in clusters of alveoli called alveolar sacs. B, Scanning electron micrograph of a bronchiole,
alveolar ducts, and surrounding alveoli. The arrowhead indicates the opening of alveoli into the
alveolar duct. (B: From Erlandsen SL, Magney J: Color atlas of histology, St Louis, 1992, Mosby.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-93
Figure 6-72.—Lobes and segments of the lungs. A, Anterior view of the lungs, bronchi, and trachea.
B, Expanded diagram showing the bronchopulmonary segments.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-94
Figure 6-73.—Lungs and pleura (transverse section). Note the parietal pleura lining the right and left pleural
divisions of the thoracic cavity before folding inward near the bronchi to cover the lungs as the visceral
pleura. The intrapleural space separates the parietal and visceral pleura. The heart, esophagus, and aorta are
shown in the central mediastinum.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-95
The respiratory center can be stimulated or Digestive Source Substance Product
depressed by a signal from the brain. For Juice Acted Upon
example, changes in one's emotional state can Amylase Salivary Starch Complex
alter respiration through laughter, crying, glands and sugars
emotional shock, or panic. pancreas (maltose)
Hydrochloric Gastric Pepsinogen Pepsin (Split
The muscles of respiration normally act acid glands (Proteins) proteins)
automatically, with normal respiration being 14 Bile Liver Fats Emulsified
to 18 cycles per minute. The lungs, when filled fats
to capacity, hold about 6,200 ml of air, but only Proteinase Pancreas Proteins and Peptides and
500 ml of air is exchanged with each normal split polypeptides
respiration. This exchanged air is called tidal proteins
air. The amount of air left in the lungs after Lipase Pancreas Fats Fatty acids
forceful exhalation is about 1,200 ml and is Carbohydrase Intestinal Complex Simple
known as residual air. glands sugars sugars
(maltose, (glucose,
sucrose, fructose, and
THE DIGESTIVE SYSTEM and lactose) galactose)
Peptidase Intestinal Peptides and Amino acids
LEARNING OBJECTIVE: glands polypeptides
6-96
Mouth
The alimentary canal (tract) is 9 meters in Image reprinted with permission from: Thibedeau, G.
length, tubular, and includes the mouth, A., & Patton, K. T. (2006). Anatomy & Physiology
pharynx, esophagus, stomach, small intestine, (6th ed.). St. Louis: Elsevier Health Sciences.
and large intestine.
6-97
Figure 6-76.—Salivary glands. A, Location of the salivary glands. B and C, Detail of submandibular
salivary gland. This mixed- or compound-type gland produces mucus from mucous cells and enzymatic
secretion from serous cells. Duct cross sections are also visible. (×140.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-98
Pharynx
Esophagus
6-99
Figure 6-78.—Esophagus. A, Diagram showing the major features of the esophagus. B, View of the muscular
wall of the esophagus from behind, showing its position relative to other structures.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-100
Figure 6-79.—Stomach. A portion of the anterior wall has been cut away to reveal the muscle layers
of the stomach wall. Notice that the mucosa lining the stomach forms folds called rugae.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-101
ILEUM.—The ileum is the last and longest The appendix, a long narrow tube with a
part of the small intestine; it is approximately blind end, is a pouch-like structure of the
3.5 meters (12 feet) long. cecum located near the junction of the ileum
and the cecum. There is no known function of
Most of the absorption of food occurs in the this structure. The appendix can become
small intestines, where fingerlike projections infected, causing inflammation to develop.
(villi) provide a large absorption surface. This inflammation of the appendix is known
After ingestion, it takes 20 minutes to 2 hours as appendicitis (Fig. 6-80) and requires
for the first portion of the food to pass through surgery to correct.
the small intestine to the beginning of the large
intestine.
Large Intestine
6-102
RECTUM.—The rectum is approximately ACCESSORY ORGANS OF DIGESTION
17-20 cm (7 or 8 inches) long and follows the
contour of the sacrum and coccyx until it The accessory organs of digestion include
curves back into the short 2.5 cm (inch) anal the salivary glands, pancreas, liver, and
canal. The anus is the external opening at the gallbladder. As stated earlier, during the
lower end of the digestive system. Except digestive process, the accessory organs
during bowel movement (defecation), it is kept produce secretions that assist the organs of the
closed by two sphincters. An internal one alimentary canal.
made of smooth muscle and external one made
of striated muscle (Fig. 6-81). Salivary Glands
6-103
Figure 6-82.—Pancreas. A, Pancreas dissected to show the main and accessory ducts. The main duct
may join the common bile duct, as shown here, to enter the duodenum by a single opening at the
major duodenal papilla, or the two ducts may have separate openings. The accessory pancreatic duct
is usually present and has a separate opening into the duodenum. B, Exocrine glandular cells
(around small pancreatic ducts) and endocrine glandular cells of the pancreatic islets (adjacent to
blood capillaries). Exocrine pancreatic cells secrete pancreatic juice, alpha endocrine cells secrete
glucagon, and beta cells secrete insulin.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006). Anatomy & Physiology
(6th ed.). St. Louis: Elsevier Health Sciences.
6-104
Liver Gallbladder
The liver is the largest gland in the body. The gallbladder is a pear-shaped sac,
It is located in the upper abdomen on the right stained dark green by the bile it contains. It is
side, just under the diaphragm and superior to located in the hollow underside of the liver
the duodenum and pylorus. (Fig. 6-83). Its duct, the cystic duct, joins the
hepatic duct from the liver to form the
Of the liver's many functions, the common bile duct, which enters the
following are important: duodenum (Fig. 6-83). The gallbladder receives
bile from the liver and then concentrates and
• It metabolizes carbohydrates, fats, and
stores it. It secretes bile when the small
proteins preparatory to their use or
intestine is stimulated by the entrance of fats.
excretion
Refer to Table 6-9 for a complete review of
• It forms and excretes bile salts and pigment the digestive organs and processes.
from bilirubin, a waste product of red
blood cell destruction
• It stores blood; glycogen; vitamins A, D,
and B-12; a n d i r o n
• It detoxifies the end products of protein
digestion and drugs
• It produces antibodies and essential
elements of blood-clotting mechanisms
Figure 6-83.—Ducts that carry bile from the liver and gallbladder. Obstruction of either the common
hepatic or the common bile duct by a stone or spasm prevents bile from being ejected into the
duodenum. The inset shows an x-ray of the gallbladder and the ducts that carry bile taken during a
procedure called endoscopic cholangiography. (From Abrahams P, Marks S, Hutchings R:
McMinn's color atlas of human anatomy, ed 5, Philadelphia, 2003, Saunders.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-105
Table 6-9.—The Big Picture
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-106
THE URINARY SYSTEM
LEARNING OBJECTIVE:
KIDNEYS
6-107
Figure 6-85.—Internal structure of the kidney. A, Coronal section of the right kidney in an artist's rendering.
B, Photo of a coronal section of a preserved human kidney. (A: Adapted from Brundage DJ: Renal disorders.
Mosby's clinical nursing series, St Louis, 1992, Mosby. B: From Abrahams P, Marks S, Hutchings R:
McMinn's color atlas of human anatomy, ed 5, Philadelphia, 2003, Mosby.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
Figure 6-86.—Circulation of blood through the kidney. A, Diagram showing the major arteries and veins of
the renal circulation. B, Renal arteriogram. Arcuate arteries (1) are seen near the junction of the cortex and
medulla, interlobar arteries (2) are present between the medullary pyramids, and lobar arteries (3) and
segmental arteries (4) are seen branching from the main renal artery (5). Note the tip of the catheter used to
inject contrast material (6) into the proximal part of the main renal artery. (B: From Weir J, Abrahams P:
Imaging atlas of the human anatomy, ed 2, Philadelphia, 1997, Mosby.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy &Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-108
Structure The principal portion of the kidney is
divided into two distinct regions: an inner
The lateral surface of the kidneys is medulla and outer cortex (Fig. 6-85). The renal
convex in shape, and the medial side is deeply medulla is composed of pyramid-shaped
concave. The medial side of each kidney masses of tubes and tubules called renal
possesses a depression that leads to a hollow pyramids. Renal pyramids drain the urine to
chamber called the renal sinus (Fig. 6-85). The the renal pelvis. The renal cortex forms a
entrance of the renal sinus is referred to as the shell over the renal medulla. Renal cortex
hilum (Fig. 6-85). Blood vessels, nerves, tissue dips down, like fingers, between the
lymphatic vessels, and the ureters pass through renal pyramids, and forms renal columns. The
the hilum. cortex possesses very small tubes associated
with nephrons. Nephrons are the functional
The superior end of the ureter forms a units of the kidneys.
funnel-shaped sac called the renal pelvis (Fig.
6-85). The renal pelvis is divided into two or RENAL BLOOD VESSELS.—The renal
three tubes, called major calyces. The major artery supplies blood to the kidneys. The renal
calyces (sing. calyx) are further subdivided artery enters the kidneys through the hilum and
into minor calyces. sends off branches to the renal pyramids. These
arterial branches are called interlobar arteries.
There are groups of elevated projections in At the border between the medulla and cortex,
the walls of the renal pelvis. These projections the interlobar arteries branch to form the
are called renal papillae. The renal papillae arcuate arteries. The arcuate arteries branch
connect to the minor calyces through tiny and form the interlobular a rt er i e s.
openings in the minor calyces (Fig. 6-87).
The venous system of the kidneys generally
follows the same paths as the arteries. Venous
blood passes through the interlobular, arcuate,
interlobar, and renal veins.
Figure 6-87.—Renal papilla. Collecting ducts (CD) Leading away from the glomerulus is the
can be seen opening into a calyx (C) at the renal tubule. The initial portion of the renal
papillary tip. The interstitial tissue (I) includes tubule is coiled and called the proximal
some Henle loops and vasa recta vessels. (From convoluted (meaning coiled or twisted)
Stevens A, Lowe J: Human histology, ed 3, tubule. The proximal convoluted tubule dips
Philadelphia, 2005, Mosby.)
down to become the descending loop of
Henle. The tubule then curves upward toward
Image reprinted with permission from: Thibedeau, G.
A., & Patton, K. T. (2006). Anatomy & Physiology the renal corpuscle and forms the ascending
(6th ed.). St. Louis: Elsevier Health Sciences. loop of Henle.
6-109
Function
6-110
The glomerulus filters an estimated 1,200 ml Structure
of blood through the kidneys each minute (or
2,500 gallons in 24 hours) and about 80 gallons The bladder is a hollow, expandable,
of glomerular filtrate in 24 hours. All the water muscular organ located in the pelvic girdle.
from this filtrate is reabsorbed in the renal Although the shape of the bladder is spherical,
tubules except those containing the its shape is altered by the pressures of
concentrated waste products. surrounding organs. When it is empty, the
inner walls of the bladder form folds. As the
The function of the ureters is to carry bladder fills with urine, the walls become
urine from each kidney to the urinary bladder. smoother.
The ureters are two membranous tubes 1 mm to
1 cm in diameter and about 25 cm in length. The internal floor of the bladder includes
Urine is transported through the ureters by a triangular area called the trigone (Fig. 6-89).
peristaltic waves (produced by the ureter's The trigone has three openings at each of its
muscular walls). angles. The ureters are attached to the two
posterior openings. The anterior opening, at the
URINARY BLADDER apex of the trigone, contains a funnel-like
continuation called the neck of the bladder. The
The urinary bladder functions as a neck leads to the urethra.
temporary reservoir for urine. The bladder
possesses features that enable urine to enter, be
stored, and later be evacuated from the body.
Figure 6-89.—Structure of the urinary bladder. Frontal view of a dissected urinary bladder (male) in
a fully distended state. Inset shows a cross section of the bladder wall, which has layers similar to
those in other hollow abdominopelvic organs (compare to Figure 25-2)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-111
The wall of the bladder consists of four URETHRA
bundles of smooth muscle fibers. These
interlaced muscle fibers form the detrusor The urethra is the tube that carries urine
muscle (which surrounds the bladder neck) and from the bladder to the outside of the body.
comprise what is called the internal urethral The urinary meatus is the external urethral
sphincter. The internal urethral sphincter orifice. In the male, the urethra is common to
prevents urine from escaping the bladder until the urinary and reproductive systems; in the
the pressure inside the bladder reaches a female, it belongs only to the urinary system.
certain level. Parasympathetic nerve fibers in
the detrusor muscle function in the micturition Female Urethra
(urination) process. The outer layer (serous
coat) of the bladder wall consists of two types The female urethra is about 4 cm long,
of tissue, parietal peritoneum and fibrous extending from the bladder to the external
connective tissue. orifice.
Micturition is the process by which urine The male urethra is about 20 cm long and
is expelled from the bladder. It involves the is divided into three parts: the prostatic,
contraction of the detrusor muscle and pressure membranous, and penile portions.
from surrounding structures to expel the urine.
Urination also involves the relaxation of the PROSTATIC URETHRA—The prostatic
external urethral sphincter. The external urethra is surrounded by the prostate gland; it
urethral sphincter surrounds the urethra about contains the orifices of the prostatic and
3 centimeters from the bladder, and is ejaculatory ducts. This portion of the male
composed of voluntary muscular tissue. urethra is about 2.5 cm long.
6-112
MALE REPRODUCTIVE SYSTEM The accessory organs include both internal
and external reproductive organs. See Figure
6-90 for an illustration of the male reproductive
LEARNING OBJECTIVE:
system.
Indentify the parts of the male reproductive
The testes, as stated earlier, are the
system and their function(s).
primary male reproductive organs. They
produce sperm cells (spermatozoa) and male
The gonads of the male and female hormones, both necessary for reproduction.
reproductive systems are concerned with the
process of reproducing offspring, and each
organ is adapted to perform specialized tasks.
The primary male sex organs of the
reproductive system are the testes. The other
structures of the male reproductive system are
termed accessory reproductive organs.
Figure 6-90.—The male reproductive system. Illustration shows the testes, epididymis, vas (ductus)
deferens, and glands of the male reproductive system in an isolation/dissection format. (Barbara
Cousins.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-113
Structure Functions
The testes are oval glands suspended The testes perform two functions: to
inside a sac (the scrotum) by a spermatic produce sperm cells and to secrete male sex
cord. The spermatic cords are formed by the hormones. The process by which sperm cells
vas deferens, arteries, veins, lymphatics, and are produced is called spermatogenesis.
nerves, all bound together by connective Spermatogenesis occurs in the seminiferous
tissue. tubules of the testes. Once the sperm cells are
formed, they collect in the lumen of each
Each testis is encapsulated by a tough, seminiferous tubule. When the sperm cells are
white, fibrous tissue called the tunica ready, they pass through the rete testis to the
albuginea. The interior of the testis is divided epididymis, where they remain to mature. The
into 200 or more cone shaped lobules (small production of sperm cells occurs continually
lobes). Each lobule contains 1 to 3 highly throughout the reproductive life of a male.
coiled, convoluted tubules called seminiferous
tubules. These tubules unite to form a complex The male hormone testosterone is
network of channels called the rete testis. The produced in the testes. This hormone is initially
rete testis give rise to several efferent ductules responsible for the formation of the male
that join a tube called the epididymis (Fig. 6-91). reproductive organs. During puberty,
testosterone stimulates the enlargement of the
testes and various other accessory reproductive
organs.
Figure 6-91.—Tubules of the testis and epididymis. A, Transilluminated photograph; the testis is the darker
sphere in the center. B, Illustration showing epididymis lifted free of testis. The ducts and tubules are
exaggerated in size. (A: Lennart Nilsson.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-114
It causes the development and maintenance smooth movable cord. It ascends as part of the
of the male secondary sexual characteristics and spermatic cord through the inguinal canal of
accessory organs such as the prostate, seminal the lower abdominal wall into the pelvic
vesicles; and adult male behavior. Refer to the cavity and transmits the sperm to the
section titled "The Endocrine System” for ejaculatory ducts. The sperm can stay here up
more detailed discussion on male secondary to a month without any loss of fertility
sexual characteristics. depending upon sexual activity.
Vas Deferens
6-115
Prostate Gland Scrotum
6-116
FEMALE REPRODUCTIVE SYSTEM OVARIES
The organs of the female reproductive The ovaries, or female gonads, are two
system are specialized to produce and almond-shaped glands suspended by ligaments
maintain the female sex cells, or egg cells; to in the upper pelvic cavity. One ovary on each
transport these cells to the site of fertilization; side of the uterus. The ligaments that suspend
to provide an environment for a developing the ovaries contain ovarian blood vessels and
offspring; to move the offspring outside; and to nerves.
produce female sex hormones. The primary
female reproductive organs are the ovaries. The The tissues of an ovary are divided into
other structures of the female reproductive two regions, an inner medulla and an outer
system are considered accessory reproductive cortex. The ovarian medulla is largely
organs. The accessory organs include both internal composed of loose connective tissue,
and external reproductive organs (Fig. 6-92). numerous blood vessels, lymph vessels, and
nerves.
Figure 6-92.—Female reproductive organs. A, Diagram (sagittal section) of pelvis showing location of
female reproductive organs.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-117
surround a developing egg cell and secrete
female sex hormones. There are approximately
400,000 primordial follicles at puberty. Fewer
than 500 will be released from the ovary during
the reproductive life of a female.
6-118
Female Sex Hormones INTERNAL ACCESSORY ORGANS
Female sex hormones of estrogen and The internal accessory organs of the female
progesterone are produced by the ovaries and reproductive system include a pair of fallopian
various other tissues, such as the adrenal tubes, the uterus, and the vagina (Fig. 6-94).
glands, pituitary gland, and placenta (during
pregnancy). The primary source for estrogen is Fallopian Tubes (uterine tubes)
the ovaries. At puberty, estrogen stimulates
enlargement of various accessory organs, The fallopian tubes serve as ducts for the
which include the vagina, uterus, fallopian ovaries providing a passageway to the uterus.
tubes, and external structures. Estrogen is also The fallopian tubes are composed of three
responsible for the development and tissue layers. These tissue layers include an
maintenance of female secondary sexual inner mucosal layer, middle muscular layer,
characteristics. See section titled “Endocrine and outer serous layer. They are continuous
System“for listing of secondary female sexual with the layers of the uterus. The fallopian
characteristics. tubes are in contact with the ovaries but are not
continuous with them. Their funnel-shaped
The ovaries are the primary source of openings, called free openings, are fringed
progesterone (in a nonpregnant female). This with fingerlike processes that pick up an ovum
hormone promotes changes that occur in the and draw it into the fallopian tubes. As the
uterus during the female reproductive cycle. ovum enters the fallopian tubes, it is transported
Progesterone stimulates the enlargement of to the uterus by peristalsis and gravity.
mammary glands and ducts, and increases fat Fertilization of an ovum normally takes place
deposits in female breasts during puberty. in the fallopian tubes.
Figure 6-94.—Female reproductive organs. B, MRI scan (sagittal view) of female pelvic viscera. (B: From
Moses K, Nava P, Banks J, Petersen D: Moses atlas of clinical gross anatomy, Philadelphia, 2005, Mosby.)
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
6-119
Uterus (Womb) Vagina
The function of the uterus is to receive the The vagina receives the male sperm during
embryo that results from the fertilization of an intercourse. It forms the lower portion of the
egg cell and to sustain its life during birth canal, stretching widely during delivery.
development. The uterus is a hollow, pear- In addition, it serves as an excretory duct for
shaped organ with thick, muscular walls. The uterine secretions and menstrual flow.
uterus is divided into two main regions, the
body and cervix (Figs. 6-92 and 6-94). The The vagina is a fibromuscular tube capable
body of the uterus consists of the upper two- of great distention. The canal is approximately
thirds of the uterus. The cervix is the lower one- 7-8 cm long extending from the uterus to the
third portion of the uterus that projects into the outside. The vaginal orifice is partially closed
upper part of the vagina. The cervical opening by a thin membrane of tissue called the hymen.
into the vagina is called the external os. The wall of the vagina consists of three layers.
The inner mucosal layer does not have mucous
The uterine wall is composed of three glands; mucous found in the vagina comes from
layers: endometrium, myometrium, and the glands of the cervix. The middle muscular
perimetrium. The inner lining consists of layer consists mainly of smooth muscles fibers.
specialized epithelium, called endometrium, At the lower end of the vagina is a thin band of
which undergoes partial destruction smooth muscle that helps close the vaginal
approximately every 28 days in the non- opening. The outer fibrous layer consists of
pregnant female. The middle layer, dense fibrous connective tissue interlaced with
myometrium, consists of bundles of elastic fibers. These fibers attach the vagina to
interlaced muscular fibers. The muscular layer the surrounding organs.
produces powerful rhythmic contractions
important in the expulsion of the fetus at birth. EXTERNAL ACCESSORY ORGANS
The perimetrium consists of an outer serosal
layer that covers part of the uterine body and Many of the external accessory organs of
none of the cervix. The uterus also has three the female reproductive system are referred to
openings: superiorly and laterally, two collectively as the vulva. The vulva includes
openings connect the fallopian tubes to the the labia majora, the labia minora, the clitoris,
uterus, and inferiorly, an opening leading to the and the vestibular glands (Fig. 6-95). The
vagina. mammary glands are also considered an
accessory organ of the female reproductive
system.
6-120
Figure 6-95.—Vulva (pudendum). A, Sketch showing major features of the external female genitals
(genitalia). Compare to Figure 32-2.
Image reprinted with permission from: Thibedeau, G. A., & Patton, K. T. (2006).
Anatomy & Physiology (6th ed.). St. Louis: Elsevier Health Sciences.
The function of the labia majora is to The clitoris is a small projectile at the
enclose and protect the other external anterior end of the vulva between the labia
reproductive organs. The labia majora are minora. It is richly endowed with sensory
composed of two round folds of fat tissue and a nerves that are associated with the feeling of
thin layer of smooth muscle, covered by skin. pleasure during sexual stimulation.
On the outer portion of the labia majora, the skin
has numerous hairs, sweat glands, and Vestibule
sebaceous glands. The inner portion of skin is
thin and hairless. The labia majora extend from The vestibule is the area enclosed by the
the mons pubis anteriorly to the perineum (the labia minora that includes those vaginal and
region between the vaginal orifice and the urethral openings. The vestibule contains a pair
anus). The mons pubis is the pad of fatty tissue of vestibular glands, more commonly known as
beneath the skin, which overlies the symphysis the Bartholin's glands. The Bartholin's glands
pubis. lay on each side of the vaginal opening. The
ducts of these glands secrete fluid that moistens
Labia Minora and lubricates the vestibule. There are also the
Skenes glands that are near the opening of the
Within the labia majora folds are two urinary meatus by way of two small ducts.
smaller folds, called the labia minora. The labia
minora extend from the clitoris to either side of
the vaginal orifice.
6-121
Mammary Glands (Breasts) The time between the last day of the
menses and ovulation is known as the
The mammary glands are accessory organs postmenstrual phase. It lasts from day 6
of the female reproductive system. They through day 13 or 14 and is characterized by
develop during puberty under the influence of proliferation of endometrial cells in the uterus,
the hormones estrogen and progesterone. The which develop under the influence of the
breasts are responsible for the secretion of milk hormone estrogen.
(lactation) for the nourishment of newborn
infants. Ovulation is the rupture of a primordial
follicle with the release of a mature ovum into
Structurally, the breasts resemble sweat the fallopian tubes. It usually occurs on day 14
glands. At the center is a nipple containing 15 or 15 of the cycle. The postovulatory
to 20 depressions into which ducts from the (premenstrual) phase is the time between
lobes of the gland empty. During pregnancy, ovulation and the onset of the menstrual
placental estrogen and progesterone stimulate bleeding and normally lasts 14 days. During this
further development of the mammary glands in phase the ovum travels through the fallopian
preparation for lactation. After childbirth, tubes to the uterus. If the ovum becomes
hormones secreted by the anterior lobe of the fertilized during this passage, it will become
pituitary gland stimulate production for 6 to 9 implanted in and nurtured by the newly
months. developed endometrial lining. If fertilization
does not take place, the lining deteriorates and
FEMALE REPRODUCTIVE CYCLE eventually sloughs off, marking day 1 of the
next cycle.
Females around age 11 begin to
experience the female reproductive cycle and SUMMARY
continue into middle age, after which it
ceases. The female reproductive cycle, or This chapter reviewed the basic structures
menstrual cycle, is characterized by regular, of the cell to the many complex systems of the
recurring changes in the uterine lining, human body. It outlined how each body system
resulting in menstrual bleeding (menses). functions and how each system is
interdependent upon each other. Anatomical
The first phase of the recurring terminology is used in describing location of
reproductive cycle is menstrual bleeding. injuries or conditions. The HM will use this
Menstrual bleeding begins when the knowledge of human anatomy and physiology
endometrial lining starts to slough off from the when performing patient assessments.
walls of the uterus, and it is characterized by
bleeding from the vagina. This is day 1 of the
cycle, and this phase usually lasts through day 5.
6-122
CHAPTER 7
This chapter covers the oral anatomy and As soon as the dental lamina is formed,
physiology of the teeth, the histology of the patches of epithelial cells located there grow
tissues and supporting structures, and into the underlying tissues to become tooth buds.
concentrates on the external features of the teeth. Usually 10 tooth buds are present in each
The teeth are identified by different sizes, shape, dental arch and they give rise to future primary
and other characteristics from one person to teeth. Tooth buds for the permanent teeth
another. Such knowledge is useful when filling form between the 17th-week of fetal life
out the dental forms in the health record. through the age of 5 years. When the primary
teeth are lost, permanent teeth will replace
FORMATION PERIOD them.
Cap Stage
LEARNING OBJECTIVE:
This stage is also known as proliferation
Describe the stages of tooth development. (reproduction or multiplication) in which the
cells of the tooth grow and the tooth bud takes a
As living things are forming, they go hollowed cap-like shape. The epithelium of the
through a developmental process to reach cap will give rise to the enamel. The zone under
maturity or a final outcome. When teeth are in the cap is called the dental papilla, a small
the odontogenesis phase (tooth formation) they nipple shaped elevation. It gives rise to the
go through three developmental periods called dentin, cementum, and the pulp.
categories: growth, calcification, and eruption.
The term emergence describes the tooth as it Bell Stage
breaks through the gingival tissue.
The last period of growth is also known as
GROWTH PERIOD histodifferentiation (the acquisition of tissue
characteristics by cell groups) or bell stage. It is
Dental development usually begins in the here the ameloblast cells form the enamel,
fifth or sixth week of prenatal life. By the odontoblast cells form the dentin, and the
seventh week, epithelial skin cells of the mouth cementoblast cells form the cementum.
thicken along the ridge of the developing jaws
creating a horse-shoe shaped band called the MORPHODIFFERENTIATION
dental lamina which follows the curve of each
developing tooth socket. The growth period of As the tooth begins the bell stage, it begins
development is divided into the bud, cap, and to take shape and form through a process called
bell stages (Fig. 7-1). morphodifferentiation. Enamel forming cells
(ameloblast) and dentin forming cells
(odontoblast) line up on a boundary line called
dentinoenamel junction (DEJ). The odontoblast
and cementoblast form the cementodentinal
junction. The dentinoenamel junction and
cementodental junction are the blueprint of the
developing tooth.
7-1
Figure 7-1.—Stages in Development of a Tooth
APPOSITION ERUPTION
Apposition refers to depositing of the matrix After the crown of the tooth has formed, the
for the hard dental structures. This matrix is root begins to develop. Now the tooth begins to
deposited by cells along the boundary line erupt (Fig. 7-l), movement of the tooth into its
(dentinoenamel junction) at the end of proper position in the mouth. For permanent
morphodifferentiation. teeth, it takes about 3 years from crown
completion to the time the tooth emerges into
CALCIFICATION the mouth. Figures 7-2 and 7-3 list the average
emergence periods of primary and permanent
Calcification (Fig. 7-1) is the process by teeth.
which organic tissue (the matrix formed
during apposition) becomes hardened by a
deposit of calcium or any mineral salts. Next,
the tooth crown receives layers of enamel that
start at the top of the crown and go downward
over the sides to the cementonenamel junction
(CEJ). The cementonenamel junction is a
linear junction between the apical border of
the enamel cap and the root cementum.
7-2
Figure 7-2.—Average Periods for Emergence and Exfoliation of Primary Teeth
7-3
EXFOLIATION (SHEDDING) The Crown
When primary teeth prepare to fall out and The crown is divided into the anatomic and
make way for the eruption of permanent teeth, clinical crown. The anatomical crown is the
they go through a process called exfoliation. The portion of the tooth encased in enamel. In young
root of the primary tooth resorbs (looses people, areas of the anatomical crown are
structure), and the permanent tooth erupts from frequently buried in gingival tissue. As a
beneath the surface of the jaw. The primary teeth person gets older, it becomes common for a
act as guides for the developing permanent teeth. tooth’s enamel to be completely exposed above
The premature loss of primary teeth can have a the gingiva with the root surface showing
serious impact on the eruption of permanent (gingival recession). The term clinical crown
teeth and how they will be positioned in the is applied to the part of the crown exposed
dental arch. (visible) in the mouth.
7-4
The Cervix ENAMEL
The cervix or cervical line (see Fig. 7-4) is Enamel is translucent and can vary in
a slight indentation that encircles the tooth and color from yellowish to grayish white. The
marks the junction of the anatomical crown different colors of enamel are attributed to the
with the root. The c e m e n t u m joins the variation in the thickness, translucent
enamel at the cervix of the tooth. The point at proprieties, the quality of the crystal structure,
which they join is called the cementoenamel and surface stains of enamel. Enamel (Fig. 7-
junction (CEJ) or cervical line. 6) is the calcified substance that covers the
entire anatomic crown of the tooth and
protects the dentin. It is the hardest tissue in the
TISSUES OF THE TEETH human body and consists of approximately
96% inorganic minerals, 1% organic materials,
and 3% water. Calcium and phosphorus (as
LEARNING OBJECTIVE: hydroxyapatite) are its main inorganic
components.
Describe the form and function of enamel,
dentin, cementum, and dental pulp.
7-5
Enamel can endure crushing pressure of approximately 55% organic material and 45%
approximately 100,000 pounds per square inorganic material; the inorganic components are
inch. A layering of the dentin and mainly calcium salts. The cementum joins the
periodontium, coupled with the hardness of enamel at the cervix of the tooth forming the
the enamel, produces a cushioning effect of CEJ.
the tooth’s different structures enabling it to
endure the pressures of mastication (chewing). In most teeth the c e m e n t u m overlaps the
Structurally, enamel is composed of millions enamel for a short distance. In some, the enamel
of enamel rods or prisms. Each rod begins at meets the cementum in a sharp line. In a few, a
the dentinoenamel junction (junction between gap may be present between the enamel and the
the enamel and dentin) and extends to the outer c e m e n t u m , exposing a narrow area of root
surface of the crown. Enamel is formed by dentin. Such areas may be very sensitive to
epithelial cells (ameloblasts) that lose their thermal, chemical, or mechanical stimuli.
functional ability when the crown of the tooth
has been completed. After formation enamel The main function of cementum is to anchor
has no power of further growth or repair. the teeth to the bony walls of the tooth sockets in
the periodontium. This is accomplished by the
DENTIN fibers of the periodontal ligament or membrane.
Cementum is formed continuously throughout
Dentin (see Fig. 7-6) is the light yellow the life of the tooth to compensate for the loss of
substance that is less dense (radiolucent) than tooth substance because of occlusal wear and to
enamel and is very porous; it constitutes the allow for the attachment of new fibers of the
largest portion of the tooth. The pulp chamber periodontal ligament to the surface of the root.
is located on the internal surface of the dentin
walls. Dentin is harder than bone but softer DENTAL PULP
than enamel. Dentin consists of approximately
70% inorganic matter and 30% organic matter The dental pulp, (Fig. 7-7), is the soft
and water. Calcium and phosphorus are its tissue inside the tooth developed from the
chief inorganic components. Dentin is a living connective tissue of the dental papilla. Within
tissue and must be protected during operative the crown, the chamber containing the dental
or prosthetic procedures from dehydration pulp is called the pulp chamber. The coronal
(drying) and thermal shock. pulp and pulp horns are within the crown and
the radicular pulp is within the root. The apical
The dentin is perforated by tubules (similar foramen is at the end or apex of the radicular
to tiny straws) that run between the pulp. Blood vessels, nerves, and connective
cementoenamel junction (CEJ) and the pulp. tissue pass through this area to reach the
Cell processes from the pulp reach part way interior of the tooth.
into the tubules like fingers. These cell
processes create new dentin and mineralize it.
Dentin transmits pain stimuli by the way of
dentinal fibers. Because dentin is a living
tissue, it has the ability for constant growth and
repair that reacts to physiologic (functional)
and pathologic (disease) stimuli.
CEMENTUM
Alveolar Crest
Trabecular Bone
Figure 7-8.—The Periodontium
7-7
Alveolar Bone Proper
PERIODONTAL LIGAMENT
7-8
Gingiva Other structures of unattached gingiva include:
• Gingival Margin: The 1mm narrow band
The gingiva shown in (Fig. 7-10), is specialized
of gingiva that forms the immediate collar
masticatory mucosa covering the alveolar
around the base of the tooth. This area is
process. Gingiva is firm and resilient encircling
first to show symptoms of gingivitis.
the necks of the teeth. It aids in the support of
the teeth, and protects the alveolar process and • Gingival Sulcus: Area between the
periodontal ligament from bacterial invasion. unattached gingiva and the tooth. Popcorn
hulls get trapped in this area.
The color of healthy gingiva range from pale
pink to darker shades (purple to black) • Epithelial Attachment: Joins the gingiva to
depending on each individual’s pigmentation. the tooth surface.
Under normal flossing and brushing activities it • Interdental Papilla: The portion of the free
does not bleed. Like the tongue, the gingiva is gingiva that fills the embrasures, a
highly vascular and receives its blood supply triangular space near the gingiva below the
from the lingual, mental, buccal, and palatine contact areas of adjacent teeth. It helps
arteries. The two types of gingiva are unattached prevent food from packing between the
and attached gingiva. teeth.
The portion of gingiva that extends from the It is located apical to the free gingiva on the
gingival crest to the crest of the bone is called labial and lingual aspects. It is firmly fixed to
unattached gingiva. It can be displaced and is the underlying bone of the cortical plates of the
not bound directly to the tooth or bone. In a alveolar process. The surface of the attached
healthy mouth, this portion is approximately 1 gingiva and interdental papillae may be stippled
to 3 mm wide and forms the soft tissue wall of (resembling the texture of an orange peel).
the gingival sulcus next to the tooth.
7-9
Lining Mucosa mandibular teeth; their roots are embedded
within the alveolar process of the mandible.
Lining mucosa is found on the inside of the Each arch contains 16 teeth. The teeth in an arch
lips, cheeks, vestibule, soft palate, and under are composed of 6 anteriors (cuspid to cuspid)
the tongue. It consists of a thin, fragile tissue and 10 posterior (all teeth distal to the cuspids).
that is very vascular. Lining mucosa is brighter
red in color than masticatory mucosa. Included
in the lining mucosa is alveolar mucosa which is
loosely attached and lies apical to the
mucogingival junction (line where the attached
gingiva and alveolar mucosa meet).
Specialized Mucosa
DENTAL ARCHES
7-10
LOCATION OF THE TEETH appearance are the lateral incisor, the cuspid,
the two bicuspids (the first bicuspid, followed
A human receives two sets of teeth during by the second bicuspid), and the three molars.
a lifetime. The first set consists of 20 teeth After the second bicuspid comes the first
referred to as deciduous or primary (baby molar, followed by the second molar, followed
teeth). The second (permanent) set usually by the third molar called the “wisdom tooth.”
consists of 32 teeth. In each quadrant, there are
eight permanent teeth: two incisors, one cuspid, Another method of describing the location
two bicuspids, and three molars. of teeth is to refer to them as anterior or
posterior teeth (Figs. 7-13 and 7-14). Anterior
The tooth positioned immediately to the teeth are those located in the front of the
side of the midline is the central incisor, mouth, the incisors, and the cuspids. These are
named due to its central location in the arch. the teeth that are visible when a person smiles.
To the side of the central incisor in order of The posterior teeth are those located in the
back of the mouth-the bicuspids and molars.
7-11
Figure 7-14.—Standard Dental Chart; Names and Numbers of Teeth
Man is omnivorous, his teeth are formed for They are used to incise food. They are
cutting, tearing, and grinding food. The human located in the front of the mouth and have sharp,
permanent dentition is divided into four classes thin edges for cutting. The lingual surface can
of teeth based on appearance and function or have a shovel-shaped appearance.
position. Figure 7-15 illustrates the types and
working surfaces of the four classes of teeth.
7-12
Molars
IDENTIFICATION OF TEETH
7-13
The 20 primary teeth are identified on the
dental chart by the use of capital letters A
through T. Lettering starts with upper right
second primary molar (tooth A, located above
the root of the maxillary second premolar);
goes across to the upper left second primary
molar (tooth J); down to the lower left second
primary molar (tooth K), and across to the lower
right second primary molar. Note that the
letters of the primary, second and first molars
appear above the roots of the permanent teeth
of the second and first premolars.
When using a dental form, the right and left
sides are reversed. The right side of the Figure 7-16.—Surfaces of the Teeth
patient’s mouth appears on the left side of the
dental chart; the left side of the patient’s mouth
appears on the right side. This arrangement is Mesial
necessary for the Dental Officer and the HM to
see the sides as they appear when looking into The mesial is the proximal surface closest
a patient’s mouth. to the midline or middle of the arch.
SURFACES OF THE TEETH Distal
Not only must the HM be able to name The distal is the opposite of mesial. The
and locate a tooth, but must also be able to distal is the proximal surface oriented away
identify the different types of tooth surfaces. from the midline of the arch.
To get a clearer picture of the various tooth
surfaces, refer to Figure 7-16. The Standard Lingual
Dental Chart shows each of the teeth
“unfolded” so that the facial, occlusal, incisal, The lingual is the surface of an anterior or
and lingual surfaces of the teeth can be shown. posterior tooth that faces toward the tongue.
For posterior teeth, the facial surfaces are shown Incisal edges are narrow cutting edges found
adjacent to the roots, followed by the occlusal only in the anterior teeth (incisors).
surfaces, and then by the lingual surfaces (which
are located next to the numbers on the chart).
For anterior teeth, the facial surfaces are shown
as a line between the facial and lingual
surfaces. The lingual surfaces are located next to
the numbers on the chart.
Facial
7-14
Proximal Surfaces EMBRASURE
A tooth has two proximal surfaces (Fig. 7- The embrasure occupies an area bordered
17), one that is oriented toward the midline of by interdental papilla, the proximal surfaces of
the dental arch (mesial) and another that is the two adjacent teeth, and the contact point
oriented away from the midline of the arch (Fig. 7-18). If there is no contact point
(distal). Other important surfaces of the between the teeth, then the area between them
proximal area are discussed in the following is called a diastema instead of an embrasure.
paragraphs.
CONTACT POINT
Figure 7-18.—Embrasure
The point on the proximal surface where
two adjacent teeth actually touch each other is
called a contact point. This is exemplified
when the HM passes dental floss in between OCCLUSAL
two teeth and resistance is felt as the dental
floss passes through the contact point. The occlusal surface is the broad chewing
surface found on posterior teeth (bicuspids and
INTERPROXIMAL SPACE molars).
7-15
VERTICAL AND HORIZONTAL
OVERLAP
OCCLUSAL PLANE
7-16
Figure 7-24.—Key to Occlusion. Shows
Figure 7-22.—Curve of Wilson
Relationship of Mandible to Maxillae
KEY TO OCCLUSION
7-17
ANGLES CLASSIFICATION TOOTH MORPHOLOGY
7-18
MAXILLARY LATERAL INCISORS
Facial Surface
7-19
MANDIBULAR CENTRAL INCISORS MANDIBULAR LATERAL INCISORS
The mandibular central incisor (tooth #24 or The mandibular incisor (tooth #23 or #26),
#25) is illustrated in Figure 7-30. These are the illustrated in Figure 7-31, is a little wider
first permanent teeth to erupt, replacing mesiodistally than the mandibular central
deciduous teeth, and are the smallest teeth in incisor, and the crown is slightly longer from the
either arch. These erupt around the same time as incisal edge to the cervical line.
the mandibular first molars, usually after them.
The root is slender and extremely flattened The root is single and extremely flattened on
on its mesial and distal surfaces. its mesial and distal surfaces.
7-20
MAXILLARY CUSPIDS Facial Surface
The maxillary cuspid (tooth #6 or #11) is The facial surface of the crown (Fig. 7-32)
illustrated in Figures 7-32 and 7-33. The differs considerably from that of the maxillary
maxillary cuspid is usually the longest tooth in central or lateral incisors. Specifically, the
either jaw. This tooth is called a canine as it incisal edges of the central and lateral incisor
resembles a dog’s tooth. are nearly straight; the cuspid has a definite
point, or cusp. There are two cutting edges, the
mesioincisal and the distoincisal. The
distoincisal cutting edge is the longer of the
two. The developmental grooves that are so
prominent on the facial surface of the central
incisor are present here, extending two-thirds
of the distance from the tip of the cusp to the
cervical line.
Lingual Surface
7-21
MANDIBULAR CUSPIDS MAXILLARY FIRST BICUSPID
The mandibular cuspid (tooth #22 or #27) is The maxillary first bicuspid (tooth #5 or
illustrated in Figure 7-34. These teeth, like the #12), illustrated in Figure 7-35, is the fourth
mandibular incisors, are smaller and more tooth from the midline. It is considered to be the
slender than the opposing teeth in the maxillary typical bicuspid. Sometimes bicuspids are
arch. called premolars because they are just in front
of the molar teeth.
7-22
Root MAXILLARY SECOND BICUSPID
The root is quite flat on the mesial and distal The maxillary second bicuspid (tooth #4 or
surfaces. In about 50 percent of maxillary first #13), illustrated in Figure 7-37 resembles the
bicuspids, the root is divided in the apical third, first bicuspid very closely, but is smaller in
and when it so divided, the tips of the facial and dimensions. The cusps are not as sharp as the
lingual roots are slender and finely tapered. maxillary first bicuspid and have only one root.
Occlusal Surface
7-23
MANDIBULAR FIRST BICUSPID MANDIBULAR SECOND BICUSPID
The mandibular first bicuspid (tooth #21 or The mandibular second bicuspid (tooth #20
#28), illustrated in Figure 7-38, is the fourth or #29), illustrated in Figure 7-39 is the fifth
tooth from the midline. It is the smallest of the tooth from the midline.
four bicuspids. The term bell-crowned is used
to describe its appearance. The mandibular first
bicuspid has many characteristics of a cuspid.
Root Surface
Figure 7-38.—Surfaces of Mandibular First
Bicuspid The root of the tooth is single, and in a great
many instances, the apical region is found to be
Root Surface
quite curved.
The root of the mandibular first bicuspid is
usually single, but on occasion can be
bifurcated (two roots).
Occlusal Surface
7-24
MAXILLARY FIRST MOLAR
Facial Surface
Figure 7-41.—Features of Occlusal Surfaces of
The facial surface has a facial groove that Maxillary First Molar
continues over from the occlusal surface, and
runs down to the middle third of the facial Occlusal Surface
surface.
In all molars the patterns of the occlusal
Lingual Surface surface (Fig. 7-41) are quite different from those
of the bicuspids. The cusps are large and
In a great many instances, there is a cusp on prominent, and the broad grinding surfaces are
the lingual surface of the mesiolingual cusp. broken up into rugged appearing ridges and
This is a fifth cusp called the cusp of Carabelli, well-defined grooves. An oblique ridge, which is
which is in addition to the four cusps on the not present on the bicuspids, appears here; it also
occlusal surface. appears on maxillary second and third molars.
Root Surface
7-25
MAXILLARY SECOND MOLAR MAXILLARY THIRD MOLAR
The maxillary second molar (tooth #2 or The maxillary third molar (tooth #1 or
#15), illustrated in Figure 7-42 is the seventh #16), illustrated in Figure 7-43 is the eighth
tooth from the midline. The second molars are tooth from the midline. Third molars are called
often called 12-year molars because they erupt “wisdom teeth” because they erupt when the
when a child is about 12 years old. young adult is passing into adulthood. The tooth
is much smaller than the maxillary first or
Because it has the same function as the second molars, with an occlusal outline that is
maxillary first molar, its physical characteristics nearly circular.
are basically the same. The second molar is
smaller, the occasional fifth cusp of Carabelli
does not appear, and there is a marked reduction
in the size of the distolingual cusp.
Occlusal Surface
Figure 7-42.—Surfaces of Maxillary Second
Molar Numerous fissures and grooves cover the
occlusal surface. There is no distinct oblique
ridge.
Root
7-26
MANDIBULAR FIRST MOLAR
The facial surface has two grooves: the The occlusal surface has five cusps (Fig. 7-
facial groove, an extension of the facial groove 45). The fifth cusp is called the distal cusp.
from the occlusal surface and the distofacial
groove, an extension of the distofacial groove Roots
from the occlusal surface.
The tooth has two roots, a mesial and a
distal.
7-27
MANDIBULAR SECOND MOLAR MANDIBULAR THIRD MOLAR
The mandibular second molar (tooth #18 or The mandibular third molar (tooth #17 or
#31), illustrated in Figure 7-46, is the seventh #32), illustrated in Figure 7-47, is the eighth
tooth from the midline. tooth from the midline. It appears in many
forms, sizes, and shapes. Since its function is
similar to that of the other two mandibular
molars, its general appearance is the same. It has
smaller surfaces, more supplemental grooves,
and four or five cusps, which are not as sharply
differentiated as those of the first two molars.
Facial Surface
The facial surface has only one groove, the Figure 7-47.—Surfaces of Mandibular Third
facial groove, which arises on the occlusal Molar
surface, extends over the facial margin onto the
facial surface. Roots
7-28
GLOSSARY OF UNIQUE DENTAL Fissure: A linear fault that sometimes occurs
ANATOMY in a developmental groove by incomplete or
imperfect joining of the lobes. A pit is usually
found at the end of a developmental groove or a
LEARNING OBJECTIVE: place where two fissures intersect (Fig. 7-50).
Describe each of the unique dental anatomy
structures and their function(s).
Figure 7-48.—Cusp
Figure 7-49.—Cingulum
Figure 7-51.—Central Fossa
7-29
Lingual Fossa: Irregular, shallow depression Developmental Groove: Fissure between the
found on the lingual surfaces of an incisor or cusps on the crown of the tooth. Cusp tips are
cuspid (Fig. 7-52). the initial site where enamel develops. As the
enamel develops and spreads laterally, it
touches enamel developing from other cusps.
This junction forms a developmental groove.
Such grooves appear on the labial, buccal, and
lingual surfaces, and are least apparent on the
labial aspect of anteriors (Fig. 7-54).
7-30
Supplemental Groove: A minor, auxiliary Mamelons: Are small, rounded projections of
groove that branches off from a much more enamel from the incisal edges of newly erupted
prominent developmental groove. They do not anterior teeth. The projections wear away soon
represent the junction of primary tooth parts after eruption (Fig. 7-57).
and gives the occlusal surface a wrinkled
appearance (Fig. 7-55).
Figure 7-57.—Mamelons
Figure 7-55.—Supplemental Groove Cusp Ridge: Each cusp has four cusp ridges
radiating from its tip. They are named
according to the direction they take away from
Lobe: Is one of the primary divisions of a the cusp tip (for example, mesial, distal, buccal,
crown; all teeth develop from four or five or lingual) (Fig. 7-58).
lobes. Lobes are usually separated by readily
identifiable developmental grooves (Fig. 7-56).
Figure 7-56.—Lobe
7-31
Lingual Ridge: The ridge of enamel that Oblique Ridge: The only tooth on which an
extends from the cingulum to the cusp tip on the oblique ridge is found is the maxillary first and
lingual surface of most cuspids (Fig. 7-59). second molars. Consists of an elevated
prominence on the occlusal surface and extends
obliquely from the tips of the mesiolingual cusp
to the distobuccal cusp (Fig. 7-61).
7-32
Transverse Ridge: The union of a buccal and SUMMARY
lingual triangular ridge that crosses the surface of a
posterior tooth transversely (roughly 90° to both the This chapter reviewed oral anatomy and
buccal and lingual tooth surfaces) (Fig. 7-63). physiology. It covered the morphology of teeth
to include their various surfaces. With this
knowledge the HM will be able to assist the
dentist, physician, or IDC with assessing,
treating, and documenting oral care provided to
patients.
Figure 7-64.—Sulcus
7-33
CHAPTER 8
ORAL PATHOLOGY
MICROORGANISMS Abscess
8-1
ELEVATED LESIONS
8-2
If the tooth surface has an area that has not Some of the causes are:
progressed past the decalcification stage, this
• Improper cavity preparation: The dentist
type of carious lesion is called incipient. As the
was unable to remove all of the decay in the
decay spreads in the enamel, it may stop. If this
tooth before the placement of a restoration
occurs, the process is called an arrested carious
lesion (Fig. 8-2). These areas in which dental • Inadequate cavity restoration: Open
caries have been arrested are dark and, in some margins (space in-between the restoration
instances, hollowed out. A dental explorer and tooth)
passed over or in these areas will feel hard to the
touch. If the area still has active decay, the • Old restorations: The margins of the
explorer may “sink in” the soft decay. restoration break down or are not
completely sealed when originally placed,
creating a "leaky margin"
RECURRENT CARIES
Figure 8-3.—Smooth Surface Caries
Recurrent caries are decay processes that
occur underneath existing dental restorations.
More simply stated another cavity has occurred
in the tooth where there was a filling or
restoration.
8-3
DISEASES OF THE DENTAL PULP PERIAPICAL ABSCESS
The dental pulp is a living tissue. All living A periapical abscess results when the pulp
tissues can die or become diseased. The dental has become inflamed and a small pus-like
pulp is composed of vascular connective tissue abscess forms in the pulpal canal. If left
encased in dentin, which provides protection. untreated, the inflammation spreads out
Even with this protection, the pulp may receive through the apex of the root and into the bone.
injuries by thermal changes, carious lesions As the abscess gets bigger, pressure from the
from mircroorganisms, and mechanical trauma. inflammation and pus at the apex of the root
The extent of pulpal damage and the vitality may cause the tooth to be pushed up higher in
(life) of the tooth depend on the severity of its socket. The patient may complain the tooth
injury and how the pulp reacts to disease. The feels “high” when biting and is very sensitive
term pulposis refers to any disease involving to touch.
the dental pulp. Some of the more common
diseases of the pulp are pulpalgia, pulpitis, Bone loss around the apex of the tooth can
periapical abscess, and necrosis. occur if left untreated. The abscess and bone
loss at the apex cause a radiolucency appearing
PULPALGIA like a “grape” when viewed on an x-ray. The
course the pus from the abscess follows from
Pulpalgia refers to pain in the dental pulp the apex, into the jaw bone, and draining into
and commonly occurs after a restoration has the mouth is referred to as a fistula.
been placed in a tooth. It can be caused by root
planing and periodontal surgery. The tooth may NECROSIS
become sensitive to touch, temperature
changes, and sweet or sour foods. Pain The death of tissue is called necrosis.
associated with pulpalgia has been described as Pulpal necrosis occurs as a result of untreated
short, sharp shooting pain that may increase pulpitis from a traumatic injury; a tooth that is
when lying down or walking upstairs. necrotic must be treated. The dead pulpal tissue
will decompose, producing toxins that will
PULPITIS smell foul or rotten when the tooth is being
treated. Dental pain may or may not occur from
Pulpitis is an inflammation of the dental necrosis.
pulp, caused by a bacterial infection resulting
from dental caries or fractured teeth. When
mircroorganisms enter the pulp, they start to
produce severe damage, which leads to the
buildup of pressure in the canal. The result of
this pressure may cause a dull ache that can
lead to a more severe, pulsating pain.
8-4
PATHOLOGY OF THE Marginal Gingivitis
PERIODONTIUM
Marginal gingivitis (Fig. 8-4) is the most
common type of gingival disease. Most
LEARNING OBJECTIVE:
frequently it is the result of poor oral hygiene
and affects both the gingival margins and
Identify the types, descriptions, and stages of
papilla. Chief irritants are food debris and
periodontal diseases.
plaque on the marginal gingiva around the
necks of the teeth, interproximal spaces, or
Periodontal disease is the most prevalent overhanging margins of dental restorations. A
chronic disease of humankind. The term localized inflamed condition may exist from a
periodontal disease refers to all diseases of the popcorn husk or toothbrush bristle. Early
periodontium and can affect the tissues around formation of calculus deposits can also form
and supporting the teeth. HMs must know under the gingival sulcus (depression or fissure)
symptoms of periodontal disease the patients on the facial and lingual surfaces of the upper
might describe: and lower teeth. Calculus deposits can also be
• Bleeding gingival tissue during tooth brushing responsible for the occurrence of marginal
gingivitis, and if left untreated, may proceed to
• Tender or red swollen gums destruction of the supporting structures (as in
periodontitis).
• Receding gingival tissue
• Tooth shifting or elongation (looks longer)
• Mobile (loose) teeth
• Purulent exudate (pus) in-between the teeth
and gums
• Abnormal change in the fit of partial dentures
• Halitosis (bad breath)
GINGIVITIS
8-5
Necrotizing Ulcerative Gingivitis Neglected deposits of calculus and
formation of additional calculus over time
Necrotizing ulcerative gingivitis (NUG) contribute to the spread of the disease. Like
(Fig. 8-5) is a disease referred to as trenchmouth, or marginal gingivitis, it may affect the entire
Vincent’s infection. It is characterized during dentition, or only localized areas.
the acute stage by redness, swelling, pain,
accumulation of calculus around the sulcus of
the teeth, and bleeding of the gingival tissues.
There is a film of necrotic white or grayish tissue
around the teeth; it may be wiped off, leaving a
raw, bleeding base. The ulceration of the
gingival crest results in a characteristic punched-
out appearance and loss of the interdental
papillae. There is an unpleasant odor and a foul
taste in the mouth. The gingival tissues bleed
easily when touched, and a patient will complain
of not being able to brush their teeth or chew
well because of the pain or discomfort.
Figure 8-6.—Periodontitis
8-6
Periodontal Abscess DISEASES OF THE ORAL SOFT
TISSUES
A periodontal abscess usually results from
long-continued irritation by food debris,
LEARNING OBJECTIVE:
plaque, deep deposits of calculus, or foreign
objects such as a toothbrush bristle or popcorn
Identify the types, descriptions and stages of
husk being tightly packed in the interproximal
oral soft tissue diseases.
spaces or within the walls of a pocket. The
gingiva surrounding the area becomes inflamed
and swollen. Many oral diseases can affect the soft
tissues. This section will cover only a small
PERICORONITIS portion of the most common types. These
lesions can be caused by viruses, bacteria,
Pericoronitis is an inflammation of the fungi, and physical and chemical agents.
gingiva around a partially erupted tooth. The Direct contact with the diseases covered may
mandibular third molars are most often present some degree of hazard or a life-
affected, although any erupting tooth may be threatening disease to the HM. Always follow
involved. In the mouth of a young adult, part of infection control procedures when in contact
a tooth can be seen projecting through the with all patients.
gingiva, usually distal to the second molar.
The surrounding tissues are usually acutely RECURRENT APHTHOUS STOMATITIS
inflamed. The inflammation may be caused by
irritation resulting from the patient’s inability Recurrent aphthous stomatitis (RAS)
to keep the area properly cleansed. (Fig. 8-7), or canker sores, are painful
ulcerations. These lesions are found in the
Another cause of inflammation is infection vestibular and buccal mucosa, tongue, soft
from oral pathogens that gained access to the palate, and in the floor of the mouth. The exact
tissue surrounding the crown of the erupting cause of these lesions is not known, but studies
tooth through the opening made by a show that physical and emotional stress make
projecting tooth cusp. The “gingival flap” them appear. Also injuries from tooth brushing,
may become infected after inflammation as a eating harsh foods, and allergies can start RAS.
result of the constant irritation caused by The healing time of the ulcers is usually 7 to 10
contact with the occlusal surface of an days.
erupting maxillary third molar.
8-7
VIRAL INFECTIONS Other lesions of the HSV-1 virus are acute
herpetic gingivostomatitis, characterized by red
The viral infections of main concern are and swollen gingiva. All of the oral mucosa is
those caused by the herpes simplex virus (HSV), tender and eating is painful. Vesicles form
and the human immunodeficiency virus (HIV) throughout the mouth and rupture, leaving
which causes acquired immunodeficiency painful ulcers.
s y n d r o m e (AIDS). Both are extremely
contagious to the HM, Dental Officer, and The most common of all the herpetic HSV-1
other dental patients through cross lesions is herpes labialis. They frequently
contamination of dental instruments and dental involve the lips and adjacent skin at the corners
equipment. The virus can gain access via the of the mouth. Recurrence usually starts at the
skin, eye, or mucous membranes. If the HM same location with a burning, tingling sensation
treats a patient with one of these or other and then forming vesicles that fuse together
viruses, ensure that proper infection control leaving large lesions. After the vesicles rupture,
procedures are followed as outlined in Chapter crusting of the surface occurs; these lesions are
9, “Preventive Medicine and Infection Control.” known as “fever blisters.” The crusted lesions
are also referred to as “cold sores,” because a
Herpes Simplex Virus common cold sometimes accompanies these
HSV-1 lesions. Known causes for the
The two herpes simplex viruses are among reoccurrence of the HSV-1 lesions are:
the most common infectious agents.
• Sunlight
• Herpes simplex virus, Type One (HSV-1):
• Menstruation
Oral herpes
• Dental treatment (local trauma)
• Herpes simplex virus, Type Two (HSV-2):
Genital herpes • Stress or anxiety
In oral pathology the most commonly The recurrent HSV-1 lesions take about 7 to
diagnosed sites for HSV-1 are the oral cavity, 10 days to resolve. Any routine dental
tongue (Fig. 8-8), lips, and the eyes. Direct treatment is recommended to be rescheduled
contact with HSV-1 lesions is the most common during the active phase of these lesions because
mode of transmission; it can be transmitted the disease is highly transmittable.
through saliva even if there are no active
lesions. Infection on the hands of healthcare HIV/AIDS Virus
personnel from patients shedding HSV can
result in herpetic lesions. The human immunodeficiency virus (HIV)
is the main cause of the acquired
immunodeficiency s y n d r o m e ( A I D S ) . I t
i s a worldwide epidemic. This deadly
disease is a direct threat to all dental health
professionals and other healthcare workers who
are exposed to patients who carry the virus.
LEARNING OBJECTIVE:
8-9
CLASSIFICATIONS OF MALIGNANT Adenocarcinoma
TUMORS
Usually found in the oral region or
Dentists are trained to give special attention salivary glands, most often of the palate
when performing an oral cancer screening on a (Fig. 8-13), and appears as a lump or a bulge
patient to detect any type of cancer. Often these under the mucosa.
lesions do not cause any pain while in the early
stages of development. A malignant tumor can
become fatal if not found in its early stages or
if left untreated. The following are
classifications of malignant tumors.
Carcinoma
Sarcomas
8-10
Smokeless tobacco, such as chewing CONGENITAL DISORDERS12
tobacco or snuff, may play a role in the
development of oral precancerous lesions on the
LEARNING OBJECTIVES:
oral mucosa and can result in increased tooth
loss from periodontal disease. The area where
Identify congenital disorders.
the user of smokeless tobacco places it in the
mouth may leave a smooth or scaly white patch
Describe various congenital disorders.
called leukoplakia or snuff-dipper’s keratosis
(Fig. 8-14).
Congenital disorders are present at birth.
The congenital disorders that may be seen are:
• Anodontia: The absence of single or
multiple teeth
• Supernumery Teeth: Development of one
or more extra teeth
• Cleft Lip: The maxillary and medial nasal
processes fail to fuse (Fig. 8-15)
• Cleft Palate: Results when the palate
shelves, right and left side do not fuse
leaving a space (Fig. 8-15)
8-11
• Ankyloglossia: Results from a short lingual IMPACTION12
frenulum attachment also known as tongue
tied (Fig. 8-16) It is the condition in which a tooth is
blocked by a physical barrier, usually teeth or
bone (Fig. 8-17).
Figure 8-17.—Impaction
Figure 8-16.—Ankyloglossia
Image reprinted with permission from:
Torres & Ehrlich: Bird, D. L. & Robinson, D. S.
Image reprinted with permission from:
(2008). Torres and Ehrlich Modern Dental
Torres & Ehrlich: Bird, D. L. & Robinson, D. S.
Assisting (9th ed.). St. Louis: Elsevier Health
(2008). Torres and Ehrlich modern dental
Sciences.
assisting (9th ed.). St. Louis: Elsevier Health
Sciences.
A tooth may not erupt in the normal time
DISORDERS AFFECTING THE period if an impaction occurs. Some of the
TEETH causes of impacted teeth are:
• Movement of the erupting tooth into a
LEARNING OBJECTIVE:
horizontal, vertical, or other abnormal
position
Identify the disorders that affect the teeth.
• Early loss of deciduous teeth
Disorders that commonly affect the teeth are: • Insufficient jaw space, abnormally large
• Impaction tooth crowns, supernumerary or other teeth
in a dental arch
• Attrition
• Abrasion
• Erosion
8-12
ATTRITION AND ABRASION In abrasion (Fig. 8-19) one or more teeth
may show wear, generally brought about by
Attrition (Fig. 8-18) is the loss of substance improper tooth brushing; biting foreign objects
of a tooth from a wearing away process caused such as a pipe stem, thread, or bobby pins; or
by teeth against teeth. Whereas, abrasion other mechanical actions such as a poorly fitted
results in the loss of tooth structure secondary clasp of partial dentures.
to the action of external agents.
Figure 8-19.—Abrasion
Figure 8-18.—Attrition Image reprinted with permission from:
Langlais, R. D., & Miller, C. S. (1998). Color Atlas
Image reprinted with permission from: of Common Oral Diseases (2nd ed). Baltimore:
Langlais, R. D., & Miller, C. S. (1998). Color Atlas Williams & Wilkins.
of Common Oral Diseases (2nd ed). Baltimore:
Williams & Wilkins.
8-13
EROSION SUMMARY
Erosion (Fig. 8-20) is a loss of tooth This chapter reviewed the various types of
substances from a chemical process that does oral pathology conditions that can be
not involve bacteria. It occurs usually on the encountered when examining the oral cavity
facial surfaces at the gingival third of the including oral lesions, dental caries, periodontal
crown and often involves the maxillary conditions, and soft tissue diseases. It touched
incisors. The enamel and dentin on the floor of on viral infections, oral cancer, congenital
the lesion are smooth, hard, and glistening. disorders, and teeth disorders. Being aware of
During the early stages of erosion, the eroded each of these pathological conditions will allow
areas are very sensitive to heat, cold, acidic the HM to assist the dentist and the patient with
foods, and tooth brushing; sensitivity may early identification and treatment leading to
decrease when secondary dentin is formed. successful resolution.
Figure 8-20.—Erosion
8-14
CHAPTER 9
Prevention and control of disease are The HM, as the Medical Department
considered the most desirable means of Representative (MDR), performs sanitation
maintaining good health. Information included inspections and provides recommendations to the
in this overview should provide the Hospital Commanding Officer (CO). The living spaces, their
Corpsman (HM) with a general knowledge of inspection, cleaning, and maintenance practices are
the principles and practices of the Navy’s discussed in detail in NAVMED P-5010.
Preventive Medicine afloat and ashore. This
information is discussed in detail in the Habitability
Manual of Naval Preventive Medicine,
NAVMED P-5010. Factors that can affect habitability of
working and berthing spaces are air ventilation,
PREVENTIVE MEDICINE heating, and air conditioning. Measurements of
thermal stress are used to monitor environmental
conditions in which personnel work, live, and
LEARNING OBJECTIVE:
exercise. Monitoring environmental conditions
is crucial to maintaining a safe environment for
Indentify the different aspects of preventive
personnel.
medicine.
VECTOR AND PEST CONTROL
SANITATION
A vector is any animal capable of
Sanitation is defined as the hygienic means transmitting pathogens or producing human or
of promoting health through prevention of animal discomfort or injury. Some commonly
human contact with the hazards of wastes. The encountered vectors are insects, arthropods
goal of the Navy’s sanitation program is to (insects with hard, jointed exoskeleton and paired,
provide personnel with a clean and healthy work jointed legs) and rodents. Pests are organisms
and living environment. (insects, rodents, snakes, etc.) that adversely
affect military operations and the well-being of
Personal Hygiene man and animal; attack real property, supplies,
and equipment; or are otherwise undesirable.
Because of the close living quarters in the
Navy, particularly aboard ships, personal FOOD-SERVICE SANITATION
hygiene is of utmost importance. Uncleanliness
or disagreeable odor affects the morale of Food-borne illnesses represent an ever-
shipmates. Disease and other health problems present threat to the health and morale of
can spread rapidly affecting an entire military personnel. To prevent food-borne
compartment or division. Good personal hygiene illnesses, HMs need to ensure that all foods are
promotes health and prevents disease. HMs are procured from approved sources and processed,
responsible for presenting health education prepared, and served with careful adherence to
training programs to the personnel in their unit, recommended sanitary practices. When assigned
including the basics of personal hygiene, proper as a MDR for a command or station, HMs may
exercise, sleep, and nutritional requirements. be given the responsibility of inspecting food,
food-service facilities, and investigating food-
borne illness outbreaks.
9-1
For guidance on safe time limits for keeping Immunizations
food, proper storage temperatures, and storage
life of perishable and semi-perishable items, Vaccines used to protect Navy and Marine
refer to tables in Naval Supply Corps personnel against certain diseases before
Publication 486, Food Service Management exposure to infection are called prophylactic
General Messes. immunizations. Prophylactic immunizations are
limited to very serious diseases for which
Training and Hygiene of Food-Service effective and reliable immunizing agents have
Personnel been developed. Immunizations procured for the
Armed Forces are required to meet the minimum
Food-service personnel should be standards set by the Department of Health and
thoroughly indoctrinated in personal hygiene, Human Services (HHS).
food sanitation procedures, and in the methods
and importance of preventing food-borne illness. Immunizations for Military Personnel
Requirements for food service training are
addressed in SECNAVINST 4061.1 series, Navy and Marine Corps personnel are
Food Service Training Program. required to be in a deployable readiness status at
all times. To make sure personnel are prepared
Food-Service Report for deployment, HMs should BUMEDINST
6230.15 series, Immunizations and
Navy and Marine Corps food-service Chemoprophylaxis, and review the
facilities are required to be inspected by a MDR, immunization records on a routine basis
together with the food-service manager, officer, including before deployments. Initial and
or designated representative. The findings of the booster dosages and routes of administration are
inspection are reported on a NAVMED Form dictated by the vaccine manufacture, the U.S.
6240/1, Food Service Sanitation Inspection. The Public Health Service Immunization Practices
inspector assigns an appropriate number of Advisory Committee (ACIP), or both.
defect points based upon the guidelines for each
area. Complete step-by-step procedures for Communicable Diseases
filing the report are provided in NAVMED P-
5010. As the name implies theses are diseases that
may be transmitted from a carrier to a
IMMUNIZATIONS AND susceptible host. They may be transmitted
COMMUNICABLE DISEASES directly from an infected person or animal or
indirectly through an intermediate host, vector,
Navy and Marine Corps personnel are or inanimate object. The illness produced is the
exposed to a wide variety of environmental result of infectious agents invading and
conditions, including climatic extremes, stressful multiplying in the host, or from the release of
situations, and close living quarters. Many of their toxins (poisons).
these personnel travel to foreign lands where
conditions may be unsanitary and have a high
level of disease. Preventive medicine’s major
role is to minimize disability by emphasizing
immunization programs.
9-2
An important step in the control of Water Quantity Requirements
communicable disease is the expeditious
preparation and submission of the Medical Event The daily water requirements for personnel
Report. Instructions and requirements for in the field vary with a number of factors
reporting to local, state, national, and including the season of the year, geographical
international health authorities can be found in location, and the tactical situation. Personnel
the preface of the NAVMED P-5038, Control who do not drink enough water can quickly
of Communicable Diseases Manual. Follow become dehydrated both in extremely hot or
instructions for the Medical Event Report extremely cold climates.
(BUMEDINST 6220.12 series), when reporting
communicable diseases affecting Navy and Water Treatment
Marine Corps personnel.
Water treatment is the process of purifying
WATER SUPPLY water to make it potable (safe to drink). Various
processes can be used to purify water. These
A hygienically safe and continuously processes include aeration, coagulation,
dependable water supply is a necessity of life. flocculation, filtration, reverse osmosis, and
Drinking water should be free of disease- disinfection, all of which are discussed in depth
producing organisms, poisonous chemicals, and in NAVMED P-5010.
from objectionable color, odor, and taste.
Water Supply Afloat
Water Supply Ashore
Potable water for shipboard use comes from
Typically, Navy and Marine Corps activities one of several sources: the ship’s distillation
ashore within the continental limits of the United plant, shore-to-ship delivery, or ship-to-ship
States are situated where a municipal water transfer. The ship’s medical department is
supply is available. BUMEDINST 6240.1 responsible for determining the quality of the
series, Standards for Potable Water, sets water. The ship’s engineering section determines
drinking water standards for U.S. Naval the quantity stored or produced and performs the
establishments worldwide, both ashore and actual chlorination or bromination.
afloat. Both municipal and Navy generated
water supplies must meet Navy standards. Water Testing
9-3
Manufacture and Handling of Ice INFECTION CONTROL
9-4
INFECTION CONTROL TERMS AND • Dental Item Classification: Dental items
DEFINITIONS are classified as critical, semi-critical or
non-critical based on the pathways through
The following terms and their definitions will which cross-contamination may occur and
help the HM understand the material that is in the location and technique of instrument use.
this chapter and in Chapter 10, “Disinfection and
Sterilization.” • Critical Items: Instruments and materials
that penetrate the skin, mucous membranes,
• Asepsis: The state of being free of or bone; these items must be sterile before
pathogenic organisms. use. Examples include surgical instruments,
periodontal knives, and suture needles.
• Aseptic Technique: A set of specific
practices and procedures performed under • Semi-Critical Items: Instruments,
carefully controlled conditions with the goal equipment, or materials that frequently
of minimizing contamination by pathogens. contact mucous membranes, but cannot be
sterilized because of their design or inability
• Bioburden: The number of micro-
to withstand heat. At minimum these items
organisms contaminating an object; known
require high-level disinfection. Examples
as bioload or microbial load.
include some radiographic positioning
• Bloodborne Pathogens: Pathogenic micro- devices and plastic impression trays.
organisms that are present in human blood
• Non-critical Items: Instruments,
and capable of causing disease in humans.
equipment, or materials that do not normally
• Bowie-Dick Type Test: A diagnostic test of penetrate or contact mucous membranes but
a prevacuum sterilizer’s ability to remove air which are exposed to splatters, sprays, or
from the chamber and detect air leaks. This splashing of blood, or are touched by con-
is not a sterility assurance test. taminated hands. These items require
intermediate-level disinfection. Examples
• Chemical Disinfection: The destruction or
include the dental unit and medical exam
inhibition of most viruses and bacteria while
table.
in their active growth phase; does not
necessarily kill all spores nor can it be • Disinfected: To cleanse something so as to
verified by a monitor. destroy or prevent the growth of disease-
carrying microorganisms.
• Chemical Indicator: Chemical dyes used to
determine whether the conditions required • Infectious Agent: An infectious agent is an
for sterilization are met; known as internal organism that is capable of producing an
or external indicators, dosage indicator, or infection or infectious disease.
process indicator.
• Infectious Micro-Organisms: Organisms
• Contaminated: The presence or reasonably capable of producing disease in a host.
expected presence of blood or other
• Invasive Procedure: A surgical entry into
potentially infectious material on an item or
the tissues, cavities, organs, or repair of
surface.
major traumatic injuries. This includes the
• Contaminated Laundry: Laundry that has manipulation, cutting, or removal of any oral
been visibly soiled with blood or other or perioral tissue during which bleeding
potentially infectious materials. occurs, or the potential for bleeding exists.
• Culture: The reproduction and growth of • Micro-Organisms: Bacteria, fungi, viruses,
micro-organisms in living tissue cells or on and bacterial spores.
a nutrient medium.
9-5
• Nosocomial Infection: An infection • Sterilizer (Gravity Displacement Type): A
resulting from treatment in a hospital and is type of sterilizer in which incoming steam
secondary to the patient's original condition; displaces via gravity, the residual air
it is unrelated to the primary diagnosis. through a port or drain usually in or near the
bottom of the sterilizer chamber.
• Personal Protective Equipment (PPE):
Specialized barrier attire worn by an • Sterilizer (Prevacuum Type): A type of
employee to protect against a hazard. sterilizer that relies on one or more pressure
and vacuum evolutions at the beginning or
• Occupational Exposure: Reasonably
the end of the cycle.
anticipated skin, eye, mucous membrane, or
parenteral exposure to blood or other • Unit Dose: The quantity of materials or
potentially infectious materials that may supplies required to treat a single patient.
result from performance of duties, despite
• Standard Precautions: A protocol for
the appropriate use of PPE.
infection control that treats all human blood
• Saturated Steam Sterilization: A process and body fluids as if known to be infectious
that uses steam heat under pressure for for human immunodeficiency virus (HIV),
sufficient length of time to kill all forms of hepatitis B virus (HBV), and other blood
micro-organisms. borne pathogens.
• Sanitary Sewer System: A sewer system • Engineered Controls: Method of managing
connected to a sewage treatment plant. environment and health by placing a barrier
between the contamination and the rest of
• Spray-Wipe-Spray: An acceptable method
the site, thus limiting exposure pathways.
of cleaning and disinfecting. Presently there
is no agent on the market with the • Work Practice Controls: Controls that
Environmental Protection Agency (EPA) reduce the likelihood of exposure by altering
registration that cleans and disinfects in one the way one performs a task such as having
step. The importance of cleaning as a patients brush their teeth or using antiseptic
separate step from disinfection and mouthwash before beginning a procedure;
sterilization cannot be overemphasized. using the rubber dam whenever possible,
disinfecting the isolated teeth, and using a
• Sterile field: A specified area, such as
disinfectant mouthwash before and after
within a tray or on a sterile towel, which is
applying the dam; heavy duty, puncture-
considered free of microorganisms.
resistant utility gloves are used when
• Sterile, Sterility: Free from all living handling instruments, and while cleaning
micro-organisms. and disinfecting instruments during the
sterilization process; using an accepted and
• Sterilization: Process that destroys all types safe technique for recapping needles; and
and forms of micro-organisms. disposing of sharps before beginning
• Sterilization Area: The area of a health cleanup procedures at the conclusion of
care facility designed for housing treatment.
sterilization equipment and conducting
sterilization procedures.
9-6
CLASSIFICATIONS OF MICRO- Some of the most common diseases caused
ORGANISMS by viruses are colds, smallpox, measles, rubella,
herpes simplex, AIDS, and hepatitis. Viruses are
Microbiology is the study of microscopic usually not affected by therapeutic treatment
life forms called micro-organisms. Disease with antibiotics.
producing organisms are said to be pathogenic.
Other micro-organisms that are not considered Most viruses are susceptible to immersion in
pathogenic can produce infections under boiling water for at least 20 minutes; an
favorable conditions. Micro-organisms are exception to this rule is hepatitis. Due to these
classified as bacteria, bacterial spores, viruses, exceptions to heat resistance, autoclaving is the
protozoa, and fungi. With regards to the process preferred method for sterilization which is
of infection control, HMs need to know the discussed in Chapter 10.
kinds of micro-organisms present and how to
deal with them so that they know how to fight Protozoa
them.
Protozoa are single-celled animals that do
Bacteria not have a rigid cell wall. Some protozoa cause
parasitic diseases but not all are pathogens. Most
Not all bacteria will take on the form of a species are harmless, living on dead organic
spore’s shell-like coating to withstand matter or bacteria. Protozoa that are pathogenic
unfavorable conditions. Bacteria in a spore state survive freely in nature and must be spread by a
remain alive but passive. They are resistant to carrier. Most protozoa pass through a life-cycle
the effects of heat, drying, and most bactericidal that has definite stages of development such as
chemicals. They remain capable of becoming malaria.
virulent (strongly pathogenic) again under
favorable conditions. Under unfavorable Fungi
conditions they will either die or remain dormant
in a spore state until another opportunity for Fungi are plants that lack chlorophyll. They
growth presents itself. are free-living organisms that are smaller than
protozoa. Mold and yeast forms of fungi, have
Viruses firm cell walls, and resemble plants more than
animals.
Viruses are micro-organisms that are much
smaller than bacteria. Viruses vary in size, from Molds usually form cells in long chains or
being the size of a single protein molecule to the threads that grow into tangled masses. Some
size of a more complicated bacterial cell. They threads of the mass bare clusters of seed-like
can be so small that they can be seen only spores that when dry are easily blown into the
through an electron microscope. air like dust. Each microscopic seed is capable
of growing new mold upon settling in a suitable
Viruses cannot live long or reproduce place. Mold spores are easily destroyed by heat.
outside of a living body (host). They must be The most common infections in humans because
able to enter and live in specific cells. For of fungus are athlete’s foot and ringworm. The
descriptive purposes, they are customarily mold penicillin is very common in nature and
divided into three subgroups, based on host contributes to the spoilage of food; the penicillin
specificity: drug is derived from this mold.
• Bacterial viruses
• Animal viruses (including those that attack
humans)
• Plant viruses
9-7
STANDARD PRECAUTIONS Hand washing must (at minimum) be completed:
• At the beginning of each day
All personnel must assume that all body
fluids, contaminated instruments, and • Before and after each patient contact
contaminated materials are infectious. Standard
Precautions must be used to protect HMs and the • Before handling food and medications
patients. Identifying potentially infectious • After coughing, sneezing, or nose blowing
patients by medical history, physical
examination, or readily available laboratory tests • After using the toilet
is not always possible. A period of up to several • In contact with blood, bodily fluids,
weeks often exists between the time a person secretions, excretions and contaminated
becomes infected with a virus and the time when items, whether or not gloves are worn
a laboratory test can detect the antigens or
antibodies that form. In an HIV-infected • Between patients, before and after going to
individual, this period could be 6 months or lunch, after taking a break, after using the
more. Even if a patient tests negative, he or she bathroom, or any time they become
may still be infectious. contaminated
• At the end of the day
Standard Precautions are intended to reduce
the transmission of microorganisms from The skin harbors two types of flora, resident or
recognized and unrecognized sources of normal flora and transient flora.
infection. Standard Precautions should be
applied to all patients receiving care regardless Resident organisms’ characteristics:
of their diagnosis or presumed infection status. • Can survive and will multiply on the skin
Universal Precautions is a subset of Standard
Precautions focusing on the infection control • Can be cultured repeatedly from the skin
methods to prevent the spread of disease from • Are usually of low virulence and are not
blood and body fluids from direct contact by easily removed
utilizing gloves, gown, goggles, and mask.
Standard Precautions include other contaminated Transient bacteria characteristics:
sources (i.e. stethoscope, linen, etc.) and • Do not survive and will not multiply on the
prevention measures. Standard precautions skin
include the following:
• Are not firmly attached to the skin
Hand Hygiene
• Are effectively removed by rubbing of the
hands together and rinsing them under
Hand washing is one of the most important
running water
procedures in preventing the transfer of micro-
organisms from one person to another. The Special attention is needed while washing hands
purpose of hand washing is to remove these to ensure common mistakes are not made, such
micro-organisms from the folds and grooves of as:
the skin by lifting and rinsing them from the
• Fingertips, thumbs, and the areas between
skin surface. Good hand washing techniques and
the fingers are washed poorly or may be
use of gloves are essential before anticipated
skipped entirely
exposure to patients’ blood or bodily fluids.
• The dominant hand is generally washed less
thoroughly than the non-dominant hand
• Microbe counts under the fingernails have
been found to remain high even after
surgical scrubs
9-8
Hand Washing Agents Hand Washing Equipment and Soap
Dispensers
There are many commercial hand washing
products available for use in clinical settings. All patient care areas should have sinks with
The HM needs to be aware of the two main hand electronic or mechanical elbow, foot, or knee
washing agents used in the Navy, water-based action faucet control for asepsis and ease of
cleaning agents and waterless hand washing function.
agents.
The uses of hands-free actuated soap
Water-Based Cleaning Agents dispenser controls are preferable. Maintenance
for refillable hand washing agent dispensers is to
Water-based cleaning agents include chlor- empty, disassemble, and clean them weekly. Do
hexidine, alcohol, and iodophors among the not use bar soaps in bathrooms or clinical and
active antimicrobial ingredients approved for common areas.
hand washing.
Hand Washing Techniques
CHLORHEXIDINE GLUCONATE.—
This antiseptic is usually marketed as 4 percent Personnel involved in patient care must
chlorhexidine gluconate with 4 percent isopropyl follow a rigid hand washing protocol including
alcohol in a sudsy base. Chlorhexidine gluconate the following practices:
is an effective antiseptic for reducing transient
• Removing all jewelry and other ornaments
and resident microbial hand flora, and has a
from the hands and wrists
sustained antimicrobial effect. It does not appear
to affect the skin adversely. It is approved as a • Wetting the hands under warm, running
surgical scrub. water and applying the necessary amount of
antimicrobial soap is required to work up a
IODOPHORS.—These are water soluble lather
complexes of iodine with organic compounds
that are effective against all gram-positive and • Vigorously rub the hands together, fingers
gram-negative bacteria and viruses. Iodophors entwined. This creates friction and loosens
usually do not have a long-acting germicidal dirt and micro-organisms
action and, if used frequently, may cause severe • Clean under the fingernails using a nail
drying of the skin. brush or pick
Waterless Hand Washing Agents • Continue scrubbing the wrists and lower
forearms
Waterless hand washing agents contain 70 • Visibly soiled hands may require more time
percent isopropyl alcohol and virtually disinfect
the skin in 20 seconds. They are effective
against bacilli, fungi, and viruses. Unfortunately,
they are volatile, flammable, evaporate quickly,
and dry the skin. Alcohol-based, waterless hand
washing agents may be used in areas where hand
washing sinks are not readily available and
should only be used when hands are not visibly
soiled.
9-9
PERSONAL PROTECTIVE • Procedural Gloves: They are manufactured
EQUIPMENT (PPE) like sterile surgical gloves but they are non-
sterile and are not individually wrapped in
pairs. Procedural gloves offer the highest
LEARNING OBJECTIVES:
quality and best fit at a greatly reduced cost
when sterile surgical gloves are not required
Identify types of personal protective equipment
(PPE). • Latex Examination Gloves: These are the
least expensive type of non-sterile gloves
Describe the purpose for each type of personal that are commonly used in routine
protective equipment (PPE). procedures. They are available in a variety
of sizes and can with cornstarch to ease
GLOVES putting them on and off. Some individuals
may develop hypersensitive reactions either
HMs should wear gloves for all patient to the latex material or the cornstarch; latex
contact activity. Complete all treatment on each powderless gloves or latex free gloves
patient, wash, and re-glove before beginning should be worn if this occurs
treatment procedures on another patient. Gloves • Nitrile Gloves: These can be sterile or
torn or punctured during patient treatment unsterile examination gloves made of
should be replaced immediately. synthetic latex. They contain no latex
proteins, reducing the possibilities of any
Washing increases the protective nature of hypersensitivities and adverse reactions
the gloves up to 60 percent, repeated use of a from patients. They offer excellent
single pair of gloves is not permitted. Do not use resistance to punctures and tears. Nitrile
petroleum-based hand lotions before donning gloves are three times more puncture
gloves as they will break down the gloves. If a resistant than rubber and can be used to offer
staff member has an allergy to latex, it should be superior resistance to many types of
documented in the member’s medical record so chemicals
that latex free gloves can be acquired.
9-10
All personnel must take the following There are several types of masks available for
precautions regarding the use of clinical apparel: different purposes:
• Wear clinic apparel only in the treatment • Surgical Mask is made from paper or other
facility non-woven material and is worn by health
professionals during surgery and at other
• Change clinic apparel daily or when visibly
times to catch the bacteria shed in liquid
soiled
droplets and aerosols from the wearer's
• Turn in soiled linen at the end of the work mouth and nose
period and place them in a soiled linen
• Cone Mask is a stiff, thin, woven mask used
receptacle
for simple procedures for protection from
• Do not leave dirty clinic attire in personal splashing and aerosols
clothing lockers or spaces overnight
• N95 Respirator is a lightweight, nose-and-
• Do not take clinic attire home to avoid the mouth respirator that can provide some level
spread of pathogens to home and family of protection for the wearer from viruses and
small particles. The masks come in different
sizes due to the necessity for a proper fit for
Face Mask and Shield
optimal protection. It can be used during
surgery or during airborne precautions
Wear a face mask or a full-length face shield
with a face mask during any patient treatment
where aerosols, particulates and splashes will be Protective Eyewear
a possibility. All personnel must wear a mask in
the surgical suite, dental treatment rooms Wear protective eyewear when assisting or
(DTR), medical treatment rooms (MTR), and providing treatment in all surgical procedures or
central sterilization room (CSR), especially on other procedures that may cause a splash,
the dirty side of the CSR. Personnel must change splatter, or airborne particles. Eyewear or
face masks in the following situations: goggles must have solid side shields to provide
maximum protection. Patients must be provided
• After each patient or when the mask is approved protective eyewear for all dental
visibly soiled exams and treatments. Disinfect patient eyewear
• When involved in other activities such as after treatment.
prosthetic laboratory and equipment repair
procedures where airborne particles or dusts Protective Headwear
are produced
Wear disposable protective headwear during
• After sorting laundry surgical procedures. Headwear must fit the head
• During decontamination procedures. When to minimize exposure of the head and hair to
cleaning spills of infectious wastes potential splashing or spraying of blood or
airborne particles. Cloth scrub caps may also be
worn, but must be washed daily and in a style in
accordance with the treatment facility
regulations.
9-11
TRANSMISSION-BASED DROPLET PRECAUTIONS6
PRECAUTIONS
Droplet precautions are used for patients
infected with microorganisms spread by
LEARNING OBJECTIVES:
coughing, sneezing, or talking such as influenza
virus, adenovirus and rhinovirus. The following
Identify the three types of transmission-based
actions should be taken:
precautions.
• If possible the patient should be placed in a
Describe the purpose of the three types of private room or one with another patient
transmission-based precautions. infected with the same organism. If that is
still not possible a 3 foot partition should be
Transmission-based precautions are the maintained between the infected patient and
second tier of infection prevention. It has been any other patients
designed for patients with confirmed or • All healthcare providers should wear a mask
suspected pathogens that can be spread by within three feet of the patient
airborne, droplet, or direct contact with the
patient. A specific and constantly updated list • Place a surgical mask over the patient’s nose
can be found on the Healthcare Infection Control and mouth while transporting
Practices Advisory Committee (HICPAC) /
CDC Isolation Guideline, on the CDC web site. NOTE:
The precautions listed below are in addition to Patient transport should be limited to essential
the standard HM precautions. purposes only.
AIRBORNE PRECAUTIONS6
NOTE:
Patient transport should be limited to essential
purposes only.
9-12
CONTACT PRECAUTIONS6 MEDICAL HISTORY REVIEW
Contact precautions should be used for A thorough review of each patient’s current
patients infected or colonized with organisms medical history is mandatory before initiating
that can be transmitted by direct contact with a any examination or treatment procedure.
provider or indirect contact (spread by contact
with patient care equipment or surfaces in the EATING, GROOMING, DRINKING, AND
patient’s room). Examples include methicillin- SMOKING
resistant Staphylococcus aureus (MRSA) and
vancomycin-resistant E. coli (VRE). Eating, grooming, drinking, and smoking are
permitted only in designated areas separate from
• Place the patient in a private room or one
MTFs and DTFs. Follow all BUMED and
with another patient infected with the same
command instructions pertaining to this matter.
organism and no other infections
• Gloves must be worn upon entering, INFECTION CONTROL IN TREATMENT
changed after handling any infective ROOMS
material, and removed before leaving the
patient’s room. Hands must be washed In accordance with BUMEDINST 6220.9
immediately after glove removal Series, Nosocomial Infection Control
Program; BUMEDINST 6600.10 Series,
• Masks are not necessarily mandatory in this Dental Infection Control Program; and the
situation, ensure to avoid touching the face NAVMED P-5010 the terms and procedures
with contaminated items such as gloves described in the following sections will be used.
• Disposable gowns are worn on entering the
patient’s room to prevent contact of any MEDICAL ASEPSIS
clothing with the patient or infected
materials. The gown is removed before Medical asepsis describes those practices
leaving the patient’s room exercising care to used to prevent the transfer of pathogenic
avoid surfaces in the room organisms from person to person, place to place,
or person to place. Medical aseptic practices are
• Transport patients only if necessary and the routinely used in direct patient care areas and
transporting team maintains contact other service areas in the healthcare environment
precautions to interrupt the chain of events necessary for the
• Patient-care equipment is dedicated to a continuation of an infectious process. The
single patient to prevent cross infections. If components of this chain of events consist of the
this is not possible, the equipment must be elements defined below.
thoroughly cleaned and disinfected before
being used by another patient Reservoir of Infectious Agents
9-13
Portal of Exit Terminal Disinfection
The avenue by which the infectious agent Consists of those measures taken to destroy
leaves its reservoir. When the reservoir is man, pathogenic organisms remaining after the patient
these avenues include various body systems, is discharged from isolation. There are a variety
such as respiratory, intestinal, genitourinary of chemical and physical means used to disinfect
tracts, and open lesions. supplies, equipment, and environmental areas.
Each facility will determine its own protocols
Mode of Transmission based on the recommendation of an Infection
Control Committee.
The mechanism by which the infectious
agent is transmitted from its reservoir to a INFECTION CONTROL IN THE
susceptible being (host). Air, water, food, dust, TREATMENT ROOM
dirt, insects, inanimate objects, and other
persons are examples of modes of transmission. As a HM, infection control in the treatment
room is an all hands responsibility throughout
Portal of Entry the day. There are many precautions and
procedures involved with infection control
The avenue by which the infectious agent practices. The implementation of aseptic
enters the susceptible host. In man, these portals technique is required when preparing for patient
correspond to the exit route avenues, including treatment, during treatment, and after the patient
the respiratory and gastrointestinal tracts, is dismissed. There can be no deviation from the
through a break in the skin, or by direct infection command written procedures and guidelines on
of the mucous membrane. infection control. The HM must be able to
accomplish the following infection control
Susceptible Host procedures:
• Prepare the treatment room for patient care
Man or another living organism that affords
an infectious agent nourishment or protection to • Assist the Medical/Dental Officer during
survive and multiply. treatment
• Disinfect the treatment room between
NOTE: patients
Removal or control of any one component in the
above chain of events will control the infectious • Secure the treatment room at the end of the
process. day
• Perform housekeeping duties
Concurrent Disinfection • Sort laundry
Consists of the daily measures taken to • Dispose of infectious waste
control the spread of pathogenic organisms
while the patient is considered infectious.
9-14
Preparing the Treatment Room Infection Control for the DTR
OSHA and the Navy require that all Aerosols (spray originating from a patient’s
treatment facilities ensure a clean and sanitary mouth during dental procedures) in the work
workplace. Work surfaces, equipment, and other environment present a potential health hazard
reusable items must be decontaminated with an for both the staff and patient. The long term
EPA-registered disinfectant upon completion of effect is cumulative and may be harmful.
procedures when contamination occurs through Aerosol levels can also be lowered and minimize
splashes, spills, or other contact with blood and the potential risk by employing the following
OPIM. Observe and perform the following procedures:
procedures:
• Clean cavity preparations with water, air, or
• Wipe all flat surfaces (tables, chairs, an air and water combination
hanging lights etc.)
• Use high-volume evacuator (HVE)
• Ensure all trash is empty from the day
• Use rubber dams
before
• Cover ultrasonic tanks when in use
• Place clean protective barriers on equipment
that is difficult to clean (microscopes, dental The Dental Officer may direct the HM to
chairs, exam beds etc.) have patients brush their teeth or rinse with a
mouthwash before treatment. This reduces the
• Open instrument trays, packs, or cassettes
microbial concentration of oral flora (saliva).
and leave wrapping material underneath as
Three 10-second rinses will temporarily reduce a
a barrier for the work surface
patient’s microbial count by up to 97 percent.
• For DTRs, at the beginning of the day flush Many Dentists are now using a 0.12 percent
each of the unit water lines and hoses for at chlorhexidine gluconate preoperative rinse that
least 1 minute, even if their use is not also significantly decreases the amount of
anticipated and flush for at least 30 seconds microbial count of an aerosol.
between patients
• Potable water supplies may contain up to
100 bacterial colony forming units per
millimeter (cfu /ml), and water in dental
units, at times, can contain in excess of
1,000,000 cfu/ml
o This microbial contamination comes from
the retraction of contaminated water and
saliva through the dental hand piece and
the growth of bacteria in the unit water
lines
o Although most incoming water is
chlorinated, chlorine loses its potency as
the water lies stagnant in the unit tubing
o Under the right circumstances, these
bacteria will multiply and may become
pathogenic
9-15
The following procedures should be used with Before leaving the DTR, all personnel will
all dental patients for infection control: remove and discard gloves and masks worn
during patient treatment, except when
• HMs must wash their hands before donning
transporting contaminated items to the CSR or to
and after removal of gloves
the prosthetic laboratory.
• Wear sterile gloves for all invasive surgical
procedures To prevent contamination of a patient’s
chart, remove gloves and wash hands (unless
• Use non-sterile gloves for examination and cover gloves are worn) before writing in dental
other non-surgical dental procedures records, viewing radiographs, or taking
• Use a rubber dam whenever possible photographs.
• Swab isolated teeth with an antimicrobial Preparing for the Next Patient
mouthwash to reduce aerosolization of oral
bacteria HMs must clean and disinfect the previously
• Use disposable suction, saliva ejector, and covered surfaces between patients when the
irrigation tips integrity of the physical barriers has been com-
promised or the surface is visibly soiled or if
• Autoclave all instruments that can withstand there is any question about the possibility of
heat sterilization contamination. For example, if moisture is
• Sterilize rotary cutting instruments such as absorbed through the cover to the underlying
burs and diamonds before using surface, then the purpose of the barrier is
defeated, and the surface must be disinfected.
• Use the unit dose concept when dispensing HMs will:
supplies for each treatment setup
• Ensure their room is clean
o This is mandatory
• Wipe down any patient contact areas
• Use sterilizable cassettes, tray sets, or packs
for instruments • Put away all equipment used for the
previous patient
• Place the proper amount of supplies in each
setup before sterilizing • Remove their gloves and wash their hands
and other exposed skin surfaces with an
• Store opened packages of supplies in closed antimicrobial soap
drawers or cabinets in the DTR (in a covered
container if practical) • Replace clean disposable barriers and set up
clean hand pieces and instruments for the
• Use clean forceps to dispense only enough next patient
supplies for immediate use. HMs must
never use their hands to dispense items from
bulk storage containers
• Use of bottled irrigation solution for surgical
and non-surgical procedures is considered
sterile only for that patient if aseptic
techniques are maintained
• Record expiration dates on all opened
containers
9-16
Securing the Treatment Room • Noninfectious waste refuse containers are
not considered infection control hazards.
HMs must thoroughly clean their space and Line them with plastic bags, leave them
all their equipment. Every command will have uncovered, and do not allow them to
different procedures to fit their needs, but the overflow
following are the basic requirements.
• Remove hinged doors on cabinet refuse
• Remove all debris and particulate matter containers and hinged lids on freestanding
before disinfection containers since they present an increased
potential for cross-contamination
• Remove and discard all the disposable
coverings or barriers contacted during • Do not pick up broken glassware directly
patient treatment while still gloved. It is with hands. Instead, use mechanical means
important to remove the surface covers such as a brush and dust pan, vacuum
carefully to prevent contamination of the cleaner, tongs, cotton swabs, or forceps
covered areas. This is accomplished by
turning the soiled outer side toward the
Securing the DTR
inside
• Using the spray-wipe-spray technique, clean For the DTR there are a few extra
and disinfect all unprotected “high touch” responsibilities that must be taken care of at the
areas. To be effective, the disinfectant must end of the day.
remain in contact with the surfaces for the
• Flush the High-Volume Evacuator (HVE)
time specified by the manufacturer
system with at least one quart of water
NOTE: • Clean the system with an HVE system
Do not use 2 percent glutaraldehyde as a surface cleaner at least once each week. Use the
disinfectant because of its caustic vapors and system cleaner more often if indicated by
high cost. problems
• Clean uncarpeted floor and other horizontal • HMs must never lay contaminated
surfaces regularly and when spills occur instruments directly on countertops or work
surfaces
• Use mops with a detergent and an EPA-
registered disinfectant or a detergent with • Rewrap cassettes, packs, or trays in the
sodium hypochlorite (1:100 dilution) original wrap and place individually
packaged instruments in a leak proof
o Mops must be cleaned once every 24 covered container to transport to the CSR
hours or more often as needed
• Flush each unit waterline and hose for 30
• Clean walls and blinds only if they are seconds
visibly soiled
• If the unit has a self-contained water
• Inspect, clean, and disinfect on a regular delivery system, follow manufacturer’s
basis, all bins, pails, cans, and similar instructions for flushing and air purging the
receptacles intended for reuse and having lines
the potential for contamination with blood or
OPIM; clean and disinfect these containers
immediately or as soon as possible upon
visible contamination
9-17
Contaminated Dental Hand Pieces • If the hand piece is autoclavable, remove the
hand piece from the couplings, clean, and
Many dental clinics with CSRs will have the lubricate following the manufacturer’s
HM remove the contaminated hand pieces they instructions
have used and turn them into the CSRs along
with their instruments. The CSR technician will
Bringing Contaminated Items to the CSR
handle, disinfect, lubricate, and sterilize the
dental hand pieces. This saves the Dental
After completion of the above procedures,
assistant valuable time and avoids any excess
the HM can now take all metal and heat stable
aerosols that occur during the disinfection and
items to the CSR for sterilization. Ensure all
lubrication procedure.
instruments and equipment are handled properly
and no sharp objects are protruding through
Some commands require the HM to perform
packs or cassettes while transporting items to the
hand piece maintenance; it includes removing
CSR.
the hand pieces after each patient, lubricating it,
and operating it for 30 seconds. This will purge
Housekeeping
the tubing removing any potentially infectious
material from retraction of coolant water during
Although micro-organisms are normal
previous treatment. Many manufacturers require
contaminants of walls and floors, these surfaces
lubrication of hand pieces before and after
are rarely associated with transmitting infection
sterilization. To prevent cross-contamination,
to staff and patients; all facilities must remain
follow these procedures:
clean. The infection control instruction will
• Use two separate containers of lubricant-one determine and implement a written schedule for
marked for lubrication before sterilization cleaning and a method of disinfection based
and another marked for after sterilization upon location within the facility. The OSHA
and NAVOSH requirements for housekeeping
• Lubricate hand pieces with one end in a
include sections on equipment, laundry, and
headrest cover to capture the aerosol
infectious waste disposal.
contaminants or use one of the many
commercial products for cleaning and
EXPOSURE INCIDENT
lubricating hand pieces
For disinfecting non-autoclavable hand pieces All personnel must pay close attention when
while wearing gloves, use the following using sharps and fluids. Accidents happen and
procedures: personnel who sustain a penetrating injury
(needle stick or cut) or a splash (into the eye or
• Submerge two gauze sponges per hand piece
onto mucous membranes) with contaminated
in a high level, EPA registered disinfectant.
fluids must not be ignored.
Squeeze out any excess
• Use one sponge to wipe the hand piece and Immediately complete the following:
discard 1. Stop activity immediately and step back
• Wrap the second sponge around the hand from the point of contamination.
piece and return it to the holder for the 2. Squeeze the skin around the needle stick or
period of time specified by the manufacturer cut to expel blood and contaminants.
• Before reuse, wipe the hand piece 3. Cleanse the puncture site or flush the eye
thoroughly with potable water to remove with cool water for 15 minutes.
residual disinfectant
4. Report the incident and seek medical
attention promptly.
5. Follow the facility’s protocol for follow-up.
9-18
If a needle stick is involved, most facilities INFECTIOUS WASTE
will draw a baseline blood sample from the
patient and the injured caregiver. Periodic blood Infectious waste is liquid or solid waste
samples are drawn over 12 months to determine containing pathogens in sufficient numbers and
health status and the need for treatment. of sufficient virulence to cause infectious
disease in susceptible hosts exposed to the
Refer to NEHC-TM89-2, Nosocomial waste. If there is doubt as to the infectiousness
Infection Control Manual for Ambulatory Care of the material in question, contact the ICO or
Facilities, and report the incident as a mishap to supervisor.
the command safety officer and command risk
manager using OPNAVINST 5102.1 series. Several examples are:
• Sharps (needles, scalpel blades)
MANAGEMENT OF INFECTIOUS
WASTE • Microbiology waste (cultures, stocks
containing microbes)
LEARNING OBJECTIVES: • Pathological waste (human tissue, body
parts)
Identify medical waste sorting, packaging,
• Liquid waste (blood, cerebrospinal fluid)
handling, and disposal procedures.
• Medical waste from isolation rooms
Identify ordinary and contaminated laundry
and how they are each handled.
Segregation
9-19
How to close a biohazard bag: Liquid Regulated Waste
1. Twist the top of the bag.
Pour liquid regulated wastes into the
2. Wrap tape around the twisted neck of the sanitary sewer system through clinical sinks (not
bag starting from the lower part of the neck hand washing sinks), unless local or state
ascending to the opening. regulations prohibit this practice.
3. At the top of the bag, bend the neck in half
and tape the neck to its self; this is known as Disposable Sharps
“goose necking.”
Treat used disposable sharps, such as
Each MTF and DTF will have their own needles, scalpel blades, capsules, disposable
protocol. HMs need to ensure they are familiar syringes, used burs, and broken instruments as
with local Hazardous Material laws and regulated waste. Handle these items with
instructions. extreme care to prevent any unintentional injury
and the possible spread of blood borne diseases.
Place sharps into rigid, puncture resistant
red sharps container (Fig. 9-1) with the In the dental and surgical setting, because a
BIOHAZARD symbol. Never clip, cut, or bend patient may require a second injection of local
needles or overfill containers. Sharps containers anesthetic, and most syringes are not disposable,
shall be closed before removal or replacement to recapping is sometimes necessary. Use the
prevent spillage or protrusion of contents during following guidelines when recapping:
handling, storage, or transport.
• Never recap a needle using a two-handed
technique
• Use one of the commercially available
sheath holders, or use the “scoop” technique
• If using the scoop technique, the cap is
scooped up from the tray with the needle tip
using only one hand
• Never allow uncovered needles to remain on
the instrument tray
9-20
Linen Handling Storage
9-21
Transportation The treatment and disposal methods shown
in Table 9-1 are the minimally acceptable
When the infectious waste is ready to be standards. The ICO should ensure that all areas
moved, there are regulations that must be within a command handle regulated waste in a
followed while in transport. uniform manner and as always consult all
Federal, State and local laws and regulations.
• Place it in ridged, leak-proof containers
marked by the biohazard symbol
• Refer to the Federal, State and Local laws
for regulations on licensing and vehicle
labeling
Several steps should be used in the treatment and disposal of infectious waste. These steps include the
identification of waste; segregation, sorting, packaging,
1. For effective sterilization, the temperature must be maintained at 121degrees C (250 degrees F) for at
least 90 minutes, at 15 pounds per square inch of gauge pressure. Bacillus stearothermophilus spore
strips must be used weekly to test the sterilization process.
2. Chemical disinfection is most appropriate for liquids.
3. Ash remaining after incineration may go directly to the sanitary landfill, unless state or local regulations
require testing the ash for characteristics of hazardous waste.
4. Disposal of placentas by grinding with subsequent discharge to a sanitary sewer is acceptable unless
prohibited by county or local laws/regulations.
5. Burial or cremation is acceptable.
6. Must be further treated by steam sterilization or incineration.
7. Discharge to a sanitary sewer is acceptable unless prohibited by county or local laws/regulations.
8. Must be treated by steam sterilization or incineration before landfill disposal.
9-22
Recordkeeping CLEANING THE
OPERATING/MEDICAL TREATMENT
The ICO should implement a practical ROOM
system to monitor disposal of infectious waste.
This system includes date, type of waste, amount
(weight, volume, or number of containers), and LEARNING OBJECTIVE:
disposition. Further guidance for infectious
waste can be found in BUMEDINST 6600.10 Identify how to properly field day a surgical
series and BUMEDINST 6280.1 series. suite.
9-23
At the completion of the day’s operations, Before an operation, it is necessary to
each operating room should be terminally sterilize and keep sterile all instruments,
cleaned using an antiseptic germicide solution materials, and supplies that come in contact with
and the following tasks accomplished. the surgical site. Every item handled by the
surgeon and the surgeon’s assistants must be
• Clean all wall or ceiling-mounted equipment
sterile. The patient’s skin and the hands of the
• Clean all spotlights and lights on tracks members of the surgical team must be
thoroughly scrubbed, prepared, and kept as
• Thoroughly scrub all furniture used in the aseptic as possible.
room, including the wheels
• Clean metal buckets and other waste During the operation, the surgeon, surgeon’s
receptacles and put them through the assistants, and the scrub HM must wear sterile
washer/sterilizer, if possible gowns and gloves and must not touch anything
that is not sterile. Maintaining sterile technique
• Clean scrub sinks is a cooperative responsibility of the entire
• Machine scrub the entire floor in each room. surgical team. Each member must develop a
If a machine is not available, use a large surgical conscience, a willingness to supervise
floor brush and be supervised by others regarding the
adherence to standards. Without this cooperative
• Suction up the disinfectant germicide and vigilant effort, a break in sterile technique
solution that is used on the floor, using a wet may go unnoticed or not be corrected, and an
vacuum. If mops are used, make sure a clean otherwise successful surgical procedure may
mop head is issued for each room result in complete failure.
NOTE: BASIC GUIDELINES
The use of mops in the operating room is the
LEAST DESIRABLE method of cleaning. To assist in maintaining the aseptic
technique, all members of the surgical team
must adhere to the following principles:
SURGICAL ASEPTIC TECHNIQUE • Practice good personal hygiene; daily
bathing and clothing change
LEARNING OBJECTIVE:
• Personnel having colds, sore throats, open
sores, and/or other infections will not be
Identify the principles and guidelines for
permitted in the operating room
surgical aseptic technique.
• Operating room attire (which includes scrub
Surgical aseptic technique is the term that suits, gowns, head coverings, and face
describes the sterilization, storage, and handling masks) must not be worn outside the
of articles to keep them free of pathogenic operating room suite. If such occurs, change
organisms. There are important procedures that all attire before re-entering the clean area.
need to be understood before entering the (The operating room and adjacent
surgical environment: the preparation and supporting areas are classified as clean
sterilization of surgical equipment and supplies; areas)
and the preparation of the operating room for • Surgical team members having direct
performing a surgical procedure. Specific contact with the surgical site must perform
methods of preparation will vary from place to the surgical hand scrub before the operation
place, but the basic principles of surgical aseptic
technique will remain the same. • All materials and instruments used in
contact with the site must be sterile
9-24
• Gowns worn by surgeons and scrub HMs • Never reach over a sterile field
are considered sterile from shoulder to waist
• When pouring sterile solutions into sterile
(in the front only), including the gown
containers or basins, do not touch the sterile
sleeves
container with the solution bottle. Once
• If sterile surgical gloves are torn, punctured, opened and first poured, use bottles of liquid
or have touched an unsterile surface or item, entirely. If any liquid is left in the bottle,
they are considered contaminated discard it
• Unsterile articles must not come in contact • Never use an outdated article. Unwrap it,
with sterile articles inspect it, and, if reusable, rewrap it in a
new wrapper for sterilization
• Ensure the patient’s skin is as clean as
possible before a surgical procedure • General rule: anything draped in blue or
green (colors of drapes and gowns may vary
• Take every precaution to prevent
for each MTF) is considered sterile and
contamination of sterile areas or supplies by
should not be touched by anyone but the
airborne organisms
“scrubbed in” surgical staff
9-25
6. Open the two side flaps. 4. With the gloves exposed, drop them on the
gown, paying attention so that the HM’s
7. Last, open the flap closest to the person
clothes do not touch the sterile field.
opening the pack.
Do not touch the gown while attempting to
grasp the corners of the flaps; as seen in Figure NOTE:
9-2. The one inch border around the edge of the
sterile field is considered contaminated. Do not
drop the gloves onto the border or they will be
considered unsterile. This would contaminate
the gown and require the process to be started
again.
LEARNING OBJECTIVE:
9-26
The following steps comprise the accepted 9. Scrub the palm and back of the hand in a
method for the surgical hand scrub. circular motion, using 20 strokes each.
1. Trim the fingernails and cuticles. Nails 10. Visually divide the forearm into two parts,
should be no longer than the finger tips to lower and upper. Scrub all surfaces of each
avoid puncturing gloves. Do not use false division 20 strokes each, beginning at the
fingernails since contamination may occur wristband progressing to the elbow.
from fungal growth between the false and
11. Scrub the elbow in a circular motion using
natural nails. Do not wear nail polish since
20 strokes.
micro-organisms can hide in small cracks in
the finish. 12. Scrub in a circular motion all surfaces to
approximately 2 inches above the elbow.
2. Before beginning the hand scrub, don a
surgical cap or hood that covers all hair, 13. Do not rinse this arm when finished
both head and facial, and a disposable mask scrubbing. Rinse only the brush.
covering the nose and mouth. 14. Pass the rinsed brush to the scrubbed hand
3. Using approximately 6 ml of antiseptic and begin scrubbing the other hand and
detergent and running water lather the hands arm, using the same procedure outlined
and arms to 2 inches above the elbow. Leave above.
detergent on the arms and do not rinse. 15. Drop the brush into the sink when finished.
4. Under running water, clean the fingernails 16. Rinse both hands and arms, keeping the
and cuticles, using a nail cleaner. hands above the level of the elbows, and
5. Starting with the fingertips, rinse each hand allow water to drain off the elbows.
and arm by passing them through the 17. When rinsing, do not touch anything with
running water. Always keep the hands above scrubbed hands and arms.
the level of the elbows.
18. The total scrub procedure must include all
6. From a sterile container, take a sterile brush anatomical surfaces from the fingertips to
and dispense approximately 6 ml of approximately 2 inches above the elbow.
antiseptic detergent onto the brush and begin
scrubbing the hands and arms. 19. Dry the hands with a sterile towel. Do not
allow the towel to touch anything other
7. Begin with the fingertips. Bring the thumb than scrubbed hands and arms.
and fingertips together and scrub across the
fingertips using 30 strokes using the brush. 20. Between operations, follow the same hand
scrub procedure.
8. Scrub all four surface planes of the thumb
and all surfaces of each finger including the
webbed space between the fingers; use 20
strokes for each surface area.
9-27
GOWNING AND GLOVING Continue the process by opening the inner glove
packet on the same sterile surface on which the
gown was opened. The entire gloving process is
LEARNING OBJECTIVE:
shown in the steps of Figure 9-5.
Identify how to properly gown and glove the 1. Pick up one glove by the cuff using the
HM and the surgeon. thumb and index finger.
2. Touching only the cuff, pull the glove
The following will provide step by step onto one hand and anchor the cuff over
instructions for gowning and gloving. the thumb.
Before beginning the hand scrub process the 3. Slip the gloved fingers under the cuff of
sterile gown and glove packages must be the other glove. Pull the glove over the
opened. Upon completion of the surgical hand fingers and hand, using a stretching
scrub, back through the door holding the hands side-to-side motion.
up to avoid touching anything with the hands 4. Anchor the cuff on the thumb. With the
and arms. Gowning technique is shown in the fingers still under the cuff, pull the cuff
steps of Figure 9-4. Pick up the sterile towel that up and away from the hand and over the
has been wrapped with the gown (touching only knitted cuff of the gown.
the towel) and proceed as follows:
5. Repeat the preceding step to glove the
other hand.
1. Dry one hand and arm, starting with the
hand and ending at the elbow, with one end 6. The gloving process is complete.
of the towel. Dry the other hand and arm
with the opposite end of the towel. Drop
the towel.
2. Pick up the gown in such a manner that
hands touch only the inside surface at the
neck and shoulder seams.
3. Allow the gown to unfold downward in
front.
4. Locate the arm holes.
5. Place both hands in the sleeves.
6. Hold the arms out and slightly up while
slipping arms into the sleeves.
7. Another person (circulator) who is not
scrubbed will pull the gown onto the scrub
HM as the hands are extended through the
gown cuffs.
9-28
Figure 9-4.—Proper Gowning Technique
9-29
Figure 9-5.—Proper Gloving Technique
9-30
To gown and glove the surgeon, follow SUMMARY
these steps:
1. Pick up a gown from the sterile linen This chapter has introduced the HM to many
pack. Step back from the sterile field basics in preventive medicine and infection
and let the gown unfold in front. Hold control procedures and philosophies such as
the gown at the shoulder seams with the standard precautions, infection control in the
gown sleeves facing inward. treatment rooms, biohazardous waste
management, and surgical aseptic technique.
2. Offer the gown to the surgeon. Once the Having a good grasp of these areas of patient
surgeon's arms are in the sleeves, let go care will give the HM a good base from which
of the gown. Be careful not to touch they can grow.
anything but the sterile gown. The
circulator will tie the gown.
3. Pick up the right glove. With the thumb
of the glove facing the surgeon, place
the fingers and thumbs of both hands in
the cuff of the glove and stretch it
outward, making a circle of the cuff.
4. Offer the glove to the surgeon. Be
careful that the surgeon’s bare hand
does not touch the HM’s gloved hands.
5. Repeat the preceding step for the left
glove.
9-31
CHAPTER 10
10-1
Table 10-1 describes the level of Organic Debris Present
disinfection required to kill the micro-
organism named. Blood, saliva, and other organic material
may contribute to the failure of a germicidal
process by either direct inactivation of the
disinfectant or the actual layering of the
Vegetative
Bacterial
Tubercle
Nonlipid
Bacteria
Bacillus
Viruses
Viruses
Level of Spores micro-organisms on the instruments or
Lipid
Bacterial equipment, thereby preventing penetration of
Activity
the germicide.
High Maybe Yes Yes Yes Yes Type and Concentration of the Germicide
Intermediate No Yes Yes Yes Yes
Low No No No Yes Yes Generally, when all other variables are
In the absence of gross organic contamination. constant, the higher concentrations of a
chemical agent are more effective and require a
shorter time to disinfect. Use of dilutions other
Table 10-1.—Micro-Organisms and Levels of than those specified by the manufacturer
Disinfection adversely affects some intermediate-level
disinfectants, specifically iodophors. In all
FACTORS INFLUENCING GERMICIDAL instances, follow the manufacturer’s
PROCEDURES recommendations.
10-2
EPA-Registered Surface Disinfectants for Dentistry
Category/Active Ingredient Contact* Pros Cons
Chlorines (sodium hypochlorite 2–10 min Economical; rapid, broad- Diluted solutions must
diluted in-office, chlorine dioxide, 20ºC or 25ºC† spectrum activity; be prepared daily;
commercial preparations of sodium tuberculocidal; effective in cannot be reused; are
hypochlorite with added dilute solution corrosive to some
surfactants) metals; may destroy
fabrics; may irritate
skin and other tissues;
chlorine dioxide is a
poor cleaner
Other halogens (sodium bromide 5 min Fast acting; tuberculocidal; For use on hard
and chlorine) 20ºC supplied in tablet form for surfaces only; chlorine
simple dilution; requires smell
minimal storage space
EPA, Environmental Protection Agency.
*Contact time/temperatures for tuberculocidal activity.
†
Varies by active ingredient or disinfectant brand.
Note: Glutaraldehydes and simple quaternary ammonium compounds should not be used for surface disinfection
in dentistry.
Image reprinted with permission from: Organization for Safety and Asepsis Procedures (non-profit organization)
which provides information and education on dental infection control and office safety.
For more information, please call 1-800-298-OSAP (6727).
10-3
Glutaraldehyde Solutions Iodophors
10-4
Phenolics SEMI-CRITICAL CATEGORY ITEMS
REQUIRING CHEMICAL DISINFECTION
Phenolics are also classified as an
intermediate-level disinfectant, provided the LEARNING OBJECTIVE:
product label indicates a claim to
tuberculocidal activity. When diluted properly, Identify semi-critical and non-critical items
phenols are used for surface disinfection. requiring chemical disinfection.
Phenolics are useful on metal, glass, rubber,
and plastic, and are less toxic and corrosive
than glutaraldehyde solutions. However, they
create a film accumulation, can degrade certain Examples of semi-critical items requiring
plastics, and etch glass with prolonged chemical disinfection are three-way syringe
exposure (Fig. 10-1). They are very irritating tips, High-Volume Evacuator (HVE) saliva
and contact with skin and mucous membranes ejector tips, and radiographic positioning
should be avoided. To prevent skin and eye devices. For the chemical disinfection of semi-
irritation, protective gloves and eyewear must critical items, use the following procedures:
be worn during their use. 1. Thoroughly wipe the item with absorbent
material saturated with an EPA-registered
disinfectant.
2. Allow the disinfecting solution to remain in
contact with the item for the length of time
specified by the manufacturer.
3. Whenever possible, all semi-critical items
that can withstand sterilization should be
sterilized.
4. Nitrous oxide masks and breathing tubes fall
into the semi-critical category, if they are
autoclavable, clean and sterilize them using
steam heat. If not autoclavable, wipe after
each use with two separate gauze pads
saturated with a high-level disinfectant. If
breathing tubes are not autoclavable, after
each use, rinse inside and outside with
running water, wipe and flush with a high-
level disinfectant, and re-rinse with water.
10-5
NON-CRITICAL CATEGORY ITEMS STERILIZATION
REQUIRING CHEMICAL
DISINFECTION LEARNING OBJECTIVE:
10-6
There may also be an area equipped with
the utilities necessary for operating dental hand
pieces. Some commands require that the
disinfection, cleaning, lubrication, and
sterilization of dental hand pieces take place in
the CSR instead of the medical treatment room
(MTR) or dental treatment room (DTR). Check
to see what the command’s policies are on
where hand piece maintenance should take
place.
PROCESSING
STERILIZATION
10-7
Whether a centralized or individual INSTRUMENT CLEANING
sterilization area is used, contaminated
instruments and equipment must be processed You should take contaminated instruments
as described next. from the receiving area wearing heavy duty
puncture-resistant gloves while handling all
MANAGEMENT OF CONTAMINATED potentially contaminated items. Break down
INSTRUMENTS all packs and place disposable items and
contaminated linens in appropriate containers.
Following the completion of a patient’s All contaminated, reusable items must be
treatment, the HM will take the contaminated decontaminated by immersion in an EPA-
instruments and equipment directly to the CSR registered disinfectant before further handling.
technician in the receiving area of the CSR. This step can be eliminated if these items are
Figure 10-3 illustrates a contaminated cleaned in an ultrasonic cleaner (bath) with an
instrument pack that has been placed in the EPA-registered disinfectant that also is
designated drop-off location in the receiving approved as an ultrasonic cleaning solution.
area. The CSR technician should take the Process contaminated instruments using one of
contaminated instruments and equipment and the following methods. They are discussed in
set them in the receiving area that has been order of preference.
designated as a temporary holding area until
they can be processed. Automated Washer Processor
NOTE:
Longer cleaning times may be required for
Figure 10-5.—Small and Large Size Ultrasonic some nonmetallic instrument cassettes.
Cleaners
Never use a hand to remove instruments from
The ultrasonic cleaner should be located in the unit. Instead, use the basket to lift the
the processing area of the CSR. The instruments from the solution, drain, and rinse
manufacturer’s instructions must be followed them under running water.
when using ultrasonic cleaners. These
instructions should be posted or readily Be sure to rinse the instruments thoroughly to
available in locations where the units are used. remove all the remaining solution.
10-9
Manual Scrubbing Perform the following procedures in the
sterilization process next.
Although manual scrubbing is time
consuming and presents an increased potential Inspection and Sorting of Instruments
for contamination injury, this method is effective
for cleaning instruments when automated washer After drying, the HM must inspect items
processors or ultrasonic cleaning units are not closely for wear, breakage, and cleanliness.
available. Triple-sink modules allow personnel Sort instruments according to sets or packs.
to perform in an orderly sequence multiple This is the pre-staging area where the
functions such as pre-rinsing, soaking, washing, instruments are sorted before wrapping and
and final rinsing. While wearing heavy-duty packaging.
utility gloves, face mask, plastic apron, and eye
protection, place instruments in a disinfecting Wrapping and Packaging
solution, allow them to soak, and then scrub
them under water to avoid generating splatter. Wrapping and packaging is the last step
just before the sterilization process. Many
PRE-STERILIZATION PROCESSING different types of sterilizers, packaging, and
wrapping materials are used in the CSR.
LEARNING OBJECTIVES:
Ensure to place consumable supplies that
are required by the command in each particular
Indentify the steps in pre-sterilization
pack before wrapping such items as needles,
processing.
cotton rolls and pellets, gauze, aluminum foil
for dental light handles, internal indicators, and
Indentify methods of sterilization.
towels.
Indentify types of sterilizers.
Instruments are usually placed in packs, on
metal trays or perforated cassettes, before
The HM is still in the processing area of placing them into the sterilizer. The most
the CSR and has just finished cleaning the common wrapping materials and containers are
instruments using one of the three methods of paper, paper/plastic, nylon tubing, and cloth.
cleaning discussed previously and letting them
dry as shown in Figure 10-6. Wash rubber tubing in an antiseptic
detergent solution. Pay attention to the inside of
the tubing. Rinse all tubing well and place it
flat or loosely coiled in a wrapper or
container.
NOTE:
These gloves are for one-time use only.
10-10
Do not place surgical knife blades or Heat sealed plastic or nylon tubing should
suture materials inside linen packs or on only be used as an overwrap after the pack has
instrument trays before sterilization. been sterilized. Heat sealed overwrapping will
extend a 30 day shelf life to 180 days.
Modern manufacturing processes make all
suture materials available in individual The practical use of some semi-critical items
packages, pre-sterilized, with or without a may preclude wrapping or packing. Basic
surgical needle attached. Once opened, do not guidance in proper wrapping techniques includes
resterilize either the individual package or an the following:
individual strand of suture material.
• Using trays or cassettes to reduce the
possibility of puncturing the wrapping
material and risk of injury during post-
NOTE: treatment handling
The only exception to this rule involves the use
of surgical stainless steel. This material is often • Wrapping loosely to allow steam to circulate
provided in unsterile packages or tubes. freely throughout the pack
Individual strands or entire packages of surgical • Arrange items so that all surfaces receive
stainless steel must be sterilized before use. direct exposure to the sterilization agent
• Opening all hinged instruments during
Paper materials are available in the form of packaging to allow steam to penetrate these
bags or flat disposable wraps. Both types are areas
sealed with adhesive indicator tape. The
combination paper/plastic peel packs NOTE:
(Fig. 10-7) are available in varied sizes of The uses of muslin wraps are discouraged.
preformed bags or rolls of varied widths that
can be cut to the desired length. Either type can • Cloth and nonwoven wraps are sealed with
be sealed with the adhesive indicator tape or external indicator tape. The indicator tape
self-sealed. will change color if exposed to the
sterilization elements
• When wrapping instrument packs with
indicator tape, always turn the tabs down on
the tape. This provides a folded edge to aid
in opening the package and removing the
tape
• Launder muslin towels after each use and
inspect for tears or pinholes
• Follow the manufacturer’s time and
temperature settings on sterilizers for the
Figure 10-7.—Paper/Plastic Peel Packs types of wrapping material used
• Using internal and external chemical
The packaging or wrapping materials that indicators or multi-parameter integrators
the HM selects depends on the compatibility of (measures temperature, steam, and time)
what type of sterilization packaging materials ensure sterilization is achieved
and their suitability to withstand steam or dry
heat sterilization. Always refer to the sterilizer
manufacturer’s instructions for suitability.
10-11
Expiration Dates Event-Related Shelf Life
After the packs, instruments, and supplies The use of the event-related method
are wrapped or placed into containers and presumes continued sterility until the package is
sealed, they must be labeled with the damaged, wet, or torn. It is a well-recognized
identification number of the sterilizer, the standard for items in good quality, self-sealed
preparer’s initials, the dates of sterilization and or hermetically (airtight) sealed, packaged in
expiration before they are placed in the paper or plastic, or sequentially-wrapped and
sterilizer. To label, use an ink marker, sealed in dust covers within a few hours after
preprinted indicator tape, or a marking device sterilization. If this method is used, the command
that won’t run or fade when exposed to policy must be clearly defined and consistently
sterilization. used throughout the healthcare facility. When
using the event-related method, all sterilizers
The shelf life or expiration date of sterilized must be biologically monitored at least weekly.
items is the period during which an item is
considered safe for use. Shelf life can be time- Sterile Storage
related or event-related. The command’s ICO
will determine what method the sterilization Sterility of materials, instruments, and
program will use. supplies is much harder to maintain than it is
to achieve. There is little value in precise
Time-Related sterilization procedures if instruments are
contaminated upon completion of the process.
Time-related shelf life is identified with an Items must be dry before they are handled or
exact expiration date. After this date, the item is stored. The time required for drying depends
considered to be outdated and should not be on the type of packs in the load and the
used. Table 10-3 lists the different wrapping sterilizing agent used. Freshly sterilized items
methods and their time-related shelf life in are never placed on metal or cold surfaces.
accordance with BUMEDINST 6600.10 series. Packages become damp from the condensation
that occurs and become contaminated.
10-12
Figure 10-8 shows an acceptable sterile STERILIZATION METHODS
storage cabinet containing sterilized packs and
instruments. Sterile items should not be stored
LEARNING OBJECTIVES:
in patient treatment or decontamination areas
unless they are protected by enclosures, such as
Indentify methods of sterilization.
drawers or cabinets.
Indentify types of sterilizers.
Methods of Sterilization
10-13
Physical Methods
A sterilizer should be loaded in a manner You should observe the following precautions
that will allow the free flow of steam in and when loading the sterilizer chamber:
around all articles. Each item sterilized must be • Do not overload. The passage of steam
dated with the expiration of sterility. from the top of the chamber to the bottom
Sterilization indicators must be used in each should not be blocked
load that is put through the sterilization
process. This verifies proper steam and • Place all packages on edges, with large
temperature penetration. packs at the bottom of the chamber, and
small packages in an upper layer crosswise
The operating procedures for a steam to the lower layer. This allows free passage
sterilizer will vary according to the type and of steam
manufacturer. There are a number of • If mixed loads of metal items and linen are
manufacturers, but there are only two types of sterilized together, the linen is placed on
steam-under-pressure sterilizers. Steam the upper shelf and the metal items on the
sterilizers are available in many sizes, ranging lower
from portable countertop to the fixed room-size
sterilizer. Two of the most common types of • Articles that require the same amount of
steam sterilizers used in the Navy are the time and the same final steps should be
downward displacement (gravity) and pre- sterilized together
vacuum, high-temperature sterilizers. • Enclosed fluids are sterilized separately
because the pressure must be slowly
Downward Displacement Autoclave released
I n the downward (gravity) displacement • Load all packages at the same time when
autoclave, air in the chamber is forced they are ready to be sterilized
downward from the top of the chamber. The A standard operation chart for the correct
temperature in the sterilizer gradually exposure period of all supplies should be
increases as the steam heats the chamber and prepared and posted for easy reference. It is
its contents (Fig. 10-9). The actual timing does important to note that sterilizing conditions are
not begin until the temperature is above 245°F based on temperature rather than on pressure.
(118°C).
10-14
Effective steam sterilization and exposure Some spores can withstand temperatures
time are measured from the moment the above the normal boiling point of water
thermometer in the discharge line indicates the (212°F or 100°C); the relationship of
desired preset temperature. The pressure inside temperature to spore killing power is critical.
the sterilizer is not an indication of positive Steam temperature and exposure time, not
sterilization because other factors determine the pressure, are crucial components of this
pressure inside the sterilizer. Pressure merely process. Pressure is used only to raise the
maintains temperature. temperature of the steam and, in itself, has
nothing to do with microbial killing action. At
Prevacuum, High-temperature Autoclave 15 pounds per square inch (psi), the boiling
point increases to 121°C (250°F), a
The prevacuum, high-temperature temperature at which all known organisms are
autoclave is the most modern and economical killed.
to operate and requires the least time to
sterilize a single load. By use of a vacuum Sterilizing Times
pump, air is extracted from the chamber
before admitting steam. The prevacuum steam If the temperature is increased, the
sterilizer (Fig. 10-10) was designed to help sterilization time may be decreased. The
overcome the trapping of air in the chamber. following are some practical sterilization time
periods.
• 250°F (121°C): 30 Min
• 273°F (134°C): 10 Min
All operating rooms are equipped with
high-speed (flash) sterilizers. Wrapped,
covered, opened instruments placed in
perforated trays are "flash" sterilized for 3
minutes at 270°F (132°C). Sterilization
timing begins when the above temperature is
reached, not before.
Bowie-Dick Test
Figure 10-10.—Prevacuum Steam Sterilizer
The Bowie-Dick type test was developed
for prevacuum sterilizers to determine if the air
Trapping of air is one of the greatest has been removed from the chamber during the
dangers encountered when using saturated steam prevacuum stage. Air must be removed so that
under gravity cycles. When errors are made by steam can penetrate the load instantaneously. It
improperly packaging items or overloading the must be understood that this is not a test for
sterilizer chamber, cool air pockets may form adequate exposure to heat in terms of time-at-
resulting in items not being sterilized. This temperature. A commercially prepared Bowie-
prevacuum process permits instant steam Dick type test can be used by carefully reading
penetration to all articles and through all and following the manufacturer’s instructions.
cotton or linen dry goods. Full heating of the All Navy prevacuum sterilizers will be tested
loads is faster in the prevacuum sterilizer than in daily using the Bowie-Dick type test.
the gravity displacement sterilizer.
10-15
Level One Maintenance A disadvantage is that the high
temperatures destroy many rubber and plastic
The interior of the steam sterilizer should based materials, melt the solder of most metal
be cleaned each day before being heated. This impression trays, and weaken some fabrics, as
simple procedure can easily be accomplished well as discolor other fabrics and paper
by using a mild detergent to wash the surfaces. materials.
Follow the wash with a thorough rinse of plain
water. Unless this is done, the chamber walls High temperatures and extended time
will collect mineral deposits and may become periods are required when using dry heat. In
greasy. most instances, this method often proves
impractical. The temperature must be 320°F to
Do not use wire brushes, steel wool, or any 375°F (160°C-190°C), and the time period
type of abrasive cleaning compounds on the depends on the manufacturer’s instructions. A
sterilizer. The manufacturer’s directions must typical dry heat cycle is 90 minutes at 320-
be followed to maintain a properly functioning 345°F, plus the time required to preheat the
sterilizer. If the sterilizer does not appear to chamber before beginning the sterilization
function properly, Bio-Medical repair cycle. A common misuse of the dry heat
technicians should check it at once. Sterilizers method occurs when the oven door is opened,
should be spot checked frequently for leaks in and an instrument is quickly removed during
lines and improperly functioning gauges, dials, the timed cycle. This interrupts the cycle and
thermometers, doors, drain strainers, and valves. timing must begin all over again. Biological
monitoring will be performed weekly. Consult
Dry-Heat Sterilization the manufacturer’s instructions of each type of
dry heat sterilizer for specific details on its
The dry-heat sterilizer (Fig. 10-11) operates operation and user maintenance.
by heating up air and transferring that heated air
into the chamber with the instruments. The dry Chemical Vapor Sterilization
heat sterilizer is the least expensive forms of
heat sterilization. The use of dry heat as a This process uses a mixture of chemicals,
sterilizing agent has limitations. It should be including alcohol, formaldehyde, ketone,
restricted to items that are unsuitable for acetone, and water, that are heated under
exposure to moist heat like metal instruments pressure to form a sterilizing gas. Sterilization
that rust or dull in the presence of water vapor. requires 20-40 minutes at 270°F with 20 psi
when instruments are either unwrapped or
bagged following the manufacturer’s
instructions.
10-16
The major disadvantage of this sterilization Preliminary Requirements
method is the requirement for adequate
ventilation. Chemical vapors, particularly Power will remain on continuously in the ready
formaldehyde, can be released when the mode.
chamber door is opened, leaving a temporary but
• Processing will be restricted to items
unpleasant odor in the area. Chemical vapor
approved for Sterrad that cannot be
sterilization is not routinely used in Navy
sterilized by steam
dentistry. Consult the manufacturer’s
instructions for specific details on operation and • Items must be properly cleaned, dried and
required user maintenance. packaged according to the manufacturer’s
guidelines
STERRAD STERILIZATION PROCEDURE
• No absorbable materials such as cellulose,
Sterilization using plasma state hydrogen foam, or linen may be placed inside the
peroxide (Fig. 10-12) will be accomplished for Sterrad
those products unable to withstand steam • Follow restrictions on items with lumens
sterilization parameters and have been approved,
in writing, for sterilization by this method by the • Trays will be placed flat on the sterilizer
medical device manufacturer. rack. They should not come in contact with
the sides of the chamber
• Wrapping Materials
o Approved peel packs with plastic and
tyvek backing
o Polypropylene materials must be used to
wrap trays
o Approved containerized systems
• Peel packs will be placed on their sides in a
tray or resting against a tray
10-17
Operating Cycle Biological Indicator Test
• Vacuum Stage: Removes air molecules and • A biological test pack will be placed on top
lowers chamber pressure of an instrument set and placed on the
bottom shelf to the rear of the chamber with
• Injection Stage: Introduces hydrogen
each load
peroxide into the chamber
• At the completion of the cycle, the test pack
• Diffusion Stage: Hydrogen peroxide vapor
will be removed and processed according to
to penetrate packages
manufacturer’s recommendation to include
• Plasma Stage: A radio frequency creates the use of Bacillus Subtilis var. niger
the electromagnetic field that converts the biological control
hydrogen peroxide into low temperature gas
• After 48 hours, the results will be
plasma
documented in the sterilization records and
• Vent Stage: Permits air into the chamber to included in the monthly report to the
return to atmospheric pressure Infection Control Officer
• At the end of a cycle, an alarm will indicate • Sterrad sterilization records are stored for 36
the completion of the process months
o Verify proper parameters have been met
Safety Issues for Aborted Cycles
o Sign printout
Follow the safety precautions when
Cassette unloading incomplete cycles. Refer to the
guidelines provided by the sterilizer
manufacturer. PPE such as gloves may be
• Each cassette holds ten (10) cells. At the
required.
end of each cycle the printout will indicate
how many cells remain
Ethylene Oxide Sterilization
• After ten (10) cycles the printout message
will read “insert new cassette”. It will also Ethylene oxide (ETO) gas uses relatively
be displayed on the LED message screen low temperatures for sterilization. Using a
heated unit, sterilization can be achieved in 4-
• Empty cassette falls into retrieval box 12 hours at 120°F. However, a lengthy
• Inspect new cassette before starting a new aeration time of at least 16 hours must follow
cycle each cycle.
10-18
Chemical Sterilization Place a chemical indicator in each tube or
wrapped bur block. At least weekly, place a
Only one liquid chemical, if properly biological monitor in one tube or foil wrapped
used, is capable of rendering an item sterile. block during the first load of the day; retrieve
That chemical is glutaraldehyde. The item to and send for culture testing following the
be sterilized must be totally submerged in the manufacturer’s recommendations.
glutaraldehyde solution for 10 hours. Anything
shorter than 10 hours is disinfection. Before Endodontic files and Gates-Glidden burs
immersion, the item must be thoroughly
cleansed and rinsed with sterile water or sterile Arrange sets in file blocks and seal in peel
normal saline. It should be noted that this packs before autoclaving. When additional
chemical is extremely caustic to skin, mucous files or burs are necessary, take them from a
membranes, and other tissues. new package or from a file storage box and
sterilize them in a bead or salt sterilizer before
CRITICAL CATEGORY ITEMS use.
REQUIRING STERILIZATION
STERILIZATION MONITORING
All critical category items require
sterilization. It also lists methods that are
LEARNING OBJECTIVES:
effective and acceptable, effective but risk
damage, and ineffective with risk of damage
Indentify the three forms of sterilization
to materials. Sterilize critical category items
monitoring.
before turning them in for service or repair.
Indentify when and how biological monitoring
Following BUMEDINST 6600.10 series,
is done.
sterilize critical category items as follows:
Clean burs and diamonds and dry them Commands should base selection of
before sterilizing. Many burs and diamonds sterilization monitors on reliability,
are used only for single patient use. One appropriateness to the process, safety, and cost
accepted method of sterilization for burs and effectiveness. Many types of monitors are
diamonds are to place them in a screw cap glass available. The three most commonly used
test tube or aluminum foil wrapped bur block sterilization monitors in the Navy are physical,
and dry heat sterilize for 90 minutes at 320- chemical, and biological monitors.
345°F.
10-19
Physical Monitoring External Indicators
Physical monitoring involves looking at External indicators are chemical dyes that
the gauges and readings on the sterilizer and change color upon short exposure to sterilizing
recording the temperatures, pressure, and conditions. They are generally printed on
exposure time. packaging materials or supplied in tape form
and are necessary to distinguish processed
Chemical Monitoring packages from those that have not been cycled
(Fig. 10-14). External indicators are not
Chemical monitoring (internal and sensitive enough to be processed as an internal
external) involves the use of a heat-sensitive indicator and should not be used.
chemical that changes color when exposed to
certain conditions.
Internal Indicators
10-20
Guidelines for Internal and External
Indicators
10-21
Evaluation Criteria If a chemical monitor in the test pack
indicates a pass of the sterilization test, these
After the completion of the sterilization loads can be distributed if necessary. The ideal
cycle, open the test pack, and evaluate the situation is to have adequate instruments and
dosage indicator to see if it passes or fails the equipment to be able to hold these items for 48
cycle. If it passes, the HM can distribute the hours after a negative biological test and then
sterile goods and continue the biological test distribute.
procedure. If it fails, follow the procedures
under guidelines for internal and external If the biological test again fails, complete the
indicators. following items:
• Secure the sterilizer
Positive Results
• Notify biomedical repair technicians and the
When positive biological monitoring ICO
occurs, the HM must follow these guidelines:
• Make a narrative entry in the log of each
• Notify the ICO and record the test results in action taken and the results as they occur
the sterilization log
• Retest the sterilizer using biological
• If another sterilizer is available, perform the monitors
following actions:
• Confirm exposure of the biological monitor
o Retrieve and sterilize all items sterilized to sterilization process
since the last negative test of that
sterilizer tested positive • Review the sterilization log for recent
repairs or maintenance
o Process a test pack with both a chemical
and biological monitor and secure the
sterilizer from further use until the results SUMMARY
of the biological and chemical tests are
read As healthcare team members in treatment
facilities HMs must understand the importance
If the results of the biological and of proper disinfection and sterilization methods.
chemical tests indicate negative growth or Most importantly they need to maintain the
pass the sterilization test, the sterilizer can be highest level of safety for both patients and the
placed into service. healthcare team. As a healthcare team member
the HM is legally and ethically responsible for
If the results from the test still indicate performing the procedures described in this
positive growth or failure of sterilization, the chapter in a thorough and careful manner.
sterilizer must be secured and biomedical Proper instrument processing is necessary to
repair personnel notified. prevent the transfer of microorganisms from a
previous patient to the next patient or to the HM.
If another sterilizer is not available, perform the
following actions:
• Notify biomedical repair technicians
• Retrieve and sterilize all items processed
since the last negative test. Use a test pack
with a biological and chemical monitor in
each load when resterilizing all items that
came up positive from the last test
10-22
CHAPTER 11
11-1
This goal is compatible with those of the The Caduceus insignia of the HM marks the
Navy Medical Department. HMs seeking person as a member of a prestigious Corps
additional detailed information about patient worthy of respect.
rights and responsibilities should refer to the
Patient’s Bill of Rights and Responsibilities PROFESSIONAL LIMITATIONS
found in BUMEDINST 6300.10 series,
Chapter 3 “Healthcare Administration,” and the In conjunction with their professional
Comprehensive Accreditation Manual for responsibilities, all healthcare providers must
Hospitals: The Official Handbook (CAMH) realize they are subject to certain limitations in
published by TJC annually. The next two providing healthcare services. These limitations
sections discuss the professional practice and are referred to as standards of practice which are
ethical behavior of HMs in relation to the based on local regulations and guidelines, as
patient and the healthcare team which directly well as, the education, training, and experience
affect meting the patient’s rights. possessed by the healthcare provider. The
mature, responsible individual recognizes,
PROFESSIONAL PRACTICE accepts, and demands these limitations be
respected.
LEARNING OBJECTIVE:
In clinical settings, HMs are tasked with
administering medication, performing treatments,
Identify key elements of professional practice.
and providing individual patient care in
compliance with the orders of the senior
Each member of the healthcare team has healthcare provider. In the hospital and some
specific responsibilities and limitations defined clinical environments, a Nurse Corps officer
by the scope of practice. To fulfill the role as a divides and delegates portions of the patient’s
member of the Hospital Corps within the care to other members of the team based on
context of the total mission of the Navy the skills and experiences of each member. In
Medical Department, it is imperative the HM’s other situations such delegation of duties may
performance of healthcare services be based on be made by that unit’s Senior Medical
a sound body of knowledge and the Department Representative (SMDR), usually
development of well-defined technical skills. an experienced Chief or Senior Chief Petty
This rate training manual (TRAMAN) Officer of the Hospital Corps.
contributes to the development of the HM’s
body of knowledge. The HM occupational ACCOUNTABILITY
standards (NAVPERS 18068 series,
Chapters 40 and 41) define minimal technical Regardless of rank, or rate, all members of
skills required of a Hospital Corpsman. As a the healthcare team are held accountable for
member of the healthcare team the their performance. Being accountable means
mechanisms of on-the-job training, in-service the HM is held responsible for actions taken.
classes, and continuing education programs As a healthcare provider, the HM should
significantly contribute to the HM’s continued continue to acquire new knowledge, skills and
growth in both healthcare knowledge and clinical competencies striving to provide the
skills. best healthcare services possible. Malpractice
occurs when an individual delivers improper
HMs must always be conscious of being care because of negligence or practicing
seen as representatives of Navy Medicine. As outside of the standard of practice.
such, they will be accorded the respect that
goes with having a specialized body of
knowledge and an inventory of unique skills.
11-2
Accountability becomes a critical issue HMs have been charged to provide
when determining issues of malpractice. Areas healthcare services to any human being with
of expertise and medical duties often overlap the same needs for compassion, safety, security
within the healthcare team; legal limits of and respect, as everyone else.
practice are defined in each state by
certifications or qualifications. PROFESSIONAL ETHICS
Another area with medical and legal All professional interactions must be
implications regarding the HM’s role as a directly related to codes of behavior which
healthcare provider is giving advice or support the principles of justice, equality of
opinions. As a result of the frequent and close human beings as persons, and respect for the
contact with patients, HMs will often be asked dignity of human beings. Upholding medical
an opinion of the care or the proposed care the ethics is the responsibility of all HMs. Upon
patient maybe undergoing. These questions completion of Hospital Corpsman Basic
are extremely difficult to respond to, School, HMs take the following pledge:
regardless of who the healthcare provider is. No
one is ever totally prepared or has so much I solemnly pledge myself before God
wisdom to intelligently respond in a and these witnesses to practice faithfully all
spontaneous fashion in these situations. It is of my duties as a member of the Hospital
best to refer the question to the nurse or Corps. I hold the care of the sick and injured
physician responsible for the patient’s care. to be a privilege and a sacred trust and
will assist the Medical Department Officer
PATIENT BEHAVIOR with loyalty and honesty. I will not
knowingly permit harm to come to any
When something is threatening the patient. I will not partake of nor administer
soundness of the body, mind, or spirit or that any unauthorized medication. I will hold all
of a loved one, an individual may behave personal matters pertaining to the private
inappropriately. Occasionally, there are lives of patients in strict confidence. I
temper outbursts, sarcastic remarks, dedicate my heart, mind, and strength to the
unreasonable demands, or other inappropriate work before me. I shall do all within my
responses, often to the point of disruptive power to show in myself an example of all
behavior. The healthcare providers are that is honorable and good throughout my
challenged to look beyond the behavior being naval career.
displayed to identify the underlying stress and
to attempt to relieve the immediate and
obvious source of anxiety.
11-3
This pledge morally binds HMs to certain Healthcare team members have no right
responsibilities and rules included in the whatsoever to divulge any personally
science of medical ethics. Ethics enable the identifiable information, however trivial, to
HM to judge accurately the moral rightness any unauthorized individuals. Upholding
and wrongness of actions. The one element patient confidentiality is essential to the
making healthcare ethics different from general maintenance of personal and professional
ethics is the inclusion of the moral rule, "Do integrity.
your duty." This statement is a moral rule
because it involves certain expectations (e.g., Another important commitment all HMs
of confidentiality). Failure to fulfill these have is the obligation to never abuse any
expectations may cause harm to the patients medications that they have access t o o r to
and/or colleagues. Through the Hospital tolerate abuse by others. These substances are in
Corpsman Pledge, the HM commits to the department or clinic for use under a medical
fulfilling certain duties, not only to those officer’s supervision for the care of patients.
entrusted to his/her care, but also to all Any other use is not authorized and will not be
members of the healthcare team. It is this tolerated.
commitment to service and to mankind that
has traditionally distinguished the United PERSONAL APPEARANCE
States Navy Hospital Corps wherever its
members have served. A HM’s appearance can positively or
negatively influence the trust and opinions of
PERSONAL TRAITS those individuals who seek out healthcare
services. HMs must be very vigilant about
upholding the reputation of the Hospital Corps
LEARNING OBJECTIVE:
as well as the Navy Medical Department.
Excellent personal hygiene, neat hair styles,
Describe important personality traits of a
and spotless, proper uniforms are essential for
healthcare professional.
instilling confidence as competent healthcare
providers throughout the world.
HMs must develop many personal traits as
part of upholding the standards of the Hospital INTERPERSONAL RELATIONS
Corps; an understanding of them can be
obtained by referring to Military
LEARNING OBJECTIVE:
Requirements for Petty O f f i c e r Third and
Second Class (NAVEDTRA 14504). The
Describe how culture, race, religion, sex, and
following traits, however, apply to Hospital
age can affect interpersonal relations between
Corps duties and are essential for good
the patient and their healthcare providers.
performance.
11-4
Many elements influence the development When this is allowed to occur, the environment
of how HMs regard and respond to people. In will feed a multitude of social illnesses and
the following section some of these elements destructive behaviors will develop.
will be discussed as to how they apply to the
HM’s involvement in the military service and It is a moral and legal responsibility of the
to the relationships with other healthcare healthcare provider to render services with
providers and the patients. respect for the life and human dignity of the
individual without regard to race, creed,
CULTURE gender, political views, or social status. The
Navy Medical Department will not tolerate any
Because of the military mission and the expressions or actions based on prejudicial
diverse workforce of the Navy Medical attitudes.
Department, HMs will frequently encounter
members of various cultures. Culture is defined RELIGION
as a group of socially learned, shared
standards and behavior patterns. Concepts As a healthcare professional, the HM must
such as perceptions, values, beliefs, and goals be prepared to accept in a nonjudgmental way,
are examples of shared standards. In addition, the religious or nonreligious beliefs of others
apparel, eating habits, and personal hygiene regardless of personal beliefs. Patients
reflect common behavior patterns of specific typically use these beliefs to guide many of
groups of people. An understanding of their life decisions and turn to them in times
common social norms and behavior patterns of distress. An individual’s religious beliefs
enhances the quality and often the quantity of frequently help give meaning to suffering and
service a provider is able to make available. illness; those beliefs may also be helpful in the
An individual’s cultural background has an acceptance of future incapacities or death.
effect on every area of healthcare service,
ranging from a simple technical procedure to Although the HM may offer religious
the content and effectiveness of health support when asked and should always
education activities. Becoming familiar with provide chaplain referrals when requested or
the beliefs and practices of different cultural indicated, it is not ethical for the HM to abuse
(American) and sub-cultural groups (the the patients by forcing personal beliefs (or
military community) is not only enriching to non-beliefs) upon them. The HM must respect
the healthcare provider, but also promotes an the patient’s freedom of choice, offering
understanding and acceptance of the various support for whatever the needs or desires of
peoples in the world community. the patient may be.
RACE GENDER
The term race is a classification assigned to In today’s Navy, HMs will encounter
a group of people who share inherited physical many situations where they are responsible for
characteristics. Information identifying racial the care and treatment of service members of
affiliation can be a valuable asset to the the opposite sex. When treating service
healthcare provider in assessing the patient’s members of the opposite sex, HMs must
needs, planning and carrying out direct-care always conduct themselves in a professional
activities, and implementing patient education manner.
programs. Unfortunately, racial identification
also has the potential to create a negative
environment in the healthcare setting when
factors such as differences in skin color motivate
prejudicial and segregation type behaviors.
11-5
To ensure the professional conduct of a Infants and Children
healthcare provider is not called into question,
the Navy Medical Department provides Caring for infants and children involves many
specific guidelines in BUMEDINST 6320.83 emotional and physical challenges. Infants can
series, Provisions of Standbys During communicate their feelings in a variety of positive
Medical Examinations. Some of the and negative ways; they may exhibit their needs
guidelines are as follows: by crying, kicking, or grabbing at the affected
area of pain. An infant will usually respond
• A standby must be present when examining
quickly and positively to cuddling, rocking,
or treating a member of the opposite sex.
touching, and soothing sounds.
Whether this standby is a member of the
same sex as the patient may be dictated by
Children may display the same feelings as
patient request and the availability of
an adult would when they feel ill; fear, anger,
personnel. In cases of sexual or domestic
worry, and/or denial and will also need
assault, the significant other cannot be the
emotional support. Ill children may also
standby
display behavior typical for an earlier age. For
• When caring for a patient, sensitivity to both example, a hospitalized child who has been
verbal and nonverbal communication is toilet trained may soil themselves. This is not
paramount. A grin, a frown, or an unusual, and parents should be informed this
expression of surprise may be behavior change is temporary.
misinterpreted by the patient
While the child is under care in the
• Explanations and reassurances will go far in hospital, the HM is a parent substitute and
preventing misunderstandings of actions or must gain the child’s confidence and trust.
intentions Offer explanations of what is going to be done
Knowledge, empathy, and mature in ways the child will understand. Using dolls
judgment guides the care provided to any or other play methods may assist in
patient. This is crucial when the care involves communication, i.e. assessing the doll with a
touching a patient. As a member of the stethoscope and BP cuff prior to assessing the
healthcare team, HMs are responsible for child to ease anxiety and answer questions.
providing complete, quality care to those who
need and seek their service. This care must also Elderly
be provided in a manner compatible with their
technical capabilities. In providing care for the elderly patient, a
healthcare professional must be alert to the
AGE patient’s mental and physical capabilities (i.e.
physical coordination, mental orientation, and
The age of the patient must be considered reduced eyesight). Medical management
in performance of patient care. The HM will be should be modified to accommodate the
responsible for the care of infants, children, individual patient’s needs. Give mature
adults, and the elderly. Communication patients the opportunity to control as many
techniques and patient interaction may need to aspects of their self-care as possible. Allowing
be modified because of the age of the patient as patients to self-pace their own care may take
age affects various physiological, cognitive, more time, but it will result in reducing their
emotional, and psychological elements which feelings of frustration, anger, and resentment.
may help or hinder care. Show genuine respect and warmth with the
elderly. The use of overly familiar terms such
as “gramps" or "granny" is unprofessional and
will be avoided.
11-6
Listen to patients and allow them to Feedback is the response given by the receiver
reminisce if they wish to. There may be a lot to the message. Feedback, at times, is used to
to learn from their history and it may even validate whether effective communication has
relate to their course of care. Conversation can taken place.
also be used as a way to bring today’s events
into focus for the patient. Remember to involve Verbal and Nonverbal Communication
family members, as needed, into the patient
education process. Some elderly patients will The two basic modes of communication are
require assistance from family members for verbal and nonverbal. Verbal communication is
their continuing medical needs once they either spoken or written. Verbal
return home. communication involves the use of words.
Nonverbal communication does not involve the
COMMUNICATION SKILLS use of words. Dress, gestures, touching, body
language, face and eye behavior, and even
silence are forms of nonverbal communication.
LEARNING OBJECTIVE:
Even though there are two forms of
communication, both the verbal and the
Identify communication techniques used in
nonverbal are inseparable in the total
a healthcare setting.
communication process. Awareness of this
fact is extremely important because the HM’s
Communication is a highly complicated professional effectiveness is highly dependent
inter-personal process of people relating to each upon successful communication.
other through conversation, gestures,
appearance, behavior, writing, and, at times, Barriers to Effective Communication
even silence. Such communications not only
occur among healthcare providers and patients, Ineffective communication occurs when
but also among healthcare providers and support obstacles or barriers interfere with the message,
personnel. Support personnel may include transmission, receipt and understanding of the
housekeeping, maintenance, security, supply, message. These barriers are classified as
and food service staff. Another critical physiological, physical, or psychosocial.
communication interaction occurs among Physiological barriers result from some kind of
healthcare providers and visitors. Because of the sensory dysfunction on the part of either the
critical nature of communication in healthcare sender or the receiver. Such things as hearing
delivery, it is important the HM understand the impairments, speech defects, and even vision
communication process and the techniques used problems influence the effectiveness of
to promote open, honest, and effective communication. Physical barriers consist of
interactions. Only through effective elements in the environment, such as noise, that
communication will the HM be able to identify contribute to the development of physiological
the goals of the individual and the Navy barriers (such as the inability to hear).
healthcare system.
11-7
Psychosocial barriers are usually the result PATIENT CONTACT POINT PROGRAM
of one’s inaccurate perception of self or
others; the presence of some defense To provide a frame of reference for the
mechanism employed to cope with some form following section, the following definitions
of threatening anxiety; or the existence of clarify and standardize some critical terms:
factors such as age, education, culture,
• Initial Contact Point: The physical
language, nationality, or a multitude of other
location where patients experience their first
socioeconomic factors. Psychological barriers
communication encounter with a person
are the most difficult to identify and the most
representing, in some role, the healthcare
common cause of communication failure or
facility
breakdown.
• Contact Point: The place or event where
An individual’s true feelings are often the contact point person and the patient meet
communicated more accurately through
nonverbal communication than through verbal • Contact Point Person: The healthcare
communication. provider in any healthcare experience who is
tasked by role and responsibility to provide
Listening a service to the patient
• Patient Contact Point Program:
Listening is a crucial element of the
communication process and one of the primary o This program is most commonly known
activities for the healthcare provider, who must as the Patient Contact Program
use communication as a tool for collecting or o It is the overarching program facilitating
giving information. When one is engaged in two-way communication with patients so
listening, it is important to direct attention to both complaints and complements are
both the verbal and nonverbal cues provided by documented, tracked, and corrections
the other person. Like many other skills made to improve the MTF/DTF
necessary for providing a healthcare service, experience
listening requires conscious effort and constant
practice. Listening skills can be improved and The contact point person has certain
enhanced by developing the following attitudes criteria to meet in establishing a good
and skills: relationship with the patient. Helping the
patient through trying experiences is the
• Hear the speaker out responsibility of all contact point personnel.
Such healthcare providers must not only have
• Focus on ideas
skills related to their professional assignment,
• Remove or manage distractions but they must also have the ability to interact
in a positive, meaningful way to communicate
• Maintain objectivity concern and the desire to provide a service.
• Concentrate on the immediate interaction
Consumers of healthcare services expect
A healthcare provider uses the to be treated promptly, courteously, and
communication process to service a patient’s correctly. They expect their care to be
needs, both short and long-term. To simplify personalized and communicated to them in
this discussion, short-term needs will be terms they understand. The Navy healthcare
discussed under the heading of "Patient system is a service system, and it is the
Contact Point Program." Long-term needs will responsibility of every healthcare provider to
be discussed under the heading of give professional, quality customer service.
"Therapeutic Communications.” The significance of the contact point and the
responsibility of the personnel staffing this
area are important to emphasize.
11-8
The following message from a former THERAPEUTIC COMMUNICATION
Surgeon General of the Navy reflects the
philosophy of the Navy Medical Department A distinguishing aspect of therapeutic
regarding contact point interactions. communication is its application to long-term
communication interactions. Therapeutic
“Some of the most frequent complaints communication is defined as the face-to-face
received by the Commander, Bureau of process of interacting that focuses on
Medicine and Surgery, are those pertaining to advancing the physical and emotional well-
the lack of courtesy, tact, and sympathetic being of a patient. This kind of
regard for patients and their families exhibited communication has three general purposes:
by Medical Department personnel and initial collecting information to determine illness,
points of contact within Navy Medical assessing and modifying behavior, and
facilities. These points of initial patient providing health education. By using
contact, which include central appointment therapeutic communication, the HM attempts to
desks, telephones, patient affairs offices, learn as much as possible about the patient in
emergency rooms, pharmacies, laboratories, relation to the illness. To accomplish this,
record offices, information desks, walk-in and both the sender and the receiver must be aware
specialty clinics, and gate guards, are critical in of the confidentiality of the information
conveying to the entering patient the sense disclosed and received during the
Navy Medicine is there to help them. The communication process. The HM must have a
personnel, both military and civilian, who staff therapeutic reason for invading a patient’s
these critical areas, are responsible for privacy.
ensuring the assistance provided is truly
reflective of the spirit of "caring" for which When collecting information, therapeutic
the Navy Medical Department must stand.” communication requires a great deal of
sensitivity and expertise in using interviewing
No matter how expert the care in the skills. The interviewer must carefully observe
facility may be, an early impression of apathy, the patient’s behavior to ensure the
disregard, rudeness, or neglect of the patient’s identification and a clearer understanding of
needs reflects poorly on its efforts and the thoughts and feelings. Listen to the patient
achievements. Personnel must be constantly on and watch and the response to the interviewer.
their guard to refrain from off-hand remarks or Observe how the patient gives and receives
jokes in the presence of patients or their both verbal and nonverbal communication.
families. HMs must insist their actions and Finally, interpret and record the data observed.
attitudes, as well as those of their colleagues
and subordinates, are professional at all times Listening is one of the most difficult skills
and particularly when in patient areas. What to master. It requires the HM to maintain an
may be commonplace to the facility staff may open mind, eliminate both internal and external
be frightening to a patient or subject to noise and distractions, and channel attention to
misinterpretation. By example and precept, all verbal and nonverbal messages. Listening
HMs must respond to each and every involves the ability to recognize pitch and tone
complaint in the same manner; providing the of voice, evaluate vocabulary and choice of
best response of which they are capable in words, and recognize hesitancy or intensity of
dealing with their beneficiaries. No complaint speech as part of the total communication
is too trivial not to deserve professional attempt. The patient crying aloud for help after
respect and treatment. a fall is communicating a need for assistance.
11-9
The ability to recognize and interpret Specifically, the goals of this process are to:
nonverbal responses depends upon consistent
• Assist individuals so they may acquire
development of observation skills. As the HM
knowledge and skills that will promote the
continues to mature in the role and
ability to care for themselves more
responsibilities as a member of the healthcare
adequately
team, both clinical knowledge and
understanding of human behavior will also • Influence individual attitudinal changes
grow. This growth will contribute to the HM’s from an orientation emphasizing disease to
ability to recognize and interpret many kinds of an orientation emphasizing health
nonverbal communication.
• Support behavioral changes to the extent
The effectiveness of an interview is individuals are willing and able to maintain
influenced by the amount of information and their health
the degree of motivation possessed by the Healthcare providers tend to be teachers
patient. Factors enhancing the quality of an more often than ever expected. Teaching is a
interview consist of the participant’s unique skill developed through the application
knowledge of the subject under consideration; of learning principles. Patient teaching begins
patience, temperament, and listening skills; with an assessment of the patient’s knowledge.
and the HM’s attention to both verbal and Through this assessment learning needs are
nonverbal cues. Courtesy, understanding, and identified. For example, a diabetic patient may
nonjudgmental attitudes must be mutual goals have a need to learn how to self-administer an
of both the interviewer and patient. injection. After the learner’s needs have been
established, goals and objectives are developed.
To function effectively in the therapeutic Objectives inform the learner of what kind of
communication process, the HM must be an (learned) behavior is expected. Objectives also
informed and skilled practitioner. Development assist the healthcare provider in determining
of the required knowledge and skills is how effective the teaching has been. These
dependent upon the HM’s commitment to basic principles of teaching and learning are
seeking out and participating in continuing applicable to all patient-education activities,
education learning experiences across the entire from the simple procedure of teaching a
spectrum of healthcare services. patient how to measure and record fluid
intake/output to the more complex programs
PATIENT EDUCATION of behavior modification in situations of
substance abuse (i.e., drug or alcohol) or
LEARNING OBJECTIVE: weight control.
Describe how patient education affects patient As a member of the healthcare team, the
care. HM shares a responsibility with all other team
members to be alert to patient education needs,
to undertake patient teaching within the
Patient education is an essential part of the limitation of knowledge and skills, and to
healthcare delivery system. In the Navy communicate to other team members the need
Medical Department, patient education is for patient education in areas the HM is not
defined as "the process that informs, personally qualified to undertake.
motivates, and helps people adapt and
maintain healthful practices and life styles."
11-10
REPORTING AND ASSESSMENT ORAL AND WRITTEN REPORTING
PROCEDURES
Equally as important as assessments is the
reporting of data and observations to the
LEARNING OBJECTIVE:
appropriate team members. Reporting consists
of both oral and written communications and,
Describe proper patient care reporting and
to be effective, must be done in a manner that
assessment procedures.
is accurate, timely, and complete. Maintaining
an accurate, descriptive clinical record serves
Although physicians determine the overall a dual purpose: It provides documentation of the
medical management of a person requiring information gathered about the patient and it
healthcare services, they depend heavily upon serves as a means of communication to
the assistance of other members of the everyone involved in the patient’s care. The
healthcare team when evaluating and clinical record provides a valuable source of
implementing the patient’s ongoing treatment. information for developing a variety of care-
HMs spend more time with hospitalized planning activities. Additionally, these records
patients than all other providers. This situation serve as an important source of material for
places them in key positions as data collection educating and training healthcare personnel,
and reporting persons. for conducting research, and for compiling
statistical data. Finally, the clinical record is a
The systematic gathering of information is legal document and is admissible as evidence
an essential aspect in assessing an individual’s in a court of law in claims of negligence and
health status, identifying existing problems, malpractice.
and developing a combined plan of action to
assist the patient with health needs. The initial Basic Guidelines for Written Entries
assessment is usually accomplished by
establishing a health history. Included in this It is imperative to follow some basic
history are elements such as previous and guidelines when making written entries in the
current health problems, patterns of daily clinical record. All entries must be recorded
living activities, medications, dietary accurately and truthfully. Omitting an entry is
requirements, and relevant occupational, social, as harmful as making an incorrect recording.
and psychological data. Additionally, both Each entry should be concise and brief; avoid
subjective and objective observations are extra words and vague notations. Vocabulary
included in the initial assessment and and terminology must be clear, concise and
throughout the course of hospitalization. free of alternate meanings. Recordings must
be legible. If an error is made, it must be
Accurate and intelligent assessments are deleted following the standard Navy policy for
the basis of good patient care and are essential correcting erroneous written notations.
elements for providing a total healthcare Finally, entries in the clinical record must
service. The HM must know what to watch for include the time and date, along with the
and what to expect. It is important to be able to signature and rank of the HM who provided the
recognize even the slightest change in a care.
patient’s condition, since such changes may
indicate an improvement or deterioration. The
HM must be able to recognize the desired
effects of medication and treatments, as well
as, any undesirable reactions to them. Both of
these factors may influence the physician’s
decision to continue, modify, or discontinue
all of or just specific parts of the treatment
plan.
11-11
SOAP Note Format PLAN.—The last part of the SOAP note
is the Plan. The plan may include laboratory
Medical documentation of the patient’s and/or radiological tests ordered, medications
chief complaint(s) and treatment must be ordered, treatments performed (e.g., minor
consistent, concise, and comprehensive. The surgery procedure), patient referrals (sending
Navy Medical Department uses the SOAP patient to a specialist), patient disposition
note format to standardize medical evaluation (e.g., binnacle list, Sick-in-Quarters (SIQ),
entries made in clinical records. The acronym admission to hospital), patient education, and
SOAP stands for SUBJECTIVE, OBJECTIVE, follow-up guidelines for the patient.
ASSESSMENT, and PLAN. The four parts of a
SOAP note are discussed below. For more ASSESSMENT PROCESS AND
detailed instructions, refer to Chapter 16 of the REPORTING
MANMED.
Assessment of a patient always begins with
SUBJECTIVE.—The initial portion of the a series of questions the HM is asking
SOAP note consists of subjective observations. internally. This “self questioning technique”
These are symptoms verbally given to the HM by prompts the HM to evaluate the patient from
the patient or by a significant other (family or the general appearance to detailed signs and
friend). These subjective observations include symptoms of injury or illness. Table 11-1
the patient’s descriptions of pain or discomfort, outlines the self questioning techniques for
the presence of nausea or dizziness, and a patient assessment and reporting and is a good
multitude of other descriptions of dysfunction, guide to assist in developing proficiency in
discomfort, or illness. assessing and reporting patient conditions.
11-12
Area of Concern Assessment Criteria
General Appearance Is the patient
• of average build, short, tall, thin, or obese?
• well-groomed?
• apparently in pain?
• walking with a limp, wearing a cast, walking on crutches, or wearing a prosthetic extremity?
Behavior Does the patient
• appear worried, nervous, excited, depressed, angry, disoriented, confused, or unconscious?
• refuse to talk?
• communicate thoughts in a logical order or erratically?
• lisp, stutter, or have slurred speech?
• appear sullen, bored, aggressive, friendly, or cooperative?
• sleep well or arouse early?
• sleep poorly, moan, talk, or cry out when sleeping?
• join ward activities?
• react well toward other patients, staff, and visitors?
Position Does the patient
• remain in one position in bed?
• have difficulty breathing while in any position?
• use just one pillow or require more pillows to sleep well?
• move about in bed without difficulty?
Skin Is the patients skin
• flushed, pale, cyanotic (bluish hue), hot, moist, clammy, cool, or dry?
• bruised, scarred, lacerated, scratched, or showing a rash, lumps, or ulcerations?
• showing signs of pressure, redness, mottling, edema, or pitting edema?
• appearing shiny or stretched?
• perspiring profusely?
• infested with lice?
Eyes Are the patients
• eyelids swollen, bruised, discolored, or dropping?
• sclera (whites of eyes) clear, dull, yellow, or bloodshot?
• pupils constricted or dilated, equal in size, and react equally to light?
• eyes tearing or showing signs of inflammation or discharge?
• complaints about pain; burning; itching; sensitivity to light; or blurred, double, or lack of vision?
Ears Does the patient
• hear well bilaterally?
• hold or pull on his ears?
• complain of a buzzing or ringing sound?
• have a discharge or wax accumulation?
• complain of pain?
Nose Is the patients
• nose bruised, bleeding, or difficult to breathe through?
• nose excessively dry or dripping?
• Are the patients nares (nasal openings) equal in size?
• Is the patient sniffling excessively?
Mouth Does the pati e nts
• mouth appear excessively dry?
• breath smell sweet, sour, or of alcohol?
• tongue appear dry, moist, clean, coated, cracked, red, or swollen?
• gums appear inflamed, ulcerated, swollen, or discolored?
• teeth appear white, discolored, broken, or absent?
Does the patient
• wear dentures, braces, or partial plates?
• complain of mouth pain or ulcerations?
• complain of an unpleasant taste?
11-13
Area of Concern Assessment Criteria
Chest Does the patient
• have shortness of breath, wheezing, gasping, or noisy respirations? Cough?
• have a dry, moist, hacking, productive, deep, or persistent cough?
• have white, yellow, rusty, or bloody sputum?
o Is it thin and watery or thick and purulent (containing pus)?
o How much is produced?
o Does it have an odor?
• complain of chest pain?
o Where is the pain?
o Is the pain a dull ache, sharp, crushing, or radiating?
o Is the pain relieved by resting?
o Is the patient using medication to control the pain (i.e., nitroglycerin)?
Abdomen Does the patient
• have an abdomen that looks or feels distended, board-like, or soft?
• have a distended abdomen, and, if so, is the abdomen distended above or below the umbilicus
or over the
• entire abdomen?
• belch excessively?
• feel nauseated, or has he vomited?
o If so, how often, and when?
o What is the volume, consistency, and odor of the vomitus?
o Is it coffee ground, bilious (containing bile), or bloody in appearance?
o Is patient vomiting with projectile force?
Bladder & Bowel Does the patient have
• bladder and bowel control?
• normal urination volume and frequency?
o Does the urine have an odor?
o Is the urine dark amber or bloody?
o Is the urine cloudy; does it have sediment in it?
o Is there pain, burning, or difficulty when voiding?
• diarrhea, soft stools, or constipation?
o What is the color of the stool?
o Does the stool contain blood, pus, fat, or worms?
o Does the patient have hemorrhoids, fistulas, or rectal pain?
Vagina or Penis Does the patient have
• ulcerations or irritations?
• a discharge or foul odor?
o If there is a discharge present, is it bloody, purulent, mucoid (containing mucous), or
watery?
o What is the amount?
• associated pain?
o If pain is present, where is it located?
o Is it constant or intermittent?
o Is it tingling, dull, aching, burning, gnawing, cramping, or crushing?
Food & Fluid Intake Does the patient
• have a good, fair, or poor appetite?
• get thirsty often?
• have any kind of food intolerance?
Medications Does the patient
• take any medications?
o If so: what, why, and when last taken?
• have medications with him?
• have any history of medication reactions or allergies?
11-14
CHAPTER 12
INPATIENT CARE
INTRODUCTION LABORATORY TESTS AND
DIAGNOSTIC PROCEDURES
There are times when patients are unable to
be treated in an outpatient setting. The disease or A variety of laboratory and diagnostic tests
injury is severe enough to require twenty-four and procedures are commonly ordered for the
hour care and monitoring to assist the patient medical patient. The HM will be assigned to
back to a self-sustaining level of health and prepare the patient for the procedure, collect the
wellness. There are many types of specialized specimens, or assist with both. The patient needs
inpatient care areas. This chapter will review the a clear and simple explanation about what is to
unique qualities and requirements of the be done and how to assist with the activity.
medical, surgical, orthopedic, and terminally ill Often the success of the test or procedure is
inpatient care areas. dependent upon the patient’s informed
cooperation. When collecting specimens, the
INPATIENT MEDICAL CARE HM must complete the following procedures:
• Wash hands
LEARNING OBJECTIVE:
• Identify the correct patient
Evaluate the needs of a medical inpatient. • Collect the correct type and amount of
specimen at the correct time
THE INPATIENT • Place the specimen in the correct container
For purposes of this section, the term • Label the container completely and
medical patient applies to any person who is accurately. This may differ somewhat for
receiving diagnostic, therapeutic, and/or each facility; local policies should be
supportive care for a condition that is not consulted
managed by surgical, orthopedic, psychiatric, or • Complete the appropriate laboratory request
maternity-related therapy. This does not mean form
that patients in other categories are not treated
for medical problems. Many surgical, • Document on the patient’s record or other
orthopedic, psychiatric, and maternity patients forms the date, time, and type of specimen
do have secondary medical problems that are collected; the disposition of the specimen;
treated while they are undergoing management and anything unusual about the appearance
for their primary condition. The basic principles of the specimen or the patient during the
of management are essentially the same for both collection
the inpatient and outpatient. When assisting with a diagnostic procedure,
the HM must understand the sequence of steps
The medical management of the patient of the procedure and exactly how the assistance
generally consists of laboratory and diagnostic can best be provided. Since many
tests and procedures, medication, food and fluid procedures terminate in the collection of a
therapy, and patient teaching. For many medical specimen, the above principles of specimen
patients during the initial treatment phase, rest is collection must be followed.
a part of the prescribed treatment.
12-1
Following the completion of a procedure or FOOD AND FLUID THERAPY
specimen collection, it is the responsibility of
the assisting HM to ensure that the patient’s Loss of appetite, food intolerance, digestive
safety and comfort are attended to, the disturbances, lack of exercise, and even
physician’s orders accurately followed, and any excessive weight gain influence a medical
supplies or equipment used appropriately patient’s intake requirements. Regardless of
discarded. their medical needs, all patients have basic
nutritional requirements that differ from those of
MEDICATIONS the healthy person. As a part of the patient’s
treatment plan, food is usually prescribed in the
The treatment of illnesses and injuries often form of a special diet. Regardless of the kind of
include the use of medication. The diet prescribed, the patient must be educated as
responsibility of preparing and administering to why certain foods are ordered or eliminated,
medications often falls to the HM. The and how compliance with the dietary regimen
preparation and administration of medications will assist in the total care. It is the responsibility
demand special knowledge and skills, integrity, of HMs to assist the patient in understanding the
and constant vigilance. A medication error, importance of the prescribed diet and to ensure
which also includes omissions, can seriously that accurate recording of the patient’s dietary
affect a patient, even to the point of death. intake is made on the clinical record.
12-2
Those areas include the following: When these findings are properly reported,
the healthcare team has time to employ
• Follow-up appointments measures that will prevent or arrest the
development of preventable complications. Key
• Modification in activities of daily living elements of prevention include turning the
(ADLs) and habits patient frequently, providing skin care at least
• Modification in diet, including fluid intake daily if not twice daily, massaging the skin to
stimulate circulation, and frequent skin
• Medications and treatment to be continued assessments; all must be done IAW local
after discharge policies and procedures.
• Measures to be taken to promote health and
prevent illness THE SURGICAL PATIENT
The primary reason for prescribing rest as a Identify the needs of a surgical patient during
therapeutic measure for the medical patient is to the preoperative, operative, recovery, and
prevent further damage to the body or body part postoperative phases of treatment.
when the normal demand of use exceeds the
ability to respond. Prolonged or indiscriminate Surgical procedures are classified into two
use of rest, particularly bed rest, is potentially major categories: emergency and elective.
hazardous. Some of the common complications Emergency surgery occurs when surgery is
occurring as a result of prolonged bed rest are: required immediately to save a life or maintain
• Circulatory problems (development of a necessary function. Elective surgery is
blockages) and subsequent skin problems surgery that needs to be done but can be
(ulcers) scheduled at a time beneficial to both the
patient and the provider. Regardless of the type
• Respiratory problems (pneumonia) of surgery, every surgical patient requires
• Gastrointestinal problems (anorexia, specialized care at each of four phases. These
constipation, and fecal impactions) phases are classified as preoperative,
operative, recovery, and postoperative.
• Urinary tract problems (retention, infection,
or the formation of calculi) PREOPERATIVE PHASE
• Musculoskeletal problems (weakness,
Before undergoing a surgical procedure, the
atrophy, and the development of
patient should be in the best possible
contractures)
psychological, spiritual, and physical condition.
• Psychological problems (apathy, depression, Psychological preparation begins the moment
and temporary personality changes) the patient learns of the necessity of the
operation. The physician is responsible for
The prevention of complications is vital in
explaining the surgical procedure to the patient,
therapeutic management for the patient on
including events that can be expected after the
prolonged bed rest. Awareness of potential
procedure. Since other staff personnel reinforce
hazards is the first step in prevention. Alert
the physician’s explanation, all members of the
observations are essential: skin condition,
team must know what the physician has told the
respirations, food and fluid intake, urinary and
patient. In this manner, they are better able to
bowel habits, evidence of discomfort, range of
answer the patient’s questions.
motion, and mood are all critical elements that
provide indications of impending problems.
12-3
All patients approaching surgery are fearful Typically, the physical preparation of the
and anxious. The staff can assist in reducing patient begins in the late afternoon or early
this fear by instilling confidence in the patient evening the day before surgery and at home for
regarding the competence of those providing those scheduled for same day surgery. As with
care. The patient is given the opportunity and the administrative preparation, each step is
freedom to express any feelings or fears clearly outlined in Alexander’s Care of the
regarding the proposed procedure. Even in an Patient in Surgery.
emergency, it is possible to give a patient and
the family psychological support. Often this is PREOPERATIVE INSTRUCTIONS.—
accomplished by the confident and skillful Preoperative instructions are an important part
manner in which the administrative and physical of the total preparation. The exact time that
preoperative preparation is performed. preoperative teaching should be initiated greatly
depends upon the individual patient and the type
The fears of pre-surgical patients may arise of surgical procedure. Most experts recommend
from their insecurities in the areas of anesthesia, that preoperative instructions be given as close
body disfigurement, pain, and/or death. as possible to the time of surgery. Appropriate
Religious faith is often a source of strength and preoperative instructions given in sufficient
courage for some patients. If a patient expresses detail and at the proper time greatly reduce
a desire to see a member of the clergy, every operative and postoperative complications.
attempt should be made to arrange a visit.
OPERATIVE PHASE
Administrative Preparation
The operative (or intra-operative) phase
Except in emergencies, the administrative begins the moment the patient is taken into the
preparation usually begins before surgery. A operating room. Two of the major factors to
step-by-step procedure is outlined in the book consider at this phase are positioning and
Fundamental Skills and Concepts in Patient anesthesia.
Care in the “Caring for the Patient Undergoing
Surgery" chapter. Only the Request for Positioning
Administration of Anesthesia and for
Performance of Operations and Other The specific surgical procedure will dictate
Procedures (SF 522) will be addressed here. The the general position of the patient. For example,
SF 522 identifies the operation or procedure to the lithotomy position is used for a vaginal
be performed; has a statement written for the hysterectomy, while the dorsal recumbent
patient indicating in lay terms a description of position is used for a herniorrhaphy (hernia
the procedure; and includes the signatures of the repair). Regardless of the specific position the
physician, patient, and a staff member who patient is placed in, there are some general
serves as a witness. A SF 522 must be patient safety guidelines that must be observed.
completed before any preoperative medications
are administered. If the patient is not capable of
signing the document, a parent, legal guardian,
or spouse may sign it. It is customary to require
the signature of a parent or legal guardian if the
patient is under 18 years of age, unless the
patient is married or a member of the Armed
Forces. In these latter two cases, the patient
may sign the permit, regardless of age.
12-4
When positioning a patient on the operating Topical Anesthesia is administered
table, remember the following: topically (surface of the body part) to
desensitize a small area of the body for a very
• Whether the patient is awake or asleep,
short time period.
place the patient in as comfortable a position
as possible
Local blocks consist of the subcutaneous
• Strap the patient to the table in a manner that infiltration of a small area of the body with a
allows for adequate exposure of the desensitizing agent. Local anesthesia generally
operative site and is secure enough to lasts a little longer than topical.
prevent the patient from falling, but that
does not cut off circulation or contribute to Nerve blocks consist of injecting the agent
nerve damage into the region of a nerve trunk or other large
nerve branches. This form of anesthesia blocks
• Secure all the patient’s extremities in a all impulses to and from the injected nerves.
manner that will prevent them from One type of nerve block is a digital block (ring
dangling over the side of the table block) which is specific to the digits of the
• Pad all bony prominences to prevent the upper and lower extremities.
development of pressure areas or nerve
damage This is the most common type of anesthesia
the HM will administer. Specific information is
• Make sure the patient is adequately located in Chapter 21, “Emergency Medical
grounded to avoid burns or electrical shock Care Procedures.”
to either the patient or the surgical team
Spinal Anesthesia consists of injecting the
Anesthesia agent into the subarachnoid space of the spinal
canal between the third and fourth lumbar space
One of the greatest contributions to medical or between the fifth lumbar and first sacral space
science was the introduction of anesthesia. It of the spinal column. This form of anesthesia
relieves unnecessary pain and increases the blocks all impulses to and from the entire area
potential and scope of many kinds of surgical below the point of insertion, provided the
procedures. Healthcare providers must patient’s position is not changed following
understand the nature of anesthetic agents and injection of the agent.
their effect on the human body.
If the patient’s position is changed, for
Anesthesia is defined as a loss of sensation example, from dorsal recumbent to
that makes a person insensible to pain, with or Trendelenburg, the anesthetic agent will move
without loss of consciousness. Some specific up the spinal column and the level of the
anesthetic agents are discussed in Chapter 18, anesthesia will also move up. Because of this
Pharmacy, of this manual. Healthcare providers reaction, care must be exercised in positioning
must understand the basics of anesthesiology the patient’s head and chest above the level of
and the specific drugs used. insertion to prevent paralysis (by anesthesia) of
the respiratory muscles. In general, spinal
The two major classifications of anesthesia anesthesia is considered the safest for most
are regional and general. routine major surgery.
REGIONAL ANESTHESIA.—Regional
anesthetics reduce all painful sensations in a
particular area of the body without causing
unconsciousness. The following is a listing of
the various methods and brief description of
each.
12-5
Epidural blocks consist of injecting the • Stage 3 is called the surgical or operative
agent into the epidural space of the spinal canal stage. There are four levels of consciousness
at any level of the spinal column. The area of (also called planes) to this stage. It is the
anesthesia obtained is similar to that of the responsibility of the anesthetist or
subarachnoid spinal method. anesthesiologist to determine which plane is
optimal for the procedure. The
The epidural method is frequently used determination is made according to specific
when continuous anesthesia is desired for a tissue sensitivity of the individual and the
prolonged period. In these cases, a catheter is surgical site. Each successive plane is
inserted into the epidural space through a spinal achieved by increasing the concentration of
needle. The needle is removed, but the catheter the anesthetic agent in the tissue.
is left in place. This provides for continuous
access to the epidural space. It is used most • Stage 4 is called the toxic or danger stage.
frequently in pregnant women during delivery This is never a desired stage of anesthesia as
for pain control. cardiopulmonary failure and death can
occur. Once surgical anesthesia has been
Saddle blocks consist of injecting the agent obtained, the healthcare provider must
into the dural sac at the third and fourth lumbar exercise care to control the level of
space. This form of anesthesia blocks all anesthesia. The fourth level of
impulses to and from the perineal area of the consciousness of stage 3 is demonstrated by
body. cardiovascular impairment that results from
diaphragmatic paralysis. If this plane is not
Caudal blocks consist of injecting the agent corrected immediately, stage 4 quickly
into the sacral canal. With this method, ensues.
anesthetic effect or loss of sensation range from
the umbilicus to the toes.
GENERAL ANESTHESIA.—General
anesthetics cause total loss of sensation and
complete loss of consciousness in the patient.
They are administered by inhalation of certain
gases or vaporized liquids, intravenous
infusion, or rectal induction. The induction of
inhalation anesthesia is divided into four stages
(Fig. 12-1).
• Stage 1 is the stage of analgesia or
induction. During this period the patient
experiences dizziness, a sense of unreality,
and a lessening sensitivity to touch and pain.
At this stage, the patient’s sense of hearing is
increased, and responses to noises are
intensified.
• Stage 2 is the stage of excitement. During
this period there is a variety of reactions Figure 12-1.—Stages of anesthesia
involving muscular activity and delirium. At
this stage, the vital signs show evidence of
physiological stimulation. It is important to
remember that during this stage the patient
may respond violently to very little
stimulation.
12-6
• Recovery Stage or phase consists of the • Monitoring intravenous therapy (including
period that begins at the completion of the blood and blood components)
operation and extends until the patient has
o Make notations including type of
recovered from anesthesia. The recovery
infusion, rate of flow, and condition of the
phase generally takes place in a specialized
infusion site
area called the recovery room or post-
anesthesia care unit (PACU). This unit is o Observe patients receiving blood or blood
usually located near the operating room and components closely for untoward
has access to the following: reactions
o Surgeons and anesthesiologists or • Monitoring skin color changes
anesthetists
o Check dressings and casts frequently to
o Nurses and HMs specially prepared to ensure they are not interfering with
care for immediate postoperative patients normal blood circulation to the area
o Special equipment, supplies, medication, o Notify a physician or nurse of general
and replacement fluids skin color changes that may indicate
airway obstruction, hemorrhage, or shock
From the time of admission to patient
discharge, routine care in the recovery room • Assessing level of responsiveness
consists of the following:
o For general anesthetics, check for
• Measuring temperature and vital signs orientation to the environment each time
(taken immediately upon admission and as vital signs are taken
ordered by the physician thereafter)
o For other anesthetics, check for return of
• Maintaining airway patency sensory perception and voluntary
movement each time vital signs are taken
o Patients having an artificial airway in
place will automatically expel it as they • Observing for side effects of the anesthetic
regain consciousness agent
o Have a mechanical suction apparatus o Each agent has the potential for causing
available to remove excess secretions specific side effects. Some common major
from the patient’s airway side effects that may occur following the
administration of both spinal and general
• Ensuring the integrity of dressings, tubes,
anesthesia consist of the following:
catheters and casts
Hypotension/shock
o Locate the presence of any of the above
Respiratory paralysis
o Make notations regarding all drainage,
including TACO: type, amount, color, and Neurological complications
odor Headache
o Immediately report the presence of Cardiac arrest
copious amounts of drainage to a nurse or
physician Respiratory depression
Bronchospasm/laryngospasm
Diminished circulation
Vomiting/aspiration
12-7
POSTOPERATIVE PHASE Cardiovascular function is assisted by
frequent position changes, early movement and
After the patient’s condition has been ambulation, and in some cases, intravenous (IV)
stabilized in the recovery room, a physician therapy. Renal function is promoted by
will order the patient’s transfer to another area adequate fluid intake and early movement and
of the facility. Generally, this transfer is to the ambulation. Nutritional status is promoted by
unit that the patient was assigned to ensuring adequate oral and intravenous intake
preoperatively such as the Same Day Surgery and by maintaining accurate intake and output
(SDS) unit or ward. With surgery and anesthesia records. Elimination functions are promoted
having unavoidable temporary ill effects on by adequate diet and fluid intake. Carefully
normal physiological functions, every effort monitor patients on opioids as these slow down
must be made to prevent postoperative gastrointestinal recovery. Postoperative patients
complications. should be advanced to a normal dietary regimen
as soon as possible, since this, too, promotes
Postoperative Goals elimination functions. Early movement and
ambulation also help to restore normal
From the time the patient is admitted to the elimination activities.
recovery room to the time recovery from the
operation is complete, there are definite goals of In addition to various medications and
care that guide the entire postoperative course. dressing change procedures ordered by the
These goals are as follows: physician, wound healing is promoted by good
nutritional intake and by early movement and
• Promoting respiratory function
ambulation. Rest and comfort are supported by
• Promoting cardiovascular function properly positioning the patient, providing a
restful environment, encouraging good basic
• Promoting renal function hygiene measures, ensuring optimal bladder and
• Promoting nutrition and elimination bowel output, and promptly administering pain-
relieving medications. Early movement and
• Promoting fluid and electrolyte balance ambulation are assisted by offering pre-
• Promoting wound healing medication, ensuring maximum comfort for the
patient, and providing the encouragement and
• Encouraging rest and comfort support for ambulating the patient. As indicated
• Encouraging movement and ambulation in the above discussion, the value of early
movement and ambulation, when permissible,
• Preventing postoperative complications cannot be overemphasized.
The physician will write orders for
postoperative care that are directed at
accomplishing the above goals. Although the
orders will be based on each individual patient’s
needs, there will be some common orders that
apply to all patients. These orders will focus on
the promotion of certain physiological functions.
12-8
Postoperative Complications Immobilization
During the early postoperative phase, the Rehabilitation is the ultimate goal when
major complications to be guarded against are forming the orthopedic patient’s care plan.
respiratory obstruction, shock and hemorrhage. Whether the patient requires surgical or non-
As the patient progresses in the postoperative surgical treatment, immobilization is often a
period, other complications to avoid are the part of the overall therapy. Immobilization may
development of pneumonia, phlebitis and consist of applying casts or splints, or using
subsequent thrombophlebitis, gastrointestinal traction equipment such as an orthopedic frame
problems ranging from abdominal distention to called a trapeze. During the immobilization
intestinal obstruction, and wound i n f e c t i o n s . phase, simple basic patient care is extremely
important. Such things as skin care, active-
Accurate implementation of the physician’s passive exercises, position changes in bed (as
orders and careful observation, reporting, and permitted), good nutrition, adequate fluid
recording of the patient’s condition will intake, regularity in elimination, and basic
contribute markedly to an optimal and timely hygiene contribute to both the patient’s physical
postoperative recovery course for the patient. and psychological well-being.
12-9
CAST FABRICATION 5. Gently massage and squeeze to remove
excess water. Do not wring it out as this is
As mentioned previously, immobilization is called the lamination process.
often a part of the overall therapy of the
6. Beginning at the wrist (Fig. 12-2C), wrap
orthopedic patient, and casting is the most
the plaster in a spiral motion, overlapping
common and well-known form of long-term
each layer by one-third to one-half.
immobilization. The HM may be required to
apply or assist in cast application. This section 7. Smooth out the layers with a gentle palmar
will discuss the method of applying a short and motion.
long arm cast, and a short leg cast. 8. When applying the plaster, make tucks by
grasping the excess material and folding it
In applying any cast, the basic materials are under as if making a pleat. Successive
the same: webril or cotton bunting, plaster of layers cover and smooth over this fold.
Paris, a bucket or basin of tepid water, a water
source (tap water), protective linen, gloves, a 9. When the plaster is anchored on the wrist,
working surface, a cast saw (if removing old cover the hand and the palmar surface
cast), and seating surfaces for the patient and the before continuing up the arm (Figs. 12-2D
HM. Some specific types of casts require and 12-2E).
additional material. 10. Repeat this procedure until the cast is thick
enough to provide adequate support,
NOTE: generally 2 to 3 layers.
When fabricating a cast ensure items used to 11. The final step is to remove any rough
directly support the casted extremity are made of edges and smooth the cast surface
fabric. Plastics and rubbers, such as the plastic (Fig. 12-2F).
covering on hospital pillows, will melt due to the
chemical heat reaction of the cast as it sets. 12. Turn the ends of the cast back and cover
with the final layer of plaster, and allow
the plaster to set for approximately 15
Short Arm Cast
minutes.
A short arm cast extends from the base of 13. Trim with a cast saw, as needed.
the metacarpal-phalangeal joints of the hand to
one inch below the anticubital space.
Depending on the location and type of fracture,
the physician may order a specific position for
the arm to be casted. Generally, the wrist is in a
neutral (straight) position, with the fingers
slightly flexed in the position of function.
1. Beginning at the wrist, apply two to three
layers of webril (Fig. 12-2A).
2. Then apply webril to the forearm and the
hand, making sure that each layer overlaps
the other by a half (Fig. 12-2B).
3. Check for lumps or wrinkles and correct
any by tearing the webril and smoothing it.
4. Dip the plaster into the water for
approximately 5 seconds or until
completely submerged in water.
12-10
Figure 12-2.—Short Arm Cast
12-11
Long Arm Cast 3. Beginning at the toes, apply webril (Figs.
12-3A-D) in the same manner as for the
The procedure for a long arm cast is short arm cast, ensuring that there are no
basically the same as for a short arm cast, lumps or wrinkles.
except the elbow is maintained in a 90° position,
4. Apply the plaster beginning at the base of
the cast begins at the wrist and ends on the
the metatarsals (Fig. 12-3E) , using the
upper arm two inches below the axilla, and in
same technique of tucks and folds and
some situations the hand is not wrapped.
smoothing as for the short arm cast.
Short Leg Cast 5. Before applying the last layer, expose the
toes and fold back the webril (Fig. 12-3F).
I n applying a short leg cast follow these 6. As the fin al step, apply a footplate to the
guidelines: plantar surface of the cast, using a generous
1. Seat the patient on a table with both legs thickness of plaster (5-7 layers) splints
over the side, flexed at the knee. secured with one or two rolls of plaster
(Fig. 12-3G). This area provides support
2. Instruct the patient to hold the affected leg,
to the cast and a weight-bearing surface
with the ankle in a neutral position (90°).
when used with a cast shoe.
Make sure that the foot is not rotated
medially or laterally.
12-12
Whenever a cast is applied, the patient must Patients are often instructed in the use of an
be given written and verbal instruction for cast assistive device when recovering from an injury
care and circulation checks (i.e., numbness, or disease during their rehabilitation. To
cyanosis, tingling of extremities). Instruct the correctly use the device a specific gait pattern,
patient to return immediately should any of these which requires great concentration to learn
conditions occur. initially, is required in order to learn how to
walk correctly.
When a leg cast is applied, the patient must
also receive instructions in the proper use of Uses of assistive devices include the
crutches. Depending upon the rehabilitation plan following7:
and co-occurring illnesses and injuries, other
• Redistribute and unload a weight-bearing
ambulation tools such as canes and or walkers
lower limb
may also be implemented. The cast will take 24
to 48 hours to completely dry, and it must be • Improve balance
treated gently during this time. Since plaster is
water-soluble, the cast must be protected with a • Reduce lower limb pain
waterproof covering when bathing or during wet • Provide sensory feedback
weather.
• Assist propulsion
Nothing must be inserted down the cast • Enable the individual with paralysis to
(e.g., coat hangers) since this action can cause obtain the physiological benefits of upright
bunching of the padding and result in pressure posture and to maneuver in places
sores. If swelling occurs, the cast may be split inaccessible to a wheelchair
and wrapped with an elastic wrap to alleviate
pressure. Additionally, the object may • Notify passersby that the user requires
compromise the skin integrity with a scratch or special considerations, such as additional
laceration on skin that will not be cleaned until time when crossing streets or taking a seat
the cast is removed creating a habitat for on the bus
bacteria and an opportunity for infection.
Types of Assistive Devices
Cast Removal
The following are assistive devices ranked
A cast can be removed in two ways: by in order of least stable to most stable:
soaking in warm vinegar-water solution until it
dissolves, or by cutting. To remove by cutting, • Canes
cast cutters, spreaders, and bandage scissors are • Crutches
necessary. Cuts are made laterally and medially
along the long axis of the cast, and then widened • Walkers
with the use of spreaders. The padding is then
cut with the scissors.
Canes8
CANES, CRUTCHES AND WALKERS Canes are often used to widen the base of
support and decrease stress on the opposite
Humans have contrived tools or devices that lower extremity. Canes can unload the lower
provided them support when they became limb weight by bearing up to 25% of a
injured. Upon recovery from a lower extremity patient's body weight. Canes can be made of
orthopedic injury the use of assistive devices can wood or aluminum; tubular aluminum is lighter
prevent harmful falls. Selection for each than wood. Aluminum canes are adjustable,
individual is based upon the amount of stability which is a characteristic that facilitates their use
and support required as well as the patient's by patients of all sizes.
strength, cognition, balance, and coordination.
12-13
Types of canes8 Fitting
• C-cane
o Most commonly used cane; other names
used: the crook-top cane, the J cane, and
the single-point cane Figure 12-5.—Cane Fitting
12-14
Stair-climbing To come down stairs (Fig. 12-7):
• Put the cane in the hand closest to the
To climb up stairs (Fig. 12-6):
unaffected leg
• Put the cane in the hand closest to the
• Put the cane on the step first
unaffected (i.e. healthy or good) leg
• Step down with the injured leg
• Step up on the good leg first or
• Finally, step down with the good leg
• If possible, grasp the handrail and step up on
the good leg first
• Step up on the injured leg and the cane at the
same time
12-15
Advantages o Brace fixes crutch to forearm and hands
grasp handles
• Adds support and improves balance o Allows use of hands without dropping
crutches
• Helps maintain stability and prevent slips
and injuries Fitting
• Assists in distributing weight evenly Axillary Crutches (Fig. 12-8):
• Can help a patient distribute weight onto the • Axillary, or underarm, crutches are
cane and away from hips, knees, and ankles measured with the crutch tips flat on the
• Can reduce stress on weak joints and help ground and approximately 6 inches lateral to
reduce soreness and 6 inches in front of the foot
Crutches9
Types of crutches
12-17
Stair-climbing Going down stairs (Fig. 12-10):
• Place the crutches on the step below, and
To negotiate steps, it is important to learn
then step down with the injured leg (“Down
the safest techniques in ascending and
with the bad”)
descending stairs to avoid falls and injuries. The
phrase “up with the good, down with the bad” • The good leg then follows
is often used to help patients recall the
appropriate step pattern for stair climbing or • Make sure the crutch tips are not too close to
traversing a street side curb. the edge of the step
• If a handrail is available, then the crutches
Going up stairs (Fig. 12-9): can be used as one on the opposite side of
• The uninjured or good leg steps up first as the handrail
you bear weight through the crutches (“Up • The sequence remains the same as without
with the good”) using a handrail
• The injured leg follows with the crutches
• Make sure that you are close to the step
before you start and that the injured leg
clears the step as you step up
12-18
Sitting (Fig. 12-11): Standing (Fig. 12-12):
• Back-up to a sturdy chair • Scoot to the front of the chair
• Put both crutches in one hand • Hold both crutches with the hand closest to
the unaffected leg
• Put the injured foot in front
• Push up and stand on the good leg
• With the other hand, feel for the chair arm
rest or seat of the chair
• Slowly lower yourself into the chair
12-19
Precautions10 Walkers
12-20
• Reciprocal Walkers11 (Fig. 12-13C) • Stair-climbing Walkers8 (Fig. 12-13E)
o Has swivel joints that allow each side of o Used to improve stair-climbing ability
the walker to be advanced forward
o Requires good balance and strong upper
alternatively and independently of the
extremities
other
Fitting:
o Allows a more reciprocal gait pattern than
other designs, and thus may provide faster • Place the front of the walker 12 inches in
and less awkward walking front of the patient. The walker should
partially surround the patient
• One-handed (Hemi Walker) (Fig. 12-13D)
• The hand grip of the walker should sit at the
o Combines the features of a walker and a
wrist crease, (ulnar styloid process), or
quad cane
greater trochanter of the patient standing
o Usually are made of tubular aluminum; erect with hands down at the side
adjustable, and can be folded
• Measure the proper height of the walker by
o Provide a wider base and more lateral having the patient stand upright with
support than regular quad canes elbows flexed 20°
o Indications • To confirm that a proper fit has been
Hemiplegics attained, the walker should be positioned so
that the rear feet of the walker are set at
Individuals requiring an intermediate about the midpoint of the patient’s shoes
step during gait training; often used (viewed in the sagittal plane)
during the period after use of the parallel
bars and before ambulation, which is a • The fit should be assessed as the user
time when the patient needs less ambulates to ensure that the walker
restrictive assistive devices functions properly with the desired gait
pattern
o Used by patients who have limited or no
use of one arm or hand
Image reprinted with permission from: Alexander , J. D. (2008). Walker. National public website on assistive
technology. Retrieved on August 21, 2009 from http://atwiki.assistivetech.net/index.php/Walker.
12-21
Techniques for walker use (Fig. 12-14): CONCLUSION
• The user first advances the walker
Ambulatory devices can help people with
• Then the patient steps forward with one foot, disabilities regain strength and mobility as well
followed by the other as to function more freely. Careful consideration
to the user’s needs, abilities, limitations, and
environment is very important to achieve ideal
Advantages
results. Obtaining the correct style, and fit are
• Provides the most support for body weight also important factors to remember.
as compared to crutches
As the right fit will be helpful and maybe
• Ease of application even speed recovery, the wrong choice may
• Provides support for balance (cerebral prolong the problem or introduce new ones.
conditions) and reduced stress (arthritic Being aware of these factors and having a better
conditions) understanding of the clinical parameters
involved with the proper selection of devices
• Folding walkers make for easier storage will allow the HM to train the patients to use the
• Less exertion with rolling walkers device most favorably.
Disadvantages
• The user first advances the walker
• Slower walking speed
• Abnormal gait pattern
• Creates bad posture and walking habits
• Cannot be safely used to climb stairs
• Awkwardness in narrow passages or crowds
• More cumbersome than crutches, especially
non-folding models
• Often have limited usability outdoors
Photograph provided by HM1 James Q. Royal, Biomedical Photography Department of Navy Medicine Support
Command, Bethesda, MD.
12-22
THE TERMINALLY ILL PATIENT Dying is an aspect of life, and it is often
referred to as the final crisis of living. Culturally
approved roles frequently encourage specific
LEARNING OBJECTIVE:
behavior responses. For example, in the
Caucasian, Anglo-European culture, a dying
Explain the needs of the terminally ill patient.
patient is expected to show peaceful acceptance
of the prognosis; the bereaved is expected to
The terminally ill patient has many needs communicate grief. When people behave
that are basically the same as those of other differently, the healthcare provider frequently
patients: spiritual, psychological, cultural, has difficulty responding appropriately.
economic, and physical. What differs in these
patients may be best expressed as the urgency to FIVE STAGES OF DEATH
resolve the majority of these needs within a
limited time frame. Death comes to everyone in A theory of death and dying has developed
different ways and at different times. For some that provides highly meaningful knowledge and
patients, death is sudden following an acute skills to all persons involved with the
illness and for others death follows a lengthy experience. In this theory of death and dying (as
illness. Death not only affects the individual formulated by Dr. Elizabeth Kubler-Ross in her
patient; it also affects family and friends, staff, book On Death and Dying), it is suggested that
and even other patients. It is essential that all most people (both patients and significant
healthcare providers understand the process of others) go through five stages: denial, anger,
dying and its possible effects on people. bargaining, depression, and acceptance.
12-23
It is important to remember that one or PATIENT SAFETY
more stages may be skipped, the patient may
alternate among the various stages in no
LEARNING OBJECTIVE:
particular order, and that the last stage may
never be reached.
Identify patient safety concerns in a medical
treatment facility.
SUPPORT FOR THE DYING
Despite the fact that human beings all The primary goal of the healthcare provider
realize their mortality, there is no easy way to is maintaining, sustaining, restoring, and
discuss death. To the strong and healthy, death is rehabilitating the physical and/or psychological
a frightening thought. The fact that sooner or function of the patient. To achieve this goal,
later everyone dies does not make death easier. healthcare facilities and providers ensure a
There are no procedure books that tell patient’s environmental and personal safety by
healthcare providers "how to do" death. The developing p o lic ie s and implementing
"how to” will only come from the individual mechanisms that ensure safe, efficient, and
healthcare provider who understands that therapeutically effective care. While patient
patients are people, and that, more than any safety is important in all patient care areas, it is
other time in life, the dying patient needs to be of particular importance in the inpatient care
treated as an individual person. setting due to the twenty-four hour care provided
in an unfamiliar environment for the patient.
An element of uncertainty and helplessness
is almost always present when death occurs. ENVIRONMENTAL SAFETY
Assessment and respect for the patient’s
individual and cultural value system are of key For purposes of this section, the environment
importance in planning the care of the dying. As is defined as the physical surroundings of the
healthcare personnel, the HMs may approach a patient and includes such things as lighting,
dying patient with some feelings of uncertainty, equipment, supplies, chemicals, architectural
helplessness, and anxiety. The HM may feel structure, and the activities of both patient and
helpless in being unable to perform tasks that staff personnel. Maintaining safety becomes
will keep the patient alive, uncertain that they even more difficult when working with people
are doing all that can be done to either make the who are ill or anxious and who cannot exercise
patient as comfortable as possible or to postpone their usual control over the environment. Loss of
or prevent death altogether. The HM may feel strength, decreased sensory input, and disability
anxious about how to communicate effectively often accompany illness. Because of this, the
with patients, their family, or even among the HM must be constantly alert and responsive to
healthcare team. This is a normal response since maintaining a safe environment.
any discussion about death carries a high
emotional risk for the patient as well as the Both The Joint Commission (TJC) and the
healthcare provider. Communicating provides National Safety Council of the American
both strength and comfort to all if done with Hospital Association (AHA) have identified four
sensitivity and dignity, and it is sensitivity and major types of accidents that continually occur
dignity that is the essence of all healthcare to patients. These hazards consist of falls,
services. electrical shocks, physical and chemical burns,
and fire and explosions. Since accidents
resulting in physical and chemical burns have
initiated numerous consumer claims of
healthcare provider and facility malpractice, all
healthcare personnel must be thoroughly
indoctrinated in the proper use of equipment,
supplies, and chemicals.
12-24
PATIENT FALL PRECAUTIONS Per the Bureau of Labor Statistics,
healthcare workers often experience
The most basic item of hospital equipment, musculoskeletal disorders (MSDs) at a rate
the patient’s bed, is a common cause of falls. exceeding that of workers in construction,
Falls occur among oriented patients getting in mining, and manufacturing.
and out of bed at night in situations where there
is inadequate lighting. Falls occur among ELECTRICAL SAFETY PRECAUTIONS
disoriented or confused bed patients when (OPNAV 5100.23 SERIES)
bedrails are not used or are used improperly.
Slippery or cluttered floors contribute to The expanded variety, quantity, and
patient, staff, and even visitor falls. Patients complexity of electrical and electronic
with physical li mit at io n s or patients being equipment used for diagnostic and therapeutic
treated with sensory-altering medications fall care have markedly increased the hazards of
when attempting to ambulate without proper burns, shock, explosions, and fire. It is
assistance. Falls result from running in imperative that healthcare providers at all levels
passageways, carelessness when going around are alert to such hazards and maintain an
blind corners, and collisions between personnel electrically safe environment. Knowledge and
and equipment. Unattended and improperly adherence to the following guidelines will
secured patients fall from gurneys and contribute significantly to providing an
wheelchairs. electrically safe environment for all personnel,
whether they are patients, staff, or visitors.
Healthcare personnel can do much to
• Do not use electrical equipment with
prevent the incidence of falls by following some
damaged plugs or cords
simple procedures. These preventive measures
include properly using side rails on beds, • Do not attempt to repair defective equipment
gurneys, and cribs; locking the wheels of
gurneys and wheelchairs when transferring • Do not use electrical equipment unless it is
patients; and not leaving patients unattended. properly grounded with a three-wire cord
Safety straps should be used to secure patients and three-prong plug
on gurneys or in wheelchairs. Maintaining dry • Do not use extension cords or plug adapters
and uncluttered floors markedly reduces the unless approved by the Medical Repair
number of accidental falls. Patients with Department or the safety officer
physical or sensory deficiencies should always
be assisted during ambulation. Patients using • Do not create a trip hazard by passing
crutches, canes, or walkers must receive electrical cords across doorways or
adequate instructions in the proper use of these walkways
aids before being permitted to ambulate • Do not remove a plug from the receptacle by
independently. The total care environment must gripping the cord
be equipped with adequate night lights to assist
orientation and to prevent falls resulting from an • Do not allow the use of personal electrical
inability to see. appliances without the approval of the safety
officer
In addition to patient falls, the HM must use • NEVER put water on an electrical fire
proper care in assisting patients in rising and
ambulating so that the patient is properly • Do not work with electrical equipment with
supported and the HM’s back is properly wet hands or feet
guarded. If patient lift equipment is available, • Have newly purchased electronic medical
ensure proper training in its use is received. This equipment tested for electrical safety by
lessens the chance of the patient or the HM Medical Repair before putting it into service
falling.
12-25
• Operate all electrical and electronic Heat (Bed) Cradle
equipment according to manufacturer’s
instructions When using the heat (bed) cradle, protect
the patient from burns resulting from
• Remove from service electrical equipment overexposure or placement of the equipment too
that sparks, smokes, or gives a slight shock. close to the area being treated. As with heating
Tag defective equipment and expedite repair pads, heat cradles present the dual hazard of
• Call Medical Repair when equipment is not potential burns and electrical shock. Another
functioning properly or Public Works if hazard to keep in mind is that of fire. Ensure
there is difficulty with the power distribution that the bedding and the heat source do not
system come in direct contact and cause the bedding to
ignite.
NOTE:
Be aware that patients with intravenous therapy Heat Lamps
and electronic monitoring equipment are at high
risk from electrical shocks. Occasionally, heat lamps are used to
accomplish the same results as a heat cradle. Do
not use towels, pillow cases, or linen of any
PHYSICAL AND CHEMICAL BURN
kind to drape over heat lamps.
PRECAUTIONS
Ice Bags or Cold Packs
Patient education should address common
causes, identify risks and list precautions to be
Like hot water bottles, ice bags and cold
taken to eliminate the occurrence of burn
packs (packaged chemical coolant) can cause
injuries.
skin-contact burns. This kind of burn is
commonly referred to as local frostbite. The
Hot Water Bottles
precautions taken for applying ice bags and cold
baths are the same as those for hot water bottles
A common cause of burns particularly in
with regard to attention to elderly, diabetic, and
the elderly, diabetics, and patients with
patients with circulatory impairments.
circulatory impairments is the hot water bottle.
Additionally, ice bags should have a towel or
When filling the bottle, the water temperature
other fabric item wrapped around it providing a
must never exceed 125°F (51°C). Test the
barrier between the ice bag and the skin.
bottle for leaks and cover it so that there is a
protective layer of cloth between the patient
Hypothermia Blankets
and the bottle itself.
Like ice bags, hypothermia blankets can
Heating Pads
also cause contact burns. Check the patient’s
skin frequently for signs of marked discoloration
Heating pads present a dual hazard of
(indicating indirect localized tissue damage)
potential burns and electrical shock. The
when using hypothermia blankets. Ensure that
precautions taken when using heating pads are
the hypothermia blanket does not come in direct
the same for hot water bottles: temperature
contact with the patient’s unprotected skin.
control and protective cloth padding.
Precautions to be observed to avoid shock
This precaution is easily accomplished by
include properly maintaining the equipment,
using sheets or cotton blankets between the
conducting pre-use inspections, and ensuring
patient and the blanket itself. When using this
periodic safety inspections are conducted by
form of therapy, follow both the physician’s
Medical Repair personnel.
orders and the manufacturer’s instructions in
managing the temperature control of the
equipment.
12-26
Steam Vaporizers and Hot Foods and Liquids Fire Evacuation Procedures
Steam vaporizers and hot foods and liquids Staff members should be familiar with the
are common causes of patient burns. When fire regulations at their duty station and know
using steam vaporizers ensure that the vapor of what to do in case of fire. Staff should know
steam does not flow directly on the patient as a how to report a fire, use a fire extinguisher, and
result of the initial equipment positioning or by evacuate patients. When a fire occurs, there are
accidental movement. Patients that are sensitive certain basic rules to follow: (1) The senior
to hot foods and liquids are more likely burned. person should take charge and appoint someone
Because of lack of coordination, weakness, or to notify the fire department and the officer of
medication, patients may be less able to handle the day of the exact location of the fire. (2)
hot foods and liquids safely without spilling Everyone should remain calm. (3) All oxygen
them. equipment, vacuum lines, and electrical
appliances must be turned off unless such
In the direct patient care units as well as in equipment is necessary to sustain life. (4) All
diagnostic and treatment areas, there is unlimited windows and doors should be closed and all
potential for inflicting burns on patients. When possible exits cleared. (5) When necessary and
the modern electrical and electronic equipment directed by proper authority, patients should be
and the potent chemicals used for diagnosis and removed in a calm and orderly fashion and
treatment are used properly, they contribute to mustered at the designated relocation area.
the patient’s recovery and rehabilitation. Used
carelessly or improperly, these same sources Smoking Regulations
may cause patients additional pain and
discomfort, serious illness, or, in some cases, By regulation (BUMEDINST 6200.12
even death. series, Tobacco Use in Navy Medical
Department Activities), smoking is no longer
FIRE AND EXPLOSION PRECAUTIONS permitted in Navy treatment facilities. To
ensure general safety and awareness of this
Healthcare facilities have very strict safety prohibition, inform patients, visitors, and staff of
features engineered and constructed into them, the facility’s no-smoking status by prominently
making them very safe. Along with building displaying "No Smoking" signs throughout the
safety features, good housekeeping, hospital especially in rooms and areas where
maintenance, education, and good discipline all oxygen and flammable agents are used and
contribute to fire prevention. Good stored.
housekeeping entails keeping trash within the
confines of its containers and emptying them GENERAL SAFETY
when full. Keeping passageways cleared of
clutter, furniture, and equipment. Never leave In addition to the specifics presented earlier,
heat producing items unattended. Good other basic principles are relevant to patient
maintenance includes checking, reporting, and safety including:
ensuring correct repair of electrical equipment,
• Ensure the patients are familiar with their
and routine checking of firefighting equipment
environment, thus making it less hazardous
by qualified personnel.
to them. This familiarization can be
accomplished by showing the patients the
The education and training of personnel are
floor plan of the ward they have been
the most effective means of preventing fires.
admitted to and by indicating key areas
Good discipline means developing a fire plan to
(lounge, bathrooms, nursing station, etc.)
use as outlined in a fire bill, having periodic fire
that may be of interest to them
drills, and enforcing no-smoking regulations.
12-27
• Be aware of patient sensory impairment and CONCURRENT AND TERMINAL
incorporate precautionary procedures into CLEANING
their patient care plan. For example, this
principle can be applied to patients who have Maintaining cleanliness is a major
been given a pain medication, such as responsibility of all members of the healthcare
morphine or Demerol®. Medications such as team, regardless of their position on the team.
these dull body senses. If a patient in this Cleanliness not only provides for patient
condition wishes to walk around, comfort and a positive stimulus, it also impacts
precautionary actions dictate that the HM on infection control. The HM is often directly
either accompany the patient with a patient responsible for the maintenance of patient care
belt to prevent accidental falls or that the areas. The management of cleanliness in patient
HM does not permit the patient to ambulate care areas is conducted concurrently and terminally.
until the effects of the medication have
stopped Concurrent cleaning is the disinfection
and sterilization of patient supplies and equipment
• Understand that all diagnostic and during hospitalization. Terminal cleaning is the
therapeutic measures have the potential to disinfection and sterilization of patient supplies
cause a patient harm and equipment after the patient is discharged
• Ensure that all accidents and incidents are from the unit or hospital. Both concurrent and
documented and analyzed to identify and terminal cleaning are extremely important
correct high-risk safety hazards procedures that not only aid the patient’s
comfort and psychological outlook, but also
contribute to both efficient physical care and
ENVIRONMENTAL HYGIENE control of the complications of illness and
injury.
LEARNING OBJECTIVE:
AESTHETICS
Identify environmental hygiene concerns in a
medical treatment facility. Aesthetically, an uncluttered look is far
more appealing to the eye than an untidy one.
Today’s public is very much aware of the Other environmental factors, such as color and
environment and its effect on the health and noise, can also enhance or hinder the progress
comfort of human beings. The healthcare setting of a person’s physical condition. In the past,
is a unique environment and has a distinct almost all healthcare facilities used white as a
character of its own. The HM needs to be aware basic color for walls and bedside equipment.
of that character and ensure that the However, research has shown that the use of
environment will support the optimum in health color is calming and restful to the patient. Rest
maintenance, care, and rehabilitation. is a very important healing agent in any kind of
illness. Colors other than white are being added
In the context of the environment, hygiene to the hospital palate to help aid in a restful
may best be described as practices that provide a recovery for the patients.
healthy environment. Environmental hygiene
practices include the following three areas of Noise control is another environmental
concern: safety (which has already been element that requires the HM’s attention. The
addressed); environmental comfort and stimuli; large number of people and the amount of
and infection control. HMs have certain equipment traffic in a facility serve to create a
responsibilities for helping to control the high noise level that must be monitored. Add to
facility’s general environment as well as the that the noise of multiple radios and televisions,
patient’s immediate surroundings. and it is understandable why noise control is
necessary if a healing environment is to be
created and maintained.
12-28
CLIMATE CONTROL Whenever possible, provide a bed lamp for
the patient. As discussed earlier under "Safety
Another important aspect of environmental Aspect," a dim light is valuable as a comfort and
hygiene is climate control. Many facilities use safety measure at night. This light should be
air conditioning or similar control systems to situated so it will not shine in the patient’s eyes
maintain proper ventilation, humidity, and and yet provide sufficient light along the floor
temperature control. In facilities without air so that all obstructions can be seen. A night
conditioning, windows should be opened from light may help orient elderly patients if they are
the top and bottom to provide for cross- confused as to their surroundings upon
ventilation. Ensure that patients are not located awakening.
in a drafty area. Window sill deflectors or
patient screens are often used to redirect drafty In conclusion, it is important that the HM
airflows. Maintain facility temperatures at understand the effects of the environment on
recommended energy-conservation levels that patients. People are more sensitive to excessive
are also acceptable as health-promoting stimuli in the environment when they are ill,
temperatures. In addition to maintaining a and they often become irritable and unable to
healthy climate, good ventilation is necessary in cooperate in their care. This is particularly
controlling and eliminating disagreeable odors. apparent in critical care areas (e.g., in CCUs and
ICUs) and isolation, terminal, and geriatric
In cases where airflow does not control units. HMs must realize and respond to the vital
odors, room fresheners should be discretely importance of the environment in the total
used. Offensive, odor-producing articles (such medical management plan of their patients.
as soiled dressings, used bedpans, and urinals)
should be removed to appropriate disposal and SUMMARY
disinfecting areas as rapidly as possible.
Objectionable odors (such as bad breath or This chapter introduced inpatient care for
perspiration of patients) are best controlled by various types of patients that will be
proper personal hygiene and clean clothing. encountered. It has also introduced standard
rules of hygiene, applying casts, ambulatory
In isolation rooms ensure that there is proper aids, safety, and environment hygiene. Having a
negative pressure by checking wall gages and good understanding of these areas of patient
evaluating the airflow. Operating rooms are care will give the HM a good base from which
required to have positive pressure as regulated to care for patients in a multitude of inpatient
by gauges. If the gauges are not indicating care settings.
proper pressures or operating properly, contact
Industrial Hygiene and Facilities to verify
airflow and to take corrective actions.
LIGHTING
12-29
CHAPTER 13
A Hospital Corpsman (HM) must The number of calories each person needs
recognize the importance nutrition plays in varies by age, gender, and activity level. There
both health and disease. Eating well in a is no “one size” fits all for calorie
healthy state is just as critical as eating well in recommendations. Generally, males require
the diseased state. The HM’s diet can be an more calories than females and the more
example to shipmates in demonstrating proper active a person is, the more calories needed.
food choices. The HMs knowledge and If a person performs mostly general office
expertise can help lead people to improving tasks, they can be considered ‘sedentary’. If a
their own diets. person is engaged in performing manual labor,
they may be considered ‘moderately active’.
ENERGY BALANCE The ‘very active’ people are engaging in high
levels of exercise, combat, or similar tasks.
The human body has basic needs for
energy. Energy comes from the food people
eat. This energy is measured in calories
(actually kilocalories, the word calorie is for
general reference). Figure 13-1 demonstrates
energy balance or the point where a person
can maintain a weight level by expending as
many calories as are consumed.
13-1
Table 13-1 shows a general number of calories The Physical Fitness Assessment
based on a person’s age and activity level. (OPNAVINST 6110.1 series, Physical
Readiness Program) is one way of preventing
overweight and obesity in the Navy.
Moderately Resources are available to assist sailors in
Sedentary Active Very Active managing their weight through OPNAVINST
Male 6110.1 and various other Health Promotion
19-30 2400-2600 2600-2800 3000 programs available at both local commands
31-50 2200-2400 2400-2600 2800-3000 and at the Navy & Marine Corps Public
51-70 2000-2200 2200-2400 2600-2800 Health Center website located at
http://www-nehc.med.navy.mil.
Female
19-30 1800-2000 2000-2200 2400 HEALTHY EATING
31-50 1800 2000 2200
51-70 1600 1800 2000-2200 Healthy eating starts with the Food
Guide Pyramid (Fig. 13-2). The five food
Table 13-1.—Generally Recommended Calories groups eaten in adequate amounts daily are
Based on Gender, Age, and Activity Level designed to maintain the health of the
population of the United States. The
A goal for the general population is to principles of the Food Guide Pyramid are
maintain a healthy weight. A healthy weight proportionality, variety, moderation,
is defined by having a “healthy” Body Mass personalization, activity, and gradual
Index (BMI). BMI is calculated by dividing a improvement. For a full review of the Food
person’s weight in kilograms (2.2# = 1 kg) by Guide Pyramid, go to www.mypyramid.gov.
the person’s height in meters squared (2.54 cm
= 1 inch) or kg/m². A normal weight BMI is
18.5 kg/m² to 24.9 kg/m². Persons below 18.5
kg/m² are considered underweight, persons
with a BMI of 25.0 – 29.9 kg/m² are
overweight, and persons with a BMI > 30 g/m²
are considered obese. Table 13-2 shows the
categories of BMI.
BMI Category
< 18.5 kg/m² Underweight
18.5 – 24.9 kg/m² Normal weight
25.0 – 29.9 kg/m² Overweight
30.0 – 34.9 kg/m² Class I Obesity
35.0 – 39.9 kg/m² Class II Obesity
> 40.0 kg/m² Class III Obesity
13-2
Each color of the pyramid represents a NUTRIENTS
food group. The small yellow sliver represents
fats and oils, which are not a food group but A nutrient is a substance that contributes to
are essential in small quantities. The five food growth or maintenance of the body. There are
groups from left to right are Grains (orange); six essential nutrients: water, carbohydrates,
Vegetables (green); Fruit (red); Fats, oils, and protein, fat, vitamins, and minerals. Three of
discretionary calories (yellow); Milk (blue); these contain calories: carbohydrates, protein,
and Meat and Beans (purple). The grain group and fat. Carbohydrates have four calories per
consists of breads, rice, crackers, cereal, pasta gram, protein has four calories per gram, and
and similar items. It is recommended at least fat has nine calories per gram. Water,
half of grains consumed be whole grains, such vitamins, and minerals do not contain calories.
as whole wheat bread or pasta, brown rice, and The food guide pyramid demonstrates the
whole grain cereals. categories of food to eat to meet the average
daily nutrient needs; a variety of foods should
A variety of different color vegetables and be eaten from all five groups.
fruits are recommended each day. The milk
group is a main supplier of protein, calcium, Water
and vitamin D. When choosing from the meat
and beans group, people should choose lean Water is THE most important nutrient. A
meats. Table 13-3 demonstrates the quantity person cannot survive for very long without
of each group associated with an amount of water, an average of three days. Water is the
calories a person may consume in a day. medium in which all chemical reactions in
the body take place. It is the main
component of blood, which transports
Meat nutrients to the entire body and the means by
Calorie and which the body excretes many of the waste
Level Grain Vegetables Fruit Milk Beans
products it generates (i.e. urine).
2
1200 4 oz 1.5 cups 1 cup cups 3 oz
1.5 2 Recommendations for water needs vary
1400 5 oz 1.5 cups cups cups 4 oz by gender. On the average a male needs
1.5 3 more water on a daily basis than a female.
1600 5 oz 2 cups cups cups 5 oz According to the National Academy of
1.5 3 Science a male needs to consume 3.7 liters of
1800 6 oz 2.5 cups cups cups 5 oz water daily vice that of the 2.7 liters needed
3 to be consumed daily by females. Water is
2000 6 oz 2.5 cups 2 cups cups 5.5 oz found in food to a wide degree making the
3 average free water need (non-food-bound
2200 7 oz 3 cups 2 cups cups 6 oz water or liquid) 3 liters for men and 2.2 liters
3 for females.
2400 8 oz 3 cups 2 cups cups 6.5 oz
Water needs will increase based on the
Table 13-3.—Quantity of Food per Food Group environment and activity level. The hotter it
by Calorie Level is, the more work the body performs to keep
the body cool through sweating. Water
losses due to sweat vary from person to
person and also due to the environment.
Water (and other essential nutrients) can also
be lost by vomiting and diarrhea. It is critical
to prevent or stop these losses and replace
fluids and electrolytes as quickly as possible.
13-3
Water needs may increase 2.5 to 4.5 liters Carbohydrates are made by green plants
per day based on sweat losses, temperature, through photosynthesis. The sun’s energy,
activity level, and other water depleting combined with water absorbed by the plant
factors. Upper tolerance levels for water from the environment and carbon dioxide
intake are approximately 8 liters. Water absorbed through the plant make sugar in the
toxicity, which can result in death, is quite presence of chlorophyll. Plant sugar in its
possible with intakes above 8 liters. simplest form is called glucose, a
monosaccharide. Sugars are simple forms of
The human body is approximately 60% carbohydrates. Fructose, galactose, and
water. Loss of body water, or dehydration, glucose are monosaccharides. Sucrose,
can be life threatening. As little as a 1 to 2% lactose, maltose are disaccharides. Starches,
loss can cause decreases in overall body glycogen, and fiber are polysaccharides.
performance and a loss of 5 to 7% can lead to
heat injury or death. Starches are plant-based long chains
glucose molecules. Starches occur in foods
The old saying “a pint’s a pound the such as potatoes, rice, pasta, corn, peas, and
world around” is a simple, yet effective way wheat. Glycogen is the storage form of
to stay hydrated or rehydrate. For every one glucose in animals and humans. The body
pound loss of body weight, a person should makes glycogen through the process of
drink one pint, or 16 fluid ounces. Weight is glycogenesis and stores it in the muscles and
the best way to check for dehydration, but in liver. There is usually between 2000 and
the absence of a scale, urine color can be a 3000 calories in body stores of glycogen.
crude measure of hydration status, the more Maximizing glycogen stores in the body can
color in the urine or ‘darker’ yellow it is, the be accomplished through a proper balance of
more fluid one needs. Both methods can be eating well and exercising; this can increase a
used to help a person remain hydrated. person’s physical performance, usually
allowing the person to exercise longer.
Carbohydrates
Fiber is a non-digestible, non-essential,
Carbohydrates (sugar, starches, plant-based polysaccharide that plays a
glycogen, and fiber) are molecular chains of significant role in digestion and elimination.
carbon and hydrogen atoms bound together. Fiber can be further defined as soluble or
Carbohydrates come in three molecular insoluble. Fruits, vegetables, and whole
‘sizes,’ mono-, di-, and polysaccharides. grain products vary in type of fiber. Good
Monosaccharides contain one carbon soluble fiber sources are oatmeal, beans, and
molecule, disaccharides contain two, and nuts. Soluble fiber has been linked to
polysaccharides contain more than two and helping people lower blood cholesterol
many polysaccharides contain thousands. levels. Insoluble fiber is usually found in
whole grains and most vegetables. The
Carbohydrates’ main role is to provide general recommendation for fiber intake is 25
energy to the cells. The human brain uses grams for women and 37 grams for men;
carbohydrates exclusively and each cell in the most Americans do not usually consume
body uses glucose to perform its required these levels of fiber. Exceeding these levels
work. All carbohydrates (excluding fiber) can be detrimental to one’s health, leading to
contain 4 calories per gram. In times of nutrient malabsorption and constipation or
stress, such as trauma or illness, carbohydrate impaction.
utilization increases and allows protein to be
spared and used in recovery.
13-4
Carbohydrates should consist of between In general, proteins support growth and
40 and 60% healthy person’s diet. The food maintenance of the body, build enzymes,
guide pyramid is proportioned to assist a hormones, and antibodies to defend the body.
person to achieve this level of carbohydrate. Additionally, proteins maintain fluid and
Excess calories from carbohydrates are easily electrolyte balance, preventing edema, and
stored as fat. thus maintaining acid-base balance in the
blood.
Another commonly used source of
carbohydrate is dextrose. Usually used in Animals are the main consumable source
intravenous fluids, dextrose has 3.4 calories of protein. They include such items as meat,
per gram. One liter of D5 is a 5% dextrose milk, and eggs which are ‘complete’ proteins.
solution. To determine how many calories Plants also contain various amounts of protein,
that is, multiply 1000mL (1L) by .05 (5%) but plant sources of protein are not complete
which equals 50 grams of dextrose. Multiply proteins, meaning they do not contain enough
50 grams by 3.4 calories per grams and there of a variety of amino acids to build the proteins
are 170 calories in 1 liter of D5. people need. If a variety of plants are eaten,
the mix of amino acids would supply the body
Protein with all the essential amino acid combinations
and allow it to make the necessary proteins.
Proteins are commonly referred to as the
"building blocks" of the body. Proteins have Protein that is consumed can be qualified
many functions in the body such as enzymes on a scale of high biological value; referred to
and hormones and are the main component of as the protein digestibility corrected amino
most body tissues. Skin, hair, blood, muscles, acid score (PDCAAS). High biological value
and all of the body’s organs are made of protein provides the most useful mix of amino
protein. Proteins are made of carbon, acids. Egg whites have the highest value
hydrogen, and an amine (a nitrogen containing followed by beef, chicken, and other animal
molecule). Proteins contain 4 calories per products to include milk. Grains, vegetables,
gram. legumes, and beans also contain protein, but
are of lower biological value.
Proteins are made up of amino acids.
There are 20 amino acids that make up all the The recommended amount of protein for
proteins the body needs. Of these, 9 are all adults is 0.8g/kg/day. For a person who
considered essential amino acids, meaning the weighs 176 pounds or 80 kg (pounds divided
body cannot make them itself. The essential by 2.2), the person requires 64 g of protein per
amino acids are tyrosine, valine, tryptophan, day. Protein needs are higher for infants and
isoleusine, leusine, lysine, phenylalanine, children and vary widely among different
methionine, and histidine. They can be disease states. For example, a patient with
remembered by the pneumonic (TV TILL PM renal disease may only require 0.6g/kg/day to
H). The 11 other amino acids can be maintain kidney function, whereas a trauma
synthesized by the body. Amino acids are patient may require upwards of 2.0 to
connected by peptide bonds to form proteins. 2.5g/kg/day to heal. Always defer disease-
Many proteins are interdependent on other specific protein needs for a patient to a
proteins and some on minerals such as iron Registered Dietitian or adequately trained
with the protein in the blood, e.g., hemoglobin. medical professional.
13-5
The protein of meat is approximately 7g Fat is found in plants and animals. Animal
per oz, milk has 8g per 8 fluid oz, bread fats (chicken skin, the marbling in beef, butter,
products have approximately 3g per slice or and milk fat) are saturated fats or fatty acid
equivalent, vegetables contain approximately chains that are ‘saturated’ with hydrogen
2g per 1 cup raw or ½ cup cooked. Fruits atoms. Saturated fats have been closely linked
contain virtually no protein. to heart disease.
The role of protein in disease is critical. There are two other types of fats,
Under-nutrition and protein-energy monounsaturated and polyunsaturated.
malnutrition typically indicate the need for Monounsaturated fats contain one double bond
more protein in a person’s diet. These states between two carbon molecules, which in turn
are commonly seen in underdeveloped eliminates a hydrogen from each of the carbon
countries where food is scarce and poverty is atoms. Olive oil, peanut oil, and sesame oil are
widespread. Although under-nutrition is seen examples. Monounsaturated fats are generally
in the United States, it is not common. Over- healthy fats, but burn easily when used in
nutrition is more common and is expressed in cooking. Polyunsaturated fats contain two or
disease states such as obesity and more double bonds among the carbon atoms.
arteriosclerosis. Protein is not directly Canola oil, safflower oil, and soybean oil are
responsible for these diseases, but a main examples. Polyunsaturated fats are used widely
source of protein, meat is also a good source of for frying foods.
saturated fat which has been shown to
contribute to many diseases and chronic The general recommendation for fat intake
conditions. is to consume between 20 and 35% of one’s
total caloric intake as fat. To calculate grams
Fat of allowable fat per day, multiply the total
estimated calorie need, 1800 calories for
Fats or lipids are as equally important to example, by .2 or .35, which results in a range
the body as carbohydrates and protein. The of 40 to 70 grams of fat per day. Lower
main role of fat in the body is to supply energy. amounts are encouraged for overall general
Fat is the main energy source of aerobic health. Extreme avoidance of fat can lead to
metabolism and sustained exercise and is fatty acid deficiencies. Most Americans meet
reliant on glucose, or carbohydrates, to be or exceed the recommended amount and should
metabolized. Fat serves in thermoregulation of limit high fat foods that contribute to obesity
the body, cushions the organs, is a source of the and related diseases such as whole milk,
4 fat soluble vitamins – vitamins A, D, E, and cheese, cream, high fat meats, fried foods,
K, provides us with a feeling of satiety when butter, and oils.
eaten, is the main molecule of the cell walls,
and provides the body with essential fatty
acids. Trans fats are not naturally occurring fats
and are generally not considered a healthy fat.
Fat is calorically dense and at 9 calories per Trans fats, or hydrogenated fats, are chemically
gram is more than double the calories per gram formed using naturally occurring fats and
of both carbohydrates and protein. Using any possess properties appealing to make foods
oil as an example, 1 tablespoon of fat contains more crispy, crunchy, taste better, or last
approximately 45 calories, the equivalent of longer. Trans fats are similar to saturated fats
about 2 oz of meat or a little less than a half a in structure and have been linked to obesity and
cup of fruit. heart disease.
13-6
Omega-3 fatty acids are a naturally Table 13-4 is a guide to the role of the
occurring polyunsaturated fat that have been most common vitamins. It is designed as a
linked to lessening the risk for heart disease guide and more advanced texts are
and improving joint health. Omega-3 fatty recommended to discuss specific roles of the
acids can be found in salmon, halibut, walnuts, vitamins. The National Academies Press is a
and flax seed. Grass fed beef and eggs from valuable reference on these essential
grass fed chickens are also worthy sources. An micronutrients and can be accessed at
easy way to consume adequate amounts of www.nap.edu or through the USDA’s Food
omega-3 fatty acids is through supplementation. and Nutrition Information Center at
A person should verify that the supplement http://fnic.nal.usda.gov.
contains adequate amounts of both omega-3
fatty acids eicosapentanenoic acid and Minerals
docosahexaenoic acid.
Minerals serve many functions in the body
Cholesterol, a sterol, is also a member of much like vitamins. Minerals are substances
the lipid family. It is mentioned in a negative found in the Periodic Chart of the Elements
way related to increasing the risk for heart which can be found in any basic chemistry
disease, but it is actually a critical part of many book. Calcium, phosphorus, magnesium,
hormones to include testosterone and estrogen. sodium, chloride, potassium, and sulfur are
It is also part of every cell in the body and is a commonly referred to as the major minerals.
part of brain structure and nerve cells. It is not Iron, zinc, iodine, selenium, copper,
essential in diets since the body can easily manganese, fluoride, chromium, molybdenum
manufacture the amount needed. Cholesterol is are referred to as trace minerals. Both the
only found in animal products. major and trace minerals serve critical
functions in the body. All of the mineral
Phospholipids are also considered lipids needs can be met through eating a wide
and are manufactured by the human body. variety of foods from all the food groups.
Phospholipids are mainly emulsifiers in the
body, aside from being part of cell structure. Table 13-5 lists information on the
The most common phospholipid is bile which minerals and just like the vitamins, more
is made in the liver and allows fat to be advanced texts are recommended to discuss
digested in the body. their specific roles. The National Academies
Press is a valuable reference on these essential
Vitamins micronutrients and can be accessed at
www.nap.edu or through the USDA’s Food
Vitamins are essential, non-calorie and Nutrition Information Center at
containing compounds found in food and http://fnic.nal.usda.gov.
needed in the body in small amounts.
Vitamins mainly act as enzymes or catalysts
and they assist in making necessary chemical
reactions occur in the body.
13-7
Vitamin Recommended daily Sources Role Deficiency Toxicity
amount
(19–30 year olds)
Vitamin A 900 μg Milk, cheese, eggs, liver Vision, skin health, Night Red blood cell lysis, bone
As beta-carotene: leafy green immunity, bone blindness, pain, abdominal pain, dry
vegetables, carrots, apricots, and tooth health (small-cell) skin and rashes, loss of
cantaloupe, sweet potato, anemia, corneal hair, enlargement of
pumpkin degeneration spleen and liver
Vitamin D 200 μg Sunlight, milk, eggs, liver, Mineralization of Rickets, Raised blood calcium
sardines bones osteomalacia
Vitamin E 15 mg Plant fats, green leafy Antioxidant Red blood cell Uncommon
vegetables, whole grains, nuts, lysis, weakness
seeds
Vitamin K 120 μg male Synthesized in digestive tract, Blood clotting Hemorrhaging Interferes with anticlotting
90 μg female liver, eggs, green leafy medications (warfarins)
vegetables, milk, green tea
Vitamin C 90 mg male Citrus fruits, peppers, Collagen synthesis, Scurvy Nausea, diarrhea
75 mg female tomatoes, potatoes, dark green wound healing,
vegetables, cantaloupe, antioxidant, assist
strawberries absorption of iron
Thiamin 1.2 mg male Pork, liver, whole grains, Energy Beriberi None
1.1 mg female legumes, nuts metabolism,
nervous system
function
Riboflavin 1.3 mg male Milk, yogurt, meat, green Energy Cheilosis, None
1.1 mg female leafy vegetables, whole grain metabolism, vision photophobia,
and enriched breads and and skin health rash
cereals
Niacin 16 mg male Milk, eggs, meat, poultry, Energy Pellagra, smooth Painful flushing and rash
14 mg female fish, whole grain and enriched metabolism, DNA, tongue, diarrhea
breads and cereals, nuts, skin, nervous
protein containing foods system, and
digestive health
B6 1.3 mg Green leafy vegetables, meat, Amino acid and Anemia, smooth Damage to nerves,
shellfish, legumes, fruit, fatty acid tongue bloating, impaired
whole grains metabolism, memory, loss of reflexes
converts
tryptophan to
niacin, helps make
red blood cells
B12 2.4 μg Animal products New cell synthesis, Anemia, smooth None
maintains nerve tongue, fatigue
cells
Folic Acid 400 μg Green leafy vegetables, New cell synthesis Anemia, None
legumes, seeds, liver smooth, red
tongue, masks
B12 deficiency
Pantothenic 5 mg Abundant in food Energy Vomiting, None
Acid metabolism intestinal
distress,
insomnia,
fatigue
Biotin 30 μg Abundant in food Energy Heart None
metabolism, fat abnormalities,
and glycogen fatigue, rash,
synthesis, amino loss of hair
acid metabolism
13-8
Mineral Recommended Sources Role Deficiency Toxicity
daily amount
(19–30 year olds)
Calcium 1000 mg Milk, oysters, tofu, Principle mineral of bones and teeth, Stunted growth, Rare
green leafy vegetables, muscle function, blood clotting, blood bone loss
legumes pressure
Phosphorus 700 mg Animal tissue Energy transfer, genetic material, Unknown May cause
buffering systems, bone and teeth calcium
formation excretion
Magnesium 400 mg male Nuts, legumes, whole Bone mineralization, protein synthesis, Weakness, Usually with
310 mg female grains, dark green enzymes, muscle contraction, confusion, laxative abuse,
leafy vegetables, transmission of nerve impulses depressed confusion, lack
seafood, chocolate, pancreatic of muscle
cocoa hormone coordination,
secretion, growth coma, death
failure,
hypocalcemia
Sodium 1.5 g Salt, soy sauce, Normal fluid balance, nerve impulses, Muscle cramps, Hypertension
processed foods, meat, major extracellular ion changes in mental
cured meats status
Chloride 2.3 g Salt, processed foods Part of hydrochloric acid used in Muscle cramps, Rare, vomiting
digestion changes in mental
status
Potassium 4.7 g Milk, many fruits and Normal fluid balance, protein and Usually Muscle
vegetables, whole glycogen synthesis, nerve impulses, associated with weakness,
grains, legumes smooth muscle function, including the dehydration, vomiting, if
heart muscle weakness, given IV, death
mental status
changes, death
Sulfur Not determinable Protein containing Part of some amino acids, biotin, None Rare
foods thiamine, insulin, stabilizes proteins
Iodine 150 μg Iodized salt, seafood, Thyroid function, which regulates Goiter, cretinism Depressed
bread growth, development and metabolic thyroid activity
rate
Iron 8 mg male Red meat, fish, Carrying oxygen via hemoglobin, part Anemia Liver injury
18 mg female shellfish, poultry, of myoglobin, energy metabolism
eggs, dried fruits,
legumes
Zinc 11 mg male Meats, fish, shellfish, Part of many enzymes, immunity, Growth failure in Fever, nausea,
8 mg female poultry, grains, wound healing, taste children, sexual vomiting,
vegetables retardation, loss diarrhea, muscle
of taste, poor dysfunction,
wound healing anemia, kidney
failure
Selenium 55 μg Seafood, organ meats, Works with vitamin E as an Cardiomyopathy, Nausea,
whole grains antioxidant muscle abdominal pain,
discomfort, nail and hair
weakness changes, nerve
damage
Fluoride 4 mg male Fluorinated drinking Bone and teeth health Tooth decay Fluorosis,
3 mg female water, milk, egg yolks, nausea,
seafood vomiting,
diarrhea, chest
pain, itching
Chromium 35 μg male Meat, unrefined Works with insulin to regulate blood Abnormal Unknown
25 μg female grains, vegetable oil glucose levels, fat metabolism glucose
metabolism
Copper 900 μg Meat, drinking water, Part of hemoglobin, collagen, and Anemia Vomiting,
nuts, beans, whole some enzymes, wound healing diarrhea
grains
13-10
Such goals could be the maintenance, FULL LIQUID DIET.—A full liquid diet
loss, or increase of weight; restriction of a includes all the liquids served on a clear liquid
particular nutrient to manage a chronic diet, with the addition of strained cream soups,
disease; return of normal gastrointestinal milk and milk drinks, ice cream, puddings, and
tract function; correction of elimination custard. The full liquid diet does not consist of
issues; or heal wounds with the overarching all five food groups, lacks meats and beans, and
goal of maintaining or improving baseline is inadequate in iron, niacin, B12, and thiamin.
health. All diet types when properly A full liquid diet can be used when a patient is
developed by a Registered Dietitian will tolerating a clear liquid diet, but may not be
comply with the food guide pyramid and all quite ready for a regular or modified diet. A full
other general healthy dietary guidelines. liquid diet is similar to a clear liquid diet; it is
not intended for more than 2-3 days.
Regular Diet/General Healthy Diet
DENTAL LIQUID, BLENDERIZED
The regular diet or general healthy diet is LIQUID DIET.—A dental liquid diet is usually
composed of all types of foods from the food indicated with patients whose jaw is wired. It
guide pyramid and is well balanced and includes regular foods blended and strained to be
capable of maintaining a state of good nutrition. able to go through a straw. It includes all foods
It is intended for convalescing patients who allowed on clear and full liquid diets. Vitamin
do not require a therapeutic diet or for the and mineral supplements may be necessary with
general nutritional health of the crew. the dental liquid diet if the recommended
amounts of food are not tolerated. Some
Modified or Therapeutic Diets patients may be able to drink from a cup while
others may need to use of a 60cc catheter tip
Modified or therapeutic diets are designed syringe with a 10-12” piece of tubing which is
to meet specific disease-related nutritional helpful to facilitate getting food past the dental
needs. Modified diets still meet all the general wires. Patients with wired jaws should usually
healthy recommendations with modifications have a wire cutting device with them in case of
to improve a patient’s disease or condition. emergencies.
Changes can be in specific nutrients such as
fat or sodium, or in texture depending on the SOFT OR BLAND DIET.—The soft diet
patient’s disease or condition. Many patients is modified in texture and consists of non-
on modified diets will need to be on them for crunchy or crispy foods that may injure the
the rest of their lives. gastrointestinal tract starting with the mouth. It
includes all liquids and semi-solid foods. It is
CLEAR LIQUID DIET.—A clear liquid indicated in certain post-operative cases, patients
diet is very common and is usually the first diet with gastrointestinal disorders such as GERD
ordered for people who have not eaten in a few (gastroesophogeal reflux disease), immediately
days or are recovering from surgery; it is used to following an acute illness, or patients who
determine a patient’s readiness for solid food. cannot tolerate spicy or highly seasoned foods.
Clear liquid diets are NOT nutritionally
complete because they do not contain foods A soft diet is an intermediate step between a
from all food groups. Foods allowed on a clear liquid and regular diet and is low in connective
liquid diet may not be clear, but are all thin tissue and indigestible dietary fiber. Little or no
liquids (water like consistency). Juices, broth, spices are used. Foods that may be incorporated
gelatin, popsicles, tea, coffee, soft drinks (as into a soft diet include well-cooked cereals,
tolerated), water, and ice are all allowed. A pastas, untoasted bread, eggs, cottage cheese,
patient is not typically on a clear liquid diet for tender meats, fish, poultry, canned fruits, and
more than 2-3 days. If a patient is on clear well cooked vegetables.
liquids more than 3 days then the patient should
be evaluated for nutritional supplements.
13-11
Further modifications of the soft diet include CALORIE-RESTRICTED DIET.—The
mechanical soft or dental soft. A mechanical calorie restricted diet is intended to promote
soft may be indicated when a person has slow weight loss. In the hospitalized patient it is
difficulty chewing. With a mechanical soft diet, important to monitor for patient improvements
hard to chew items such as meats should be in order to not nutritionally compromise a
ground and usually kept moist with gravy. A patient who may need more calories. Calorie
dental soft diet is indicated after many dental restrictions should be no lower than 1200
procedures and would include foods that require calories and still include foods from all five food
little or no chewing or that will not put much groups. Foods on the calorie restricted diet
pressure on the teeth when bitten. A soft or include lower calorie and lower fat versions of
bland diet is considered nutritionally complete those on the regular diet. Examples are sugar
since all five food groups would be represented. free gelatin, pancake syrup or jelly; lean meats;
skim milk; and other low fat food items. Foods
PUREED DIET.—The pureed diet is a excluded on a calorie restricted diet are usually
texture modification of the regular diet. It is desserts, fried foods, gravies, sauces, cheese,
typically indicated with patients who are whole or 2% milk, and fruit juices. Most
edentulous or partially edentulous, recovering hospitalized patients on a calorie restricted diet
from a stroke, have failed a Modified Barium should be followed by a nutrition professional.
Swallow, or who may not be cognitively aware People commonly calorie restrict to lose weight
enough to chew. Many elderly and mentally and should be encouraged to follow the general
disabled patients need a pureed diet. The pureed healthy diet using the appropriate food guide
diet is nutritionally complete, but the patient pyramid calorie pattern.
may benefit from a general multivitamin. The
diet is usually lower in fiber, therefore the PROTEIN RESTRICTED DIET.—A
patient’s bowel movements should be monitored protein restricted diet is indicated in patients
more closely on a pureed diet as the stool may with renal disease or hepatic disease. Many of
be harder and be excreted less frequently. these patients require other nutrient
modifications as well and should be followed by
HIGH CALORIE/HIGH PROTEIN a nutrition professional. A typical protein
DIET.—A high calorie and/or high protein diet restriction is 60 grams per day. At times the
is most typically indicated with trauma, restriction may be lower depending on the level
underweight, failure to thrive (at any age), of renal or hepatic dysfunction. Low protein
burns, wound healing, and occasionally after diets are almost always below the recommended
major surgery. Along with the higher calorie protein level of 0.8 g/kg. With appropriate
diet, research indicates vitamin C, zinc, and nutritional counseling, patients should be able to
glutamine (an amino acid) may aid in wound meet all their other nutritional requirements.
healing. Research is ongoing so check with the The main foods excluded or limited with a low
local registered dietitian for the latest data. protein diet are meat, milk, cheese, eggs, and at
times grains and vegetables. Other nutrients
This diet is also a variant of the regular diet, typically restricted along with protein are
with the high calorie part including more phosphorus, sodium, and potassium depending
‘calorically’ dense foods such as whole milk, on the stage of disease.
gravy, butter, cream, additional desserts or
sweets, or hard candies. When combined with RESIDUE/FIBER RESTRICTED
the high protein part extra meat or egg entrées, DIET.—Some gastrointestinal conditions
additional milk, or cheese can be provided. require a modification in residue or fiber.
Both modifications can be accomplished through Residue refers to anything that increases stool
double portions at each meal, in-between meal volume or frequency or that is not digested by
snacks, homemade milkshakes, or through the body that is not plant fiber. This can be
commercially available liquid or powder tough, fibrous meats, milk products, spicy food,
supplements. or caffeinated items.
13-12
Fiber is found in whole grains, beans, nuts, For instance, if a patient is ordered an 1800
and all vegetables and fruits, especially those calorie carbohydrate consistent diet, their level
with an edible peel. A low residue diet is of carbohydrate may be 75 grams of
indicated during times where minimal stool carbohydrate at each of the three main meals,
production is warranted. A low residue diet is breakfast, lunch, and dinner, and may also
usually more restrictive than a low fiber diet. include a bedtime snack (HS) of 30 grams of
Both are nutritionally complete with foods such carbohydrate. The consistent amount of
as well-cooked vegetables, peeled fruits, tender carbohydrate at consistent times each day along
meats, milk as prescribed or in small amounts, with healthy fat and protein choices will
non-whole grain breads, cereals, white rice, or promote adequate blood sugar management.
pasta. A low residue diet and or a low fiber diet Each hospital will have its own meal patterns for
may be ordered for patients with diverticulitis, patients to follow. On carbohydrate
active ulcerative colitis, irritable bowel consistent/controlled diet foods such as juice,
syndrome (IBS) flare ups, or post desserts, regular syrup or jelly, sugar, and candy
gastrointestinal surgery. A typical fiber are eliminated. Additional information is
restriction is approximately 10-15 grams per available at www.diabetes.org.
day.
LOW SODIUM, LOW CHOLESTEROL,
HIGH FIBER DIET.—A high fiber diet LOW FAT, CARDIAC DIET.—Sodium,
can also be helpful in the chronic management cholesterol, and fat (specifically saturated fat)
of many gastrointestinal diseases. Conditions are the three nutrients usually restricted when a
such as diverticulosis and non-acute irritable patient has any kind of heart or cardiovascular
bowel syndrome or ulcerative colitis usually condition. It can be used to prevent conditions
benefit from a higher fiber diet. The normal such as hypertension, congestive heart failure,
fiber recommendation is approximately 25g for hyperlipidemia, heart attacks, and strokes. It is
women and 37g for men. A high fiber diet often times used in conjunction with a
would include a variety of foods such as whole carbohydrate consistent diet because many
grain breads, cereals, and pastas; brown rice; and patients who have diabetes also have heart
fresh fruits and vegetables. It is also important disease and may be overweight or obese.
to encourage an adequate fluid intake while on a
high fiber diet to prevent constipation and Sodium is salt. Salt is found in most foods,
encourage regular, easily to eliminate stools. but is concentrated in processed foods, canned
foods, lunch meats, processed meats (hot dogs),
CARBOHYDRATE CONSISTENT / cheese, canned tomato products, salted crackers,
CONTROLLED, DIABETIC DIET.—A and pretzels. Salt is often added during cooking.
carbohydrate consistent/controlled diet is mainly
used in the nutritional treatment of diabetes. Cholesterol and saturated fat have been
Classically it has been called the diabetic diet linked to heart disease. Both are lipids that are
and sometimes referred to as an ‘ADA’ diet, as consumed in the diet and that are made in the
in American Diabetes Association®. The diet body. These two substances are limited in the
itself is designed to help manage a patient’s diet to both prevent and manage high blood
blood sugar levels. As implied, a consistent cholesterol and are useful to be consumed only
level of carbohydrate should be consumed at in small amounts in the general healthy diet.
each meal. Cholesterol is found only in animal products
including egg yolks; meat; dark meats of
This diet is usually combined with a calorie poultry; liver and other organ meats; cheese; and
restricted diet, not always to promote weight whole, 2%, and 1% milk. A cholesterol
loss, but more for general management and restriction starts at 300 mg and can be as low as
energy balance. 200 mg per day.
13-13
To put this in perspective, one egg yolk Use a reliable drug reference manual to check
contains approximately 225 mg of cholesterol for specific guidelines.
and 3 oz of beef contains approximately 90 mg
of cholesterol. NUTRITION SUPPORT
13-14
It is important to monitor the rate of the SUMMARY
feeding, flushing the tube with sterile water at
least three times per day, document and report Eating healthy is a goal every Sailor should
bowel movements, check the patient’s lungs for pursue daily. Nutrition plays a critical role in
aspiration of the tube feed, and keep the preventing and managing diseases and
patient’s head elevated 30-45 degrees as an conditions. Modifications in the nutrient content
aspiration precaution. Typically tube feeding of a person’s diet can mean the difference
residuals are checked; review the local enteral between maintenance of health and having
safety guidelines at the facility. Each patient on disease. The base of a good diet always starts
enteral feeds should be followed by a nutrition with the food guide pyramid, focusing on the
professional, check the medical record for the five main food groups, and the avoidance or
most recent recommendations. reduction of foods low in nutrient content such
as sodas and snack foods.
Parenteral Nutrition
Sailors who eat healthy are less likely to be
Parenteral nutrition is most commonly used diagnosed with a chronic disease and more
in cases where patients are unable to meet their likely to add quality to their lives. The Navy
nutritional needs by mouth and DO NOT have a Corpsman plays a key role in promoting healthy
functioning gastrointestinal tract. There are rare eating with the crew and an even more critical
instances when parental nutrition is paired with role in improving the health of patients who are
enteral nutrition. Parenteral refers to feeding a hospitalized or have chronic conditions. For
patient via a vein, usually the subclavian vein, further information, contact the local Navy
but peripheral veins can be used as well. Dietitian or visit the Navy Dietetics website in
NKO.
Parenteral nutrition is the most aggressive
nutritional therapy used. Solutions are usually
individualized and provide all of the patient’s
nutrient needs. It is imperative a Registered
Dietitian and a Pharmacist are involved in all
patients before and while receiving parenteral
nutrition. Parenteral nutrition requires close
monitoring of the infusion, the patient’s
response, the patient’s weight, laboratory tests,
urine, and other outputs.
13-15
CHAPTER 14
PHYSICAL EXAMINATIONS
INTRODUCTION The first of these examinations is the
entrance (enlistment, appointment, or
The Department of Defense (DoD) and the commissioning) physical examination, and the
Department of the Navy (DoN) have established last is the physical examination that occurs upon
uniform physical standards for entry and separation from the service. In addition to these
sustainment of military service, DoD Directive two, there may be several others, depending on
6130.3, DoD Instruction 6130.4 series, and the length of the member’s service or special
NAVMED P-117, Manual of the Medical duty requirements.
Department (MANMED). Physical
examinations are conducted to interpret each A Licensed Independent Practitioner,
individual’s physical qualification for initial Physician Assistant, or Independent Duty
entry, mobilization, retention, assignment to Corpsman (IDC) may perform all physical
special duties, and training programs that lead to examinations covered in this chapter unless
enlistment and commissioning. The purpose of otherwise indicated (i.e. an IDC may complete a
the examination is to identify physical defects physical examination but must have all
and psychological problems that would documents co-signed by a licensed physician).
compromise a member’s ability to perform A General Medical Officer may independently
duties normally assigned. Physical standards are perform examinations upon successfully
intended to preclude acceptance of those completing an accredited internship. All
individuals who present contagious or infectious examiners, regardless of clinical specialty,
hazards to other personnel, would be unable to performing and recording physical examinations
perform assigned duties, or who have conditions must be familiar with the standards outlined
likely to be aggravated by naval service. herein. Some special duty examinations (e.g.,
Aviation) must be performed or co-signed by
This chapter will review the various types of examiners with specific training and/or
physical examinations and their requirements, qualifications, as an example, a Physician’s
provide a general understanding of how physical Assistant may perform and record an aviation
examination forms and reports are completed, physical examination but must have the
and cover some of the testing procedures and documents co-signed by a licensed aviation
equipment which Hospital Corpsmen (HM) may physician. Review MANMED, Chapter 15,
be responsible. HMs function as both clerical Section IV for further guidance.
and medical assistants to the medical
practitioner. To do this properly, HMs must be Most physical examinations will require
familiar with administrative regulations that special studies (tests) which are performed prior
apply to physical examinations. They ensure the to the physical examination. These special
patient’s health record is accurate and complete, studies may include laboratory tests to detect
all tests and laboratory results are recorded, and syphilis (RPR), HIV, and cholesterol levels;
the completed physical examination documents optometric evaluation to determine visual acuity;
are properly filed in the member’s health record. audiometric testing for hearing capabilities; and
dental examination to determine dental fitness.
Physical examinations, whether routine or For more information on special study
special duty, are mandatory for members at requirements for each type of physical
certain times during their military careers. examination, refer to the MANMED, Chapter 15
and directives that address specific physical
examinations.
14-1
TYPES OF PHYSICAL Periodic Health Assessment (SECNAVINST
EXAMINATIONS 6120.3 series)
14-2
Separation Examination For service members separating from
service after serving 30 or fewer consecutive
Separation examinations are required for days on active duty, a different separation
personnel separating from the Navy, the Marine process applies. An authorized examiner will
Corps, and Activated Reservists serving 31 interview each service member focusing on any
consecutive days or greater on active duty. A new or materially changed medical conditions
thorough physical examination must be occurring since the start of active duty and, if
completed not less than 180 days from the last indicated, conduct a focused physical
day served on active duty. This comprehensive examination. An SF 600 entry will be made
examination is conducted to ensure the service stating: “I have evaluated this service member
member has not developed any medical and reviewed available medical record entries
conditions that may constitute a disability and and found him or her physically qualified for
should be processed through a Physical release from active duty.” For members found
Evaluation Board (PEB) or Medical Evaluation not qualified due to a service-incurred or
Board (MEB). If the separation is the result of service-aggravated injury or illness, a Notice of
an evaluation by a MEB or PEB, that Eligibility (NOE) may be appropriate, see
documentation serves as the separation SECNAVINST 1770.3 series, Management
examination. and Disposition of Incapacitation and
Incapacitation Benefits for Members of Navy
Members who separate from the service for and Marine Corps Reserve Components.
any reason (i.e., retirement, end-of-enlistment,
or administrative discharge) are required to read For service members found “unfit for
the following statement at the time of their continued naval service” an SF 600 will be
physical examination: generated stating member found unfit and
processed for separation. See MILPERSMAN
You have been evaluated because of Article 1910-216 (enlisted), MILPERSMAN
your planned separation or retirement from 1920 (officers), and Marine Corps Separations
active duty service. You have been found Manual section 1011-8508 for requirements
physically qualified to separate or retire, about conducting examinations on discharges or
which means that no medical condition has separation characterized as adverse.
been noted that disqualifies you from the
performance of your duties or warrants SPECIAL DUTY PHYSICAL
disability benefits from the Department of EXAMINATIONS
the Navy, you must be unfit to perform the
duties of your office, grade, or exacerbated Military personnel who are assigned to or
while in receipt of base pay. Some applying for special duty such as aviation duty,
conditions, while not considered diving duty, submarine duty, etc., are required to
disqualifying for separation or retirement, meet physical requirements above the basic
may entitle you to benefits from the entrance examination requirements. In addition,
Department of Veteran’s Affairs. If you personnel are required to have a special duty
desire additional information regarding physical if they have psychosocial
these benefits, contact the Department of considerations, are exposed to extreme physical
Veteran’s Affairs at 1-800-827-1000 or view hazards, or if they are to be assigned to sites
the Website at: http://www.va.gov. with inadequate medical facilities. Other special
duties requiring pre-placement examinations
include handling explosives, operating
explosives vehicles, and duty as a fire fighting
instructor.
14-3
As with routine physicals, special duty OCCUPATIONAL HEALTH MEDICAL
examinations are performed by medical officers SURVEILLANCE EXAMINATIONS
or DoD civilian physicians. For operational
units (squadrons or groups), the medical officer The Navy uses many materials in its work
assigned will normally perform special duty places, some of which are potentially hazardous
examinations. If there is not a unit medical to personnel. To minimize the risk associated
officer, a medical officer assigned to a with these hazardous substances, the Navy
supporting clinic, hospital, or related operational developed the OPNAVINST 5100.23 series,
unit should perform the examination. Navy Occupational Safety and Health
(NAVOSH) Program. Within the NAVOSH
Physician assistants (PAs) and nurse Program is the Medical Surveillance Program.
practitioners may perform special duty
examinations if a medical officer or DoD The Medical Surveillance Program provides
physician is not available or if the examination physical examination and medical monitoring
workload is too great. When a PA or nurse guidelines for personnel who are exposed to or
practitioner performs special duty examinations, work with/in hazardous materials or hazardous
the DD 2808 must be co-signed by proper environments.
authority, MANMED, Article 15-4.
Medical surveillance examinations assess
OVERSEAS/OPERATIONAL the health status of individuals as it relates to
SUITABILITY SCREENING their work. Although these exams are not
EXAMINATIONS physical examinations as described in this
chapter, they are actually surveillance
These examinations are used to determine examinations that produce specific information
suitability of Navy and Marine Corps service with regard to an individual’s health during
members and their families upon receipt of actual or potential exposure to hazardous
orders overseas or to a remote assignment. They materials (i.e., the Asbestos Medical
identify special needs medical, dental or Surveillance Program [AMSP]). Specific
educational requirements determining the guidance on the Asbestos Medical Surveillance
enrollment into the Exceptional Family Member Program is provided in OPNAVINST 5100.23
Program (EFMP), BUMEDINST 1300.2 series, series. Another example of a medical
Suitability Screening, Medical Assignment surveillance program is the Occupational Noise
Screening, and Exceptional Family Member Control and Hearing Conservation Program.
Program (EFMP) Identification and Personnel who work in areas of high sound
Enrollment. Suitability screenings prevent the generation (e.g., flight deck of a carrier) are
arrival of service members and families at a duty required to be evaluated annually for hearing
station with special requirements beyond the loss. Specific guidance on the Occupational
capability of the local medical, dental, Noise Control and Hearing Conservation
educational, or community facilities. This may Program is provided in NAVMEDCOMINST
result in decreased quality of life, early return 6260.5 series and OPNAVINST 5100.23 series.
from assignment, and billet gaps. Proper
screening helps ensure a positive and productive MEDICAL EVALUATION BOARD (MEB)
tour for the service member. All screening EXAMINATIONS
should be completed within 30 days of receipt of
orders. Medical evaluation boards are the single
most important factor in determining fitness for
duty in today’s Navy. Medical boards are
convened and reviews are conducted to
determine the various degrees of fitness for
military service.
14-4
There are two purposes for the MTF The SECNAVINST 1850.4 series,
Convening Authority (CA) to convene an Department of the Navy Disability Evaluation
evaluation of a military member: Manual, provides a listing of “Medical
Conditions and Physical Defects Which
• Placing a patient on temporary limited duty
Normally are Cause for Referral to the Physical
(TLD or LIMDU)
Evaluation Board.”
• Referring a patient to Physical Evaluation
Board (PEB) for determination of the ABBREVIATED TEMPORARY LIMITED
patient’s fitness for continued Naval service DUTY (TLD) MEDICAL BOARD AND
REPORT
• An MEB shall be initiated when a physician
or authorized personnel who have been The abbreviated board report is used only
trained and certified for MEB membership when a member is expected to return to full duty
by the MTF CA determine that: after an adequate period of treatment. Processing
o A member has a condition that appears to time should not exceed 5 working days to report
significantly interfere with performance TLD. The LIMDU Coordinator is responsible
of duties for reviewing the medical board, verifying the
content, and verifying the processing time
o A member has a condition that will
ensuring consistency with current policy. The
prohibit returning the patient to the parent
Abbreviated Medical Board Report (MEBR) is a
command
local action taken by an appropriate medical or
o A member has a condition that may dental officer and does not require external
seriously compromise the member’s departmental review by NAVPERSCOM. The
health or well-being if the member were form (NAVMED 6100/5), “Abbreviated Limited
to remain in the military service Duty Medical Board Report”, is used for this
report. It is a vehicle for recording basic medical
o A member has a condition that may
findings, plans, and expectations in terms of
prejudice the best interests of the
prognosis and length of medical restriction of
Government if the member were to
activity. It also authorizes for the parent
remain in the military service
command to provide acknowledgment and
o A member has a condition that requires comments. The MEBR, NAVMED 6100/5, is to
assignment limitations be used when all of the following criteria are
met:
o An inactive reservist incurs or aggravates
an injury or illness during a period of • The member is enlisted in the U.S. Navy or
active service and the period of required Marine Corps
treatment, rehabilitation, or convalescence
is expected to exceed 12 weeks or require • The member suffers from an uncomplicated
retention beyond authorized active duty illness or injury which makes them
service orders temporarily unable to fully perform duties to
which they are assigned or expected to be
o A member refuses reasonable medical or assigned, but will most likely be returned to
dental treatment (including surgery) and medically unrestricted duty after an
the member’s ability to perform medically adequate period of treatment not exceeding
unrestricted duty is suspect 6 months
o A member who has “self-referred” for • The member’s health or clinical record
elective care outside the direct Military contains adequate documentation on the
Health System (MHS) nature and circumstances of the illness or
injury, its course, prognosis, and treatment
14-5
COMPLETING REQUIRED FORMS This section discusses the most commonly used
physical examination forms.
LEARNING OBJECTIVE:
REPORT OF MEDICAL HISTORY, DD
2807-1
Identify the appropriate form(s) used for
specific types of physical examinations.
This form (Fig. 14-1) is used to complete
Routine, Special Duty, and Medical Evaluation
While there are several forms used to record Boards examinations.
physicals, the scope and purpose of the physical
dictates which form or forms should be used.
For example, the pre-placement and annual
physical evaluation of food service personnel or
personnel exposed to hazardous materials can be
adequately documented on a SF 600.
14-6
Figure 14-1.—From DD2807-1 (Page 2)
14-7
Figure 14-1.—Form DD 2807-1 (Page 3)
14-8
REPORT OF MEDICAL EXAMINATION,
DD 2808
14-9
Figure 14-2.—Form DD 2808 (Page 2)
14-10
Figure 14-2.—Form DD 2808 (Page 3)
14-11
REPORT OF MEDICAL ASSESSMENT,
DD 2697
14-12
ABBREVIATED MEDICAL EVALUATION
BOARD REPORT, NAVMED 6100/5
14-13
MEDICAL, DENTAL AND EDUCATIONAL
SUITABILITY SCREENING FOR SERVICE
AND FAMILY MEMBERS, NAVMED
1300/1
14-14
Figure 14-5.—Form NAVMED 1300/1 (Page 3)
14-15
PHYSICAL EXAM TESTING Acuity testing is performed with and without
PROCEDURES AND EQUIPMENT the glasses being worn and the results are
documented in blocks 61 and 63 on the DD
2808. Visual acuity requirements are discussed
LEARNING OBJECTIVE:
in the MANMED.
Identify visual acuity, color vision,
Snellen Charts
audiometric, and EKG test equipment and
procedures.
The most familiar of the visual testing
equipment, Snellen charts, are the preferred
Some of the basic procedures used to gather method for testing distant visual acuity, and can
information for a physical examination are test both monocular and binocular visual acuity.
taught in Hospital Corpsman "A" School (e.g., Operational guidelines for Snellen charts are
vital signs, venipuncture, and height and weight provided by the chart’s manufacturer. The local
measurements). Other tests require advanced military optometrist or eye clinic can also
technical expertise, such as serological testing, provide operational guidelines for this chart.
and pressure and oxygen-tolerance testing. Some Specific details and current conditions for
testing procedures may be learned by on-the-job testing with Snellen charts are as follows:
training (OJT) or by short courses of instruction.
Common physical exam testing procedures and • If the examinee wears corrective lenses,
the equipment used will be reviewed here. have them remove the lenses before the
examination
VISUAL ACUITY • Test the examinee first without corrective
lenses, and then with the corrective lenses in
Visual acuity testing determines the ability place
of the eye to discriminate fine detail. It is the
most important test of eye function. Throughout • Hang the chart on the wall so the 20/20 line
the Navy, there are three accepted methods for is 64 inches from the floor. Direct the
testing visual acuity: the Snellen chart, Jaeger examinees to stand 20 feet from the chart
cards, and the Armed Forces Vision Tester • Test each eye individually, then both eyes
(AFVT). together. Do not allow the examinee to
squint or tilt their head
The Snellen chart and Jaeger cards are used
together to test visual acuity. The Snellen charts • With the graduation of the size of the letters
test distant visual acuity; the Jaeger cards are advocated by Snellen, the visual acuity is
used to evaluate near visual acuity. The Armed expressed according to the classical formula
Forces Vision Tester (AFVT) checks both V = d/D, where as d (the distance at which
distant and near visual acuity, and assists in the letters are read), is divided by D (the
evaluating other optical conditions. distance at which the letters should be read)
• Then record the smallest line read on the
The first step in testing for visual acuity is to chart from the 20-foot distance in block 61
find out if the patient wears corrective eyewear. of the form DD 2808 as the distant vision;
On the day of the visual acuity testing, patients e.g., 20/20, 20/200
should bring their glasses. Contact lenses are not
recommended for use during visual acuity
testing. Contact lenses cause an increase in time
needed for testing purposes creating an
inconvenience for both the patient and
healthcare provider.
14-16
Jaeger Cards Farnsworth Lantern Test
When the AFVT is not available, Jaeger The purpose of the Farnsworth Lantern Test
cards are used to test near vision. There are six (FALANT) is to evaluate color perception. The
paragraphs on each card, each paragraph is Farnsworth Lantern is a machine with a light
printed in a different font (size) and labeled as J- source directed at the examinee. What the
1 (the smallest print size) through J-6. examinee sees are two lights in a vertical plane.
These lights appear in two of three possible
When testing with these cards, hold the card colors, red, green, or white, shown in varying
at a distance of 14 to 16 inches from the combinations.
examinee and tell the examinee to read the
paragraphs. Record the visual acuity as the The examinee is asked to identify the color
smallest type that can be comfortably read and combinations from top to bottom at a distance of
record the distance in block 63 of the form DD 8 feet; the examiner rotates the drum to provide
2808 as the near vision; e.g., J-2 at 14 inches. the different combinations. The examinee must
identify a total of nine different combinations to
pass the FALANT test. A passing FALANT
NOTE:
score is obtained by correctly identifying 9 out
The distance of the card from the examinee may
be converted to centimeters, but ensure the of 9 presentations on the first test series. If any
incorrect identification is made, a second
results of the test are also recorded in
consecutive series of 18 presentations is
centimeters. ACCURACY is key!
administered. On the second series, a passing
score is obtained by correctly identifying 16, 17,
Armed Forces Vision Tester or 18 presentations.
14-17
AUDIOGRAM
14-18
The standard 12 lead EKG is named because The recording device alternates the
of the usual electrode placement and how the combination of electrodes that are active during
recording device receives and interprets the the recording of electrical signals from the heart
electrical signal from 12 different views. The and from the four limb leads. This results in six
four limb leads and six precordial leads, or chest standard views, or leads (I, II, III, aVR, aVL, and
leads, are attached to the patient as depicted in aVF) that are recorded in the hearts frontal plane.
Figure 14-7. The six precordial leads (V1, V2, V3, V4, V5, and
V6) are arranged across the chest to record
electrical activity on the horizontal plane of the
heart.
Abnormal localized areas of myocardial
conduction, such as those that occur with
ischemia (a lack of blood flow to myocardium),
or infarction (myocardial tissue death) may be
identified in the leads that are nearest to the
affected part of the heart. For example,
abnormalities in leads II, III, and aVF are
indications that there is a blockage of blood flow
to the inferior (bottom) portion of the heart.
14-19
EKGs are performed only as clinically
indicated or as required for special duty and they
are interpreted by physicians or cardiologists.
Refer to the Manual of the Medical Department
Chapter 15 for current information on EKG
testing. The Naval Medical Department
routinely uses EKGs with 12 leads for physical
examinations performed on Navy and Marine
Corps personnel.
SUMMARY
14-20
CHAPTER 15
DENTAL EXAMINATIONS
INTRODUCTION Dental examinations are performed by
dentists in different areas of the dental clinic.
The dental examination is one of the basic The Oral Diagnosis Department has the
professional services provided by the Navy responsibility of providing dental examinations
dental team. Soon after recruits entered the and holding "sick-call" hours, while dentists and
military service, they received their first dental- auxiliary personnel (hygienists and HMs) in
oral examination to determine their dental other departments of the dental clinic also
health. Throughout their service with the Navy, perform oral examinations. This chapter
they will receive annual or periodic dental concentrates on the HM’s duties in pre-
examinations. The results of these examinations examination, examination types, occasions for
are recorded in their individual U.S. Navy dental examinations, dental classifications,
Medical Outpatient and Dental Treatment designations, charting and abbreviations,
Record (NAVMED 6150/21-30). The Forensic recording dental treatment, additional dental
Examination Section, which is located on the treatment forms, and patient dismissal.
inside back cover of the NAVMED 6150/21-30;
will be discussed in this chapter since it covers PRE-EXAMINATION DUTIES
an examination.
LEARNING OBJECTIVE:
The Hospital Corpsman’s (HM’s)
responsibility is to assist the dentist in all areas Explain the pre-examination duties required to
of dental examinations. The HM must be able to be performed prior to each dental examination.
understand and complete various dental forms
used in the examination process that become a
part of the NAVMED 6150/21-30. Information Before seating a patient for a dental
on dental examinations and related forms can be examination, ensure that the Dental Treatment
found in the Manual of the Medical Room (DTR) is neat and professional in
Department, NAVMED P-117, Chapters 6 and appearance. Make sure the area is clean and the
15. equipment is disinfected
PATIENT PREPARATION
15-1
When the patient is seated, make him or her The dentist will need them standing by to
as comfortable as possible. Adjust the headrest evaluate proper fit and condition during the
and place the chair in the working position exam.
favored by the dentist, usually the fully reclined
position shown in Figure 15-1. In this position, A patient who is wearing corrective glasses
the patient's head is level with the dentist's should be asked to leave them in place during
elbow when the dentist is seated on the dental the exam, while a patient not wearing corrective
stool. glasses should be given eye protection.
INSTRUMENT/EQUIPMENT
PREPARATION
15-2
OCCASIONS FOR DENTAL Type 2, Oral Examination
EXAMINATIONS
Comprehensive hard and soft tissue
Dental examinations are performed on examination, which will include: oral cancer
various occasions. The type of the examination screening examination; mouth-mirror, explorer,
performed will depend on what the patient and periodontal probe examination; adequate
needing an examination requires (i.e. retirement, natural or artificial illumination; appropriate
annual, etc.). panoramic or intraoral radiographs as indicated
by the clinical examination; and blood pressure
ACCESSION recording. An appropriate treatment plan will be
recorded. This type is the routine examination,
All Navy and Marine Corps personnel who which is normally done only one time per
enter the military service will have a dental treatment regimen per patient, unless
record established with an accession circumstances warrant another complete
examination and radiographs. examination.
Dental examinations of all active duty Navy This examination consists of diagnostic
and Marine Corps personnel must be conducted procedures as appropriate for: consultation
annually and on other appropriate occasions to between staff or staff residents; observation
establish the need for dental treatment and verify where no formal consult is prepared; certain
dental records. Periodic dental examinations categories of physical examinations; and
access the readiness status of active duty Navy emergency oral examinations for evaluation of
personnel. The annual examination should pain, infection, trauma, or defective restorations.
normally be a Type 2 examination.
Type 4, Screening Evaluation
Type 1, Comprehensive Examination
This type of examination consists of a
This is the ideal examination, for it is the mouth-mirror and explorer or tongue depressor
most extensive dental examination. The dentist examination with whatever illumination is
will perform a comprehensive hard and soft available. This category includes the initial
tissue examination that includes: oral cancer dental processing of recruits without necessarily
screening examination; mouth-mirror, explorer, being examined by a dentist or other screening
and periodontal probe examination; adequate procedures. A qualified dental assistant or dental
natural or artificial illumination; panoramic or hygienist may perform a Type 4 examination.
full-mouth periapical, and posterior bitewing
radiographs; blood pressure recording; and when SUITABILITY FOR OVERSEAS
indicated, percussive, thermal and electrical test, ASSIGNMENT (OVERSEAS SCREENING)
transillumination, and study models. Included
are those lengthy clinical evaluations required The procedures for the medical and dental
to establish a complex clinical diagnosis and the evaluation of Navy and Marine Corps members
formulation of a total treatment plan. For and their accompanying family members, who
example: treatment planning for full-mouth are undergoing suitability processing for
reconstruction; determination of the etiology or overseas assignment, are provided in
differential diagnosis of a patient's chief NAVMEDCOMINST 1300.1 series. Based
complaint. upon the findings of the dental examination, a
dental officer recommends suitability or
unsuitability of a member and family members
for overseas assignment.
15-3
This is documented on a NAVMED 1300/1, SEPARATIONS, RETIREMENTS AND
Medical and Dental Overseas Screening Review SPECIAL PROGRAMS
for Active Duty or Dependent. The examining
dentist will complete Part II: Dental Screening Dental examinations are required for
(Fig. 15-3) on the NAVMED 1300/1. personnel who separate from the Naval Service,
retire, or apply for special programs. The
The ultimate responsibility rests with the Manual of the Medical Department, NAVMED
member's commanding officer to approve or P-117, Chapters 6 and 15, outlines procedures
disapprove the member or family members for for these examinations.
overseas assignment.
15-4
DENTAL CLASSIFICATIONS CLASS 2
The Navy Dental Corps has a uniform Class 3 is the classification for patients who
system for recording the results of a dental have oral conditions that the examining dentist
examination. It is a classification system that lets expects will result in dental emergencies within
the provider determine the dental status of each 12 months if not treated. Patients should be
individual and establishes priorities of treatment. placed in class 3 when there are questions in
Numbers are used to record one of four possible determining classification between class 2 and
dental classifications. Each classification is class 3.
carefully determined using prescribed criteria
and is accurately recorded. The following is a CLASS 4
description of each classification.
Class 4 is the classification for patients who
CLASS 1 require a dental examination. This includes
patients who require annual or other required
This classification is for patients who do not dental examinations and patients whose dental
require dental treatment or reevaluation within classifications are unknown.
12 months. Class 1 patients must meet these
conditions: DESIGNATIONS, CHARTING, AND
• No dental caries or defective restorations ABBREVIATIONS
• Arrested caries for which treatment is not The designations and abbreviations are to be
indicated used when making entries in a patient's EZ603
• Healthy periodontium, no bleeding on or EZ603A (dental continuation sheet). The
probing; oral prophylaxis not indicated names of permanent and deciduous teeth and
numbers that correspond with them have been
• Replacement of missing teeth not indicated discussed in Chapter 7, “Oral Anatomy.”
• Unerupted, partially erupted, or malposed
teeth that are without historical, clinical, or
radiographic signs or symptoms of pathosis
and are not recommended for prophylactic
(preventive) removal
• Absence of temporomandibular disorders;
stable occlusion
15-5
TOOTH SURFACES STANDARD ABBREVIATIONS AND
ACRONYMS
The following designation of tooth surfaces
are used to record pathologic conditions and The use of standard abbreviations and
subsequent restoration of teeth. (Information on acronyms is not mandatory, but it is desirable for
pathologic conditions and restorations of teeth expediency. Dental forms used to record dental
can be found in Chapter 24). Table 15-1 outlines treatment have limited amounts of space to
tooth surface designations. write. Use only abbreviations and acronyms that
will not be misinterpreted. When recording
treatment, ensure to correctly spell all terms.
Surface Designation Well known medical and scientific signs and
Facial (labial and buccal) F symbols such as: Rx (prescription), WNL
Lingual L (within normal limits), BP (blood pressure) and
Occlusal O O2 (oxygen) may be used in recording dental
Mesial M treatment. The following abbreviations and
Distal D
acronyms are commonly found in dental
charting as noted in Table 15-2.
Incisal I
GENERAL CHARTING
15-6
Assessment A Objective O
15-7
RECORDING DENTAL TREATMENT Missing Teeth
When the HM is involved in recording Draw a large "X" on the root or roots of
dental treatment from an examination or teeth not visible in the mouth. Figure 15-4
charting treatment that has been completed, illustrates teeth #6, #11, and #12 as missing or
certain markings are charted on the examination extracted teeth.
form being used. The five forms that will be
discussed in this section are the Forensic Edentulous Arch
Examination, located on the inside back cover of
the NAVMED 6150/21-30, and Current Status Make crossing lines each running from the
Form located on the inside back cover section of uppermost aspect of one third molar to the
NAVMED 6150/21-30 (Dental Record Jacket) lowermost aspect of the third molar on the
underneath the record identifier for Personnel opposite side. Figure 15-4 illustrates an
Reliability Program (if applicable). The last edentulous mandibular arch.
three forms are the Dental Exam Form (EZ603),
Dental Continuation Form (EZ603A), and the Edentulous Mouth
Report of Medical Examination (DD 2808).
Inscribe crossing lines (Fig. 15-5) one
FORENSIC EXAMINATION extending from the maxillary right third molar to
the mandibular left third molar and the other line
This examination is pre-printed in the Dental from the maxillary left third molar to the
Record Jacket, NAVMED 6150/21-30. It is mandibular right third molar
intended that the forensic exam be completed
only once (usually at accession) during the
member's military career. If a replacement
record is made, a new forensic exam will be
completed.
CHARTING/MARKINGS
15-8
Figure 15-4.—Missing Teeth and Edentulous Mandibular Arch
15-9
Partially Erupted Tooth • Double Occlusal (O): This restoration is
often referred to as "snake eyes." Chart
In the diagram of the tooth, draw an arcing along the two separate grooves on the
line through the long axis. Figure 15-6 illustrates occlusal surface (Fig. 15-7, tooth #4)
teeth #17 and #32 as partially erupted.
• Facial (F): Chart along the facial groove, in
Amalgam Restorations the facial pit (Fig. 15-7, tooth #14), or at the
gingival margin of the facial surface (Fig.
15-7, tooth #13)
In the diagram of the tooth, draw an outline of
the restoration showing size, location, and shape, • Lingual (L): Chart these along the lingual
and block in solidly. The following are different groove, in the lingual pit (Fig. 15-7, tooth
types of amalgam restorations: #14), or at the gingival margin on the lingual
surface (Fig. 15-7, tooth #15). On anterior
• Occlusal (O): Chart along the grooves on teeth, chart these restorations in the lingual
the occlusal surface (Fig.15-7, teeth #l, #2, pit (Fig. 15-7, tooth #9)
and #5)
15-10
Figure 15-6.—Partially Erupted Teeth
15-11
• Mesial-Occlusal (MO): Chart by beginning • Occlusal-Lingual (OL): Chart starting at
at the mesial surface and following the the central groove on the occlusal surface
grooves on the occlusal surface to the and down the lingual groove on the lingual
central pit or groove (Fig. 15-8, tooth #18). surface (Fig. 15-8, tooth #31). Like (OF)
There can be two amalgam restorations amalgams, (OL) amalgams are usually
(e.g., an MO and a DO) on the same tooth. placed only on molars
In this case the restoration will reach into the
• Mesial-Occlusal-Distal (MOD): Chart
central groove, but not include the central pit
starting at the mesial surface and follow the
(Fig. 15-8, tooth #20). Rarely will a
grooves on the occlusal surfaces to the distal
restoration cross the oblique ridge (Fig. 15-8,
surface (Fig. 15-8, tooth #13 and #19).
tooth #2, #3, #14, and #15)
Think of a (MOD) amalgam restoration as
• Distal-Occlusal (DO): Chart by beginning an (MO) and a (DO) amalgam restoration
at the distal surface, and follow the grooves joined together through the central groove
on the occlusal surface to the central pit or on the occlusal surface
groove (Fig. 15-8, tooth #28)
• Occlusal-Facial (OF): Chart starting at the
central groove on the occlusal surface and
down the facial groove on the facial surface.
Occlusal-facial restorations are usually
placed only on molars. On some molars, all
of the occlusal pits will be included in the
restoration (Fig. 15-8, tooth #17)
15-12
• Mesial-Occlusal-Distal-Facial (MODF): • Mesial-Occlusal-Distal-Facial-Lingual
Chart the same way as a (MOD) amalgam (MODFL): Chart by combining the
restoration, but include the facial surface. (MODF) and (MODL) restorations. These
The facial surface may be charted in several restorations may include carious portions of
ways. It may be charted in the facial groove the facial and lingual surfaces. Figure 15-10
(Fig. 15-9, tooth #3), or it may be wrapped illustrates the different types of (MODFL)
around the mesial or distal facial surface restorations
(Fig. 15-9, tooth #14). The (MODF)
amalgam may include a part of the facial
surface (Fig. 15-9, tooth #1), or it may
include the entire facial surface (Fig. 15-9,
tooth #15). Some (MODFs) include the
coronal third of the facial surface (Fig. 15-9,
tooth #16)
• Mesial-Occlusal-Distal-Lingual (MODL):
Chart the same way as a (MOD) amalgam
restoration, but include the lingual surface.
The lingual aspect may be charted in the
lingual groove (Fig. 15-9, tooth #18) or it
may wrap around the mesial and distal
surfaces in the same manner as that
discussed for the (MODF). Figure 15-9,
tooth #30 and tooth #31, illustrates examples
of the (MODL) restorations that include
various portions of the lingual surfaces
15-13
Figure 15-9.—Four Surface Amalgam Restorations
15-14
Non-Metallic Permanent Restorations Gold Restorations
Nonmetallic Permanent Restorations include Outline and inscribe horizontal lines within
filled and unfilled resins, glass ionomer cement, the outline. If made of an alloy other than gold
and pit and fissure sealants. In the diagram of (chrome), the same charting applies. Indicate in
the tooth, draw an outline of the restorations "Remarks" section on the Forensic Exam form
showing size, location, and shape. Do not block the type crown and metal used.
in. The following paragraphs explain how to
chart nonmetallic restorations. Figure 15-12 shows examples of gold
restorations. Tooth #4 has a facial (F) gold
• Mesial (M) and distal (D): Chart these single
restoration, tooth #7 has a (DIL) gold
surfaces on the mesial or the distal side of
restoration, and tooth #31 has a (MODFL) gold
the facial surface. Figure 15-11, illustrates a
restoration.
mesial restoration (M) on tooth #8, and a
distal restoration (D) on tooth #9
To chart a full gold crown, outline each
• Incisal (I): These restorations include the aspect of the crown, and then draw horizontal
incisal surface and/or one or more of the lines in the outlined area (Fig. 15-12, tooth #19).
other surfaces (MI or DI). Tooth #10 in Fig. Gold crowns may have a tooth-colored facial
15-11, shows an (MI) restoration; tooth #7 surface made of acrylic resin or porcelain called
in the same figure shows a (DI) restoration "facings." These facings are inserted to give the
restoration a natural appearance. Tooth #5 and
• Facial (F): Chart along the gingival margin tooth #9 in Figure 15-12 show full gold crowns
of the facial surface unless otherwise with nonmetallic facings. The nonmetallic
instructed by the dentist. Tooth #6 in Fig. facing is only outlined. Where a full crown is
15-11 shows a facial (F) restoration not needed, a three quarter gold crown may be
• Lingual (L) on anterior teeth: Usually used as shown on tooth #28 in Figure 15-12.
charted in the lingual pit (Fig. 15-11, tooth
#11) or at the gingival margin line of the
tooth
• Nonmetallic restorations with two or more
surfaces: Chart these restorations as shown
in the mandibular arch in Figure 15-11.
Tooth #26 shows a mesial-facial (MF)
restoration; tooth #23, a distal-facial (DF)
restoration; tooth #22, a mesial-facial-distal
(MFD) restoration; tooth #25, a mesial-
incisal-lingual (MIL) restoration; and tooth
#24, a distal-incisallingual (DIL) restoration
• Porcelain, Acrylic Resin, Glass Ionomer,
Artificial Crowns, Facings, and Pontics:
Chart these nonmetallic restorations by
outlining all aspects of the crown or facing
as shown on tooth #27 in Figure 15-11. In
the "Remarks" section, indicate the material
used
15-15
Figure 15-11.—Non-Metallic Restorations
15-16
Combination Restoration Fixed Partial Dentures (FPDs)
Outline the area showing the approximate Outline each aspect, including abutments
overall size, location, and shape; partition at and pontics. Show partition at junction of
junction of materials used. Indicate each type of materials and indicate each type of material
material used. used. Inscribe diagonal parallel lines to indicate
gold. In the "Remarks" section, indicate each
Removable Partial Dentures (RPDs) and FPD type of material used (gold or chrome).
Complete Dentures (CDs) Figure 15-14 illustrates gold or chrome fixed
partial dentures and what they look like charted.
Mark the missing teeth as previously
described. Place a horizontal line between the Post Crown
outline of the teeth and the numerals designating
teeth replaced by the RPD or CD (Fig. 15-13). Chart the type of crown attached to the post.
Outline each nonmetallic material and show
restorative metallic materials. Outline
NOTE:
approximate size and position of post or posts.
On the Forensic Examination form in the
In the "Remarks" section, indicate the material
"Remarks" section, describe the RPD or CD,
indicating whether they are maxillary or used.
mandibular and the type of restoration and
material used.
An example of this would be Man RPD (acrylic,
gold, or chrome-cobalt).
15-17
Figure 15-13.—Removable Partial Dentures
15-18
Root Canal Filling (RCF) Deciduous Teeth
15-19
Figure 15-15.—Root Canal Fillings and Apicoetomy
15-20
Temporary Restorations Hard Tissue Remarks Section
In the diagram of the tooth, draw an outline This is just a partial list of some of the more
of the restoration showing size, location, and common non-pathologic findings to facilitate
shape. If possible, describe the material in the charting. Leave section blank if the condition
remarks section. does not exist.
• Intrinsic Staining: Indicate teeth involved.
REMARKS SECTION Check tetracycline, if appropriate
• Tori (Bony Prominences): Indicate
Use this section to indicate the restorative
location and approximate size of projection
materials and to differentiate between sealants,
composites, and temporaries. • Rotated Teeth: Indicate teeth involved and
approximate number of degrees to the
Soft Tissue Remarks Section nearest 45 degrees
• Malposed (Faulty Position Of) Teeth:
This is just a partial list of some of the more Indicate teeth involved and whether facio or
common non-pathologic findings to facilitate linguo-version
charting. For each condition indicate
approximate size or extent and location. Leave • Other: Use this space when noting other
blank if a condition does not exist. hard tissue conditions not listed above
15-21
Figure 15-17.—Current Status Form
Box 1, Accession and Subsequent Diseases Use the following instructions for charting
and Abnormalities. All carious lesions, in the section, Accession and Subsequent
indications for extraction, indications for root Diseases and Abnormalities Section (Box 1). Do
canal treatment, and periradicular lesions that not enter these symbols in Box 2, Missing Teeth
the examining dentist recommends for the at Time of Accession and Treatments Completed
patient are drawn in pencil using the charting After Accession. Entering these symbols in the
symbols listed in this section. When the wrong area would prevent differentiation
indicated treatment is completed, the pencil between the caries and the restorations. Figure
entry is erased. 15-18 illustrates charting symbols for Box 1.
15-22
Figure 15-18.—Charting Symbols for Box One, Accession and Subsequent Diseases and Abnormalities
• Unerupted Tooth: Outline all aspects of the • Fractured Tooth: Trace a jagged fracture
tooth with a single oval. This includes line in the relative position on the crown or
impacted teeth roots affected
15-23
• Fistula: Draw a straight line from the Charting Symbols (Box 2)
involved area, ending in a small circle in a
position on the chart corresponding to the Use the same instructions and symbols from
location of the tract orifice (opening) in the the Forensic Examination section for charting
mouth missing teeth at Time of Accession and
Treatments Completed after Accession (Box 2).
• Underfilled Root Canal: Draw a vertical When charting existing restorations, draw the
line from the crown toward the apex restoration and show the approximate size,
showing the extent of the filling location, and shape in the diagram of the tooth.
• Resorption of Root: Draw an even line on Identify missing teeth and restorative materials
the root showing the extent of resorption of as previously shown in the Forensic
the root Examination section (Charting/Markings).
• Periodontitis and Alveolar Resorption:
Indicate the extent of gingival recession by NOTE:
drawing a continuous line across the roots to No remarks are made on the Current Status form
approximate the extent of involvement. to indicate materials used.
Draw another continuous line at the proper
level across the roots of the teeth to indicate Box 3
the extent of alveolar resorption. Base this
finding on the dentist’s clinical and Box 3, Medical Alert, is readily seen by all
radiographic findings clinicians when opening the record. If a medical
Box 2 alert exists, the word "ALERT" is written or
stamped in large red letters with a brief
Box 2, Missing Teeth at Time of Accession explanation following (i.e. ALLERGIC TO
and Treatments Completed After Accession: PENICILLIN). The use of red ink stamps is
mandated.
• The information is cumulative on this form
throughout the patient’s military career
Box 4
• Missing teeth from the accession exam are
also included in this box. By including this Box 4 is used to record the patient's last
information, the DD2808, Box 18 can be name, first name, middle initial, and the
completed by looking at Boxes 1 and 2 of sponsor’s Social Security Number.
the Current Status Form
DENTAL EXAM FORM
All extractions, restorations and root canal
treatment completed during the patient’s service
The Dental Examination form (EZ603) is
career are entered using the symbols mentioned
illustrated in Figure 15-19. It is intended to be
previously in this chapter under designations,
used on the initial, subsequent periodic, annual,
abbreviations, and charting.
recall, DD2808, and separation exams. It is not
intended for emergency or specialty consult
When indicating fixed partial dentures,
exams. All entries are made in black ink except
ignore the spaces on the form in between the
as noted. During the dental exam, the examining
teeth and draw the prosthesis on each tooth as
dentist may direct the HM to fill out the EZ603
usual. Only use black ink to make entries in Box
and associated boxes on the form with
2.
information.
15-24
Figure 15-19.—Dental Examination Form, EZ603
15-25
The front page of the Dental Exam Form INSTRUCTIONS FOR COMPLETING THE
contains the "S," "O," "A," and "P" sections of the EZ603A
exam that are briefly discussed next.
Record the completion of all dental
• Subjective Section (S): This section of the
treatment such as the treatment plan, dental
form is used to fill out the reason for the
emergencies and any other narrative dental
examination and the patient's chief
findings on the EZ603A (Fig. 15-20).
complaint
• Objective Section (O): This section is An additional column has been added on the
generally meant to record findings and not a far left side to indicate the tooth number (s) of
diagnosis. The major exception is the caries the treatment provided on that date. This will
section where the findings and diagnosis are facilitate piecing together a treatment history of
one and the same a particular tooth.
• Assessment Section (A): This section is A medical alert, if present, is written in red
generally used by the examiner to make a ink at the top of the EZ603A. All entries, except
diagnosis for the medical alert, are made per MANMED
• Plan Section (P): This section is the Chapter 6, Section 13 through 15, in black ink.
"Treatment Plan" for the patient Complete the patient identification box as
indicated at the bottom portion of the EZ603A.
Instructions for the completion of the EZ603
can be found in MANMED, Chapter 6, or
current BUMED instructions.
15-26
Figure 15-20.—Dental Examination Form, EZ603A
15-27
REPORT OF MEDICAL EXAMINATION, Box 43 and 44
(DD 2808)
Box 43-Dental Defects and Disease- check
Frequently, patients needing a dental the acceptable or not acceptable block and
examination will need it in conjunction with a record the current dental class. Box 44-Include
medical physical. The DD2808 (Fig. 15-21) is here a summary of the patient's dental defects
used to record the findings of a dental and the dentist's diagnosis.
examination. Only boxes 43, 44, and 83 will
require dental entries. Although this form is self- Box 83
explanatory and quite simple to complete, it is
important that the entries made are neat and Block 83a- Type, print or stamp the
accurate in every detail. examining dentist's name, rank, DC, and USN
(or USNR) or civilian title (DDS/DMD) if a
civil service or contract dentist performs the
examination. Block 83b- The dentist or
physician signs his or her signature.
Figure 15-21.—Medical Examination Report, Page 1 (Left) and Page 3 (Right), DD 2808
15-28
MEDICAL CONSULTATION SHEET • Reason for Request: The reason as stated
by the requester
Consultation Sheet, SF 513
• Provisional Diagnosis: The diagnosis as
Dental Treatment Facilities (DTFs), Medical stated by the requester
Treatment Facilities (MTFs), and shipboard • Doctor's Signature: Type, print, or stamp
medical and dental departments use the SF 513 the name, rank, title of the requester with his
(Fig. 15-22) to refer patients from one or her signature in this space
DTF/MTF, or department to another. Please note
that SF 513 refers patients with both dental and • Place of Consultation: Check "bedside" or
medical conditions needing a second opinion or "On Call." Also mark the next box as
a referral to a specialist for further evaluation or "Routine," "Today," "72 Hours," or
treatment. Here are guidelines for filling out the "Emergency"
SF 513: • Consultation Report: Leave blank. This
• To: Enter the name of the DTF/MTF, or section will be filled in by the person
department to which the patient is being receiving the form
referred • Patient's Identification: The patient's name
• From: The name of the requesting facility (last, first, and middle initial), branch of
service and status, rank/rate, family prefix
• Date of Request: The date the Consultation code, social security number, and the
Sheet is prepared activity to which the patient is assigned
15-29
PATIENT DISMISSAL SUMMARY
Once the examination is completed, return This chapter has introduced the basics in
the patient’s dental prosthesis if it was removed Dental Examinations, such as Patient
for the exam. The dentist may have instructions Preparation, Dental Examinations, Dental
for the patient; for example, information Classifications, Standard Abbreviations and
regarding medications or future appointments. Acronyms, Charting/Markings, and
Make sure that the patient understands the Medical/Dental Forms. Having a strong working
instructions given by the dentist. Remove the knowledge in these areas of Dental
patient napkin from the patient and place it over Examinations will give the Hospital Corpsman a
the contaminated instruments. good base from which to grow with dental skills
and abilities.
Push the dental operating light and the
bracket table out of the way so the patient will
not bump against them. Return the dental chair
to its lowest upright position, raise the arm of
the chair, and assist the patient from the chair.
Direct the patient to the front desk to make
future appointments if needed. Remove all
instruments and prepare the DTR for the next
patient.
15-30
CHAPTER 16
OPERATIVE DENTISTRY
INTRODUCTION DENTAL SPECIALTIES
Operative dentistry is the area of dental Each operative procedure may not be
concerned with the prevention and treatment of performed in the same manner. Basic procedures
defects in tooth enamel and dentin. Operative are usually performed during each operative
dentistry includes the treatment and restoration appointment. Some of these procedures are also
of carious teeth with metallic and nonmetallic used in other dental specialties. Dental specialty
dental materials. These materials are usually areas are as follows:
amalgam, composite resins, and glass ionomer
• “Preventive Dentistry: The goal of
restorations. Since many patients need treatment
preventive dentistry is to assist the patient in
that is provided in operative dentistry, this is
either establishing control of the dental
where most of the dental assistants are assigned.
disease or in continuing to maintain good
oral health
PURPOSE
• Endodontics: The specialty of dentistry that
Operative dentistry provides treatment to manages the prevention, diagnosis, and
restore a patient’s dental condition to a healthy, treatment of the dental pulp and the
functional, and high level of esthetic quality. periradicular tissues that surround the root of
Operative dentistry is primarily responsible for the tooth (root canals)
the restoration of decayed or fractured teeth.
• Prosthodontics: The specialized areas of
This chapter provides information and
dentistry involved in replacing missing teeth
procedures that the Hospital Corpsman (HM)
with gold or porcelain prosthesis (crown and
may be required to perform in operative
bridge)
dentistry.
• Oral and Maxillofacial Surgery: Involved
RESPONSIBILTIES in the diagnosis and surgical treatment of
diseases, injuries, and defects of the hard
Listed below are a few responsibilities vital and soft tissues of the head and neck
to the HM’s role in operative dentistry: (extractions and reconstruction)
• Be familiar with the procedure and • Periodontics: The dental specialty involved
anticipate the dentist’s needs in the diagnosis and treatment of diseases of
the supporting tissues
• Prepare the setup for the restorative
procedure • Orthodontics: The specialty of dentistry
that is concerned with the supervision,
• Provide moisture control and better
guidance, and correction of growing and
visualization for the dentist by using high-
mature dentofacial structures (braces and
volume evacuation and air-water syringe
retainers)12”
• Transfer dental instruments and accessories
• Mix and transfer dental materials
• Maintain appropriate infection control
precautions
16-1
DENTAL INSTRUMENTS
LEARNING OBJECTIVE:
IDENTIFICATION OF OPERATIVE
INSTRUMENTS
Spoon Excavators
16-2
Chisels
Figure 16-3.—Hatchet
Hoes
Hatchets
16-3
Gingival Margin Trimmers (GMTs) AMALGAM RESTORATION
INSTRUMENTS
The gingival margin trimmers (GMTs)
(Fig. 16-5) are modified hatchets that have Amalgam carriers (Fig. 16-6) transport the
working ends with opposite curvatures and freshly prepared amalgam restorative material to
bevels. As the name implies, GMTs are used to the cavity preparation. These carriers have
trim, smooth, and shape the gingival margin of a hollow working ends called barrels, into which
cavity preparation. GMTs are available in the amalgam is packed for transportation. Both
double-ended styles and are used in pairs, such single and double-ended carriers are available
as the #26 and #27. The working ends of the with a variety of barrel sizes including: mini,
even-numbered instruments are designed for use large, and jumbo. When the lever (located on the
on the distal surfaces, and the odd numbered top of the carrier) is depressed, the amalgam is
instruments are used on the mesial surfaces. ejected into the cavity preparation.
16-4
Condensers
Figure 16-8.—Carvers
Burnishers
Carvers
16-5
COMPOSITE RESIN INTRUMENTS Other types of composite resin instruments
are made of plastic. Plastic instruments can be
A variety of double-ended instruments make steam sterilized and used on composites and
up this instrument group. They are used to cements. They either come included in the kit of
transport and place dental cements, resins, resin material from the manufacturer or, in some
temporaries, and insulating and pulp-capping cases, can be ordered as a set as shown in Figure
materials. The working ends on composite resin 16-11. Some advantages to using plastic
instruments range from small cylinders to instruments are that they will not discolor or
angled, paddle-like shapes. Figure 16-10 contaminate the composite restoration, and
illustrates the Woodson #3, #W3, and #11 (also composite resin material will not cling to the
known as Stellite), which are some of the instrument.
commonly used instruments in this category.
16-6
Spatulas Insulating Base Instruments
Three different spatulas are available for Insulating base instruments have a small
mixing restorative materials, as shown in metal ball at the working end and are often
Figure 16-13. Some of these spatulas can cause referred to as calcium hydroxide (Dycal®)
discoloration in the material being mixed. The instruments. They are used to mix, carry, and
selection of a mixing spatula is not critical place insulating bases, and are available as a
except when preparing a permanent anterior single-ended or double-ended, shown in
composite restoration. Some composite Figure 16-14.
restoration material discolors easily. This can be
prevented by using the spatulas provided by the
manufacturer when working with it. The single-
ended #322 and #324 are suitable for mixing
materials other than composites. A smaller
version for the #324 is the #313 spatula. The
#313 is used for mixing small quantities of Figure 16-14.—Double-Ended Calcium Hydroxide
cement. Instrument
MISCELLANEOUS INSTRUMENTS,
MATERIALS, AND EQUIPMENT
Aspirating Syringe
16-8
Each needle has either a plastic or metal hub Rubber Dam Punch
designed to screw onto the threaded end of the
syringe (Fig. 16-18). This hub is positioned to The rubber dam punch is used to make
permit the needle to extend inward to penetrate necessary spaced holes in the rubber dam
the rubber seal portion of a loaded anesthetic material. The working end is designed with a
carpule. plunger on one side and a wheel on the other
side (Fig. 16-19). This wheel has different sized
holes on the flat surface facing the plunger.
These features let the operator select and adjust
the wheel to punch the desired diameter hole in
the rubber dam. Figure 16-19 also illustrates the
recommended holes on the wheel to use. The
largest hole is used on the tooth that the clamp
will go on. The last five remaining holes
correspond to the teeth that are included in the
isolation.
Figure 16-18.—Parts of the Aspirating Syringe
Needle
16-9
Rubber Dam Clamps The clamps with "W" prefixes, such as the
#W8A or W3, indicate that the clamps are
After the required numbers of holes are without wings on the outer portions opposite the
punched in the rubber dam, it is stretched to fit holes. The space between the gripping edges of
over each designed tooth. To maintain a snug fit the clamp is narrower than the diameter of the
around the neck of the tooth, a rubber dam corresponding tooth. Thus, to place the clamp
clamp is used. These clamps are made of spring around the tooth, it is necessary to spread the
steel in various sizes (Fig. 16-20) to fit the gripping edges wider than the tooth's diameter.
general contours of the different teeth. To spread the gripping edges, rubber dam clamp
forceps are used.
16-10
Rubber Dam Frame Preparation
In order to provide access to the tooth being The first step in applying the rubber dam is
treated and keep the area visible, the dentist to check the contact areas of the teeth to be
must clamp a rubber dam around the tooth and isolated. Use a piece of dental floss to do this.
hold the loose outer edges of the rubber dam in The next step is to determine which tooth the
place with an instrument called a rubber dam rubber dam clamp will be placed upon. Upon
frame. Most of the rubber dams used today are determination, select a rubber dam clamp for a
U-shaped. trial placement.
LEARNING OBJECTIVES:
The use of the rubber dam is an important Figure 16-23.—Ligature on Rubber Dam Clamp
part of quality dental treatment and infection
control. To save valuable chair side time, place Hold the clamp with the bow facing upward
the rubber dam following the administration of and away from the forceps. Place the small
local anesthetic (as directed by the dentist). To projections on the working ends of the rubber
place the rubber dam, the HM will need the dam forceps into the corresponding holes on the
rubber dam material, frame, punch, clamps, and rubber dam clamp. Squeeze the handles of the
clamp forceps. forceps together to align projections with the
corresponding holes on the clamp.
16-11
Once the clamp is placed on the forceps, tilt
the forceps upright and slide the locking device
on the forceps downward to lock the handles in
position. Locking the forceps handles is
necessary to maintain the tension required to
keep the clamp attached to the forceps. The
clamp is ready for trial placement.
16-12
As the dentist stretches the rubber dam In the third method, the clamp is held in the
material over each tooth to be isolated, the rubber dam forceps and the rubber dam is placed
assistant uses floss to slip the septum (rubber over the bow of the clamp. Holding the edges of
dam material between the holes) between the the rubber dam with the fingers, use the forceps
teeth without tearing the material. Always place to carry the dam and clamp into the patient’s
the floss on the tooth, never directly on the mouth. Place the clamp on the tooth and remove
rubber dam itself. Placement of the floss upon the forceps. Continue the placement as in the
the tooth assists in bringing a single thickness second method. The last two methods of rubber
of the dam through the proximal contact when dam placement are valuable when a rubber dam
the floss is carried through. Floss placed on the must be placed by one individual rather than
rubber dam itself tears the dam and requires the two. After the restoration is placed, remove the
passing of two thicknesses of the dam through rubber dam.
the contact.
Removal
Once the floss passes the contact of the
teeth, release the lingual end of the floss. Loop Before the rubber dam is removed, use the
this end toward the opposite end and floss water syringe and high-volume evacuator (HVE)
through the contact again. Next, gently remove to flush out all debris collected during the
the floss by pulling it from the side horizontally; procedure. Rather than pulling the septa through
do not attempt to pull the floss back up through the contact of a newly placed restoration, the
the contact vertically. Continue using the floss to septa is cut. Stretch the rubber dam material
invert the inter-proximal septum, mesially and outward in the facial area of the isolated teeth.
distally as well. Inversion of the rubber dam This pulls the septa facially to provide access for
turns the edges of the dam inward or under, cutting. Use a pair of small blunt-nose scissors
around the isolated teeth, to provide a seal. After to cut each septum of the rubber dam from the
this is completed, pass the rubber dam clamp facial aspect (Fig. 16-25). When all the septa are
forceps and attached clamp to the dentist for final cut, gently pull the dam lingually to free the
placement on the tooth. rubber dam completely from the interproximal
spaces. Use the clamp forceps to remove the
Adjustment of the rubber dam material on clamp. Simultaneously, remove the clamp
the frame can be made at this time to ensure a ligature from the frame. Set the clamp forceps
smooth and stable fit. Wrap the ligature attached and clamp aside. Next, remove the dam with the
to the clamp around a projection on the side of frame attached. Wipe the patient's mouth, lips,
the frame. This prevents the clamp from and chin with a tissue or gauze.
becoming a dangerous projectile if it should
spring off the tooth. Pass a dull instrument, such
as a stellite instrument, to the dentist for
inversion of the rubber dam on the facial and
lingual areas of the exposed teeth. Dry the
exposed teeth with air from the three-way
syringe as needed to assist in the inversion.
16-13
Carefully inspect the dam on a flat surface Amalgam Matrices
for missing pieces. If a fragment of the rubber
dam is missing, check the corresponding Amalgam matrices are made of very thin
interproximal area of the oral cavity with a flexible stainless steel available in either roll
mirror and explorer. Pieces of the rubber dam form or in bands. At times, the standard
left under the free gingiva cause severe gingival packaged matrix bands do not provide the
irritation. Use dental floss to remove any necessary length, width, or shape for a particular
material stuck between the teeth. Rinse the cavity preparation. When this is the case, the
patient’s mouth with the water syringe and HVE dentist can cut the metal matrix strips to form
or saliva ejector to remove all debris from the the needed band. Bands used with the
oral cavity. Tofflemire retainers completely encircle the
tooth. Matrix bands come in assorted sizes and
MATRIX RETAINERS shapes, as shown in Figure 16-27. The most
commonly used band is the Universal or Straight
Matrix retainers are used to hold the #1 size. The Junior #13 is the smaller pedodontic
matrices (metal bands or strips) firmly in place version of the #1 Universal. The Wide #2 and
around a tooth. Matrix retainers and metal bands Junior #15, (which have extensions known as
are used in combination for a temporary mold “aprons”) are used when additional length is
while the filling material is being packed into needed for a preparation extending below the
place. The Tofflemire retainer (or matrix gingiva. A dentist usually prefers certain types
retainer) is available in three different designs: of these bands over others. With practice, the
the universal straight, contra-angle, and contra- Corpsman should become very proficient in
angle junior (pedodontic), all shown in having the preferred band on the appropriate
Figure 16-26. These retainers are practically retainer.
maintenance free.
16-14
ASSEMBLING MATRICES To assemble the matrix (Fig. 16-28) hold the
retainer in one hand with the slots in the guide
When multiple surfaces of the tooth are posts and locking vise facing upward. Turn the
removed during the cavity preparation, a matrix large inner nut counter clockwise to position the
is used to approximate the original surface and locking vise close to the guidepost. Turn the
hold the restorative material in proper form and small outer nut counterclockwise until the rod is
position until it sets. The type of matrices used not visible in the locking vise slot. In the other
depends on the type of restorative material hand, grasp the band with the ends placed evenly
placed. The HM will need to have the right type together. Place the edge of the band with the
of matrix available and assembled ready for use larger circumference (occlusal edge) into the
during the procedure. diagonal slot at the vise end of the retainer.
16-15
With the band placed in this manner, the The dentist gently manipulates the matrix
larger circumference is toward the occlusal band into the inter-proximal space on either side
surface and the smaller circumference is toward of the tooth. The dentist then places an index
the gingiva, as shown in Figure 16-29. Continue finger or thumb over the occlusal surface to hold
to ease the band through the inner guide post the band in place and tightens the band by
slot. turning the inner nut clockwise to fit snugly
around the tooth. At this time, the dentist may
decide to place a wedge along the side of the
matrix band.
Wedges
Figure 16-31.—Wedges
16-16
Matrix Removal ZONES AND POSITIONS
Because new restorations fracture easily, use The position of the patient is determined by
extreme care when removing the matrix band. the procedure to be performed. Most dental
To remove the matrix band and retainer, the treatment is provided with the patient in the
dentist, first gently manipulates the point of an supine position. Once the patient has been
explorer around the inside edge of the band. This seated, the dentist and the assistant should place
contours the marginal ridge of the restoration themselves in the proper positions for treatment.
and removes the excess amalgam around the These positions are best understood by relating
matrix band. The assistant will pass the dentist them to a clock. In the clock concept, an
cotton forceps or hemostats to remove the wedge imaginary circle is placed over the dental chair,
if one was placed. With the thumb or finger over with the patient’s head at the center of the circle.
the occlusal surface of the restoration and matrix The circle is numbered like a clock with the top
band, the outer and inner nuts are turned of the circle at 12 o'clock. The clock is divided
counterclockwise to loosen the retainer from the into four zones of operation:
band. After the retainer is removed, the
remaining band is carefully removed. A loose • Static zone
end of the band is grasped with the hemostats or • Assistant's zone
cotton forceps and gently rocked back and forth
until the band comes out of the interproximal • Transfer zone
space. Remove the band from the other • Operator's zone
interproximal space in the same manner.
The use of these zones is the key to the
FOUR-HANDED DENTISTRY efficient implementation of the principles of
four-handed dentistry. For right-handed dentists,
seated to the right of the patient, the operator's
LEARNING OBJECTIVE:
zone is between 8 and 11 o'clock, and the
assistant's zone is between 2 and 4 o'clock.
Describe proper methods for handling and
For left-handed dentists, seated to the right of
passing instruments.
the patient, the operator's zone is between 1 and
4 o'clock position and the assistant's zone
The goal of four-handed dentistry is to allow between 8 and 10 o'clock. Whenever the
the dentist and assistant to function as a team in treatment site is on the lingual surfaces of
a seated position with maximal efficiency and anterior teeth, the dentist (right or left-handed)
minimal strain. Four-handed dentistry, increases generally uses the 12 o'clock position.
productivity, and reduces stress and fatigue on
the provider and assistant. Four-handed dentistry The transfer zone is from 4 to 8 o'clock.
can be used in all of the specialty areas and Instruments and materials are passed and
operative dentistry. It is crucial that it be received in this zone over the chest and at the
mastered by the HM. chin of the patient. All instruments and materials
are located in the assistant's zone.
To be an effective dental assistant in four-
handed dentistry, the HM must know the correct The static zone, from 11 to 2 o'clock, is a
zones and positions and where the HM is in non-traffic area where equipment, such as
relation to the patient and dentist. Correct nitrous oxide, can be placed with the top
passing and receiving of instruments and extending into the assista n t's zone. When an
materials to the dentist is another task that must object is heavy, or material or an instrument is
be practiced to work efficiently with the dentist. objectionable if held near the patient's face, the
HM may pass or hold it in the static zone.
16-17
For example, anesthetic syringes are PASSING AND RECEIVING
sometimes passed to the dentist in this area so INSTRUMENTS AND MATERIALS
that the patient will not be alarmed at the sight
of the syringe. Part of this area can also be used To increase production while reducing stress
when the provider is positioned in the 12 o'clock and fatigue, the HM and the dentist will need to
position as previously mentioned. work together as a team. The HM must be able
to anticipate the dentist’s needs and fulfill those
Dentists and dental assistants should sit with needs without unnecessary delay. To accomplish
their back straight and head relatively erect. This this, the HM must know the sequence of the
helps prevent curvature of the spine. The patient treatment procedure and have the required
should be lowered to a position that places the instruments and materials ready at the proper
treatment site as close to the dentist's elbow time. When assisting in four-handed dentistry,
level as possible. When the patient is properly the HM must also irrigate with air and water as
positioned, the dentist's eyes should be 14 to 16 well as aspirate with the high-volume evacuator
inches from the treatment site. throughout the procedure. To familiarize the HM
with passing and receiving items efficiently
As the assistant, the HM should sit as close as during the procedure, this section will begin
possible to the back of the patient's chair with the with instrument transfers.
feet directed toward the head of the chair. This
position lets the HM reach the treatment site, Instrument Exchange
hose-attached instruments and materials from
the mobile cart or instrument tray without Instrument exchange between the dentist
leaning, twisting, or overextending the arms. and assistant takes place in the transfer zone
This position allows the HM to observe the near the patient's chin. As the assistant, the HM
patient’s responses throughout the procedure. must anticipate the dentist's needs, and be ready
when signaled by the dentist to pass the next
Adjust the stool so that it is at eye level 4 to instrument and receive the used one in a smooth
6 inches above the dentist's eye level. Like the motion. An alert assistant does not need a verbal
dentist, the assistant should sit in an erect command to make the exchange, but should be
position. The assistant's chair may have a constantly ready when the exchange signal
curved, movable armrest. This armrest may be occurs. Ideally, the instrument transfer is
adjusted in front to support the body just below accomplished with a minimum of motion
the rib cage. Using this armrest as a brace, involving movement only of the fingers, wrist,
allows the HM to be able to lean slightly and elbow. During the transfer, the dentist
forward from the hips only. Place feet firmly on should not move his/her finger rest or eyes from
the foot-support ring at the base of the assistant the treatment site. When the exchange is
chair so that the HM’s feet are parallel to the completed, the dentist pivots the working hand
floor. The mobile cart or instrument tray should back to the working position.
be placed toward the head of the patient's chair,
and positioned to allow the HM easy access to The HM should arrange the instrument setup
the needed instruments and materials. in an orderly fashion. Usually the instruments
are set up from left to right, in the sequence in
which they are to be used. The HM should
return them to their original position following
use in case they need to be reused.
16-18
One Hand Instrument Exchange If the instruments become tangled during the
exchange, this is usually caused by failure to
The actual instrument transfer is divided into parallel the handles before the exchange. The
four stages—working, signal, pre-transfer, and exchange of all instruments is done with firm,
mid-transfer (Fig. 16-32). In the working stage, deliberate movements to give both the dentist
pick up the next instrument to be used from and the assistant the feeling of confidence and to
the instrument tray with the left hand. Grasp eliminate lost time and motion. Return the used
the instrument between the thumb and first two instrument to its original position on the
fingers by the end opposite from the working instrument tray and prepare to repeat the
end as shown in Figure 16-32A. Hold the procedure with the next instrument required.
working instrument close to the treatment area
and parallel to the instrument being used. Extend Refer to Figure 16-33 for an overhead view
the little finger to receive the instrument being (left-handed) of an instrument exchange during
used by the dentist as shown in Figure 16-32B. patient treatment. When the HM assists from
the right side of the patient, use right hand in the
The signal stage takes place when the dentist same manner described for the left hand.
signals for the next instrument by slightly
raising the instrument from the tooth. During
this stage, the dentist maintains the fulcrum
(finger rest) and, with a pivotal action, rotates
the working hand away from the patient's oral
cavity. This positions the used instrument so that
the HM can grasp it with the little finger.
16-19
Figure 16-32.—Instrument Exchange (Steps A Through D)
16-20
Figure 16-33.—Overhead View of Instrument Exchange
16-21
Preparing and Passing Materials The overall idea in passing and receiving
dental instruments and materials is to have the
Dental materials are exchanged under the necessary item at the right place, in the right
patient's chin and over the patient’s chest in the position, at the right time. This leaves the dentist
transfer zone. This prevents materials from free to concentrate more on the area of
being dropped on the patient’s face. Small treatment.
amounts of dental materials may be mixed and
passed on a glass slab, paper pad, or dappen BASIC DENTAL PROCEDURES
dish.
LEARNING OBJECTIVES:
As a HM, it is necessary to prepare dental
materials at the proper time during the Identify anesthetics used in dental procedures.
procedure. A material mixed too soon does not
allow sufficient handling time. Knowing when Describe irrigation and aspiration procedures.
to mix is equally as important as knowing how
to mix. As with instruments, knowing the
Some basic dental procedures, such as
routine of the procedure lets the HM anticipate
administration of local anesthetic, irrigation,
when the dentist will need the specific material.
aspiration, and retracting of tissues, are
The HM should have the mixing equipment
performed in nearly all aspects of all clinical
ready and the material in position and in place
dentistry. Others such as rubber dam application
slightly before the time it is needed following
and assembling of matrices are performed in
manufacturer’s instructions. Begin mixing only
operative procedures. Except for the
when the dentist is ready.
administration of local anesthetic, the HM must
be able to perform these procedures. When
When the HM is assisting during an
administration of local anesthetic is required, the
amalgam restoration, load the amalgam into the
HM needs to prepare all the items used for this
carrier and pass the loaded carrier to the dentist.
procedure.
Occasionally, there will be use of two or more
amalgam carriers, which allows filling the barrel
of one while the dentist is using the other. The PRE-INJECTION ITEMS (LOCAL
HM must also add into this sequence; the filling ANESTHETIC)
and refilling the amalgam carriers and the
passing of condensing instruments to the dentist Before giving a local anesthetic, the dentist
during the amalgam restoration process. may use the following pre-injection items to
prepare the injection site:
During the use of cements, most dentists • Antiseptic solution
prefer that the HM leaves the mixed cement on
the glass slab or mixing pad while holding the • 2 x 2 inch gauze sponges
pad or slab in the hand near the treatment site. • Cotton tip applicators
The dentist can select the amount desired.
Another option has the HM holding the air • Topical anesthetic
syringe to dry the area for application and The dentist may have the patient use an
placement of the material. With the use of some antiseptic mouthwash to rinse the oral cavity
materials, the HM may need to hold a gauze before applying a topical anesthetic. The gauze
sponge in one hand (rather than the air syringe) sponges are used to dry the injection site mucosa
to wipe excess material from the application before applying the topical anesthetic. The
instrument. topical anesthetic, usually supplied in an
ointment, is applied with a cotton tip applicator
to reduce the pain associated with the injection
of the needle.
16-22
INJECTION ITEMS Placing the carpule end in the aspirating syringe
is fairly easy. Use the following steps:
The items used to give local anesthetics are
1. Use the thumb ring to pull the plunger back
an aspirating syringe, a needle, and a carpule. It
against the syringe body.
is important to know the different types of
anesthetic and how to assemble and disassemble 2. Place the cartridge into the barrel of the
the aspirating syringe properly for the dentist's syringe with the rubber stopper end in first,
use. positioned toward the plunger.
3. Break the seal on the needle container and
The HM will find many types of anesthetic remove only a small portion of the plastic
carpules in Navy dentistry. The two most needle cover.
common local anesthetics used in dentistry are
2% lidocaine hydrochloride and 2% 4. Insert the needle into the syringe and screw
mepivacaine. Each type of anesthetic is sealed in the hub onto the syringe.
a 1.8-cc glass carpule. The needle end of each 5. Engage the harpoon into the rubber stopper
carpule is sealed with a rubber membrane and of the cartridge by holding the body portion
held in place by a metal band. The other end has of the syringe with one hand while lightly
a different colored rubber stopper. Each type of tapping the end of the thumb ring with the
anesthetic has a different colored rubber stopper. other hand.
Assembling an Aspirating Syringe CAUTION:
Do not tap the thumb ring with too much force;
Based on the patient's health history and the this might cause the glass carpule to shatter.
procedure to be performed, the dentist will
inform the HM which type of anesthetic Make a quarter turn with the thumb ring to
(including vasoconstrictor content), needle ensure that the harpoon is firmly engaged in the
length, and needle gauge to use to prepare the rubber stopper. If it is, the thumb ring will rotate
syringe. The HM will become familiar with each back to its original position.
dentist's preference and various procedures for
needle length and gauge. However, always Force a small, but visible amount of anesthesia
verify the type of anesthetic solution. Assemble through the needle to expel air.
the syringe out of the patient's view to reduce
unnecessary patient apprehension. Assembly can Loosen the needle cap, but keep the plastic
be done while the dentist administers the topical needle covering in place until passing the syringe
anesthetic. to the dentist to guard against possible
contamination.
First, always check the carpule for cracks or
suspended articles floating in the solution. If the The plastic needle cover must be removed to
HM finds any, discard the carpule and notify the check the syringe's operation and during the
dental and dental supply to ensure other batches injection.
of anesthetic are usable. Disinfect the rubber
diaphragm on the carpule with a 2x2 alcohol pad
before loading it in the syringe. Do not touch the
rubber diaphragm after disinfecting it.
16-23
Passing and Receiving the Syringe Additionally, the HM is required to irrigate
and aspirate (drawn by suction) often throughout
The dentist will be ready to administer the the treatment procedure to maintain a clean
local anesthetic after the topical anesthetic is treatment site.
applied. The assistant passes the syringe with the
needle cover in place. Hold the barrel of the Irrigation
syringe in the hand. Place the thumb ring of the
syringe over the dentist's thumb and the finger The dentist expects the HM, to irrigate the
grip between the dentist's index and middle oral cavity when necessary. By applying water
fingers. While still holding the syringe by the or saline solutions to the treatment site in the oral
barrel, use the other hand to remove the needle cavity, small tooth particles, dried blood, and
cap. other debris are flushed from the area and
removed by aspiration. Handpieces with water
After the dentist gives the injection, spray systems provide some irrigation, but
carefully remove the syringe by grasping the additional irrigation is always necessary. At
barrel and lifting the syringe out of the dentist's times, the dentist may decide not to use the
hand. Remember to exercise extreme caution water spray system on the handpiece for a
when grasping the barrel of the syringe because particular procedure.
the needle is exposed and contaminated. DO
NOT attempt to recap the needle while the During routine operative procedures, the
syringe is in the dentist's hand. If it is necessary HM will use the three-way syringe on the dental
to recap the needle, it must be done using some unit to irrigate the treatment site with water or
type of mechanical device or the one-handed water spray. The tip of the three-way syringe
scoop technique discussed in Chapter 12, rotates easily to direct the water, spray, or air at
"Preventive Medicine and Infection Control." the specific treatment sites. The tip disconnects
to allow for sterilization.
Disassembling the Aspirating Syringe
When the HM irrigates treatment sites
Before the patient is dismissed, the syringe during surgical procedures, sterile saline
must be disassembled safely. It is vitally solution or sterile water will be used as the
important to prevent needle sticks from the irrigation solution. Sterile saline or sterile water
contaminated needle. It is advisable to first is applied by using a bulb-type or Luer (piston-
remove the carpule with the needle remaining in barrel) syringe. The main purpose for irrigation
place. This provides an air vent to prevent the during surgical procedures is to keep a clean
glass carpule from shattering. To unload the treatment site. The cleansing is not complete
carpule, pull the piston rod back as far as possible until the irrigating solution is aspirated from the
to disengage the harpoon from the rubber stopper mouth.
without pulling the stopper from the carpule.
The carpule can then be easily removed from the
syringe. After removing the used needle and
carpule they should be disposed into the sharps
container.
16-24
Aspiration OPERATIVE PROCEDURES
16-25
Figure 16-35 illustrates a typical selection A cavity preparation is a mechanical
and arrangement of instruments for a routine procedure that removes caries or existing
operative procedure. Items should be arranged in restorative materials and a limited amount of
sequential order of the procedure to proceed healthy tooth structure to receive and retain
smoothly without delay. restorative materials in the cavity preparation. A
cavity wall is a side or surface of the cavity
preparation that aids in enclosing the restorative
TERMINOLOGY AND CLASSIFICATION
material.
OF CAVITIES
16-26
The HM should already be familiar with the STEPS IN CAVITY PREPARATION
terms used to describe the various tooth
surfaces, such as mesial, distal, lingual, facial, After the dentist decides which tooth or
incisal, and occlusal. A bevel is a slanting of the teeth to restore, the anesthesia is administered
enamel margins of the tooth preparation cut at and the rubber dam is placed. If the HM is well
an angle with the cavity wall. prepared, the steps in the cavity preparation
should proceed smoothly without delay and the
Cavities can occur on one or more surfaces, patient will be more at ease. Watch closely
and can be of various sizes, ranging from very during the procedure and be ready to irrigate and
small to those that include all five surfaces of the aspirate as needed. Pass the instruments and
tooth. Simply, cavities are those which occur on material to the dentist when needed. The initial
one surface of the tooth. When two surfaces of cavity preparation is generally done using the
the tooth are involved, the cavity is called a high-speed handpiece and a variety of rotary
compound cavity. A cavity is considered a instruments.
complex cavity when three or more surfaces are
involved. Compound and complex cavities may Cavity Design
include one or both of the proximal surfaces as
well as portions of the facial and lingual
The design of the cavity preparation for
surfaces. When caries attack the proximal
either a tooth with initial caries or replacement
surfaces of posterior teeth, the cavity preparation
restoration is based on several factors including
must also include preparation of the occlusal
the location of the caries, the amount and extent
surfaces.
of the caries, the amount of lost tooth structure,
and the restorative material to be used. Some
Cavities may be classified according to the
basic principles should be considered when
location where the carious lesion begins. Caries
preparing a cavity preparation. The dentist
frequently start in the developmental pits and
must determine the overall shape of the
fissures of the teeth. These areas are deeper than
preparation along the cavity margins of the
the surrounding tooth substance and are nearly
restoration and the tooth surfaces. The outline
impossible to clean thoroughly, creating ideal
form is determined by the size and shape of the
conditions for bacterial plaque formation. Pit
carious lesion and by the need for a suitable
and fissure caries can be located in any of the
design that will hold a restoration firmly in
following areas:
place.
• Lingual pits of maxillary incisors
Normally, the dentist is able to visualize the
• Lingual grooves and pits of maxillary
shape of the completed cavity before cutting the
molars
preparation by viewing the extent of the caries
• Occlusal surfaces of posterior teeth on the radiograph and examining the tooth and
soft tissues.
• Facial grooves and pits of mandibular molars
• Pits occurring in areas because of Removal of Remaining Caries
irregularities in the formation of enamel
Smooth surface cavities can be found on all Carious dentin not removed during the
teeth on the proximal surfaces and the gingival design of the cavity preparation is removed by
one-third of the facial and lingual surfaces. using either round burs or spoon excavators.
When the dentin has a firm feel with the
explorer, removal of the tooth structure should
cease, even if stained dentin remains.
16-27
Finishing the Enamel Walls and Margins More instruments are needed to place the
restoration than to prepare the tooth; therefore,
The last cutting step in the preparation of the more instrument transfers are necessary and
cavity is finishing the enamel walls. This is a occur more rapidly than in cavity preparation.
process of angling, beveling, and smoothing the Once the restorative materials have been placed
walls of the cavity preparation to achieve the in the oral cavity, the dentist begins to finish the
best marginal seal possible between the restoration.
restorative material and tooth structure. The
dentist may use burs, diamond stones, or hand- Cavity Liners and Bases
cutting instruments (chisels, hoes, hatchets, and
gingival margin trimmers) to complete the walls Most dentists use some type of cavity liner
by removing loose or unsupported enamel to or base in almost all cavity preparations. They
create the strongest possible enamel wall. are used primarily to protect the pulp and to aid
the pulp in recovering from irritation resulting
Cleansing the Cavity from cavity preparation. Liners and bases are
placed when the cavity preparation is completed,
The final step in cavity preparation is just before insertion of the restorative material.
cleansing the cavity. This includes the removal
of accumulated debris, drying the cavity, and Glass ionomer cements and dentin bonding
final inspection before placing restorative agents are used primarily to seal the dentin and
materials. All debris must be removed from the protect the pulp from bacterial invasion.
cavity, especially on the margins, because Calcium hydroxide can be used in extremely
deposits left on them subsequently dissolve, deep areas as an antibacterial agent and/or as a
resulting in a leak that invites recurrent caries. pulp capping material.
Irrigating the cavity preparation with warm Most bases are applied best when the
water usually removes all debris. Stubborn assistant wipes the instrument clean between
particles of debris may be removed with a small each small application. The HM will hold a
cotton pellet dampened with water or hydrogen gauze sponge in the transfer zone and quickly
peroxide. Following irrigation and aspiration to wipe the end of the instrument as the dentist
remove the debris, the cavity must be dried moves toward the base mix. If the dentist
thoroughly with pressurized air from the 3-way inadvertently gets the base on the enamel walls
syringe or dry cotton pellets. of the cavity preparation, the HM will pass an
instrument for removal of the material.
Placement of Restorative Materials
Cavity varnish is a liner used to seal the
After the cavity preparation is completed, dentinal tubules to help prevent micro-leakage
the HM’s attention as the assistant is especially and is placed in a cavity to receive amalgam
critical. The HM must rapidly anticipate each alloy after any bases have been placed. Cavity
step in the procedure to have the necessary varnish is being used less and less with amalgam
material ready at the proper time. The HM must restorations, and dentin bonding agents are
prepare and pass restorative materials, mix them replacing cavity varnish as the liner of choice.
at the right time, and follow the manufacturer's Cavity varnish has an organic solvent of ether or
instructions. chloroform that quickly evaporates, leaving the
resin as a thin film over the preparation. This
varnish should be slightly thicker than water. If
it becomes very thick, discard it. Cavity varnish
is not used with composites since the varnish
retards the set of composites and interferes with
the bonding of composites.
16-28
A small cotton pellet held by cotton forceps
is dipped into the varnish just enough to wet
the pellet. The cavity varnish is applied to the
pulpal area, walls of the cavity preparation, and
onto the edge of the margins of the preparation.
Any excess varnish can be removed from the
enamel with a fresh cotton pellet. A second
application of cavity varnish is placed over the
first to thoroughly coat the surfaces of the dentin
and fill any voids from bubbles created when the
first application dries. After liners and bases are
placed into the cavity preparation, the tooth may
be restored with materials, such as amalgam, Figure 16-36.—Properly Contoured and Wedged
composite resin, or glass ionomer. Matrix Band
16-29
Some dentists permit the assistant to In addition to passing and receiving a
dispense the amalgam into the cavity variety of carvers to the dentist, the HM will
preparation. Other dentists prefer to pass the need the high-volume evacuator (HVE) tip in the
loaded amalgam carrier and dispense the other hand to aspirate the shavings from the
amalgam themselves. In either case, once the carving procedure at various times. When the
amalgam is placed the HM must pass the amalgam restoration has been carved, remove
amalgam condenser to the dentist. The dentist the rubber dam. Irrigate and aspirate the
uses the condenser to pack the amalgam firmly patient’s mouth and check the occlusion of the
into all the areas of the prepared cavity. During new restoration for any necessary adjustments.
the condensing procedure, the dentist indicates
when a change of condensers is needed. Have the articulating paper ready for use by
Through experience, the HM will know when a placing it into a hemostat or articulating paper
change is needed by observing the stage of holder. Pass this to the dentist to check the
completion. The exchange of amalgam carrier occlusion of the restoration. The articulating
and condensers continues until the cavity paper is placed in the teeth of the opposing
preparation is slightly overfilled. When the quadrant and the patient is instructed to gently
condenser is used for the last time, the dentist close the teeth together. If the patient closes the
may use a burnisher and or an explorer on the teeth together too suddenly or with too much
restoration before removing the matrix band. pressure, the new amalgam restoration will
fracture if it is too high. Have an amalgam carver
The dentist uses a burnisher to bring any ready to pass to the dentist to reduce any high
excess mercury from the amalgam placed to the spots on the amalgam restorations.
top of the restoration. Next the explorer is used
to slightly contour the restoration between the The restoration is checked with the
tooth and the band before removal of the matrix articulating paper and carved until the proper
and retainer. For dentists who choose to initially occlusion is obtained. Have a burnisher, such as
carve the occlusal anatomy into the restoration a ball or ovoid, ready to pass to the dentist to
before removal of the matrix, have an amalgam burnish the amalgam restoration. When the
carver ready to pass after receiving the explorer. restoration is completed, the oral cavity is
The HM will need to have the cotton forceps or irrigated and aspirated using the water syringe.
hemostat ready to pass when the dentist is ready Use the HVE to remove amalgam shavings
to remove the wedge, retainer, and matrix band. resulting from the occlusal adjustment. Before
dismissal, ensure the patient is given the
The dentist uses an interproximal carver to postoperative instructions and understands them.
smooth the gingival margin of the amalgam
restoration at the interproximal area. Only the MERCURY CONTROL PROGRAM
excess amalgam is removed near the gingival FOR DENTAL TREATMENT FACILITIES.—
margin to allow the proximal contact to be All dental personnel will follow BUMEDINST
retained. The dentist continues carving the 6260.30 series, Mercury Control Program for
proximal surfaces to conform to the contour of Dental Treatment Facilities because of the
the inter-proximal area of the tooth. The dentist health hazard potential of mercury. This
uses another carver, such as the discoid-cleoid, instruction discusses control procedures for the
to carve the primary grooves on the occlusal handling and disposal of amalgam or mercury-
surface and remove excess amalgam. The HM contaminated items.
may need to have another carver ready to pass to
the dentist to carve the facial and lingual
margins of the amalgam, if applicable.
16-30
FINISHING AND POLISHING Many of the recently developed hybrids achieve
AMALGAM RESTORATIONS.—When good polishability and esthetics—one reason for
amalgam restorations are placed in the tooth, increased popularity.
finishing and polishing of the restorations
generally take place at another appointment. The Composite resin materials are available in
appointment should be at least 24 hours after the self-curing two-paste systems and light-curing
placement of the amalgam. Polishing the single-paste systems. Some brands offer several
amalgam smoothes the surface so that plaque color selections; whereas, others are supplied in
does not adhere to it readily and makes the a universal shade. The shade must always be
restoration look more attractive. The dentist selected before the teeth are allowed to dry
checks the margins and proximal contacts of the because dehydration results in lighter shades.
restoration initially. A metal filing strip can be
used to remove any roughness or overhang of The restorative material is retained in the
the restoration in the proximal area. cavity preparation by mechanical retention.
Chipped or fractured teeth rely mostly on acid-
The dentist may use finishing burs or stones etch enamel for retention of the restorative
in the handpiece, followed by discs and abrasive material. Acid-etching the enamel portion of
points. Before use, discs may be coated with a cavity preparations with a 35 to 50 percent
lubricant, or in some cases, wet with water. The solution of phosphoric acid results in improved
abrasive points progresses from a more-abrasive retention for resin restorations. A celluloid matrix
to a less-abrasive point until a smooth mirror- may be placed before the acid-etching procedure
like surface is obtained on the amalgam to protect the adjacent teeth. The phosphoric
restoration. Extra-fine pumice and dry tin oxide, acid is applied to the enamel surface of the
or commercial silicone-mounted polishing cups, cavity preparation and is allowed to be in
may be used for a final polishing. contact with the enamel for 1 minute. Then the
area is rinsed thoroughly with water and dried.
COMPOSITE RESIN RESTORATIONS.— The etched enamel surface, when dried, appears
The restoration of tooth surfaces that are chalky white because of a slight dissolving of
normally easily visible are restored with tooth- the surface enamel that leaves microscopic
colored restorative materials for an esthetic undercuts (retention). After etching the tooth, a
appearance. One of the most commonly used bonding agent is applied.
tooth-colored restorative materials is the
composite resin. The three types of composite The dentist may need an instrument to pack
resins available are: the composite resin material into the cavity
preparation and to avoid formation of air
• Macrofilled
bubbles. When the composite resin material is
• Microfilled applied to the etched and bonded surface, the
resin invades the surface void, undercuts, and
• Hybrid irregularities. When surfaces in the proximal
The classification of each composite resin area are restored, the dentist will place a
depends on the particle size of its inorganic celluloid matrix that will assist in preventing the
filler. The macrofilled and hybrid resins have composite material from adhering to adjacent
higher amounts of inorganic fillers and lower teeth and also acts as a form to properly place the
amounts of organic resin than the microfilled material (Fig. 16-38). If using a light-cured
resins. This provides the strength needed for system of composite resin, the light source is
proximal-incisal restorations. On the other hand, positioned near the restoration and exposed
because microfilled resins have a smaller according to the manufacturer's instructions. The
particle size, they are easier to polish than dentist, assistant, and patient should wear
macrofilled resins. protective glasses during the light exposure.
16-31
The surface of the restoration is smoothed
further with a fine and an extra-fine disc of
silicon carbide and zirconium silicate. These
smooth surfaces prevent retention of food debris
or plaque. If a higher gloss of the facial surface
is desired, a coating of sealant material is placed
over the finished restoration. After completion
of the restoration, the rubber dam is removed
and oral cavity irrigated and aspirated. If
necessary, the dentist checks the occlusion and
makes adjustments.
Figure 16-38.—Using a Celluloid Matrix for a
GLASS IONOMER RESTORATIONS.—
Proximal Composite Restoration
Usually, the gingival areas on the facial aspect
of the maxillary anterior teeth are restored with
Once the resin material cures, a mechanical one of the tooth-colored restorative materials for
bond forms. This type of surface union between an esthetic appearance. Restorations located on
the restorative material and the enamel improves the gingival third o f th e to o th may b e
retention qualities and provides a smoother necessary becau se th e tooth is carious or
cavity margin, improving the esthetics of the because it has been worn away or abraded by
restoration. In addition, less marginal leakage is incorrect brushing habits. Since glass ionomer
likely to occur because of the improved union of cements bond directly with enamel, dentin, and
the enamel and restoration. cementum, they may be used for such
restorations where minimal preparation of the
To finish the restoration, the matrix is tooth is desired, or where the fluoride release
removed and any rough areas are smoothed with from the cement is desired to resist recurrence of
composite-type finishing burs. If the restoration caries. During placement of the glass ionomer
involves proximal surfaces, abrasive strips cement restoration, the cavity area must be kept
similar to those shown in Figure 16-39 are used totally dry because moisture will cause a failure
to smooth these surfaces. If applicable, the of the restoration.
gingival margin of the restoration is checked to
remove any excess composite material. FLUORIDE APPLICATION
16-32
A variety of trays are available for fluoride SUMMARY
gel application. The use of disposable trays
reduces the chance of cross contamination and This chapter has introduced the HM to the
eliminates the need to clean and sterilize basics in Operative Dentistry, such as Operative
reusable ones. Trays come in several arch sizes Procedures, Dental Specialties, Instruments,
to ensure optimal fit for each patient. The tray Materials, Cavity Preparation and Four Handed
should provide complete coverage of all erupted Dentistry. Having a strong working knowledge
teeth without going beyond the most distal tooth in these areas of patient care will give a good
surface in the arch. Custom-fitted trays can be base from which the HM can grow as a Hospital
made that require less gel and promote contact Corpsman and chair side assistant.
of the gel with the teeth. The extra time and
expense of custom fluoride tray fabrication will
limit the use to specific patients who require
daily application of fluoride gel.
16-33
CHAPTER 17
RADIOLOGY
INTRODUCTION • Cardiovascular-Interventional Technologists
“use sophisticated imaging techniques such
Radiology technologists (X-Ray Technician) as biplane fluoroscopy to help guide
are Hospital Corpsmen (HM) performing catheters, vena cava filters, stents or other
diagnostic imaging. Technologists may tools through the body. Using these
specialize in a number of areas with the ultimate techniques, disease can be treated without
goal to provide quality radiographic images of open surgery13.”
patients for interpretation by a Radiologist.
• Nuclear Medicine Technologists
“administer trace amounts of
Based on the American Society of
radiopharmaceuticals to a patient to obtain
Radiologic Technologists website, “Radiologic
functional information about organs, tissues
technologists often specialize in a particular
and bone. The technologist then uses a
diagnostic imaging area:13”
special camera to detect gamma rays emitted
• General “Diagnostic” Radiographers “use by the radiopharmaceuticals and create an
radiation (x-rays) to produce black-and- image of the body part under study. The
white images of anatomy. The images are information is recorded on a computer
captured on film, computer or videotape. X- screen or on film13.”
ray may be used to detect bone fractures,
• Sonographers “use sound waves to obtain
find foreign objects in the body, and
images of organs and tissues in the body.
demonstrate the relationship between bone
During an ultrasound examination, the
and soft tissue. The most common type of x-
sonographer places a transducer in contact
ray exam is chest radiograph13.”
with the patient's body. It emits high-
• Computed Tomography (CT) Technologists frequency sound waves that pass through the
“use a rotating x-ray unit to obtain "slices" body, sending back "echoes" as they bounce
of anatomy at different levels within the off organs and tissues. Special computer
body. A computer then stacks and assembles equipment converts those echoes into visual
the individual slices, creating a diagnostic data13.”
image. With CT technology, physicians can
• Mammographers “produce diagnostic
view the inside of organs - a feat not
images of breast tissue using special x-ray
possible with general radiography13.”
equipment. Under a federal law known as
• Magnetic Resonance (MR) Technologists the Mammography Quality Standards Act,
“are specially trained to operate MR mammographers must meet stringent
equipment. During a Magnetic Resonance educational and experience criteria in order
Imaging (MRI) scan, atoms in the patient's to perform mammographic procedures13.”
body are exposed to a strong magnetic field.
• Oral radiography is the art of recording
The technologist applies a radiofrequency
images of a patient’s oral structures on film
pulse to the field, which knocks the atoms
by using X-rays. As the X-ray films are
out of alignment. When the technologist
processed, the resulting radiographs provide
turns the pulse off, the atoms return to their
the Dental Officer with a valuable diagnostic
original position. In the process, they give
aid. In the case of death, radiographs can be
off signals that are measured by a computer
used to aid in identification.
and processed to create detailed images of
the patient's anatomy13.”
17-1
HISTORY OF X-RAY
LEARNING OBJECTIVE:
The first dental radiograph was taken during Photograph provided by HM2 Pablo A. Mercado of
the same year by Dr. Otto Walkoff. Within 10 the Biomedical Photography Department of Navy
years of the first discovery of x-ray, radiographs Medicine Support Command, Bethesda, MD.
were being used for diagnosis of medical and
dental conditions, for X-ray therapy, and for
scientific studies. Although technology over the
years has made tremendous improvements in X-
ray equipment, the basic concepts are the same.
17-2
Film Viewers Some of the characteristics and properties of X-
rays are:
The film viewer is a metal case with a back-
• They travel in straight lines at the speed of
lighted screen. The viewer is used to mount and
light
examine radiographs. Figure 17-3 shows a wall
mount film viewer. Never light the film viewer • They affect photographic film by producing
in the darkroom when working with unwrapped a hidden image made visible by processing
or unprocessed film. Keep the viewer screen
clean at all times (Fig. 17-3). • They cause certain substances to fluoresce
(glow)
• They cause irritation of living cells. In large
amounts can cause necrosis (death) of the
cells, a fact that necessitates caution in using
X-rays
X-rays are produced in the x-ray tube head
when a metal (tungsten) target is bombarded by
a stream of electrons. The X-rays are sent from
the x-ray machine the cone head, through the
patient, and then reach the x-ray cassette (holds
the film) to produce an image on the film.
Figure 17-3.—Wall Mount Film Viewer
The density of the X-ray image is controlled
Photograph provided by HM2 Pablo A. Mercado of by four factors: kilo-voltage (kVp), exposure
the Biomedical Photography Department of Navy time, milli-amperage (mA), and target-film
Medicine Support Command, Bethesda, MD. distance (TFD). All of these factors are
interrelated and may be varied by the operator.
Identify the aspects of patient protection. Several groups and national committees
were created to monitor the use of ionizing
radiation after many occupational workers were
MEDICAL X-RAY
killed or developed a medical condition due to
excessive radiation exposure. One of these
Like visible light rays, X-rays are
national groups is the Nuclear Regulatory
electromagnetic rays that traveling in a wave
Commission (NRC). During the early years of
motion. The measurement of this wave motion is
radiation use, there were no monitoring or
called a wavelength. The difference between X-
governing bodies which resulted in improper use
rays and other electromagnetic rays is their
of radiation such as x-rays of shoes for foot size
wavelength. The wavelength for X-rays is
and heads for hats sizes.
extremely short in comparison to
electromagnetic rays which are longer. The
shorter wavelength enables them to penetrate
matter that usually absorbs or reflects light. X-
rays and other electromagnetic rays have actions
that are considerably different.
17-3
Radiation protection is sub-divided into It is based on the principle that the
occupational radiation protection (protection of probability of the occurrence of negative effects
workers); medical radiation protection of radiation exposure increases with the total
(protection of patients); and public radiation lifetime dose. X-ray and other practices
protection (protection of individual members of involving the use of radiation bring great benefit
the public population). The types of exposure, as to the patient population and limiting radiation
well as government regulations and legal exposure will reduce negative effects when
exposure limits are different for each of these utilized safely.
groups, so they must be considered separately.
Attention to shielding and the rule of
There are several factors that affect the ALARA protects the patient and workers. There
amount of exposure (dose) a patient receives are four major ways to reduce radiation exposure
from the source. Radiation exposure is managed to patient and workers:
by a combination of these factors14:
• Shielding: Use proper barriers to block or
• Time: Reducing the time of an exposure reduce ionizing radiation
reduces the effective dose proportionally.
• Time: Spend less time in radiation fields
An example of reducing radiation doses by
reducing the time of exposures can be • Distance: Increase distance between
accomplished through operator training to radioactive sources and workers or
reduce the amount of repeated x-rays. The population. As a good rule during radiation
MAS (milliampere per second) controls the exposures, the radiation worker should be a
exposure time to the patient14 minimum distance of 6 feet from the source
• Distance: Increasing distance (x-ray source • Amount: Limit the number of x-ray
to patient) reduces dose due to the “Inverse exposure taken to the lowest number
Square” law. Another distance example possible
includes having non essential personnel
The facility will have Standard Operating
standing further away from the radiation
Procedures (SOP) for the operation of
exposure area14
radiographic (X-ray) units and equipment. The
• Shielding: Adding shielding will reduce HM will be required to read these procedures
radiation dose to the patient. The radiation before operating equipment in the Radiology
getting through decreases with the thickness Department.
of the shield. The walls of X-ray rooms are
lead lined providing an element of shielding RADIATION PROTECTION STANDARDS
to people outside the room. The X-ray
machine operator is shielded when standing Patient Protection
behind a leaded glass window and can wear
a lead apron. Almost any material can act as Safety precautions will be observed by all
a shield from X-rays if used in sufficient persons working in or near an area where X-rays
amounts. Lead aprons and vests are the best are generated. A number of precautions are
methods of shielding14 taken to prevent the patient from being
overexposed to radiation.
A good rule is the acronym, ALARA, "As
Low As Reasonably Achievable." The aim is to
When taking radiographs, the HM should
minimize the risk of radioactive exposure or
always have patients wear lead aprons and
other hazards. The rule of ALARA is based on
thyroid collars to shield reproductive organs and
the principle that any amount of radiation
thyroid glands. The only exception is when
exposure, no matter how small, can increase the
obtaining a panorex radiograph as the thyroid
chance of negative biological effects such as
collar blocks part of the X-ray beam.
cancer.
17-4
Before taking radiographs on a female, Radioactive material shall not be used in
always ask whether or not she is pregnant or if such a manner to cause any non-radiation
pregnancy is questionable. If there is belief of a worker to exceed a total effective dose
pregnancy, consult a provider. equivalent of 500 mRem (5 mSv) per year
considering occupancy factors and source usage.
Other radiation safety measures include X- When taking radiographs on a patient, observe
ray machines that have built-in safeguards that the following precautions to avoid unnecessary
filter out harmful radiation and restrict the exposure to radiation:
central X-ray to the smallest possible area.
• NEVER stand in the path of the central X-
ray beam during exposure
Occupational Worker Protection
• NEVER hold the X-ray film packet in the
When working near a source of radiation, patient's mouth during a dental exposure
personnel assigned to the Radiology department
will be issued an environmental dosimetry • NEVER hold the tube head or the tube head
radiation film badge (Fig. 17-4). Film badges cylinder of the X-ray machine during
are used to monitor scatter (stray) radiation that exposure
occurs in the Radiology department. The badges • ALWAYS stand behind a lead-lined
are placed in the X-ray room behind the window during an exposure
technician’s protective lead-lined barrier or at
least 6 feet from the tube head and never in the
direct line of radiation during exposure. X-Ray Film Log
NOTE:
When stating the reason for an x-ray retake, be
specific on the nature of the retake.
Figure 17-4.—Environmental Dosimetry
Radiation Film Badge For example: cone-cut, elongated, foreshortened,
dark image, etc.
The film badges contain X-ray sensitive film
in a light-tight packet. They are collected by Radiation Levels
radiation health technician every 6 to 7 weeks.
After collection, the film is sent to the radiation The NRC has established total whole body
detection laboratory for processing and doses for radiation workers which is found in
evaluation. In an ideal environment, zero REM Title 10, Part 20, of the Code of Federal
[Radiological Equivalent Man or mammal] Regulations (10 CFR Part 20), "Standards for
exposure is expected for all workers. On Protection Against Radiation." It sets the
occasion there might be an exposure (i.e., annual total effective dose limit at 5,000 mRem
greater than 0.010 REM) a n d w i l l be (5 Rem) for the entire body.
referred to the Radiation Health Office for
investigation.
17-5
The Navy has trained Radiation Health Handwashing
professionals to monitor medical and non-
medical radiation doses. Refer to the local Follow proper hand washing procedures
Radiation Health department or the P-5055, when treating radiology patients. Refer to
Radiation Health Protection Manual, for further Chapter 9 of this manual for handwashing
guidance. technique.
Prolonged exposure to radiation may result The darkroom might be a location that is
in loss of hair, redness and inflammation of the overlooked as an area being contaminated.
skin, blood count change, cell atrophy (wasting Disinfect all surfaces that the HM comes in
away), ulcerations, sterility, genetic damage, contact with on daily basis which includes
cancer, leukemia, and death. Adherence to doorknobs, light switches, and other surfaces.
radiation safety will reduce the possibility of Good infection control measures include
these conditions. disinfecting all area that HMs and patients
touch.
Precious Metals Recovery Program
Oral Film Positioning Devices
The precious metals recovery program is
designated to save Department of Defense Film positioning devices should be
(DOD) money by recycling precious metals and disposable (single use) or steam sterilized
using those funds to offset the cost of supplies between patients. The treatment facility should
for DOD activities. Both lead and silver are have an adequate supply of film positioning
precious metals found in all x-ray departments. devices for the daily patient load. If supplies
Lead is found in X-ray tube packets, floor are short, the HM may disinfect film
coverings, wall shielding, patient shields, and x- positioning devices between patients by
ray packets. Silver is found in used fixer immersion in an EPA-registered chemical
solutions and medical/dental films. Precious disinfection such as a 2 percent glutaraldehyde
metals will be saved and turned into the Supply solution. Rinse thoroughly after disinfection.
Department following the guidelines in Follow manufacturer's instructions for high-
BUMEDINST 4010.3, Precious Metals level disinfection. Wear gloves when placing
Recovery Program. intra-oral films and handling contaminated film
packets.
Infection Control
Panoramic Unit Bite-Blocks
Both radiographic equipment and film can
become contaminated resulting in the Use a disposable panoramic unit bite block
transmission of infectious agents. To cover for each patient. When disposable covers
protect workers and the patients, HMs will are not available, disinfect bite blocks in the
ensure that infection control standards are used same manner as a film holding device.
in the radiology area. Information and
procedures on the Infection Control Program can Intraoral Film Packets
be found in BUMEDINST 6220.9 Series,
Nosocomial Infection Control Program and Intraoral film packets become contaminated
BUMEDINST 6600.10 series, Dental Infection when placed in a patient's mouth during
Control Program. exposure. The following section explains
procedures to handle and process contaminated
intraoral film packets from the X-ray room to
the dark room to avoid cross contamination.
17-6
PATIENT PREPARATION 2. If the patient is a woman, ask if she is
PROCEDURES pregnant.
3. If she is or the HM suspects that she
LEARNING OBJECTIVE: might be, consult the ordering physician.
Identify steps for preparing a patient for an 4. Ask the patient to remove eyeglasses,
x-ray. jewelry (affected area), or any other
object in the area of examination.
To prepare a patient for an X-ray procedure, 5. Drape the patient with a lead apron
employ the following techniques: ensuring the reproductive organs are
covered, unless area of examination will
1. Ensure a provider’s order for the
preclude covering.
examination.
6. Position the affected anatomy securely
a. Only a Medical Officer, Dental
against the film screen. Positioning the
Officer, Nurse Practitioner, Physician
patient varies according to the type of
Assistant (PA) and Independent Duty
radiographic examination and the film
Corpsmen (IDC) can order a
placement technique to be used.
radiographic examination.
7. Give appropriate instructions (breathing,
b. The order may be in the Composite
remain still, etc.) to the patient.
Health Computer System (CHCS) or a
written order on a SF-519, 8. Set KVp and Mas based on current
RADIOLOGIC CONSULTATION facility charts.
REQUEST/REPORT.
9. Make the exposure.
NOTE: After the X-ray procedure is completed,
If working in an operational environment or area return the lead apron and/or thyroid collar back
not within close proximity of a Radiologist, seek to the storage device(s) to avoid damage.
the ordering provider’s impression of findings
prior to forwarding the films to the Radiologist.
17-7
MEDICAL X-RAY PROCEDURES 1. Film Size 8 X 10 or 10 X 12
2. Source to image distance (SID)- 40 inches
LEARNING OBJECTIVES: (x-ray tube 40 inches from film)
3. Part position
Identify the proper patient positioning
techniques. a. Rest the patient’s forearm on the table:
b. Place the hand with the palm down
Identify the proper film size for an x-ray exam.
c. Slightly spread the fingers
Identify structures shown in an x-ray. 4. Central ray
a. Perpendicular to the film
POSITIONING OF THE HAND
b. Direct the central ray to the third
Posterior anterior (PA) Projection (Fig. 17-5)
metacarpophalangeal (MCP) joint
c. Adjust the long axis of the cassette
parallel with the long axis of the hand
and forearm
5. Structures shown
a. PA projection of the:
i. Carpals
ii. Metacarpals
iii. Phalanges
iv. Thumb will be oblique to 45o
v. Interarticulations of the hand
vi. Distal radius and ulna
6. Indications
a. Discomfort due to mechanism of injury
17-8
Oblique Projection (Fig. 17-6)
1. Film size 8 X 10 or 10 X 12
2. SID - 40 inches
3. Part Position
a. Rest the patient’s forearm on the table
with the hand pronated and the palm
resting on the cassette. If possible use an
angled sponge as it will allow the fingers
to remain straight and provide increased
visualization of the joint spaces.
b. Adjust the obliquity of the hand so that
the MCP joints form an angle of
approximately 45 degrees with the
cassette
c. Fingers are flexed with fingertips resting
on the cassette
4. Central ray
a. Perpendicular to the film
b. Direct central ray to the third
metacarpophalangeal joint
c. Adjust the midline to be parallel with the
long axis of the hand and forearm
5. Structure shown:
a. PA oblique projection of the bones and
soft tissues of the hand
6. Indication
a. Determine possibility of fracture
NOTE:
X-rays of the wrist use the same positions as
hand x-rays. Finger extension is not required.
6. Indication
a. Phalangeal fracture
17-10
POSITIONING OF THE CHEST
1. Film size - 14 x 17
Posterior anterior (PA) projection15
(Fig. 17-8) 2. SID - 72 inches
3. Part position
a. Patient is in the upright position
b. The upper border of the film is positioned
approximately 1 ½ inches above the
relaxed shoulders
c. The median sagittal plane of the body is
centered to the midline of the grid device
d. Body weight is evenly distributed over
both feet
e. The head is adjusted so that the median
sagittal plane of the skull is vertical and
the chin is resting over the edge of the
grid device
f. Place the back of the hands on the hips
g. Adjust the shoulders to lie in the same
transverse plane
h. If a woman’s breasts are large enough to
superimpose over the lower part of the
lung field, have the patient pull them
upward and laterally
4. Central ray (Cross-hairs)
a. Perpendicular to the film
b. Directed to the level of T-7 (Inferior
Scapula Angle)
5. Respirations
a. Exposure is made following full
inhalation on the second breath
Figure 17-8.—Posterior Anterior (PA) Projection b. For certain conditions, an additional
of the Chest exposure is taken following exhalation
Photograph provided by HM1 James Q. Royal of the 6. Indications
Biomedical Photography Department of Navy
Medicine Support Command, Bethesda, MD by the a. Routine physical
Radiology Department of National Naval Medical b. Chronic cough
Center, Bethesda, MD.
c. Respiratory disease
d. Asbestos
e. Fractured ribs
f. Pain with respirations
17-11
Lateral Projection15 (Fig. 17-9)
1. Film size - 14 x 17
2. SID - 72 inches
3. Part position
a. Patient is in the upright position
b. Place the appropriate shoulder (Left
Lateral preferred) against the grid device
c. The median sagittal plane of the body is
parallel to the cassette with the adjacent
shoulder in contact with the grid device
d. The upper border of the film is 1 to 2
inches above the shoulders
e. Center the thorax to the grid device
f. Extend the arms over the head
4. Central ray
a. Perpendicular to the film
b. Directed to the level of T7
5. Respirations
a. Exposure is made following full
inspiration on the second breath
6. Structures shown
a. Lateral projection of the heart and aorta
b. Pulmonary lesions of the side closest to
the film
c. Interlobular fissures
d. The lobes are differentiated
7. Indications
a. Routine physical
b. Chronic cough
c. Respiratory disease
d. Asbestos
e. Fractured ribs
f. Pain with respirations
Figure 17-9.—Lateral Projection of the Chest
17-12
POSITIONING OF THE ABDOMEN16
1. Film size - 14 X 17 lengthwise
KUB (Kidneys, Ureter, Bladder) AP projection 2. SID – 40 inches
(Supine/standing position) 3. Part Position
(Fig. 17-10)
a. Patient is supine or standing
b. The median sagittal plane is
perpendicular and centered to the grid
device
c. Adjust the shoulders to lie in the same
transverse plane and place arms where
they will not cast shadows on the film
4. Central ray (cross-hairs)
a. Perpendicular to the cassette
b. Centered to the level of the iliac crest for
supine
c. 2” above iliac crest for standing position.
5. Respirations
a. Suspended at the end of exhalation
6. Structures shown:
a. Bilaterally Kidney
b. Ureter
c. Bladder
NOTE:
For standing, must include inferior aspect of
lungs (Costophrenic angles).
7. Indications
a. Quadrant pain
b. Abnormal bowel movement
c. Bladder trauma
Figure 17-10.—AP Projection of the Abdomen d. Abdominal trauma
Photograph provided by HM1 James Q. Royal of the e. Impaled object
Biomedical Photography Department of Navy
f. Lower spine (defects, trauma related,
Medicine Support Command, Bethesda, MD by the
Radiology Department of National Naval Medical
impaled, injuries.)
Center, Bethesda, MD.
17-13
SPINE/PELVIS
1. Film size - 8 x 10 or 10x 12
15
Positioning of the Cervical Spine 2. SID – 40 inches
AP axial projection (Fig. 17-11) 3. Part position
a. Patient is supine or upright
b. Adjust the shoulders to lie in the same
transverse plane
c. Center the median sagittal plane of the
patient’s body to the midline of the grid
device
d. Extend the chin so that a line from the
upper occlusal plane to the mastoid tips is
perpendicular to the grid device
e. Center the cassette at C4 (1/2” above
Adam’s apple)
4. Central ray
a. Angled 15 - 20 degrees cephalic
(towards head)
b. Directed to C4 (1/2” above Adam’s
apple)
5. Respirations
a. Suspended
6. Structures shown
a. C3 to T1 in entirety
7. Indications
a. Tracheal deviation
b. Foreign body
c. Trauma
17-15
Positioning of the Thoracic Spine 1. Film size: 14 x 17
AP projection (Fig. 17-13)
2. SID – 40 inches
3. Part position
a. Patient is in the supine or upright position
b. Center the median sagittal plane of the
body to the midline of the grid
c. Place arms along the sides of the body
d. If the patient is supine, flex the hips and
knees to place back in contact with the
table
e. If the patient is erect, distribute body
weight equally between both feet
f. Center film at the level of the T-7
approximately three to four inches below
the manubrial notch (Normally this
will place the upper edge of the cassette 1
1/2 to 2 inches above the shoulder)
4. Central ray
a. Directed perpendicularly to T7
b. Utilize the anode heel effect by
positioning the cathode end of the tube
towards the feet
5. Respirations
a. Breathing technique
i. Slow, shallow breaths
b. Non-breathing technique
i. Suspend following full exhalation
6. Structures shown
a. AP projection of the thoracic bodies,
interpediculate spaces and surrounding
structures
7. Indications
a. Chronic pain
Figure 17-13.—AP Projection of the Thoracic
Spine b. Trauma
c. Cervical spine
Photograph provided by HM1 James Q. Royal of the
Biomedical Photography Department of Navy d. Musculoskeletal injuries/abnormalities
Medicine Support Command, Bethesda, MD by the
Radiology Department of National Naval Medical
Center, Bethesda, MD.
17-16
Lateral projection (Fig. 17-14) 1. Film size: 14 X 17
2. SID – 40 inches
3. Part position
a. Patient is in a true lateral position, either
recumbent or upright
b. Place a firm pillow under the patient’s
head
c. Flex the hips and knees to a comfortable
position
d. Center the median coronal plane of the
body to the midline of the grid at the
level of T7
e. Adjust the arms at right angles to the
long axis of the body
f. Use a radiolucent support under the lower
thoracic region to place the vertebral
column horizontal with the film
4. Central ray
a. Directed perpendicularly to the median
coronal plane at the level of T7
b. Utilize an angulation of 10 degrees for
women and 15 degrees for men, due to
the differing shoulder widths, if
necessary
5. Respirations
a. Long exposure
i. Quiet breathing
b. Short Exposure
i. Suspend respirations at the end of
exhalation
6. Structures shown
a. A lateral image of the thoracic bodies,
their interspaces, the intervertebral
foramina and the lower spinous processes
b. The upper three or four segments are
usually not demonstrated in this position
Figure 17-14.—Lateral Projection of the Thoracic
Spine 7. Indications
a. Chronic pain
Photograph provided by HM1 James Q. Royal of the
Biomedical Photography Department of Navy b. Trauma
Medicine Support Command, Bethesda, MD by the c. Cervical Spine
Radiology Department of National Naval Medical
Center, Bethesda, MD.
d. Musculoskeletal injuries/abnormalities
17-17
Positioning of the Lumbar Spine 1. Film size: 11 x 14
AP Projection (Fig. 17-15)
2. SID – 40 inches
3. Part position
a. Patient may be either supine or upright
b. Center the median sagittal plane to the
midline of the grid
c. Adjust the shoulders to lie in the same
transverse plane
d. Flex the knees to help flatten the natural
lordotic curve of the spine
e. Flex the patient’s elbows and place the
hands on the upper chest
f. Center the film at the level of L-3
4. Central ray
a. Perpendicular to the film
b. Directed to the level of L-3
5. Respirations
a. Suspended on expiration
6. Structures shown
a. Lumbar bodies
b. Intervertebral disk space
c. Interpediculate spaces
d. Laminae
e. Spinous and transverse processes
7. Indications
a. Chronic pain
b. Trauma
c. Cervical Spine
d. Musculoskeletal injuries/abnormalities
17-18
Lateral Projection (Fig. 17-16)
1. Film size: 11 X 14 lengthwise
2. SID – 40 inches
3. Part position
a. Use the same body position (recumbent
or upright) as used for the AP
b. Place patient on the indicated side and
flex the hips and knees for stability and
comfort
c. Align the median coronal plane of the
body to the midline of the grid
d. Place the arms at right angles to the body
e. If needed, place a support under the
lower thorax to position the long axis of
the spine in a horizontal plane
f. Place a sheet of leaded rubber on the
table behind the patient
4. Central ray
a. Perpendicular to the film
b. Directed to the level of L3
5. Respirations
a. Suspended on exhalation
6. Structures shown
a. Lumbar bodies and their interspaces
b. Spinous processes
c. Lumbosacral junction
d. The first four lumbar intervertebral
foramina
7. Indications
a. Chronic pain
b. Trauma
c. Cervical spine
Figure 17-16.—Lateral Projection of the
Lumbar Spine d. Musculoskeletal injuries/abnormalities
17-19
Positioning of the Pelvis 1. Film size 14 x 17 crosswise
AP Projection (Fig. 17-17)
2. SID – 40 inches
3. Position of patient
a. Place the patient on the table in the
supine position
4. Position of part
a. Center the mid-sagittal plane of the body
to the mid-line of the grid
b. Adjust the patient in a true supine
position
c. Have the patient rest their hands across
their chest
d. Unless contraindicated, medially rotate
the feet and lower limbs about 15-20
degrees to place the femoral neck parallel
with the plane of the cassette
e. The heels should be 8-10 inches apart
f. Immobilize the legs with a sandbag
across the ankles, if needed
g. Position upper border of the film 1 ½
inches above the iliac crest
5. Respirations
a. Suspend respiration prior to exposure
Figure 17-17.—AP Projection of the Pelvis 6. Central ray
a. Perpendicular to the midpoint of the
Photograph provided by HM1 James Q. Royal of the cassette
Biomedical Photography Department of Navy
7. Shield reproductive organs
Medicine Support Command, Bethesda, MD by the
Radiology Department of National Naval Medical 8. Structures shown
Center, Bethesda, MD. a. AP projection of
i. The pelvis
ii. Femoral head
iii. Femoral neck
iv. Trochanters
v. Proximal 1/3 or 1/4 of the shaft of the
femur
9. Indications
a. Pelvic fracture
b. Genitourinary system complications
c. Discoloration
d. Deformity
e. Hip pain
17-20
POSITIONING OF THE FOOT
1. Film size 8 x 10 or 10 x 12
AP Projection (Fig. 17-18)
2. SID - 40 inches
3. Position of patient
a. Place the patient on seated or supine
position on the table
b. Flex the knee of the affected side
c. Rest the sole of the foot firmly on the
radiographic table
4. Position of part
a. Position the cassette under the patient’s
foot
b. Center the cassette to the base of the third
metatarsal
c. Adjust cassette so that its long axis is
parallel with the long axis of the foot
d. Ensure that no rotation of the foot occurs
5. Central ray
a. 10 degrees towards the heel
b. Direct central ray to the base of the third
metatarsal
6. Shield reproductive organs
7. Structure shown:
a. AP projection (Dorsoplantar) of the:
i. Tarsal bones anterior to the talus
ii. Metatarsals
iii. Phalanges
8. Indications
a. Chronic pain
b. Trauma
c. Abnormalities
17-22
Lateral Projection (Fig. 17-20)
1. Film size 8 x 10 or 10 x 12
2. SID – 40 inches
3. Position of patient
a. Have the patient lie on the radiographic
table and turn toward the affected side
b. Place the opposite leg behind the patient
4. Position of part
a. Elevate the patient’s knee enough to
place the patella perpendicular to the
horizontal plane
b. Adjust a sandbag support under the knee
c. Center the cassette to the mid-area of the
foot
d. Adjust the cassette so that its long axis is
parallel to the long axis of the foot
e. Dorisflex the foot to form a 90-degree
angle with the lower leg
5. Central ray
a. Perpendicular to the film
Figure 17-20.—Lateral Projection of the Foot b. Direct central ray to the base of the third
metatarsal
Photograph provided by HM1 James Q. Royal of the
Biomedical Photography Department of Navy 6. Shield reproductive organs
Medicine Support Command, Bethesda, MD by the
Radiology Department of National Naval Medical 7. Structures shown
Center, Bethesda, MD. a. The entire foot in profile
b. The ankle joint
c. The distal ends of the tibia and fibula
8. Indications
a. Chronic pain
b. Trauma
c. Abnormalities
17-23
Positioning of the Ankle
1. Film size 8 x 10 or 10 x 12
AP Projection (Fig. 17-21)
2. SID – 40 inches
3. Position of patient
a. Place the patient in the supine or seated
position with the affected limb fully
extended
4. Part position
a. Adjust the ankle joint in the anatomic
position to obtain a true AP projection
b. Flex the ankle and foot enough to place
the long axis of the foot in the vertical
position
c. The leg should have no rotation
5. Central ray
a. Perpendicular to the ankle joint at a point
midway between the Malleoli
6. Shield reproductive organs
7. Structures shown
a. Ankle joint
b. Distal ends of the Tibia and Fibula
c. Proximal portion of the talus
8. Indications
a. Chronic pain
b. Trauma
c. Abnormalities
17-24
Oblique Projection (Medial Rotation)
1. Film size 8 x10 or 10 x 12
(Fig. 17-22)
2. SID – 40 inches
3. Position of patient
a. Place the patient in the supine or seated
position with the affected limb fully
extended
4. Part position
a. Center the cassette to the ankle joint
midway between the Malleoli
b. Adjust the cassette so that its long axis is
parallel with the long axis of the leg
c. Dorisflex the foot enough to place the
ankle at nearly right-angle flexion
d. Grasp the lower femur with one hand and
the foot with the other. Internally rotate
the entire leg and foot together until the
45-degree position is achieved
5. Central ray
a. Perpendicular to the ankle joint
b. Entering midway between the Malleoli
6. Shield reproductive organs
7. Structures shown
a. Distal ends of the Tibia and Fibula
b. Parts of Tibia and Fibula are often
superimposed over the talus
c. Tibiofibular articulation should be
demonstrated
8. Indications
a. Chronic pain
b. Trauma
c. Abnormalities
17-25
Lateral Projection (Fig. 17-23)
1. Film size 8 x 10 or 10 x12
2. SID – 40 inches
3. Position of patient
a. Have the supine patient turn toward the
affected side until the ankle is lateral
4. Part position
a. Place the long axis of the cassette parallel
with the long axis of the patient’s leg and
center it to the ankle joint
b. Have the patient turn anteriorly or
posteriorly as required to place the patella
perpendicular to the horizontal plane
c. Place a support under the knees if
necessary
d. Dorisflex the foot, and adjust it in the
lateral position
5. Central ray
a. Perpendicular to the ankle joint, entering
the medial Malleolus
6. Shield reproductive organs
7. Structures shown
a. Lower third of the Tibia and Fibula
b. Ankle joint\Tarsal Bones
8. Indications
a. Calcaneous fracture
b. Abnormalities
c. Twisted ankles
17-27
When using the paralleling technique, center Assembling the Anterior Device
the X-ray film packet behind, and parallel with
the long axis of the tooth being X-rayed. A tube Figure 17-26 shows an assembled anterior
head with a 16-inch X-ray source to cylinder end paralleling device. Refer to this figure during the
distance (long cone) should be used. The tube following explanation on assembling the
head must be positioned so that the central X-ray paralleling device:
beam is projected perpendicular to the tooth and
1. Grasp the periapical film packet between
the film packet. To properly position the film
the thumb and first two fingers of the right
and the tube head, use paralleling devices.
hand. The printed surface of the packet
should be facing the HM and the side with
There are two different paralleling devices;
the raised dot should be in the film
one for radiographs of anterior teeth and one for
positioning slot of the paralleling device.
radiographs of posterior teeth. Each paralleling
device consists of a bite-block, indicator rod, 2. Hold the base of the anterior bite-block
and locator ring (Fig. 17-25). The bite-block has between the thumb and first two fingers of
a slot and a film backing support to hold the X- the left hand. Ensure that the plastic film
ray film packet. support is pointed upward and the film
positioning slot is away from the HM.
3. Holding the film packet in position, press it
against the plastic support and slide the
film down into the positioning slot. The
printed side of the packet should be facing
the plastic support, and the raised dot
should be located toward the positioning
slot.
4. The two prongs of the indicator rod are
inserted into the openings in the bite-block.
Slide the anterior locator ring onto the
indicator rod. Look through the locator ring.
If the bite-block and film are centered in the
locator ring, the device is properly
assembled and ready for positioning in the
patient’s mouth.
17-28
Assembling the Posterior Device
3. Guide the bite-block and the film packet • Right Bicuspid area
into position, centering the packet behind • Right Molar area
the area being X-rayed. The film packet
should be positioned far enough behind the
tooth so it will be parallel to the long axis of BISECTING-ANGLE TECHNIQUE
the tooth.
Use the bisecting-angle technique when
4. After positioning the film packet, slide the paralleling devices are not available; when a
locator ring down the indicator rod until the patient finds it painful or impossible to close on
ring almost touches the surface of the the bite-block; or when an X-ray is needed when
patient's face. Then, position the tube head a rubber dam is in place. This technique
cylinder. The end of the cylinder should be incorporates the use of a tube head with an X-
parallel with the locator-ring, and its side ray source to cylinder end distance of 8 inches
should be parallel with the indicator rod. (short cone). The bisecting-angle technique is
5. Once these procedures have been not recommended for routine use.
accomplished, the film packet and the tube
head are in proper alignment. The HM is Paralleling devices are not used with the
now ready to expose the film. bisecting-angle technique. The HM must pay
special attention to positioning the patient, the
film packet, and the tube head.
17-29
Positioning the Patient
17-30
After the film packet is properly positioned,
guide a free hand of the patient to the
holding device. The patient holds the device
with the hand from the opposite side of the arch
being radiographed.
WARNING:
The assistant should never hold the film packet
in position during an exposure.
17-31
HORIZONTAL ANGULATION.— 3. Set the vertical angulation of the tube head
This is the side-to-side positioning of the tube according to the chart in Figure 17-30.
head. Position the tube head so the central X-ray
4. Center the tube head cylinder on the area to
beam is directed straight through the embrasures
be radiographed. To simplify this process,
of the teeth being radiographed. If the horizontal
the numbered anatomical landmarks are
angulation is faulty, the central ray will be
provided in Figure 17-32. Take radiographs
directed at an angle to the embrasures. This will
of the area by centering the tube head
produce a faulty radiograph, with the images of
cylinder on these landmarks:
the teeth overlapping one another. Figure 17-31
illustrates the correct and incorrect cylinder a. Maxillary incisor area: Landmark 1, the
direction. tip of the nose.
b. Maxillary cuspid area: Landmark 2,
beside the ala of the nose.
c. Maxillary bicuspid area: Landmark 3,
below the pupil of the eye.
d. Maxillary molar area: Landmark 4,
below the outer angle of the eye and
below the zygomatic bone.
e. Mandibular incisor area: Landmark 5,
the tip of the chin.
Figure 17-31.—Correct and Incorrect Direction f. Mandibular cuspid area: Landmark 6,
for Horizontal Angulation
directly below landmark 2 1/4 inches
above the lower border of the mandible.
Guidelines for Taking Periapical
g. Mandibular bicuspid area: Landmark
Radiographs, Bisecting-Angle Technique
7, directly below landmark 3 1/4 inches
above the lower border of the mandible.
Take the same 14 radiographs using the same
exposure sequence as that discussed for the h. Mandibular molar area: Landmark 8,
paralleling technique. Complete the following directly below landmark 1/4 inches above
steps: the lower border of the mandible.
1. Program the X-ray machine for mA and
kVp settings. The exposure time varies.
Refer to the film manufacturer's
instructions for correct time/impulse
settings. Remember to reduce the kVp by 5
when taking radiographs in edentulous
(condition of being toothless to at least
some degree) areas, and to 70 when taking
radiographs on children. Position the
patient as shown in Figure 17-28 for
maxillary radiographs or Figure 17-29 for
mandibular radiographs. Remember that
the patient's midsagittal plane must be
perpendicular to the floor.
2. Position the film packet in the patient's
mouth. Have the patient hold the film
packet in place with a pair of hemostats or Figure 17-32.—Cylinder Positioning Landmarks
other holding device. for Periapical Radiographs
17-32
5. With the tube head cylinder centered on the Bitewing X-ray film packets are used for the
horizontal landmark, ensure that the correct interpromixal examination. The bitewing film
horizontal angulation has been obtained. packet (Fig. 17-34) has a paper tab, or wing, that
The central X-ray beam should be projected the patient bites on to hold the packet in place
straight through embrasures of the teeth to during the exposure (thus the name bitewing).
be examined. Interpromixal radiographs can be made using
either the paralleling technique or the bisecting
6. Make the exposure.
angle technique.
7. Remove the film packet from the patient's
mouth and place it in a clean paper cup.
Place the disposable container in a lead
container or behind a protective screen
before making the next exposure.
INTERPROXIMAL (BITEWING)
EXAMINATION
17-33
BISECTING-ANGLE TECHNIQUE
17-34
5. Center the tube head cylinder on the wing
of the film packet. Be sure that the central
X-ray beam passes through the embrasures
as shown in Figure 17-38.
MAXILLARY OCCLUSAL
RADIOGRAPHS
Figure 17-38.—Centering the Tube Head Cylinder Maxillary occlusal radiographs are taken
using the following procedures:
6. Make the exposure. After making the
exposure, put the exposed film in a clean 1. Set the X-ray machine at 10 mA, 90 kVp,
paper cup and place in a lead lined and 60 impulses (1 second).
container or behind a protective screen. The a. Reduce the kilovoltage 5 kVp if the arch
HM is now ready to take the radiograph on is edentulous.
the opposite side of the patient's mouth.
b. Use 70 kVp if the patient is a child.
OCCLUSAL EXAMINATION 2. Position the patient so that the ala-tragus
line is parallel with the floor and the mid-
An occlusal examination is usually sagittal plane is perpendicular to the floor.
conducted when fractures of the jaw or gross 3. Place the film in the patient's mouth.
pathological conditions are suspected. A typical Occlusal films are normally very
occlusal radiograph (Fig. 17-39) shows a large comfortable.
area of the maxillary or mandibular arch. The
occlusal film packet is shaped much like the a. Have the patient relax the muscles of the
periapical packet, only larger. Unlike the mouth and cheek as much as possible.
periapical and bitewing packets, the occlusal b. The pebbled surface of the packet should
packet contains two X-ray films. This allows be toward the occlusal surfaces of the
different developing times to be used for these maxillary teeth, and the narrow side of the
films. The finished radiographs can then be packet toward the patient’s cheeks.
compared for diagnostic purposes. Occlusal
radiographs are exposed using the bisected angle c. To place the packet, retract one corner of
technique. the patient’s mouth until the packet can be
inserted.
d. Position the packet far enough in the
mouth so that it covers all the teeth.
17-35
e. Special care must be taken to avoid MANDIBULAR OCCLUSAL
gagging the patient. Have the patient RADIOGRAPHS
close gently but firmly on the packet to
hold it in place. Mandibular occlusal radiographs are taken
using the following procedures:
4. Position the tube head.
1. Program the X-ray machine for 10 mA, 90
5. For maxillary anterior occlusal
kVp, and 60 impulses (1 second). (Reduce
radiographs, set the vertical angulation of
the kVp setting for edentulous patients and
the tube head at +65°. Center the tube
children as discussed earlier.)
head cylinder on the bridge of the
patient's nose so that the central X-ray 2. Position the patient.
beam will be projected as shown in
a. For mandibular anterior occlusal
Figure 17-40.
radiographs, position the patient so the
ala-tragus line is at a 45° angle with the
floor, and the midsagittal plane is
perpendicular to the floor (Fig. 17-41).
6. Figure-Projection of central ray (CR) Figure 17-41.—Projection of central ray (CR) for
for maxillary anterior occlusal Mandibular anterior radiograph
radiographs.
7. For maxillary posterior occlusal b. For mandibular posterior occlusal
radiographs, set the vertical angulation of radiographs, position the patient so that
the tube head at +75°. Center the tube head the ala-tragus line and mid-sagittal plane
at the top of the patient's nose so that the are perpendicular to the floor.
central X-ray beam will be projected as 3. Place the film packet in the patient's mouth
shown in Figure 17-40. with the pebbled surface toward the
8. Projection of central ray (CR) for maxillary occlusal surfaces of the mandibular teeth,
posterior occlusal radiographs. and the short sides of the packet is toward
the patient's cheeks. Have the patient close
9. Take the exposure. gently on the packet to hold it in place.
17-36
4. Position the tube head. FILM PROSSESSING
a. For mandibular anterior occlusal radio-
graphs, set the vertical angulation of the LEARNING OBJECTIVES:
tube head at - 10°. Center the tube head
cylinder on the tip of the patient’s chin Identify film processing methods.
so that the central X-ray beam will be
projected as shown in Figure-17-42. Identify start-up and securing procedures for
x-ray processors.
FUNDAMENTALS
17-37
In DR, the imaging plate is fixed to the x-ray A safelight, which contains a 15 watt bulb
table. DR has digital image receptors that with a special filter (usually red) is the only safe
interrupt the x-ray exposure based on the amount source of illumination in the darkroom when
of x-radiation reaching the cassette. The image processing X-ray film. The safelight must be
is then displayed on a computer screen. The located no less than 4 feet from the work surface
stored information is placed on a secure server so that the HM can open film cassette and
for future retrieval. In Radiology departments process film. Limit the length of exposure of
the HM may see either CR or DR. CR is the undeveloped imaging film to the safelight for no
most economical based on current technologies. more than 2 minutes. Films not stored in
protective coverings exceeding this time might
Dental digital radiography uses an electronic get a fogged image (discussed under faulty
sensor and computerized imaging system that radiographs).
produces x-ray images almost instantly on a
computer monitor. In dental radiography, a Occasionally, film is exposed (ruined)
sensor, or small detector, is placed inside the because of light leakage. White light may leak
mouth of the patient to capture the radiographic through the filter on the safelight or it may leak
image. The sensor is used instead of the into the darkroom from an outside source. A
intraoral dental film. As in conventional simple test will enable the HM to detect leakage.
radiography, the x-ray beam from the tube head To check for possible light leakage from an
is aimed to strike the sensor. An electronic outside source, perform the test with all lights
charge is produced on the surface of the sensor; off, including the safelight.
the electronic signal is digitized, or converted
1. Obtain a piece of unexposed X-ray film.
into “digital” form. The digital sensor in turn
transmits the information to a computer. 2. Lay the film on the workbench, and place a
penny over it for a period of 5 minutes.
Digital radiography systems are not limited 3. Process the film.
to intraoral images; panoramic and
cephalometric images may also be obtained. 4. The processed film should show no image.
If the outline of the penny can be seen,
WET PROCESSING there is light leakage and the HM should
inform the supervisor.
Automatic film processors are the most The HM should perform this test at every
commonly utilized systems. Manual processing location in the darkroom where unwrapped film
can be used for a backup method for the is being processed.
automatic film processor. If the command has
manual processing capabilities, refer to the AUTOMATIC PROCESSING
manufacturer's operating instructions.
There are five basic steps involved in processing Automatic processing is the most commonly
X-ray film: developing, rinsing, fixing, washing, used method of processing medical and dental
and drying. radiographs in the Navy. The automatic film
processor mechanically transports exposed X-
DARKROOM PROCEDURES ray film through the developing, fixing,
washing, and drying cycles. Automatic
The darkroom has two sources of processing is quicker than manual processing,
illumination: white light and safelight. A white and it produces finished radiographs of uniform
light is a standard ceiling light. It provides quality. A variety of automatic film processors
regular illumination for mixing solutions and are in use in the Navy and they can be generally
cleaning the darkroom. An unwrapped, classified as small or large. Refer to the
unprocessed X-ray film package must never be command SOP or manufacturer’s guide for
exposed to white light. Exposed film is useless. processing instructions.
17-38
PROCEDURES FOR PROCESSING FILM Safety Precautions
If processing a large quantity of X-ray films, Because of the alkaline and acid nature of
the HM must avoid any mix-up. To do this, after the developer and fixer solutions, minor
inserting one patient’s X-ray films, wait 15 chemical irritation or burns can occur when they
seconds before inserting the next patient’s films. come in contact with the skin, the eyes, and the
After inserting the X-ray films of each patient, mouth. Use caution when stirring or mixing
set the X-ray mount, envelope, and identification solutions. Always wear rubber gloves and
label aside; make sure to keep them in the order protective eye wear or a protective face shield
in which they were processed. This will help the and an apron when working around these
HM match the processed radiographs to the solutions. If the solutions come in contact with
patient’s unit, envelope, or identification label the skin, flush the area with large amounts of
when the film exits the processor. water. If the solutions accidentally splash into
the eyes or mouth, flush with large amounts of
For medical films, the identification flasher water and immediately seek medical attention.
machine will be utilized to stamp the films with Fixer solution can stain and discolor clothing.
the patient’s information prior to the film being
processed. This machine can be located either Maintenance Schedule
inside or outside of the darkroom.
The HM is responsible only for user
Securing the Processor maintenance of the processor; equipment repairs
are the responsibility of the Dental equipment
The processor should be secured at the end repair technician.
of the day. The securing procedures are as
follows: Monthly maintenance consists of cleaning
the roller transports and solution tanks. Weekly
1. Depress the on/off switch to the off
maintenance consists of soaking the transport
position.
rollers, solution agitators, and other removable
2. Turn the water supply valve to the off internal parts for 5 to 10 minutes with a
position. (Some models will be stand alone, processor cleaner.
and will not require this step.)
3. Unplug the power supply cable. NOTE:
Any time the processor cover is lifted and
4. Wipe the cover and housing of the
maintenance is being performed, the HM must
processor with a damp sponge or cloth.
wear a safety face shield, apron, and protective
5. Open the lid to allow ventilation gloves.
Change the developer and fixer at a Faulty radiographs are caused by the
minimum of once every 3 to 4 weeks. If a large incorrect positioning of the film packet or the
quantity of X-rays has been processed, change tube head; incorrect kVp, mA and time setting;
the developer sooner. Replenish the solutions or by incorrect processing procedures. One
following the manufacturer’s instructions. common cause of faulty radiographs due to tube
head and film misalignment have already
NOTE: been discussed (e.g., incorrect horizontal angles
The solutions used for automatic processing are produce superimposed radiographic images, and
not the same as those used for manual incorrect vertical angles produce images that
processing. may be foreshortened or elongated).
17-39
The following are additional causes of faulty • Very dark image (Fig. 17-46): The film
radiographs: was over-exposed (kilo-voltage too high); the
developer was too warm; or the film was left
• No image (Fig. 17-44): The film was
in the developer too long
immersed in the fixer before the developer.
If the film is completely clear, it was never
exposed
17-40
• Blurred image (Fig. 17-48): The patient or • Herringbone image (Fig. 17-50): The
tube head moved during the exposure wrong side of the film, packet was facing
the source of the X-ray beam during
exposure causing the embossing pattern
from the lead backing to appear on the film
17-41
MOUNTING DENTAL RADIOGRAPHS
Medical x-rays are not mounted. They are Place the radiographs on a flat, dry surface
placed in folders. If there are multiple types of with the convex surface of the identifying
medical x-rays (diagnostic, Ultrasound, Cat "dimple" toward the observer. Pick up a
Scan, etc., the x-rays are placed in sub-folders to radiograph by the edges. Hold it up to the film
keep them separated and easier to locate. viewer. The line representing the occlusal
surface of the bicuspids and molars should
Interproximal (Bite-Wing) Mounting gradually curve upward, forming one-half of a
smile. If the line curves upward on the right,
Figure 17-52 shows a serial mount for inter- slide the radiograph into the right-hand slot on
proximal (bite-wing) radiographs. The mount the back of the mount with the upward curve
contains slots for mounting five pairs of toward the outside of the mount. Keep the raised
interpromixal radiographs for a patient taken at dimples facing outward. If the line curves
different times/dates and mounted in upward on the left, slide the radiograph into the
chronological order. Serial mounting enables the left-hand slot. If both radiographs are mounted
Dental Officer to compare radiographs taken at correctly, they will appear as shown in Figure
different intervals to detect changes in the 17-55, forming a complete smile. Each time an
patient's oral structures. additional pair of inter-proximal radiographs is
mounted, enter the date on the line beneath the
The front of the mount contains spaces for mounting slots.
the patient's name and social security number,
mount number, and the date of each exposure. Full Mouth Periapical Mounting
Fill in this information whenever a new mount is
started. After completing the necessary Figure 17-53 shows a full mouth periapical
information on the front side, turn the mount over film mount. The mount contains 14 slots for
and lay it face down on a table top. periapical radiographs and 2 slots for
interproximal (bite-wing) radiographs.
17-42
Figure 17-53.—Full Mouth Periapical Mount
When mounting full mouth periapical Mandibular Cuspid and Bicuspid Areas
radiographs, there will be multiple radiographs;
take care to sort and mount them correctly. To Radiographs of these areas show a fine
do this, the HM must be able to recognize network of tiny white lines around and below
certain maxillary and mandibular anatomical the roots and a dark area in the cuspid area
landmarks. representing the mental foramen which is one of
two holes ("foramina") located on the anterior
ANATOMICAL LANDMARKS surface of the mandible (Fig. 17-54).
17-43
Figure 17-54.—Maxillary and Mandibular Radiographic Landmarks
17-44
MOUNTING PROCEDURES 6. Insert the mandibular radiographs. Start
with the radiographs of the central incisor
Place all the radiographs in the full mouth areas and work outward. The raised dots
periapical series on a dry, flat working surface will be toward the HM and the
with the dimple side up. On the front of the film incisal/occlusal surfaces of the teeth should
mount, enter the patient’s name, social security be pointing upward toward the center of the
number, rank/rate, the date, and the name of the mount.
dental treatment facility. Place the mount face
7. After inserting all of the radiographs, hold
down on the working surface. The two small
the mounted radiographs up to the viewer.
arrows on the back of the mount should point
Double check to see that each radiograph is
toward the HM. Follow these steps to mount the
mounted correctly.
radiographs:
1. Check each radiograph and make sure e
PANORAMIC RADIOGRAPHS
surface with he raised dimple faces the
HM.
The panoramic X-ray machine is used to
2. Mount interproximal radiographs. If inter- produce an extraoral radiograph that shows both
proximal (bite-wing) radiographs are dental arches and the temporomandibular joints
included in the full mouth series, insert (Fig. 17-55). The radiograph is made by rotating
them in the slots provided. the tube head and film around the patient while
the patient remains stationary. Because of the
3. Divide the radiographs into maxillary and
different manufacturers and models of
mandibular groups. Using the film viewer,
panoramic X-ray machines used in the Navy,
locate the anatomical landmarks discussed
this operation and maintenance will vary.
earlier. The maxillary radiographs are
Always refer to manufacturer's instruction
inserted in the 7 slots across the top of the
manual prior to use.
film mount and the mandibular radiographs
in the 7 slots across the bottom.
4. Insert the maxillary radiographs. Identify
the radiograph of the central incisor area.
Keeping the side with the raised dimple
facing toward the HM, rotate the
radiograph until the incisal edges of the
teeth point down. With the back of the
mount toward the HM, slide the radiograph
into the incisor slot. When the radiograph is
properly mounted, the side with the raised
dimple will face the HM, and the incisal
edges pointing down toward the center of
the mount.
5. Work outward from the central incisor slot,
inserting the rest of the maxillary
radiographs in the following order: cuspid
areas, bicuspid areas, and molar areas.
17-45
Figure 17-55.—Panoramic X-Ray
Photograph provided by the Dental Readiness Department of National Naval Medical Center, Bethesda, MD.
17-46
Preparing the Film Operating the Panoramic X-Ray Machine
When the X-ray machine is operational, With the machine operational and the film
prepare the panoramic film. Load the film into a cassette drum in the cassette drum assembly, the
cassette drum, and then mount it in the cassette HM is now ready to take the radiograph on the
drum assembly on the X-ray machine. To load patient. Follow the manufacturer's instructions
and mount the cassette drum, follow the for patient positioning and operation. When the
manufacturer's instructions. patient is being positioned, explain the exposure
procedures. Make the exposure and process the
Labeling the Cassette film. The HM should wait 5 minutes between
exposures to prevent overheating of the X-ray
The cassette is labeled for the purposes of head.
orientation and patient identification.
Panoramic X-Ray Machine Maintenance
There are two ways to label the cassette for
patient identification. The HM can use a self- The panoramic X-ray machine requires very
adhesive label or an X-ray film identification little user maintenance. Wipe the metal and
printer. Follow the manufacturer's instructions painted parts with a soft, dry cloth daily. Report
when using the printer. The patient information malfunctions to the supervisor. All repairs are
includes: the patient's name (last name, first the responsibility of the biomedical repair
name, and middle initial), family member prefix technician.
code, social security number, and the date of the
exposure. SUMMARY
Requirements for a Good Panoramic Result This chapter outlined the details of radiation
safety & protection applying to radiation
Follow the manufacturer's operating workers, patients, and the population; patient
instructions for complete operation of the positioning techniques; film processing
panoramic X-ray machine before attempting to techniques; and examples of finished
use it. The following is a list of important radiographs. Ensuring that all of these details are
procedures that must be followed to ensure a followed will provide quality x-ray images for
good quality X-ray is produced. proper diagnosis in a setting that is destined to
provide radiation exposure that follows the
• Make sure patient's back and cervical spine
principles of ALARA (As Low As Reasonably
are as straight as possible
Achievable). The imaging department is an
• Check that the patient's mid-sagittal plane is integral part of the Healthcare Team that
centered within the unit provides healthcare providers with the tools
needed to combat medical and dental disease
• Ensure the patient's Frankfurt plane
processes in any setting worldwide.
(anatomical position of the human skull) is
horizontal
• Ensure the anterior maxillary and
mandibular teeth are located on the indents
of the bite-block. If the patient's bite is
abnormal, adjust mandible forward or
backward to compensate
• Observe patient to ensure there is no
movement during the radiographic
procedure
17-47
CHAPTER 18
PHARMACY
INTRODUCTION • Pharmacotherapeutics is the study of the
uses of medications in the treatment of
As the Hospital Corpsman (HM) advances disease
in rate, there will be increased involvement in
• Toxicology is the study of poisons, their
the administration of medicines. Although
actions, their detection, and the treatment of
medications and their dosages are prescribed by
the conditions produced by them
Medical Officers (MO) and other authorized
prescribers, the HM is involved in the • Therapeutics is the science of treating
administration. It is necessary for the HM to disease by any method that will relieve pain,
learn medication sources, composition, methods treat or cure diseases and infections, or
of preparation and administration, and prolong life
physiologic and toxicologic action. This chapter
o Therapeutics does not deal solely with
covers pharmacology, toxicology, medication
giving or taking medicine
calculations, pharmaceutical preparations, and
prescriptions. o This field also includes many other
methods, such as radiological treatment,
PHARMACOLOGY diathermy, and hydrotherapy
18-1
This publication is used as a reference for in- Closely associated with "dosage range" are
depth information on pharmaceutical products the terms minimum dose (the least amount of
by healthcare providers and pharmacy medication required to produce a therapeutic
personnel. effect), maximum dose (the largest amount of
medication that can be given without reaching the
Drug Information Handbook is an easy to toxic effect), and toxic dose (the least amount of
use reference for clinicians and healthcare medication that will produce symptoms of
providers seeking quick and concise medication poisoning).
information. The information in this is similar
to that which is contained in the Drug Facts and THERAPEUTIC DOSE.—is referred to as
Comparisons. the normal adult dose, the usual dose, or average
dose. It is the amount needed to produce the
Remington: The Science and Practice of desired therapeutic effect. This therapeutic
Pharmacy is the most widely used text/reference dose is calculated on an average adult male of 24
in American pharmacies. It contains all areas years who weighs approximately 150 pounds.
relevant to the art/science of pharmacy. It is a
textbook of pharmacology, toxicology, and MINIMUM LETHAL DOSE.— is the least
therapeutics. This work is known as the "blue amount of medication that can produce death.
bible" of pharmacology.
FACTORS AFFECTING DOSAGE.—
MEDICATION ADMINISTRATION The two primary factors that determine or
influence the dosage of a medication are the age
The quantity and frequency of a and weight of the patient.
medication's administration to a patient
depend on several factors, as does the method Age⎯Age is the most common factor that
of that medication's administration. This influences the amount of medication to be
section covers some factors affecting dosage given. An infant requires a lower dose tha n an
calculations and methods of administration. adult. Elderly patients may require a higher or
lower dose than the average dose, depending
Dosage upon the action of the medication and the
condition of the patient.
The amount of medication to be
administered is referred to as the dose. The A rule governing calculation of pediatric
study of dosage a n d the criteria that influence it (child's) doses, Young’s Rule, is expressed as:
is called posology. The doses given in the
United States Pharmacopeia and National Age in years
Formulary (USP-NF) are average therapeutic x adult dose = child's dose
doses and are known as "usual adult doses." Age in years + 12
The following terms are used in connection
with doses. The age in years of the child is the
numerator, and the age plus 12 is the
DOSAGE RANGE.—It is a term applying denominator. This fraction is then multiplied
to the range between the minimum and by the normal adult dose.
maximum amounts of a given medication
required to produce the desired effect. Many
Example: The adult dose of aspirin is 650 mg.
medications (such as penicillin) require large
What is the dose for a 3-year-old child?
initial doses that are later reduced to smaller
amounts.
3 x 650 mg = 260 mg
3 + 12
18-2
Weight⎯In the calculation of dosages, The child's weight in pounds is the
weight has a more direct bearing on the dose numerator, and the average adult weight (150
than any other factor. This is especially true in pounds) is the denominator. This fraction is
the calculation of pediatric doses. The doses of multiplied by the adult dose.
the majority of medications based on body
weight are conveniently expressed in terms of Example: The adult dose of aspirin is 650 mg.
mg/kg, since the doses of most medications are What is the dose for a child weighing 60
administered in milligram amounts19. However, pounds?
this is not always the case. Depending on the 60 x 650 mg = 260 mg
medication, dosage form or other factors, the 150
dose of some medications may be expressed in
different units of measure.
NOTE:
A useful equation for the calculation of Young’s and Clark’s rule are not generally used
doses based on body weight is: because the majority of medications are now
dosed based according to weight, providing a
Patient’s dose (mg) = Patient’s weight (kg) × more patient specific dose.
Medication dose (mg) / 1 (kg)19
If different units are given, other units may Other Factors that Influence Dosage
be substituted in the equation as long as the
terms used are consistent. • Sex: Females usually require smaller doses
than males
Example: The dose of medication “A” is 22 • Race: Black individuals usually require
mg/kg. How many milligrams of medication larger doses, and Asians require smaller
“A” are needed for a patient weighing 17 kg? doses than Caucasians
x (mg) = 17 kg × 22 mg • Occupation: Persons working in strenuous
jobs may require larger doses than those
x (mg) = 17 × 22 who sit at a desk all day
• Habitual use: Some patients must take
x = 374 mg medications continuously, causing their
bodies to build up tolerance to the
Another rule governing calculation of medication. This tolerance may require
pediatric doses based on weight is Clark's Rule, larger doses than their initial doses to obtain
expressed as: the same therapeutic effect
• Time of administration: Therapeutic
Weight in pounds
x adult dose = child's dose effect may be altered depending upon time
of administration (e.g., before or after
150
meals)
• Frequency of administration: Medications
given frequently may need a smaller dose
than if administered at longer intervals
• Mode of administration: Injections may
require smaller doses than oral
medications
18-3
Methods of Administering Medications PARENTERAL medications are
introduced by injection. All medications used
Medications may be introduced into the by this route must be pure, sterile, pyrogen-
body in several ways, each method serving a free (pyrogens are products of the growth of
specific purpose. The most common routes of microorganisms), and in a liquid state.
administration are oral (enteral) and injection
(parenteral). EXAMINATIONS OF PARENTERAL
SOLUTIONS.⎯ Parenteral solutions are
ORAL is the most common method of examined at least three times at the activity at
administering medications. Among the which they are ultimately used:
advantages of administering medication orally
(as opposed to other methods) are: • Upon receiving the solution
18-4
Methods of Parenteral Administration INHALATION is a means of introducing
medications through the respiratory system in
Subcutaneous is the medication injected the form of a gas, vapor, or powder. Inhalation
just below the skin's cutaneous layers. Example: is divided into three major types: vaporization,
Insulin. gas inhalation, and nebulization.
• Vaporization - the process by which a
Intradermal is the medication injected
medication is changed from a liquid or solid
within the dermis layer of the skin. Example:
to a gas or vapor by the use of heat (such as
Purified Protein Derivative (PPD).
in steam inhalation)
Intramuscular is the medication injected • Gas Inhalation - almost entirely restricted
into the muscle. Example: Procaine Penicillin G. to anesthesia
18-5
"RIGHTS" OF MEDICATION The HM must double-check measurements
ADMINISTRATION and make sure of the correct number of pills or
capsules before taking the medication to the
To prevent medication errors, there are six patient. Tablets may need to be split. If using the
important steps to follow when administering automated system, there should be a warning of
medication to a patient. Many medication errors the dosage difference. The HM must not
can be linked to an inconsistency in adhering to exclusively rely on that for accuracy. Check the
the six “right” steps of medication packaging against the MAR.
administration.
Right Route
Right Patient
If the medication is ordered PO, make sure it
Make sure the patient is identified. This is is given it PO. Don't give an injection as an IV
more than asking for the patient’s name. infusion. If it's ordered deep IM, make sure the
Sometimes the patient is confused, their level of right length and correctly gauged needle is used
consciousness may be altered due to medication for accurate administration. Do not leave the
or a procedure, or they may be unable to medication on the bedside table; watch the
communicate. The HM should use two forms of patient to make sure the medication is taken
patient identification. Check the patient's arm correctly. Patients have been known to ingest
band and verify it with the Medication suppositories or make other mistakes while
Administration Record (MAR). confused or under the influence of pain
medications.
Right Medication
Right Time
A medication order is required for every
medication to be administered to a patient. Medication doses can be spaced at specific
Compare the order with the MAR when the intervals. Levels may need to be maintained in
order was initially ordered. After determining the bloodstream, certain meds may need to be
the information on the MAR is accurate, use the given an hour or more apart from other
MAR to prepare the medications. When medications, or they may need to be taken in
preparing medications from bottles or container, specific relation to meals. Absorption and
compare the label with the MAR three times: (1) efficacy may be affected if medications are
before removing from the shelf or drawer, (2) as incorrectly administered, If in question, review
the amount of medication ordered is removed the MAR and reference books, and refer to
from the container, and (3) before returning the the patient's chart if needed in order to make
container to storage. If it is listed as a generic sure the appropriate guidelines are being
equivalent and the HM is unsure if it is the same followed for the ordered medication(s).
as what is ordered on the MAR, they must
consult a medication book or other reference to There are established windows for
confirm that the medication to be given is the administering oral, IM, and IV medications.
same as the one ordered. Certain medications are These windows allow for certain flexibility, but
frequently confused with another with a similar the medication should be given within the
name or appearance. established framework unless extenuating
circumstances prevent it. In that case, the HM
Right dose needs to document why the medication was
given outside the parameters and notifies the
With the use of generic drugs increasing in MO and pharmacy to adjust the future doses.
hospitals, the HM may be confronted with the
need to give more than one of a specific tablet or
capsule, or to measure a liquid into a syringe or
dose cup.
18-6
Right Documentation Medications are classified according to set
criteria and fall into three specific areas:
Health care providers use accurate general, chemical, and therapeutic.
documentation to communicate with each other.
• General: Grouped according to their source
Many medication errors result from inaccurate
whether animal, vegetable, or mineral in
or incomplete documentation. Before
origin
administering medications, ensure the MAR
clearly reflects the patient’s name, name of the • Chemical: Grouped by their chemical
medication ordered written out in full, and the characteristics
medication’s dosage route and frequency. After
administering the medication, document which • Therapeutic (Pharmacological): Grouped
medications were given on the patient’s MAR according to their action on the body
according to local policy to verify that the
NOTE:
medication was given as ordered.
Some medications may have more than one
action and fall into more than one therapeutic
Healthcare professionals have a
class.
responsibility to make sure that patients receive
the best care possible. Safe medication
administration is an important part of quality MEDICATION NOMENCLATURE
care and will help minimize the occurrence of
negative effects while the patient is under care. Medications normally have three names:
chemical, generic (nonproprietary), and brand
MEDICATION CLASSIFICATIONS (proprietary).
18-7
MEDICATION CLASSES • Petrolatum (petroleum jelly) is a good
emollient that provides a highly occlusive,
The types of medications outlined in this protective barrier. When petrolatum is used
chapter and the correlating medications in as an ointment base, it may not release some
common use described in appendix IV are drugs.
grouped according to pharmacological classes.
Only a brief summary is possible here, the HM • Zinc Oxide is a white petrolatum containing
desiring a more complete description of each approximately 20% zinc oxide powder. It is
medication should refer to the USP-NF, Drug used as an emollient with slightly astringent
Facts and Comparisons, Medication properties. Because of its opaqueness, is
Information Handbook, or other medication ideal for protecting the skin and relieving
reference books. chafing.
Expectorants and Antitussives
Astringents
Expectorants and Antitussives are
Astringents are medications that cause commonly used in the symptomatic treatment of
shrinkage of the skin and mucous membranes. the common cold or bronchitis. (See appendix
Mainly used to stop seepage, weeping, or IV, page 1.) Expectorants are more accurately
discharge from mucous membranes. known as bronchomucotropic agents. These
agents assist in the removal of secretions or
• Aluminum Acetate solution (Burow’s
exudates from the trachea, bronchi, or lungs.
Solution, Domeboro®) is used as a wet to
Therefore, they are used in the treatment of
dry dressing for the relief of inflammatory
coughs to help expel these exudates and
conditions of the skin, such as athlete’s foot,
secretions. Antitussives are agents that inhibit or
poison ivy, swelling, external otitis, bruises
suppress the act of coughing. Other cold and
and insect bites.
allergy relief preparations are discussed later in
• Calamine, zinc oxide, glycerin, and this chapter.
bentonite magma in calcium hydroxide
• Guaifenesin and dextromethorphan
(calamine lotion) is used to treat various
(Robitussin® DM) In this drug
skin afflictions in the same way as
combination, guaifenesin acts as an
aluminum acetate. It is a topical astringent
expectorant. It may be useful in
and protectant. It should be applied to
symptomatic relief of dry, nonproductive
blistered, raw, or oozing areas of the skin.
cough, and in the presence of mucous in the
respiratory tract. Dextromethorphan is a
Emollients synthetic non-narcotic derivative of codeine
that acts as an antitussive. It is used to
Emollients are bland or fatty substances that control non productive coughs by soothing
may be applied to the skin to make it more minor throat and bronchial irritations.
pliable and soft. They may serve as vehicles for
application of other medicinal substances. • Guaifenesin and codeine phosphate
Emollients are available as ointments, creams, or (Robitussin® AC) are combined to relieve
lotions. the symptoms of the common cold.
Guaifenesin is an expectorant, and codeine
• Theobroma oil (cocoa butter) is an phosphate is a narcotic antitussive. Patients
excellent emollient with a pleasant odor. should be advised that this medication
Ideal for the treatment of chapped skin and contains a narcotic and, if abused, could
lips, cracked nipples, or minor irritated or cause dependency.
abraded skin areas.
18-8
Nasal Decongestants • Diphenhydramine Hydrochloride
(Benadryl®) Diphenhydramine HCl is
Nasal Decongestants reduce congestion and given for active and prophylactic treatment
the swelling of mucous membranes. They are of motion sickness, as a nighttime sleep aid,
used for temporary relief of nasal congestion due and for the symptomatic relief of urticaria,
to the common cold, allergies, and sinusitis, and allergic rhinitis, and other allergic
to promote nasal or sinus drainage. They are conditions.
used to relieve Eustachian tube congestion. They
are often combined with antihistamines, • Chlorpheniramine Maleate (Chlor-
antitussives, and expectorants to relieve the Trimeton®) Chlorpheniramine HCl is used
symptoms of colds, allergies, and sinusitis. for the symptomatic treatment of urticaria
and other allergic conditions.
• Pseudoephedrine Hydrochloride
(Sudafed®) Pseudoephedrine hydrochloride • Meclizine Hydrochloride (Antivert®,
(HCL) is indicated for the symptomatic Bonine®) Meclizine HCl is given to prevent
relief of nasal congestion due to the and treat nausea, vomiting, and dizziness of
common cold, hay fever, or other upper motion sickness. It has a longer duration of
respiratory allergies. action than diphenhydramine hydrochloride.
18-9
Antacids Disinfectants are agents used to disinfect
inanimate objects and are primarily germicidal
Antacids are used to counteract hyperacidity in their action. All of these agents are for
in the stomach. Normally, there is a certain external use only, unless otherwise indicated.
degree of acidity in the stomach. An excess of
• Phenol (carbolic acid) Historically, one of
acid can irritate the mucous membranes and
the first antiseptic agents used. It is the
commonly known as indigestion, heartburn, or
standard by which all other antiseptic,
dyspepsia. In some disease states, the
disinfectant, and germicidal agents are
gastrointestinal tract may become excessively
measured in effectiveness. Because of its
acidic (very low pH), causing diarrhea or
highly caustic nature, phenol must be
leading to peptic ulcer formation. Antacids may
handled with care. The effect of phenol is
interfere with the body’s ability to use or
coincident with the concentration: high
metabolize many medications. For this reason,
concentrations are germicidal and can cause
oral medications normally should not be taken
tissue destruction; lower concentrations are
within 2 hours of taking an antacid.
antiseptic. Phenol is inactivated by alcohol.
• Magnesium Hydroxide (Milk of Magnesia Because more effective and less damaging
USP) is used for the symptomatic relief of agents have been developed, phenol is no
upset stomach associated with hyperacidity, longer used extensively.
treatment and maintenance of duodenal
• Povidone-iodine (Betadine®) Numerous
ulcers, and used to reduce phosphate
iodine and iodine-complex agents are
absorption in patients with chronic renal
available for use in disinfection. The most
failure. It should be taken on an empty
common of these is povidone-iodine
stomach with lots of fluids. It should not be
(Betadine ®). It is used externally to
used in the presence of abdominal pain,
destroy bacteria, fungi, viruses, protozoa,
nausea, or vomiting. Prolonged use may
and yeasts. Povidone-iodine is relatively,
result in kidney stones. Magnesium
nontoxic, nonirritating, and non-sensitizing
hydroxide also has a laxative effect.
to the skin. When used as an antiseptic, the
• Aluminum Hydroxide Gel (Amphojel®) is complex breaks down on contact with skin
used to manage peptic ulcers, gastritis, and or mucous membranes to release free iodine,
gastric hyperacidity. The major advantage of which is slowly absorbed. Most commonly
this drug is that no systemic alkalosis is used as a preoperative skin antiseptic.
produced. It may cause constipation.
NOTE:
• Alumina and Magnesia Oral Suspension Check for iodine allergies before using this
(Maalox®) Alumina and magnesia oral antiseptic on patients.
suspension coats the stomach lining and
neutralizes gastric acid. It is less • Isopropyl Alcohol (Isopropanol) is used in
constipating than aluminum hydroxide a 70% solution as a skin antiseptic; it is
alone. volatile and also has a drying effect on the
skin.
Antiseptics, Disinfectants, and Germicides
18-10
• Hexachlorophene (pHisoHex®) Synthetic CAUTION:
preparation is a bacteriostatic cleansing When using silver nitrate as a wet dressing, use
agent effective against gram-positive precautions to keep the dressing from drying
organisms. The presence of pus or serum out.
decreases its effectiveness. It is a neurotoxin
agent and must not be used on premature If the wet dressing dries out, the silver nitrate
infants, denuded skin, burns, or mucous will precipitate and be absorbed into the skin,
membranes. It is used as an antiseptic scrub which will turn a slate gray.
by physicians, dentists, food handlers, and
others. Residual amounts can be removed This condition is known as argyria.
with alcohol.
• Glutaraldehyde (Cidex®) is effective There is no known reversal for this condition.
against vegetative gram-positive, gram-
negative, and acid-fast bacteria, bacterial Sulfonamides
spores, some fungi, and viruses. It is used in
an aqueous solution for sterilization of fiber Sulfonamides were the first effective
optics, plastics, rubber, and other materials chemotherapeutic agents to be available in safe
that are not resistant to heat. therapeutic dosage ranges. Prior to the
• Hydrogen Peroxide is a germicide and introduction of penicillins in 1941, sulfonamides
routinely used to cleanse pus-producing were the main therapy for bacterial infections in
wounds and in the treatment of necrotizing humans. Sulfonamides are synthetically
ulcerative gingivitis (NUG) also known as produced and are effective against both gram-
trench mouth. It is an oxidizing agent that is positive and gram-negative organisms.
destructive to certain pathogenic organisms, • Sulfisoxazole (Gantrisin®) is a systemic
but it is mild enough to be used on living sulfonamide that is a bacteriostatic and is
tissue. It is for external use only and is indicated to treat urinary tract infections and
normally available in 3% solution. acute otitis media.
• Silver Nitrate The soluble salts of silver • Trimethoprim and Sufamethoxazole
nitrate ionize in water to produce highly (Bactrim®, Septra®) The combination of
concentrated astringent and antiseptic trimethoprim and sufanethoxazole is an anti-
solutions. In a solid form is most commonly infective used to treat urinary tract infection
used to cauterize mucous membranes and to and otitis media.
treat aphthous ulcers. The most common
side effect of silver nitrate is the skin turns • Sulfacetamide Sodium (Sodium
black where the silver nitrate comes in Sulamyd®, Bleph®-10) Sulfacetamide
contact with it. The black area on the skin is sodium is an ophthalmic bacteriostatic for
not harmful and will resolve slowly. Silver the treatment of conjunctivitis, corneal ulcer,
nitrate in liquid form is used as eye drops to and other superficial ocular infections. It is
prevent gonorrheal ophthalmia in newborns. available in solutions of various strengths
Liquid silver nitrate is also used as a wet and in ointment form.
dressing. • Silver Sulfadiazine (Silvadene® Cream) is
a topical antimicrobial agent used to treat
second and third degree burns to prevent
wound sepsis. It is water soluble and easily
washed off the skin.
18-11
Penicillins • Amoxicillin (Amoxil®) The spectrum of
amoxicillin is essentially identical to
Penicillin is one of the most important ampicillin, except that amoxicillin is more
antibiotics. It is derived from a number of effective against shigella. Amoxicillin also
Penicillium molds commonly found on breads has the advantage of more complete
and fruits. The mechanism of action is the absorption than ampicillin.
inhibition of cell wall synthesis during the
reproductive phase of bacterial growth. It is one • Amoxicillin and Clavulanate potassium
of the most effective and least toxic of the (Augmentin®) is used to treat many
antimicrobial agents. different infections caused by bacteria, such
as sinusitis, pneumonia, ear infections,
• Penicillin G, Aqueous is indicated for bronchitis, urinary tract infections, and
susceptible infection such as meningococcal infections of the skin.
meningitis, anthrax, and gonorrhea.
Penicillin G is for parenteral (IV) use only.
Cephalosporins
• Penicillin G, Benazathine (Bicillin® LA)
is indicated for conditions such as syphilis Cephalosporins are a group of semi-
and upper respiratory tract infections caused synthetic derivatives of cephalosporin C, an
by streptococcal (Group A) bacteria. This antimicrobial agent of fungal origin. They are
drug is injected into a large muscle. structurally and pharmacologically related to the
penicillins. Because cephalosporins are similar
• Penicillin G Procaine, Aqueous
to penicillins, some patients allergic to penicillin
(Wycillin®) is indicated for conditions such
may also be allergic to cephalosporin
as uncomplicated pneumonia, middle ear
medications. The incidence of cross-sensitivity
and sinus infections, NUG and pharyngitis,
is estimated to be 5 to 16 percent.
and scarlet fever. Penicillin G procaine is for
parenteral use only, and it has longer
This family of antibiotics is generally
duration of action than most of the other
divided into three generations: first, second, and
penicillins.
third generation. The main differences among
• Penicillin V Potassium (Pen-Vee K®, the groups are the change in the antibacterial
Betapen-VK®, V-Cillin K®) is used to spectrum. The third generation agents have a
treat conditions such as upper respiratory much broader gram-negative spectrum than the
tract infection, otitis media, sinusitis, earlier generations.
bacterial endocarditis, and mild
• Cefazolin Sodium (Ancef®, Kefzol®) is
staphylococcal infection of skin and soft
used to treat a wide range of medical
tissue. Penicillin V has the same spectra of
conditions, such as lower respiratory tract
activity of penicillin G and is usually the
infections (pneumonia and lung abscess),
drug of choice for uncomplicated group-A
septicemia, and bone and joint infections. It
beta-hemolytic streptococcal infections. It is
is used preoperatively to reduce the chance
available as oral tablets or powder for
of certain infections following surgical
reconstitution for oral suspension.
procedures (such as vaginal hysterectomy,
• Dicloxacillin Sodium (Dynapen®) is used gastrointestinal surgery, and transurethral
to treat infections caused by penicillin G- prostatectomy).
resistant staphylococci. It may be used to
• Cephalexin (Keflex®) is indicated for the
initiate therapy in any patient in whom a
treatment of infection of the respiratory
staphylococcal infection is suspected.
tract, otitis media, skin and skin structures,
• Ampicillin (Polycillin®) is used to treat and genitourinary system.
conditions such as shigella, salmonella,
escherichia coli, and gonorrhea.
18-12
• Cefprozil (Cefzil®) is used to treat • Tetracycline hydrochloride (Achromycin®,
pharyngitis, tonsillitis, otitis media, Sumycin®) is used to treat infections caused
bronchitis, and mixed infections of the skin by rickettsiae (such as Rocky Mountain
and skin structure. Mixed infections are spotted fever and typhus fever), agents of
infections that include both aerobic and lymphogranulomas venereum and
anaerobic pathogenic organisms. This granuloma inguinale, and the spirochetal
medication is used preoperatively to prevent agent of relapsing fever. Tetracycline
the incidence of certain postoperative hydrochloride is indicated for severe acne as
infections. an adjunctive therapy. Food and some dairy
products may interfere with absorption;
antacids containing aluminum, calcium, or
Tetracyclines
magnesium impair absorption of the
antibiotic as well. This medication should
Tetracyclines introduced in 1948, were the
be given 1 hour before or 2 hours after
first truly broad-spectrum antibiotics. They
meals.
include a large group of medications with a
common basic structure and chemical activity. • Doxycycline Hyclate (Vibramycin®) is
The most important mechanism of action of the active against a wide range of gram-positive
tetracyclines is the blocking of the formation of and gram-negative microorganisms and has
polypeptides used in protein synthesis. Because a low affinity for binding with calcium. In
of their broad spectrum of activity, are most addition to the conditions listed under
valuable to treat mixed infection, such as tetracycline, doxycycline is indicated for the
chronic bronchitis and peritonitis; however, they treatment of uncomplicated chlamydial
are medications of choice for only a few infections and uncomplicated gonococcal
bacterial infections. Tetracycline is also used as infections. Doxycycline can be used for
a topical preparation to treat acne. malaria prophylaxis.
18-13
Because of their high toxicity, • Clindamycin hydrochlorids (Cleocin®) is
aminoglycosides are not recommended when the used to treat susceptible anaerobic
infective organism is susceptible to less toxic organisms. The use of clindamycin
preparations. hydrochloride has often been associated
with severe colitis and profuse diarrhea; if
• Gentamicin sulfate (Garamycin®) is used
this condition occurs, the drug should be
to treat serious systemic infections of
discontinued. A topical preparation is
susceptible gram-negative organisms. While
available for the treatment of acne.
the patient is on gentamicin sulfate, it is
necessary to monitor renal and hepatic • Vancomycin hydrochloride (Vancocin®)
function to determine if toxic levels have is indicated in potentially life-threatening
been reached. It is available as a topical infections not treatable with other effective,
preparation for the treatment of burns and less toxic antimicrobials, including the
infected wounds, and as an ophthalmic penicillins and cephalosporins. Potentially
preparation for eye infections. life-threatening infections that vancomycin
may be used for include endocarditis,
• Tobramycin sulfate (Nebcin®) is used to
osteomyelitis, pneumonia, and septicemia.
treat serious infections such as septicemia,
meningitis, and infections of the eye. • Azithromycin (Zithromax®) is used for
the treatment of community-acquired
• Neomycin sulfate (Mycifradin®) is used as
pneumonia, otitis media, infections of the
a topical preparation to treat skin infections,
skin structure, sexually transmitted diseases,
burn wounds, ulcers, and dermatoses. It is
chancroid, and bacterial sinusitis. It can be
given orally to reduce intestinal flora prior
given as a one dose treatment, oral or
to surgery involving the bowel or anus.
parenteral, or over several days.
Macrolides
Antifungals
Antibiotics constituting a large group of
Agents that inhibit or suppress the growth
bacteriostatic agents that inhibit protein
systems of fungi, dermatophytes, or Candida.
synthesis. They are effective against gram-
Antifungals have not been developed to the
positive cocci, Neisseria, Hemophilus, and
same degree as antibacterial agents. Most fungi
mycobacteria. All are similar to penicillin in
are completely resistant to the action of
their antibacterial spectra and are often used in
chemicals at concentrations that can be tolerated
patients who are sensitive to penicillin.
by the human cell. There are only a few
• Erythromycin (E-Mycin®, Ilotycin®) is available for internal use, most antifungal agents
one of the drugs of choice when penicillin is are topical. The antifungal agents that are
contraindicated. This medication is indicated available for systemic use generally produce
to treat medical conditions such as hepatic or renal dysfunction or other serious side
gonorrhea; uncomplicated urethral, effects. Because of these side effects, systemic
endocervical, and anal infections; early antifungals should be limited to serious or
syphilis; and cases of severe or prolonged potentially fatal conditions. Therapy that
diarrhea associated with campylobacter includes topical preparations may be provided in
enteritis and enterocolitis. It is prescribed, as conjunction with oral or parenteral antifungal
a prophylactic agent, prior to colorectal agents.
surgery. Erythromycin is available in
enteric-coated tablets, as an ophthalmic
ointment, and as a topic preparation for the
adjunctive treatment of acne. Erythromycin
can make the skin more sensitive to sunlight
and sunburn may result.
18-14
• Nystatin (Mycostatin®) is primarily used They are especially prevalent in the tropics or
to treat candidal infections. It is fungicidal subtropics and in lesser-developed countries where
and fungistatic against a wide variety of overcrowding and poor sanitation exist. Parasitic
yeasts and yeast-like fungi, and is most often infections include protozoal infections (malaria,
used to treat candidiasis. It is can be used amebiasis, and to a lesser extent, trichomoniasis),
concurrently with tetracycline to suppress helminthic infections (intestinal worms), and
the overgrowth of Candida in the bowel. ectoparasites. Ectoparasites, such as head lice and
crab lice, although not disabling, are considered
• Griseofulvin (Gris-PEG®, Fulvicin®) is a a nuisance and can transmit disease.
fungistatic agent given orally to treat fungal
infections of the nails, hair, and skin. It is • Permethrin (Elimite®/Nix) is a
generally reserved for chronic infections that pediculicide used to treat Pediculosis capitis
have not responded to topical therapy alone. (head lice) and Phthirus pubis (crab lice). It
Because treatment may last for several is indicated for scabies. Use with caution,
months, the patient should be instructed to especially in infants, children, and pregnant
follow the treatment regimen even though women, since it penetrates human skin and
symptoms may abate. Inclusion of topical has the potential for systemic poisoning.
therapy is a must for effective elimination of This drug is irritating to the eyes and should
the infection. be discontinued immediately if local
irritation occurs. It is applied only once per
• Miconazole nitrate (Monistat®, treatment, and must be removed by water
Micatin®) is a synthetic antifungal that after the appropriate contact time has
inhibits the growth of common elapsed.
dermatophytes. It is indicated to treat
cutaneous fungal infections and • Metronidazole (Flagyl®) is effective in
vulvovaginal candidiasis. treating amebiasis. It is also used as a
trichmonoacide. Patients should be warned
• Undecylenic acid (Desenex®) is used about combining Flagyl and alcohol, as it
primarily to treat and prevent tinea pedis and can produce violent side effects.
is often compounded with zinc to act as an
astringent. It is available in ointment, • Mebendazole (Vermox®) is regarded as the
dusting powder, solution, and spray. drug of choice for pinworm and roundworm
infestations.
• Tolnaftate (Tinactin®, Aftate®) was the
first fungicide synthesized. It is indicated for • Pyrantel pamoate (Antiminth®) is
the topical treatment of tinea pedis, tinea effective in treating infestations of
corporis, tinea capitis, and tinea versicolor. hookworm, roundworm, pinworm, and
whipworm.
• Clotrimazole (Lotrimin®, Mycelex®) is a
broad-spectrum antifungal that inhibits the • Thiabendazole (Mintezol®) is a vermicide
growth of pathogenic dermatophytes, yeast, used to destroy pinworms, roundworms,
and other types of fungus growth, including threadworms, hookworms, and whipworms.
Candida albicans. It is indicated for the It is not indicated as a prophylactic agent.
treatment of tinea pedis, tinea cruris, tinea
corporis, and candidiasis. Antimalarial Preparations
18-15
• Chloroquine phosphate (Aralen®) is the • Magnesium citrate (Citrate of magnesia)
drug of choice in treating acute malarial is a saline irritant laxative that also inhibits
attacks. It is used in the prevention and the absorption of water from the intestine. It
suppression of malaria in endemic areas. is preferred by radiology departments for
use prior to special x-rays.
• Primaquine phosphate is the drug of
choice for the prevention or relapse of • Psyllium hydrophilic mucilloid
malaria caused by P.vivax and P.ovale. It is (Metamucil®) is a bulk laxative that works
contraindicated in G-6-PD-deficient by absorbing water. The effect occurs within
personnel, as it may result in hemolytic 12 to 72 hours. It is provided as a dry
anemia. powder that is stirred into water or fruit
juice. This laxative should be drunk
immediately after mixing, while the material
Laxatives
is in suspension.
Laxatives are medications that facilitate the • Ducosate calcium (Surfak®) is a stool
passage and elimination of feces from the colon softener that promotes water retention in the
and rectum. They are indicated to treat simple fecal mass.
constipation and to clean the intestine of any
irritant or toxic substances (catharsis). They
Diuretics
may be used to soften painfully hard stools and
to lessen straining of certain cardiac patients
Diuretics are agents that increase the rate of
when defecating. They are contraindicated in
urine formation. These agents are useful in
certain inflammatory conditions of the bowel,
treating hypertension and edematous
bowel obstruction, and abdominal pain of
conditions, such as congestive heart failure and
unknown origin, and should not be used in the
acute pulmonary edema. However, loss of body
presence of nausea and vomiting. They are
fluids due to use of diuretics can seriously
classified as irritant, bulk, emollient, or stool
deplete electrolytes from the system, and care
softeners. Frequent or prolonged use of any
should be taken to monitor and replenish lost
laxative may result in dependence.
sodium and potassium through diet and
• Mineral oil is an emollient laxative used to supplement therapy.
lubricate the fecal mass. It is often used in
• Hydrochlrothiazide (Esidrix®, Oretic®)
combination with an irritant agent such as
is used for edema associated with congestive
phenolphthalein (Ex-Lax). It can also be
heart failure and other edematous
used for bowel irrigation.
conditions. It is also used to manage
• Lactulose (Enulose®) is used for the hypertension as the sole agent or in
treatment of chronic constipation. Diarrhea combination with other antihypertensive
may be a sign of overuse or overdosing. It agents.
may be mixed with fruit juice, milk, or citrus
• Chlorthalidone (Hygroton®) is used in the
flavored beverages.
same manner as hydrochlorothiazide.
• Bisacodyl (Dulcolax®) is a relatively
• Furosemide (Lasix®) a potent diuretic is
nontoxic irritant cathartic that reflexively
used to treat edema associated with
stimulates the colon on contact. It usually
congestive heart failure, cirrhosis of the liver
produces softly formed stools in 6 to 12
and renal disease. It is particularly useful
hours and is normally taken at bedtime. It is
when greater diuretic potential is desired,
often used as a preparatory agent prior to
and may be used alone or in combination
some surgeries and radiological
with other antihypertensive agents to treat
examinations.
hypertension.
18-16
• Acetazolamide (Diamox®) is used for the • Ibuprofen (Motrin®) is indicated for the
treatment of various forms of glaucoma. It relief of mild to moderate pain, including
can also be used to treat edema in patients headaches and menstrual cramps. It is also
with congestive heart failure and acute used as an anti-inflammatory agent to treat
mountain sickness. arthritis, tendonitis, bursitis, etc. It is not
recommended for use in cases of
• Triamterene and hydrochlorothiazide
gastrointestinal bleeding or renal
(Dyazide®, Maxzide®) This combination
impairment, or during the third trimester of
of a potassium-sparing (triamterene) and
pregnancy.
potassium-depleting diuretic is often more
effective than either drug alone. It is used • Indomethacin (Indocin®) is a potent anti-
for edema associated with congestive heart inflammatory agent with antipyretic and
failure and other edematous conditions. It is analgesic properties. With the potential for
also used in the management of adverse reactions, indomethacin should be
hypertension. reserved for cases of chronic rheumatoid
arthritis, osteoarthritis, and acute gout.
Non-Narcotic Analgesics, Anti-pyretics, and • Naproxen (Naprosyn®, Anaprox®) an
Anti-Inflammatory Agents analgesic indicated for the relief of mild to
moderate pain and for the treatment of
Non-narcotic analgesics are medications primary dysmenorrheal, rheumatoid
that relieve pain without producing arthritis, osteoarthritis, tendinitis, bursitis,
unconsciousness or impairing mental capacities. and acute gout. The effects are similar to
Antipyretics relieve or reduce fevers. Anti- those of aspirin and indomethacin, but with
inflammatory agents counteract or suppress fewer and less toxic gastrointestinal side
inflammation or the inflammatory process. Many effects; however, it is not indicated for
of the medications discussed were developed patients with a history of gastrointestinal
with two or more of these properties. disease, especially those with a propensity
for peptic ulcer disease.
• Aspirin (ASA, Ecotrin®) is still the most
economical analgesic, antipyretic, and anti- • Meloxicam (Mobic®) is an anti-
inflammatory agent available. Some inflammatory agent used for treatment
preparations have an antacid-type buffer to osteoarthritis, rheumatoid arthritis and
assist in the reduction of gastric irritation. It juvenile rheumatoid arthritis. It is
is an analgesic for mild to moderate pain and contraindicated in the 3rd trimester of
an effective antipyretic. It is indicated for pregnancy.
various inflammatory conditions, such as
rheumatoid arthritis and bursitis. • Piroxicam (Feldene®) is an anti-
inflammatory agent used to relieve the signs
• Acetaminophen (Tylenol®) is an analgesic and symptoms of acute and chronic
and antipyretic used to relieve pain and osteoarthritis and rheumatoid arthritis.
fever accompanying diseases (such as the
common cold and influenza). It is also used
Central Nervous System Stimulants
to relieve pain and discomfort of upper GI
disease (ulcer and gastritis), gouty arthritis, a
C e r t a i n medications stimulate the activity
variety of arthritic and rheumatic conditions
of various portions of the central nervous
involving musculoskeletal pain, as well as
system (CNS). The Ma n u a l o f t h e M e d i c a l
other painful disorders. It is indicated for
Depa rt m en t (MANMED) Chapter 21 is
patients who are allergic to aspirin.
explicit as to the usage of these medications in
the Navy. Primary indications for this class of
medications are narcolepsy, hyperkinesis, and
attention deficit disorders in children.
18-17
Central nervous system stimulants are • Pentobarbital (Nembutal®) is indicated
generally contraindicated in patients with for short-term treatment of insomnia. It is
hypertension, arteriosclerosis, symptomatic used as a preanesthetic medication.
cardiovascular disorders, agitated states,
glaucoma, or history of medication abuse. • Phenytoin sodium (Dilantin®) is a
nonbarbiturate anticonvulsant that is the
• Methylphenidate hydrochloride drug of choice for the treatment and
(Ritalin®) is indicated for use in management of grand mal epilepsy.
hyperkinetic children and children with Because phenytoin sodium possesses no
attention deficit disorders. In children, this hypnotic properties, it is preferred to
drug is used as a central nervous system Phenobarbital in treating seizure disorders.
depressant. Methylphenidate HCl is also However, Phenytoin sodium and
indicated for narcolepsy in adults. Phenobarbital are frequently used in
combination to more effectively manage
• Dextroamphetamine sulfate (Dexadrine®)
certain types of epilepsies.
is primarily indicated for narcolepsy.
However, because of dextroamphetamine’s Opium and Opium Alkaloids
anorexia effect (it diminishes appetite); it is
occasionally used as an adjunct to diet The activity of opium is primarily due to its
therapy for obesity caused by overeating. morphine content. The major medical use of
opium has been for its antiperistaltic activity,
particularly in diarrhea. Opium alkaloids, e.g.,
Central Nervous System Depressants
morphine and codeine, have replaced opium in
medical use. Members of this medication group
Central nervous system (CNS) depressants
are used as analgesics, cough sedatives, and for
range in depressive action from mild sedation to
certain types of diarrhea.
deep coma, differing mainly in rapidity, degree,
and duration of action. Any of these CNS
depressants may, in sufficient doses, cause NOTE:
respiratory depression. Alcohol use while taking
CNS depressants should be avoided. Many of Warn patients taking opium or opium alkaloids
the central nervous system depressants are that drowsiness, dizziness, and blurring of vision
controlled medications. Refer to Chapter 21 of may occur.
the MANMED for control, custody, and
accountability guidelines for controlled For this reason, they should not drive or perform
substances. other tasks that require alertness.
Barbiturates comprise a widely used group Also, caution patients against consuming alcohol
of CNS depressants. They are used mainly as and other CNS depressants.
sedative-hypnotics, anticonvulsants, anesthetics
for short anesthesia, and may be used in Patients should notify their physician
combination with analgesics to enhance their immediately if shortness of breath or difficulty
analgesic effect. NOTE: Barbiturates may be in breathing occurs.
habit forming.
• Morphine Sulfate (Roxanol®, MS
• Phenobarbital (Luminal®) is a long- Contin®) is an opium alkaloid indicated for
lasting barbiturate frequently used to treat the relief of severe pain. It is used to
convulsive disorders. This is the drug of preoperatively sedate patients and to treat
choice in petit mal epilepsy, and it is used as severe pain associated with myocardial
a hypnotic or sedative. infarction. Morphine is contraindicated for
patients with head injuries, acute
alcoholism, and convulsive disorders.
18-18
• Codeine Sulfate is an opium alkaloid is like • Amitriptyline hydrochloride (Elavil®) is
morphine. However, it has only one-sixth of an antidepressive mood elevator with mild
the analgesic power and one-fourth of the tranquilizing effects. It is indicated for the
respiratory depressant effect of morphine. long-term treatment of depressive disorders.
Codeine is used for moderate to severe pain
• Chlordiazepoxide hydrochloride
and as an antitussive.
(Librium®) is an antianxiety agent for the
• Meperidine hydrochloride (Demerol®) is treatment of anxiety disorders. It is not
a synthetic analgesic similar to morphine. It indicated for anxiety or tension associated
is used for moderate to severe pain and as a with the stress of everyday activities. It is
preoperative medication. Meperidine HCl is indicated in the abatement of acute
not as effective as morphine in its analgesic withdrawal symptoms of alcoholism.
properties.
• Hydroxyzine pamoate (Vistaril®,
Atarax®) is a rapid-acting antianxiety and
Psychotherapeutic Agents antiemetic with antispasmodic and muscle
relaxant effects. It is most often used in pre-
Tranquilizers and mood modifiers are the and postoperative sedation and in
two primary groups of psychotherapeutic conjunction with meperidine hydrochloride
agents. Psychotherapeutic agents are to enhance its effects and reduce nausea.
classified as major tranquilizers, minor
tranquilizers, and mood modifiers. The mood • Diazepam (Valium®) is useful in treating
modifiers have replaced amphetamines as mild to moderate depression with anxiety
treatment of choice for depressive states. and tension. Because of its muscle relaxant
properties, it is used to treat spastic muscle
• Chlorpromazine hydrochloride conditions and convulsive seizure episodes.
(Thorazine®) is indicated for alleviating It is the drug of choice in status epilepticus.
manifestations of psychosis, tension, and In the United States Military diazepam is
agitation. Dosage is highly individualized also known as CANA (Convulsive Antidote,
depending on the severity of symptoms and Nerve Agent). One CANA kit is typically
degree of response. It may be used as an issued to service members, along with three
antiemetic. Mark I NAAK kits when operating in
circumstances where chemical weapons in
• Thioridazine (Mellaril®) is used for
the form of nerve agents are considered a
antipsychotic purposes and is considered to
potential hazard.
be a good all around tranquilizer.
• Fluoxetine hydrochloride (Prozac®) is an
• Prochlorperizine (Compazine®) is most
oral antidepressant used to treat depression.
often used in the symptomatic treatment of
It may be useful in treating bulimia nervosa
nausea and vomiting, but it shares all the
and obsessive compulsive disorders.
antipsychotic effects of chlorpromazine.
• Zolpidem (Ambien®) is a non-
• Haloperidol (Haldol®) is indicated in
benzodiazepine and hypnotic indicated for
treating schizophrenia with manifestations
the short term treatment of insomnia
of acute manic symptoms, social
(difficult with sleep onset).
withdrawal, paranoid behavior, and the
manic stage of manic-depressive patients.
Skeletal Muscle Relaxants
• Lithium (Eskalith®, Lithonate®) is used
to treat manic episodes of manic-depressive
Skeletal muscle relaxants are used in
illness. It is the drug of choice to prevent or
connection with the treatment of muscle spasm
diminish the intensity of manic episodes.
due to various conditions. They may also be
used to produce muscular relaxation during
surgical anesthesia.
18-19
Skeletal muscle relaxants may cause • Procainamide hydrochloride (Pronstyl®,
drowsiness and impair performance of tasks Procan® SR) is indicated for the treatment
that require alertness. of premature ventricular contractions,
ventricular tachycardia, and atrial
• Methocarbamol (Robaxin®) is used as an
fibrillation. It may be used for cardiac
adjunct therapy for the relief of discomfort
arrhythmias associated with anesthesia and
associated with acute, painful
surgery.
musculoskeletal conditions. It may have a
beneficial effect in the control of • Verapamil (Isoptin®) is indicated for the
neuromuscular manifestations of tetanus. treatment of angina pectoris and for the
management of essential hypertension.
• Cyclobenzaprine (Flexeril®) is indicated
as an adjunct to rest and physical therapy for • Diltiazem (Cardizem®) is indicated for the
relief of muscle spasm with acute painful treatment of angina pectoris and for the
musculoskeletal conditions. management of essential hypertension.
18-20
Anticoagulants • Vitamin B2 (Riboflavin) is a water-soluble
vitamin functioning in the body as a
Anticoagulants delay or prevent blood coenzyme necessary in tissue respiratory
coagulation. Before an anticoagulant agent is processes, e.g., oxidation reduction
prescribed and its dosage determined, laboratory reactions. Deficiency is associated with
testing of the patient's blood-clotting capabilities cheilosis, glossitis, visual disturbances, or
should be performed. visual fatigue.
• Heparin sodium is used in prophylaxis and • Vitamin B3 (Niacin) is a water-soluble
treatment of venous thrombosis (and its vitamin indicated for the correction of niacin
expansion) and of pulmonary embolism. deficiency and in the prevention and
treatment of pellagra.
• Warfarin sodium (Coumadin®) is used
extensively to treat embolism in the • Vitamin B6 (Pyridoxine hydrochloride) is
prevention of occlusions. a water-soluble vitamin and a coenzyme in
the metabolism of protein, carbohydrate, and
Vitamins fat. It is most often used during isoniazid
(INH) therapy to prevent the development
Vitamins are unrelated organic substances of peripheral neuritis.
that occur in many foods and are necessary for • Vitamin B12 (Cyanocobalamin) is a water-
the normal metabolic functioning of the body. soluble vitamin that is essential to growth,
Vitamins may be water-soluble or fat-soluble. cell reproduction, and blood cell formation.
The majority of vitamins are water-soluble. When vitamin B12 therapy is used to treat
Water-soluble vitamins are excreted in the urine pernicious anemia, the treatment is
and are not stored in the body in appreciable continued indefinitely, and folic acid is
quantities. The fat-soluble vitamins (A, D, E, and normally included in the therapy protocol.
K) are soluble in fat solvents and absorbed along
with dietary fats. Fat-soluble vitamins are not • Vitamin C (Ascorbic acid) is a water-
normally excreted in the urine and tend to be soluble vitamin necessary for the prevention
stored in the body in moderate amounts. and cure of scurvy. Vitamin C in high doses
is believed to prevent the common cold, and
• Vitamin A (Retinol) is a fat-soluble vitamin to treat asthma, atherosclerosis, wounds,
is necessary for visual adaptation to schizophrenia, and cancer.
darkness. Deficiencies rarely occur in well-
nourished individuals, and an excess of • Vitamin D is a fat-soluble vitamin involved
vitamin A can be toxic. Conditions which in the regulation of calcium and
may cause vitamin A deficiency include phosphorous metabolism. Vitamin D
biliary tract or pancreatic disease, colitis, deficiency leads to rickets in children and
hepatic cirrhosis, and extreme dietary asteomalacia in adults.
inadequacy (such as anorexia). Retinoic • Vitamin E (Tocopherol) is a fat-soluble
acid, a degradation product of retinol, is vitamin and an antioxidant that prevents the
useful to treat acne and pseudofollicultis destruction of red blood cells by preventing
barbae. fatty acids in the red blood cells from taking
• Vitamin B1 (Thiamine hydrochloride) is a on too much oxygen. It stimulates the
water-soluble vitamin necessary for production of an enzyme necessary to cell
carbohydrate metabolism. This vitamin is respiration and protects the cell membrane.
used to treat patients with appetite loss
resulting from dietary disturbances. The
deficiency disease is beriberi.
18-21
• Vitamin K The naturally occurring form of • Ketamine Hydrochloride (Ketalar®) is a
vitamin K is fat-soluble. However, many fast acting general anesthetic agent used as a
synthetic forms of vitamin K are water- preinduction agent or for procedures that do
soluble. Vitamin K is involved in the not require skeletal muscle relaxation. One
formation of prothrombin and other blood significant effect of this agent is that when
clotting factors. Deficiency results in an the patient begins to recover from the drug,
increase in blood clotting time. they might experience psychological
manifestations ranging from pleasant dream-
like states to hallucinations to delirium
General and Local Anesthetics
accompanied by confusion and irrational
behavior. The effects of these
Generally speaking, anesthesia means
manifestations may be minimized by
“without feeling” and application of the
keeping aural and tactile stimuli to a
word anesthetic to medication leads to the
minimum. It is contraindicated for patients
insensibility to pain.
with hypertensive disease.
• General anesthetics are usually gaseous or
• Fentanyl and droperidol (Innovar®)
vaporized and are administered by
Fentanyl and droperidol are a combination
inhalation. Anesthesiology is a highly
of a narcotic (fentanyl) and a tranquilizer
specialized field and the administration of a
(droperidol). Because of the self-
general anesthetic should never be
potentiating combination, the combination
undertaken without the supervision of a MO.
must be used with extreme caution in
HMs may be called upon to assist in
patients with any respiratory problems.
administering general anesthesia. HMs
should become familiar with the most • Procaine hydrochloride (Novocain®)
commonly used general anesthetics and their Administered only by injection, it may be
respective properties. used for many types of anesthesia, including
spinal anesthesia. It is available in various
• Local anesthetics produce loss of sensation
solutions for injection.
to pain in a specific area or locality of the
body, without loss of consciousness or • Lidocaine hydrochloride (Xylocaine®) is
mental capacity. The majority of these the standard to which all other anesthetics
medications are administered parenterally or are compared. It may be combined with
topically. epinephrine for vasoconstrictive effects.
Lidocaine is also used to treat myocardial
• Nitrous Oxide commonly called laughing
infarctions to prevent or suppress
gas and is used with oxygen in general
preventricular contractions.
anesthesia. It may produce a condition
during which the patient may laugh and
CAUTION:
become quite talkative. It is commonly used
Total dosage injected in 24 hours should not
in dentistry or as a preinduction agent to
exceed 0.05 g per patient when used with
other general anesthesia.
epinephrine.
CAUTION:
• Dibucaine (Nupercainal®) is used as a
High concentrations of nitrous oxide may cause
topical local anesthetic on mucous
cyanosis and asphyxia.
membranes and may also be administered
parenterally.
• Halothane (Fluothane®) is used for
inhalation anesthesia in most operative • Proparacaine (Ophthectic®, Ophthaine®)
procedures with patients of all ages. It is is a local ophthalmic anesthetic used
nonflammable and non-explosive. It is topically. It is suited for almost every
contraindicated in obstetrics or in patients ophthalmic procedure. Proparacaine is
with hepatic dysfunction. fairly long lasting.
18-22
Oxytocics • Hepatitis A vaccine is given to prevent
hepatitis A, an acute infection of the liver,
Oxytocics are medications that produce a acquired by consuming food or water
rhythmic contraction of the uterus. Although contaminated with hepatitis A virus during
their action is selective for the uterus, other deployment or travel to areas with poor
smooth muscles are affected. food, water, and sewage sanitation. Hepatitis
A is endemic worldwide.
• Ergonovine maleate (Ergotrate®
Maleate) is used in the treatment of • Hepatitis B vaccine is given to prevent
postpartum and post-abortal hemorrhage. hepatitis B, an acute or potentially chronic
infection of the liver that is acquired through
• Oxytocin (Pitocin®) is indicated for the
percutaneous, sexual, and other permucosal
initiation or improvement of uterine
exposure to blood and body fluids from
contractions or to control postpartum
people infected with hepatitis B virus.
hemorrhage.
Hepatitis B infections occur worldwide, and
some infected people maintain a chronic
Immunizations carrier state.
18-23
• Tetanus, diphtheria, and pertussis is METROLOGY AND CALCULATION
indicated to prevent tetanus, diphtheria, and
pertussis, primarily by boosting immunity Metrology, called the arithmetic of
acquired from childhood immunization. pharmacy, is the study and science of weights
Tetanus is an acute illness caused by an and measures. The use of metrology in
exotoxin of Clostridium tetani, bacteria that pharmacy applies to medications, their dosage,
grows at the site of wounds contaminated preparation, compounding, and dispensing. It is
with its spores. The C. tetani spores are absolutely vital for HMs to thoroughly
ubiquitous in the environment worldwide. understand the principles and applications of
Diphtheria is an acute disease caused by a metrology in pharmacy. Errors in this area may
cytotoxin of the bacteria Corynebacterium endanger the health and even the life of the
diphtheriae. Diphtheria occurs worldwide. patient.
Pertussis is an acute illness caused by the
bacteria Bordetella pertussis. Available THE METRIC SYSTEM OR
vaccines include bivalent tetanus–diphtheria INTERNATIONAL SYSTEM OF UNITS
(Td) toxoids and Td combined with acellular (SI)
pertussis (Tdap) antigens. The Tdap is
preferred so that people vaccinated sustain The Metric System, also called the
immunity to pertussis. International System of Units (SI)19, is the
official system of weights and measures used by
• Yellow fever is administered to prevent Navy Pharmacy Departments for weighing and
yellow fever, a mosquito-borne viral calculating pharmaceutical preparations. The
disease, and to meet international health Metric System is becoming the accepted system
requirements during deployment or travel to throughout the world. HMs need to be
yellow–fever–endemic areas. concerned primarily with the divisions of
weight, volume, and linear measurement of the
NOTE:
metric system. Each of these divisions has a
Always refer to the most recent BUMED
primary or basic unit and is listed below:
instruction for current immunization
requirements. • Basic unit of weight is the gram,
abbreviated " g "
PHARMACY CALCULATIONS • Basic unit of volume is the liter, abbreviated
"l"
LEARNING OBJECTIVES: • Basic linear unit is the meter, abbreviated
"m"
Identify the various pharmaceutical weight and
measurement system. By using the prefixes deka, hecto, and kilo
for multiples of, ten, one hundred, and one
Recognize medication dosage by using the thousand, respectively, and the prefixes micro,
conversion process or the percentage and ratio milli, centi, and deci for one-ten thousandth,
calculations. one- thousandth, one-hundredth, and one-tenth,
respectively, makes up the basic structure of the
Metric System.
This section will provide the HM with a
basic introduction to the field of pharmacy and
help in preparing for these responsibilities.
18-24
By applying the appropriate basic unit to the • Symbols should not be combined with
scale of Figure 18-1, the HM can readily spelled-out terms in the same expression.
determine its proper terms. For example, using Example: 3 mg/mL, not 3 mg/milliliter.
the gram as the basic unit of weight, the HM can
readily see that 10 g equals 1 dekagram; 100 g • A zero should be placed in front of a leading
equals 1 hectogram; and 1000 g is referred to as decimal point to prevent medication errors
a kilogram. Conversely, going down the scale, caused by uncertain decimal points.
0.1 g is referred to as a decigram, 0.01 g is Example: 0.5 g, not .5 g.
called a centigram, and 0.001 g is a milligram.
NOTE:
It is critically important to recognize that a
misplaced or misread decimal point can lead to
an error in calculation or dispensing of a
minimum of one tenth or ten times the desired
quantity.
Figure 18-1.—Graph Comparing the Metric In addition to the metric system, the HM
System with the Decimal Equivalent should be aware of two other systems of
measurement: the avoirdupois and apothecaries’
systems.
The following are select guidelines for the
correct use of the metric system from the U.S. The Apothecaries’ System
Metric Association, with additional
considerations relevant to the practice of Although fast becoming obsolete, is a
pharmacy19. system for weighing and calculating
• Unit names and symbols are generally not pharmaceutical preparations. It is still used and
capitalized except when used at the must be taken into consideration. It has two
beginning of a sentence or in headings. divisions of measurement: weight and volume.
However, the symbol for liter (L) may be In the Apothecaries’ system, the basic unit of
capitalized or not. Examples: 4 L or 4 l, 4 weight is the grain ("gr"), and the basic unit of
mg and 4 g. volume is the minim (“m”).
• Periods are not used following metric
symbols except at the end of a sentence.
Examples: 4 mL and 4 g, not 4 mL. and 4 g.
18-25
The Avoirdupois System Table of Weights and Measures
A system used in the United States for See Table 18-1, a table of weights and
ordinary commodities. The basic units of the measures with metric doses and their
avoirdupois system are dram (27.344 grains), equivalents.
ounce (16 drams), and pound (16 ounces).
18-26
CONVERTING WEIGHTS AND
MEASURES
CAUTION:
There are times when it will be necessary
Exact equivalents must be used when converting
to convert weights and measures from one
specific quantities in a prescription and when
system to another, either metric to apothecary
converting a pharmaceutical formula from one
or vice versa. Patients are not expected to be
system to another.
familiar with either system. Therefore, the HM
must always translate the dosage directions on When quantities in units of the apothecaries or
the prescription into terms the patient can
avoirdupois systems are encountered they should
easily understand. Household measurements
be converted to equivalent quantities in metric
are standardized on the assumption that the
units.
utensils are common enough to be found in any
home. Table 18-2 is a table of household The required calculation should then be solved
measures, with their metric and apothecary
in the usual manner.
equivalents.
CONVERSION
Metric Apothecary Household
Conversion Table
for Weights and Liquid Measures
1 grain = 0.065 gram or 65 milligrams
1 gram = 15.432 grains
1 milliliter = 16.23 minims
1 fluid ounce = 29.57 milliliters
18-27
Examples of Weight and Liquid Conversions SOLVING PERCENTAGE PROBLEMS
Table 18-4.—Examples of Weight and Liquid Solution: Substitute the known values in the
Conversions equation and use X for the percent (the unknown
factor).
Percentage means "parts per hundred" or Therefore, X = 5, which is the percent strength
the expression of fractions with denominators of the solution.
of 100. Thus, a 10 percent solution may be
expressed as 10%, 10/100, 0.10, or 10 parts per
100 parts. A variation of the alternate percentage
equation, illustrated below, uses "parts per
It is necessary for the Pharmacist to hundred " instead of percent, with X used as
compound solutions of desired percentage the unknown.
strength. Percentage in that respect means
Amt of active ingredient Parts of active
parts of active ingredient per 100 parts of ingredient
total preparation. ————————— = ——————————
Amt of total preparation 100 parts (total
mixture)
18-28
Proportion is the expression of equality of To find out how many milligrams are in
two ratios. It may be written in any one of the 10 mL, set up the following ratio and
following three standard forms: proportion.
• a:b = c:d
10 mg x mg
• a:b :: c:d ——— = ———
1 ml 10 ml
• a/b = c/d
The key to setting up ratio and proportions
Each of these expressions is read: a is to b as is to keep like units consistent. If the first
c is to d, and a and d are called the extremes fraction is stated as mg/ml, the second fraction
(meaning “outer members”) and b and c the should be stated the same way. Doing this
means (“middle members”). will enable the HM to solve the equation and
identify the answer using the correct units.
Application of Proportion The HM must be aware of which units are
needed for the final answer, such as
In any proportion, the product of the milligrams, milliliters, and liters.
extremes is equal to the product of the means.
This principle assists the HM to find the Example: Medication B is supplied as 15 mg /
missing term in any proportion when the other ml. How many milliliters of medication B are
three terms are known. If the missing term is required to provide a patient with a 20 milligram
a mean, it will be the product of the extremes dose?
divided by the given mean, and if it is an
extreme, it will be the product of the means Set up the first fraction with the given
divided by the given extreme19. information, 15 mg / ml. The second fraction is
set up in the same manner, mg / ml.
The important factor when working
proportions is to put the right values in the 15 mg 20 mg
right places within the proportion. If the ——— = ———
proportion is set up properly, the position of 1 ml x ml
the unknown term does not matter. By
following a few basic rules, the HM can Multiply the means (20 x 1) and divide by the
accomplish this without difficulty and solve extremes (15). (20 x 1) / 15 = 1.33 ml
the problem correctly.
18-29
ELIXIRS PHARMACEUTICAL INSTRUMENTS
OINTMENTS
SUPPOSITORIES
CAPSULES
18-30
PHARMACEUTICAL BALANCES ERLENMEYER FLASK
NOTE:
Figure 18-3.—Electronic Balances Metal mortars and pestles should never be used
when the medications are likely to react with the
Image reprinted with permission from: Ansel metals.
H.C. (2010). Pharmaceutical Calculations
(13th ed.). St. Louis, MO: Wolters and Kluwer.
SPATULA
18-31
GRADUATES
18-32
MEDICATION INCOMPATIBILITIES, Physical Incompatibilities
CONTRAINDICATIONS, AND
ADVERSE EFFECTS Physical incompatibilities are often called
pharmaceutical incompatibilities and are
evidenced by the failure of the medications to
LEARNING OBJECTIVE: combine properly. It is virtually impossible for
uniform dosages of medicine to be given from
Identify the three classifications of medication such solutions or mixtures. Ingredients such as
incompatibility and what causes these oil and water (which are physically repellant to
medication incompatibilities to occur. each other) and substances that are insoluble
in the prescribed vehicle are primary examples
Occasionally, the medications used to of physical incompatibilities.
improve a patient’s condition may not work in
the manner intended. The outcome may be Chemical Incompatibilities
contrary to that which was expected, and,
indeed, could even cause harm to the patient. It Chemical incompatibilities occur when
is important to be aware of symptoms that may prescribed agents react chemically upon
indicate a medication is not doing its job combination to alter the composition of one or
properly. more of the ingredients (constituents).
There are instances when a medication The following list outlines the various
used simultaneously with another medication ways incompatibility between or among
or substance does not perform as intended. medication agents may be manifested. The
These medications or substances may be respective type of incompatibility is also
incompatible together and should not be noted.
administered at the same time. A medication
• Insolubility of prescribed agent in vehicle
incompatibility can also occur when
(physical)
medications are compounded together in the
pharmacy. There are three classes of • Immiscibility (incapable of being mixed) of
medication incompatibilities: therapeutic, two or more liquids (physical)
physical, and chemical.
• Precipitation due to change in a solution that
Therapeutic Incompatibilities results in decreased solubility (called salting
out) (physical)
Therapeutic incompatibilities occur when • Liquification of solids mixed in a dry state,
agents antagonistic to one another are prescribed called eutexia (physical)
together. Such circumstances seldom occur, but
when they do, the HM should bring the • Cementation (hardening) of insoluble
perceived incompatibility to the attention of the ingredients in liquid mixtures (physical)
physician. The pharmaceutical agents may have • Evolution or changes in color (chemical)
been used together for one agent to modify the
activity of the other. The physician will verify • Reduction or explosive reaction (called
the prescription as necessary. oxidation) (chemical)
• Precipitation due to chemical reaction
(chemical)
• Inactivation of sulfa medications by
procaine HCl (therapeutic)
18-33
It is impossible to eliminate all medication- MEDICATION INTERACTIONS
agent incompatibilities, some combinations
may respond to one of the following corrective Patients may receive more than one
measures. medication at a time (as happens frequently in
the case of hospitalized patients). Combining
• Addition of an ingredient that does not alter
medications may cause the individual
the therapeutic value (such as the addition of
medications to have a positive or negative
an ingredient to alter solubility of an agent)
outcome that would not usually occur if the
• Omission of an agent that has no therapeutic medications were administered separately.
value or that may be dispensed separately Such interactions may affect the intensity of a
medication’s response, the duration of its
• Change of an ingredient (e.g., substitution effect, and side effects that may occur. As
of a soluble form of an ingredient for an stated above, medication interactions can be
equivalent insoluble form) positive as well as negative, and two or more
• Utilization of special techniques in com- medications are often administered to achieve
pounding a greater therapeutic effect.
INFORMATION CONCERNING
CONTRAINDICATION AND MEDICATION CONTRAINDICATIONS,
ADVERSE MEDICATION REACTIONS ADVERSE REACTIONS, AND
INTERACTIONS
LEARNING OBJECTIVE:
Descriptions of medication contraindications,
Identify medication contraindications, adverse adverse reactions, and interactions may be
medication reactions, and interactions. found in several publications, most notably the
Drug Facts and Comparisons. However, the
most important location for finding this
CONTRAINDICATION
information is the manufacturer's package insert
and associated literature that accompanies each
Contraindication is any condition which
medication.
makes a particular treatment or procedure
inadvisable. These conditions include, but are
not limited to, the disease process and other
PRESCRIPTIONS
administered medications.
LEARNING OBJECTIVES:
ADVERSE MEDICATION REACTIONS
Identify the parts of a prescription and
Adverse medication reactions may occur authorized prescribers.
when a medication, administered in a dose
appropriate for human prophylaxis, diagnosis, Identify how prescriptions are written, filled,
or therapy, has an unintended and harmful verified, labeled, and filed.
effect on the patient receiving it. HMs must be
aware of the possibility of adverse effects of The most important tool used by the
medications so that they can be prevented or at pharmacy is the prescription. A prescription is
least minimize the impact on the patient. a written or computerized order from a
Healthcare Provider (prescriber) directing the
pharmacy to compound and dispense a
medication for a patient to use.
18-34
Of special importance is understanding and PARTS OF THE PRESCRIPTION
conformance to the following protocols:
Currently, there are two standardized forms
• All information pertaining to a prescription
used for prescriptions: the DoD Prescription,
is confidential and should not be divulged
DD Form 1289 (Fig. 18-5) and the
to any persons not specifically involved in
Polyprescription, NAVMED 6710/6
the treatment
(Fig. 18-6). Information placed on these
• No prescription or any of its parts may be forms must be either typewritten or legibly
applied to or transferred to any person other handwritten in ink or indelible pencil. In
than the patient specified addition to these two forms, many of today’s
treatment facilities now have automated
To fill a prescription correctly, the HM
pharmacy systems that allow healthcare
must thoroughly understand the prescription
providers to enter prescription orders into
writing and filling process. Because
computers in their offices instead of
regulations and policies governing pharmacies
handwriting prescriptions. Prescriptions,
sometimes change, it is important for to be
written or computerized, have, for the most
familiar with pharmacy policies in the
part, the same information requirements. The
Manual of the Medical Department
only major difference is that automated
(MANMED), NAVMED P-117. Chapter 21 of
prescriptions do not require the prescriber’s
the MANMED is the basic guide to pharmacy
signature (they are completed electronically).
operations.
The DD 1289 is used extensively for
outpatient prescriptions. The DD 1289 will
contain only one medication order. All
controlled medications should be written on the
DD 1289. The Polyprescription is available for
up to four prescriptions for one patient to be
written together. If a controlled medication must
be written on a polyprescription due to
unavailability of a DD 1289, it must be the only
medication prescribed on that form. See Figure
18-5 for examples of specific block entries.
18-35
Figure 18-5.—DOD Prescription Form
18-36
Patient Information Block
NOTE:
The medication should be written generically,
In the patient information block, located at and the dosage size or strength written
the top of the DD 1289, the patient’s full name
metrically.
and date of birth are required. At most
treatment facilities additional patient
information is added to this block. This SUBSCRIPTION.—The subscription follows
additional information may include the the inscription and is that part of the
patient’s duty station; social security number prescription that gives directions to the
with family member prefix; rate; and branch of compounder.
service.
SIGNA.—The signa, not to be confused
Medical Facility and Date Block with the prescriber’s signature, is the part of the
prescription that gives the directions for the
The treatment facility block, located below patient. This portion is preceded by the
the patient information block, should contain abbreviation “Sig.”
the name of the treatment facility where the
prescription was written. Completion of this Prescriber Signature Block
block is important if the source of the
prescription needs to be traced. Finally, the prescriber signature block,
located at the bottom of the form, must
The date block, located to the right of the contain a legible signature of the prescriber, as
treatment facility block, should contain the well as the prescriber's full name, rank, corps,
date in which the prescription was written. and service, stamped, typed, or hand-printed.
Mimeographed, preprinted, or rubber-stamped
Prescription Block prescriptions may be used, but signatures must
be original and in the handwriting of the
The large block in the center of the DD 1289 prescriber. Facsimiles are not acceptable.
is the prescription block. It contains four parts:
the superscription, the inscription, the AUTHORIZED PRESCRIBERS
subscription, and the signa.
Prescriptions from treatment facilities and
SUPERSCRIPTION.—The superscription DoD authorized providers for formulary drugs
"Rx" means "take" or "take thou" or, in effect, will be honored. Authorized prescribers may
"I want this patient to have the following include: Medical and Dental Corps Officers,
medication." Optometrists, Physician Assistants, Pharmacists,
Physical Therapists, Podiatrists, Nurse
INSCRIPTION.— The inscription is that Practitioners (Certified Nurse Anesthetists,
part of the prescription that lists the name and Nurse Midwives, Women’s Health Nurse
quantity of the medication to be used. This part Practitioners, Family and Pediatric Nurse
of the prescription is of greatest importance, Practitioners), Veterinarians (when prescribing
since the spelling of many unrelated medications for military working animals), or
medications is similar. Whenever there is civilian Physicians employed by the Navy or the
doubt as to the medication or the amount Military Health System.
listed in the inscription, the individual
filling the prescription should always
verify the inscription with the prescriber.
18-37
Authorized prescribers also include Navy Prescription Verification
Independent Duty Hospital Corpsmen (IDC)
personnel authorized in Section IV of Verify that the prescription received is a
MANMED Chapter 21, and others authorized in bonafide one and the patient providing the
writing by the Commanding Officer (CO) (or prescription is entitled to have it filled by the
delegated representative) to prescribe in their pharmacy. Be thorough with the verification
official capacities and defined by the treatment process due to high abuse and fraud potential.
facilities’ Professional Affairs office. The simplest and best way is to ask for an ID
card to verify the name and expiration date on
Prescriptions written by civilian the ID card.
prescribers, other than those employed by the
Navy, may be filled for authorized Review the prescription carefully and make
beneficiaries, at treatment facilities with a sure that the medication prescribed is
licensed Pharmacist assigned, provided the reasonable; that its amount or dosage is realistic
prescribed item is on the treatment facility’s in consideration of the patient's age and that the
formulary (a published listing of medications) quantity of the medication is practical. A
and the prescribed quantity is within prescription calling for 1,000 tetracycline
limitations established by the command. tablets or a pint of Ipecac®, for example,
warrants further inquiry.
With the exception of the polyprescription,
prescriptions are limited to one item per If, in the process of verification, it is
prescription. The quantity of the medication believed that there is a discrepancy, an
prescribed should be a reasonable amount ambiguity, an incompatibility, or for any reason;
needed by the patient. Excessive or unrealistic the HM must consult the prescriber. Be careful
quantities should not be prescribed. Erasures to never allow the patient to suspect that
on prescriptions are prohibited, and anything is amiss. Never fill a prescription that
interlineations (information inserted between is not completely understood or appears
lines of writing) must be initialed. incorrect. What appears to be an overdose may
be the desired dose for a specific patient; the
Persons authorized to prescribe cannot prescriber will appreciate being called for
write prescriptions for themselves or members verification.
of their immediate families.
When the HM understands the prescription
FILLING PRESCRIPTIONS and is satisfied that it is correct, it is filled.
Most mistakes are made when the person filling
When receiving a prescription for filling, the prescription is either interrupted while
certain basic steps must be followed to make doing so or is trying to accomplish more than
sure that the correct patient receives the correct one task at a time.
medicine in the correct amount in the correct
way. During the process of filling a prescription,
the label on the containers used in filling the
prescription should be verified at least three
times. Initially, the label should be read when
the container is taken from the shelf. Then it
should be read again when the contents are
removed from the container. The container’s
label should be read before it is returned to the
shelf. By following these three verification steps
for each prescription filled, there is a reduction
in the possibility of making a prescription error.
18-38
Prescription Labeling
NOTE:
Pharmaceutical preparations should be identified
and labeled with the generic name. However,
trade or brand names may be used if the trade or
brand name is actually on the container.
18-39
Filling Prescriptions Every HM must understand the
responsibility concerning the custody and
Prescriptions that have been filled must be handling of controlled substances and other
maintained in one of three separate files: medications and to be familiar with the
regulations and laws.
• Schedule II (narcotics): Prescriptions
containing narcotics are numbered
RESPONSIBILITY
consecutively, proceeded by the letter "N”,
and filed separately
The MANMED specifically assigns
• Schedule III, IV, and V (controlled custodial responsibility for controlled
medications): These prescriptions are substances to a Commissioned Officer. The
numbered consecutively, preceded by the HM has the responsibilities of administering
letter “C” and filed separately and securing them properly. All controlled
substances and other medications are to be kept
• General files: All other prescriptions are under lock and key. Neither keys nor
numbered consecutively and filed together medications should ever be entrusted to a
Currently, prescriptions are required to be patient.
kept on file for at least 2 years after the date of
issue. ACCOUNTABILITY
18-40
Schedule I SECURITY AND CUSTODY OF
CONTROLLED SUBSTANCES
Substances that have high abuse potential
and no accepted medical use. Examples Schedule I and II controlled substances
include heroin, marijuana, and LSD. require vault or safe storage and inventory by
the Controlled Substance Inventory Board
Schedule II (discussed in more detail in the section entitled
"Inventory of Controlled Substances”).
Substances that have high abuse potential Working stock may be kept in a locked area
and severe psychological and/or physical within the pharmacy. A copy of the safe
dependence liability. Examples include combination must be kept in a sealed envelope
narcotics, amphetamines, and barbiturates. on file with the CO or representative.
Prescriptions for schedule II substances can
never be ordered with refills and in most cases Schedule III, IV, and V controlled
must be filled within 7 days of the date substances require locked cabinet security for
originally written. See MANMED Chapter 21 storage of bulk medications. A minimum
for further information. amount of working stock may be dispersed
among other pharmacy stock, provided the
Schedule III pharmacy stock itself is secure. Otherwise, all
stock in this category must be kept in locked
Substances that have less abuse potential cabinets.
than schedule II substances and moderate
dependence liability. Examples include Custodial responsibility for controlled
nonbarbiturate sed at iv e s, nonamphetamine substances at treatment facilities is entrusted to
stimulants, and medications that contain a a Commissioned Officer or a civilian
limited quantity of certain narcotics. Pharmacist who is appointed in writing by the
Prescriptions must be filled within 30 days of CO. At remote Branch Health Clinics that do not
the date written and may be refilled up to five have a Commissioned Officer or a civilian
times within 6 months. Pharmacist, the CO will designate, in writing a
member of the branch clinic as custodian. On
Schedule IV board large naval vessels, the CO will appoint
an officer of the Medical Department or another
Substances that have less abuse potential officer, in writing, as the bulk custodian.
than schedule III substances and limited
dependence liability. Prescriptions must be This officer will be responsible for, and
filled within 30 days of the date written and maintain custody of, all bulk controlled
may be refilled up to five times within a 6- substances. On board smaller naval vessels,
month period. access to controlled substances is limited to
the bulk custodian and the Senior Medical
Schedule V Department Representative (SMDR). Only
individuals whose official duties require
Substances that have limited abuse access to such spaces are provided the safe
potential. Schedule V substances are primarily combinations.
antitussives or antidiarrheals. Prescriptions
must be filled within 30 days of the date
written and may be refilled up to five times
within 6 months.
18-41
INVENTORY OF CONTROLLED After certification is completed, approved
SUBSTANCES by the CO, and signed by the members
witnessing the destruction, the certification of
Quarterly, or more frequently if necessary, destruction is retained and filed as required by
the Controlled Substances Inventory Board current instructions. The destroyed substances
(CSIB) takes an unannounced inventory of should then be removed from the stock records
controlled substances. and the controlled substance log.
NOTE: SUMMARY
An exception to this frequency may be made
for ships with an Independent Duty Corpsman. Inpatients and the majority of outpatients
will receive pharmaceutical products as part of
On these ships, the inventory may be conducted the treatment. As a healthcare provider
on a quarterly basis if there have been no administering these products or filling
transactions of controlled substances (including prescriptions, it is crucial to have a good
filled prescriptions or receipts of items foundation of knowledge in pharmacology,
requisitioned from supply). toxicology, and the proper handling of
prescriptions and controlled substances. This
chapter provided a review of these topics to
The CO appoints the members of the CSIB assist in the duties. Always consult the
in writing. The board consists of three members, recommended publications, such as the Manual
at least one of whom is a Commissioned of the Medical Department, Drug Facts and
Officer. After the board conducts the inventory, Comparisons, and the Drug Information
it submits a report to the CO. The officer Handbook, to provide the guidance and
having custodial responsibility cannot be a knowledge needed to provide the best possible
member of the board. On small ships and care for patients.
installations, the SMDR may be a board
member. For further guidance on controlled
substance inventory procedures, refer to
MANMED Chapter 21 Pharmacy Operation
and Drug Control and BUMEDINST 6710.70
series.
SURVEY OF CONTROLLED
SUBSTANCES
18-42
CHAPTER 19
CLINICAL LABORATORY
19-1
These systems enable providers to enter Patient and Specimen Identification
laboratory test requests into computers located
in their spaces. After providers enter their test Before accepting laboratory request forms
requests, patients may report immediately to the and specimens in the laboratory, check patient
Laboratory Department, where specimens are identification information on both the request
obtained and tests are performed. form and the specimen container label for
completeness and legibility. Ensure the
Use of Laboratory Request Forms specimen(s) label(s) and request form
information match with the patient. Proper
Write information on the laboratory request documentation of patient identification on these
forms in black or blue-black ink. Use a separate items prevents errors.
laboratory request form for each patient.
Document the patient's full name, family Filing Laboratory Forms
member prefix and sponsor’s social security
number, rate/rank, date of birth, status, and After providers have reviewed laboratory test
branch of service in the "Patient Identification" reports, they will initial or sign the form to
block. Additionally, identify the ward or indicate the review of the test results. This
department ordering the test in this block. acknowledgement may be electronic via
Computer-generated laboratory test requests AHLTA or CHCS, or via initial/signature on a
require the same patient identification data as hard copy lab chit. After the provider releases
manual laboratory requests and the required the laboratory report, it will be filed in the
information is automatically populated on the patient’s treatment record. Manual, automated,
requests. HMs are required to verify the patient or computer-generated laboratory test reports
information before specimen collection and will be placed above SF-545 (Fig. 19-1) in the
labeling. health record. All forms will be filed
chronologically with the each new result placed
The results of laboratory test are closely on top of the previous results.
associated with the patient’s health and
treatment. The requesting provider’s name must
be included on the request. This practice ensures
that reports/results get back to the requesting
provider as soon as possible.
19-2
Figure 19-1.—SF–545, Laboratory Report Display
19-3
ETHICS AND GOOD PRACTICES IN UNIVERSAL BLOODBORNE PATHOGEN
THE LABORATORY PRECAUTIONS21 (See www.osha.gov and
Standard 1910.1030 for complete details)
LEARNING OBJECTIVES: Under the concept of "Universal Bloodborne
Pathogen Precautions" outlined by Occupational
Identify the correct steps to perform blood Safety & Health Administration (OSHA), all
collection by the finger puncture method and human blood and certain other human body
venipuncture method. fluids are treated as if known to be infectious for
HIV, HBV, and other bloodborne pathogens,
Explain Universal Precautions and other safety and therefore considered potentially infectious.
precautions that apply to blood collection. Remember from Chapter 9 that Universal
Precautions are a subset of Standard Precautions.
The nature of laboratory tests and their The following Universal Precautions are in
results will be treated as a confidential matter effect for all phlebotomy procedures:
between the patient, the provider, and the
• Gloves are required to be worn in
performing technician. Chapter 16 of the
conjunction with proper hand washing
MANMED outlines the Navy's ethics policy
techniques
with regard to disclosure of the contents of a
patient's medical record, including lab reports. • Gloves will be disposed of after each
Other agencies that regulate medical ethics and patient
patient confidentiality include The Joint
Commission, Medical Inspector General (MED • Needles and other sharp instruments
IG), and the Department of Health and Human used in the blood collection process will
Services (HHS). Of specific concern is the be handled with extreme caution and
Health Insurance Portability and Accountability disposed of in biohazard sharps
Act (HIPAA) enacted by Congress and enforced containers
via HHS detailing how protected health • Sharps containers will be conveniently
information (PHI) may be transmitted and located near phlebotomy work sites to
released. It is good practice to prevent reduce the distance between patient care
unauthorized access to these reports, to leave and sharps disposal
interpretation of the test results to the requesting
provider, and to refrain from discussing results • Absorbent materials, such as cotton
with the patient. Always refer the patient back 2 x 2’s used to cover blood extraction
to their requesting provider for all laboratory sites, normally contain only a small
results. amount of blood and can be disposed of
as general waste
There are two principal methods of obtaining • If a large amount of blood is absorbed,
blood specimens: the capillary method and the the absorbent material will be placed in
venipuncture method. For most clinical a biohazard waste container and treated
laboratory tests requiring a blood specimen, as infectious waste
venous blood obtained by venipuncture is
preferred. Infection control practices, equipment • Clean phlebotomy work site equipment
requirements, and step-by-step instructions on and furniture daily with a disinfectant,
performing both of these blood collection or as needed after patient care
methods will be discussed in the following
sections.
19-4
CAPILLARY BLOOD COLLECTION 4. Locate the correct puncture location on the
finger. Always puncture away from the
Capillary blood collection is performed when midline of the finger or heel to prevent
a small quantity of blood is needed for testing as injury to the bone (Fig 19-2). Do not
in the case of some pediatric blood draws. It puncture parallel to the grooves or lines of
may also be used when access to normal the fingerprint. A parallel puncture will
venipuncture draw sites are limited on a patient allow blood to run down the finger rather
such as severely burned patients or ICU patients. than form a well rounded drop, and make
Most adult capillary blood collections are from collection difficult.
the finger. Capillary blood collections for
newborns may occur from the heel.
19-5
6. Wipe away the first drop of blood with a Materials Required for Venipuncture
sterile 2 x 2 gauze. This prevents
contamination of the specimen with excess To perform a venipuncture, the following
tissue fluid. Avoid squeezing the fingertip materials are required:
to accelerate bleeding as this tends to dilute
• Sterile gauze pads (2" x 2")
the blood with excess tissue fluid. Position
the site downward to enhance blood flow • 70% isopropyl alcohol or povidone-
and apply gentle intermittent pressure to iodine solution pads
tissue surrounding a finger puncture site.
• Tourniquet
7. Collect blood in the correct specimen
container by “scooping” blood one drop at • Vacutainer needles and holder with
a time. safety device to prevent accidental
needle sticks
8. When the required amount of blood has
been obtained, apply a pad of sterile gauze, • Vacutainer tube(s) appropriate for the
instruct the patient to apply pressure, and test to be performed
then apply a bandage. Arrange the equipment in an orderly manner and
have it within easy reach. The HM will wash
When dealing with newborns, infants, and hands before and after the procedure.
very small children, the heel or great toe
puncture may be used to obtain a blood Venipuncture Procedure
specimen. This method is performed in a similar
fashion. Additional training is required before The patient must be positioned so that the
these methods are performed by the HM. vein is easily accessible and the HM is able to
perform the venipuncture in a comfortable
VENIPUNCTURE (VACUTAINER position. Always have the patient either lying in
METHOD) bed or sitting in a chair with the arm propped up.
NOTE:
Do not draw blood from an arm with IV fluid
running into it or on the same side of a patient's
mastectomy. Choose another site.
19-6
To perform venipuncture, follow the steps given 3. Position the patient’s arm extended with
below. little or no flexion at the elbow.
1. Explain the procedure to the patient. 4. Locate a prominent vein by palpation
(feeling). If the vein is difficult to find, it
2. Apply tourniquet around the arm
may be made more prominent by having
approximately 3 to 4 inches above the
the patient hold their arm in a downward
intended venipuncture site, usually the
position.
antecubital fossa (the depression in the
anterior region of the elbow (Fig. 19-3). A 5. Cleanse the desired site with a 70% alcohol
BP cuff (sphygmomanometer) may be used pad or povidone-iodine solution and allow
instead of a tourniquet if a patient is it to dry.
difficult to draw. This technique should
only be performed by experienced HM. CAUTION:
After cleaning the desired site, only the sterile
needle should be allowed to touch it.
19-7
Figure 19-4.—Phlebotomy
Image reprinted with permission from: McCall, R. E. & Tankersly, C. M. (2008). Phlebotomy Essentials
(4th ed.). Baltimore, MD: Lippincott Williams & Wilkins.
19-8
Blood tubes
8. Holding the vacutainer barrel with one hand,
push the tube into the holder with the other
It is common that one venipuncture may
hand and watch for the flow of blood into
result in filling numerous blood tubes for more
the tube.
than one laboratory test. Blood tubes have
9. The tourniquet should be removed as soon standardized color-coded stopper tops to indicate
as blood flows freely into the tubes. In some which additive or anticoagulant is used in each
difficult draw situations, the tourniquet is tube. Different testing methodologies
sometimes left on until the last tube is filled. (hematology, chemistry, alcohol) are performed
Do not leave the tourniquet on for more than on different colored tubes that prepare the blood
one minute. sample for testing.
10. Once all the specimens have been collected,
remove the final tube, hold the vacutainer It is important for every HM to understand
with one hand and release the tourniquet the different tubes available at a specific
with the other. command and know what each colored tube is
used for. For example, a lavender-top is often
11. Place a sterile gauze over the puncture site used for complete blood counts (CBCs), and a
and remove the needle with a quick and red-top is often used for blood chemistry. Tubes
smooth motion. and their uses change from one facility to the
12. Apply pressure to the puncture site and next, so it is important to understand the
instruct the patient to keep the arm in a procedures of each facility. Refer to Table 19-1
straight position. Have the patient hold for a list tubes and their common uses.
pressure while the tubes are labeled.
13. Take this time to invert any tubes that need
to have anticoagulant mixed with the blood.
14. Specimens are to be labeled immediately
after blood collection and never before. The
label must be permanently attached to the
tube(s) before leaving an inpatient's bedside
or dismissing an outpatient.
15. Re-inspect the puncture site to make sure
bleeding has stopped, and apply a bandage.
19-9
Table 19-1.—Tubes and Their Common Uses
Image reprinted with permission from: McCall, R. E. & Tankersly, C. M. (2008). Phlebotomy Essentials
(4th ed.). Baltimore, MD: Lippincott Williams & Wilkins.
19-10
THE MICROSCOPE FRAMEWORK
ILLUMINATION SYSTEM
19-11
MAGNIFICATION SYSTEM Coarse Control Knob is the larger inner
knob. Rotating the coarse control knob allows
The magnification system of the compound the image to appear in approximate focus.
microscope contains at least two lens systems.
The two lens systems are mounted on either end Fine Control Knob is the smaller outer
of a tube called the body tube. The lens nearest knob. Rotating this control knob renders the
the object is called the objective lens, and the image clear and well-defined.
lens nearest the eye is the ocular lens or eye
piece. FOCUSING THE MICROSCOPE
Objective Lens is responsible for the Focusing the microscope must be done in a
magnification and resolution of detail in a specific order to avoid accidentally damaging
specimen. On a compound microscope, there is the objective lens, the specimen, or both. The
usually a set of three objective lenses (or process of focusing consists of adjusting the
"objectives"). Each objective lens has a different relationship between the optical system of the
focus distance and magnification power. A set of microscope and the object to be examined so
objectives normally consists of a low-power lens that a clear image of the object is obtained. The
(approximate magnification 10X), a high-power distance between the upper surface of the glass
lens (approximate magnification 40X), and an slide on the microscope stage and the faces of
oil-immersion lens (approximate magnification the objective lens varies depending upon which
100X). The colors on each lens may vary by of the three objectives is in the focusing
manufacturer; objective lenses are also marked position. It is important to obtain a focus with
for easy recognition: 10X, 40X, and 100X. the low-power objective first, then change to the
higher objective.
Revolving Nosepiece contains openings into
which objective lenses are fitted, and revolves With the low-power (10X) objective in
objectives into desired position. focusing position, observe the following steps in
focusing.
Body Tube is a tube that permits light to
1. The person using the microscope will be
travel from the objective to the ocular lens.
seated facing the microscope so that the
ocular lenses are facing the person. The
Ocular Lenses or eyepieces are located on
head of the person will be lowered to one
top of the body tube and usually have a
side of the microscope until the eyes are
magnification power of 10X. To calculate the
approximately at the level of the stage.
total magnification of a specimen, multiply the
magnification power of the objective by the 2. Using the coarse adjustment knob, the body
magnification power of the ocular lens. For tube will be lowered until the face of the
example, the 10X ocular and the 40X objective objective is within 1/4 inch of the object.
provide a magnification of 400X. Most microscopes are constructed in such a
way that the low-power (10X) objective
FOCUSING SYSTEM cannot be lowered and make contact with
the object on the stage. While looking
Focusing is accomplished by moving the through the ocular, use the coarse
stage up or down with the coarse and fine adjustment knob to elevate the lenses until
control knobs. Whether the stage needs to be the image becomes visible. Once the object
raised or lowered depends on each individual is clearly visible, the fine adjustment knob
sample and objective being used. The coarse is used to obtain a clear and distinct image.
control knob is used initially to bring the The focusing knob must not be moved
specimens image into approximate focus. Once while changing lenses.
this is accomplished, the fine control knob
sharpens the image.
19-12
3. If the high-power objective (40X) is to be Lenses may be wiped carefully with lens
used next, it is brought into position by tissue. When the oil-immersion lens is not being
revolving the nosepiece (a distinct "click" used, remove the oil with lens tissue. Use lens
indicates it is in proper alignment). The cleaning solution on lenses only when required
fine adjustment knob is used only to bring to remove dried oil and only in the minimal
the object into exact focus. amount necessary. Never use alcohol or similar
solvents to clean lenses since alcohol will
4. If the specimen is too dark, increase
damage the lens assembly.
lighting by opening the iris diaphragm of
the condenser located at the base of the
microscope on the light source. COMPLETE BLOOD COUNT
5. The oil-immersion objective (100X) is used
for detailed study of stained blood and LEARNING OBJECTIVES:
bacterial smears. The distance between the
objective lens and the object is very short. Identify the parts of a complete blood count.
Great care must be taken to not damage the
specimen. After focusing with the high- Identify the normal values for each part.
power objective and scanning for well-
defined cells, turn the objective. Place a A complete blood count routinely consists of
small drop of immersion oil, free of the following tests:
bubbles, on the slide. Center the drop in the
• Total red blood cell (RBC) count
circle of light coming through the
condenser. Revolve the objective carousel • Hemoglobin determination (Hgb)
to bring the oil-immersion objective into
• Hematocrit calculation (Hct)
place. Do not attempt coarse adjustment at
this time or the lens and specimen may be • Total white blood cell (WBC) count
damaged. The final step in focusing is done
with the fine adjustment knob. It is with • White Blood Cell Differential count
this lens in particular that lighting is The complete blood count, commonly
important. The final focus, clear and well- referred to as a CBC, is used in the diagnosis of
defined, will be obtained only when proper many diseases. Blood collected for these tests
light adjustment is made. are capillary or venous blood. CBCs may be
performed either manually or by using
CARE OF THE MICROSCOPE automated hematology analyzers. The manual
methods performed by laboratory technicians
The microscope is an expensive and delicate and Independent Duty Corpsmen are used in
instrument that must be given proper care. isolated locations and onboard some Naval
Moving or transporting microscopes will be vessels where a hematology analyzer is not
accomplished by grasping the arm of the scope practical.
in one hand and supporting the weight of the
scope with the other hand under the base. Avoid RED BLOOD CELL COUNTS
sudden jolts and jars. Keep the microscope clean
at all times. When not in use, microscopes The red cell count is used in the diagnosis of
should be enclosed in dustproof cover or stored many diseases. A red cell count that drops below
in their case. Remove dust with a lint-free lens normal values may indicate anemia. A red cell
tissue. count that rises above the normal values may
indicate dehydration.
19-13
Manually counting red blood cells HEMATOCRIT (PACKED CELL
(erythrocytes) is a time-consuming procedure VOLUME) DETERMINATION
that provides only limited value in an
operational setting, so it is no longer included in The hematocrit, or packed RBC volume, is
this manual. the ratio of the volume of RBCs to the volume
of whole blood. It is usually expressed as a
HEMOGLOBIN DETERMINATION percentage. The normal values for hematocrit
determinations are:
A routine test performed on practically every
patient is the Hemoglobin determination, or Percentage of blood volume
hemoglobinometry. It is the measurement of the
concentration of hemoglobin within the patient’s Woman …….. 37 to 47%
red blood cells. The primary function of Men ………... 42 to 52%
hemoglobin is delivery and release of oxygen to
the tissues and facilitation of carbon dioxide When hematocrit determinations are below
excretion. The formation of hemoglobin takes normal, medical conditions such as anemia may
place during the development of red cells be present. Above-normal hematocrit
located in bone marrow. determinations indicate medical conditions like
dehydration.
Values are affected by age, sex, disease, and
altitude. Different situations affect the function Automated hematology analyzers currently
of hemoglobin in different ways. For example, supply most hematocrits. When hematology
iron deficiency anemia may drop hemoglobin analyzers are not available, determinations can
from a normal value to a critically low value. be manually performed by the microhematocrit
Above-normal values may occur when method. This method calls for the blood to be
dehydration develops. Changes in altitude affect centrifuged. The percentage of packed red cells
the oxygen content of the air and, therefore, also is found by calculation and reported as a
affect hemoglobin values. At higher altitudes percentage.
there is less oxygen in the air, resulting in an
increase in red cell counts and hemoglobin TOTAL WHITE BLOOD CELL COUNT
values. At lower altitudes there is more oxygen,
resulting in a decrease in red cell counts and The total white cell (leukocyte) count
hemoglobin values. determines the number of white cells per cubic
millimeter of blood. A great deal of information
The normal values for hemoglobin can be derived from white cell studies. The
determinations are: white blood cell (WBC) count and the
differential count are common laboratory tests,
Grams per 100 ml blood and they are almost a necessity in determining
the nature and severity of systemic infections.
Woman …….. 12 to 16 Normal WBC values in adults range from 4,800
Men ……….... 14 to 18 to 10,800 cells per cubic millimeter; reported as
4.8 to 10.8 X 106/ml (per cubic millimeter.)
In manual methods for determining blood
hemoglobin, blood is mixed with White blood cell counts are performed either
cyanomethoglobin. This process hemolyzes, or manually or with automated hematology
destroys the red cells, disrupting the integrity of analyzers. Only the manual method will be
the red cells' membrane and causing the release covered in this chapter. After a brief
of hemoglobin, which, in turn, is converted to a introduction on abnormal white blood cell
brownish-colored solution which is then counts, the Unopette method will be covered for
compared with a color standard. manually counting white blood cells.
19-14
Abnormal White Cell Counts WHITE BLOOD CELL DIFFERENTIAL
COUNT
When the WBC rises above normal values,
the condition is referred to as leukocytosis. A total WBC is not necessarily indicative of
Leukocytosis frequently occurs when systemic the severity of a disease, since some serious
or local infections (usually due to bacteria) are ailments may show a low or normal overall
present. In severe medical conditions, white cell white cell count. For this reason, a differential
counts will exceed 50,000/mm3. white cell count is performed. This consists of
an examination of blood to determine the
Counts for infections are highly variable presence and the number of different types of
based on each individual patient, onset of white blood cells usually expressed in a
infection, and a patient’s individual response. percentage. This study often provides more
Other physiological conditions that can cause helpful information in determining the severity
leukocytosis may occur as follows: and type an infection than any other single
procedure used in the examination of the blood.
• Shortly after birth
• Pregnancy The role of white blood cell is to control
various disease conditions. Although these cells
• Appendicitis do most of their work outside the circulatory
• Ulcers system, they use the blood for transportation to
sites of infection. The amount and type of cells
• Emotional stress in the circulating blood can provide valuable
• Anxiety information about the body’s immediate
response to infection or disease.
• Strenuous exercise
An abnormally low white cell count, known Five types of white cells are normally found
as leukopenia, may be caused by the following in the circulating blood. They are:
conditions: • Neutrophils
• Severe or advanced bacterial infections • Eosinophils
such as typhoid, paratyphoid, and
sometimes tularemia • Basophils
• When a bacterial infection has been • Lymphocytes
undetected for a period of time • Monocytes
• Infections caused by viruses and
rickettsiae, such as measles, rubella, Cell Identification
smallpox, infectious hepatitis,
psittacosis, dengue fever, and influenza To perform a differential white cell count, a
• Protozoal infections (such as malaria) laboratory technician or HM must be able to
and helminthic infections (such as identify the different types of white blood cells.
trichinosis) The ability to properly identify the different
types of white cells is not difficult to develop,
• Overwhelming infections when the but does require a thorough knowledge of
body’s defense mechanisms break down staining characteristics and morphology (the
• Anaphylactic shock study of the form and structure of organisms).
This knowledge can be gained only by
• Radiation extensive, supervised practice, but an
introduction is included in this chapter for a
better understanding.
19-15
Laboratories use a blood smear to obtain a Neutrophilic Band.—sometimes called a
differential white cell count. To prepare a blood "stab" cell, is an older or intermediate
smear, a blood specimen is spread across a glass neutrophil. It has started to elongate and has
slide, stained to enhance leukocyte curved itself into a horseshoe, C or U-shape. As
identification, and examined microscopically. the band ages, it matures into a segmented
Material requirements and the step-by-step neutrophil (Fig. 19-7).
procedure for performing a blood smear will be
covered later in this chapter.
Figure 19-6.—Neutrophil
19-16
EOSINOPHIL.—The function is to destroy LYMPHOCYTE.—The function is
parasites and respond in immediate allergic associated with immune response and the body's
reactions. The cytoplasm of an eosinophil defense against viral infection. The cytoplasm of
contains numerous large reddish-orange a lymphocyte is clear sky blue, scanty, with few
granules (Fig. 19-8). The most common cause of unevenly distributed, blue granules with a halo
increased eosinophils worldwide is parasitic, in around them (Fig. 19-10). It is generally round,
particular helminthic, infections. oval, or slightly indented, and the chromatin (a
network of fibers within the nucleus) is lumpy
and condensed at the periphery.
Figure 19-8.—Eosinophil
Figure 19-9.—Basophil
BACTERIA CLASSIFICATION
Disease-Producing Ability
19-18
Growth Requirements Morphologic Characteristics
The four growth requirements for bacteria are: The structural (or morphologic)
characteristics of bacteria are based on three
• Temperature
distinct shapes or categories:
• Oxygen
• Coccus (pl. cocci) spherical, appears
• Nutrition singly, in pairs, chains, clusters, or
packets
• Moisture
• Bacillus (pl. bacilli) rod-shaped, appears
singly, in chains, or in different
TEMPERATURE REQUIREMENTS.—-
organizations, (i.e. railroad tracks or
Temperature requirements are divided into the
school of fish)
following three categories.
• Spirochetes (pl. spirilla) helical, spiral-,
• Psychrophilic "cold loving" bacteria
corkscrew-shaped, appearing singly only
that reproduce best at low temperatures
(4°C)
Toxins Produced
• Mesophilic bacteria that reproduce best
at body temperature (35 °C) and are the Generally, toxins produced are waste
primary pathogens in man products of metabolism in a bacterial cell. Some
bacteria produce toxins that cause febrile or fatal
• Thermophilic bacteria that reproduce
reactions. Toxins are divided into two
best at higher temperatures (42 °C) categories:
• Endotoxin - Comprises part of the cell wall
OXYGEN REQUIREMENTS.—The
and is released as the bacterial cell is
amount of oxygen needed for an organism to
destroyed. Endotoxins are less potent than
grow or reproduce varies with the type of
exotoxins, but may affect the patient during
organism. Aerobes are organisms that reproduce
the course of antibiotic therapy
in the presence of oxygen. Anaerobes are
organisms that do not reproduce in the presence • Exotoxin - Produced by bacteria and found
of oxygen. Other bacteria have varying oxygen outside the bacterial cell in the surrounding
requirements. medium. Exotoxins are highly poisonous and
associated with septic shock
NUTRITION REQUIREMENTS.—Nutrition
requirements for the various types of bacteria Gram Stain Reaction
depends on what particular environment is
required in the body or laboratory setting. A gram-stained smear is a key diagnostic
tool. It can detect bacteria in patient specimens
MOISTURE REQUIREMENTS.—Moisture and is critical in identifying cultured bacteria.
is indispensable for bacterial growth providing This differential stain is based on the cell wall
an environment for metabolic reactions to take differences between gram positive and gram
place. negative bacteria. Gram positive cells retain the
primary crystal violet stain during decolorization
and retain the violet stain; gram negative do not,
and are counterstained pink. The basic staining
and morphological characteristics (gram
negative rods, gram positive cocci, gram
negative diplococci) provide an initial
classification of bacteria that enable selection of
the correct antibiotic therapy.
19-19
COMMON BACTERIA BACTERIOLOGIC METHODS
Bacteria are named by genus and species. There are a variety of methods used in the
The first word (capitalized) indicates the genus; laboratory to identify bacteria. However, only a
the second word (not capitalized) indicates the few of these bacteriologic methods can be
species, a subdivision of the genus. For example: performed in isolated duty locations or onboard
Naval vessels by HMs. One of these methods is
GENUS SPECIES the smear. The smear permits healthcare
Neisseria gonorrhoeae personnel to examine specimens microscopically.
COMMON BACTERIA
Morphologic Gram- Genus & Species Type of Infection
Shape Positive or
-Negative
Cocci Positive Streptococcus pneumoniae Pneumonia
Streptococcus pyogenes (Beta Strep throat
Streptococci Group A)
Staphylococcus aureus Boils, furuncles, osteomyelitis,
pneumonia, septicemia,
endocarditis, and impetigo
Negative Neisseria gonorrhoeae Gonorrhea
Neisseria meningitis Meningitis
(meningococcus)
Bacilli Positive Corynebacterium Diphtheria
diphtheriae
Clostridium Gas gangrene
(all are anaerobic and Tetanus
spore producers) Botulism
perfringens (welchii)
tetani
botulinum
19-20
Smear Gram-negative organisms stain a deep pink,
but since the background material is also pink,
Smears may be prepared from clinical minute and detailed inspection is necessary
specimens (i.e. discharge or CSF) or from before reporting the results (Fig. 19-14).
culture media spread across a glass slide for
microscopic examination. To enhance the
visualization of microorganisms on the smear,
Gram staining is used. Once the smear is
stained, it is ready to be examined under the
microscope. Normally, smears are examined by
laboratory technicians who report their
findings.
19-21
SEROLOGY RAPID PLASMA REAGIN (RPR)
CARD TEST
LEARNING OBJECTIVE:
The RPR Card test is a non-specific, easily
performed screening test for syphilis. Reactions
Identify principles and procedures for the
are occasionally observed with other acute and
Rapid Plasma Reagin (RPR) Card Test and the
chronic conditions associated with tissue
Monospot Test.
damage. Everything needed for the test is in a kit
that is available commercially. This test kit is
Serology consists of procedures by which very useful aboard ship and at small Naval
antigens and reacting serum globulin antibodies station settings. The kit is standard throughout
may be measured qualitatively and Navy medicine.
quantitatively. These tests have been devised to
detect either antigens present or antibodies Principle of the RPR Card Test
produced in a number of conditions. Most tests
are based on agglutination reactions between an In the RPR Card test method of syphilis
antigen and a specific antibody. The reactions detection, a specific antigen (carbon-particle
result in a visual clumping of test solution when cardiolipin) detects "reagin," a substance present
antigens and antibodies react. The HM may have in the serum of persons who are infected with
the opportunity to perform simple screening syphilis or suffering from similar tissue damage.
serology tests. Reagin is usually developed 1 - 4 weeks after the
appearance of a primary chancre. Reactive
An antigen is a substance that, when specimens appear as black clumps against a
introduced into an individual’s body is white background. Nonreactive specimens
recognized as foreign by an individual’s immune appear as an even, light-gray color.
system and causes a detectable reaction.
The RPR is a non-specific screening test and
Antibodies are specific defensive proteins is not reported as positive or negative for
produced when an antigen stimulates individual disease. It is reported as reactive or non-reactive.
cells. The primary function of an antibody in
body defenses is to combine with antigens. MONOSPOT TEST
Antibodies are produced by the host in response
to the presence of an antigen and are capable of Mononucleosis imitates many diseases so
reacting with antigens in some detectable way. well that diagnosis is confirmed only by
selective serologic testing. The Monospot Test is
The antigen-antibody reaction takes place an accurate, 2-minute disposable test designed to
when antibodies bind with specific antigens detect the presence of infectious mononucleosis
depending on a close three-dimensional fit. antibodies in serum, plasma, or whole blood.
Agglutination tests are widely used to detect and Although there are numerous tests for infectious
measure the presence of antigen-antibody mononucleosis, all have the same principle, and
reactions. similar methods.
19-22
A positive result is indicated by Scrapings from the affected area of the skin
agglutination, or clumping, and a negative result are mounted in commercially prepared 10%
is indicated by no agglutination (Fig. 19-15). A KOH for positive laboratory diagnosis.
negative monospot may not necessarily rule out
the presence of infectious mononucleosis. To detect fungi in infected tissue using the KOH
preparation, follow the steps below:
1. Place skin, hair, or nail scrapings from the
affected area on a glass slide and add one
drop of 10% KOH.
2. Place a coverslip on the preparation.
3. Warm the preparation gently over the tip of
a flame, being careful not to boil it, and
allow it to stand until clear. Do not allow
the preparation to dry out.
4. Examine the preparation by using the high-
Figure 19-15.—Illustration of Positive and power objective on microscope with
Negative Monosticon DRI-DOT® Slide Test subdued light.
Results
a. Fungi on the skin and nails appear as
refractile, or reflective, fragments of
FUNGUS TEST fungal elements.
b. Fungi in the hair appear as dense clouds
LEARNING OBJECTIVE: around the hair stub or as linear rows
inside the hair shaft.
Identify how potassium hydroxide (KOH)
preparation is used in the detection of fungi.
URINALYSIS
Fungi (sing. fungus) are chlorophyll-free,
heterotrophic (not self-sustaining) of the same LEARNING OBJECTIVES:
family of plants as algae and lichens. They
reproduce by spores that germinate into long Identify the three types of urine specimens.
filaments called hyphae. As the hyphae continue
to grow and branch, they develop into a mat of Identify the methods used to preserve urine
growth called the mycelium (pl. mycelia). From specimens.
the mycelium, spores are produced in
characteristic patterns. These spores, when Identify the steps for performing a urinalysis.
dispersed to new substances, germinate and form
new growths. Reproduction is often asexual, The analysis of urine is considered the
usually by budding (as in yeast), but certain beginning of laboratory medicine. Urine is
fungi have sexual reproduction. Common readily available, easily collected, and contains
superficial infections of the skin caused by fungi information about many of the body’s major
are athlete’s foot and ringworm of the scalp. metabolic functions.
A simple and frequently used method of The physical and chemical properties of
detecting fungi is the potassium hydroxide normal urine are constant and abnormalities are
(KOH) preparation. Fungi are seen in clustered easily detected. The use of simple tests provides
round buds with thick walls, accompanied by the provider with information for the diagnosis
fragments of mycelia. and management of many diseases.
19-23
This section outlines the three types of urine First Morning Urine Specimen is the first
specimens, methods used to preserve urine urine voided upon rising. It is the ideal screening
specimens, the procedure for performing a specimen, because it is usually concentrated and
routine and microscopic examination of urine more likely to reveal abnormalities. If positive
specimens, and some simple interpretations of results are obtained from the first morning
the findings. specimen, the physician may order a 24-hour
specimen for quantitative studies.
URINE SPECIMENS
Twenty-Four Hour Urine Specimen
Urine specimens for routine examinations measures the exact output of urine over a 24-
must be collected in aseptically clean containers. hour period. Use the following steps to collect
Unless circumstances warrant, avoid this specimen.
catheterization as it may cause a urinary tract
1. Have patient empty bladder early in the
infection. Specimens of female patients are
morning and record time. Discard this
likely to be contaminated with albumin (protein)
urine.
and blood from menstrual discharge, or with
albumin and pus from vaginal discharge. For 2. Collect all urine voided during next 24
bacteriologic studies, care must be taken to hours.
ensure that the external genitalia have been 3. Instruct patient to empty bladder at 0800
thoroughly cleansed as directed by laboratory the following day (end of 24-hour period).
procedures for clean-catch specimen collection. Add this urine to pooled specimen.
The patient must void the initial stream of urine
into the toilet or a suitable container and the
remainder directly into a sterile container. All Refrigerate specimen during collection.
urine specimens should either be examined Depending on the test being performed, add a
when freshly voided, or refrigerated to prevent preservative to the first specimen voided.
decomposition of urinary constituents and to
limit bacterial growth. The following sections The normal daily urine volume for adults
will cover three types of urine specimens: ranges from 600 to 2,000 ml, averaging about
random, first morning, and 24-hour. 1,500 ml. The amount of urine excreted in 24
hours varies with fluid intake and the amount of
Random Urine Specimen is the most water lost through perspiration, respiration, and
commonly received specimen because of the bowel activity. Diarrhea or profuse sweating
ease of collection and convenience for the reduces urinary output; diabetes is associated
patient. These specimens are collected without with increased urinary output.
regard to the time of day or fasting state. This
sample is useful for routine screening tests to
detect obvious abnormalities. It may produce
erroneous results caused by dietary intake or
physical activity just prior to the collection of
the specimen. It is the least valid specimen, and
patients may later be requested to collect
additional specimens under more controlled
conditions.
19-24
PRESERVATION OF URINE SPECIMENS • Light amber
A routine urinalysis includes the examination Urine’s appearance may be reported as clear,
of physical characteristics, chemical hazy, slightly cloudy, cloudy, or turbid. Freshly
characteristics, and microscopic structures in the passed urine is usually clear or transparent.
sediment. A sample for urinalysis (routine and Urine can appear cloudy when substances such
microscopic) should be at least 12 ml in volume as blood, leukocytes, crystals, pus, or bacteria
(adult), and either a random or first morning are present. A report of transparency is of value
specimen. Children may only be able to provide only if the specimen is fresh. After standing, all
a small volume, but 10-15 ml is preferred. urine becomes cloudy because of
decomposition, salts, and the action of bacteria.
Physical Characteristics Upon standing and cooling, all urine specimens
will develop a faint cloud composed of mucus,
Physical characteristics evaluated during a leukocytes, and epithelial cells. This cloud
routine urinalysis include color, appearance, and settles to the bottom of the specimen container
specific gravity. and is of no significance.
19-25
Chemical Characteristics
The first morning specimen of urine is more
concentrated and will have a higher specific Chemical characteristics evaluated during a
gravity than a specimen passed during the day. routine urinalysis include pH, protein, glucose,
A high fluid intake may reduce the specific ketones, blood, bilirubin, urobilinogen, nitrite,
gravity to below 1.010. In the presence of leukocytes, and specific gravity depending on
disease, the specific gravity of a 24-hour the test strip used. Each manufacturer of reagent
specimen may vary from 1.001 to 1.060. strips includes a color chart for multiple
chemical determinations. The strip is dipped
Specific gravity is measured with an index into the urine specimen and compared to the
refractometer, available as standard equipment color values for the various tests on the
at most duty stations (Fig. 19-16). It may be accompanying chart. The color chart also
held manually or mounted on a stand like a indicates numerical pH values, which should be
microscope. The specific gravity of urine is reported. Since this test is based on color
determined by the index of light refraction changes, those with color deficiency may need
through solid material. to take extra care to interpret the results.
19-26
To ensure against run-over, blotting the edge All bottles are stamped with an expiration
of the strip and holding the strip horizontally date that represents the functional life
while comparing it with the color chart is expectancy of the chemical pads. Reagent strips
recommended. The amount of time needed for should not be used past the expiration date. Care
reactions to take place varies from an immediate must be taken not to touch the chemical pads
reaction to two minutes. The required reaction when removing the strips.
time is written on the comparison chart located
on the side of the reagent strip container Microscopic Examination of Urine Sediment
(Fig. 19-17).
Microscopic examination of urine sediment
at 40X is usually performed in addition to
routine chemical procedures. This examination
requires a degree of skill acquired through
practice under the immediate supervision of an
experienced technician. The specimen used for
microscopic examination should be as fresh as
possible. Red cells and many formed solids tend
to disintegrate upon standing, particularly if the
specimen is warm or alkaline.
19-27
CLINICALLY SIGNIFICANT FINDINGS.—
Leukocytes, erythrocytes, and casts may all be
of clinical significance when found in urine
sediment.
Leukocytes.—Normally, 0 to 3 leukocytes
per high-power field will be seen on microscopic
examination (Fig. 19-18). More than 3 cells per
high-power field may indicate disease
somewhere in the urinary tract. Estimate the
number of leukocytes present per high-power
field and report it as the "estimated number per
high-power field."
Figure 19-19.—RBC in Urine
19-28
Casts.—These urinary sediments are RESULTS AND READINESS
formed by coagulation of albuminous material in
the kidney tubules. Casts are cylindrical and
LEARNING OBJECTIVES:
vary in diameter (Figs. 19-21 and 19-22). The
sides are parallel, and the ends are usually
Explain the clinical significance of critical
rounded. Casts in the urine always indicate some
results.
form of kidney disorder and should always be
reported. If casts are present in large numbers,
Identify the significance of laboratory function
the urine is almost sure to be positive for
as they relate to operational readiness.
albumin.
CRITICAL RESULTS
Figure 19-22.—Cast
19-29
Walking Blood Bank22 (WBB) SUMMARY
19-30
CHAPTER 20
Battle Dressing
In a first aid situation, the HM must always
be ready to improvise. In many field emergency A battle dressing is a combination compress
situations, standard medical equipment and and bandage in which a sterile gauze pad is
supplies may not be immediately available, or fastened to a gauze, muslin, or adhesive
the supplies are exhausted. bandage. Most of the Navy first aid kits contain
both large and small battle dressings of this
When assigned to Marine Corps units, HMs kind. Most prepackaged battle dressings are 4
carry a medical equipment and supplies in a tailed bandages for use in bandaging extremity,
special bag. It is referred to as a “Unit One Bag" abdominal, and head wounds (Fig. 20-1).
which is currently being replaced by the
Modular Lightweight Load Carrying Equipment
(MOLLE) bag or a “Stomp” bag.
20-1
Figure 20-1.—Battle Dressing
20-2
Roller Bandage (Fig. 20-2) consists of a
NOTE:
long strip of material (usually gauze, muslin, or In applying the turns of the bandage, it is often
elastic) wound into a cylindrical shape. Roller necessary to transfer the roll from one hand
bandages come in various widths and lengths.
to the other.
Most of the roller bandages in first aid kits have
been sterilized, so pieces may be cut off and
Bandages should be applied evenly, firmly, but
used as compresses in direct contact with
not too tightly.
wounds.
Excessive pressure may cause interference
with the circulation and lead to disastrous
consequences.
20-3
Starting and Finishing the Roller bandage Roller Bandage for Elbow
20-4
Roller Bandage for Hand and Wrist 3. Continue the figure-eight turns overlapping
one-third to one-half the width of the
For the hand and wrist, a figure-eight bandage is bandage and with an occasional turn
ideal. around the ankle, until the compress is
secured or until adequate support is
1. Anchor the dressing at the wrist, whether
obtained (Fig. 20-5).
the wound is on the hand or wrist, with
several turns of a 2 or 3 inch bandage. If on
the hand, anchor the dressing with several
turns and continue the bandage diagonally
upward and around the wrist and back over
the palm.
2. Make as many turns as necessary to secure
the compress properly (Fig. 20-4).
Figure 20-4.—Roller Bandage for Hand and Heel 4. Perform pulse check of the extremity upon
completion of applying roller bandage.
Roller Bandage for Ankle and Foot
Roller Bandage for Heel
The figure-eight bandage is also used for
dressings of the ankle, such as for supporting a Due to the shape of the heel, it is one of the
sprain. most difficult parts of the body to bandage.
1. While keeping the foot at a right angle, 1. Place the free end of the bandage on the
start a 3-inch bandage around the instep for outer part of the ankle and bring the
several turns to anchor it. bandage under the foot and up.
2. Carry the bandage upward over the instep 2. Carry the bandage over the instep, around
and around behind the ankle, forward, and the heel, and back over the instep to the
again across the instep and down under the starting point. Overlap the lower border of
arch, thus completing one figure-eight. the first loop around the heel and repeat the
turn, overlapping the upper border of the
loop around the heel. Continue this
procedure until the desired number of
turns is obtained, and secure with several
turns around the lower leg.
20-5
Roller Bandage for Arm and Leg Barton Bandage
The spiral reverse bandage must be used to The Barton bandage is frequently used for
cover wounds of the forearm and lower fractures of the lower jaw and to retain
extremities; only such bandages can keep the compresses to the chin.
dressing flat and even. A spiral reverse bandage
1. As in the progressive steps illustrated
is a bandage that is turned and folded back on
below (Fig. 20-7), the initial end of the
itself as necessary to make it fit the contour of
roller bandage is applied to the head, just
the body more securely.
behind the right mastoid process.
1. Make two or three circular turns around the
lower and smaller part of the limb to
anchor the bandage and start upward.
2. Make reverse laps on each turn,
overlapping about one-third to one-half the
width of the previous turn.
3. Continue as long as each turn lies flat.
4. Continue the spiral and secure the end
when completed.
5. Perform pulse check of the extremity upon
completion of applying roller bandage.
Four-Tailed Bandage
20-6
5. Carry the bandage around the head under Triangular Bandage for Head
the left ear, around the front of the chin,
and under the right ear to the point of This bandage is used to retain compresses on
origin. the forehead or scalp.
6. This procedure is repeated several times, 1. Fold back the base about 2 inches to make
each turn exactly overlaying the a hem.
preceding turn.
2. Place the middle of the base on the
7. Secure the bandage with a pin or strip of forehead, just above the eyebrows, with the
adhesive tape at the crossing on top of the hem on the outside.
head.
3. Let the point fall down over the back of
the head.
TRIANGULAR BANDAGE
4. Bring the ends of the triangle around the
back of the head above the ears, cross them
Triangular bandages are usually made of
over the point, carry them around the
muslin. They are made by cutting a 36 to 40
forehead, and tie in a SQUARE KNOT
inch square of a piece of cloth and then cutting
(Fig. 20-9).
the square diagonally, thus making two
triangular bandages (in sterile packs on the
Navy’s medical stock list). A smaller bandage
may be made by folding a large handkerchief
diagonally. The longest side of the triangular
bandage is called the base; the corner directly
opposite the middle of the base is called the
point; and the other two corners are called ends
(Fig. 20-8).
20-7
Triangular bandage for shoulder Triangular Bandage for Chest
20-8
Triangular Bandage for Foot or Hand 1. Bring the point of the triangular bandage to
the middle of the base and continue to fold
This bandage is used to retain large until a 2 inch width is obtained.
compresses and dressings on the foot or the
2. The cravat may be tied, or it may be
hand.
secured with safety pins (if the pins are
available).
For the foot:
1. After the compresses are applied, place the
Cravat Bandage for Head
foot in the center of a triangular bandage
and carry the point over the ends of the toes
This bandage is useful to control bleeding from
and over the upper side of the foot to the
wounds of the scalp or forehead.
ankle.
1. After placing a compress over the wound,
2. Fold the excess bandage at the side of the
place the center of the cravat over the
foot, cross the ends, and tie in a square knot
compress.
in front.
2. Carry the ends around to the opposite side.
For the hand:
3. Cross them and continue to carry them
1. After the dressings are applied, place the
around to the starting point
base of the triangle well up in the palmar
surface of the wrist. 4. Tie in a square knot.
2. Carry the point over the ends of the fingers
and back of the hand well up on the wrist. Cravat Bandage for Eye
3. Fold the excess bandage at the side of the
hand, cross the ends around the wrist, and 1. After applying a compress to the affected
tie a square knot in front. eye, place the center of the cravat over the
compress on a slant so that the lower end is
pointed downward.
Cravat Bandage
2. Bring the lower end around under the ear
A triangular bandage can be folded into a on the opposite side.
strip for easy application during an emergency. 3. Cross the ends in back of the head, bring
When folded as shown in Figure 20-11, the them forward, and tie them over the
bandage is called a cravat. When necessary, a compress.
cravat can be improvised from common items
such as T-shirts, bed linens, trouser legs, 4. Figure 20-12 shows the proper application
scarves, or any other item of pliable and durable of a cravat bandage for the eye.
material that can be folded, torn, or cut to the
desired size.
20-10
Cravat Bandage for Axilla (Armpit) COMBAT APPLICATION TOURNIQUET®
(C-A-T®)
This cravat is used to hold a compress in
the axilla. It is similar to the bandage used to The Combat Application Tourniquet®
control bleeding from the axilla. (C-A-T®, Fig. 20-16) is a small and lightweight
one-handed tourniquet that completely occludes
1. Place the center of the bandage in the axilla
arterial blood flow in an extremity. The C-A-T®
over the compress.
uses a Self-Adhering Band and a Friction
2. Carry the ends up over the top of the Adaptor Buckle to fit a wide range of
shoulder and cross them. extremities combined with a one-handed
3. Continue across the back and chest to the windlass system. The windlass uses a free
opposite axilla, and tie them. moving internal band to provide true
circumferential pressure to an extremity. The
4. Do not tie too tightly or the axillary artery windlass is then locked in place; this requires
will be compressed, adversely affecting only one hand, with the Windlass Clip™. The
the circulation of the arm (Fig. 20-15). C-A-T® also has a Hook-and-Loop Windlass
Strap™ for further securing of the windlass
during patient transport.
5. Perform pulse check of the extremity upon Image provided by: Department of the Army.
completion of applying roller bandage. (2009). Soldier’s handbook and training guide
for MOS 68W STP 8-68W13-SM-TG.
BATTLE DRESSING
Asherman Chest Seal
A battle dressing is a combination compress
and bandage in which a sterile gauze pad is Utilized as standard rapid management in
fastened to a gauze, muslin, or adhesive emergency situations, the Asherman Chest Seal
bandage. Most Navy first aid kits contain both (ACS™) is a sterile occlusive dressing for
large and small battle dressings of this kind. treating an open pneumothorax and preventing a
Most pre-packaged battle dressings are 4 tailed tension pneumothorax in chest injuries from
bandages for use in bandaging extremity, gunshots, stab wounds, or other penetrating
abdominal and head wounds (see Fig. 20-1). chest trauma. The unique one-way valve is
designed to let air and blood escape while
preventing re-entry of either. It has been proven
to be more effective treatment than standard
petroleum gauze. The ACS™ is 5.5" in
diameter, includes a gauze pad (4" x 4") to clean
and dry the wound, and is clear so the wound
can be observed.
20-11
MONITORING DEVICES INTRAVENOUS FLUIDS AND
DELIVERY DEVICES
Automated External Defibrillator (AED) is
a portable electronic device capable of analyzing
LEARNING OBJECTIVE:
cardiac rhythms and selecting the appropriate
strength of defibrillation (the application of
Describe the appropriate intravenous fluids
electrical therapy which stops the arrhythmia,
based upon their uses.
allowing the heart to reestablish an organized
electrical message to the heart tissue). The user
simply places two self-adhesive pads on the There are two types of fluids used for
torso of a cardiac arrest casualty and presses a intravenous drips; crystalloids and colloids.
button on the AED. The AED analyzes the Crystalloids are aqueous solutions of mineral
rhythm and recommends the appropriate salts or other water-soluble molecules. Colloids
treatment. Some systems will go into an contain larger insoluble molecules, such as
automatic analysis of the heart rhythm without gelatin; blood itself is a colloid. The most
pushing a button. Initially reserved for use by commonly used crystalloid fluid is normal
trained medical responders such as firefighters saline, a solution of sodium chloride at 0.9%
and EMTs, the devices are being used with great concentration, which is close to the
success in various public settings such as in concentration in the blood (isotonic). Ringer's
airports and training environments. lactate or Ringer's acetate is another isotonic
solution often used for large-volume fluid
CAUTION: replacement.
Not all AED’s are approved for use in
operational platforms. Normal Saline (NS) is the commonly-used
term for a solution of 0.91% w/v (percent weight
by volume) of Sodium Chloride NaCl. Less
Pulse Oximeter is a medical device that
commonly, this solution is referred to as
measures the oxygen saturation of a patient's
physiological saline or isotonic saline, neither of
blood and changes in blood volume in the
which is technically accurate. NS is used
skin, producing a photoplethysmograph
frequently in intravenous drips (IVs) for patients
(measured changes in light absorption). It is
who cannot take fluids orally and have
often attached to a medical monitor allowing
developed or are in danger of developing
staff to monitor a patient's oxygenation. Some
dehydration or hypovolemia. NS is typically the
monitors also display the heart rate. Portable,
first fluid used when hypovolemia is severe
battery-operated pulse oximeters are available
enough to threaten the adequacy of blood
for home blood-oxygen monitoring. A blood-
circulation and has long been believed to be the
oxygen monitor displays the percentage of
safest fluid to give quickly in large volumes.
arterial hemoglobin in the oxyhemoglobin
However, it is now known that rapid infusion of
configuration. Acceptable normal ranges are 95
NS can cause metabolic acidosis. The amount
to 100 percent, although values down to 90
of normal saline infused depends on the needs of
percent are common. The pulse oximeter should
the patient (e.g. ongoing diarrhea or heart
be used in conjunction with other findings from
failure) but is typically between 1.5 and 3 liters a
the physical examination to monitor patient
day for an adult.
airway, breathing, and shock.
Lactated Ringers Solution (LR) is often
used for fluid resuscitation after a blood loss due
to trauma, surgery, or a burn injury. Overall, it is
used to increase body fluid and buffer acidosis.
Previously, it was used to induce urine output in
patients with renal failure.
20-12
The intravenous dose of LR solution is The technique of using this device is readily
usually calculated by estimated fluid loss and applicable in low light conditions or when there
presumed fluid deficit. For fluid resuscitation the is an absence of the tibia (common spot for some
usual rate of administration is 20 to 30 ml/kg IO devices) such as trauma from land mines or
body weight/hour. LR solution is not suitable for improvised explosive device (IED).
maintenance therapy because the sodium content
is considered too high for adults, in view of Infusion Pump
electrolyte daily requirement.
An infusion pump allows precise control
Hetastarch is a synthetic plasma expander over the flow rate and total amount delivered.
that works by producing expansion of plasma Infusion pumps can administer fluids in ways
blood volume. It is used to prevent shock that would be impractically expensive or
following severe blood loss caused by trauma, unreliable if performed manually by nursing
surgery, or some other problem. It increases the staff. These pumps can administer as little as 0.1
blood volume, allowing red blood cells to mL per hour injections (too small for a drip),
continue to deliver oxygen to the body. It is not injections every minute, injections with repeated
a substitute for blood or plasma. It does not have boluses requested by the patient, up to maximum
oxygen-carrying capacity. Dosage for plasma number per hour (e.g. patient-controlled
volume expansion: Adults: 500-1000 mL (up to analgesia), or fluids whose volumes vary by the
1500 mL/day) or 20 mL/kg/day (up to 1500 time of day.
mL/day).
BREATHING AIDS
INFUSION EQUIPMENT
LEARNING OBJECTIVE:
Intravenous Infusion Set
Describe breathing aids and their uses.
A standard IV infusion set consists of a pre-
filled, sterile container (glass bottle, plastic
bottle or plastic bag) of fluids with an attached As a HM, it is imperative to become
drip chamber which allows the fluid to flow one familiar with the breathing aids that may be
drop at a time, making it easy to see the flow available to help maintain an open airway and to
rate (and also reducing air bubbles); a long restore breathing in emergency situations.
sterile tube with a clamp to regulate or stop the Breathing aids include oxygen, artificial
flow; a connector to attach to the access device; airways, bag-valve mask ventilator, pocket face
and connectors to allow "piggybacking" of mask, and suction devices.
another infusion set onto the same line, e.g.
adding a dose of antibiotics to a continuous fluid USE OF OXYGEN (O2)
drip.
In an emergency situation, HMs will have a
Intraosseous Device size D or E cylinder of oxygen available.
20-13
SETTING UP A D-SIZED OXYGEN
NOTE:
TANK23 Check the oxygen cylinder tag to determine
whether the tank is "FULL", "IN USE"(partially
Condition
full), or "EMPTY" (Fig. 20-18).
The HM needs to set up a D-sized oxygen
tank. The HM has already performed a patient
care hand-wash. The HM will need a full oxygen
cylinder with a regulator/flowmeter, non-
sparking cylinder wrench, oxygen
regulator/flowmeter for D cylinders, yoke
attachment, humidifier, sterile water, oxygen
cylinder transport carrier and/or stand oxygen,
oxygen administration device, and warning
signs. The HM is not in a CBRNE environment.
20-14
Performance Steps
8. Secure the oxygen cylinder.
1. Cylinder with regulator/flowmeter.
(Fig. 20-19). a. Upright position or as directed in local
standard operating procedures.
b. Secured with straps or in a stand.
c. Away from doors and areas of high
traffic.
9. Remove the cylinder valve cap.
NOTE:
The cylinder valve cap may be noisy or difficult
to remove; however, the threads of the cylinder
Figure 20-19.—Cylinder Regulator cap should never be oiled.
20-15
f. Fill the humidifier bottle to the level
b. Examine the yoke attachment and locate
indicated (about two-thirds full) with
the three corresponding pins on the yoke
sterile water.
attachment (Fig. 20-21).
g. Attach the humidifier to the flowmeter.
NOTE:
If an oxygen tube connector adapter is present,
remove it from the flowmeter by turning the
wing nut.
CAUTION:
c. Slide the yoke attachment over the "OXYGEN" and "NO SMOKING" signs should
cylinder stem, ensuring that the pins are be posted in the areas where oxygen is in use or
seated in the proper holes. stored.
d. Turn the vise-like screw on the side of the
yoke attachment to secure it.
e. Open the valve to test for leaks, and then
close it.
i. If you hear a leak, check the regulator
connection and obtain a new
Regulator/flowmeter and/or cylinder,
if necessary.
ii. When in-wall oxygen is available,
the flowmeter will be attached to the
oxygen outlet as follows:
1. Turn the flow adjusting valve of
the flowmeter to the OFF
position.
2. Insert the flowmeter adapter into
the opening outlet and press until
a firm connection is made.
20-16
Bag-Valve Mask (BVM) Ventilator Procedures for Operating the Bag-Valve
Mask Ventilator
The BVM ventilator is designed to help
ventilate an unconscious casualty for long To use the BVM ventilator:
periods while delivering high concentrations of
oxygen. When using external cardiac 1. Connect the bag up to an oxygen supply and
compressions, the cardiac output is cut to 25 to adjust the flow in the range of 10 to 15 liters
30 percent of the normal capacity, and artificial per minute, depending on the desired
ventilation does not supply enough oxygen concentration (15 liters per minute will
through the circulatory system to maintain life deliver an oxygen concentration of 90
for a long period. For this reason, this system percent).
can be useful in extended CPR attempts. 2. After opening the airway or inserting an
oropharyngeal airway, place the mask over
Various types of BVM systems come in the face and hold it firmly in position with
adult and pediatric sizes and are in use in the the index finger and thumb, while keeping
Navy. Essentially, they consist of a self-filling the jaw tilted upward with the remaining
ventilation bag, an oxygen reservoir, plastic face fingers (Fig. 20-22).
masks of various sizes, and tubing for
connecting to an oxygen supply.
20-17
Pocket Face Mask When available, oxygen should be
administered, as described below, to cardiac
A face mask designed with an oxygen-inlet arrest patients and to self-ventilating patients
flow valve for mouth-to-mask ventilation can be who are unable to inhale enough oxygen to
used to give oxygen-enriched artificial prevent hypoxia (oxygen deficiency). Hypoxia
ventilation. The pocket face mask system cannot is characterized by tachycardia, nervousness,
achieve oxygen concentrations as high as the irritability, and finally cyanosis.
BVM system. It has the advantage of providing
greater air volume (up to 4 liters per breath) and Oxygen must never be used near open
being much easier to use (both hands are free to flames since it supports burning. Oxygen
maintain the airway and keeping the mask firmly cylinders must be handled carefully since they
in place). The pocket face mask acts as a barrier are potentially lethal missiles if punctured or
device preventing the rescuer from coming in broken.
contact with the patient’s body fluids and breath,
which are possible sources of infection. ARTIFICIAL AIRWAYS
20-18
A method of insertion is to depress the
tongue with a tongue blade and slide the
airway in. Another method is to insert the
airway upside down into the casualty’s mouth;
then rotate it 180 ° as it slides into the pharynx;
this technique is for adults only (Fig. 20-24).
For full step by step directions for application
of the oropharyngeal airway refer to Chapter
21.
Nasopharyngeal Airway
20-19
Suction Devices RESCUE AND TRANSPORTATION
In the field, a HM may have access to a It is a basic principle of first aid that an
fixed (installed) suction unit or a portable injured person must be given essential
suction device. Both types of suction devices treatment before being moved. However, it is
are equipped with flexible tubing, suction tips impossible to treat an injured person who is in
and catheters, and a non-breakable collection a position of immediate danger. If the casualty
container. is drowning, or if the life is endangered by fire,
steam, electricity, poisonous or explosive
Maintenance of suction devices consists of gases, or other hazards, rescue must take place
testing the suction pressure regularly and before first aid treatment can be given.
cleaning the device after each use.
The life of an injured person may well
Before using a suction device, always test depend upon the manner in which rescue and
the apparatus. Once the suction pressure has transportation to a medical treatment facility
been tested, attach a suction catheter or tip. are accomplished. Rescue operations must be
Position the patient on their side and open the accomplished quickly. After rescue and essential
patient’s mouth. This position permits first aid treatment have been given, further
secretions to flow from the patient’s mouth transportation must be accomplished in a manner
while suction is being delivered. Use caution that will not aggravate the injuries. In these
in patients with suspected neck or spinal operations, a HM may be responsible to direct
injuries. If the patient is fully and securely others as well as acting as the primary rescuer.
immobilized on a backboard, the backboard
may be tilted to place the patient on the side. If This section will cover the use of common
the HM suspects such injuries but the patient is types of protective equipment; rescue
not immobilized, suction as best as possible procedures; special rescue situations; ways of
without turning the patient. Carefully insert the moving the patient to safety; and procedures
suction tip or catheter at the top of the throat. for transporting the injured after first aid has
DO NOT push the tip down into the throat or been given.
into the larynx. Apply suction no more than a
few seconds at a time, since supplemental PROTECTIVE EQUIPMENT
oxygen or ventilations cease while suctioning
which will keep oxygen from the patient. The use of appropriate items of protective
Suction may be repeated after a few breaths. equipment will increase the HM’s ability to
affect rescue from life-threatening situations.
Protective equipment that is generally available
on naval vessels and some shore activities
include the oxygen breathing apparatus (OBA);
hose (air line) masks; protective (gas) masks;
steel-wire lifelines; and devices for detecting
oxygen insufficiency, explosive vapors, and
some poisonous gases.
20-20
Oxygen Breathing Apparatus Safety belts are furnished with each air line
mask and MUST BE WORN. A lifeline must
An oxygen breathing apparatus (OBA) is be fastened to the safety belt; and the lifeline
provided for emergency use in compartments should be loosely lashed to the air hose to
containing insufficient oxygen. The apparatus is reduce the possibility of fouling. The air hose
used for rescue purposes as it is a self-contained and lifeline must be carefully tended so that they
unit. The wearer is not dependent upon outside do not become fouled or cut. The person
air or any type of air line within the effective life wearing the air line mask and the person tending
of the canister. Independence of the outside the lines should maintain communication by
atmosphere is achieved by having air within the means of standard divers' line-pull signals.
apparatus circulated through a canister. Never
allow oil or grease to come in contact with any Protective (Gas) Masks
part of an OBA as the oxygen can become
violently explosive in its presence. If any part Protective masks provide respiratory
of the apparatus becomes contaminated with oil protection against chemical, biological, and
or grease smudges, clean it before it is stowed. radiological warfare agents. They do not
provide protection from the effects of carbon
Another device used is a Self Contained monoxide, carbon dioxide, and a number of
Breathing Apparatus (SCBA). The source of industrial gases. Protection from these gases is
oxygen comes from a bottle that is usually discussed in the section, "Rescue from
strapped to the back. The effective life of the Unventilated Compartments.”
canister (as used in the OBA) or bottle varies
from 20 to 45 minutes, depending on the In emergencies, protective masks may be
particular apparatus and the type of work being used for passage through a smoke-filled
done. One of the newer types of OBA is compartment or for entry into such a
designed so that personnel can change canisters compartment to perform a job that can be done
without leaving the toxic atmosphere. quickly (such as to close a valve, secure a fan,
or de-energize a circuit). However, they
If a HM requires entering an extremely provide only limited protection against smoke.
hazardous area, a lifeline must be worn. The The length of time personnel can remain in a
lifeline should be tended by two persons, one of smoke-filled compartment depends on the type
whom is also wearing a breathing apparatus. of smoke and its concentration. Protective
masks are only designed to filter air that passes
Hose (Air Line) Masks through the canister.
20-21
Lifelines are used as a precautionary RESCUE PROCEDURES
measure to aid in the rescue of persons. Rescue,
if necessary, should be accomplished by having If a HM is faced with rescuing a person
another person equipped with a breathing threatened by fire, explosive or poisonous gases,
apparatus follow the lifeline to the person being or some other emergency, the scene survey must
rescued, rather than by attempting to drag the be completed to determine the extent of the
person out. Attempts to drag a person from a danger and ability to cope with it. In a large
space may result in fouling the lifeline on an number of accidents, the rescuer rushes in and
obstruction. becomes the second casualty. Do not take
unnecessary chances!
An important point to remember is that a
stricken person must never be hauled by a Phases of Rescue Operations
lifeline attached to the waist. The casualty may
be dragged along the deck a short distance, but In disasters where there are multiple
the weight must never be suspended on a line patients (as in explosions or ship collisions),
attached to the waist. If not wearing a harness rescue operations should be performed in
of some kind, pass the line around the chest phases. These rescue phases apply only to
under the armpits and fasten it in front or in extrication operations.
back.
• The first phase is to remove lightly pinned
casualties, such as those who can be freed
When tending a lifeline, rescue personnel
by lifting boxes or removing a small amount
must wear gloves to be able to handle the line
of debris
properly. Pay out the line carefully to keep it
from fouling. Try to keep the lifeline in contact • The second phase removes those casualties
with grounded metal; do not allow it to come in who are trapped in more difficult
contact with any energized electrical equipment. circumstances but who can be rescued by
use of the equipment at hand and in a
Detection Devices minimum amount of time
The detection devices used to test the • The third phase removes casualties where
atmosphere in closed or poorly ventilated extrication is extremely difficult and time
spaces include the oxygen indicator, for consuming
detecting oxygen deficiency; combustible-gas o This type of rescue may involve cutting
indicators, for determining the concentration through decks, breaching bulkheads,
of explosive vapors; and toxic-gas indicators, removing large amounts of debris, or
such as the carbon monoxide indicator, for cutting through an expanse of metal
finding the concentration of certain poisonous
o An example would be rescuing a worker
gases. The devices are extremely valuable and
from beneath a large, heavy piece of
used whenever necessary. However, they
machinery
MUST BE USED ONLY AS DIRECTED.
Improper operation of these devices may lead to • The fourth phase is the removal of dead
false assurances of safety or, worse, to an bodies
increase in the actual danger of the situation.
For example, the use of a explosion proof safety
lamp in a compartment filled with acetylene or
hydrogen could cause a violent explosion.
20-22
Stages of Extrication The risk of injury to other personnel and
additional injury to the previously wounded
As part of the four rescue phases outlined soldiers/sailors will be reduced if immediate
above, the extrication process takes place in attention is directed to the suppression of hostile
stages. fire. The medical personnel may therefore
initially need to assist in returning fire instead of
• The first stage is gaining access to the
stopping to care for the casualty. The best
casualty(s). Much will depend on the
medicine on any battlefield is fire superiority.
location of the accident, damage within the
As soon as the medic is directed, or is able to,
accident site, and the position of the
keeping the casualty from sustaining additional
casualty(s). The means of gaining access
injuries is the first major objective. Wounded
must take into account the possibility of
soldiers/sailors who are unable to participate
causing further injury to the casualty
further in the engagement should lay flat and
• The second stage involves giving lifesaving still if no ground cover is available, or move as
emergency care. If necessary, establish and quickly as possible if nearby cover is available.
maintain an open airway, start artificial If there is no cover and the casualty is unable to
respiration, and control hemorrhage move himself to find cover, he should remain
motionless on the ground so as not to draw
• The third stage is disentanglement. The additional fire. There are typically limited
careful removal of debris and other medical personnel available. If they sustain
impediments from the casualty(s) will injuries, no other medical personnel may be
prevent further injury to both the casualty(s) available until the time of evacuation in the
and the rescuer CASEVAC phase.
• The fourth stage is preparing the casualty(s)
for removal, with special emphasis on the Combat is a frightening experience, and
protection of possible fractures being wounded, especially seriously, can
generate tremendous anxiety and fear. Engaging
• The fifth stage is removing the casualty(s) a casualty with reassurance is therapeutically
from the trapped area and transporting to an beneficial, and communication is just as
ambulance or sickbay. This may be as important in patient care on the battlefield as it is
simple as helping the casualty(s) walk out of in the MTF.
the area or as difficult as carrying the
casualty(s) out of a burning space Key Points
20-23
Rescue from Fire It is often said that the "best” air in a
burning room or compartment is near the floor,
If a HM must go to the aid of a person but this is true only to a limited extent. There is
whose clothing is on fire, smother the flames by less smoke and flame down low, near the floor,
wrapping the casualty in a coat, blanket, or rug. and the air may be cooler. But it is also true that
Leave the head UNCOVERED. If there is no carbon monoxide and other deadly gases are just
material to smother the fire, roll the casualty as likely to be present near the floor as near the
over SLOWLY and put out the flames with ceiling. If possible, use an oxygen breathing
hands beginning around the head and shoulders, apparatus or other protective breathing
and then work downward toward the feet. If the equipment when inside a burning compartment.
casualty tries to run, force them to the ground. If protective equipment is not available, cover
The casualty MUST lie down while trying to mouth and nose with a wet cloth to reduce the
extinguish the fire. Running will cause the danger of inhaling smoke, flame, or hot air.
clothing to burn rapidly. Sitting or standing may
cause the casualty to be killed instantly by
CAUTION:
inhaling flames or hot air.
A wet cloth gives no protection against
poisonous gas or lack of oxygen.
CAUTION:
Inhaling flames or hot air can kill.
RESCUE FROM STEAM-FILLED SPACES
Do not put the face directly over the flames.
Turn face away from the flame when inhaling. It is sometimes required to rescue a person
from a space in that has a steam leak. Since
If a rescuer’s clothing catches fire, roll up in steam rises, escape upward may not be
a blanket, coat, or rug. KEEP HEAD possible. If the normal exit is blocked by
UNCOVERED. If material to smother the fire escaping steam, move the casualty to the
is not available, lie down, roll over slowly, and escape trunk or, if there is none, move to the
pat at the flames with hands. lowest level in the compartment.
20-24
RESCUE FROM ELECTRICAL CONTACT Rescue from Unventilated Compartments
Rescuing a person who has received an Rescuing a person from a void, gasoline or
electrical shock can be difficult and dangerous. oil tank, or any closed compartment or
Extreme caution must be used to avoid unventilated space can be a hazardous
electrocution of the rescuer (Fig. 20-26). operation. Aboard naval vessels and at naval
shore stations, no person is permitted to enter
any such space or compartment until a gas free
engineer in concurrence with a damage control
officer (DCO), or some person designated by
the DCO, has indicated that the likelihood of
suffocation, poisoning, and fire or explosion
has been eliminated as far as possible. The
rescue of a person from any closed space
should be performed under the supervision of
the DCO or in accordance with the DCO’s
instructions. In general, observe the following
precautions when attempting to rescue a person
from any closed or poorly ventilated space:
• If possible, test the air for oxygen deficiency,
poisonous gases, and explosive vapors
Figure 20-26.—Moving an Electrical Shock
Victim Away from the Electrical Source • Wear a hose (air line) mask or oxygen
breathing apparatus.
o The air line mask is preferred for use in
CAUTION:
spaces that may contain high
Do not touch the casualty’s body with the wire
concentrations of oil or gasoline vapors
or any other object that may be conducting
electricity. o Do not depend on a protective mask or a
wet cloth held over the face to protect
from oxygen deficiency or poisonous
The first step is to look for the power
gases
switch. If found, turn the power off
immediately. Do not waste time hunting for the o Before going into a compartment that may
switch as every second is important. contain explosive vapors, be sure that
people are stationed nearby with fire-
If the switch cannot be found, try to extinguishing equipment
remove the wire from the casualty with a DRY
• When going into any space that may be
broom handle, branch, pole, oar, or similar
deficient in oxygen or contain poisonous or
NON-CONDUCTING object. It may be
explosive vapors, be sure to maintain
possible to use a DRY rope or DRY clothing
communication with someone outside
to pull the wire away from the casualty. The
contact can be broken by cutting the wire with o Wear a lifeline and be sure that it is
a WOODEN-HANDLED axe. This is tended by a competent person
extremely dangerous as the cut ends of the
wire are likely to curl and lash back at the
person’s hands before having time to get out
of the way. When trying to break an electrical
contact, always stand on some non-conducting
material such as a DRY board, DRY
newspapers, or DRY clothing.
20-25
• Do not use, wear, or carry any object or Various methods are used aboard ship to
material that might cause a spark pick up survivors from the water. The methods
used in any particular instance will depend upon
o Matches, cigarette lighters, flashlights,
weather conditions, the type of equipment
candles or other open flames, and
available aboard the rescue vessel, the number
ordinary electrical lights must NEVER
of people available for rescue operations, the
be taken into a compartment that may
physical condition of the people requiring
contain explosive vapors
rescue, and other factors.
o The types of portable lights used by
cleaning parties in boilers, fuel tanks, It is frequently difficult to get survivors up
and similar places may be taken into a to the deck of the rescuing vessel, even after
suspect compartment they have been brought alongside the vessel.
Cargo nets are often used, but many survivors
o This is a steam-tight, glove-type light
are unable to climb them without assistance.
whose exposed metal parts are either
Persons equipped with lifelines (and, if
made of non-sparking alloy or protected
necessary, dressed in anti-exposure suits) can be
in some way so they will not strike a
sent over the side to help survivors up the nets.
spark.
If it is necessary to go into a space that may A seriously injured person should never,
contain explosive vapors, do not wear clothing except in an extreme emergency, be hauled out
that has any exposed spark-producing metal. For of the water by means of a rope or lifeline.
example, do not wear boots or shoes that have Special methods must be devised to provide
exposed nail heads or rivets, and do not wear proper support, both to keep the casualty in a
coveralls or other garments that might scrape horizontal position and to provide protection
against metal and cause a spark. from any kind of jerking, bending, or twisting
motion. The Stokes stretcher (Fig.3-25) can
Particular caution must be made concerning often be used to rescue an injured survivor.
the use of the steel-wire lifeline in compartments People on the deck of the ship can then bring the
that may contain explosive vapors. If the steel- stretcher up by means of hand- lines. Life
wire line is used, ensure it is carefully tended preservers, balsa wood, unicellular material, or
and grounded at all times. When other other flotation gear can be used, if necessary, to
considerations permit, use a natural fiber rope keep the stretcher afloat
line instead of the steel-wire lifeline when
entering these compartments. Treatment of Radioactive Contaminated
Personnel24
Rescue from the Water
Treatment of life-threatening injuries, e.g.,
Never attempt to swim to the rescue of a severe trauma, shock, hemorrhage, and
drowning casualty unless properly trained in respiratory distress, always takes precedence
lifesaving methods and then only if there is no over decontamination procedures. This includes
better way of reaching the casualty. A drowning treatment of possible symptoms from irradiation
casualty may panic and fight against the rescuer and dose estimation procedures. Medical
in a violent manner making rescue difficult. The emergency response personnel teams must not
rescuer must avoid injury to themselves or the be impeded when proceeding to render emergent
casualty. A non-trained rescuer can help a care for reasons such as issuing dosimeters or
drowning casualty by holding out a pole, oar, or controlling access to restricted areas. To stop
stick for the casualty to grasp; or by throwing a emergency response personnel in such situations
lifeline or some buoyant object that will support clearly displays a lack of understanding and
the casualty in the water. good judgment.
20-26
It is instructive to note no health care worker Stokes Stretcher
in the United States has ever suffered radiation
injury secondary to rendering emergency care to The Navy service litter most commonly used
a contaminated patient. These points must be for transporting sick or injured persons is the
stressed because of a number of events that have Stokes stretcher (Fig. 20-27). It is a wire basket
occurred. supported by iron rods. Even if the stretcher is
tipped or turned, the casualty can be held
Under no circumstances will any individual securely in place, making the Stokes adaptable
be denied access to necessary treatment or to a variety of uses. This stretcher is particularly
Treatment Facilities because of radioactive valuable for transferring injured persons to and
contamination. Medical treatment of emergency from boats. As mentioned before, it can also be
medical conditions (conditions which can used with flotation devices to rescue injured
become medically critical or life threatening) survivors from the water. Additionally, it can be
and medical conditions with the risk of used for direct ship-to-ship transfer of injured
morbidity (conditions which will result in persons. Fifteen-foot tending lines are attached
permanent injury or deficits) must always take to each end for shipboard use in moving the
precedence over decontamination or casualty. It is limited to one casualty or 400 lbs.
containment procedures. Concerns about the
spread of radioactivity, i.e., radioactive
contamination, or the possible contamination of
medical personnel are nonetheless appropriate
and should be attended to after the patient has
been stabilized.
Stretchers
20-27
The Stokes stretcher should be padded with Miller (Full Body) Board
three blankets: two of them should be placed
lengthwise so that one will be under each of the The Miller Board (Fig. 20-29) is
casualty s legs), and the third should be folded constructed of an outer plastic shell with an
in half and placed in the upper part of the injected foam core of polyurethane foam. It is
stretcher to protect the head and shoulders. The impervious to chemicals and elements. It can
casualty should be lowered gently into the be used in virtually every confined-space rescue
stretcher and made as comfortable as possible. and vertical extrication. It provides for full
The feet must be fastened to the end of the body immobilization through a harness system,
stretcher so that the casualty will not slide including a hood and two-point contact for the
down. Another blanket (or more, if necessary) head (forehead and chin) to stabilize the head
should be used to cover the casualty. The and cervical spine. The narrow design allows
casualty must be fastened to the stretcher by passage through hatches and crowded
means of straps that go over the chest, hips, passageways. It fits within a Stokes (basket)
and just above the knees. Note that the straps stretcher and will float a 250-pound person.
go OVER the blanket or other covering, thus
holding it in place.
20-28
Improvised Stretchers It has one vertical lift point and four
horizontal lift points for helicopter hoist
Standard stretchers should be used capability allowing the sleeve to hoist patients
whenever possible to transport a seriously from any angle. For head and cervical support,
injured person. If none are available, it may be it includes removable Velcro head-securing
necessary to improvise. Shutters, doors, blocks, adjustable head- and chin-securing
boards, and even ladders may be used as straps, a chest- and arm-securing flap with
stretchers. All stretchers of this kind must be Velcro, a leg-securing flap with Velcro and a
very well padded (to reduce pressure points) and spine board compartment for added strength and
care must be taken to see that the casualty is rigidity. Six chest and six leg straps with buckles
fastened securely in place. and a yellow "fail-safe" strap are used for
security. This stretcher has a load capacity of
At times, a blanket may be used as a over 1,000 lbs.
stretcher. The casualty is placed in the middle
of the blanket in the supine position. Three or Spineboards
four people kneel on each side and roll the
edges of the blanket toward the casualty. When Spineboards are equipment used in the
the rolled edges are tight and large enough to immobilization of suspected or real fractures of
grasp securely, the casualty should be lifted and the spinal column. They are made of fiberglass
carried. or exterior grade plywood, come in two sizes,
short (18" × 32") and long (18" × 72"), and are
Stretchers may be improvised by using provided with handholds and straps.
two long poles (about 7 feet long) and strong Spineboards have a runner on the bottom to
cloth (such as a rug, a blanket, a sheet, a allow clearance to lift (Fig. 20-30).
mattress cover, two or three gunny sacks, or
two coats).
CAUTION:
Many improvised stretchers do not give
sufficient support in cases where there are
fractures or extensive wounds of the body.
20-29
The short and long boards are often used Figure 20-31 shows an emergency rescue
together. For example, at an automobile line used to hoist a person from a void or small
accident site, the HM’s first task is to assess compartment. The running bowline is passed
the whole situation and to plan the rescue. If around the body, just below the hips, and a half
bystanders must be used, it is essential that they hitch is placed just under the arms. The
be briefed in thorough detail on what the HM guideline is tied loosely to the casualty’s ankles
wants them to do. to prevent banging against bulkheads and
hatchways.
Securing the casualty to the spineboard:
1. After all accessible bleeding has been
controlled and the fractures splinted, the
short spineboard should be moved into
position behind the casualty.
2. A neck collar should be applied in all cases
and will aid in the immobilization of the
head and neck.
3. The head should then be secured to the
board with a headband or a 6-inch self-
adhering roller bandage.
4. The casualty’s body should then be
secured to the board by use of the supplied
straps around the chest and thighs.
5. The casualty may then be lifted
out.
6. If the casualty is too large, or further
immobilization of the lower extremities is
necessary, the long spineboard may be slid
at a right angle behind the short
spineboard, and the casualty maneuvered
onto the side and secured to the longboard. Figure 20-31.—Emergency Rescue Line
The steel-wire lifeline can be used to haul a The HM may be required to evacuate a sick
person to safety. An emergency rescue line can or injured casualty from an emergency scene to
be made from any strong fiber line. Both should a location of safety. A casualty carried by
be used only in extreme emergencies, when an manual means must be properly handled;
injured person must be moved and no other otherwise the injuries may become more serious
means is available. or possibly fatal. Situation permitting,
evacuation or transport of a casualty should be
organized and unhurried.
20-30
Manual carries should be accomplished by • Pack-strap Carry: With the pack-strap
one or two stretcher bearers, if possible. They carry, shown in Figure 20-33, it is possible
provide more comfort to the casualty, are less to carry a heavy casualty for a considerable
likely to aggravate injuries, and are also less distance. Use the following procedure:
tiring for the stretcher bearers. The distance a
casualty can be carried depends on many factors:
• Strength and endurance of the stretcher
bearer(s)
• Weight of the casualty
• Nature of the casualty’s injury
• Obstacles encountered during transport
ONE-RESCUER TECHNIQUES
20-31
• Arm Carry: The technique for a one-person • Tied-hands Crawl: The tied-hands crawl,
arm carry is shown in Figure 20-34. Never shown in Figure 20-36, may be used to drag
try to carry a person who is seriously injured an unconscious casualty for a short distance.
with this method. Unless that casualty is It is useful when required to crawl
smaller than the rescuer, the HM will not be underneath a low structure. It is the least
able to carry the casualty very far using this desirable method as the casualty’s head is
technique not supported.
1. Place the casualty in the supine position.
2. Cross the wrists and tie them together.
3. Kneel astride the casualty and lift the
arms over the HM’s head so that the
wrists are at the back of the neck.
4. When crawling forward, raise shoulders
high enough so that the casualty’s head
will not bump against the deck.
20-32
TWO-RESCUER TECHNIQUES
Emergency Vehicles
20-33
There are many differences in design and
1. AIRCRAFT DESIGNED FOR
storage capacity and most ambulances are
MEDEVAC:
equipped to meet the same basic emergency
requirements. They contain equipment and a. UH-1V: Crew of 2 pilots, 1 crew chief
supplies for emergency airway care, artificial and 1 medic. Standard configuration is 3
v en tilatio n, suction, oxygenation, hemorrhage litters and 4 ambulatory. The maximum
control, fracture immobilization, shock control, configuration is 6 litters or 9 ambulatory.
blood pressure monitoring, and poisoning. They Red Cross Markings 4: one on the nose,
also contain litters, spineboards, and other the belly, and each cargo door.
extrication equipment. b. UH-60A: Same crew as the UH-1V.
Standard configuration is 4 litters and 1
Deployed units at sea, in the field, and at ambulatory. The maximum configuration
certain commands near air stations will also is 6 litters and 1 ambulatory or 7
have access to helicopter MEDEVAC support ambulatory or some configuration
(Fig. 20-39). Helicopters are ideal for use in thereof. Red Cross Markings 5: one on
isolated areas but are of limited practical use at the nose, belly, one on each cargo door,
night, in adverse weather, under certain tactical and one on top.
conditions, or in developed areas where
buildings and power lines interfere. In addition c. CH-47: Crew of 2 pilots, 2 crew chiefs
to taking these factors into consideration, the and 1 medic for every 6 litter patients.
HM must decide if the casualty’s condition is The standard configuration is 16
serious enough to justify a call for a helicopter. ambulatory and 12 litters. The maximum
Some injuries require very smooth configuration is 31 ambulatory or 1
transportation or are affected by pressure ambulatory and 24 litters. This aircraft
changes that occur in flight. The final decision has no Red Cross markings. The primary
will be made by the unit commander, mission of this aircraft is mass casualty
responsible for requesting the helicopter support. evacuation. Various configurations are
noted below.
CONFIGURATION
AMBULATORY LITTER
31 0
25 4
19 8
16 12
10 16
4 20
1 24
NOTE:
Figure 20-39.—Loading a patient onto a The capacity of all aircraft may be reduced
helicopter for MEDEVAC because of temperature, humidity or age of the
aircraft. Any aircraft may be used for
Image provided by: Department of the Army.
(2009). Soldier’s handbook and training guide CASEVAC.
for MOS 68W STP 8-68W13-SM-TG.
20-34
Preparing the Patient for Transport During this phase the HM can perform an
initial patient evaluation assessing for H-A-B-C
Once emergency medical care has been (life-threatening Hemorrhage, Airway,
completed on-scene, the patient must be Breathing, and Circulation). The HM can re-
transferred to the treatment facility. A process check that tourniquet applied earlier, dress
known as packaging provides the means of wounds, perform a needle thoracotomy or start
properly positioning, covering, and securing the IVs as needed, and employ other emergency
patient to avoid any unnecessary aggravation to measures. It is important to remember that the
the patient’s condition. Covering helps maintain TFC phase can be dynamic and the threat may
the patient’s body temperature, prevents quickly return, so dedicated efforts such as CPR
exposure to the elements, and provides privacy. are not initiated.
Do not "package” a badly traumatized patient; it
is more important to transport the critical or
• Tactical Evacuation Care
unstable patient to the treatment facility quickly.
The most important aspect of each rescue or The Tactical Evacuation Care phase
transfer is to complete it as safely and efficiently (TACEVAC), formerly called the Casualty
as possible. Evacuation (CASEVAC) stage, will consist of
medical treatment rendered during movement to
Care of Patient en Route26 the appropriate treatment facility. This care may
range from continued treatment provided by the
The emergency care a HM can offer first responder during a hasty evacuation to a
patients en route is limited only by the safe zone, to advanced medicine performed by
availability of supplies, the level of external dedicated medical crews en route to a trauma
noise and vibrations, and the competency and center. Movement of the patient away from the
ingenuity the HM possesses. There are three threat zone and toward definitive medical care is
phases to en route care in the military the defining feature of this phase.
operational environment. The degree to which
they affect the scenarios varies by situation; they The principles of Tactical Combat Casualty
are relevant to some degree in the operational Care have been constantly refined and have been
and non-operational environments. The phases are: in widespread use among military and civilian
tactical teams for over a decade, with a track
• Care Under Fire
record of saving lives. Further incorporation of
The Care Under Fire (CUF) defines the care these guidelines and practices into teams not yet
to be provided while there is a direct and using them will help ensure the safety, health,
ongoing threat to the patient and HM. CUF is and survivability of its members. In this
aid which can be rendered very quickly to particular section the HM will focus on the steps
address an immediate life threat. This is of preparing for the TACEVAC outside of
commonly viewed as the placement of a patient care procedures.
tourniquet on a bleeding extremity, moving the
wounded out of the line of fire if able, and little
REQUEST MEDICAL EVACUATION23
more.
• Tactical Field Care Once the HM has a casualty requiring
medical evacuation (MEDEVAC) a medical
The Tactical Field Care (TFC) phase is that
evacuation will be requested. The HM will need
point in time when the threat is reduced or
a patient pickup site, operational
resolved but the patient is still in a tactically
communications equipment, MEDEVAC
unstable environment. Perhaps the direct fire has
request format, and unit signal operation
temporarily stopped, or the Corpsman and his or
instructions (SOI).
her patient have found some cover where the
HM can focus safely on patient rather than
achieving fire superiority.
20-35
Transmit a MEDEVAC request. At a
3. Transmit the MEDEVAC request.
minimum, transmit line numbers 1 through 5
during the initial contact with the evacuation a. Contact the unit that controls the
unit. Transmit lines 6 through 9 while the evacuation assets.
aircraft or vehicle is en route, if not included i. Make proper contact with the intended
during the initial contact. receiver.
NOTE:
CBRN line 9 information is only included when
contamination exists.
NOTE:
Unless the MEDEVAC information is
transmitted over secure communication systems,
it must be encrypted.
20-36
MEDEVAC Request Form
WHO
WHERE/HOW
LINE ITEM EXPLANATION NORMALLY REASON
OBTAINED
PROVIDES
Encrypt the grid coordinates of the
pickup site. When using the Required so evacuation vehicle
DRYAD Numeral Cipher, the same knows where to pick up patient.
“SET” line will be used to encrypt Also, so that the unit
Location of the
the grid zone letters and the coordinating the evacuation
1 pick-up site
coordinates. To preclude
From map Unit leader(s)
mission can plan the route for
misunderstanding, a statement is the evacuation vehicle (if the
made that grid zone letters are evacuation vehicle must pick up
included in the message (unless unit from more than one location).
SOP specifies its use at all times)
Special equipment
Encrypt the applicable brevity
required:
codes.
Corpsman or Required so that the equipment
From evaluation
A - None senior person can be placed on board the
4 B - Hoist
A - None of patient/situation
present evacuation vehicle prior to the
B - Hoist
C - Extraction start of the mission.
C - Extraction equipment
equipment
D - Ventilator
D – Ventilator
20-37
WHO
WHERE/HOW
LINE ITEM EXPLANATION NORMALLY REASON
OBTAINED
PROVIDES
Specific information
regarding patient wounds
Required to assist evacuation
by type (gunshot or From evaluation of Corpsman or senior
Number and type of wound, personnel in determining
6 injury, or illness (Peacetime)
shrapnel). Report serious patient(s) person present
treatment and special equipment
bleeding, along with
needed.
patient’s blood type, if
known.
NBC Contamination:
Required to assist in planning
N - Nuclear
Corpsman or senior for the mission (determine
B - Biological
9 C – Chemical
From situation From situation person present which evacuation vehicle will
accomplish the mission and
when it will be accomplished).
* In peacetime - terrain
description of pick-up site
20-38
Establish a Helicopter landing site i. When the ground slope is less than 7
degrees, the helicopter should land up
The HM needs to establish a helicopter slope.
landing site. The HM will need smoke grenades,
ii. When the ground slope is 7 to 15
strobe lights, flashlights or vehicle lights, marker
degrees, the helicopter must land side
panels, and the equipment and personnel to clear
slope (Fig. 20-40).
the site if required.
20-39
2. Establish security for the landing site.
Landing sites should offer some security
from enemy observation and direct fire.
Good landing sites will allow the helicopter
to land and depart without exposing it to
unneeded risks. Security is normally
established around the entire landing site.
3. Mark the landing site and touchdown point.
a. When and how the landing site should be Figure 20-41.—Helicopter on the ground
marked is based on the mission,
capabilities, and situation of the unit Image provided by: Department of the Army.
concerned. Normally, the only mark or (2009). Soldier’s handbook and training guide
signals required are smoke (colored) and for MOS 68W STP 8-68W13-SM-TG.
a signalman. VS-17 marker panels may
be used to mark the landing site, but 2. Identify the landing site and guide pilot in.
MUST NOT be used any closer than 50 a. Once the pilot is within the HM’s area,
feet to the touchdown point. In addition radio contact will be established with the
to identifying the landing site, smoke will unit for positive identification.
give the pilot information on the wind
direction and speed. b. The pilot will be oriented to the landing
site by using the clock method (12
b. At night, the landing site and touchdown o'clock is always the direction of flight).
point are marked by an inverted "Y" The pilot will be provided with the
composed of four lights. Strobe lights, corresponding time position of the HM’s
flashlights, or vehicle lights may also be location. For example: "The LZ is now at
used to mark the landing site. 3 o'clock to HM’s position."
c. Mark or identify the landing site:
GUIDE A HELICOPTER TO A
LANDING POINT i. Day--The only signals required are
colored smoke and a signalman. VS-
How to guide the helicopter to a safe landing 17 marker panels may be used to mark
identified by MEDEVAC request, identifying the landing site, but are NOT used any
the landing site to the pilot and controlling the closer than 50 feet to the touchdown
landing using the correct arm-and-hand signals. point. In addition to identifying the
landing site, the smoke will give the
1. As the aircraft approaches, provide the pilot pilot the wind direction and speed.
with tactical and security information.
Provide information on the conditions that ii. Night--The landing site and
may affect the landing such as terrain, touchdown point are marked by an
weather, landing site markings, and inverted "Y" composed of four lights
possible obstacles (Fig. 20-41). (Fig. 20-42).
20-41
4. Proper positioning when using arm-and- HAZARDOUS MATERIAL
hand signals. EXPOSURE27
a. The signaling person’s position when
directing a helicopter is to the right front LEARNING OBJECTIVE:
of the aircraft in order to be seen by the
pilot. The position for utility helicopters Explain hazardous material personal safety
is 30 meters to the right front of the guidelines and hazardous material
aircraft during day or night operations. information sources.
b. Signals at night are given by using
lighted batons or flashlights. In the Hazardous materials are substances with the
illustrations, the person is using a lighted potential of harming people or the environment.
wand. This is a flashlight with a plastic They can be gaseous, liquid, or solid, and can
wand attached to the end and used when include chemical or radioactive materials.
there is decreased visibility. (Radiological exposure is covered in depth in
Chapter 23 of this manual). The most common
c. The speed of the arm movement indicates
substances involved in incidents of hazardous
the desired speed of aircraft compliance
material (HAZMAT) exposure are volatile
with the signal.
organic compounds, pesticides, ammonia,
chlorine, petroleum products, and acids.
NOTE: The HM’s initial action at the scene of a
The "hover" signal should be used to change hazardous materials incident must be to assess
from one arm-and-hand signal to another. the situation as the safety of the HM, patient,
and the public are of primary concern. The HM
For example, the signal person desires to land an must determine the nature of the HAZMAT and
approaching helicopter and the signal "move then establish a safety zone. After this has been
ahead" has been given to pilot. The helicopter is accomplished, a casualty having been exposed to
now positioned directly over the desired landing hazardous materials can be rescued, transported
area. to an appropriate facility, and properly
decontaminated.
Before giving the pilot to the signal to move
downward, the signal person should execute the The Department of Transportation (DOT)
"hover" signal. This gives the pilot time to publication, Emergency Response Guidebook
change from the "move ahead" to the "move (ERG series, published every four years),
downward" signal. RSPAP5800.8, is a useful tool for first
responders during the initial phase of a
hazardous materials/dangerous goods incident.
ERG series addresses labeling, identification,
toxicity, safety/contamination zones, and
decontamination procedures. It is available at
http://www.phmsa.dot.gov/hazmat.
NOTE:
It is imperative that all personnel involved with
hazmat incident response be familiar with this
publication.
20-42
DETERMINING THE NATURE OF THE The ERG series provides a list of hazardous
HAZARDOUS MATERIAL materials and appropriate emergency response
actions. It is a tool enabling first responders to
When an incident involving the exposure of quickly identify the specific or generic
hazardous material occurs, it is important to any classification of the material(s) involved in the
rescue operation to determine the nature of the incident, and to protect themselves and the
substance(s) involved. All facilities that produce general public during the initial phase of the
HAZMAT are required by law to prominently incident.
display this information, as is any vehicle
transporting it. Any carton or box containing SAFETY GUIDELINES
such material must also be properly labeled. The
name of the substance may also be displayed, The HM’s first objective should be to try to
along with a required four-digit identification read the labels and identification numbers
number (sometimes preceded by the letters UN FROM A DISTANCE. If necessary, use
or NA - United Nations-North America number. binoculars. DO NOT enter into the area unless
It is also known as the UN or DOT number). absolutely certain that there has not been a
hazardous spill. Relay any and all information
The various kinds of hazardous materials available to the dispatch center where it can be
have different labels to assist in the used to identify the HAZMAT.
identification. These are diamond-shaped signs
having specific colors to identify the type of Once the HAZMAT has been identified, it
HAZMAT involved. Table 20-2 provides a list can be classified as to the danger it presents
of the Department of Transportation (DOT)- (i.e., toxicity level). Based on this classification,
mandated classifications of hazardous materials. the appropriate specialized equipment (known
as personal protective equipment or PPE) can be
determined to provide adequate protection level
HAZMAT Type Label Description from secondary contamination to rescue
Explosives Solid Orange Color personnel and healthcare providers.
Non-Flammable
Solid Green Color Toxicity Levels
Gases
Flammable
Solid Red Color The National Fire Protection Association
Liquids
Flammable Solids White and Red Stripes (NFPA) has developed a system to indicate the
Oxidizers & health, flammability, and reactivity hazards of
Solid Yellow Color chemicals. It is called the NFPA 704 Labeling
Peroxides
Poisons & System and is made up of symbols arranged in
Solid White Color squares to comprise a diamond-shaped label
Biohazards
Radioactive Half White / Half Yellow (Fig. 5-7). Each of the four hazards is indicated
Materials with black radiation Symbol by a different colored square:
Corrosives Half White / Half Black • Red indicates the flammability
Other Usually White • Yellow indicates the reactivity
• White indicates any special hazards
Table 20-2.—Classification of HAZMAT • Blue indicates health hazards
20-43
The health hazard levels are The HM is required to wear gloves at all
four protection levels. If the correct type of
• 4 - deadly
glove to be used is not known, use neoprene or
• 3 - extreme danger rubber, and avoid using latex or vinyl. In any
instance, contact with HAZMAT should be
• 2 - hazardous avoided or minimized, and proper
• 1 - slightly hazardous decontamination should be performed
promptly. Protect feet from contact with
• 0 - normal material HAZMAT by using a disposable boot/shoe
cover made from appropriate material.
Protection Levels
Site Control
The protection levels A, B, C, and D
indicate the type and amount of protective For management purposes, site control is
equipment required in a given hazardous divided up into three sections.
circumstance. Level A provides the greatest • Exclusion Zone (Hot Zone): The area the
amount of protection and is used for the most contamination has occurred. The outer
hazardous incident(s). boundary of the exclusion zone should be
• Level A - positive pressure-demand, full- marked either by lines, placards, hazard tape
face piece self-contained breathing and/or signs, or enclosed by physical
apparatus (SCBA) or positive pressure- barriers. Access control points should be
demand supplied air respirator with escape established at the periphery of the exclusion
SCBA; fully encapsulating, chemical- zone to regulate the flow of personnel and
resistant suit; inner chemical-resistant equipment. Remain upwind of the danger
gloves; chemical-resistant safety area and avoid low areas where toxic
boots/shoes; and two-way radio gases/vapors may settle.
communication. • Contamination-Reduction Zone (Warm
• Level B - positive pressure-demand, full- Zone): The transition area between the
face piece SCBA or positive pressure- contaminated area and the clean area. This
demand supplied air respirator with escape zone is designed to prevent the clean
SCBA; chemical-resistant clothing (overalls support zone from becoming contaminated
and long-sleeved jacket with hooded one- or or affected by other site hazards.
two-piece chemical splash suit or disposable Decontamination of personnel/equipment
chemical-resistant one-piece suit); chemical- takes place in a designated area within the
resistant safety boots/shoes; hard hat; and contamination-reduction zone called the
two-way communication. "contamination-reduction corridor."
• Level C - full-face piece, air-purifying • Support Zone: The location of the
canister-equipped respirator; chemical- administrative and other support
resistant clothing (overalls and long-sleeved functions needed to keep the operations in
jacket with hooded one- or two-piece the exclusion and contamination- reduction
chemical splash suit or disposable chemical- zones running smoothly. The command post
resistant one-piece suit); inner and outer supervisor/incident commander should be
chemical-resistant gloves; chemical-resistant present in the support zone. Personnel may
safety boots/shoes; hard hat; and two-way wear normal work clothes within this zone.
communication.
• Level D - coveralls, safety boots/shoes,
safety glasses or chemical splash goggles,
and hard hat.
20-44
RESCUE AND PATIENT CARE Rescue from Exclusion Zone (Hot Zone)
PROCEDURES
The most dangerous element of any
After a safety zone has been established HAZMAT incident both to the exposed
and regardless of the HM’s level of training casualties and the rescuers is the rescue from
the HM should follow the procedures outlined the hot zone. Rescue operations should always
below: be performed using appropriate protective
equipment (PPE). Never enter the area unless
• Help isolate the incident site and keep the
properly trained to do so. Only the experts
area clear of unauthorized and unprotected
should handle this aspect of the rescue. Be
personnel
prepared to provide supportive care once the
• Establish and maintain communications with casualty is clear of the contaminated area.
the dispatcher
As soon as the casualty has been moved to
• Stay upwind and uphill from the site safety, the HM should follow normal primary
• Monitor wind and weather changes and secondary survey procedures, including
interviews of the casualty and bystanders.
• Do not breathe any smoke, vapors, or fumes Observe the casualty providing basic life
• Do not touch, walk, or drive through the support, supplemental oxygen, and monitoring
spilled materials as this will increase the area vital signs.
of the spill
Patient Decontamination Procedures
• Do not eat, drink, or smoke at the site
• Do not touch the face, nose, mouth, or eyes Decontamination is the process of removing
as these are all direct routes of entry into the or neutralizing and properly disposing of
body contaminants that have accumulated on
personnel and equipment. Decontamination
• Eliminate any possible source of ignition protects site personnel by minimizing the
(e.g., flares, flames, sparks, smoking, transfer of contaminants, helps to prevent the
flashes, flashlights, engines, portable mixing of incompatible chemicals, and protects
radios) the community by preventing uncontrolled
• Notify the dispatcher and give location transportation of contaminants from the site. All
personnel, clothing, and equipment that leave
• Request the assistance of the HAZMAT the contamination area (exclusion zone) must be
response team decontaminated to remove any harmful
chemicals that may have adhered to them. Some
• If possible, identify the hazardous material
decontamination methods include those listed
and report it to the dispatcher
below.
• Observe all safety precautions and directions
• Dilution: the flushing of the contaminated
given by the on-site HAZMAT expert. All
person or equipment with water. It is the
orders should be given and received face
most frequently appropriate method of
to face
decontamination
• Stay clear of restricted areas until the on-site
• Absorption: the use of special filters and
HAZMAT expert declares them to be safe
chemicals to absorb the hazardous material
• Chemical washes: specific chemicals used
to neutralize the hazardous material
• Disposal and isolation: the proper disposal
of contaminated materials instead of
attempting to decontaminate them
20-45
Decontamination requires the use of PPE, The nature of the HAZMAT involved and
although the level of protection required may be the threat to the health of others (rescue team,
less once the casualty is out of the hot zone. A other casualties, medical personnel, and
casualty who is exposed to a gas may not transport crew) determines the degree of
require actual "decontamination” after rescue decontamination necessary before treatment or
and only require cessation of exposure and an transporting the casualty. It is preferred that
opportunity to breathe fresh air. However, if a decontamination be accomplished before
casualty is soaked with a liquid, the HAZMAT treatment or transport. However, the patient's
may pose an ongoing risk to the casualty and to immediate medical condition may be more
the rescuers or medical personnel. serious than the contamination itself. For
example, ingested HAZMAT may pose little
immediate threat to nearby personnel, but be
NOTE: an imminent threat to the casualty's life.
It is important to always assume that the Therefore, the consequences of delaying the
casualty has been contaminated with something emergency care of the patient's injuries to
that could harm the HM and others until accomplish gut decontamination must be
determined otherwise. carefully evaluated. In some cases,
decontamination and emergency medical care
Once the casualty is medically evaluated, can be carried out simultaneously. In some
carefully remove any solid material that remains instances, the casualty may require
on the patient's clothing. If the material is dry, transportation to the treatment facility before
immediately remove the casualty's clothing decontamination. In these instances, notify
while avoiding or minimizing contact with the both the treatment facility and transportation
HAZMAT or loss of the HAZMAT from the crew of the p a t i e n t ’ s medical condition and
clothing. Unless specifically contraindicated by contamination. Depending on the situation, the
the hazardous nature of the HAZMAT and transportation crew will have to prepare to
directed by the incident commander or the carry and care for the contaminated casualty;
supporting medical advisor, flush the patient s otherwise, the crew themselves could be
skin, clothing, and eyes with water. To the contaminated. For example, the transport crew
maximum extent possible, control or retain the may need to wear level A or B suits and/or
runoff (which is contaminated) which will be respirators. If the casualty is contaminated and
containerized for proper disposal. Remove all the transport requires personal protective
of the casualty's clothing, shoes, and jewelry. devices, it is likely that the vehicle will be
Place everything that may have contacted the contaminated and requires appropriate
HAZMAT in a special container. Mark the decontamination. There is also a potential to
container as contaminated. Continue flushing contaminate the receiving treatment facility
the skin with water for at least 20 minutes and its staff.
trying to retain the runoff. Using available
items, towels or clean rags, mechanically
remove the HAZMAT by wiping; avoid
rubbing the skin too vigorously. Dry the skin
and provide uncontaminated dry clothing or
coverings.
20-46
Diagnosis, Treatment, and Transport SUMMARY
As soon as the casualty has been removed This chapter covered first aid equipment,
from danger and moved to safety, follow supplies, and rescue/transportation of the
primary and secondary survey procedures, casualty. The HM should be able to recognize
including interviews of the casualty and the various types of dressings and bandages, as
bystanders. Observe the casualty and provide well as how and when to apply them. The HM
the ABCs of basic life support (airway, should be familiar with protective equipment,
breathing, and circulation) add "D" and "E" for rescue operations, the stages of extrication, and
disability and exposure. Look for signs of the precautionary steps that must be taken in
trauma and provide proper exposure (i.e., special rescue situations. Additionally, the HM
remove clothing) to fully assess the casualty. As should be acquainted with the different patient-
a guideline, give the patient supplemental moving devices and lifting techniques. Further,
oxygen (4 to 6 liters per minute), start an IV at the HM should be able to identify essential
an area of skin not exposed to the hazardous basic life support equipment and supplies and
material (or at least that has been thoroughly should be able to recognize different forms of
decontaminated), monitor vital signs. emergency transportation. Finally, the HM
should now be able to recall preparatory, en
If the casualty has swallowed a known or route, and turnover procedures for casualties
identified toxic material, treat the casualty as a being transported to treatment facilities. The
poisoned casualty using the information HM may stay informed through contact with
provided above. Dress wounds and prepare the the local Poison Control Center, MEDIC
casualty for transport to a treatment facility for a releases, or via the World Wide Web on the
complete medical evaluation and treatment. Internet.
Care should be taken during transport to
stabilize the casualty by maintaining normal
body temperature, administering oxygen, and
treating shock.
20-47
CHAPTER 21
21-1
Mental preparation is an often overlooked TRIAGE
aspect of emergency care. While it is possible to
provide life-like training and scenarios to HMs,
LEARNING OBJECTIVE:
there is no substitute for being able to handle a
real emergency. The HM can takes steps in order
Explain the procedures for tactical and non-
to prepare for the stressors encountered as a
tactical triage.
result of a severe trauma or medical scene.
1. Regular exercise and a healthy lifestyle will Triage, a French word meaning "to sort”, is
allow the HM’s body to better handle the the process of quickly assessing patients in a
physical symptoms it will experience multiple-casualty incident and assigning
resulting from stress. patients a priority (or classification) for
2. Keeping abreast of current medical receiving treatment according to the severity of
procedures and emergency medicine the illness or injury. In the military, there are
procedures will keep the HM mentally two types of triage, tactical and non-tactical,
prepared. and each type uses a different set of prioritizing
criteria.
3. Keeping current with the latest and greatest
medical equipment and how to operate the The person in charge is responsible for
equipment at the command is vitally balancing the human lives at stake against the
important. As emergency responders, HMs realities of the tactical situation, the level of
have a large dependence on medical medical consumable resources on hand, and the
equipment. It is essential that the HM realistic capabilities of medical personnel on the
knows the location, function and scene. Triage is a dynamic process, and a
application of the medical gear to be used. patient’s priority is subject to change as the
On the way to the scene IS NOT THE situation progresses.
TIME to get familiar with the gear.
4. Know the surroundings and the resources SORTING FOR TREATMENT29 (NON-
available. It is important to think and plan TACTICAL)
at least three steps ahead. For example: All
injured patients are going to be moved to a In civilian or non-tactical situations, sorting
certain location. What resources will be of casualties from a multiple casualty incident
needed to move the patients; will extra is slightly different from combat situations.
people be needed to help carry the patients There are four basic classes (priorities) of
or extra gear? These are just a couple of injuries, and the order of treatment of each is
questions to ask before an operation begins different.
or an injury occurs.
Priority I - Immediate.
These are a few guidelines to keep in mind Casualties whose injuries are critical but
while reading this chapter. More detail will be who will require only minimal time or
provided in the following sections. equipment to manage and who have a good
prognosis for survival. An example is the
casualty with a compromised airway or massive
external hemorrhage.
21-2
Priority II - Delayed Priority V - Dead
Casualties whose injuries are debilitating Casualties who are unresponsive, pulseless
but who do not require immediate management and breathless. In a disaster, resources rarely
to salvage life or limb. An example is the allow for attempted resuscitation of cardiac
casualty with a long bone fracture. arrest casualties.
Priority IV - Expectant
Figure 21-1.—START Triage Algorithm (Courtesy Newport Beach Fire Department, Newport
Beach, CA)
Image reprinted with permission from: Mosby. (2007). Prehospital Trauma Life Support (6th ed.).
St. Louis, Mo: Mosby.
21-3
SIMPLE TRAIGE AND RAPID Please note the differences as noted in the
TRANSPORT (S.T.A.R.T.) 29 Tactical Combat Casualty Care (TCCC) Triage
categories table below (Table 21-1). Review the
Triage in the tactical environment is very TCCC Triage Algorithm as well (Fig. 21-2).
different due to the environmental and human
hazards, i.e. bullets and ordnance.
21-4
Care under Fire
Casualty in respiratory
distress
DELAYED
21-5
AIRWAY MANAGEMENT h. Place the casualty's arms at his or her
side.
LEARNING OBJECTIVE:
NOTE:
The following steps are employed when the HM
Perform airway management using simple and
must secure a patent (open) airway and either
advanced airway adjuncts.
establish or maintain breathing.
a. Kneel beside the casualty. iv. Lift the chin upward, bringing the
entire lower jaw with it, helping to tilt
b. Raise the near arm and straighten it out the head back.
above the head.
c. Adjust the legs so that they are together CAUTION:
and straight or nearly straight. Do not use the thumb to lift the lower jaw.
d. Place one hand on the back of the Do not press deeply into the soft tissue under the
casualty's head and neck. chin with the fingers.
e. Grasp the casualty under the arm with the
free hand. Do not completely close the casualty's mouth.
21-6
4. Take appropriate action.
b. Jaw-thrust maneuver.
a. If the casualty resumes breathing on his
CAUTION: or her own, maintain the airway and (if
Use this method if a spinal injury is suspected. no spinal injury is assessed or suspected)
place the casualty in the recovery
position.
WARNING:
Do NOT place suspected spinal injury patients i. Roll the casualty as a single unit onto
in the recovery position. his or her side.
ii. Place the hand of the upper arm under
i. Kneel above the supine casualty's the chin.
head. Rest elbows on the surface on
which the casualty is lying. iii. Flex the upper leg.
21-7
Performance Steps 5. Prepare equipment.
a. Open the basin package.
CAUTION:
b. Pour the saline solution into the basin.
All body fluids should be considered potentially
infectious. Always observe body substance c. Open the suction catheter package.
isolation (BSI) precautions by wearing gloves
6. Explain to the patient the reason for
and eye protection as a minimal standard of
suctioning.
protection.
7. Pre-oxygenate the patient with 100%
1. Position the patient in a semi-Fowler's oxygen.
(semi-sitting) position or, in the case of
a. If the patient is receiving oxygen therapy,
severe trauma, roll the patient onto his side
increase the oxygen to 100% for 1
to allow gravity to assist in clearing the
minute.
airway.
b. Monitor the patient's pulse oximeter
NOTE: reading during the entire procedure.
In some cases, such as spinal injuries, the patient
c. If the patient is not receiving oxygen
must remain in whatever position they are
therapy, have him take a minimum of
initially found or must be managed while they
five deep breaths or administer the
are immobilized on a long spine board.
breaths with a bag-valve-mask (BVM)
2. Check the suction unit for proper assembly system.
of all its parts.
NOTE:
3. Turn on the assembled unit and check to After each suctioning attempt or suctioning
see if it is operational. period, re-oxygenate the patient.
21-8
ii. Flexible catheter.
10. Suction the patient.
1. Measure the catheter from the
a. Oral route.
patient's earlobe to the corner of
i. Rigid catheter. the mouth or the center of the
1. Instruct a conscious patient to mouth to the angle of the jaw.
cough to help bring secretions up 2. Insert the catheter into the patient's
to the back of the throat. mouth to the correct depth, without
2. If the patient is unconscious, use the suction applied.
the cross finger method of opening
NOTE:
the airway.
If an oropharyngeal airway (OPA) is in place,
3. Place the convex (outward curving) insert the catheter alongside the airway and then
side of the rigid tip against the roof back into the pharynx.
of the mouth and insert to the base
of the tongue. 3. Place the thumb of the non-
dominant hand over the suction
NOTE: control port on the catheter,
A rigid tip does not need to be measured. applying intermittent suction by
Only insert the tip as far as YOU can see it. Be moving the thumb up and down
aware that advancing the catheter too far may over the suction control port.
stimulate the patient's gag reflex and cause
4. Apply suction in a circular motion
vomiting.
while withdrawing the catheter.
4. Apply suction by placing the 5. Suction for no longer than 15
thumb of the non-dominant hand seconds removing secretions from
over the suction control port. the back of the throat, along outer
gums, cheeks, and base of tongue.
WARNING:
Never suction for more than 15 seconds at one WARNING:
time for adults, 10 seconds for children, and 5 Advancing the catheter too far into the back of
seconds for infants. the patient's throat may stimulate the gag reflex.
Longer periods of continuous suctioning may This could cause vomiting and the aspiration of
cause oxygen deprivation and subsequent stomach contents.
hypoxic injury to the brain.
6. Clear the secretions from the
5. Clear the secretions from the catheter between suctioning by
catheter between each suctioning inserting the tip into the saline
interval by inserting the tip into the solution and suction the solution
saline solution and suction the through the catheter until the
solution through the catheter until catheter is clear of secretions.
the catheter is clear of secretions.
7. Repeat steps 10-a-ii-1 through 10-
6. Repeat steps 10-a-i-1 through 10-a- a-ii-6 until all secretions have been
i-5 until all secretions have been removed or until the patient's
removed or until the patient's breathing becomes easier. Noisy,
breathing becomes easier. Noisy, rattling or gurgling sounds should
rattling or gurgling sounds should no longer be heard.
no longer be heard.
21-9
Objective
NOTE:
If the patient is uncooperative or oral entry is not
possible due to facial trauma, nasopharyngeal Insert an OPA without causing further injury
to the casualty.
suctioning may be required.
13. Place the patient in the recovery (lateral b. Measure from the casualty's ear lobe to
recumbent, coma) position, unless the corner of the mouth.
contraindicated by a suspected spinal
injury. NOTE:
The measurement from the ear lobe to the corner
14. Record the procedure. of the casualty's mouth is equivalent to the depth
15. Evacuate the patient. of insertion in the airway.
21-10
3. Open the casualty's mouth. 5. Insert the OPA using a tongue depressor.
a. Place the crossed thumb and index finger a. Use the tongue depressor to depress the
of one hand on the casualty's upper and tongue, ensuring the tongue remains
lower teeth at the corner of the mouth. forward.
b. Use a scissors motion to pry the b. Insert the OPA sideways from the corner
casualty's teeth apart. of the mouth until the flange reaches the
teeth.
NOTE:
If the teeth are clenched, wedge the index finger c. Rotate the OPA at a 90° angle, removing
behind the casualty's back molars to open the the tongue depressor while exerting
gentle backward pressure on the OPA
mouth.
until it rests securely in place against the
4. Insert the OPA. lips or teeth.
a. Insert the airway with the tip facing the 6. Monitor the casualty's respirations on a
roof of the mouth. regular basis.
b. Slide the OPA along the roof of the a. Reassess air exchange and placement
mouth. Follow the natural contour of the every time the casualty is moved.
tongue past the soft palate. b. Assist with respirations if the respiratory
c. Rotate the airway 180° as the tip reaches rate falls below 8 or rises above 30 per
the back of the tongue. minute or a pulse oximeter reading
<90%.
NOTE: 7. Evacuate the casualty.
The airway may be difficult to insert. If so, use a
gauze pad to pull the tongue forward or a tongue NOTE:
depressor to depress the tongue. The airway may need to be taped or tied in place
to avoid dislodgement during evacuation. If so,
d. Gently advance the airway and adjust it the casualty must be constantly monitored for
so the flange rests against the casualty's the return of consciousness.
lips or teeth.
21-11
Performance Steps
NOTE:
CAUTION: NPA insertion may cause nasal bleeding.
All body fluids should be considered potentially
infectious. Always observe body substance 5. Place the patient in the recovery (lateral
isolation (BSI) precautions by wearing gloves recumbent, coma) position to prevent
and eye protection as a minimal standard of aspiration of blood, mucus, or vomitus.
protection. 6. Monitor the casualty's respirations on a
regular basis.
1. Place the patient supine with the head in a
neutral position. a. Reassess air exchange and placement
every time the casualty is moved.
CAUTION:
b. Assist with respirations if the respiratory
Do not use a NPA if the patient has
rate falls below 8 or rises above 30 per
maxillofacial or head trauma.
minute or a pulse oximeter reading
2. Select the appropriate size NPA by <90%.
measuring from the tip of the patient's nose 7. Record the procedure.
to earlobe.
8. Evacuate the patient.
3. Coat the distal tip (non-flanged end) of the
NPA with a water-soluble lubricant.
INSERT A COMBITUBE®23
CAUTION:
Do not use a petroleum-based or non-water- Scenario
based lubricant. These substances can cause
damage to the tissues lining the nasal cavity and An unconscious casualty requires the
pharynx thus increasing the risk for infection. insertion of an esophageal tracheal
Combitube®. An assistant is performing
4. Insert the NPA. resuscitative measures. No cervical spine injury
is present.
a. Push the tip of the nose upward gently.
b. Position the tube so that the bevel of the Objective
airway faces toward the septum.
Insert the Combitube® and successfully
NOTE: ventilate the casualty without causing further
Most NPAs are designed to be placed in the injury.
right nostril.
Performance Steps
c. Gently advance the lubricated NPA into
the nostril with the curvature of the
1. Take Body Substance Isolation (BSI)
device following the curve of the floor of
precautions.
the nose. Advance it until the flange rests
against the nostril. 2. Inspect upper airway for visible
obstruction.
CAUTION:
3. Inspect and test equipment.
Never force the NPA into the patient's nostril.
If resistance is met, pull the tube out and attempt 4. Lubricate distal end of tube.
to insert it in the other nostril. 5. Perform a tongue-jaw lift.
If the patient becomes intolerant of the airway,
gently withdraw it from the nasal passage.
21-12
6. Insert device until casualty's teeth sit Performance Steps
between printed black rings, within 3
attempts.
1. Take body substance isolation (BSI)
7. Inflate #1 (blue) cuff with appropriate precautions.
amount of air based on size of tube.
2. Inspect the upper airway for visible
8. Inflate #2 (white) cuff with appropriate obstruction.
amount of air based on size of tube.
3. Direct the assistant to pre-oxygenate the
9. Direct assistant to ventilate casualty with a casualty for a minimum of 30 seconds.
BVM through primary tube.
4. Inspect and test equipment.
10. Perform steps 5-9 in less than 30 seconds.
5. Lubricate the distal end of the tube with
11. Watch for rise and fall of the chest, water soluble lubricant.
auscultate for breath sounds and over the
6. Perform a tongue-jaw lift.
epigastrium to confirm tube placement.
7. Insert the device until the base connector is
12. Assess casualty for spontaneous
aligned with the casualty's teeth.
respirations for 10 seconds.
8. Inflate the cuffs with the appropriate
13. Attach pulse oximeter to casualty, if
amount of air based on the size of the tube.
available.
a. Use size 3 if the casualty is less than 61
14. Monitor the casualty's respirations on a
inches in height. Inflate with 60 ml of air.
regular basis.
b. Use size 4 if the casualty is 61 inches to
a. Reassess air exchange and placement
71 inches in height. Inflate with 80 ml of
every time the casualty is moved.
air.
b. Assist with respirations if the respiratory
c. Use size 5 if the casualty is taller than 71
rate falls below 8 or rises above 30 per
inches in height. Inflate with 80 ml of air.
minute or a pulse oximeter reading
<90%. 9. Direct the assistant to ventilate the casualty
with a BVM.
15. Secure device to the casualty around
casualty's neck. 10. Auscultate the lung fields and epigastrium,
and watch for rise and fall of the chest to
confirm tube placement.
INSERT A KING LT® AIRWAY23
11. Assess casualty for spontaneous
Scenario respirations for 10 seconds.
12. Attach pulse oximeter to casualty.
An unconscious casualty requires the
insertion of an esophageal airway. An assistant 13. Ventilate casualty when respirations are <8
is performing resuscitative measures. No or > 30 or a pulse oximeter reading <90%.
cervical spine injury is present. 14. Secure the device to the casualty.
Objective
21-13
15. Monitor the casualty's respirations on a b. Airway tube: ET tube, tracheotomy tube,
regular basis. or any non-collapsible tube that will
allow enough airflow to maintain oxygen
a. Reassess air exchange and placement
saturation.
every time the casualty is moved.
b. Assist with respirations if the respiratory NOTE:
rate falls below 8 or rises above 30 per In a field setting, an ET tube is preferred
minute or a pulse oximeter reading because it is easy to secure. Use a size 6.0 to 7.0
<90%. ET tube, and ensure the cuff will hold air.
16. Evacuate the casualty. 2. Hyperextend the casualty's neck.
21-14
6. With the cutting instrument in the dominant 15. Secure the tube, using tape, cloth ties, or
hand, make a 1-1/2 inch vertical incision other measures, and apply a dressing to
through the skin over the cricothyroid further protect the tube and incision.
membrane.
16. Monitor the casualty's respirations on a
regular basis.
NOTE:
A vertical incision will allow visualization of the a. Reassess air exchange and placement
cricothyroid membrane, but keep the scalpel every time the casualty is moved.
blade away from the lateral aspect of the neck.
b. Assist with respirations if the respiratory
This is important because of the large blood
rate falls below 8 or rises above 30 per
vessels located there, i.e. carotid artery and
minute or a pulse oximeter reading
jugular vein.
<90%.
17. Evacuate casualty.
CAUTION
Do not cut the cricothyroid membrane with this PERFORM A NEEDLE CHEST
incision. DECOMPRESSION23
21-15
Performance Steps
WARNING:
Proper positioning of the needle is essential to
NOTE: avoid puncturing blood vessels and or nerves.
Pneumothorax is defined as the presence of air Blood vessels and nerves run along the bottom
within the chest cavity. Air enters either from of each rib.
the lungs through a rupture, laceration, or from
the outside through a sucking chest wound. 3. Withdraw the needle while holding the
Trapped air in the chest cavity under pressure, catheter still.
called a tension pneumothorax, compresses the
lung beneath it. NOTE:
The casualty's respiration should improve.
21-16
2. Assemble and prepare the equipment. 5. Apply the NRB mask.
a. Inspect the oxygen cylinder and its a. Select the correct size of mask.
markings.
NOTE:
NOTE: The apex of the mask should fit over the bridge
Ensure the cylinder is labeled for medical of the patient's nose and extend to rest on the
oxygen; the bottles may be completely green, chin, covering the mouth and nose completely.
silver, or chrome with a green area around the NRB masks come in different sizes for adults,
valve stem on top. children, and infants.
21-17
8. Check the equipment for security of tubing f. Determine the flow rate as prescribed by
connections and administration device, medical direction.
oxygen flow, and humidified water level as
g. Determine the duration of the oxygen by
indicated.
dividing the available liters by the flow
rate. Example: 288 available liters
NOTE:
divided by the prescribed flow rate of 10
Change the delivery device and tubing IAW
LPM = 28.8 (29) minutes duration of
local protocols.
oxygen flow.
9. Calculate the duration of flow of the 10. Follow safety precautions.
oxygen cylinder.
a. Ensure "OXYGEN" and "NO
a. Determine the remaining pressure in the SMOKING" signs are posted wherever
tank by reading the regulator gauge. oxygen is used or stored.
b. Determine the safe residual level of the b. Inform the patient and visitors about the
oxygen tank. restrictions.
NOTE: WARNING:
The safe residual level of the oxygen at which The principle danger in using oxygen is fire.
the tank should be replaced has been established
to be 200 psi. The presence of oxygen in increased
concentrations makes all materials more
c. Determine the available cylinder pressure combustible.
by subtracting the safe residual level
from the remaining pressure. Example: Materials that burn slowly in ordinary air, burn
2000 psi remaining pressure minus 200 violently and even explosively in the presence of
psi safe residual level = 1800 psi oxygen.
available pressure.
d. Determine the conversion factor for the c. Use only non-sparking wrenches on
oxygen cylinder in use. oxygen cylinders.
d. Ensure all electrical equipment is
NOTE: properly grounded.
Each type of oxygen cylinder, depending on its
size, employs a specific conversion factor. e. Position oxygen cylinders away from
doors and high traffic areas.
i. D size oxygen cylinder--0.16. f. Do not use oil or grease around oxygen
ii. E size oxygen cylinder--0.28. fittings.
iii. G size oxygen cylinder--2.41. g. Secure and store oxygen cylinders in an
upright position.
iv. H size oxygen cylinder--3.14.
v. K size oxygen cylinder--3.14.
vi. M size oxygen cylinder--1.56.
e. Determine the available liters by
multiplying the conversion factor by the
amount of available pressure. Example:
A "D" size cylinder is being used. A 0.16
conversion factor x 1800 psi available
pressure = 288 liters of oxygen available
for use.
21-18
SHOCK28 2. Distributive (Vasogenic) shock - occurs
when the vascular container (blood vessels)
dilate (enlarge) without a proportional
LEARNING OBJECTIVES:
increase in fluid volume. As a result, the
heart’s preload decreases (blood available
Explain the signs and symptoms of shock.
for pumping out to the body to provide
oxygen and nutrients), and thus cardiac
Determine treatment by the type of shock
output falls leaving the tissues hypoxic and
presented.
starved for energy.
21-19
STAGES OF SHOCK seconds. In a tactical environment, treatment
should not be delayed. Controlling major
Shock occurs in three successive stages. hemorrhage should be the first priority over
The HM's goal is to recognize the signs of the securing an airway.
early stages of shock and begin immediate
treatment before the permanent damage Signs and symptoms seen with hemorrhagic
occurs. The three stages of shock are shock are normally linked with the amount of
compensated, decompensated and irreversible. blood lost and the casualty’s internal reaction to
this blood loss. DO NOT rely on BP as the main
• Compensated (Non-progressive) Shock: At
indicator of shock! More attention should be
this stage, the blood pressure is maintained;
paid to the casualty’s mental status, quality of
however, there is a narrowing of the pulse
distal pulses, and tachycardia. Hemorrhagic
pressure, which is the difference between
shock, which is hypovolemic shock resulting
the systolic and diastolic pressures.
from blood loss, can be categorized into four
Treatment at this stage will typically result
classes, depending on the severity of
in recovery
hemorrhage. Remember these parameters are
• Decompensated (Progressive) Shock: At only guidelines and should not be taken as
this stage, the blood pressure is falling absolute amounts of associated blood loss
because the blood volume has dropped 15 to (Table 21-3).
25%. The compensatory mechanisms are
beginning to fail, and signs and symptoms
What happened to ABC’s?
are much more obvious. At this point,
vasoconstriction can have a disastrous effect
The brain can go four to six minutes without
if allowed to continue. Treatment at this
oxygen before permanent damage or death.
stage will sometimes result in recovery
Death from massive hemorrhage may occur
• Irreversible Shock: Shock has progressed to within two minutes.
a terminal stage. Arterial blood pressure is
abnormally low. There are life-threatening
reductions in cardiac output, blood pressure,
and tissue perfusion. Even aggressive
treatment at this stage does not normally
result in recovery
21-20
CLASSIFICATIONS OF HEMORRHAGIC SHOCK
Class I Class II Class III Class IV
Amount of Blood Loss <750ml 750- 1500-2000ml >2000ml
(% total blood volume) (<15%) 1500ml (30%- 40%) (>40%)
(15%- 30%)
Heart rate Normal or >100 >120 >140
minimally
increased
Pulse (quality) Normal Thready Thready/ very No Radial/ thready
weak Carotid
Capillary Refill Normal Delayed Delayed Delayed
(3-5 seconds) (>5 seconds) (>5 seconds)
Respiratory Rate Normal 20-30 30-40 >35
SBP Normal Normal Decreased Greatly Decreased
(<80 mmHg) (approx. 60 mmHg)
Skin Color Pink Pale White White extremities/
extremities/ Ashen Gray/
Ashen Gray Cyanotic
Skin Temperature Cool Cool, Moist Cool Cold Extremities
Extremities
Mental Status Normal Anxiety Severe Anxiety Lethargic
Fright Confused Unconscious
This stage has few clinical manifestations. At this point, unfavorable signs begin to
The casualty's body is able to compensate to appear. The body’s compensatory systems can
maintain homeostasis. “A tactically relevant no longer maintain adequate perfusion. The
definition of shock in a combat trauma casualty classic signs of shock (tachycardia, tachypnea,
is an abnormal radial pulse (weak or absent) and and confusion) become obvious. HMs must see
an abnormal mentation (LOC) not attributed to the importance of catching the casualty in the
drug therapy or brain injuries28.” early stages of shock because by the time the
casualty gets to this stage, he or she is in
Class II Shock significant trouble.
21-21
Treatment NEUROGENIC SHOCK
See soft tissue injury section for Shock caused by an injury that interrupts the
Hemorrhage control procedures. spinal cord's sympathetic nervous system
pathway, resulting in significant dilation of
The field care phase will determine the peripheral arteries. Because of the loss of
HM’s actions; Care Under Fire phase use a sympathetic control of the vascular system
tourniquet for life-threatening extremity which controls the smooth muscle in the walls of
hemorrhage and Tactical Field Care phase use the blood vessels, the peripheral vessels dilate
direct pressure and or a hemostatic dressing. below the level of injury.
Once the bleeding is stopped obtain vascular
access, give resuscitative fluids, and coordinate Signs and Symptoms
Casualty Evacuation (CASEVAC).
See Table 21-3 and below.
Three Types of Distributive Shock 1. Injuries consistent with spinal injury.
2. Bradycardia with hypotension (low
Septic heart rate with low blood pressure
Neurogenic should be a red flag, start suspecting
Psychogenic neurogenic shock).
3. The casualty with neurogenic shock, in
SEPTIC SHOCK the absence of traumatic brain injury, is
alert, orientated, and lucid (clear in the
Shock caused by a systemic infection. In mind) when in the supine (laying down
these cases the bacteria multiply rapidly on back) position.
throughout the body releasing toxins into the
blood stream. The toxins cause the blood vessels Treatment
in the periphery (arms and legs) to dilate
maldistributing the blood away from critical 1. Maintain ABC’s.
areas (i.e. brain, heart, and lungs).
2. Spinal Immobilization (if mechanism of
Signs and Symptoms injury causes a high suspicion of spinal
injury).
See Table 21-3. 3. Oxygen therapy to keep oxygen
saturation >92% (if available).
Treatment
4. Obtain IV access and give fluids, if
It typically takes between 5-7 days for septic necessary.
shock to develop. However, HMs may be called 5. Trendelenburg position (head down, feet
on to care for a casualty who sustained an injury elevated).
and did not promptly seek medical attention. If
6. Keep patient warm.
so, a HM’s primary focus should be to
CASEVAC the casualty to a higher echelon of 7. CASEVAC.
care. Additionally, the casualty will require IV
antibiotic therapy with a broad spectrum
antibiotic.
21-22
PSYCHOGENIC (VASOVAGAL) SHOCK Signs and Symptoms
Because it is a self-limited condition, a External factors that cause the heart not to
vasovagal episode is unlikely to result in true work properly (i.e., tension pneumothorax and
“shock” and normal blood pressure is quickly cardiac tamponade)
restored when the casualty is placed in a
horizontal position.
Why do WE learn something that WE can’t
CARDIOGENIC SHOCK treat?
Failure of the heart to adequately pump Answer: Use these signs and symptoms of
blood throughout the body, resulting from cardiac tamponade as a way for ruling out
causes that can be categorized as either intrinsic tension pneumothorax.
(a result of direct damage to the heart itself, a
heart attack, for instance) or extrinsic (related to
Signs and Symptoms
a problem outside the heart, a tension
pneumothorax, for example). In this scenario, • Tension Pneumothorax:
the container is the correct size and is filled with
• Chest trauma
the right amount of fluid; it is the pump that is
not functioning properly. • Shortness of breath/dyspnea
21-23
• Cardiac Tamponade: In fact, one researcher found that IV fluids
administered in the field were beneficial only
• Chest Trauma when three conditions existed:
• Shortness of breath/dyspnea • Casualty is bleeding at a rate of 25 to
• Tachycardia 100 mL/min
• Cyanosis • IV fluid administration rate is equal to
the bleeding rate
• Distant (muffled) heart tones/sounds
• Scene time and transport time exceed 30
• Narrowing pulse pressure minutes
Therefore, transport of the trauma casualty
Treatment should never be delayed to start an IV.
21-24
Scene Assessment / Scene Size Up The second priority once arriving on scene
is identifying the total number of patients. Some
The Scene Assessment is broken down into of this information may be provided to the HM
two stages with the first being Scene Assessment during the initial notification of incident, but
and the second being the Scene Size Up. The once on the scene it is imperative that the HM
Scene Assessment process begins from the visualize each patient and begin a triage process.
moment HMs are notified of the incident. Think The third priority in the Scene Assessment / Size
of it as a mental exercise or checklist. HMs Up process is to identify and consider the
should “Arm Chair Quarterback” the mechanism of injury (MOI). The MOI will lead
information received once notified and start to the HM to the index of suspicion (IOS).
brain storming what could potentially be seen
once he/she arrives on the actual scene. The size The MOI is simply defined as the basic
up occurs once HMs can visualize the scene for manner in which the casualty was injured. For
themselves. The reason for the two step process example, a casualty that was involved in a
is simple; as with the communication exercise collision is subject to multiple forces resulting
“Telephone,” what is assessed upon arriving at from the collision. Regardless of injury pattern,
the scene may be totally different then what was the MOI is generally described as deceleration
reported through the notification process. The trauma (abrupt stopping from being in motion).
three priorities of the Scene Assessment / Size As an additional example, a casualty that
Up are: receives a gunshot or stab wound has a MOI of
penetrating trauma and conversely a member
1. Safety.
struck with a bat has a MOI of blunt trauma.
2. Identification of Patients.
3. Mechanism of Injury. The IOS is derived directly from the MOI
and is defined as the injury patterns the casualty
Once on scene, the first priority is always will display based on the MOI. Using the
safety. Safety is a relative term when examples above, deceleration trauma can result
considering a tactical environment. The HM’s in cervical spine injury, solid organ shear, or
responsibility is to place the patient, bystanders, musculoskeletal injury. Penetrating trauma can
and ultimately him/herself in the safest position result in hollow organ rupture, sucking chest
relative to the situation. wounds, and abdominal evisceration. Blunt
trauma can result in hollow organ or solid organ
In the Scene Size Up, consideration should rupture. These examples are meant to simply
also be paid to the environmental and identify potential injury patterns specific to this
geographic area that the incident has occurred. text. The responder must fully assess and
For example, a casualty who has been injured in evaluate each patient to positively identify life
a desert environment may require interventions threatening conditions and treat them
to treat an environmental injury as well as the accordingly.
physical injuries identified during the patient
assessment. An additional example would be Once the Scene Assessment and Size Up are
arriving on the scene of a patient that has complete the HM will have a better idea of the
received a gunshot wound and was bleeding number of patients and their severity of injury.
onto an absorbent material such as house carpet. After completing the patient assessment, he/she
This patient may require additional treatment for will then be able to compose a comprehensive
shock due to the blood loss not readily visible treatment and evacuation plan to deliver the
due to the carpet. patients to definitive medical care.
21-25
PATIENT ASSESSMENT CEREBROVASCULAR ACCIDENT
21-26
CONVULSIONS Petit mal seizure is of short duration and is
characterized by an altered state of awareness or
Convulsions, or seizures, are a startling and partial loss of consciousness, and localized
often frightening phenomenon. Convulsions muscular contractions. The patient has no
are characterized by severe and uncontrolled warning of the seizure‘s onset and little or no
muscle spasms or muscle rigidity. Convulsive memory of the attack after it is over.
episodes occur in one to two percent of the
general population. First aid treatment for both types of
epileptic seizure consists of protecting the
Although epilepsy is the most widely casualty from self-injury. Additional methods
known form of seizure activity, there are of seizure control may be employed under a
numerous forms of convulsions that are medical officer's supervision. In all cases, be
classified as either central nervous system prepared to provide suction to the casualty
(CNS) or non-CNS in origin. It is especially since the risk of aspiration is significant.
important to determine the cause in patients Transport the patient to a medical treatment
who have no previous seizure history. This facility once the seizure has ended.
determination may require an extensive
medical workup in the hospital. Since epilepsy DROWNING
is the most widely known form of seizure
activity, this section will highlight epileptic Drowning is a suffocating condition in a
seizure disorders. water environment. Water seldom enters the
lungs in appreciable quantities because, upon
Epilepsy, also known as seizures or fits, is contact with fluid, laryngeal spasms occur, and
a condition characterized by an abnormal these spasms seal the airway from the mouth
focus of activity in the brain that produces and nose passages. To avoid serious damage
severe motor responses or changes in from the resulting hypoxia, quickly bring the
consciousness. Epilepsy may result from head casualty to the surface and immediately, even
trauma, scarred brain tissue, brain tumors, before the casualty is pulled to shore, start
cerebral arterial occlusion, fever, or a number artificial ventilation. Do not interrupt artificial
of other factors. Fortunately, epilepsy can ventilation until the rescuer and the casualty are
often be controlled by medications. ashore. Once on dry ground, quickly
administer an abdominal thrust (Heimlich
Grand mal seizure is the more serious type maneuver) to empty the lungs, and then
of epilepsy. Grand mal seizure may be but is immediately restart the ventilation until
not always preceded by an aura. The casualty spontaneous breathing returns. Oxygen
soon comes to recognize these auras, which enrichment is desirable if a mask is available.
allows him or her time to lie down and prepare Remember that an apparently lifeless person
for the seizure‘s onset. A burst of nerve who has been immersed in cold water for a
impulses from the brain causes long period of time may be revived if artificial
unconsciousness and generalized muscular ventilation is started immediately.
contractions, often with loss of bladder and
bowel control. The primary dangers in a grand PSYCHIATRIC EMERGENCIES
mal seizure are tongue biting and injuries
resulting from falls. A period of sleep or A psychiatric emergency is defined as a
mental confusion follows this type of seizure. sudden onset of behavioral or emotional
When full consciousness returns, the casualty responses that, if not responded to, will result in
will have little or no recollection of the attack. a life-threatening situation. Probably the most
common psychiatric emergency is the suicide
attempt. A suicide attempt may range from
verbal threats and suicidal gestures to a
successful suicide.
21-27
Always assume that a suicide threat is real; Toxic epidermal necrolysis is a condition
do not leave the patient alone. In all cases, the characterized by sudden onset, excessive skin
prime consideration for the HM is to keep irritation, painful erythema (redness of skin
patients from inflicting harm to themselves and produced by congestion of the capillaries),
to get them under the care of a trained bullae (large blisters), and exfoliation of the
psychiatric professional. When dealing with skin in sheets. TEN is also known as the
suicidal gestures or attempts, treat any self- scalded skin syndrome because of its
inflicted wounds appropriately. appearance. TEN is thought to be caused by a
staphylococcal infection in children and by a
In the case of ingested substances, do not toxic reaction to medications in adults.
induce vomiting in a patient who is not awake
and alert. For specific treatment of ingested Since skin is the largest single organ of the
substances, refer to Chapter 22, “Poisoning and body and serves as a barrier to infection,
Drug Abuse.” prevention of secondary skin infection is very
important. Treatment of skin infections
There are numerous other psychiatric consists of isolation techniques, silver nitrate
conditions that would require volumes to compresses, aggressive skin care, intravenous
expound upon. In almost all cases, appropriate antibiotic therapy, and in drug-induced cases,
first aid treatment consists of a calm, systemic steroids.
professional, understanding demeanor that
does not aggravate or agitate the patient. With
NOTE:
an aggressive or hostile patient, a show of
In the following assessment and treatment
force may be all that is required. A show of
sections assume the following is true for the
force involves at least 4 and preferably 5 scenarios presented:
personnel who approach the patient with one
person designated to maintain communication
(1) All required equipment is available.
with him or her. The intent is to let the patient
know that he or she must control his or her (2) None of the situations takes place in a
behavior or there is a team who will help the CBRNE environment.
patient control the behavior. Almost all cases
of psychiatric emergencies will present with a
third party often the family or friend of the
patient who has recognized a distinct change
in the behavior pattern of the patient and who is
seeking help for them.
DERMATOLOGIC EMERGENCIES
21-28
MEDICAL PATIENT ASSESSMENT23 d. Assess the airway.
i. Perform an appropriate maneuver to
Scenario
open and maintain the airway if
necessary.
The HM has a patient with a complaint that
is medical in nature and no significant ii. Insert an appropriate airway adjunct,
mechanism of injury. if necessary.
e. Assess breathing.
Objective
i. Determine the rate, rhythm, and
Perform a medical patient assessment quality of breathing.
without causing further injury. ii. Administer oxygen if necessary using
the appropriate delivery device.
NOTE: f. Assess circulation.
Take Body Substance Isolation (BSI)
precautions. i. Check skin color and temperature.
ii. Assess the pulse for rhythm and force.
1. Perform scene size-up. 1. Check the radial pulse in adults.
a. Determine the safest route to access the 2. Check the radial pulse and
patient. capillary refill in children under 6
years old.
b. Determine the mechanism of
injury/nature of illness. 3. Check the brachial pulse and
capillary refill in infants.
c. Determine the number of patients.
iii. Check for major bleeding.
d. Request additional help if necessary.
iv. Control major bleeding.
e. Consider stabilization of the spine.
v. Treat for shock.
2. Perform an Initial Assessment.
g. Identify priority patients and make a
a. Form a general impression of the patient
transport decision (load and go or stay
and the patient's environment.
and play).
b. Assess the patient's mental status using
the Alert, Verbal, Pain, Unresponsive NOTE:
(AVPU) scale. High priority conditions that require immediate
transport include poor general impression,
i. A - Alert and oriented. unresponsive, responsive but not following
ii. V - Responsive to verbal stimuli. commands, difficulty breathing, shock,
complicated childbirth, chest pain with systolic
iii. P - Responsive to painful stimuli.
blood pressure less than 100, uncontrolled
iv. U - Unresponsive. bleeding, and severe pain.
c. Determine the chief complaint/apparent
life-threatening condition.
21-29
3. Conduct a rapid physical exam if the 6. Time - How long has the patient
patient is unconscious. Inspect each of the had this feeling?
following areas for deformities, contusions,
7. Interventions - Has the patient
abrasions, punctures or penetration, burns,
taken any medication to help him
tenderness, lacerations, swelling (DCAP-
or her breathe? Did it help?
BTLS).
ii. Cardiac.
a. Assess the head.
1. Onset - When did it begin?
b. Assess the neck.
2. Provocation - What was the patient
c. Assess the chest. doing when this came on?
d. Assess the abdomen. 3. Quality - Can the patient describe
the feeling he or she has?
e. Assess the pelvis.
4. Radiates - Does the feeling seem to
f. Assess the extremities.
spread to any other part of the
g. Assess the posterior. body? Does the patient have pain
4. Gather a SAMPLE history from the patient: or discomfort anywhere else in the
signs and symptoms, allergies, medications, body?
past/pertinent medical history, last oral 5. Severity - On a scale of 1 to 10,
intake, and events preceding illness or how bad is the breathing trouble
injury. (10 is worst, 1 is best)?
21-30
8. Fever - Did the patient have a vi. Environmental emergency.
fever? What was the patient's
1. Source - What caused the injury?
temperature?
2. Environment - Where did the
iv. Allergic reaction.
injury occur?
1. History of allergies - Does the
3. Duration - How long was the
patient have any allergies?
patient exposed?
2. What the patient exposed to - Is
4. Loss of consciousness - Did the
there any chance that he or she was
patient lose consciousness at any
exposed to something to which he
time?
or she is allergic?
5. Effects (general or local) - What
3. How was the patient exposed -
signs and symptoms is the patient
How did he or she come into
having? What effect did being
contact with ___________
exposed have on the patient?
(whatever the patient is allergic
to)? vii. Obstetrics.
4. Effects - What kind of symptoms is 1. Is the patient pregnant?
the patient having? How long after 2. How long has she been pregnant
he or she was exposed did the (weeks or months)?
symptoms start?
3. Is the patient having pain or
5. Progression - How long after contractions?
exposure did the symptoms start?
Are they worse now than they were 4. Is the patient bleeding? Is the
before? patient having any discharge?
6. Interventions - Has the patient 5. Does she feel the need to push?
taken anything to help? Did it 6. When was her last menstrual
help? period?
v. Poisoning/overdose. viii. Behavioral.
1. Substance - What substance was 1. How does the patient feel?
involved?
2. Determine suicidal tendencies -
2. When did the patient Does the patient have a plan to hurt
ingest/become exposed - When did himself or herself or anyone else?
the exposure/ingestion occur?
3. Is the patient a threat to self or
3. How much did the patient ingest - others?
How much did the patient ingest?
4. Is there a medical problem?
4. Over what time period - Over how
long a period did the ingestion 5. Interventions?
occur? b. Allergies?
5. Interventions - What interventions c. Medications?
did the family or bystanders take?
d. Past pertinent history?
6. Estimated weight - What is the
patient's estimated weight? e. Last oral intake?
f. Event(s) leading to present illness?
21-31
5. Perform a focused physical examination on ii. Note whether or not the patient can
the affected body part/system. speak in full sentences.
6. Obtain baseline vital signs. iii. Look for the presence of drooling that
may indicate a partial or complete
7. Provide medication, interventions, and
airway obstruction.
treatment as needed.
b. Assist with artificial ventilations if
8. Re-evaluate the transport decision.
respiratory effort and rate are inadequate.
9. Consider completing a detailed physical
i. Look for the rise and fall of the chest
examination.
during inspiration and expiration.
10. Perform Ongoing Assessment.
ii. Listen for the presence of noisy
a. Repeat the initial assessment. respirations (e.g., stridor, wheezing).
b. Repeat vital signs. c. Apply supplemental oxygen by mask or
c. Repeat the focused assessment regarding nasal cannula.
the patient's complaint or injuries.
NOTE:
Any casualty complaining of difficulty breathing
RESPIRATORY EMERGENCY should receive supplemental oxygen.
ASSESSMENT23
d. Place the patient in the position of
Scenario comfort.
CAUTION:
A patient experiencing respiratory distress can
rapidly progress to full arrest. Always be
prepared to utilize advanced airway procedures.
21-32
3. Obtain a focused history. e. Have the patient place his lips on the
mouth piece and slowly inhale and exhale
a. Ask the patient if there is an existing
the mist.
condition such as asthma.
f. Monitor the patient's vital signs every 5
b. Ask the patient if he is taking any
minutes. If available, attach the casualty
medications.
to a pulse oximeter.
c. Question the patient about allergies to
6. Document the procedure.
medications.
7. Evacuate the patient.
d. Ask the patient if difficulty breathing was
of sudden or gradual onset.
CARDIAC EMERGENCIES
4. Assist the patient in using a metered dose
inhaler. A number of heart conditions are commonly
referred to as heart attacks. These conditions
NOTE: include angina pectoris, acute myocardial
This step may only be performed if the casualty infarction, and congestive heart failure. Together
has an inhaler prescribed to him. these heart conditions are the cause of at least
half a million deaths per year in the United
a. Perform the five rights of medication States. Heart conditions occur more commonly
dosage. in men in the 50-to-60-year age group.
b. Have the patient exhale deeply. Predisposing factors are the lack of physical
conditioning, high blood pressure and blood
c. Have the patient place his lips around the cholesterol levels, smoking, diabetes, and a
opening and press the inhaler to activate family history of heart disease.
the spray as he inhales deeply.
d. Instruct the patient to hold his breath as Angina Pectoris
long as possible before exhaling.
Angina pectoris, also known simply as
e. Repeat steps 4b through 4d. angina, is caused by insufficient oxygen being
5. Administer a nebulizer treatment. circulated to the heart muscle. This condition
results from a spasm of the coronary artery,
NOTE: which allows the heart to function adequately
This step may only be performed with a medical at rest but does not allow enough oxygen-
officer's order for a nebulizer treatment. enriched blood to pass through the heart to
support sustained exercise. When the body
a. Set up the nebulizer per manufacturer's exerts itself, the heart muscle becomes starved
guidelines. for oxygen. The result of this condition is a
b. Instill the appropriate medicine IAW squeezing, substernal pain that may radiate to
local SOP. the left arm and to the jaw.
21-33
Other first aid procedures include CARDIAC EMERGENCY ASSESSMENT24
providing supplemental oxygen, reassurance,
comfort, monitoring vital signs, and Scenario
transporting the casualty to a medical treatment
facility. The HM has a conscious patient who is
complaining of chest pain. The HM has already
Acute Myocardial Infarction taken the appropriate body substance isolation
(BSI) precautions. The HM has already done the
Acute myocardial infarction results when initial patient assessment, focused history, and
a coronary artery is severely occluded by physical.
arteriosclerosis or completely blocked by a clot.
The pain associated with myocardial infarction Objective
is similar to that of angina pectoris but is
longer in duration, not related to exertion or Complete all necessary steps to manage a
relieved by nitroglycerin, and leads to death of patient with a cardiac emergency, without
heart-muscle tissue. Other symptoms are causing any further injury.
sweating, weakness, and nausea. Additionally,
although the patient’s respirations are usually
1. Identify the signs and symptoms of cardiac
normal, his pulse rate increases and may be
emergency or compromise.
irregular, and his blood pressure falls. The
casualty may have an overwhelming feeling of a. Pain, pressure, or discomfort in the chest
doom. Death may result. or upper abdomen (epigastrium).
b. Dyspnea.
Congestive Heart Failure
c. Palpitations.
A heart suffering from prolonged d. Sudden onset of sweating with nausea or
hypertension, valve disease, or heart disease vomiting.
will try to compensate for decreased function by
increasing the size of the left ventricular e. Anxiety (feeling of impending doom or
pumping chamber and increasing the heart rate. irritability).
This condition is known as congestive heart f. Abnormal pulse.
failure. As blood pressure increases, fluid is
forced out of the blood vessels and into the i. Bradycardia (less than 60 beats per
lungs, causing pulmonary edema. Pulmonary minute).
edema leads to rapid shallow respirations, the ii. Tachycardia (greater than 100 beats
appearance of pink frothy bubbles at the nose per minute).
and mouth and distinctive rattling sounds
(known as rales) in the chest. Increased blood g. Abnormal blood pressure.
pressure may also cause body fluids to pool in i. Hypotensive (systolic pressure less
the extremities resulting in peripheral edema. than 90).
Emergency treatment for congestive heart
failure is essentially the same as that for acute ii. Hypertensive (systolic pressure
myocardial infarction. Do not start CPR unless greater than 140).
the patient s heart function ceases. If an
intravenous line is started, it should be
maintained at the slowest rate possible to keep
the vein open since an increase in the
circulatory volume will make the condition
worse. Immediately transport the patient to a
medical treatment facility.
21-34
h. Pulmonary edema.
v. Have the patient close his or her
i. Shortness of breath. mouth and hold the tablet under the
tongue.
ii. Dyspnea.
vi. Replace the oxygen mask.
iii. Rales upon auscultation.
vii. Recheck the blood pressure within
iv. Blood tinged sputum.
two minutes.
i. Pedal edema.
NOTE:
2. Administer the appropriate treatment.
If the blood pressure falls below 100, treat the
a. Place the patient in a position of comfort. patient for shock and transport immediately.
21-35
2. Recognize the early manifestations of an 4. Treat allergic reactions.
allergic or anaphylactic reaction.
NOTE:
a. Skin. Take Body Substance Isolation (BSI)
i. Flushing. precautions.
ii. Urticaria (hives).
iii. Swelling of face (especially eyes and a. Perform initial assessment ABCs (treat
lips), hands, feet, neck. any life-threatening conditions).
iv. Swelling of mouth, tongue, airway b. Perform a focused history and physical
(angioedema). exam.
b. Respiratory. c. Assess baseline vital signs and SAMPLE
history.
i. Tightness in throat and chest.
d. Manage the patient's airway and
ii. Cough.
breathing. If the patient has an
iii. Rapid, labored noisy breathing. epinephrine autoinjector and has
symptoms of anaphylaxis, assist in the
iv. Stridor (harsh, high pitched sound
epinephrine administration.
during inspiration).
5. Evacuate the patient to the nearest medical
v. Wheezing (may be audible without a
treatment facility (MTF).
stethoscope).
c. Cardiac.
ANAPHYLACTIC EMERGENCY
i. Increased heart rate.
This condition, also called anaphylaxis or
ii. Decreased blood pressure.
anaphylactic shock, is a severe allergic reaction
d. Generalized feelings. to foreign material. The most frequent causes
i. Itchy, watery eyes. are probably penicillin and the toxin from bee
stings, although foods, inhalants, and contact
ii. Headache. substances can also cause a reaction.
iii. Runny nose. Anaphylaxis can happen at any time, even to
people who have taken penicillin many times
iv. Sense of impending doom. before without experiencing any problems. This
3. Recognize the signs of anaphylactic shock. condition produces severe shock and
cardiopulmonary failure of a very rapid onset.
a. May have any of the above, but must Because of the rapidity and severity of the
have signs of respiratory distress or onset of symptoms, immediate intervention is
shock. necessary. The general treatment for severe
b. Altered mental status. anaphylaxis is the subcutaneous injection of
0.3 cc of epinephrine and supportive care.
c. Signs of respiratory distress.
d. Signs of shock. The most characteristic and serious
symptoms of an anaphylactic reaction are loss
of voice and difficulty breathing. Other typical
signs are giant hives, coughing, and wheezing.
As the condition progresses, signs and
symptoms of shock develop, followed by
respiratory failure. Emergency management
consists of maintaining vital life functions.
Summon the medical officer immediately.
21-36
ANAPHYLACTIC SHOCK ASSESSMENT23 v. Respiratory failure.
c. Circulatory.
Scenario
i. Weak, rapid pulse.
The HM needs to treat a casualty for an ii. Falling blood pressure.
anaphylactic shock.
iii. Hypotension.
Objective iv. Dizziness or fainting.
Initiate treatment for anaphylactic shock, v. Coma.
stabilize the casualty, and minimize the effects 2. Open the airway, if necessary.
of anaphylaxis without causing further injury to
the casualty. NOTE:
In cases of airway obstruction from severe
Performance Steps glottic edema, a cricothyroidotomy may be
necessary.
NOTE:
Anaphylactic reactions occur within minutes or 3. Administer high concentration oxygen.
even seconds after contact with the substance to 4. Administer epinephrine.
which the patient is allergic. Reactions occur in
the skin, respiratory system, and circulatory a. Administer 0.3 - 0.5 ml of epinephrine,
system. 1:1000 solution, subcutaneously (SQ) or
intramuscularly (IM).
NOTE: NOTE:
Take Body Substance Isolation (BSI) Annotate the time of injection.
precautions.
b. Additional epinephrine may be required
1. Check the casualty for signs and symptoms if anaphylaxis progresses. Additional
of anaphylactic shock. doses may be administered every 5 to 10
minutes if needed.
a. Skin.
5. Initiate an intravenous (IV) infusion.
i. Flushed or ashen.
6. Provide supportive measures for the
ii. Burning or itching. treatment of shock, respiratory failure,
iii. Edema (swelling), especially in the circulatory collapse or cardiac arrest.
face, tongue, or airway. a. Infuse additional IV fluid if blood
iv. Urticaria (hives) spreading over the pressure continues to drop.
body. b. Position the casualty in the supine
v. Marked swelling of the lips and position with legs elevated if injuries
cyanosis about the lips. permit.
b. Respiratory. c. Perform rescue breathing, if necessary.
i. Tightness or pain in the chest. d. Administer external chest compressions,
if necessary.
ii. Sneezing and coughing.
7. Check the casualty's vital signs every 3 to 5
iii. Wheezing, stridor, or difficulty in minutes until the casualty is stable.
breathing (dyspnea).
8. Record the treatment given.
iv. Sputum (may be blood tinged).
21-37
9. Evacuate the casualty, providing supportive b. Inhaled poisons.
measures en route.
i. Carbon monoxide.
1. Headache.
POISONS/DRUG ABUSE/HAZARDOUS
MATERIALS EMERGENCIES 2. Dizziness.
3. Dyspnea.
HMs can encounter special situations that
include poisoning, suspected drug abuse, or 4. Nausea/vomiting.
exposure to hazardous materials. Knowledge of 5. Cyanosis.
these conditions along with the ability to assess
and treat them is essential. These situations are 6. Coughing.
discussed in detail in Chapter 22, "Poisoning ii. Smoke Inhalation.
and Drug Abuse."
1. Dyspnea.
23
POISONED CASUALTY ASSESSMENT 2. Coughing.
Scenario 3. Breath that has a smoky smell or
the odor of chemicals involved at
The HM has a casualty that has been the scene.
poisoned. All other more serious injuries have 4. Black residue in any sputum
been assessed and treated. The HM has taken coughed up by the casualty.
body substance isolation (BSI) precautions and
has performed an initial assessment. 5. Nose-hairs singed from super-
heated air.
Objective c. Injected poisons.
21-38
iii. Hallucinogens (LSD). 1. Adults and children: 1 gram of
activated charcoal/kg of body
1. Tachycardia.
weight.
2. Dilated pupils.
2. Usual adult dose: 25 - 50 grams.
3. Flushed face.
3. Usual pediatric dose: 12.5 - 25
4. Often sees or hears things, has very grams.
little concept of time.
NOTE:
iv. Narcotics (Morphine, heroin).
Mix with soda for easier consumption.
1. Reduced rate of breathing.
v. Give supplemental oxygen.
2. Dyspnea.
vi. Record the name, dose, and time of
3. Low skin temperature.
administration of medication.
4. Muscles relaxed.
vii. Transport to the nearest medical
5. Pinpoint pupils. treatment facility.
6. Very sleepy. b. Inhaled poisons.
d. Absorbed poisons. i. Remove the casualty from the unsafe
environment.
i. Liquid or powder on the casualty's
skin. ii. Maintain the airway.
ii. Burns. iii. Administer high concentrations of
oxygen.
iii. Itching.
iv. Irritation. NOTE:
Oxygen therapy is the most important treatment
v. Redness.
for inhalation poisoning.
2. Administer emergency care.
iv. Transport to the nearest medical
a. Ingested poisons. treatment facility.
i. Maintain the airway. v. Document interventions.
ii. Gather all information about the type c. Absorbed poisons.
of ingested poisoning.
i. Remove the casualty from the source.
iii. Initiate IV therapy.
ii. Remove contaminated clothing.
iv. Administer activated charcoal.
iii. Brush off any powders from the
CAUTION: casualty's skin.
Activated charcoal is contraindicated for patients
iv. Flush the skin with large amounts of
that have an altered mental status that are
water for at least 20 minutes.
suspected of swallowing acids or alkalis, or have
an inability to swallow.
NOTE:
Be prepared to provide oral suctioning if the
casualty starts to vomit. All vomitus must be
saved.
21-39
d. Injected poisons. Respirations are deep, and a sickly sweet
acetone odor is present on the breath. The skin
i. Maintain the airway and be prepared
is warm and dry.
to provide assisted ventilations.
ii. Give supplemental oxygen.
NOTE:
iii. Initiate IV therapy. Diabetic casualties are often mistakenly treated
as if intoxicated since the signs and symptoms
iv. Look for gross soft tissue damage
presented are similar to those of alcohol
("tracks").
intoxication.
v. Protect the casualty from harming self
and others.
The diabetic under treatment tries to
NOTE: balance the use of insulin against glucose intake
Be prepared to use restraints. to avoid the above problems. The casualty or
the casualty’s family may be able to answer
vi. Transport to the nearest medical two key questions:
treatment facility. 1. Has the casualty eaten today?
3. Document procedures. 2. Has he taken the prescribed insulin?
If the answer is yes to the first and no to the
DIABETIC EMERGENCIES second question, the casualty is probably in a
diabetic coma.
Diabetes mellitus is an inherited condition
in which the pancreas secretes an insufficient Emergency first aid centers on ABC
amount of the protein hormone insulin. Insulin support, administration of oral or intravenous
regulates carbohydrate metabolism by enabling fluids to counter shock, and rapid evacuation to
glucose to enter cells for use as an energy medical officer's supervision.
source.
Insulin Shock
Diabetic Ketoacidosis
Insulin shock results from too little sugar in
Diabetic ketoacidosis most often results the blood (hypoglycemia). This type of shock
either from forgetting to take insulin or from develops when a diabetic exercises too much or
taking too little insulin to maintain a balanced eats too little after taking insulin. Insulin shock
condition. Diabetics may suffer from rising is a very serious condition because glucose is
levels of glucose in the blood stream driven into the cells to be metabolized, leaving
(hyperglycemia). The rising levels of glucose too little glucose in circulation to support the
result in osmotic diuresis, an increased renal brain. Brain damage develops quickly. Signs
excretion of urine. Serious dehydration and symptoms of insulin shock include:
(hypovolemia) may result.
• Pale, moist skin
Concurrently, the lack of glucose in the • Dizziness and headache
cells leads to an increase in metabolic acids in
the blood (acidosis) as other substances, such • Strong, rapid pulse
as fats, are metabolized as energy sources. The • Fainting, seizures, and coma
result is gradual central nervous system
depression, starting with symptoms of Treatment is centered on getting glucose
confusion and disorientation, and leading to into the system quickly to prevent brain damage.
stupor and coma. Blood pressure falls, and the Placing sugar cubes under the tongue or
pulse rate becomes rapid and weak. administering oral liquid glucose are the most
beneficial treatments.
21-40
Hard candies are a good interim treatment ii. Intoxicated appearance, staggering,
as well. Transport the casualty to a medical slurred speech, or unconsciousness.
treatment facility as soon as possible.
iii. Elevated heart rate.
iv. Cold, clammy skin.
NOTE:
If the HM is in doubt as to whether the casualty v. Hunger.
is in insulin shock or a ketoacidotic state, give
vi. Seizures.
them sugar.
vii. Uncharacteristic behavior.
Brain damage develops very quickly in insulin viii. Anxiety.
shock and must be reversed immediately.
ix. Combativeness.
If the casualty turns out to be ketoacidotic, a b. Hyperglycemia. (High blood sugar)
condition that progresses slowly, the extra
sugar will do no appreciable harm. i. Slow onset.
ii. Warm, red, dry skin.
DIABETIC EMERGENCY ASSESSMENT23 iii. Sweet, fruity breath odor (acetone).
Scenario iv. Deep, rapid breathing.
v. Dry mouth.
The HM has a patient with a diabetic
emergency. vi. Intense thirst.
vii. Abdominal pain.
Objective
viii. Nausea and vomiting.
Initiate treatment for hypoglycemia or 2. Administer the appropriate treatment.
hyperglycemia, stabilize the patient, and
minimize the effects without causing further
injury to the patient. NOTE:
If unsure whether the patient has hyperglycemia
NOTE: or hypoglycemia, it is safer to treat the patient
Take Body Substance Isolation (BSI) for hypoglycemia.
precautions.
a. Hypoglycemia.
1. Identify the signs and symptoms of a i. If conscious, administer oral glucose
diabetic emergency. IAW local protocol.
a. Hypoglycemia. (Low blood sugar)
NOTE:
NOTE: Give it only if the patient has a history of
Hypoglycemia is the most common of all diabetes, the patient has an altered mental status
diabetic emergencies. and the patient is awake enough to swallow.
21-41
ii. Monitor the patient for complications. HEAD INJURIES
iii. Assess vital signs.
Head wounds must be treated with particular
iv. If unconscious: care, since there is always the possibility of
1. Secure the airway and administer brain damage. The general treatment for head
oxygen. wounds is the same as that for other fresh
wounds. However, certain special precautions
2. Assess vital signs. must be observed if The HM is giving first aid
3. Start an intravenous IV at to keep to a person who has suffered a head wound.
vein open (TKO) rate.
HEAD INJURY ASSESSMENT23
4. Place the patient in the recovery
position. Scenario
21-42
i. Deformity of the head. iii. The casualty has a headache or is
seeing double.
ii. Clear fluid or blood escaping from the
nose and or ear(s). iv. The casualty may or may not have a
skull fracture.
iii. Periorbital discoloration (raccoon
eyes). c. Contusion--an internal bruise or injury.
It is more serious than a concussion. The
iv. Bruising behind the ears, over the
injured tissue may bleed or swell.
mastoid process (battle sign).
Swelling may cause increased
v. Lowered pulse rate if the casualty has intracranial pressure that may result in a
not lost a significant amount of blood. decreased level of consciousness and
vi. Signs of increased intracranial even death.
pressure. d. Open head injury.
1. Headache, nausea, and or vomiting. i. Penetrating wound--an entry wound
2. Possible unconsciousness. with no exit wound.
21-43
5. Assess the casualty's pupil size. vi. Control bleeding.
a. Observe the size of each pupil.
WARNING:
Do not apply pressure to or replace exposed
NOTE:
brain tissue.
A variation of pupil size may indicate a brain
injury.
vii. Treat for shock.
In a very small percentage of people, unequal
pupil size is normal. viii. Monitor the casualty for convulsions
or seizures.
b. Shine a light into each eye to observe the
ix. Position the casualty with the head
pupillary reaction to light.
elevated 6 inches to assist with the
drainage of blood from the brain.
NOTE:
The pupils should constrict promptly when
CAUTION:
exposed to bright light.
Do not give the casualty anything by mouth.
Failure of the pupils to constrict may indicate
brain injury. 8. Continue to monitor the casualty and check
and record the following at 5 minute
6. Assess the casualty's motor function.
intervals.
a. Evaluate the casualty's strength, mobility,
a. Level of consciousness.
coordination, and sensation.
b. Pupillary responsiveness and equality.
b. Document any complaints, weakness, or
numbness. c. Vital signs.
d. Motor functions.
NOTE:
Progressive loss of strength or sensation is an 9. Record the treatment.
important indicator of brain injury.
10. Evacuate the casualty.
7. Treat the head injury.
CHEST INJURIES
a. Treat a superficial head injury.
i. Apply a dressing. Since chest injuries may cause severe
ii. Observe for abnormal behavior or breathing and bleeding problems, all chest
evidence of complications. injuries must be considered as serious
conditions. Any casualty showing signs of
b. Treat a head injury involving trauma. difficulty in breathing without signs of airway
i. Maintain a patent airway using the obstruction must be inspected for chest injuries.
jaw thrust maneuver. The most serious chest injury that requires
immediate first aid treatment is the sucking
ii. If the casualty is unconscious, insert chest wound. This is a penetrating injury to the
an oropharyngeal airway without chest that produces a hole in the chest cavity.
hyper-extending the neck. The chest hole causes the lung to collapse,
iii. Administer high concentration oxygen preventing normal breathing functions. This is
by non-rebreather mask (NRB) and an extremely serious condition that will result
evaluate the need for artificial in death if not treated quickly.
ventilations with supplemental
oxygen.
iv. Apply a cervical collar.
v. Dress the head wound(s).
21-44
Casualties with open chest wounds gasp for i. Paradoxical breathing - the motion of the
breath, have difficulty breathing out, and may injured segment of a flail chest, opposite
have a bluish skin color to their face. Frothy- to the normal motion of the chest wall.
looking blood may bubble from the wound
j. Enlarged neck veins.
during breathing. The proper treatment for a
sucking chest wound is as follows: k. Coughing up blood or bloody sputum.
l. Tracheal deviation - shift of the trachea
TREAT A CASUALTY WITH A CHEST from the midline toward the unaffected
INJURY23 side due to pressure buildup on the
injured side. THIS IS A LATE SIGN.
Scenario
3. Check for an exit wound or injury.
The HM has a casualty with a chest injury. 4. Determine the type of injury.
All other more serious injuries have been
assessed and treated. a. Open pneumothorax - air entering
pleural space through defect in pleural
Objective wall.
i. Signs and symptoms.
Treat a chest wound without causing
additional injury to the casualty. 1. Respiratory distress.
2. Anxiousness.
Performance Steps
3. Tachypnea.
NOTE: ii. Treatment.
Take Body Substance Isolation (BSI) 1. Seal the wound(s), covering the
precautions. larger wound first.
1. Perform an initial assessment of the NOTE:
casualty. All penetrating chest wounds should be treated
2. Check the casualty for signs and symptoms as if they were sucking chest wounds.
of chest injuries.
2. Cut the dressing wrapper on one
a. Deformities, contusions, abrasions, long and two short sides and
punctures/penetrations (DCAP), remove the dressing.
bleeding, tenderness, lacerations,
swelling (BTLS). NOTE:
b. Pleuritic pain that is increased by or In an emergency, any airtight material can be
occurs with respirations and is localized used. It must be large enough so it is not sucked
around the injury site. into the chest cavity.
21-45
5. If the HM does not have the ability ii. Complications.
to perform a needle chest
1. Internal bleeding (hemothorax).
decompression, seal by applying
overlapping strips of tape to three 2. Shock.
sides of the plastic covering to iii. Treatment.
provide a flutter-type valve.
1. Use a sling and swathe to
6. If the HM has the ability to immobilize the affected side, i.e.
perform a needle chest immobilizing the arm as a means to
decompression (NCD), ensure all support the rib cage.
four sides of the occlusive dressing
are secured. (NCD procedures 2. Administer oxygen as necessary.
outlined later.)
NOTE:
7. Cover the exit wound in the same The broken rib may puncture the lung or the
way, if applicable. skin.
NOTE:
Assess the effectiveness of the flutter valve WARNING:
when the casualty breathes. Do not tape, strap, or bind the chest, these
interventions increase the development of
When the casualty inhales, the plastic should be pneumonia.
sucked against the wound, preventing the entry
of air. c. Flail chest - two or more ribs fractured in
two or more places or a fractured
When the casualty exhales, trapped air should be sternum.
able to escape from the wound and out the un-
taped side of the dressing. i. Signs and symptoms.
1. Severe pain at the site.
8. Supplement with oxygen if
available. 2. Rapid shallow breathing.
3. Paradoxical respirations.
WARNING:
Complication - if tension pneumothorax is ii. Complications.
suspected, perform a needle chest 1. Respiratory insufficiency.
decompression (NCD).
2. Pneumothorax with hemothorax.
b. Rib fracture - generally caused by a iii. Treatment.
direct blow to the chest or compression
of the chest. Severe coughing can also 1. Establish and maintain an airway.
cause rib fracture. 2. Administer oxygen, if available.
i. Signs and symptoms. 3. Assist the casualty's respirations, if
1. Pain is aggravated by respirations necessary.
and coughing. 4. Monitor the casualty for signs of
2. Crepitus is present. hemothorax or tension
pneumothorax, as necessary.
3. The casualty will guard to protect
the injury.
21-46
d. Hemothorax - bleeding from lacerated 4. Position the casualty for
blood vessels in the chest cavity and or evacuation. Conscious - in a
lungs. It results in the accumulation of comfortable position, preferably
blood in the chest cavity not outside the sitting. Unconscious - on the
lungs. injured side.
i. Signs and symptoms. ii. Treatment.
1. Hypotension due to blood loss. 1. Establish and maintain an airway.
2. Shock. 2. Perform NCD if indicated.
3. Cyanosis. 3. Administer oxygen.
4. Tightness in the chest. 4. Assist the casualty's respirations, as
necessary.
5. Mediastinal shift may produce
deviated trachea away from the 5. Monitor the casualty for
affected side. LATE SIGN progression of symptoms.
6. Coughing up frothy red blood. 5. Treat the injury.
ii. Complications. 6. Treat the casualty for shock.
1. Possibility of hypovolemic shock. 7. Record the care provided.
2. Frequently accompanies a 8. Evacuate the casualty.
pneumothorax.
NOTE:
iii. Treatment. Continue to assess the casualty.
1. Establish and maintain an airway. The casualty should be evacuated by the most
expedient means.
2. Administer oxygen.
3. Assist the casualty's breathing, as
ABDOMINAL INJURIES
necessary
e. Tension pneumothorax. A deep wound in the abdomen is likely to
constitute a major emergency since there are
NOTE: many vital organs in this area. Abdominal
Condition in which air enters the chest cavity wounds typically cause intense pain, nausea and
(pleural space) through a hole in the lung, vomiting, spasm of the abdominal muscles, and
expanding the space with every breath the severe shock. Immediate surgical treatment is
casualty takes. almost always required; therefore, the casualty
must receive medical attention at once, or the
The air becomes trapped and cannot escape. chances of survival will be poor. The HM should
give only the most essential first aid treatment,
i. Signs and symptoms. and concentrate efforts on getting the casualty
1. Chest pain. to a medical treatment facility. The following
first aid procedures may be of help to a person
2. Increased pressure in the chest suffering from an abdominal wound.
causes the lung(s) to collapse.
3. May result from the laceration of
the lung by a broken rib or by
spontaneous rupture of a bleb or
lesion on the lung.
21-47
ABDOMINAL INJURY ASSESSMENT23 4. Stabilize any protruding objects.
5. Apply a sterile abdominal dressing.
Scenario
NOTE:
The HM has a casualty with an open Protruding abdominal organs should be kept
abdominal wound. All other more serious moist to prevent the tissue from drying out.
injuries have been assessed and treated.
A moist, sterile dressing should be applied if
Objective available.
Treat an open abdominal wound, minimize a. Using the sterile side of the dressing, or
the effects of the injury, and stabilize the other clean material, place any protruding
casualty without causing additional injury. organs near the wound.
Performance Steps b. Ensure that the dressing is large enough
to cover the entire mass of protruding
organs or area of the wound.
NOTE:
Take Body Substance Isolation (BSI) c. If large enough to cover the affected area,
precautions. place the sterile side of the plastic
wrapper directly over the wound to
1. Position the casualty. provide an additional barrier layer to
protect the organs from rupture and
a. Place the casualty on his back (face up). contamination. Open abdominal wounds
b. Ensure the casualty has a patent airway. can become infected quickly and lead to
systemic infection, or sepsis.
c. Flex the casualty's knees.
d. Place the dressing directly on top of the
d. Turn the casualty's head to the side and
wound or plastic wrapper, if used.
keep the airway clear if vomiting occurs.
e. Tie the dressing tails loosely at the
2. Treat for shock. Initiate one large bore (18
casualty's side.
gauge) IV if the casualty is exhibiting signs
and symptoms of shock. CAUTION:
Do not apply pressure on the wound or expose
WARNING:
internal parts.
The most important concern in the initial
management of abdominal injuries is shock. f. If two dressings are needed to cover a
large wound, repeat steps 5a through 5e.
Shock may be present initially or develop later. Ensure that the ties of additional
dressings are not tied over each other.
Neither the presence nor absence of a wound,
nor the size of the external wound are safe g. If necessary, loosely cover the dressings
guidelines for judging the severity of the wound. with cravats. Tie them on the side of the
casualty opposite that of the dressing ties.
3. Expose the wound. Inspect for distention, 6. Do not cause further injury to the casualty.
contusions, penetration, eviscerations or
obvious bleeding. a. Do not touch any exposed organs with
bare hands.
CAUTION:
b. Do not try to push any exposed organs
Do not attempt to replace protruding internal
back into the body.
organs or remove any protruding foreign objects.
21-48
c. Do not tie the dressing tails tightly or • If the mother senses that she has to
directly over the dressing. move her bowels (if so, then the baby‘s
d. Do not give the casualty anything by head is well advanced down the birth
mouth (NPO). canal)
• If there is crowning of the baby’s head
NOTE: at the vaginal opening (crowning
Continue to assess the casualty. indicates that the baby is ready to
present itself)
7. Prepare the casualty for evacuation.
• How long will it take to get to the
a. Place the casualty on his back (face up) hospital
with the knees flexed.
The HM must weigh the answers to these
b. If evacuation is delayed, check the questions and decide if it will be safe to
casualty for signs of shock every 5 transport the patient to the hospital.
minutes.
c. Consider pain management as necessary. Preparation
8. Record the treatment given. Prior to childbirth, The HM must quickly
9. Evacuate the patient. "set the stage.”
• Do not allow the mother to go to the
CHILDBIRTH EMERGENCIES bathroom since straining may
precipitate delivery. However, do not
Every HM must be prepared to handle the try to inhibit the natural process of
unexpected arrival of a new life into the childbirth
world. If the HM is fortunate, a prepackaged
• The mother should lie back on a sturdy
sterile delivery pack will be available;
table, bed, or stretcher with a folded
unfortunately this is usually not the case. This
sheet or blanket placed under her
pack will contain all the equipment needed for
buttocks for absorption and comfort
the normal delivery of a healthy baby. If the
pack is not available the HM will require • Ensure one side of the pelvis is
imaginative improvisation of clean elevated (place hip roll under right or
alternatives. left side; left side is more common) to
ensure blood flow in the pelvic region
When faced with an imminent childbirth, and thus ensuring oxygenation of the
first determine whether there will be time to fetus: the weight of the fetus and
transport the expectant mother to a hospital. uterus can compress the abdominal
To help make this determination, the HM aorta resulting in insufficient blood
should try to find out: flow
• Which delivery will this be the woman • Remove all of the patient’s clothing
(first vaginal deliveries normally take below the waist, bend the knees, move
much longer than subsequent deliveries) the thighs apart (i.e. lithotomy position),
and drape her lower extremities with
• Have there been any complications with
clean towels or sheets
this pregnancy (or previous pregnancies)
• Don sterile gloves, or, if these are not
• Has her water broken or is there blood
available, the HM must rewash his or
• The time between contractions (if less her hands
than 3 minutes, delivery is approaching)
21-49
Normal Vaginal Delivery (NVD) 5. Support the baby’s head with one hand and
use the bulb syringe from the pack to
In a normal delivery, the HM’s calm suction the mouth and then the nostrils.
professional manner and sincere reassurance to Before placing the bulb in the baby’s
the mother will reduce her anxiety and make the mouth or nose, compress it; otherwise, a
delivery easier for everyone. Help the woman forceful aspiration into the lungs will
rest and relax as much as possible between result.
contractions.
NOTE:
During a contraction, deep, open-mouth Always suction the mouth first and then the
breathing will relieve some pain and straining. nose.
As the child’s head reaches the area of the
rectum, the mother will feel an urgent need to This is critical in newborns who have had a
defecate. Reassurance that this is a natural bowel movement (meconium) within the womb
feeling and a sign that the baby will be born and need the meconium cleared from the airway.
soon will help alleviate her apprehension.
6. The baby will now start a natural rotation
DELIVERY STEPS.—Watch for the to the left or right, away from the face-
presentation of the top of the baby’s head. down position.
1. Once the head appears, the HM takes up NOTE:
station at the foot of the bed and gently Baby needs to be on his or her side to allow for
supports the head (with the palms of the manipulation and delivery of the shoulders.
hand) to keep it from emerging too quickly.
Allow the head to come out slowly. 7. As this rotation occurs, keep the baby’s
2. Once the head presents, direct the mother head in alignment with his or her body.
to breathe and not to push while checking
for the umbilical cord. As more of the NOTE:
head appears, visually check to be sure From this point on, it is essential to remember
that the umbilical cord is not wrapped that the baby is VERY slippery, and great care
around the neck. must be taken not to drop him or her. The
surface beneath the mother should extend at
3. Cord around the baby’s neck: If it is, least 2 feet out from her buttocks so that the
either gently try to untangle the cord or baby will not be hurt if he or she does slip.
move one section over the baby’s
shoulder. If neither of these actions is 8. The shoulders appear next, usually one at a
possible, clamp the cord in two places, 2 time. Deliver the top shoulder first using
inches apart, and cut it between the the flexibility of the posterior pelvic floor
clamps. to move the shoulder under and out from
the symphysis pubic bone. The bottom
4. Once the baby’s chin emerges, direct the
shoulder will typically deliver itself with a
mother to breathe and not to push.
bit of force. Remember, the baby is VERY
slippery.
9. Keep one hand beneath the baby’s head,
and use the other hand to support its
emerging body.
21-50
Infant Care Post-Delivery Mother Care Post-Delivery
Care immediately after delivery is critical This is a relatively dangerous period for
for successful transition of the baby from the mother, as hemorrhage and shock may
inutero circulation and oxygenation (all occur. Steps must be taken to ensure all
provided by the mother) to extrautero infection control procedures are followed.
circulation and oxygenation (all required of Additionally, close hemodynamic monitoring
the baby). The following are steps to is needed as the mother transitions from
successfully transition the baby: pregnancy to post-partum physiologic status.
The following are steps to ensure a successful
1. Airway and Breathing.
and safe transition:
a. Once the baby has been born, suction the
1. The placenta (afterbirth) will deliver itself
nose and mouth again if breathing has not
in 10 to 20 minutes. Massaging the
started.
mother’s lower abdomen can aid this
b. Wipe the baby’s face, nose, and mouth delivery. Do not pull on the umbilical
clean with sterile gauze. cord to hasten its delivery. Log the time of
c. Vigorously rub the baby’s back and flick the placenta’s delivery, and wrap it up for
its feet to get the baby to cry and or to hospital analysis.
sustain a good healthy cry (if the cry is
NOTE:
depressed). The reward is the baby’s
If there are any concerns regarding delivery of
hearty cry.
the placenta or its presentation upon delivery,
2. Circulation. immediately contact a medical officer for
guidance.
a. Keep the baby level with the mother’s
uterus until the cord is cut.
2. Place a small strip of tape (½ -inch wide),
b. Clamp the umbilical cord as the folded and inscribed with the date, time of
pulsations cease. delivery, and mother’s name, around the
baby’s wrist.
c. Use two clamps from the prepackaged
sterile delivery pack, 2 inches apart, 3. Place the same identification tape around
with the first clamp 6 to 8 inches from the mother’s wrist so that the mother and
the navel. baby can be matched later at the medical
treatment facility.
d. Cut the cord between the clamps.
4. Monitor vital signs every 5 minutes for the
e. For safety, use gauze tape to tie the cord
first 15 minutes, every 15 minutes for
1 inch from the clamp toward the navel.
three recordings, every 30 minutes for 2
Secure the tie with a square knot.
recordings, and every hour for 4 hours.
3. Warmth. Then resort to vital signs every 4 hours. If
the patient is bleeding heavily or shock
a. Wrap the baby in a warm, sterile blanket,
signs and symptoms are present, continue
and log its time of arrival.
every 5 minute vital signs until the mother
b. If the baby has a low body temperature, is stabilized.
place chest to chest with the mother (who
5. Monitor for uterine hemorrhage.
must be stable) and place a blanket over
the two of them to allow for heat transfer a. The uterus should be gently massaged to
from the mother. keep it hard.
b. For first time mothers, the uterus will be
at or slightly above the navel.
21-51
c. For experienced mothers, the uterus will Final Notes
be at or slightly below the navel.
Stay with the mother until relieved by
NOTE: competent personnel. Almost all emergency
If the uterus appears too high or is offset to the births are normal. The babies typically thrive
right or left the mother has a full bladder that and the mothers recover quickly. It is very
must be emptied (either on her own or via important when assisting with an emergency
urinary catheterization). delivery that the HM continually reassures the
mother and attempts to keep her calm.
A full bladder will prevent the uterus from
contracting and closing the vessels that are COMPLICATIONS IN CHILDBIRTH
bleeding.
Unfortunately, not all deliveries go
d. Have mother put infant to breast to aid smoothly. The following sections cover
with contractions which clamps down the various complications in childbirth.
uterine arteries and veins and decreases
the bleeding. Breech Delivery
6. Nutrition and restoration of resources.
A breech delivery occurs when the baby’s
a. The mother will need nourishment and legs and or buttocks emerge first. Follow the
will wish to rest and watch her baby. steps for a normal delivery, and support the
7. Care of the vaginal opening and canal. lower extremities with one hand. If the head
does not emerge within 3 minutes, try to
a. The mother should keep her hands away maintain an airway by gently pushing fingers
from the area surrounding the birth into the vagina. Push the vagina away from the
outlet. baby’s face and open his or her mouth with
b. If uncontaminated water is available, she one finger. Get medical assistance
may wish to wash off her thighs. She immediately.
may get up and go to the bathroom or
seek better shelter. Prolapsed Cord
c. All care should be taken to avoid If the cord precedes the baby, protect it with
introducing infection into the birth canal. moist, sterile wraps. If a physician cannot be
d. Educate the mother about the amount and reached quickly, place the mother in an
color of vaginal discharge. extreme shock position. Give the mother
oxygen, if available, and gently move a sterile
i. She can expect some vaginal gloved hand into the vagina to keep its walls
discharge for several days. and the baby from compressing the cord. The
ii. This is reddish for the first day or so HM will provide support until the baby is
but lightens and becomes less profuse delivered. The HM cannot remove his or her
within a few days. hand until told to do so by a medical officer.
Get medical assistance immediately.
iii. May bleed longer than a typical
period.
Excessive Bleeding
iv. If bleeding increases, immediately
assess the location and firmness of the If the mother experiences severe bleeding,
uterus and ensure the mother has treat her for shock and give her oxygen, if
voided recently. available. Place sanitary napkins over the
vaginal entrance and rush her to a hospital.
21-52
If hemorrhaging does occur, do the following: Limb Presentation
1. The uterus should be gently massaged to
If a single limb presents itself first,
keep it hard.
immediately get the mother to a hospital.
2. The woman should lie flat, and the bottom
of the bed should be elevated. NON-TACTICAL TRAUMA ASSESSMENT
3. Put a cold pack (such as a small towel
dipped in cold water and wrung out) on the If there is no immediate danger to the HM
lower abdomen to irritate the uterus to or the surroundings are non-threatening, then
contract. the HM’s only limitations are the resources
available and the nature of the injury. During
4. Put pressure on the perineum with several these types of scenarios, it is quite reasonable
sanitary napkins and the pressure of a hand. to use the following patient assessment
algorithm while assessing a trauma patient
(Fig. 21-3).
21-53
Figure 21-3.—Non-Tactical Trauma Assessment
21-54
TCCC GUIDELINES FOR CARE b. Casualty with airway obstruction or
impending airway obstruction.
Basic Management Plan for Care Under
i. Chin lift or jaw thrust maneuver.
Fire28
ii. Nasopharyngeal airway.
1. Return fire/take cover. iii. Allow casualty to assume a position
that best protects the airway, to
2. Direct/expect casualty to remain engaged
include sitting up.
as a combatant, if appropriate.
iv. Place unconscious casualty in the
3. Direct casualty to move to cover/apply self-
recovery position.
aid if able.
v. If previous measures unsuccessful:
4. Try to keep the casualty from sustaining
Surgical cricothyroidotomy (with
additional wounds.
lidocaine if conscious)
5. Airway management is best deferred until
3. Breathing.
the Tactical Field Care Phase.
a. In a casualty with progressive respiratory
6. Stop LIFE-THREATENING external
distress and known or suspected torso
hemorrhage if tactically Feasible.
trauma, consider a tension pneumothorax
a. Direct casualty to control hemorrhage by and decompress the chest on the side of
self-aid if able. the injury with a 14-gauge, 3.25 inch
needle/catheter unit inserted in the
b. Use a tourniquet for hemorrhage that is
second intercostal space at the mid-
anatomically amendable to
clavicular line. Ensure that the needle
tourniquet application.
entry into the chest is not medial to the
c. For hemorrhage that cannot be controlled nipple line and is not directed towards the
with a tourniquet, apply currently heart.
approved hemostatic dressing with
b. All open and or sucking chest wounds
pressure.
should be treated by immediately
applying an occlusive material to cover
Basic Management Plan for Tactical Field the defect and securing it in place.
Care28 Monitor the casualty for the potential
1. Casualties with an altered mental status development of a subsequent tension
should be disarmed immediately. pneumothorax.
21-55
b. For compressible hemorrhage not b. If not in shock:
amenable to tourniquet use or as an
i. No IV fluids necessary.
adjunct to tourniquet removal (if
evacuation time is anticipated to be ii. PO fluids permissible if conscious and
longer than two hours), use Combat can swallow.
Gauze as the hemostatic agent of choice. c. If in shock:
Combat Gauze should be applied with at
least 3 minutes of direct pressure. Before i. Hextend®, 500-mL IV bolus.
releasing any tourniquet on a casualty ii. Repeat once after 30 minutes if still in
who has been resuscitated for shock.
hemorrhagic shock, ensure a positive
response to resuscitation efforts (i.e., a iii. No more than 1000 mL of Hextend®.
peripheral pulse normal in character and d. Continued efforts to resuscitate must be
normal mentation if there is no traumatic weighed against logistical and tactical
brain injury (TBI). considerations and the risk of incurring
c. Reassess prior tourniquet application. further casualties.
Expose wound and determine if e. If a casualty with TBI is unconscious and
tourniquet is needed. If so, move has no peripheral pulse, resuscitate to
tourniquet from over uniform and apply restore the radial pulse.
directly to skin 2-3 inches above wound.
If a tourniquet is not needed, use other 7. Prevention of hypothermia.
techniques to control bleeding. a. Minimize casualty’s exposure to the
d. When time and the tactical situation elements. Keep protective gear on or with
permit, a distal pulse check should be the casualty if feasible.
accomplished. If a distal pulse is still b. Replace wet clothing with dry if possible.
present, consider additional tightening of
the tourniquet or the use of a second c. Apply Ready-Heat Blanket to torso.
tourniquet, side by side and proximal to d. Wrap in Blizzard Rescue Blanket.
the first, to eliminate the distal pulse.
Expose and clearly mark all tourniquet e. Put Thermo-Lite Hypothermia
sites with the time of tourniquet Prevention System Cap on the casualty’s
application. Use an indelible marker. head, under the helmet.
21-56
8. Penetrating Eye Trauma. v. Add second lozenge, in other cheek,
as necessary to control severe pain.
a. If a penetrating eye injury is noted or
suspected. vi. Monitor for respiratory depression.
i. Perform a rapid field test of visual vii. IV or IO access obtained:
acuity.
1. Morphine sulfate, 5 mg IV/IO.
b. Cover the eye with a rigid eye shield
2. Reassess in 10 minutes.
(NOT a pressure patch).
3. Repeat dose every 10 minutes as
c. Ensure that the 400 mg moxifloxacin
necessary to control severe pain.
tablet in the combat pill pack is taken if
possible and that IV/IM antibiotics are 4. Monitor for respiratory depression.
given as outlined below if oral viii. Promethazine, 25 mg IV/IM/IO every
moxifloxacin cannot be taken. 6 hours as needed for nausea or for
9. Monitoring: synergistic analgesic effect.
a. Pulse oximetry should be available as an 13. Splint fractures and recheck pulse.
adjunct to clinical monitoring. 14. Antibiotics: recommended for all open
b. Readings may be misleading in the combat wounds.
settings of shock or marked hypothermia. a. If able to take PO:
10. Inspect and dress known wounds. i. Moxifloxacin, 400 mg PO one a day.
11. Check for additional wounds. b. If unable to take PO (shock,
12. Provide analgesia as necessary. unconsciousness):
a. Able to fight: i. Cefotetan, 2 g IV (slow push over 3-5
minutes) or IM every 12 hours OR
i. These medications should be carried
by the combatant and self- ii. Ertapenem, 1 g IV/IM once a day.
administered as soon as possible after 15. Communicate with the casualty if possible.
the wound is sustained.
a. Encourage; reassure.
1. Mobic®, 15 mg PO once a day.
b. Explain care.
2. Tylenol®, 650-mg bilayer caplet, 2
PO every 8 hours. c. Cardiopulmonary resuscitation (CPR) -
Resuscitation on the battlefield for
b. Unable to fight: casualties of blast or penetrating trauma
who have no pulse, no ventilations, and
NOTE:
no other signs of life will not be
Have naloxone readily available whenever
successful and should not be attempted.
administering opiates.
d. Documentation of Care - Document
i. Does not otherwise require IV/IO clinical assessments, treatments rendered,
access. and changes in the casualty’s status.
ii. Oral transmucosal fentanyl citrate Forward this information with the
(OTFC), 800 ug transbuccally. casualty to the next level of care.
21-57
Basic Management Plan for Tactical 2. Breathing:
Evacuation Care29
a. In a casualty with progressive respiratory
distress and known or suspected torso
The new term “Tactical Evacuation”
trauma, consider a tension pneumothorax
includes both Casualty Evacuation (CASEVAC)
and decompress the chest on the side of
and Medical Evacuation (MEDEVAC) as
the injury with a 14-gauge, 3.25 inch
defined in Joint Publication 4-02.
needle/catheter unit inserted in the
1. Airway Management. second intercostal space (over the top of
the 3rd rib) at the mid-clavicular line.
a. Unconscious casualty without airway
Ensure that the needle entry into the chest
obstruction:
is not medial to the nipple line and is not
i. Chin lift or jaw thrust maneuver. directed towards the heart.
ii. Nasopharyngeal airway. b. Consider chest tube insertion if no
iii. Place casualty in the recovery improvement and or long transport is
position. anticipated.
21-58
3. Bleeding: 4. Intravenous (IV) access:
a. Assess for unrecognized hemorrhage and a. Reassess need for IV access.
control all sources of bleeding. If not
i. If indicated, start an 18-gauge IV or
already done, use a Council of TCCC
saline lock.
(CoTCCC)-recommended tourniquet to
control life-threatening external ii. If resuscitation is required and IV
hemorrhage that is anatomically access is not obtainable, use
amenable to tourniquet application or for intraosseous (IO) route.
any traumatic amputation. Apply directly 5. Fluid resuscitation:
to the skin 2-3 inches above wound.
a. Reassess for hemorrhagic shock: altered
b. For compressible hemorrhage not mental status in the absence of brain
amenable to tourniquet use or as an injury and or change in pulse character.
adjunct to tourniquet removal (if
evacuation time is anticipated to be b. If not in shock:
longer than two hours), use Combat i. No IV fluids necessary.
Gauze as the hemostatic agent of choice.
Combat Gauze should be applied with at ii. PO fluids permissible if conscious and
least 3 minutes of direct pressure. Before can swallow.
releasing any tourniquet on a casualty c. If in shock:
who has been resuscitated for
hemorrhagic shock, ensure a positive i. Hextend® 500-mL IV bolus.
response to resuscitation efforts (i.e., a ii. Repeat once after 30 minutes if still in
peripheral pulse normal in character and shock.
normal mentation if there is no TBI).
iii. No more than 1000 mL of Hextend®.
c. Reassess prior tourniquet application.
Expose wound and determine if d. Continue resuscitation with packed red
tourniquet is needed. If so, move blood cells (PRBCs), Hextend® (not to
tourniquet from over uniform and apply exceed 1000 ml), or Lactated Ringer’s
directly to skin 2-3 inches above wound. solution (LR) as indicated.
If a tourniquet is not needed, use other e. If a casualty with TBI is unconscious and
techniques to control bleeding. has a weak or absent peripheral pulse,
d. When time and the tactical situation resuscitate as necessary to maintain a
permit, a distal pulse check should be systolic blood pressure of 90 mmHg or
accomplished. If a distal pulse is still above.
present, consider additional tightening of 6. Prevention of hypothermia.
the tourniquet or the use of a second
tourniquet, side by side and proximal to a. Minimize casualty’s exposure to the
the first, to eliminate the distal pulse. elements. Keep protective gear on or with
the casualty if feasible.
e. Expose and clearly mark all tourniquet
sites with the time of tourniquet b. Continue Ready-Heat Blanket, Blizzard
application. Use an indelible marker. Rescue Wrap, and Thermo-Lite Cap.
c. Apply additional interventions as needed.
d. Use the Thermal Angel or other portable
fluid warmer on all IV sites, if possible.
e. Protect the casualty from wind if doors
must be kept open.
21-59
7. Penetrating Eye Trauma: 5. Monitor for respiratory depression.
a. If a penetrating eye injury is noted or ii. IV or IO access obtained:
suspected:
1. Morphine sulfate, 5 mg IV/IO.
i. Perform a rapid field test of visual
2. Reassess in 10 minutes.
acuity.
3. Repeat dose every 10 minutes as
ii. Cover the eye with a rigid eye shield
necessary to control severe pain.
(NOT a pressure patch).
4. Monitor for respiratory depression.
iii. Ensure that the 400 mg moxifloxacin
tablet in the combat pill pack is taken iii. Promethazine, 25 mg IV/IM/IO every
if possible and that IV/IM antibiotics 6 hours as needed for nausea or for
are given as outlined below if oral synergistic analgesic effect.
moxifloxacin cannot be taken. 12. Reassess fractures and recheck pulses.
8. Monitoring. 13. Antibiotics: recommended for all open
a. Institute pulse oximetry and other combat wounds.
electronic monitoring of vital signs, if a. If able to take PO:
indicated.
i. Moxifloxacin, 400 mg PO once a day.
9. Inspect and dress known wounds if not
already done. b. If unable to take PO (shock,
unconsciousness):
10. Check for additional wounds.
i. Cefotetan, 2 g IV (slow push over 3-5
11. Provide analgesia as necessary. minutes) or IM every 12 hours OR
a. Able to fight: ii. Ertapenem, 1 g IV/IM once a day.
i. Mobic®, 15 mg PO once a day. 14. The Pneumatic Anti-shock Garment
ii. Tylenol®, 650-mg bilayered caplet, 2 (PASG) may be useful for stabilizing
PO every 8 hours. pelvic fractures and controlling pelvic and
abdominal bleeding. Application and
b. Unable to fight:
extended use must be carefully monitored.
The PASG is contraindicated for casualties
NOTE:
with thoracic or brain injuries.
Have naloxone readily available whenever
administering opiates. 15. Documentation of Care:
21-60
MORPHINE USE FOR PAIN RELIEF • Poisoning is always a danger. There is a
narrow safety margin between the
LEARNING OBJECTIVE: amounts of morphine that may be given
therapeutically and the amounts that
Explain morphine dosage, administration produce death
routes, indications, contraindications, and • Causes considerable mental confusion
casualty marking procedures. and interferes with the proper exercise
of judgment. Therefore, morphine
A HM may be issued morphine for the should not be given to ambulatory
control of shock through the relief of severe patients
pain. This controlled drug is issued under very • Is a highly addictive drug. Morphine
strict accountability procedures. Possession of should not be given trivially and must be
this drug is a medical responsibility that must rigidly accounted for. Only under
not be taken lightly. Policies pertaining to emergency circumstances should
morphine administration are outlined in morphine be administered
BUMEDINST 6570.2 series, Morphia Dosage
and Casualty Marking. Rigidly control morphine administration to
patients in shock or with extensive burns.
MORPHINE ADMINISTRATION Because of the reduced peripheral circulation,
morphine administration by subcutaneous or
Morphine is the most effective of all pain- intramuscular routes may not be absorbed into
relieving drugs. It is most commonly available the bloodstream, and pain may persist. When
in pre-measured doses in syrettes or tubexes. pain persists, the uninformed often give
Proper administration in selected patients additional doses, hoping to bring about relief.
relieves distressing pain and assists in When resuscitation occurs and the peripheral
preventing shock. The adult dose of morphine is circulation improves, the stored quantities of
10 to 20 mg, which may be repeated, if morphine are released into the system, and an
necessary, in no less than 4 hours. extremely serious condition (morphine
poisoning) results. When other pain-relieving
Morphine has several undesirable effects, drugs are not available and the patient in shock
however, and the HM must thoroughly or with burns is in severe pain, 20 mg of
understand these effects. Morphine: morphine may be given intramuscularly
(followed by massage of the injection site).
• Is a severe respiratory depressant and Resist the temptation to give more, however.
must not be given to patients in Unless otherwise ordered by a medical officer,
moderate or severe shock or in doses should not be repeated more than twice
respiratory distress and then at least 4 hours apart.
• Increases intracranial pressure and may
induce vomiting. These effects may be If the pain from a wound is severe,
disastrous in head injury cases morphine may be given when examination of the
patient reveals no:
• Causes constriction of the pupils
(pinpoint pupils). This effect prevents • Head injury
the use of the pupillary reactions for • Chest injury, including sucking and non-
diagnosis in head injuries sucking wounds
• Is cardiotoxic and a peripheral • Wounds of the throat, nasal passages,
vasodilator. Small doses of morphine oral cavity, or jaws wherein blood might
may cause profound hypotension in a obstruct the airway
patient in shock
• Massive hemorrhage
21-61
• Respiratory impairment, including CLASSIFICATION OF WOUNDS
chemical burns of the respiratory tract
(any casualty having fewer than 16 Wounds may be classified according to
respirations per minute should not be their general condition, size, location, the
given morphine) manner in which the skin or tissue is broken,
and the agent that caused the wound. It is
• Evidence of severe or deepening shock necessary to consider these factors to determine
• Loss of consciousness what first aid treatment is appropriate for the
wound.
CASUALTY MARKING General Condition of the Wound
Morphine overdose is always a danger. For If the wound is fresh, first aid treatment
this reason, plainly identify every casualty who consists mainly of stopping the flow of blood,
has received morphine. Write the letter "M” and treating for shock, and reducing the risk of
the hour of injection on the patient’s forehead infection. If the wound is already infected, first
(e.g., M0830) with a skin pencil or semi- aid consists of keeping the casualty quiet,
permanent marking substitute. Attach the empty elevating the injured part, and applying a warm
morphine syrette or tubex to the patient’s shirt wet dressing. If the wound contains foreign
collar or another conspicuous area of the clothing objects, first aid treatment may consist of
with a safety pin or by some other means. This removing the objects if they are not deeply
action will alert others that the drug has been embedded. DO NOT remove objects embedded
administered. in the eyes or the skull, and do not remove
impaled objects. Stabilize the impaled object
SOFT TISSUE INJURIES to prevent further injury and minimize
bleeding. Impaled objects should be surgically
LEARNING OBJECTIVES: removed.
21-62
The possibility of infection is great in all Having classified the wound into one or
puncture wounds, especially if the penetrating more of the general categories listed, the HM
object has tetanus bacteria on it. will have a good idea of the nature and extent of
the injury, along with any special complications
AVULSIONS⎯An avulsion is the tearing that may exist. This information will aid in the
away of tissue from a body part. Bleeding is treatment of the casualty.
normally heavy. In certain situations, the torn
tissue may be surgically reattached. It can be MANAGEMENT OF OPEN SOFT-TISSUE
saved for medical evaluation by wrapping it in a INJURIES
sterile dressing and placing it in a cool
container, and rushing it along with the There are three basic rules to be followed
casualty to a medical facility. Do not allow the in the treatment of practically all open soft tissue
avulsed portion to freeze, and do not immerse it injuries: to control hemorrhage, to treat the
in water or saline. casualty for shock, and to prevent infection.
These will be discussed, along with the proper
AMPUTATIONS⎯A traumatic amputation application of first aid materials and other
is the non-surgical removal of the limb from the specific first aid techniques.
body. Bleeding is heavy and requires a
tourniquet (which will be discussed later) to Hemorrhage
stop the flow. Shock is certain to develop in
these cases. As with avulsed tissue, wrap the Hemorrhage is the escape of significant
limb in a sterile dressing, place it in a cool amounts of blood from the vessels of the
container, and transport it to the hospital with circulatory system. The average adult body
the casualty. Do not allow the limb to be in contains about 5-6 liters of blood. Five hundred
direct contact with ice, and do not immerse it in milliliters of blood, the amount given by blood
water or saline. The limb can often be donors, can normally be lost without any
successfully reattached. harmful effect. The loss of 1 liter of blood
usually causes shock, but shock may develop if
Causes of Wounds (Kinematics of Trauma) small amounts of blood are lost rapidly, since the
circulatory system does not have enough time to
Although it is not always necessary to compensate adequately. The degree of shock
know what agent or object has caused the progressively increases as greater amounts of
wound, it is helpful. Knowing what has caused blood escape. Young children, sick people, or
the wound may give the HM some idea of the the elderly may be especially susceptible to the
probable size of the wound, its general nature, loss of even small amounts of blood since their
the extent to which it is likely to become internal systems are in such delicate balance.
contaminated with foreign matter, and what Capillary blood is normally dark brick red in
special dangers must be guarded against. Of color. If capillaries are cut, the blood oozes out
special concern in wartime setting is the slowly. Blood from the veins is dark red.
velocity of wound-causing missiles (bullets or Venous bleeding is characterized by a steady,
shrapnel). A low-velocity missile damages only even flow. If an artery near the surface is cut,
the tissues with which it comes into contact. On the blood, which is bright red in color, will gush
the other hand, a high-velocity missile can do out in spurts that are synchronized with the
enormous damage by forcing the tissues and heartbeats. If the severed artery is deeply
body parts away from the track of the missile buried, however, the bleeding will appear to be
with a velocity only slightly less than that of the a steady stream.
missile itself. These tissues, especially bone,
may become damage-causing missiles
themselves, thus accentuating the destructive
effects of the missile.
21-63
In actual practice, it can be difficult to Objective
decide whether bleeding is venous or arterial,
but the distinction is not important. The Control the bleeding from the extremity
important thing to know is that all bleeding without causing further harm to the casualty.
must be controlled as quickly as possible.
Performance Steps
External hemorrhage is of greatest
importance because it is the most frequently
NOTE:
encountered and the easiest to control. It is Take Body Substance Isolation (BSI)
characterized by a break in the skin and
precautions.
visible bleeding. Internal hemorrhage (which
will be discussed later) is far more difficult to 1. Determine if the bleeding is life-
recognize and to control. threatening.
Control of Hemorrhage and the use of 2. Apply a tourniquet if direct pressure and
Tourniquets28 the emergency bandage fail to control the
bleeding.
In the past, emphasis has been placed on
elevation of an extremity and compression on CAUTION:
a pressure point (proximal to the bleeding site) Under combat conditions, while under effective
as intermediate steps in hemorrhage control. enemy fire, a temporary tourniquet may often be
No research has been published on whether or the primary means to control bleeding.
not elevation of an extremity slows
hemorrhage. If the extremity is fractured, this A properly applied tourniquet will quickly
maneuver could potentially result in control life-threatening hemorrhage until the
converting a closed fracture to an open one or casualty can be moved away from the effective
in causing increased internal hemorrhage. fire.
Similarly, the use of pressure points for
hemorrhage control has not been studied. a. Improvised tourniquet.
Thus, in the absence of compelling data, these i. Don BSI
interventions can no longer be recommended
for situations where direct pressure or a ii. Apply pressure to pressure point
pressure dressing has failed to control above the wound.
hemorrhage. iii. Prepare equipment.
iv. Expose the wound.
If external bleeding from an extremity
cannot be controlled by pressure, application v. Place the prepared cravat and windlass
of a tourniquet is the reasonable next step in 2-3 inches above the wound (not over
hemorrhage control. a joint) and secure the cravat tightly
against the extremity with a full non-
APPLY A TOURNIQUET TO CONTROL slip knot.
BLEEDING23
vi. Twist the windlass until the bleeding
stops.
Scenario
vii. While holding tension on the
The HM has encountered a casualty who is windlass, place the windlass inside the
bleeding profusely from an extremity and needs half knot of the second cravat
a tourniquet to control the bleeding. All other proximal to the tourniquet (if
more serious injuries have been assessed and possible).
treated.
21-64
viii. Tighten the second cravat around 5. If the source of bleeding was due to a
windlass and secure the second cravat traumatic amputation.
to the extremity with a full non-slip
a. Wrap the amputated part in a clean cloth
knot.
or sterile dressing (if available).
ix. Assess for the absence of a distal
b. Wrap or bag the amputated part in
pulse (not indicated for amputations).
plastic.
x. Place a "T" and the time of application
c. Label the plastic bag with the casualty's
on the casualty.
information.
xi. Secure the tourniquet in place with
d. Transport the amputated part in a cool
tape.
container (if available) with the casualty.
b. C-A-T®:
CAUTION:
i. Don BSI.
ii. Apply pressure to pressure point Do not place the amputated part directly in
above the wound. contact with ice.
iii. Expose the wound enough to ensure
Do not submerge the part directly in water.
the tourniquet is placed above the
injury.
Do not allow the part to freeze.
iv. Place C-A-T® between the heart and
the wound on the injured extremity, 2- 6. Evacuate the casualty.
3 inches above the wound.
v. Pull the free end of the self adhering MANAGEMENT OF INTERNAL SOFT-
band through the buckle and route TISSUE INJURIES
through the friction adapter buckle (it
is not necessary to route through Internal soft-tissue injuries may result from
friction adapter on an arm wound). deep wounds, blunt trauma, blast exposure,
crushing accidents, bone fracture, poison, or
vi. Pull the self adhering band tight
sickness. They may range in seriousness from a
around the extremity and fasten it
simple contusion to life-threatening
back on itself.
hemorrhage and shock.
vii. Twist the windlass until the bleeding
stops. Visible Indications
viii. Lock the windlass in place within the
Visible indications of internal soft-tissue
windlass clip.
injury include the following:
ix. Secure the windlass with the windlass
• Hematemesis (vomiting bright red
strap.
blood)
x. Assess for the absence of a distal
pulse (not indicated for amputations). • Hemoptysis (coughing up bright red
blood)
xi. Place a "T" and the time of application
on the casualty. • Melena (excretion of tarry black stools)
xii. Secure the C-A-T® in place with tape. • Hematochezia (excretion of bright red
blood from the rectum)
3. Record the treatment.
• Hematuria (passing of blood in the
4. Reassess the injury to ensure bleeding has urine)
been controlled.
21-65
• Nonmenstrual (vaginal bleeding) Objective
• Epistaxis (nosebleed) Initiate treatment for hypovolemic shock,
• Ecchymosis (pooling of the blood near stabilize the casualty, minimize the effect of
the skin surface) shock, and prepare for immediate evacuation
without further injury to the casualty.
Other Signs and Symptoms Performance Steps
More often than not, however, there will be
no visible signs of injury, and the HM will have NOTE:
to infer the probability of internal soft-tissue Take Body Substance Isolation (BSI)
injury from other symptoms such as the precautions.
following:
1. Control bleeding.
• Pale, moist, clammy skin
2. Maintain the airway.
• Subnormal temperature
NOTE:
• Rapid, feeble pulse
Administer oxygen, if available.
• Falling blood pressure
3. Reassure the casualty to reduce anxiety.
• Dilated, slowly reacting pupils with
impaired vision NOTE:
• Tinnitus Anxiety increases the heart rate, which worsens
the casualty's condition. Anyone who has just
• Syncope been shot or who has experienced detonation of
• Dehydration and thirst explosives nearby will have tachycardia.
• Yawning and air hunger 4. Initiate one large bore (18 gauge) IV.
• Anxiety, with a feeling of impending 5. Maintain the IV flow with Hextend®.
doom a. Continue the flow until the systolic blood
pressure stabilizes at greater than 80mm
Immediate Treatment Hg.
i. The usual amount is 500 ml; repeat
There is little that the HM can do to correct the dose of 500 ml one time. A total of
internal soft-tissue injuries since they are almost 1000 ml maximum amount of
always surgical problems. The goal must be to Hextend® can be used for
obtain the greatest benefit from the casualty’s hypovolemia.
remaining blood supply.
ii. A palpable radial pulse typically
INITIATE TREATMENT FOR indicates that the casualty has a
HYPOVOLEMIC SHOCK23 systolic blood pressure of 80 mm Hg.
Scenario
21-66
6. Elevate the casualty’s legs. WOUND CLOSURE
a. Elevate the casualty's legs above chest
level, without lowering the head below LEARNING OBJECTIVES:
chest level.
Discuss the different types of suture material
NOTE: and their uses.
Splint leg or ankle fractures before elevating the
legs, if necessary. Explain topical, local infiltration and nerve-
block anesthetic administration procedures.
b. If the casualty is on a litter, elevate the
foot of the litter. Explain the steps in wound suturing and suture
7. Maintain normal body temperature. removal.
Aggressively treat for hypothermia in a
trauma patient. The care of the wound is largely controlled
by the tactical situation, facilities available, and
8. Monitor the casualty.
the length of time before proper medical care
NOTE: may be available. Normally, the advice to HMs
Give nothing by mouth. Moisten the casualty's regarding the suturing of wounds is DO NOT
lips with a wet cloth. ATTEMPT IT. However, if days are expected to
elapse before the patient can be seen by a
a. Check vital signs every 5 minutes until surgeon, he or she should know how to use the
they return to normal, and then check various suture procedures and materials, and
every 15 minutes. how to select the most appropriate of both.
b. Check the casualty's level of Before discussing the methods of
consciousness. coaptation (bringing together), some of the
contraindications to wound closing should be
NOTE: described.
If the blood pressure is unstable or drops, the
pneumatic anti-shock garment (PASG) should
be applied by qualified personnel. • If there is reddening and edema of the
wound margins, infection manifested by the
9. Record the procedure. discharge of pus, and persistent fever or
toxemia, DO NOT CLOSE THE WOUND
10. Evacuate the casualty.
o If these signs are minimal, the wound
should be allowed to "clean up"
o The process may be hastened by warm,
moist dressings, and irrigations with
sterile saline
o This aids in the liquefaction of necrotic
wound materials and the removal of thick
exudates and dead tissues
21-67
• If the wound is a puncture wound, a large SUTURE MATERIALS
gaping wound of the soft tissue, or an animal
bite, leave it un-sutured. Even under the care In modern surgery, many kinds of ligature
of a surgeon, it is the rule not to close wounds and suture materials are used. All can be
of this nature until after the fourth day grouped into two classes: non-absorbable
sutures and absorbable sutures.
o This is called "delayed primary closure”
and is performed upon the indication of a
Non-Absorbable Sutures
healthy appearance of the wound
o Healthy muscle tissue that is viable is These are sutures that cannot be absorbed
evident by its color, consistency, blood by the body cells and fluids in which they are
supply, and contractibility embedded during the healing process. When
used as buried sutures, these sutures become
o Muscle that is dead or dying is
surrounded or encapsulated in fibrous tissue
comparatively dark and mushy; it does
and remain as innocuous foreign bodies. When
not contract when pinched, nor does it
used as skin sutures, they are removed after the
bleed when cut. If this type of tissue is
skin has healed. The most commonly used
evident, do not close the wound
sutures of this type and the characteristics
• If the wound is deep, consider the support of associated with each are listed below.
the surrounding tissue; if there is not enough
• Silk frequently reacts with tissue and
support to bring the deep fascia together, do
can be "spit" from the wound
not suture because dead (hollow) spaces will
be created • Cotton loses tensile strength with each
o In this generally gaping type of wound, autoclaving
muscles, tendons, and nerves are typically • Linen is better than silk or cotton but is
involved more expensive and not as readily
o Only a surgeon should attempt to close available
this type of wound • Synthetic materials (e.g., nylon,
dermalon) are excellent, particularly for
If the wound is small, clean, and free from surface use. They cause very little tissue
foreign bodies and signs of infection, steps reaction; however, there is a tendency for
should be taken to close it. All instruments the knots to come untied. Because of this
should be checked, cleaned, and thoroughly tendency, most surgeons tie 3 to 4
sterilized. Use a good light and position the square knots in each such suture. Nylon
patient on the table so that access to the wound is preferred over silk for face and lip
will be unhampered. areas because silk too often causes
tissue reactions
The area around the wound should be • Rust-proof metal (usually stainless
cleansed and then prepared with an antiseptic. steel wire) has the least tissue reaction
The wound area should be draped, whenever of all suture materials and is by far the
possible, to maintain a sterile field in which the strongest. The primary problems
HM will work. The HM should wear a cap and associated with it are that it is more
mask, scrub hands and forearms, and wear difficult to use because it kinks and that
sterile gloves. it must be cut with wire cutters
21-68
Absorbable Sutures SUTURE NEEDLES
These are sutures that are absorbed or Suture needles may be straight or curved,
digested during and after the healing processes and they may have either a tapered round point
by the body cells and tissue fluids in which they or a cutting edge point. They vary in length,
are embedded. It is this characteristic that curvature, and diameter for various types of
enhances their use beneath the skin surfaces suturing. Specific characteristics of suture
and on mucous membranes. needles are listed below.
• Size: Suture needles are sized by
Surgical gut fulfills the requirements for
diameter and are available in many sizes
the perfect suture ease of manufacture, tensile
strength, and variety available more often than • Taper point: Most often used in deep
any other material. tissues, this type needle causes minimal
amounts of tissue damage
• Manufacture of catgut: Though it is
referred to as "catgut," surgical gut is • Cutting edge point: This type needle is
derived from the submucosal preferred for suturing the skin because
connective tissue of the first one-third of the needle's ability to penetrate the
(about 8 yards) of the small intestine of skin's toughness
healthy government-inspected sheep.
The intestine of the sheep has certain • Atraumatic (atraloc, wedged): These
characteristics that make it especially needles may either have a cutting edge
adaptable for surgical use. Among these or a taper point. Additionally, the suture
characteristics are its uniformly fine- may be fixed on the end of the needle by
grained tissue structure and its great the manufacturer to cause the least
tensile strength and elasticity. tissue trauma
21-69
3. Select an anesthetic with care. Consider the The anesthetizing agent is then infiltrated
patient’s tolerance to pain, time of injury, into the lateral and medial aspects at the base of
medications the patient is taking or has the digit with a small bore needle (25- or 26-
been given, and the possible distortion of gauge), taking care not to inject into the veins
the tissue when the anesthetic are or arteries. Proper placement of the anesthesia
infiltrated. should result in a loss of sensitivity in a few
minutes. This is tested by asking if the patient
can distinguish a sharp sensation or pain when a
Selection of Anesthesia
sharp object is gently applied to the skin.
The most common local anesthetic used is
Administering local anesthesia is similar
Xylocaine, which comes in various strengths
except the HM is anesthetizing nerves
(0.5%, 1%, and 2%) and with or without
immediately adjacent to where the work will be
epinephrine. Injectables containing epinephrine
done instead of nerve trunks. There are two
must never be used on the fingers, toes, ears,
generally accepted methods of infiltrating the
nose, or any other appendage with small
anesthesia. One is through the skin surrounding
vessels because of the vasoconstricting effect
the margin of the wound and the other is
of the epinephrine which would eliminate blood
through the wound into the surrounding tissue.
flow causing tissue death in these areas.
In either case, sufficient quantities must be
Epinephrine is also contraindicated in patients
infiltrated to effect anesthesia approximately ½
with hypertension, diabetes, or heart disease.
inch around the wound, taking care not to inject
into a vein or artery.
The three methods of anesthesia
administration are topical, local infiltration, and
nerve block. Topical anesthetics are generally CAUTION:
reserved for ophthalmic or plastic surgery and The maximum recommended amount of
nerve blocks are generally accomplished by an Xylocaine to be used is 50 ml for a 1% solution
anesthesiologist or nurse anesthetist for the or the equivalent.
surgical patient. For HMs, topical anesthesia is
limited to the instillation of eye drops for mild GENERAL PRINCIPLES OF WOUND
corneal abrasions after all foreign bodies have SUTURING
been removed. DO NOT attempt to remove
embedded foreign bodies. Nerve blocks are Wounds are closed either primarily or
limited to digital blocks wherein the nerve secondarily. A primary closure takes place
trunks that enervate the fingers or toes are within a short time of when the wound occurs,
anesthetized. The most common method of and it requires minimal cleaning and
anesthesia used by HMs is the infiltration of the preparation. A secondary closure, on the other
anesthetizing agent around a wound or minor hand, occurs when there is a delay of the closure
surgical site. for up to several days after the wound's
occurrence. A secondary closure requires a
Administration of Anesthesia more complex procedure. Wounds 6 to 14 hours
old may be closed primarily if they are not
Performing a digital block is a fairly simple grossly contaminated and are meticulously
procedure, but it should not be attempted except cleaned. Wounds 14 to 24 hours old should not
under the supervision of a medical officer or be closed primarily. When reddening and
after a great deal of practice. The first step is edema of the wound margins, discharge of pus,
cleansing the injection site with an antiseptic persistent fever, or toxemia are present, do not
solution. close the wound.
21-70
Do not use a primary closure for a large,
gaping, soft-tissue wound. This type of wound
will require warm dressings and irrigations,
along with aseptic care for 3 to 7 days to clear
up the wound. Then a secondary wound closure
may be performed.
21-71
Suture MANAGEMENT OF
Suture Location
Size MUSCULOSKELETAL INJURIES
Can be used to suture in G-Tube or Chest
2-0
Tube
LEARNING OBJECTIVE:
Skin: Foot
3-0
Deep: Chest, Abdomen, Back
Select the appropriate stabilization and
Skin: Scalp, Chest, Abdomen, Foot,
4-0 Extremity treatment procedure for the management of
Deep: Scalp, Extremity, Foot bone injuries.
Skin: Scalp, Brow, Oral, Chest, Abdomen,
5-0
Hand, Penis BONE INJURIES
Skin: Ear, Lid, Brow, Nose, Lip, Face,
6-0
Penis
A break in the bone is known as a fracture.
7-0 Skin: Eyelid, Lip, Face There are two main kinds of fractures. A closed
fracture is one in which the injury is entirely
Table 21-5.—Suture Size by Location internal; the bone is broken but there is no
break in the skin. An open fracture is one in
10. When cutting sutures, subcutaneous catgut which there is an open wound in the tissues and
should have a 1/16-inch tail. Silk skin the skin. Sometimes the open wound is made
sutures should be cut as short as is practical when a sharp end of the broken bone pushes out
for removal on the face and lip. Elsewhere, through the flesh; sometimes it is made by an
skin sutures may have longer tails for object such as a bullet that penetrates from the
convenience. A tail over ¼-inch is outside.
unnecessary, however, and tends to collect
exudate. Open fractures are more serious than closed
fractures. They typically involve extensive
11. The following general rules can be used in damage to the tissues and are quite likely to
deciding when to remove sutures: become infected. Closed fractures are
sometimes turned into open fractures by rough
a. Face: As a general rule, 4 or 5 days. or careless handling of the casualty.
Better cosmetic results are obtained by
removing every other suture and any It is not always easy to recognize a fracture.
suture with redness around it on the third All fractures, whether closed or open, are likely
day and the remainder on the fifth day. to cause severe pain and shock; but the other
b. Body and scalp: 7 days. symptoms may vary considerably. A broken
bone sometimes causes the injured part to be
c. Soles, palms, back, or over joints: 10 deformed or to assume an unnatural position.
days, unless excess tissue reaction is Pain, discoloration, and swelling may be
apparent around the suture, in which case localized at the fracture site, and there may be
they should come out sooner. wobbly movements if the bone is broken clear
d. Any suture with pus or infection around through.
it should be removed immediately, since
the suture's presence will make the It may be difficult or impossible for the
infection worse. casualty to move the injured part; if able to
move it, there may be a grating sensation
e. When wire is used, it may be left in safely (crepitus) as the ends of the broken bone rub
for 10 to 14 days. against each other. However, if a bone is
cracked rather than broken through, the casualty
may be able to move the injured part without
much difficulty.
21-72
An open fracture is easy to recognize if an o If the casualty must be transported for
end of the broken bone protrudes through the some distance, or if a considerable period
flesh. If the bone does not protrude, however, of time will elapse before treatment by a
the HM might see the external wound but fail to medical officer, it may be better to
recognize the broken bone. remove enough clothing to apply well
padded splints directly to the injured part
General Guidelines
To remove clothing over the injured
part, cut the clothing or rip it along the
If required to give first aid to a person who
seams
has suffered a fracture, follow these general
guidelines: In any case, be careful! Rough handling
of the casualty may convert a closed
• If there is any possibility that a fracture has fracture into an open fracture, increase
been sustained, treat the injury as a fracture the severity of shock, or cause extensive
until an X-ray can be made damage to the blood vessels, nerves,
• Get the casualty to a definitive care facility muscles, and other tissues around the
at the first possible opportunity. All broken bone
fractures require medical treatment • If the fracture is open
• Do not move the casualty until the injured o Take care of the wound before dealing
part has been immobilized by splinting with the fracture
(unless the move is necessary to save life or
to prevent further injury) o Bleeding from the wound may be profuse,
but most bleeding can be stopped by
• Treat for shock direct pressure on the wound.
• Do not attempt to locate a fracture by o Other supplemental methods of
grating the ends of the bone together hemorrhage control were discussed in the
• Do not attempt to set a broken bone unless a section on wounds of this chapter. Use a
medical officer will not be available for tourniquet as a last resort
many days o After the bleeding has been stopped, treat
• When a long bone in the arm or leg is the fracture
fractured, the limb should be carefully Now that the general rules for treating
straightened so that splints can be applied, fractures have been reviewed, please read on
unless it appears that further damage will be regarding the symptoms and emergency
caused by such a maneuver treatment of specific fracture sites.
o Never attempt to straighten the limb by
applying force or traction with any Forearm Fracture
improvised device
There are two long bones in the forearm, the
o Pulling gently along the long axis of the radius and the ulna. When both are broken, the
limb is permissible and may be all that is arm may appear to be deformed. When only one
necessary to get the limb back into is broken, the other acts as a splint and the arm
position retains a more or less natural appearance. Any
• Apply splints fracture of the forearm is likely to result in pain,
tenderness, inability to use the forearm, and a
o If the casualty is to be transported only a kind of wobbly motion at the point of injury. If
short distance, or if treatment by a medical the fracture is open, a bone will show through.
officer will not be delayed, it is best to
leave the clothing on and place
emergency splinting over it
21-73
If the fracture is open, stop the bleeding If the fracture is open, stop the bleeding
and treat the wound. Apply a sterile dressing and treat the wound before attempting to treat
over the wound. Carefully straighten the the fracture.
forearm. Remember that rough handling of a
closed fracture may turn it into an open fracture.
NOTE:
Apply a pneumatic splint if available; if not,
Treatment of the fracture depends partly upon
apply two well-padded splints to the forearm,
the location of the break.
one on the top and one on the bottom. Be sure
that the splints are long enough to extend from
the elbow to the wrist. Use bandages to hold the If the fracture is in the upper part of the
splints in place. Put the forearm across the arm near the shoulder, place a pad or folded
chest. The palm of the hand should be turned in, towel in the armpit, bandage the arm securely to
with the thumb pointing upward. Support the the body, and support the forearm in a narrow
forearm in this position by means of a wide sling sling (Fig. 21-6).
and a cravat bandage, as shown in Figure 21-5.
The hand should be raised about 4 inches above
the level of the elbow. Treat the casualty for
shock and evacuate as soon as possible.
21-74
If the fracture is at or near the elbow, the It is essential that a fractured thigh be
arm may be either bent or straight. No matter in splinted before the casualty is moved.
what position the arm is found, DO NOT Manufactured splints, such as the Hare or the
ATTEMPT TO STRAIGHTEN IT OR Thomas half-ring traction splints are best, but
MOVE IT IN ANY WAY. Splint the arm as improvised splints may be used. Remember, DO
carefully as possible in the position in which NOT MOVE THE CASUALTY UNTIL
found. This will prevent further nerve and THE INJURED LEG HAS BEEN
blood vessel damage. The only exception to IMMOBILIZED. Treat the casualty for shock,
this is if there is no pulse distal to the fracture, and evacuate at the earliest possible
in which case gentle traction is applied and opportunity.
then the arm is splinted. Treat the casualty for
shock and get him under the care of a medical Lower Leg Fracture
officer as soon as possible.
When both bones of the lower leg are
Femur Fracture broken, the usual signs of fracture are likely to
be present. When only one bone is broken, the
The femur is the long bone of the upper part other one acts as a splint and, to some extent,
of the leg between the kneecap and the pelvis. prevents deformity of the leg. However,
When the femur is fractured through, any tenderness, swelling, and pain at the point
attempt to move the limb results in a spasm of fracture are almost always present. A fracture
the muscles and causes excruciating pain. The just above the ankle is often mistaken for a
leg has a wobbly motion, and there is complete sprain. If both bones of the lower leg are
loss of control below the fracture. The limb broken, an open fracture is very likely to
may assume an unnatural position, with the toes result.
pointing outward. By actual measurement, the
fractured leg is shorter than the uninjured one If the fracture is open, stop the bleeding
because of contraction of the powerful thigh and treat the wound. Carefully straighten the
muscles. Serious damage to blood vessels and injured leg. Apply a pneumatic splint if
nerves often results from a fracture of the femur, available; if not, apply three splints, one on
and shock is likely to be severe. each side of the leg and one underneath
(Fig. 21-7). Be sure that the splints are well
If the fracture is open, stop the bleeding padded, particularly under the knee and at the
and treat the wound before attempting to treat bones on each side of the ankle.
the fracture itself. Serious bleeding is a special
danger in this type of injury, since the broken
bone may tear or cut the large femoral artery in
the thigh.
21-75
A pillow and two side splints work very the forearm across the chest. The palm of the
well for treatment of a fractured lower leg. hand should be turned in, with the thumb
Place the pillow beside the injured leg, then pointed up. The hand should be raised about 4
carefully lift the leg and place it in the middle inches above the level of the elbow. Support
of the pillow. Bring the edges of the pillow the forearm in this position by means of a wide
around to the front of the leg and pin them sling. A wide roller bandage (or any wide strip
together. Then place one splint on each side of of cloth) may be used to secure the casualty’s
the leg (over the pillow), and fasten them in arm to the body. A figure-eight bandage may
place with strips of bandage or adhesive tape. also be used for a fractured clavicle. Treat the
Treat the casualty for shock and evacuate as casualty for shock and evacuate to a definitive
soon as possible. When available, use the Hare care facility as soon as possible.
or Thomas half-ring traction splints.
Rib Fracture
Kneecap Fracture
If a rib is broken, make the casualty
Carefully straighten the injured limb. comfortable and quiet so that the greatest
Immobilize the fracture by placing a padded danger the possibility of further damage to the
board under the injured limb. The board lungs, heart, or chest wall by the broken ends is
should be at least 4 inches wide and should minimized.
reach from the buttock to the heel. Place extra
padding under the knee and just above the heel. The common finding in all casualties with
Use strips of bandage to fasten the leg to the fractured ribs is pain localized at the site of the
board in four places: (1) just below the knee; fracture. By asking the patient to point out the
(2) just above the knee; (3) at the ankle; and (4) exact area of the pain, the location of the injury
at the thigh. Do not cover the knee itself. can be determined. There may or may not be a
Swelling is likely to occur very rapidly, and rib deformity, chest wall contusion, or
any bandage or tie fastened over the knee would laceration of the area. Deep breathing,
quickly become too tight. Treat the casualty for coughing, or movement is painful. The patient
shock and evacuate as soon as possible. generally wishes to remain still and may often
lean toward the injured side, with a hand over
Clavicle Fracture the fractured area to immobilize the chest and
to ease the pain.
A person with a fractured clavicle shows
definite symptoms. When the casualty stands, Ordinarily, rib fractures are not bound,
the injured shoulder is lower than the uninjured strapped, or taped if the casualty is reasonably
one. The casualty is usually unable to raise the comfortable. However, they may be splinted by
arm above the level of the shoulder and may the use of external support. If the patient is
attempt to support the injured shoulder by considerably more comfortable with the chest
holding the elbow of that side in the other immobilized, the best method is to use a
hand. This is the characteristic position of a swathe in which the arm on the injured side is
person with a broken clavicle. Since the strapped to the chest to limit motion. Place the
clavicle lies immediately under the skin, it may arm on the injured side against the chest, with
be possible to detect the point of fracture by the palm flat, thumb up, and the forearm raised
the deformity and localized pain and to a 45 ° angle. Immobilize the chest, using wide
tenderness. strips of bandage to secure the arm to the
chest.
If the fracture is open, stop the flow of
blood and treat the wound before attempting to
treat the fracture. Then apply a sling and Do not use wide strips of adhesive plaster
swathe splint as described below. Bend the applied directly to the skin of the chest for
casualty’s arm on the injured side, and place immobilization since the adhesive tends to limit
21-76
the ability of the chest to expand (interfering Treat the casualty for shock and evacuate as soon
with proper breathing). Treat the casualty for as possible.
shock and evacuate as soon as possible.
Skull Fracture
Nose Fracture
When a person suffers a head injury, the
A fracture of the nose causes localized pain greatest danger is that the brain may be
and swelling, a noticeable deformity of the severely damaged; whether or not the skull is
nose, and extensive nosebleed. fractured is a matter of secondary importance.
In some cases, injuries that fracture the skull do
Stop the nosebleed. Have the casualty sit not cause serious brain damage; but brain
quietly, with the head tipped slightly backward. damage can and frequently does result from
Tell the casualty to breathe through the mouth apparently slight injuries that do not cause
and not to blow the nose. If the bleeding does damage to the skull itself.
not stop within a few minutes, apply a cold
compress or an ice bag over the nose. It is often difficult to determine whether an
injury has affected the brain because the
Treat the casualty for shock. Ensure the symptoms of brain damage vary greatly. A
casualty receives a medical officer’s attention person suffering from a head injury must be
as soon as possible. Permanent deformity of the handled very carefully and given immediate
nose may result if the fracture is not treated medical attention.
promptly.
Some of the symptoms that may indicate
Jaw Fracture brain damage are listed below. Remember that
all of these symptoms are not always present in
A person who has a fractured jaw may any one case and that the symptoms that do
suffer serious interference with breathing. occur may be greatly delayed.
There is likely to be great difficulty in talking,
• Bruises or wounds of the scalp may
chewing, or swallowing. Any movement of the
indicate that the casualty has sustained a
jaw causes pain. The teeth may be out of line,
blow to the head. Sometimes the skull is
and there may be bleeding from the gums.
depressed (caved in) at the point of
Considerable swelling may develop.
impact. If the fracture is open, there may
be glass, shrapnel, or other objects
One of the most important phases of
penetrating the skull
emergency care is to clear the upper respiratory
passage of any obstruction. If the fractured jaw • The casualty may be conscious or
interferes with breathing, pull the lower jaw unconscious. If conscious, the casualty
and the tongue well forward and keep them in may feel dizzy and weak, as though
that position, jaw thrust position. about to faint
Apply a four-tailed bandage (also known as • Severe headache sometimes (but not
a Barton bandage). Be sure that the bandage always) accompanies head injuries
pulls the lower jaw forward. Never apply a • The pupils of the eyes may be unequal in
bandage that forces the jaw backward, since size and may not react normally to light
this might seriously interfere with breathing.
The bandage must be firm so that it will support • There may be bleeding or cerebrospinal
and immobilize the injured jaw, but it must not fluid (CSF) leakage from the ears, nose,
press against the casualty’s throat. or mouth
Be sure that the casualty has scissors or a • The casualty may vomit
knife to cut the bandage in case of vomiting.
21-77
• The casualty may be restless and Spinal Fractures
perhaps confused and disoriented
If the spine is fractured at any point, the
• The arms, legs, face, or other parts of spinal cord may be crushed, cut, or otherwise
the body may be partially paralyzed damaged so severely that death or paralysis will
• The casualty’s face may be very pale, or result. However, if the fracture occurs in such a
it may be unusually flushed way that the spinal cord is not seriously
damaged, there is a very good chance of
• The casualty is likely to be suffering complete recovery, provided that the casualty is
from shock, but the symptoms of shock properly cared for. Any twisting or bending of
may be disguised by other symptoms the neck or back whether due to the original
It is not necessary to determine if the skull injury or carelessness from handling later is
is fractured when giving first aid to a person likely to cause irreparable damage to the spinal
who has suffered a head injury. The treatment is cord.
the same in either case, and the primary intent is
to prevent further damage to the brain. The primary symptoms of a fractured spine
are pain, shock, and paralysis. Pain is likely to
Keep the casualty lying down. If the face is be acute at the point of fracture. It may radiate to
flushed, raise the head and shoulders slightly. If other parts of the body. Shock is normally
the face is pale, have the casualty lie so that the severe, but (as in all injuries) the symptoms
head is level with, or slightly lower than, the may be delayed for some time. Paralysis occurs
body. Watch carefully for vomiting. If the if the spinal cord is seriously damaged. If the
casualty begins to vomit, position the head to casualty cannot move the legs, feet, or toes, the
prevent choking on the vomitus. fracture is probably in the back; if the fingers
will not move, the neck is probably broken.
If there is serious bleeding from the wounds, Remember that a spinal fracture does not
try to control that bleeding by the application of always injure the spinal cord, so the casualty is
direct pressure, using caution to avoid further not always paralyzed. Any person who has an
injury to the skull or brain. Use a donut-shaped acute pain in the back or the neck following an
bandage to gently surround protruding objects. injury should be treated as though there is a
Never manipulate those objects. fractured spine, even if there are no other
symptoms.
• Be very careful about moving or
handling the casualty. Move the Emergency treatment for all spinal
casualty no more than is necessary. fractures, whether of the neck or of the back,
If transportation is necessary, keep the has two primary purposes: (1) to minimize
casualty lying down shock, and (2) to prevent further injury to the
• In any significant head or facial injury, spinal cord. Keep the casualty comfortably
assume injury to the cervical spine. warm. Do not attempt to keep the casualty in
Immobilization of the cervical spine is the position ordinarily used for the treatment of
indicated shock, because it might cause further damage to
the spinal cord. Just keep the casualty lying flat
• Be sure that the casualty is kept and do NOT attempt to lower the head.
comfortably warm, but not too warm
• Do not give the casualty anything to
drink. DO NOT GIVE ANY
MEDICATIONS. See that the casualty
receives a medical officer’s attention as
soon as possible
21-78
To avoid further damage to the spinal cord, • When placing the casualty on a spine board,
DO NOT MOVE THE CASUALTY one of two acceptable methods may be used
UNLESS IT IS ABSOLUTELY
o DO NOT ATTEMPT TO LIFT/ROLL
ESSENTIAL! If the casualty’s life is
THE CASUALTY UNLESS ADEQUATE
threatened in the present location or
ASSISTANCE IS AVAILABLE
transportation is necessary to receive medical
attention, then, of course, the HM must move o Remember: Any bending or twisting of
the casualty. However, if movement is the body is almost sure to cause serious
necessary, be sure that the HMs do it in a way damage to the spinal cord
that will cause the least possible damage.
o One person lifts and supports the head
• DO NOT BEND OR TWIST THE while two other persons each lift at the
CASUALTY S BODY shoulders and hips, respectively
• DO NOT MOVE THE HEAD o A fourth person aligns the spine board
FORWARD, BACKWARD, OR next to the patient
SIDEWAYS o The casualty is log rolled as a single unit
• DO NOT UNDER ANY CIRCUMSTANCES towards the rescuers. It is critical that the
ALLOW THE CASUALTY TO SIT UP head is kept aligned with the neck and the
rest of the body
If it is necessary to transport a person who o The spine board is positioned, the casualty
has suffered a spinal fracture, has a suspected is rolled back onto the spine board and
spinal fracture, or the MOI indicates a high IOS both are lowered gently to the ground, and
of spinal fracture follow these general ru le s: then the patient is secured in place
• Assume that the patient has a cervical o If there are at least four (preferably six)
fracture which has the most potential for people present to help lift/roll the
negative outcomes (i.e. quadriplegic on a casualty, they can accomplish the job
ventilator) without too much movement of the
casualty’s body
• Transport patient lying on the back, face up
o NEVER attempt to lift/roll the casualty,
• Place pillows or sandbags beside the head so however, with fewer than four people
that it cannot turn to either side. DO NOT
put pillows or padding under the neck or • Evacuate the casualty very carefully
head
• No matter where the spine is broken, use a Pelvic Fracture
firm support in transporting the casualty; use
a rigid stretcher, or a door, shutter, wide Fractures in the pelvic region often result
board, etc. from falls, heavy blows, and accidents that
involve crushing. The great danger in a pelvic
• Pad the support carefully, and put blankets fracture is that the organs enclosed and
both under and over the casualty protected by the pelvis may be seriously
damaged when the bony structure is fractured.
• Use cravat bandages or strips of cloth to
In particular, there is danger that the bladder
secure the casualty firmly to the s u p p o rt
will be ruptured. There is also danger of
severe internal bleeding; the large blood
vessels in the pelvic region may be torn or cut
by fragments of the broken bone.
21-79
The primary symptoms of a fractured In general, joint and muscle injuries may
pelvis are severe pain, shock, and loss of ability be classified under four headings:
to use the lower part of the body. The casualty is
• Dislocations
unable to sit or stand. If the casualty is
conscious, there may be a sensation of • Sprains
"coming apart.” If the bladder is injured, the
casualty’s urine may be bloody. • Strains
• Contusions (bruises)
Do not move the casualty unless
ABSOLUTELY necessary. The casualty
should be treated for shock and kept warm but Dislocations
should not be moved into the position
ordinarily used for the treatment of shock. When a bone is forcibly displaced from its
joint, the injury is known as a dislocation. In
If the HM must transport the casualty to some cases, the bone slips back quickly into its
another place, do it with the utmost care. Use a normal position, but at other times it becomes
rigid stretcher, a padded door, or a wide board. locked in the new position and remains
Keep the casualty supine. In some cases, the dislocated until it is put back into place.
casualty will be more comfortable if the legs are Dislocations are typically caused by falls or
straight, while in other cases the casualty will be blows but occasionally by violent muscular
more comfortable with the knees bent and the exertion. The most frequently dislocated joints
legs drawn up. are those of the shoulder, hip, fingers, and jaw.
When the casualty is in the most A dislocation is likely to bruise or tear the
comfortable position, immobilization should be muscles, ligaments, blood vessels, tendons,
accomplished. Fractures of the hip are best and nerves near a joint. Rapid swelling and
treated with traction splints. Adequate discoloration, loss of ability to use the joint,
immobilization can also be obtained by placing severe pain and muscle spasms, possible
pillows or folded blankets between the legs and numbness and loss of pulse below the joint,
using cravats, roller bandages, or straps to hold and shock are characteristic symptoms of
the legs together, or through the use of MAST dislocations. The fact that the injured part is
garments. Then, fasten the casualty securely to stiff and immobile, with marked deformation
the stretcher or improvised support, and at the joint, will help to distinguish a
evacuate very carefully. dislocation from a fracture. In a fracture, there
is deformity between joints rather than at joints,
JOINT AND MUSCLE INJURIES and there is generally a wobbly motion of the
broken bone at the point of fracture.
Injuries to joints and muscles often occur
together, and it is sometimes difficult to tell As a general rule do not attempt to reduce a
whether the primary injury is to a joint or to dislocation, to put a dislocated bone back into
the muscles, tendons, blood vessels, or nerves place, unless it is known that a medical officer
near the joint. Sometimes it is difficult to cannot be reached within 8 hours. Unskilled
distinguish joint or muscle injuries from attempts at reduction may cause great damage
fractures. In case of doubt, always treat any to nerves and blood vessels or actually fracture
injury to a bone, joint, or muscle as though it the bone. Therefore, except in great
were a fracture. emergencies, HMs should leave this treatment
to specially trained medical personnel and
concentrate their efforts on making the
casualty as comfortable as possible under the
circumstances.
21-80
The following emergency measures will be DISLOCATION OF THE FINGER.⎯T h e
helpful: joints of the finger are particularly susceptible
1. Loosen the clothing around the injured part. to injury, and even minor injuries may result in
prolonged loss of function. Great care must be
2. Place the casualty in the most comfortable used in treating any injury of the finger.
position possible.
3. Support the injured part by means of a To reduce a dislocation of the finger,
sling, pillows, bandages, splints, or any grasp the finger firmly and apply a steady pull
other device that will make the casualty in the same line as the deformity. If it does not
comfortable. slip into position, try it again, but if it does not
go into position on the third attempt, DO NOT
4. Treat the casualty for shock. TRY AGAIN. In any case, and whether or not
5. Get medical help as soon as possible. the dislocation is reduced, the finger should be
strapped, slightly flexed, with an aluminum
HMs should NEVER attempt to reduce the splint or with a roller gauze bandage over a
more serious dislocations, such as those of the tongue blade. A dislocated finger can be
hip. However, if it is probable that the immobilized by strapping it to a flat, wooden
casualty cannot be treated by a medical officer stick, such as a tongue depressor.
within a reasonable time, the HM should make
a careful effort to reduce certain dislocations DISLOCATION OF THE
(such as those of the jaw, finger, or shoulder) SHOULDER.⎯Before reduction, place the
if there is no arterial or nerve involvement casualty in a supine position. After putting the
(pulse will be palpable and there will be no heel of a foot in the casualty’s armpit, grasp
numbness below the joint). Treat all other the wrist and apply steady traction by pulling
dislocations as fractures, and evacuate the gently and increasing resistance gradually.
casualty to a definitive care facility. Pull the arm in the same line as it is found.
After several minutes of steady pull, flex the
DISLOCATION OF THE JAW.⎯When casualty’s elbow slightly. Grasp the arm below
the lower jaw is dislocated, the casualty the elbow, apply traction from the point of the
cannot speak or close the mouth. Dislocation elbow, and gently rotate the arm into the
of the jaw is typically caused by a blow to the external or outward position. If three reduction
mouth; sometimes it is caused by yawning or attempts fail, carry the forearm across the
laughing. This type of dislocation is not always chest and apply a sling and swathe.
easy to reduce, and there is considerable danger
that the operator’s thumbs will be bitten in the An alternate method involves having the
process. patient lie face down on an examining table
with the injured arm hanging over the side.
For protection, wrap the thumbs with a Apply prolonged, firm, gentle traction at the
handkerchief or bandage. While facing the wrist with gentle external rotation. A water
casualty, the HM should press the thumbs bucket with a padded handle placed in the
down just behind the last lower molars and, at crook of the patient’s elbow may be
the same time, lift the chin up with the fingers. substituted. Gradually add sand or water to the
The jaw should snap into place at once. The bucket to increase traction. Grasping the wrist
HM will have to remove the thumbs quickly to and using the elbow as a pivot point, gently
avoid being bitten. No further treatment is rotate the arm into the external position.
required, but warn the casualty to keep the
mouth closed as much as possible during the
next few hours.
21-81
Sprains Strains
Sprains are injuries to the ligaments and Injuries caused by the forcible
soft tissues that support a joint. A sprain is overstretching or tearing of muscles or
caused by the violent wrenching or twisting of tendons are known as strains. Strains may be
the joint beyond its normal limits of caused by lifting excessively heavy loads,
movement and involves a momentary sudden or violent movements, or any other
dislocation, with the bone slipping back into action that pulls the muscles beyond their
place of its own accord. Although any joint normal limits.
may be sprained, sprains of the ankle, wrist,
knee, and finger are most common. The chief symptoms of a strain are pain,
lameness or stiffness (sometimes involving
Symptoms of a sprain include pain or knotting of the muscles), moderate swelling at
pressure at the joint, pain upon movement, the place of injury, discoloration due to the
swelling and tenderness, possible loss of escape of blood from injured blood vessels into
movement, and discoloration. Treat all sprains the tissues, possible loss of power, and a
as fractures until ruled out by X-rays. distinct gap felt at the site.
Emergency care for a sprain includes Keep the affected area elevated and at rest.
application of cold packs for the first 24 to 48 Apply cold packs for the first 24 to 48 hours to
hours to reduce swelling and to control internal control hemorrhage and swelling. After the
hemorrhage; elevation and rest of the affected swelling stops, apply mild heat to increase
area; application of a snug, smooth, figure- circulation and aid in healing. As in sprains,
eight bandage to control swelling and to heat should not be applied until 24 hours after
provide immobilization (basket weave the last cold pack. Muscle relaxants, adhesive
adhesive bandages can be used on the ankle); straps, and complete immobilization of the
a follow-up examination by a medical officer; area may be indicated. Evacuate the casualty
and X-rays to rule out the presence of a to a medical facility where X-rays can be taken
fracture. to rule out the presence of a fracture.
Contusions
NOTE:
Check bandaged areas regularly for swelling that
Contusions, commonly called bruises, are
might cause circulation impairment and loosen
responsible for the discoloration that almost
bandages if necessary.
always accompanies injuries to bones, joints,
and muscles. Contusions are caused by blows
After the swelling stops (24 to 48 hours), that damage bones, muscles, tendons, blood
moist heat can be applied for short periods (15 vessels, nerves, and other body tissues. They
to 30 minutes) to promote healing and reduce do not necessarily break the skin.
swelling. Moist heat can be warm, wet
compresses, warm whirlpool baths, etc. The symptoms of a contusion or bruise are
familiar to everyone. There is immediate pain
CAUTION: when the blow is received. Swelling occurs
Heat should not be applied until 24 hours after because blood from the broken vessels leaks into
the last cold pack. the soft tissue under the skin. At first the injured
place is reddened due to local skin irritation
from the blow. Later the characteristic "black
and blue" marks appear. Perhaps several days
later, the skin turns yellowish or greenish before
normal coloration returns. The bruised area
may be very tender.
21-82
As a rule, slight bruises do not require Performance Steps
treatment. However, if the casualty has severe
bruises, treat for shock. Immobilize the injured
NOTE:
part, keep it at rest, and protect it from further
Take Body Substance Isolation (BSI)
injury. Sometimes the casualty will be more
precautions.
comfortable if the bruised area is bandaged
firmly with an elastic or gauze bandage. If
possible, elevate the injured part. A sling may 1. Perform visual acuity testing.
be used for a bruised arm or hand. Pillows or
folded blankets may be used to elevate a 2. Assess eyes: pupils, equal and round,
bruised leg. regular in size, and react to light
(PEARRL).
SPECIAL WOUNDS AND THEIR 3. Locate the foreign body.
TREATMENT
a. Method one.
Objective CAUTION:
If the foreign bodies cannot be located, bandage
Treat foreign bodies of the eye, minimizing both eyes and seek further medical aid
the effects of the injury, without causing immediately.
additional injury to the eye.
21-83
iii. Cover the uninjured eye with a dry
4. Remove the foreign body.
dressing or eye patch.
CAUTION: iv. Reassure the casualty by explaining
Do not put pressure on the globe. why both eyes are being covered.
i. For a foreign body under the lower In hazardous conditions, leave the good eye
eyelid, pull the lower lid down. uncovered long enough to ensure the casualty's
ii. For a foreign body under the upper safety.
eyelid, pull the upper lid up.
d. Seek further medical aid immediately.
iii. Remove the foreign body with a
moistened, sterile cotton-tipped swab. 5. Obtain details about the injury.
a. Source and type of the foreign bodies.
CAUTION:
Bandage both eyes if foreign bodies are not b. Whether the foreign bodies were wind-
easily removed by these methods or if there is blown or high velocity.
pain or loss of vision in the eye. c. Time of onset and length of discomfort.
Seek further medical aid immediately.
d. Any previous injuries to the eye.
6. Record the procedure
NOTE:
In hazardous conditions, leave the good eye 7. Do not cause additional injury to the eye.
uncovered long enough to ensure the casualty's a. Do not probe for foreign bodies.
safety.
b. Do not put pressure on the globe.
c. Foreign body stuck or impaled in the eye. c. Do not remove an impaled object.
CAUTION: 8. Evacuate the casualty, as required.
Do not attempt to remove a foreign body stuck
to or sticking into the eyeball.
NOTE:
This will help prevent further contamination and
minimize movement of the object.
21-84
CRUSH SYNDROME29 THERAPY.—On scene while still trapped.
The primary goal of therapy is to prevent acute
When a casualty is crushed or trapped with renal failure in crush syndrome. Suspect,
compression on the extremities for a prolonged recognize, and treat rhabdomyolysis early in
time, there is the possibility for crush syndrome casualties of entrapment. Therapy should be
(CS), characterized by ischemia and muscle initiated as soon as possible, preferably in the
damage (rhabdomyolysis). With rhabdomyolysis field, while the casualty is still trapped. Ideally it
there is an efflux of potassium, nephrotoxic is recommended to establish IV access in a free
metabolites, myoglobin, purines, and arm or leg vein.
phosphorous into the circulation, resulting in
cardiac and renal dysfunction. REMOVING FOREIGN OBJECTS
1. Recognition.
Many wounds contain foreign objects.
a. History. Wood or glass splinters, bullets, metal
i. Suspect in patients in whom there is a fragments, bits of wire, fishhooks, nails, tacks,
history of being trapped (e.g., urban cinders, and small particles from grinding
operations, mountain operations, wheels are examples of the variety of objects or
earthquakes, or bombings) for a materials that are sometimes found in wounds.
prolonged period (from hours to When such objects are near the surface and
days). exposed, first aid treatment includes their
removal.
ii. Clear history is not always available
in combat, and the syndrome may However, first aid treatment does not
appear insidiously in patients who include the removal of deeply embedded
initially appear well. objects, powdered glass, or any widely
b. Physical findings. scattered material of this nature. HMs should
never attempt to remove bullets, but they should
i. A thorough examination must be done try to find out whether the bullet remains in the
with attention to extremities, trunk, casualty. Look for both entrance and exit
and buttocks. The physical findings wounds. The general rule to remember is this:
depend on the duration of entrapment,
treatment rendered, and time since the
casualty’s release. NOTE:
Remove foreign objects from a wound when it
ii. Extremities. can be done easily and without causing further
1. May initially appear normal just damage; but NEVER HUNT FOR OR
after extrication. ATTEMPT TO REMOVE DEEPLY
BURIED OR WIDELY SCATTERED
2. Edema develops and the extremity OBJECTS OR MATERIALS, except in a
becomes swollen, cool, and tense. definitive care environment.
3. May have severe pain out of
proportion to examination.
4. Anesthesia and paralysis of the
extremities, which can mimic a
spinal cord injury with flaccid
paralysis, but there will be normal
bowel and bladder function.
iii. Trunk/buttocks: may have severe pain
out of proportion to examination.
21-85
The following procedure may be used to
remove a small object from the skin or tissues if
the object is near the surface and clearly visible:
1. Cleanse the skin around the object with
soap and water and paint with any
available skin antiseptic solution.
2. If necessary, pierce the skin with a sharp
instrument; a needle, razor, or sharp knife
that has been sterilized by passing it
through a flame three or four times.
3. Grasping the object at the end, remove it.
Tweezers, small pincers, or forceps may be
used for this purpose. (Whatever instrument
used should first be sterilized by boiling if
at all possible.)
4. If the wound is superficial, apply gentle
pressure to encourage bleeding.
5. Cover the wound with a dry, sterile Figure 21-8.—Removing a Fishhook
dressing.
If the foreign object is under a fingernail or ANIMAL BITES
toenail, HMs may have to cut a V-shaped notch
in the nail so that the object can be grasped by A special kind of infection that must be
the forceps. Do not try to dig the object out from guarded against in case of animal bites is rabies
under the nail with a knife or similar instrument. (sometimes called "hydrophobia"). This
disease is caused by a virus that is present in
A curved or barbed object (such as a the saliva of infected animals. The disease
fishhook) may present special problems. Figure occurs most commonly in wild animals, but it
21-8 shows one method of removing a fishhook has been found in domestic animals and
that has become embedded in the flesh. As household pets. In fact, it is probable that all
illustrated in Figure 21-8A, the barb on the mammals are susceptible to it. The virus that
hook prevents its direct removal. However, if causes rabies is ordinarily transmitted by a bite,
the HM pushes the hook forward through the but it can be transmitted by the saliva of an
skin, as shown in Figure 21-8B, then the HM infected animal coming in contact with a fresh
can clip off the barb with a wire cutter or wound or with the thin mucous membrane of
similar tool, as shown in Figure 21-8C. The the lips or nose. The virus does not penetrate
remainder of the fishhook can then be normal unbroken skin. If the skin is broken,
withdrawn in the manner indicated in Figure DO NOT attempt wound closure.
21-8D.
If rabies develops in man, it is normally
fatal. A preventive treatment is available and it
is very effective, but only if it is started shortly
after the bite. This treatment is outlined in
BUMEDINST 6220.8 series, Streptococcal
Infection Control Program.
21-86
Since the vaccine can be obtained only at a ENVIRONMENTAL INJURIES
medical treatment facility or a major ship, any
person bitten by an animal must be transferred
LEARNING OBJECTIVES:
quickly to the nearest treatment facility for
evaluation, along with a complete report of the
Explain the classification and evaluation
circumstances surrounding the incident.
process for burns.
Remember, prevention is of utmost importance.
Determine the appropriate treatment for each
Immediate local treatment of the wound
type of burn.
should be given. Wash the wound and the
surrounding area carefully, using sterile gauze,
soap, and sterile water. Use sterile gauze to dry Under the broad category of
the wound, and then cover the wound with a environmental injuries, HM’s will consider a
sterile dressing. DO NOT use any chemical number of emergency problems. Exposure to
disinfectant. Do not attempt to cauterize the extremes of temperature, whether heat or cold,
wound in any way. All of the animal’s saliva causes injury to skin, tissues, blood vessels,
must be removed from the casualty’s skin to vital organs, and, in some cases, the whole
prevent further contamination of the wound. body. In addition, contact with the sun’s rays,
electrical current, or certain chemicals causes
injuries similar in character to burns.
CAUTION:
DO NOT allow the animal’s saliva to come in THERMAL BURNS
contact with open sores or cuts on any exposed
skin while providing patient care. True burns are generated by exposure to
extreme heat that overwhelms the body’s
When a person has been bitten by an animal, defensive mechanisms. Burns and scalds are
every effort must be made to catch the animal essentially the same injury: Burns are caused
and to keep it confined for a minimum of 8 to by dry heat, and scalds are caused by moist
10 days. DO NOT kill it if there is any possible heat. The seriousness of the injury can be
chance of catching it alive. The symptoms of estimated by the depth, extent, and location of
rabies are not always present in the animal at the burn, the age and health of the casualty, and
the time the bite occurs, but the saliva may other medical complications.
nevertheless contain the rabies virus. It is
essential; therefore, that the animal is kept Classification of Severity
under observation until a diagnosis can be
made. Burns are classified according to their
depth as first-, second-, and third-degree burns
The rabies treatment is given if the animal (Fig. 21-9).
develops any definite symptoms, if it dies
during the observation period, or if for any
reason the animal cannot be kept under
observation. Remember that any animal bite is
dangerous and MUST be evaluated at a
treatment facility.
21-87
Epidermis First de gre e
S econd de gre e
Dermis
Appendages
Third degr ee
Subcutaneous
Tissue
Illustration provided by HMCS (SS/SW) Christopher Santee of Navy Medicine Manpower Personnel
Education and Training Command, Bethesda, MD.
FIRST-DEGREE BURN.⎯With a first- Tissue color will range from white (scalds)
degree burn, the epidermal layer is irritated, to black (charring burns). Although the wound
reddened, and tingling. The skin is sensitive to is typically dry, body fluids will collect in the
touch and blanches with pressure. Pain is mild underlying tissue. If the area has not been
to severe, edema is minimal, and healing occurs completely cauterized, significant amounts of
naturally within a week. fluids will be lost by plasma "weeping" or by
hemorrhage, thus reducing circulation volume.
SECOND-DEGREE BURN.⎯A second- There is considerable scarring and possible loss
degree burn is characterized by epidermal of function. Skin grafts may be necessary.
blisters, mottled appearance, and a red base.
Damage extends into but not through the Rule of Nines
dermis. Recovery takes 2 to 3 weeks, with some
scarring and depigmentation. This condition is Of greater importance than the depth of the
painful. Body fluids may be drawn into the burn in evaluating the seriousness of the
injured tissue, causing edema and possibly a condition is the extent of the burned area. A
"weeping" fluid (plasma) loss at the surface. first-degree burn over 50 percent of the body
surface area (BSA) may be more serious than a
THIRD-DEGREE BURN.⎯A third- third-degree burn over 3 percent. The Rule of
degree burn is a full-thickness injury Nines is used to give a rough estimate of the
penetrating into muscle and fatty connective surface area affected. Figure 21-10 shows how
tissues, or even down to the bone. Tissues and the rule is applied to adults.
nerves are destroyed. Shock, with blood in the
urine, is likely to be present. Pain will be absent
at the burn site if all the area nerve endings are
destroyed, and the surrounding tissue (which is
less damaged) will be painful.
21-88
Figure 21-10.—Rule of Nines
21-89
Other Factors 9. Pain Relief.
a. Pain resulting from small burns may
A third factor in burn evaluation is the
be relieved with an anesthetic
location of the burn. Serious burns of the head,
ointment if the skin is not broken.
hands, feet, or genitals will require
hospitalization. b. Relieve mild pain (as with first degree
burns) with aspirin. Relieve moderate
The fourth factor is the presence of any pain with cool, wet compresses or ice
other complications, especially respiratory tract water immersion (for burns of less
injuries or other major injuries or factors. The than 20 percent BSA).
HM must take all these factors into c. Severe pain may be relieved with
consideration when evaluating the condition of morphine or Demerol® injections.
the burn casualty, especially in a triage
situation.
Aid Station Care
First Aid
Once the casualty has arrived at the aid
station, observe the following procedures.
1. After the casualty has been removed
from the source of the thermal injury, 1. Continue to monitor for airway patency,
first aid should be kept to a minimum. hemorrhage, and shock.
2. Maintain an open airway. 2. Continue intravenous therapy that is in
place, or start a new one under a medical
3. Control hemorrhage, and treat for shock. officer’s supervision to control shock
4. Remove constricting jewelry and and replace fluid loss.
articles of c l o t h i n g . 3. Monitor urine output (UOP); at least
5. Protect the burn area from 30cc/kg/hr is minimal output.
contamination by covering it with clean 4. Wound care.
sheets or dry dressings. DO NOT
remove clothing adhering to a wound. a. Shave body hair well back from the
burned area.
6. Splint fractures.
b. Cleanse the area gently with
7. For all serious and extensive burns (over disinfectant soap and warm water.
20 percent BSA), and in the presence of
shock, start intravenous therapy with an c. Remove dirt, grease, and nonviable
electrolyte solution (Ringer’s lactate) in tissue.
an unburned area. d. Apply a sterile dressing of dry gauze.
8. Maintain intravenous treatment during e. Place bulky dressings around the
transportation. burned parts to absorb serous
exudates.
5. All major burn casualties should be given
a booster dose of tetanus toxoid to guard
against infection. Administration of
antibiotics may be directed by a medical
officer or an Independent Duty
Corpsman.
21-90
6. If evacuation to a definitive care facility Before treatment is started, ensure that the
will be delayed for 2 to 3 days, start casualty is no longer in contact with a live
topical antibiotic therapy after the electrical source. Shut the power off or use a
patient stabilizes and following non-conducting rope or stick to move the
debridement and wound care. casualty away from the line or the line away
from the casualty.
a. Gently spread a 1/16-inch thickness
of or Silvadene Cream® over the
HMs can do little for these casualties other
burn area.
than monitoring the basic life functions;
b. Repeat the application after 12 hours, delivering CPR; treating for shock; covering the
and then after daily debridement. entrance and exit wounds with a dry, sterile
c. Treat minor skin reactions with dressing; and transporting the casualty to a
antihistamines. medical treatment facility. Due to the nature of
the injury, the patient may require defibrillation
SUNBURN with an AED or cardiac defibrillator in order to
re-set the electric circuits in the heart so that a
Sunburn results from prolonged exposure normal cardiac rhythm can return. AEDs are
to the ultraviolet rays of the sun. First- and the device of choice for HMs; follow the
second-degree burns similar to thermal burns manufacturer’s directions for use.
result. Treatment is essentially the same as that
outlined for thermal burns. Unless a major CHEMICAL BURNS
percentage of the body surface is affected, the
casualty will not require more than first aid When acids, alkalis, or other chemicals
attention. Commercially prepared sunburn come in contact with the skin or other body
lotions and ointments may be used. Prevention membranes, they may cause injuries that are
through education and the proper use of sun generally referred to as chemical burns. For the
screens is the best way to avoid this condition. most part, these injuries are not caused by heat
but by direct chemical destruction of body
ELECTRICAL BURNS tissues. Areas most often affected are the
extremities, mouth, and eyes. Alkali burns are
Electrical burns may be far more serious more serious than acid burns because alkalis
than a preliminary examination may indicate. penetrate deeper and burn longer.
The entrance and exit wounds may be small,
but as electricity penetrates the skin it burns a
large area below the surface (Fig. 21-11).
21-92
Superficial burns caused by simple skin HEAT EXPOSURE INJURIES
contact or burning clothes should be flushed
with water and treated like thermal burns.
LEARNING OBJECTIVE:
Partially embedded white phosphorus particles
must be continuously flushed with water while
Describe the signs, symptoms, and emergency
the first aid provider removes them with
treatment of heat cramps, heat exhaustion, and
whatever tools are available (i.e., tweezers,
heat stroke.
pliers, forceps). Do this quickly, but gently.
Firmly or deeply embedded particles that Excessive heat affects the body in a variety
cannot be removed by the first aid provider must of ways. When a person exercises or works in a
be covered with a saline-soaked dressing, and hot environment, heat builds up inside the body.
this dressing must be kept wet until the casualty The body automatically reacts to get rid of this
reaches a medical treatment facility. The wounds heat through the sweating mechanism. This
containing embedded phosphorus particles may depletes water and electrolytes from the
then be rinsed with a dilute, freshly mixed 1% circulating volume. If they are not adequately
solution of copper sulfate. This solution replaced, body functions are affected, and,
combines with phosphorus on the surface of the initially, heat cramps and heat exhaustion
particles to form a blue-black cupric phosphate develop. If the body becomes too overheated or
covering, which both impedes further oxidation water or electrolytes too depleted, the sweat-
and facilitates identification of retained control mechanism of the body malfunctions
particles. Under no circumstances should the and shuts down. The result is heat stroke
copper sulfate solution be applied as a wet (sunstroke). Heat exposure injuries are a threat
dressing. in any hot environment, but especially in desert
or tropical areas and in the boiler rooms of
Wounds must be flushed thoroughly with a ships. Under normal conditions, it is a
saline solution following the copper sulfate preventable injury. Individual and command
rinse to prevent absorption of excessive awareness of the causes of heat stress problems
amounts of copper. (Copper has been associated should help eliminate heat exposure injuries.
with extensive intravascular hemolysis.) An
adjunct to the management of phosphorus burn HEAT CRAMPS
injuries is the identification of the retained
phosphorescent particles in a darkened room Excessive sweating may result in painful
during debridement. cramps in the muscles of the abdomen, legs,
and arms. Heat cramps may also result from
drinking ice water or other cold drinks either too
NOTE: quickly or in too large a quantity after exercise.
Combustion of white phosphorus results in the Muscle cramps are often an early sign of
formation of a severe pulmonary irritant. approaching heat exhaustion.
The ignition of phosphorus in a closed space To provide first aid treatment for heat
(such as the BAS tent or sickbay) may result in cramps, move the casualty to a cool place.
the development of irritant concentrations Since heat cramps are caused by loss of salt and
sufficient to cause acute inflammatory changes water, give the casualty plenty of cool (not cold)
in the tracheobronchial tree. water to drink, adding about one teaspoon of
salt to a liter or quart of water. Apply manual
The effects of this gas, especially during pressure to the cramped muscle, or gently
debridement, can be minimized by placing a massage it to relieve the spasm. If there are
moist cloth over the nose and mouth to indications of anything more serious, transport
inactivate the gas and by ventilating the tent. the casualty immediately to a medical treatment
facility.
21-93
HEAT EXHAUSTION In heat stroke, the casualty suffers a
breakdown of the sweating mechanism and is
Heat exhaustion (heat prostration or heat unable to eliminate excessive body heat buildup
collapse) is the most common condition caused while exercising. If the body temperature raises
by working or exercising in hot environments. too high, the brain, kidneys, and liver may be
In heat exhaustion, there is a serious disturbance permanently damaged.
of blood flow to the brain, heart, and lungs. This
causes the casualty to experience weakness, Sometimes the casualty may have
dizziness, headache, nausea, and loss of preliminary symptoms such as headache,
appetite. The casualty may faint but will nausea, dizziness, or weakness. Breathing will
probably regain consciousness as the head is be deep and rapid at first, later shallow and
lowered, which improves the blood supply to almost absent. The casualty will be flushed,
the brain. Signs and symptoms of heat very dry, and very hot. The pupils will be
exhaustion are similar to those of shock; the constricted (pinpoint) and the pulse fast and
casualty will appear ashen gray, the skin cool, strong. Compare these symptoms with those of
moist, and clammy and the pupils may be heat exhaustion. When providing first aid for
dilated. The vital signs usually are normal; heat stroke, remember that this is a true life-and-
however, the casualty may have a weak pulse, death emergency. The longer the casualty
together with rapid and shallow breathing. remains overheated, the more likely irreversible
Body temperature may be below normal. brain damage or death will occur. First aid is
designed to reduce body heat fast.
Treat heat exhaustion as if the casualty
were in shock. Move the casualty to a cool or Reduce heat immediately by dousing the
air-conditioned area. Loosen the clothing, apply body with cold water or by applying wet, cold
cool wet cloths to the head, maxilla, groin, and towels to the whole body. Move the casualty to
ankles, and fan the casualty. Do not allow the the coolest place available and remove as much
casualty to become chilled. (If this does occur, clothing as possible. Maintain an open airway.
cover with a light blanket and move into a Place the casualty on his back, with the head
warmer area.) If the casualty is conscious, give and shoulders slightly raised. If cold packs are
a solution of 1 teaspoon of salt dissolved in a available, place them under the arms, around the
liter of cool water. If the casualty vomits, do neck, at the ankles, and in the groin. Expose the
not give any more fluids. Transport the casualty casualty to a fan or air conditioner, since drafts
to a medical treatment facility as soon as will promote cooling. Immersing the casualty in
possible. Intravenous fluid infusion may be a cold water bath is also very effective. If the
necessary for effective fluid and electrolyte casualty is conscious, give cool water to drink.
replacement to combat shock. Do not give any hot drinks or stimulants.
Discontinue cooling when the rectal
HEAT STROKE temperature reaches 102°F; watch for
recurrence of temperature rise by checking
Sunstroke is more accurately called heat every 10 minutes. Repeat cooling if
stroke since it is not necessary to be exposed to temperature reaches 103°F rectally.
the sun for this condition to develop. It is a less
common but far more serious condition than Get the casualty to a medical facility as
heat exhaustion, since it carries a 20 percent soon as possible. Cooling measures must be
mortality rate. The most important feature of continued while the casualty is being
heat stroke is the extremely high body transported. Intravenous fluid infusion may be
temperature (105°F, 41°C or higher) necessary for effective fluid and electrolyte
accompanying it. replacement to combat shock.
21-94
PREVENTION OF HEAT EXPOSURE COLD EXPOSURE INJURIES
INJURIES
LEARNING OBJECTIVE:
LEARNING OBJECTIVE:
Describe the signs, symptoms, and emergency
Determine the steps needed to prevent heat treatment of each type of cold exposure injury.
exposure injuries.
When the body is subjected to extremely
The prevention of heat exposure injuries is a cold temperatures, blood vessels constrict, and
command responsibility, but the medical body heat is gradually lost. As the body
department plays a role in it by educating all temperature drops, tissues are easily damaged
hands about the medical dangers, monitoring or destroyed.
environmental health, and advising the
commanding officer. The cold injuries resulting from inadequate
response to the cold in military situations have
On the individual level, prevention centers spelled disaster for many armies such as those
on water and salt replacement. Sweat must be of Napoleon and Hitler in their Russian
replaced ounce for ounce; in a hot environment, campaigns. The weather (i.e. temperature,
water consumption must be drastically humidity, precipitation, and wind) is the
increased. Salt should be replaced by eating predominant influence in the development of
well-balanced meals, three times a day, salted to cold injuries. Falling temperature interacting
taste. In the field, "C" rations contain enough with high humidity, a wet environment, and
salt to sustain a person in most situations. DO rising wind accelerates the loss of body heat.
NOT use salt tablets unless specified by a
physician. DO NOT consume alcoholic Other factors that influence the development
beverages. of cold injuries are the individual's level of
dehydration, the presence of other injuries
At the command level, prevention centers (especially those causing a reduction in
on an awareness of the environment. The Wet circulatory flow), and a previous cold injury
Bulb Globe Temperature (WBGT) must be which increases susceptibility by lowering
monitored regularly, and the results interpreted resistance. In addition, the use of any drug
with the Physiological Heat Exposure Limit (including alcohol) that modifies autonomic
(PHEL) chart before work assignments are nervous system response or alters judgment
made. In addition, unnecessary heat sources, ability can drastically reduce an individual’s
especially steam leaks, must be eliminated, and chance for survival in a cold environment.
vents and exhaust blowers must be checked for
adequate circulation. The results will be a Like heat exposure injuries, cold exposure
happier, healthier, and more productive crew. injuries are preventable. Acclimatization, the
availability of warm, layered clothing, and
maintenance of good discipline and training
standards are important factors. These are
command not medical responsibilities, but the
HM plays a crucial role as a monitor of
nutritional intake and personal hygiene (with
emphasis on foot care) and as an advisor to the
commanding officer. The HM is also responsible
for acquainting the troops with the dangers of
cold exposure and with preventive measures.
21-95
Two major points must be stressed in the Shock becomes evident as the casualty’s
management of all cold injuries: Rapid re- eyes assume a glassy stare, respiration becomes
warming is of primary importance, and all slow and shallow, and the pulse is weak or
unnecessary manipulations of affected areas absent. As the body temperature drops even
must be avoided. More will be said about these lower, peripheral circulation decreases and the
points later. extremities become susceptible to freezing.
Finally, death results as the core temperature of
In military operations the treatment of cold the body approaches 80°F.
injuries is influenced by the tactical situation, the
facilities available for the evacuation of The steps for treatment of hypothermia are as
casualties, and the fact that most cold injuries follows:
are encountered in large numbers during periods
1. Carefully observe respiratory effort and
of intense combat when many other wounded
heart beat; CPR may be required while the
casualties appear. Highly individualized treatment
warming process is underway.
under these circumstances may be impossible
because examination and treatment of more 2. Re-warm the casualty as soon as possible.
life-endangering wounds must be given
a. It may be necessary to treat other injuries
priority. In a high-casualty situation, shelter
before the casualty can be moved to a
cold-injury casualties, and try to protect them
warmer place.
from further injury until there is sufficient time
to treat them. b. Severe bleeding must be controlled and
fractures splinted over clothing before the
All cold injuries are similar, varying only in casualty is moved.
the degree of tissue damage. Although the
3. Replace wet or frozen clothing and remove
effects of cold can, in general, be divided into
anything that constricts the casualty’s arms,
two types general cooling of the entire body and
legs, or fingers, interfering with
local cooling of parts of the body cold injuries are
circulation.
seldom strictly of one type or the other; rather,
these injuries tend to be a combination of both 4. If the casualty is inside a warm place and is
types. Each type of cooling, however, will be conscious, the most effective method of
discussed separately in the sections that follow. warming is immersion in a tub of warm
(100 to 105 °F or 38 to 41 °C) water.
GENERAL COOLING (HYPOTHERMIA) a. The water should be warm to the elbow
never hot.
General cooling of the whole body is
caused by continued exposure to low or rapidly b. Observe closely for signs of respiratory
falling temperatures, cold moisture, snow, or failure and cardiac arrest (re-warming
ice. Those exposed to low temperatures for shock).
extended periods may suffer ill effects, even if c. Re-warming shock can be minimized by
they are well protected by clothing, because warming the body trunk before the limbs
cold affects the body systems slowly, almost to prevent vasodilatation in the
without notice. extremities with subsequent shock due to
blood volume shifts.
As the body cools, there are several stages
of progressive discomfort and disability. The
first symptom is shivering, which is an attempt
to generate heat by repeated contractions of
surface muscles. This is followed by a feeling
of listlessness, indifference, and drowsiness.
Unconsciousness can follow quickly.
21-96
5. If a tub is not available, apply external heat Injuries of this nature require no specific
to both sides of the casualty. treatment except warming of the affected part
a. Natural body heat (skin to skin) from two (if possible use water bath of 90F° to 105°F),
rescuers is the best method. This is called keeping it dry, and preventing further exposure.
"buddy warming."
Immersion Foot
b. If this is not practical, use hot water
bottles or an electric re-warming blanket. Immersion foot, which also may occur in
i. Do not place the blanket or bottles the hands, results from prolonged exposure to
next to bare skin. wet cold at temperatures ranging from just
above freezing to 50°F (10°C). Immersion foot
ii. Monitor the temperature of the is typically seen in connection with limited
artificial heat source, since the motion of the extremities and water-soaked
casualty is very susceptible to burn protective clothing.
injury.
c. Because the casualty is unable to Signs and symptoms of immersion foot are
generate adequate body heat, placement tingling and numbness of the affected areas;
under a blanket or in a sleeping bag is not swelling of the legs, feet, or hands; bluish
sufficient treatment. discoloration of the skin; and painful blisters.
Gangrene may occur. General treatment for
6. If the casualty is conscious, give warm immersion foot is as follows:
liquids to drink. Never give alcoholic
beverages or allow the casualty to smoke. 1. Get the casualty off his or her feet as soon
as possible.
7. Dry the casualty thoroughly if water is used
for re-warming. 2. Remove wet shoes, socks, and gloves to
improve circulation.
8. As soon as possible, transfer the casualty to
a definitive care facility. Be alert for the 3. Expose the affected area to warm, dry air.
signs of respiratory and cardiac arrest 4. Keep the casualty warm.
during transfer, and keep the casualty
warm. 5. Do not rupture blisters or apply salves and
ointments.
21-97
Frostbite The objectives of treatment are to protect
the frozen areas from further injury, to rapidly
Frostbite occurs when ice crystals form in thaw the affected area, and to be prepared to
the skin or deeper tissues after exposure to a respond to circulatory or respiratory
temperature of 32°F (0°C) or lower. Depending difficulties.
upon the temperature, altitude, and wind speed, 1. Carefully assess and treat any other injuries
the exposure time necessary to produce first. Constantly monitor the casualty’s
frostbite varies from a few minutes to several pulse and breathing since respiratory and
hours. The areas most commonly affected are heart problems can develop rapidly. Be
the face and extremities. prepared to administer CPR if necessary.
The symptoms of frostbite are progressive. 2. Do not attempt to thaw the frostbitten area
Casualties generally incur this injury without if there is a possibility of refreezing. It is
being acutely aware of it. Initially, the affected better to leave the part frozen until the
skin reddens and there is an uncomfortable casualty arrives at a medical treatment
coldness. With continued heat loss, there is a facility equipped for long-term care.
numbness of the affected area due to reduced Refreezing of a thawed extremity causes
circulation. As ice crystals form, the frozen severe and disabling damage.
extremity appears white, yellow-white, or 3. Treat all casualties with injuries to the feet
mottled blue-white, and is cold, hard, and or legs as litter patients. When this is not
insensitive to touch or pressure. Frostbite is possible, the casualty may walk on the
classified as superficial or deep, depending on frozen limb, since it has been proven that
the extent of tissue involvement. walking will not lessen the chances of
successful treatment as long as the limb has
SUPERFICIAL FROSTBITE.—In not thawed out.
superficial frostbite the surface of the skin will
feel hard, but the underlying tissue will be soft, 4. When adequate protection from further
allowing it to move over bony ridges. This is cold exposure is available, prepare the
evidence that only the skin and the region just casualty for re-warming by removing all
below it are involved. General treatment for constricting clothing such as gloves, boots,
superficial frostbite is as follows: and socks. Boots and clothing frozen on the
body should be thawed by warm-water
1. Take the casualty indoors. immersion before removal.
2. Re-warm hands by placing them under the 5. Rapidly re-warm frozen areas by
armpits, against the abdomen, or between immersion in water at 100°F to 105°F
the legs.
(38°C to 41°C). Keep the water warm by
3. Re-warm feet by placing them in the armpit adding fresh hot water, but do not pour the
or against the abdomen of the buddy. water directly on the injured area. Ensure
that the frozen area is completely
4. Gradually re-warm the affected area by
surrounded by water; do not let it rest on the
warm water immersion, skin-to-skin
side or bottom of the tub.
contact, or hot water bottles.
5. Never rub a frostbite area.
21-98
6. After re-warming has been completed, pat 2. Whirlpool baths, twice daily at 98.6°F
the area dry with a soft towel. Later it will (37°C) with surgical soap added, assist in
swell, sting, and burn. superficial debridement, reduce superficial
a. Blisters may develop. These should be bacterial contamination, and make range of
protected from breaking. motion exercises more tolerable.
LEARNING OBJECTIVE:
Introduction
Determine the steps needed for the later
A general approach to the medical aspects of
management of cold-exposure injuries.
diving and altitude injuries would be to say it is
literally “medicine under pressure.” The
When the patient reaches a hospital or a physiological insult is by definition “pressure
facility for definitive care, the following related.” The solution to most dive and altitude
treatment should be employed: related injuries is to reintroduce the patient to
1. Maintain continued vigilance to avoid pressure. Additionally, the vague and often
further damage to the injured tissue. In misleading presentation a diving patient presents
general, this is accomplished by keeping adds its own unique pressure in medicine.
the patient at bed rest with the injured part
elevated (on surgically clean sheets) and “Caissons Disease”
with sterile pieces of cotton separating the
toes or fingers. The word caisson is a French word meaning
“big boxes” Caissons were developed to allow
a. Expose all lesions to the air at normal workers a dry environment in which they could
room temperature. work on the bottom. They used these boxes to
b. Weight bearing on injured tissue must be excavate bridge footings and build tunnels under
avoided. water.
21-99
As the use of caissons increased, a new and
1 atmosphere = 14.7
unexplained illness began to affect the workers.
Upon returning to the surface the workers often 1 foot sea water = .445 psi
experienced dizziness, difficulty breathing and 33 feet sea water = 14.7 psi
sharp pains in their joints and abdomen. The
workers usually recovered but not always Measuring pressure while descending the
completely. The caisson workers often noted water column (going deeper) there will be an
that they felt better while on the bottom in the increase of .445 psi for every foot of seawater
caissons. The malady was logically called, descended into. This is known as “hydrostatic
caissons disease. However, workers on the pressure.” At 33 feet of seawater (fsw) the
Brooklyn bridge project in New York gave the amount of pressure on the diver’s body doubles
malady a more descriptive name “the bends.” from the surface. This increase remains
The “bends” is a slang term used for .445psi/fsw no matter how deep because water
Decompression Sickness (DCS). does not compress (Fig. 21-12). The deeper a
diver descends the more water that is over the
This demonstrates the importance that all diver, the more weight that is acting on the
medical personnel have a basic understanding of diver.
the effects of pressure on the human body.
Whether stationed at a diving command or a
high mountain airstrip; understanding pressure 1 atm
related emergencies can make the difference by
knowing the mechanisms of injury and the
presentation with an elevated index of suspicion.
Injuries specific to diving are the result of 33 fsw 14.7 psi
exposure to increased pressure over and above
what bodies are normally exposed to at the
earth’s surface. The three principle categories 1 fsw .445 psi
for injuries are barotraumas, toxicities, and
decompression sickness.
21-100
Barotrauma (Boyles Gas Law) The most common type of squeeze, “middle
ear squeeze,” can be experienced by simply
Boyles Law (Fig. 21-13) – For any gas at a jumping in a swimming pool and swimming to
constant temperature, pressure, and volume are the bottom – pressure increases, the volume of
inversely related. Boyles Law predicts gas gas in the middle ear decreases resulting in pain.
changes in volume. As a bubble descends the If not corrected/equalized by forcing more gas
water column, increasing pressure will act on it into the middle ear (valsalva), barotrauma will
causing it to compress and shrink in size. occur. The space inside the middle ear is
Inversely, as it ascends the water column, enclosed. As a diver descends in the water,
pressure decreases thereby allowing it to pressure is increasing and compressing that
expand/enlarge. space, if the diver does not valsalva and equalize
the pressure inside the middle ear to match the
Barotrauma is defined as damage to tissues pressure being applied outside, damage will
caused by a change in ambient pressure. The occur.
human body has gas filled, semi rigid cavities
that are subject to changes in volume due to General Treatment for middle ear squeeze:
changes in pressure – lungs, sinuses, and middle Upon surfacing after a middle ear squeeze, the
ear for example. A diver must equalize for this diver may complain of pain, fullness in the ear,
volume change otherwise barotrauma will occur. hearing loss, or even mild vertigo. Occasionally,
This is also known as a squeeze on descent and the diver may have a bloody nose, the result of
reverse squeeze on ascent. blood being forced out of the middle ear space
and into the nasal cavity through the eustachian
tube.
21-101
Treatment consists of decongestants, Arterial Gas Embolism (AGE) capillaries
NSAID’s for pain and inflammation as needed, on the alveolar sacs at the location of a tear in
and discontinue diving until healed. Three days the lung draw gas into the blood stream. These
to several weeks depending on severity. If the gas bubbles will follow the circulatory system
eardrum is ruptured antibiotics may be traveling from the lung to the heart then out to
prescribed as well. Never administer medication the body via arterial flow. The bubble continues
directly into the external ear canal if a ruptured until it becomes lodged ultimately resulting in
eardrum is suspected or confirmed without decreased blood flow and hypoxia downstream
consulting an ear, nose, and throat (ENT) from its location, acting like a blood clot.
specialist.
Severity of symptoms depends on the
General Types of Squeezes/Barotrauma – location of the bubble. The brain and heart are
Outer Ear, Middle Ear, Inner Ear, Sinus, Tooth, the two most serious locations for AGE to occur
Dry Suit, Mask, POIS, etc. As noted above, that with stroke and heart attack symptoms
which affects the middle ear affects other gas- presenting respectively. Due to the obstruction
filled, semi-rigid areas as well. Of particular occurring on the arterial side of the circulatory
concern are the pulmonary over inflation system, symptoms present rapidly. The general
syndrome (POIS) injuries which are discussed rule is “Any neurological deficit within 10
below. minutes of a diver reaching the surface is
considered AGE4.”
Pulmonary Over Inflation Syndrome
(POIS) is barotrauma of the lung. Expanding Given the mechanism of injury for POIS it is
gas if trapped in the lung(s) and not allowed to entirely possible to have all 4 types of injury at
escape can result in tearing at the alveolar sacs. the same time. Any time a diver presents with
This can result in one or several types of POIS - any POIS symptoms, a neurological exam must
Mediastinal Emphysema, Subcutaneous be completed to rule out AGE.
Emphysema, Pneumothorax, and Arterial Gas
Embolism. Toxicities: Dalton’s Law – increasing partial
pressure
Mediastinal Emphysema is the tearing of
the lung with air leaking out and remaining As a gas descends in the water column it is
inside the chest cavity. Symptoms are mild with exposed to increased pressure and becomes
a substernal burning sensation or pain on deep more concentrated (Fig. 21-13). The ratio or
inspiration. This is enough air to cause percentage of gas (21% oxygen/79% nitrogen in
discomfort yet not enough to cause the lung to air for example) remains the same, but because
collapse. gasses compress, the number of molecules that
fit in a given volume increases. Take human
Subcutaneous Emphysema tearing of the lung lungs for instance. Tidal Volume at rest is
with air leaking out of the lung then migrating 500ml. At a depth of 33 fsw the body still
up and out of the chest cavity and stopping at the requires 500ml of Tidal Volume, however,
base of the neck. Air bubbles can be felt beneath because gases compress twice the amount of
the skin. nitrogen and oxygen is received in a single
breath compared to what is normally received at
Pneumothorax is the tearing of the lung surface. This is what’s known as “partial
with air leaking out and collapsing the lung. pressure”, gas becomes “concentrated” under
pressure. This “concentration” relative to
atmospheres increases linearly: 33fsw x 2, 66fsw
x 3, and 99fsw x 4. At 99fsw the diver is at 4
atmospheres absolute (3 water + 1 surface).
21-102
Higher partial pressures/concentrations of Our bodies are 85% water and on the surface
gasses have adverse and toxic effects on the the body is at equilibrium (balance) with the
body. inert gases in breathing air. Tissues are
“saturated” to the 14.7 psi of 1 atmosphere of
Nitrogen Narcosis at depths greater than 99 pressure.
fsw, Nitrogen exerts a progressive depression of
the central nervous system (CNS). Nitrogen Air is 79% Nitrogen, 21% Oxygen. There is
Narcosis doesn’t cause damage but, its greatest about 1% of other trace elements, but not in high
hazard is gross lack of judgment which can enough concentration to have an effect. Our
cause a diver to make life threatening mistakes bodies metabolize the oxygen. When the ppO2
at depth. falls below the surface equivalent of 16% signs
of decreased mental status and function present
CNS Oxygen Toxicity at partial pressures themselves. Nitrogen is not necessary for
greater than 1.3, oxygen has a toxic effect on the anything, it is not metabolized. It is an “inert
CNS. Prolonged exposure to oxygen can irritate gas.” It basically provides a buffer or vehicle for
the tissues of the respiratory tract and lungs oxygen. During a dive, pressure increases due to
resulting in a burning sensation, also called the weight of water over the diver causing the
Pulmonary Oxygen Toxicity. inert gas to become more concentrated. Thus at
depth, because the pressure on the diver has
Carbon Dioxide Toxicity build up is the increased, the amount of inert gas dissolved in
waste product of respiration. Hyperbaric the diver’s tissue also increases.
environment (increased pp) not required but due
to the nature of work diving and ventilation Then what happens to this gas on ascent to
limitations of diving apparatus make this the the surface? The external ambient pressure
most common toxicity encountered in diving. reduces on ascent, so the partial pressure of inert
gas in the breathing mix decreases.
Carbon Monoxide Toxicity Carbon Correspondingly, per Henry’s Law, the amount
Monoxide binds to hemoglobin 200 times faster of inert gas dissolved in tissues drops.
than oxygen, thereby causing a state of hypoxia.
Breathing medium (tanks) contaminated by When a diver maintains a normal ascent rate
exhaust from internal combustion engines is the from the bottom to the surface, the inert gases
main cause for this toxicity. Hyperbaric have time to “off gas” or come out of solution at
environment not required, but increased pp a controlled rate where the body can naturally
exacerbates effects of carbon monoxide. dispose of the gas through the normal process of
respiration. If ascent is too rapid the diver’s
Decompression Sickness: Henry’s Law – body exceeds the capacity for dissolved inert gas
absorption/saturation in its tissues, then the excess gas dissolved in
tissues has nowhere else to go except to form
The amount of gas which will dissolve in a bubbles in the body.
liquid is proportional to the partial pressure of
that gas above the liquid (Fig. 21-13). Take a Essentially, DCS (decompression sickness)
closed container half filled with water, half with is the formation of bubbles in tissues. Where
air, increase the pressure inside the chamber by these bubbles form determines the type and
adding more air – air is going to dissolve into severity of DCS. By following rules for
the water. Now rapidly open the container decompression, such as a controlled rate of
reducing the pressure –the air will come back ascent and limiting time at depth will prevent
out of the liquid in the form of bubbles. This is significant bubble formation and reduce the risk
the same action as shaking a carbonated of DCS.
beverage prior to opening, it explodes when
opened because the pressure is decreased and the
gas is forced out of the liquid.
21-103
Decompression Sickness Type I Lungs – When a bubble forms in the lungs it
results in Pulmonary DCS (the chokes). This is
Pain – Dull aching pain localized to a joint, characterized by burning, substernal discomfort
normally not made worse with movement. It can on inspiration, non-productive coughing that can
progress from a dull ache to a deep ache and become paroxysmal, and severe respiratory
typically results from bubble formation in joint distress. Symptoms can start up to 12 hours after
tissue. This is the most common manifestation a dive and persist for 12 to 48 hours.
of DCS Type I.
Inner Ears – When a bubble forms within
Marbling – When a bubble forms “in” the the inner ears, it results in Inner Ear DCS
skin, the dermis and or epidermis, it results in a (staggers). It is characterized by tinnitus (ringing
condition known as Cutis Marmorata. This is a in the ears), hearing loss, vertigo, dizziness,
mottling or marbling of the skin or a popular or nausea, and vomiting. The affected person will
plaque like violet colored rash. This is often have difficulty walking, hence the name
accompanied by an itching or burning sensation. staggers.
On rare occasions, skin has an orange-peel
appearance. This condition is often called “skin Aviation Bends
bends.” This is not to be confused with
Subcutaneous Emphysema; they are two DCS caused by rapid decompression of an
different disease processes. aircraft cabin or a rapid vertical climb; typically
seen in fighter jets, either of them can produce
Swelling – When a bubble forms in the similar mechanics of surfacing too rapidly in the
lymphatic system it will cause swelling of the water. Symptoms will present as Type I or II
affected lymph nodes. The most commonly DCS and are treated accordingly.
involved lymph nodes are in the inguinal and
axillary areas. The affected nodes are usually General rules
painful and swollen.
DCS Types I and II, and AGE can progress
Decompression Sickness Type II to permanent or life threatening conditions.
Recompression in a hyperbaric chamber is the
Central Nervous System (CNS) – When a only definitive treatment for DCS and AGE.
bubble forms within the CNS it will produce a
neurological deficit. Some examples include Pain alone is not AGE. A Neurological
weakness, decreased sensation, paralysis, deficit would need to be present for it to be true
confusion, memory loss, visual disturbances, or AGE and present within the first 10 minutes.
extreme fatigue. The onset of symptoms takes
place 10 minutes after surfacing from a dive up Other POIS may be present. Recompression
to 48 hours post dive. Any neurological therapy is not indicated for pneumothorax or
symptom within the first 10 minutes after mediastinal and subcutaneous emphysema
surfacing from a dive is considered an unless considered severe.
Arterial Gas Embolism.
21-104
Treatment AGE can occur in as shallow as a few feet of
water. DCS requires depth with improper off
ABCs. gassing, excessive time at depth, or both. Get a
thorough history!
• 100% O2 by mask
• Obtain dive history SUMMARY
o Depth of dive
A medical emergency can occur at anytime.
o Time spent on dive HMs must be prepared to act expeditiously and
o Time the diver reached the surface confidently, whether in a combat situation, on
board a naval vessel, or at the Navy Exchange.
o What are the symptoms This chapter covers the preliminary steps that
o When did they start should be followed when managing sick or
injured patients. The preliminary emergency
o Have they improved or worsened steps include triage, patient assessment, and,
o Does anything make them better or worse when needed, basic life support. Other related
topics covered in this chapter are breathing aids,
o Were any other dives prior to last dive, if shock, diagnosis and emergency treatment
so depth and time of dive and time spent procedures for medical conditions and injuries,
on surface between dives and other emergencies.
o Are there any prior diving related injuries
• If diving related injury is suspected contact
closest recompression facility, Dive Medical
Technician(DMT), and or dive medical
officer (DMO)
• Upon recommendation transport patient flat
on O2 – do not elevate feet or head. If
aircraft used maintain cabin pressure /
altitude < 1000 feet above sea level
• Start a large bore IV (16 or 18 gauge) at
75cc/hr or KVO as indicated
CAUTION:
Do NOT give medications as they will mask the
symptoms.
21-105
CHAPTER 22
22-1
A poisoning is defined as the presence of There are six steps in the initial evaluation and
signs or symptoms associated with exposure or follow-on poison management:
contact with a substance. If there are no
1. Stabilization: consists of a brief evaluation
clinical manifestations or toxic effects, the
and assessment directed toward identifying
incident is simply an "exposure" or a contact
the measures required to maintain life and
with a potentially poisonous substance. Just
prevent further deterioration of the patient.
being exposed to a chemical does not mean
that a poisoning has or will occur. It is a a. Observe the ABC + D & E.
matter of dose and a few other variables (e.g., i. Airway, Breath, and Circulation.
age, sex, individual resistance, and state of
health) that determine if, or what, toxic effects ii. Drug-induced central nervous system
will occur. (CNS) depression.
iii. Expose (undress/uncover) the patient
ASSESSMENT AND TREATMENT OF for disabilities/injuries to ensure areas
PATIENT of contact or exposure to a chemical
can be properly visualized and
In most cases, ASSESSMENT AND assessed.
TREATMENT OF THE PATIENT IS MORE
IMPORTANT THAN EFFORT TO b. Complete basic neurologic exam; be sure
IDENTIFY AND TREAT A SPECIFIC to check the pupils for size and reactivity
POISON. Supportive therapy managing the to light.
ABCs (Airway, Breathing, and Circulation) of c. Administer oxygen as needed.
basic life support and treating the signs and
symptoms are safe and effective in the vast d. Start an IV.
majority of poisonings. Extraordinary means e. Watch for signs and symptoms of
to enhance elimination of the poison anaphylaxis.
(hemodialysis and hemoperfusion) are seldom
needed. Except for agents with a delayed 2. Evaluation: must be performed once the
onset of toxicity (such as acetaminophen), most patient is stabilized.
ingested poisons produce signs and symptoms a. Include a full history, physical exam, and
in less than four hours. Most efforts to ordering of appropriate tests (i.e. labs,
decontaminate the stomach through gastric EKG, x-rays) directed toward
lavage or activated charcoal to remove an identification of toxic agent(s),
ingested poison have little value more than one evaluating the severity of toxic effects,
hour after ingestion. and searching for trauma and
complications.
In acute poisonings, prompt treatment is
indicated. After the patient has been evaluated b. Periodically reassess the patient. Look
and stabilized, general poison management can for changes. Monitor vital signs, urine
be initiated. output (UOP), and cardiac rhythm.
c. Record the findings (including time) and
respond to important changes
appropriately.
3. Prevention or limitation of absorption:
through skin decontamination, flushing of
eyes, ventilation, stomach emptying, and
administration of charcoal and cathartics.
22-2
4. Elimination enhancement: through o Other people including the HM may
serially administered activated charcoal, become contaminated through contact
ion-trapping (pH adjustment of the urine to with the container. Handle it carefully.
promote excretion of certain poisons),
• When did the exposure happen?
hemodialysis, and hemoperfusion (similar
to hemodialysis, but used for larger size • What was the duration of exposure?
molecules).
• What is the location of the bite or injury (if
5. Administration of specific antidotes: Less applicable)?
than 5 percent of poisons have specific
antidotes. All patients who present should • Has this happened before?
receive glucose, thiamine, and naloxone. • Are there other people involved?
Consider supplemental oxygen.
• Does the patient have a significant past
6. Continuing care and disposition: medical history?
including a period of observation and
education (i.e. poison prevention) or • Is the patient’s condition improving or
psychiatric counseling. Establish follow-up. deteriorating?
The presence of a toxic syndrome or
THE DIAGNOSIS OF POISONING toxidrome can help establish that a poison has
been involved by suggesting the class of
In many situations, the treatment of a poison(s) to which the patient may have been
poisoning victim will be under the direction of a exposed. Table 22-1 provides a list of commonly
medical officer. However, the HM must be encountered toxidromes, their sources and
ready to treat the victim. symptoms.
22-3
Syndrome Sources Signs & Symptoms
opiates, benzodiazepines, “beady eyes,” sunglasses, decreased blood
Narcotic
barbiturates pressure, CNS and respiratory depression
alcohol, barbiturates, diarrhea, dilated pupils, goose bumps, increased
Withdrawal benzodiazepines, narcotics, heart rate, tearing, yawning, stomach cramps,
sedative-hypnotics hallucinations
theophylline, caffeine, LSD, CNS excitation (confusion, in-coordination,
Sympathomimetic PCP, amphetamine, cocaine, agitation, hallucination, delirium, seizures),
decongestants increased blood pressure and heart rate
antihistamines, atropine,
scopolamine, antidepressants,
anti-Parkinson L, dry skin, increased heart rate, dilated pupils,
Anticholinergic antipsychotics, fever, urinary retention, decreased bowel
antispasmodics, mush- sounds, CNS excitation
rooms, hallucinogens,
antidepressants
“SLUDGE,” increased salivation,
organophosphates, lacrimation, urination, defecation,
Cholinergic carbamates, physostigmine, GI cramping, emesis; CNS (headache,
neostigmine, endrophonium restless, anxiety, confusion, coma,
seizures); muscle weakness and fasciculation
22-4
The toxicity range of absorbed poisons First aid for most forms of noncorrosive
extends from non-toxic to extremely toxic. poisoning centers on quickly emptying the
Ingestion substances with a low order of stomach of the irritating substance(s). The
toxicity may result in the production of only following steps are suggested:
minor systemic effects that are mild, self-
1. Maintain an open airway. Be prepared to
limiting, and do not require significant
give artificial ventilation.
medical intervention including nausea,
vomiting, and or diarrhea. 2. Dilute the poison by having the conscious
victim drink one to two glasses of water or
milk.
NOTE:
Do not induce unnecessary vomiting to 3. Empty the stomach using an emetic, gastric
discourage a patient from repeating a voluntary lavage, adsorbent, and or cathartic.
ingestion.
a. Giving an emetic is a preferred method
for emptying the contents of the
Noncorrosives stomach. It is quick and (except in cases
of caustic or petroleum distillate
Many noncorrosive substances have the poisoning, or when an antiemetic has
common characteristic of irritating the been ingested) can be used in almost
stomach. They produce nausea, vomiting, every situation when the victim is
convulsions, and severe abdominal pain. The conscious.
victim may complain of a strange taste, and the
i. Ipecac syrup is the most commonly
lips, tongue, and mouth may look different than
used substance to which an HM will
normal. Shock may occur. Examples of
have access.
noncorrosives are listed in Table 22-2.
1. This emetic acts locally by
Irritant Sources of Contact irritating the gastric mucosa and
Dyes, insecticides, paint, printer centrally by stimulating the
Arsenic
sink, wood preservatives medullary vomiting center in the
Antifouling paint, batteries, brain.
canvas preservative, copper
Copper plating, electroplating, 2. The usual adult dose is 15-30 ml,
fungicides, insecticides, and the dose for a child (age 1 to
soldering, wood preservatives 12 years) is 15 ml.
Iodine Antiseptics
ii. The dosage should be followed
Bactericides, batteries, dental
supplies and appliances,
immediately by a glass of water.
disinfectants, dyes, fungicides, Most people will vomit within 30
Mercury minutes.
ink, insecticides,
laboratories, photography, iii. The amount of stomach contents (and
wood preservatives
poison) recovered will vary.
Incendiaries, matches,
Phosphorus
pesticides, rat poison iv. In an emergency room, the medical
Batteries, cleaning solutions, officer can rapidly induce vomiting
Silver nitrate ink, photographic film, silver by the injection of various
polish, soldering medications.
Disinfectants, electroplating,
fungicides, galvanizing, ink, v. As a last resort, tickle the back of the
Zinc insecticides, matches, metal victim’s throat with a finger or a
plating and cutting, paint, blunt object. This procedure should
soldering, wood preservatives induce vomiting.
Table 22-2.—Common Stomach Irritants and
Possible Sources of Contact
22-5
b. Trained personnel may use gastric lavage Corrosives
by itself or after two doses of Ipecac
syrup has failed to induce vomiting. Acids and alkalis (bases) produce actual
chemical burning and corrosion of the tissues of
i. After passing a large caliber
the lips, mouth, throat, and stomach. Acids do
nasogastric tube, aspirate the stomach
most of their damage in the acidic stomach
contents.
environment, while alkalis primarily destroy
ii. Instill 100 ml of normal saline into tissues in the mouth, throat, and esophagus.
the stomach. Stains and burns around the mouth, and the
iii. Aspirate it out again. presence of characteristic odors provide clues
as to an acid or base ingestion. Swallowing and
iv. Continue this flushing cycle until the breathing may be difficult, especially if any
returning fluid is clear. Gastric lavage corrosive was aspirated into the lungs. Stridor,
is preferred when the victim is a high-pitched sound coming from the upper
unconscious or as in the case of airway, may be heard. The abdomen may be
strychnine poisoning is subject to tender and swollen with gas and perforation of
seizures. the esophagus or stomach may occur.
c. Activated charcoal (AC) adsorbs many
substances in the stomach and prevents NEVER ATTEMPT TO TREAT AN
absorption into the body. ACID OR BASE INGESTION BY
ADMINISTERING A NEUTRALIZING
i. After the substance is adsorbed to the SOLUTION BY MOUTH. GIVE WATER
AC, the bound substance moves ONLY, UNLESS DIRECTED BY A POISON
through the stomach and is CONTROL CENTER (PCC) OR MEDICAL
eliminated with the production of a OFFICER. Monitor the ABC+D&Es, and
charcoal-black bowel movement. watch for signs of shock. Examples of
ii. AC may be administered after emesis corrosive agents and sources of contact are
or lavage, or it may be used alone. listed in Table 22-3.
22-6
Agent Sources of Contact
PHENOLS Creosol Disinfectants, ink, paint and varnish removers, photo developer, stains
Table 22-3.—Examples of Common Acids, Alkalies, and Phenols, with Possible Sources of Contact
22-7
Food Poisoning Inhaled Substance Source of Exposure
Food poisoning can occur from ingesting Acetone, isopropyl Nail polish remover
animal or plant materials, or even from the alcohol, amyl acetate
chemicals that are used in raising, processing, or Aliphatic Fuels, Stoddard solvent,
preserving crops and livestock. Most bacterial hydrocarbons PD-680, mineral spirits,
and viral food poisonings appear within eight naphtha
hours of ingesting food. The signs and
“
symptoms of poisoning include nausea, Butane Throw-away” lighters
vomiting, diarrhea, muscle aches, and low-
grade fever. Carbon dioxide Fire suppression/fighting,
evaporation of dry ice,
wells
The general treatment is supportive and
and sewers
directed at preventing dehydration through the
administration of fluids. If diarrhea persists Carbon monoxide Fires, lightning, heating
more than 24 hours, or the patient is unable to and
keep fluids down, further definitive medical fuel exhausts
care is necessary. Food poisoning can also Chlorinated Shoe polish
hydrocarbons
occur from ingestion of parasites.
Chlorine Water purification, sewage
INHALATION POISONS treatment
22-8
Carbon monoxide is the most common agent If trained rescuers are not immediately
of gas poisoning. It is present in exhaust gases available and the HM can reach and rescue the
of internal combustion engines as well as in victim; this can be accomplished by taking a
sewer gas, lanterns, charcoal grills, and in deep breath, holding it, entering the area, and
manufactured gas used for heating and pulling the victim out.
cooking. It gives no warning of its presence as
it is completely odorless and tasteless. The Immediately after pulling the victim out,
victim may lose consciousness and suffer follow the steps below:
respiratory distress with no warning other than
1. Start basic life support (the ABC+D&Es).
slight dizziness, weakness, and headache. The
lips and skin of a victim of carbon monoxide 2. Remove clothing to expose the victim (if
poisoning are characteristically cherry red. chemical warfare agents or volatile fuels
Death may occur within a few minutes. were the cause).
3. Keep the victim calm, detect and treat for
Most inhalation poisoning causes life-threatening conditions to include
shortness of breath and coughing. The victim's administering oxygen.
skin will turn blue. If the respiratory problem is
not corrected, cardiac arrest will follow due to 4. Perform focused history and physical exam.
hypoxia. 5. Transport the victim to a treatment facility
for further treatment with all containers,
Inhaling fine metal fumes can cause a bottles and labels of substance if available.
special type of acute or delayed poisoning.
These metal fumes are generated from heating
metal to boiling and evaporation during hot ABSORBED POISONS
metal work in such operations as metal cutting
or welding. The resulting illness is called Some substances cause tissue irritation or
metal fume fever (MFF). In the Navy, the most destruction by contact with the skin, eyes, and
common cause of MFF is the inhalation of lining of the nose, mouth, and throat. These
vaporized zinc found in the galvanized substances include acids, alkalis, phenols, and
covering of iron and steel. Proper local and some chemical warfare agents. Direct contact
general ventilation and or the use of respiratory with these substances will cause inflammation
protection are necessary to prevent this illness. or chemical burns in the affected areas. Consult
The first stage of treatment for an inhalation t h e “ C h e m i c a l Burns "and “ C h e m i c a l
poisoning is to remove the victim from the Agents " sections of Chapter 23 of this manual
toxic atmosphere immediately. for treatment guidelines.
22-9
The vast majority of stings cause a minor Scorpion Stings
local reaction at the injection site, with pain,
redness, itching, and swelling. These symptoms About 40 species of scorpions (Fig. 22-1)
usually fade after a short time. A small exist in America. Centruroides exilicauda, also
percentage of these stings can cause an allergic called "bark scorpion," is the scorpion found
victim severe anaphylactic reactions, presenting in Mexico and the southwest region of United
with itching, swelling, weakness, headache, States and may cause severe effects.
difficulty breathing, and abdominal cramps.
Shock may follow quickly, and death may
occur.
22-10
6. Antivenom is available for severe stings by
Centruroides exilicauda. It is available
from the Good Samaritan Poison Center in
Phoenix (602-253-3334) and Banner
Poison Control Center Hotline at 1-800-
222-1222.
CAUTION:
Morphine and meperidine hydrochloride may
worsen the respiratory depression from the
venom of Centruroides exilicauda.
Spider Bites
22-11
A progressively enlarging necrotic • Atractaspididae: Includes the burrowing
ulcerating lesion eventually develops. asps/mole vipers, stiletto snakes, and adders.
Intravascular hemolysis is most often seen in Venom method of toxic action varies
children and may be fatal. Antivenom is not according to type of snake.
currently available.
Within the United States, poisonous snakes
are Crotalids (rattlesnakes, copperheads, and
Treatment for brown recluse spider bites
moccasins) and the Elapids (coral snakes).
includes the following:
1. Debridement of lesion, followed by CROTALIDS.—are of the Viperidae
peroxide cleansing and Aluminum Acetate (viper) family and are called "pit vipers" because
solution soaks. of the small, deep pits between the nostrils and
2. Application of polymyxin-bacitracin- the eyes (Fig. 22-3). They have two long, hollow
neomycin ointment and sterile dressing. fangs. These fangs are normally folded against
the roof of the mouth, but they can be extended
3. Treat with appropriate oral antibiotics as when the snake strikes. Other identifying
directed by the physician. features include thick bodies; slit-like pupils of
the eyes; and flat, triangular heads. The most
Snakebites identifying feature of a pit viper is the relative
width of the snake head compared to the
Poisonous snakes are found throughout the thickness of the body. The head will be much
world, with the exception of certain islands and wider than the body, giving the appearance of
the Antarctic. There are five venomous families an arrowhead. The difference in size is so
of snakes. obvious that identification of a snake as a pit
viper can usually be made from a safe distance.
• Viperidae: Includes rattlesnakes,
moccasins, South American lance-headed
vipers and bushmasters, Asian pit vipers,
African and Asian vipers and adders,
European adders, and saw-scaled vipers
(Middle-eastern). Death results mainly by
coagulopathy (a blood clotting disorder) and
shock.
• Elapidae: Includes cobras, kraits, mambas,
and coral snakes. Death results from
neurotoxic venom that causes respiratory
failure, paralysis, and cardiac failure.
• Hydrophidae: Includes sea snakes and
venomous snakes from the islands of the Figure 22-3.—American Pit Viper
southern Pacific Ocean, including Australia,
New Zealand, Guam, and New Guinea. Also
Further identification can be made by
kills from neurotoxic venom.
examining the wound for signs of fang entry in
• Colubridae: Includes most of the common the bite pattern. Pit viper bites leave two
nonvenomous species, as well as the puncture marks (sometimes only one, and
boomslang, and vine/twig/bird snake sometimes more). Nonvenomous snakes (for
(Africa); Japanese yamakagashi; Southeast example, garter snakes) leave a series, often in a
Asian red-necked callback. Venom method curve or semi-circle, of tiny scratches or
of toxic action varies according to type of punctures.
snake.
22-12
Individual identifying characteristics Venom, which is stored in sacs in the
include rattles on the tails of most rattlesnakes, snake’s head, is introduced into a victim
and the cotton-white interior of the mouths of through hollow or grooved fangs. An important
moccasins. point to remember, however, is that a bitten
patient has not necessarily received a dose of
ELAPIDS.—Coral snakes are of the venom. Snakes can control whether or not it
family Elipidae and related to the cobra, will release the venom and how much it will
kraits, and mamba snakes in other parts of the inject. Baby snakes are unable to control the
world (Fig. 22-4). Corals, which are found in release of venom. Symptoms in a poisonous
the Southeastern United States, are snakebite incident can be either severe, mild
comparatively thin snakes with small bands of or not develop at all.
red, black, and yellow (or almost white). Some
nonpoisonous snakes have similar coloring. Signs and Symptoms of Snakebites
22-13
Usually enough symptoms present 8. Until evacuation or treatment is possible,
themselves within an hour of a poisonous ensure the victim lies quietly and does not
snakebite to erase any doubt as to the victim move any more than necessary.
having been envenomated or not. The victim’s
9. Do not allow the victim to smoke, eat, or
condition provides the best information as to the
drink any fluids. (Water is permissible if it
seriousness of the situation.
is anticipated more than several hours will
pass before arriving at a hospital and prior
The aims of first aid for envenomated
to establishing an IV line.)
snakebites are to reduce - not stop - the
circulation of blood through the bite area, delay 10. Transport the victim to a treatment facility.
absorption of venom, prevent aggravation of the 11. Apply a bandage, wrapped two to four
local wound, maintain vital signs, and transport inches above the bite (towards the heart), to
the victim as soon as possible to a treatment help slow the venom. This should not cut
facility with minimum movement. off the flow of blood from a vein or artery.
The band should be loose enough to slip a
First Aid and Treatment finger under it.
12. Splint the extremity at a level below the
1. Try to identify the snake. Positive heart. DO NOT ELEVATE THE
identification is important to selecting the EXTREMITY
correct antivenom for the treatment of the
patient. 13. Hospitalize and observe all snakebites for
at least 24 hours.
NOTE:
In the case of spitting cobras (found in
Do not risk further injury by trying to kill the
Africa, Thailand, Malaysia, Indonesia, and the
snake.
Philippines), which attempt to spray venom into
victims' eyes, rinse the eyes with large volumes
2. GENTLY wash the wound with soap and
of cool water with pressure similar to that of
water (it may remove some of the venom).
water coming from a water tap. Apply
Do NOT rub vigorously, as it may cause
antibacterial eye ointment and a patch with just
the venom to be absorbed more rapidly.
enough pressure to keep the eyelid from
3. Certain suction extractors have benefit (for blinking. Other aid will be mainly supportive:
example, the Sawyer® Extractor™),
especially if used within the first 3 • Check pulse and respiration frequently. Give
minutes. If available immediately, use the artificial ventilation, if necessary
extractor and leave it on for 30 minutes. • Treat for shock, including IV fluids (normal
The cups may fill up. Empty and re-use saline or Lactated Ringer’s solution)
them as necessary.
• Clean the area of the bite with soap and
4. Place the victim in a comfortable position. water; cover the wound to prevent further
5. Tell the patient to remove any jewelry contamination
(especially rings and bracelets, as these • Give acetaminophen for pain if delay in
may impede blood flow if there is swelling hospital treatment is anticipated
of the extremities). Assist, if necessary.
Antivenom (also called antivenin) is
6. Start an IV. available for many snakes, and is indicated for
7. Monitor vital signs (including ABC + severe envenomations by Viperidae family
D&Es) closely, responding appropriately as snakes and snakes of the other poisonous
necessary. families. Antivenom is best given as soon as
possible after an envenomation, but may be of
value up to a few days after a bite.
22-14
If possible, antivenom specific to the snake Bites, Stings, and Punctures from Sea
should be used. Otherwise, a polyvalent Animals
specific antivenom may be used. READ
THE PACKAGE INSERT OF THE A number of sea animals are capable of
ANTIVENOM FOR VALUABLE inflicting painful wounds by biting, stinging,
INFORMATION. or puncturing. Except under rare
circumstances, these stings and puncture
Epinephrine and diphenhydramine must be wounds are not fatal. Major wounds from
available; as allergic reactions (including sharks, barracuda, moray eels, and alligators
anaphylaxis) to antivenom have occurred (they can be treated by controlling the bleeding,
are often prepared from horse serum, to which preventing shock, giving basic life support,
some people are allergic). splinting the injury, and transporting the victim
to a medical treatment facility. Minor injuries
Antivenom is diluted (for example, 1:10) inflicted by turtles and stinging corals require
and given at 5 ml/minute IV, and the dose is only that the wound be thoroughly cleansed
based on stopping the progression of signs and and the injury splinted. Examples of fish that
symptoms, not the v i c t i m ’ s body weight are known to be poisonous AT ALL TIMES
(the c h i l d r e n ’ s dose is the same as the adult are shown in Figure 22-5.
dose). For neurotoxic snakebites, if there is no
improvement in 30 minutes, the dose should be
repeated. For Viperidae (which can cause
bleeding disorders), spontaneous bleeding
should stop after sufficient antivenom is
given; continue giving antivenom until
bleeding stops and progression of swelling is
retarded. Because the HM may need to
administer antivenom a number of times, one
vial may not be enough to treat a patient.
22-15
Local symptoms following a sting may first 6. Medication usage:
include severe pain later combined with
a. Calcium gluconate injections, diazepam,
numbness or even hypersensitivity around the
or methocarbamol may help to reduce
wound. The wound site may become cyanotic
muscle spasms.
with surrounding tissue becoming pale and
swollen. General symptoms include nausea, b. Infiltration of the wound with 0.5 percent
vomiting, sweating, mild fever, respiratory to 2.0 percent Xylocaine without
distress and collapse. The pain induced may epinephrine is helpful in reducing pain.
seem disproportionately high to apparent **If Xylocaine with epinephrine is
severity of the injury. Medical personnel should mistakenly used, local necrosis may
be prepared for serious anaphylactic reactions result from both the toxin and
from apparently minor stings or envenomation. epinephrine present in the wound.**
c. Narcotics may also be needed to manage
First Aid and Treatment4 severe pain.
1. Get victim out of water: Watch for fainting. 7. Clean and debride wound. Spines and
2. Lay patient down and reassure. sheath (covering of the spines) frequently
remain. Be sure to remove the entire sheath
3. Observe for signs of shock.
as it may continue to release venom.
4. Initially rinse wound with cold salt water or
8. Injury site management:
sterile saline solution. Surgery may be
required to open up the puncture wound. a. Tourniquets or ligatures are no longer
Suction is not effective to remove this advised.
toxin. b. Use an antiseptic or antibiotic ointment
5. Soak wound in hot water for 30 to 90 and sterile dressing.
minutes. Heat may break down the venom. c. Restrict movement of the extremity with
a. The water should be as hot as the victim immobilizing splints and cravats.
can tolerate but not hotter than 114ºF 9. Administer tetanus prophylaxis as
(45.6ºC). appropriate.
b. Immersion in water not hotter than 114ºF 10. Treat prophylactically with topical
(45.6ºC) for longer than a brief period antibiotic ointment. If delay in treatment
may lead to scalding. has occurred, it is recommended that the
c. Immersion in water not hotter than 114ºF wound be cultured prior to administering
(45.6ºC) should therefore be brief and systemic antibiotics.
repeated as necessary.
d. Use hot compresses if the wound is on Stonefish, Zebrafish, Scorpionfish4-Stings
the face. by stonefish, zebrafish, and scorpionfish have
been known to cause fatalities. While many
e. Adding magnesium sulfate (Epsom salts)
similarities exist between these fish and the
to the water offers no benefit.
venomous fish of the previous section, a
separate section has been included because of
the greater toxicity of their venom and the
availability of an antivenin.
22-16
The antivenin is specific for the stonefish 4. Antivenin is available from the
but may have some beneficial effects against the Commonwealth Serum Lab, Melbourne,
scorpionfish and zebrafish. Local symptoms are Australia. Utilize the medical chain of
similar to other fish envenomation except that command to obtain.
pain is more severe and may persist for many
a. If antivenin is used, the directions
days. Generalized symptoms are often present
regarding dosage and sensitivity testing
and may include respiratory failure and
on the accompanying package insert
cardiovascular collapse. These fish are widely
should be followed and the physician
distributed in temperate and tropical seas and in
must be ready to treat for anaphylactic
some arctic waters. They are shallow-water
shock.
bottom dwellers. Stonefish (Fig. 22-6) and
scorpionfish are flattened vertically, dark and b. In brief, one or two punctures require
mottled. Zebrafish are ornate and feathery in 2,000 units (one ampule); three to four
appearance with alternating patches of dark and punctures, 4,000 units (two ampules);
light color. and five to six punctures, 6,000 units
(three ampules).
c. Antivenin must be delivered by slow IV
injection and the victim closely
monitored for anaphylactic shock.
5. Institute tetanus prophylaxis, analgesic
therapy, and antibiotics as described for
other fish stings.
22-17
The spine is located near the base of the tail.
Wounds are either of the laceration or puncture
type and are extremely painful. The wound
appears swollen and pale with a blue rim.
Secondary wound infections are common.
Systemic signs and symptoms may be present
and can include fainting, nausea, vomiting,
sweating, respiratory difficulty, and
cardiovascular collapse.
1. Give the same first aid as that given for Figure 22-8.—Portuguese Man-of-War
venomous fish. No antivenin is available.
2. Institute hot water therapy as described Image reprinted with permission from: Edmonds, C.
under fish envenomation. (1995). Dangerous Marine Creatures.
Flagstaff, AZ: Best Publishing Company.
3. Clean and debride wound.
a. Removal of the spine may additionally The most common stinging injury is the
lacerate tissues due to retropointed barbs. jellyfish sting. Jellyfish can come into direct
b. Be sure to remove integumental sheath as contact with a diver in virtually any oceanic
it will continue to release toxin. region, worldwide. When this happens, the diver
is exposed to literally thousands of minute
4. Observe patient carefully for the possible stinging organs in the tentacles called
development of life-threatening nematocysts. Most jellyfish stings result only in
complications. painful local skin irritation. The sea wasp or box
a. Signs and symptoms can include cardiac jellyfish and Portuguese man-of-war are the
dysrhythmias, hypotension, vomiting, most dangerous types. The sea wasp or box
diarrhea, sweating, muscle paralysis, jellyfish (found in the Indo-Pacific) can induce
respiratory depression, and cardiac arrest. death within 10 minutes by cardiovascular
collapse, respiratory failure, and muscular
b. Fatalities have been reported
paralysis. Deaths from Portuguese man-of-war
occasionally.
stings have also been reported. Even though
5. Institute tetanus prophylaxis, analgesic intoxication from ingesting a poisonous sea
therapy, and broad-spectrum antibiotics as anemone is rare, sea anemones must not be
described for fish envenomation. eaten.
22-18
Protection against Jellyfish -Wet suits, Symptomatic Treatment can include
body shells, or protective clothing should be topical steroid therapy, anesthetic ointment
worn when diving in waters where jellyfish are (Xylocaine, 2 percent), antihistamine lotion,
abundant. Petroleum jelly applied to exposed systemic antihistamines or analgesics.
skin (e.g., around the mouth) helps to prevent Benzocaine topical anesthetic preparations
stinging, but caution should be used since should not be used as they may cause
petroleum jelly can deteriorate rubber products. sensitization and later skin reactions.
22-19
Sensitivity reaction to the antivenin should 3. Cover with a clean dressing.
be treated with a subcutaneous injection of
4. Administer tetanus prophylaxis as
epinephrine (0.3 ml of 1:1,000 dilution),
appropriate.
corticosteroids, and antihistamines. Treat any
hypotension (severely low blood pressure) with 5. Topical antibiotic ointment has been
IV volume expanders and pressor medication as proven very effective in preventing
necessary. The antivenin may be obtained from secondary infection.
the Commonwealth Serum Laboratories, 6. Stinging coral wounds may require
Melbourne, Australia. Utilize the medical chain symptomatic management such as topical
of command to obtain. steroid therapy, systemic antihistamines,
and analgesics.
Coral4 - Coral, a porous, rock-like
formation and found in tropical and subtropical a. In severe cases, restrict the patient to bed
waters. It is extremely sharp and the most rest with elevation of the extremity, wet-
delicate coral is often the most dangerous to-dry dressings, and systemic
because of their razor-sharp edges. Coral cuts, antibiotics.
while usually fairly superficial, take a long time b. Systemic steroids may be needed to
to heal and can cause temporary disability. manage the inflammatory reaction
resulting from a combination of trauma
The smallest cut, if left untreated, can and dermatitis.
develop into a skin ulcer. Secondary infections
often occur and may be recognized by the
presence of a red and tender area surrounding Octopus4 - The octopus inhabits tropical
the wound. All cuts should receive medical and temperate oceans. Species vary depending
attention. on region. It has a large sac surrounded by 8 to
10 tentacles (Fig. 22-10). The head sac is large
Some varieties of coral can actually sting a with well-developed eyes and horny jaws on the
diver since coral is a coelenterate like jellyfish. mouth. Movement is made by jet action
Some of the soft coral of the genus Palythoa produced by expelling water from the mantle
have been found recently to contain the deadliest cavity through the siphon.
poison known to man. This poison is found
within the body of the organism and not in the
stinging nematocysts. The slime of this coral
may cause a serious skin reaction (dermatitis) or
even be fatal if exposed to an open wound. No
antidote is known.
22-20
The octopus will hide in caves, crevices and 6. Medical therapy for blue-ringed octopus
shells. It possesses a well-developed venom bites is directed toward management of
apparatus in its salivary glands and stings by paralytic, cardiovascular, and respiratory
biting. Most species of octopus found in the U.S. complications.
are harmless. The blue-ringed octopus common
a. Respiratory arrest is common and
in Australian and Indo-Pacific waters may inflict
intubation with mechanical ventilation
fatal bites. The venom of the blue-ringed
may be required.
octopus is a neuromuscular blocker called
tetrodotoxin and is also found in Puffer (Fugu) b. Duration of paralysis is between 4 and 12
fish. hours.
c. Reassure the patient.
Envenomation from the bite of a blue-ringed
octopus may lead to muscular paralysis, 7. Administer tetanus prophylaxis as
vomiting, respiratory difficulty, visual appropriate.
disturbances, and cardiovascular collapse.
Octopus bites consist of two small punctures. A Segmented Worms4 (Annelida)
burning or tingling sensation results and may (Examples: Bloodworm and Bristleworm) -
spread. Swelling, redness, and inflammation are This invertebrate type varies according to region
common. Bleeding may be severe and the and is found in warm, tropical, or temperate
clotting ability of the blood is often retarded by zones. It is usually found under rocks or coral
the action of an anticoagulant in the venom. and is especially common in the tropical Pacific,
Bahamas, Florida Keys, and Gulf of Mexico.
First Aid and Treatment4
Annelida have long, segmented bodies with
1. Control local bleeding. stinging bristle-like structures on each segment.
Some species have jaws and will also inflict a
2. Clean and debride the wound and cover very painful bite. Venom causes swelling and
with a clean dressing. pain.
3. For suspected blue-ringed octopus bites,
apply direct pressure with a pressure First Aid and Treatment4
bandage and immobilize the extremity in a 1. Remove bristles with a very sticky tape
position that is lower than the heart using such as adhesive tape or duct tape. Topical
splints and elastic bandages. Do not apply application of vinegar will lessen pain.
a loose constrictive band.
2. Treatment is directed toward relief of
4. Be prepared to administer mouth-to-mouth symptoms and may include topical steroid
resuscitation and cardiopulmonary therapy, systemic antihistamines, and
resuscitation if necessary. analgesics.
5. Blue-ringed octopus venom is heat stable 3. Wound infection can occur but can be
and acts as a neurotoxin and neuromuscular easily prevented by cleaning the skin using
blocking agent. an antiseptic solution of 10 percent
a. Venom is not affected by hot water povidone-iodine and topical antibiotic
therapy. ointment.
b. No antivenin is available. 4. Systemic antibiotics may be needed for
established secondary infections that first
need culturing, aerobically and
anaerobically.
22-21
Sea Urchins4 - There are various species of Cone Shells4 - The cone shell is widely
sea urchins with widespread distribution. Each distributed in all regions and is usually found
species has a radial shape and long spines. under rocks and coral or crawling along sand.
Penetration of the sea urchin spine can cause The shell is most often symmetrical in a spiral
intense local pain due to venom in the spine or coil, colorful, with a distinct head, one to two
from another type of stinging organ called the pairs of tentacles, two eyes, and a large flattened
globiferous pedicellariae. Numbness, foot on the body (Fig. 22-11).
generalized weakness, paresthesias, nausea,
vomiting, and cardiac dysrhythmias have been
reported.
22-22
First Aid and Treatment4 8. Management of severe stings is supportive.
Respiration may need to be supported with
intubation and mechanical ventilation.
1. Lay the patient down.
9. Administer tetanus prophylaxis as
2. Direct pressure with a pressure bandage
appropriate.
over the site and immobilization in a
position lower than the level of the heart
using splints and elastic bandages is Sea Snakes4 - The sea snake is an air-
recommended. Do not apply a loose breathing reptile which has adapted to its aquatic
constricting band or ligature. environment by developing a paddle tail. Sea
snakes inhabit the Indo-Pacific area and the Red
3. Some authorities recommend incision of
Sea and have been seen 150 miles from land.
the wound and removal of the venom by
The most dangerous areas in which to swim are
suction, although this is controversial.
river mouths as sea snakes are more numerous
a. General agreement is that if an incision is and the water more turbid. The sea snake is a
to be made, the cuts should be small (one true snake, usually 3 to 4 feet in length, but may
centimeter), linear and penetrate no reach 9 feet. It is generally banded (Figs. 22-12
deeper than the subcutaneous tissue. and 22-13). The sea snake is curious and is often
b. The incision and suction should only be attracted by divers and usually not aggressive
performed if it is possible to do so within except during its mating season.
two minutes of the sting. Otherwise, the
procedure may be ineffective.
c. Incision and suction by inexperienced
personnel has resulted in inadvertent
disruption of nerves, tendons, and blood
vessels.
4. Transport the patient to a medical facility
while ensuring that the patient is breathing
adequately. Be prepared to administer
mouth-to-mouth resuscitation if necessary. Figure 22-12.—Yellow-Bellied Snake
5. Cone shell venom results in paralysis or Image reprinted with permission from: Edmonds, C.
paresis of skeletal muscle, with or without (1995). Dangerous Marine Creatures.
myalgia. Symptoms develop within Flagstaff, AZ: Best Publishing Company.
minutes of the sting and effects can last up
to 24 hours.
6. No antivenin is available.
7. Respiratory distress may occur due to
neuromuscular block. Patient should be
admitted to a treatment facility and
monitored closely for respiratory or
cardiovascular complications. Treat as
symptoms develop.
Local anesthetic with no epinephrine may
be injected into the site of the wound if Figure 22-13.—Hydrophis Snake
pain is severe. Analgesics which produce
respiratory depression should be used Image reprinted with permission from: Edmonds, C.
with caution. (1995). Dangerous Marine Creatures.
Flagstaff, AZ: Best Publishing Company.
22-23
Sea Snake Bite Effects4 - The sea snake 7. Respiratory arrest may result from
injects a poison that has 2 to 10 times the generalized muscular paralysis; intubation
toxicity of cobra venom. The bites usually and mechanical ventilation may be
appear as four puncture marks but may range required.
from one to 20 punctures. Teeth may remain in
8. Renal function:
the wound. The neurotoxin poison is a heat-
stable nonenzymatic protein; hence, bites should a. Monitor renal function and fluid balance
not be immersed in hot water as with venomous anticipating acute renal failure.
fish stings. Due to its small jaws, bites often do b. Peritoneal or hemodialysis may be
not result in envenomation. needed.
Bites characteristically produce little pain c. Alkalinization of urine with sufficient IV
and there is usually a latent period of 10 minutes fluids will promote myoglobin excretion.
to as long as several hours before the 9. Vital signs should be monitored closely.
development of generalized symptoms: muscle Cardiovascular support plus oxygen and IV
aching and stiffness, thick tongue sensation, fluids may be required.
progressive paralysis, nausea, vomiting,
difficulty with speech and swallowing, 10. Because of the possibility of delayed
respiratory distress and failure, plus smoky- symptoms, all sea snake-bite victims
colored urine from myoglobinuria, which may should be observed for at least 12 hours.
lead to kidney failure. 11. If symptoms of envenomation occur within
one hour, antivenin should be administered
First Aid and Treatment4 as soon as possible.
a. In a seriously envenomated patient,
1. Keep victim still. antivenin therapy may be helpful even
2. Apply direct pressure using a compression after a significant delay.
bandage and immobilize the extremity in b. Antivenin is available from the
the dependent position with splints and Commonwealth Serum Lab in
elastic bandages. This prevents spreading Melbourne, Australia.
of the neurotoxin through the lymphatic
circulation. Do not apply a loose c. If specific antivenin is not available,
constricting band or tourniquet. polyvalent land snake antivenin (with a
tiger snake or krait Elapidae component)
3. Incise and apply suction (see cone shell may be substituted.
stings).
d. If antivenin is used, the directions
4. Transport all sea snake-bite victims to a regarding dosage and sensitivity testing
treatment facility as soon as possible, on the accompanying package insert
regardless of their current symptoms. should be followed and the physician
5. Watch to ensure that the patient is must be ready to treat for anaphylaxis.
breathing adequately. Be prepared to e. Infusion by IV method or closely
administer mouth-to-mouth resuscitation or monitored drip over a period of one hour
cardiopulmonary resuscitation if required. is recommended.
6. The venom is a heat-stable protein which 12. Administer tetanus prophylaxis as
blocks neuromuscular transmission. appropriate.
Myonecrosis with resultant myoglobinuria
and renal damage are often seen.
Hypotension may develop.
22-24
Sponges4 - Sponges are composed of minute Neurological symptoms may include pain,
multicellular animals with spicules of silica or ataxia (stumbling gait), paresthesias (tingling),
calcium carbonate embedded in a fibrous and circumoral parasthesias (numbness around
skeleton. Exposure of skin to the chemical the mouth). Sensory reversal of hot and cold
irritants on the surface of certain sponges or sensation when touching or eating objects of
exposure to the minute sharp spicules can cause extreme temperatures may occur.
a painful skin condition called dermatitis.
In severe cases, respiratory failure and
First Aid and Treatment4 cardiovascular collapse may occur. Pruritus
(itching) is characteristically made worse by
1. Adhesive or duct tape can effectively
alcohol ingestion. Gastrointestinal symptoms
remove the sponge spicules.
usually disappear within 24 to 72 hours.
2. Vinegar or a 3- to 10-percent acetic acid Complete recovery will occur in the majority of
should be applied with saturated cases with neurological symptoms persisting for
compresses as sponges may be secondarily months or years. Signs and symptoms of
inhabited by stinging coelenterates. ciguatera fish poisoning may be misdiagnosed as
3. Antihistamine lotion (diphenhydramine) decompression sickness or contact dermatitis
and later a topical steroid (hydrocortisone) from unseen fire coral or jellyfish.
may be applied to reduce the early
inflammatory reaction. Because of rapid modern travel and
refrigeration, ciguatera poisoning may occur far
4. Antibiotic ointment is effective in reducing from endemic areas with international travelers
the chance of a secondary infection. or unsuspecting restaurant patrons. Table 22-5
lists some of toxins found in fish and shellfish
POISONOUS MARINE ANIMALS and their potential sources.
22-25
First Aid and Treatment4 A rapid bacterial production of histamine
and saurine (a histamine-like compound)
produce the symptoms of a histamine reaction:
1. Treatment is largely supportive and
nausea, abdominal pain, vomiting, facial
symptomatic. If the time since suspected
flushing, urticaria (hives), headache, pruritus
ingestion of the fish is brief and the victim
(itching), bronchospasm, and a burning or
is fully conscious, induce vomiting (syrup
itching sensation in the mouth. Symptoms may
of Ipecac) and administer purgatives
begin one hour after ingestion and last 8 to 12
(cathartics, laxatives) to speed the
hours. Death is rare.
elimination of undigested fish.
2. In addition to the symptoms described Prevention - Immediately clean the fish and
above, other complications which may preserve by rapid chilling. Do not eat any fish
require treatment include hypotension and that has been left in the sun or in the heat longer
cardiac dysrhythmias. than two hours.
3. Medication management:
First Aid and Treatment4
a. Antiemetics and antidiarrheal agents may
be required if gastrointestinal symptoms Oral antihistamine, (e.g., diphenhydramine,
are severe. cimetidine), epinephrine (given subcutaneously),
b. Atropine may be needed to control and steroids are to be given as needed. Table
bradycardia. 22-5 lists some of toxins found in fish and
shellfish and their potential sources.
c. IV fluids may be needed to control
hypotension. Puffer (Fugu) Fish Poisoning4
d. Calcium gluconate, diazepam, and
methocarbamol can be given for muscle An extremely potent neurotoxin called
spasm. tetrodotoxin is found in the viscera, gonads,
liver, and skin of a variety of fish, including the
e. Amytriptyline has been used successfully puffer fish, porcupine fish, and ocean sunfish.
to resolve neurological symptoms such as Puffer fish also called blow fish, toad fish, and
depression. balloon fish, and called Fugu in Japanese are
Scombroid Fish Poisoning4 found primarily in the tropics but also in
temperate waters of the coastal U.S., Africa,
Unlike ciguatera fish poisoning where actual South America, Asia, and the Mediterranean.
toxin is already concentrated in the flesh of the Puffer fish is considered a delicacy in Japan,
fish, scombroid fish poisoning occurs from where it is thinly sliced and eaten as sashimi.
different types of fish that have not been Licensed chefs are trained to select those puffer
promptly cooled or prepared for immediate fish least likely to be poisonous and also to
consumption. Typical fish causing scombroid avoid contact with the visceral organs known to
poisoning include tuna, skipjack, mackerel, concentrate the poison.
bonito, dolphin fish, mahi mahi (Pacific
dolphin), and bluefish. Fish that cause The first sign of poisoning is usually
scombroid poisoning are found in both tropical tingling around the mouth, which spreads to the
and temperate waters. extremities and may lead to a body wide
numbness. Neurological findings may progress
to stumbling gait (ataxia), generalized weakness,
and paralysis. The victim, though paralyzed,
remains conscious until death occurs by
respiratory arrest with a 50 to 60 % mortality
rate if untreated.
22-26
First Aid and Treatment4 Allergic reactions such as urticaria (hives),
pruritus (itching), dryness or scratching
1. Provide supportive care with airway sensation in the throat, swollen tongue and
management and monitor breathing and bronchospasm may also be an individual
circulation. hypersensitivity to a specific shellfish and not
PSP.
2. Monitor renal function.
3. Monitor and treat cardiac dysrhythmias. First Aid and Treatment4
22-27
First Aid and Treatment4 DRUG ABUSE
22-28
Opium &
Mind-Altering
Stimulants Depressant Opium Inhalants
Drugs
Alkaloids
PHENOBARBITAL
(goofballs, phennies,
barbs)
SECOBARBITAL (red
devils, barbs,
Seconal®)
22-29
CENTRAL NERVOUS SYSTEM Alcohol Intoxication
DEPRESSANT INTOXICATION
Alcohol is the most widely abused drug
Opium and Opium Alkaloid Intoxication today. Although there are many other chemicals
that are in the chemical grouping of "alcohols,"
This group of drugs includes the most the type consumed by people as a beverage (in
effective and widely used pain killers in wines, beers, and distilled liquors) is known as
existence. Prolonged use of narcotic drugs, ethyl alcohol, ethanol, grain alcohol, or just
even under medical supervision, inevitably "alcohol." It is a colorless, flammable,
leads to physical and psychological intoxicating liquid, classed as a drug because
dependence. it depresses the central nervous system,
affecting physical and mental activities.
The more commonly known drugs within
this group are opium, morphine, heroin, Alcohol affects the body of the abuser in
codeine, and methadone (a synthetic narcotic). stages. Initially, there is a feeling of relaxation
Next to cocaine, heroin is the most popular and well-being, followed by confusion with a
narcotic drug because of its intense euphoria gradual disruption of coordination, resulting in
and long-lasting effect. It is far more potent an inability to accurately and efficiently perform
than morphine but has no legitimate use in the normal activities and skills. Continued alcohol
United States. Heroin appears as a white or consumption can lead to a stuporous state of
brown powder. The most common method of inebriation resulting in vomiting, an inability to
using heroin is by injection directly into the walk or stand, blackouts, and impaired
vein, although it can be sniffed. Codeine, consciousness (sleep or stupor). Excessive
although milder than heroin and morphine, is consumption can cause loss of consciousness,
sometimes abused as an ingredient in cough coma, and death from alcohol poisoning or
syrup preparations. aspiration.
Signs and symptoms of narcotic drug The potential for physical and
abuse include: coma (or depressed level of psychological addiction is very high when
consciousness), respiratory depression or alcohol is abused. The severely intoxicated
arrest (slow, shallow respiratory effort), individual must be closely monitored to avoid
restlessness, dizziness, lethargy and scars inhalation of vomit (aspiration) and other
caused by injections. These symptoms can adverse effects and behaviors.
progress rapidly to hypoxia and death.
Individuals withdrawing from alcohol are at
The narcotic user, suddenly withdrawn a greater risk of serious complications or death
from drugs, may appear as a wildly disturbed than those withdrawing from narcotics. The
patient who is agitated, restless, and possibly effects of alcohol withdrawal include severe
hallucinating. Initial symptoms start within a agitation, anxiety, confusion, restlessness, sleep
few hours after last dose and peaks at about 72 disturbances, sweating, profound depression,
hours. Although these signs and symptoms are delirium tremens (“DTs," a particular type of
not commonly life-threatening, most users will confusion and shaking that is a medical
state that they feel so bad they wish they were emergency), hallucinations, seizures,
dead. The signs and symptoms of withdrawal tachycardia and hypertension resulting in stroke.
immediately stop upon re-administering a
narcotic and withdrawing the drug by tapering
the dose over several days.
22-30
Barbiturate Intoxication Most of the traditional, non-barbiturate
sedative-hypnotics are either no longer
Benzodiazepines have largely replaced available (Methaquaalone, Ethchlorovynol,
barbiturates, or "downers," as sedatives, Glutethimide) or rarely used today (chloral
hypnotics (sleeping pills), or anxiolytic (anti- hydrate) because of their profound "hangover
anxiety) agents. Barbiturates are still used to effect." Newer sedative-hypnotics are
treat various seizure disorders. They are emerging for the temporary treatment of
classified based on their duration of action: short insomnia. Benzodiazepines are widely used to
acting agents (<6 hours), intermediate acting treat seizure disorders, anxiety, muscle spasms,
agents (6-18hours), and long-acting agents (>18 and insomnia. Signs and symptoms are sedation,
hours). Barbiturate use causes various degrees of dizziness and drowsiness. Short acting
CNS depression with nystagmus (eyes moving benzodiazepine (Xanax®/alprazolan)
up and down, or side-to-side involuntarily), withdrawal is particularly harsh.
vertigo (sensation of the room spinning), slurred
speech, lethargy, confusion, ataxia (difficulty CENTRAL NERVOUS SYSTEM
walking), and respiratory depression. Severe STIMULANT INTOXICATION
overdose may result in coma, shock, apnea
(stopped breathing), and dilated pupils. In The stimulants directly affect the central
combination with ethanol or other CNS nervous system by increasing mental alertness
depressants, there are compounded CNS and and combating drowsiness and fatigue. One
respiratory depression effects. group of stimulants, called amphetamines, is
legitimately used in the treatment of conditions
Prolonged use of barbiturates can lead to a such as mild depression, obesity, narcolepsy
state of physical and psychological dependence. (sleeping sickness) and attention-deficit/
Upon discontinued use, the dependant patient hyperactivity disorder (ADHD).
may go into withdrawal. Unlike narcotic (opiate)
withdrawal, barbiturate withdrawal is LIFE Amphetamines are commonly abused and
THREATENING! Depending on the type of are referred to as speed, or uppers.
barbiturate, signs and symptoms start within 24 Amphetamines can be taken orally,
hours. The withdrawal syndrome includes intravenously, or smoked as "ice." They are
anxiety, insomnia, muscle tremors (trembling or abused for their stimulant effect, which lasts
shaking), loss of appetite, convulsion, delirium, longer than cocaine.
and death. The signs and symptoms will stop
upon re-administration of the barbiturate and by Amphetamines cause central nervous system
tapering the dose slowly over several days. stimulation with euphoria, increased alertness,
intensified emotions, aggressiveness, altered
Non-Barbiturate Sedative-Hypnotic self-esteem, and increased sexuality. In higher
(Benzodiazepine) Intoxication doses, unpleasant CNS effects of agitation,
anxiety, hallucinations, delirium, psychosis, and
Non-barbiturate sedative-hypnotics (a seizures can occur. When stimulants are
"hypnotic" is a sleeping pill) have actions very combined with alcohol ingestion, patients have
similar to the barbiturates. However, they have a increased psychological and cardiac effects due
higher margin of safety, overdose and addiction to patients drinking more alcohol.
require larger doses, and addiction requires a
longer time period to occur. Like the
barbiturates, when combined with ethanol or
other d ep r e ss an t s, there are additive CNS-
and respiratory-depression effects.
22-31
Signs and symptoms associated with The symptoms of hallucinogenic drugs
amphetamine use include mydriasis (dilated include dilated pupils, flushed face, increased
pupils), sweating, increased temperature, heartbeat, and a chilled feeling. In addition, the
tachycardia (rapid pulse), and hypertension. patient may display a distorted sense of time
Patients seeking medical attention usually and self, show emotions ranging from ecstasy
complain of chest pain, palpitations, and to horror, and experience changes in visual
shortness of breath that can lead to myocardial depth perception.
infarction (MI).
Although no deaths have resulted from the
Stimulants are highly addictive. Tolerance to drugs directly, hallucinogen-intoxicated
increasingly higher doses develops. Abruptly patients have been known to jump from
stopping chronic amphetamine use does not windows, walk in front of automobiles, or
cause convulsions or present a life-threatening injure themselves in other ways because of the
situation. The withdrawal is typically vivid but unreal perception of their
characterized by apathy, sleep disturbances, environment.
irritability, disorientation, and depression with
suicidal tendencies. Even though no longer under the direct
influence of a hallucinogenic drug, a patient
Cocaine, although classified as a narcotic, who has formerly used one of the drugs may
acts as a stimulant and is commonly abused. It is experience a spontaneous recurrence
relatively ineffective when taken orally; (flashback) of some aspect of the drug
therefore, the abuser either injects it into the vein experience. The most common type of
or "snorts" it through the nose. Its effect is flashback is the recurrence of perceptual
much shorter than that of amphetamines, and distortion; however, victims of flashback may
occasionally the abuser may inject or snort also experience panic or disturbing emotion.
cocaine every few minutes in an attempt to Flashback may be experienced by heavy or
maintain a constant stimulation and prevent occasional users of hallucinogenic drugs, and
the depression experienced during withdrawal its frequency is unpredictable and its cause
(come-down). Overdose is very possible, often unknown.
resulting in convulsion and death. The
physical symptoms observed in the cocaine Cannabis Intoxication
abuser will be the same as those observed in
the amphetamine abuser. Cannabis sativa, commonly known as
marijuana, is widely abused and may be
MIND-ALTERING DRUGS classified as a mild hallucinogen. The most
common physical appearance of marijuana is as
Hallucinogen Intoxication ground, dried leaves, and the most common
method of consumption is smoking, but it can be
The group of drugs that affect the central taken orally.
nervous system by altering the user’s perception
of self and environment are commonly known as A commercially prepared product of the
hallucinogens. Included within this group are active ingredient in marijuana, tetrahydro-
(LSD), mescaline, dimethoxy-methylamphetamine cannabinol (THC), is dronabinol (Marinol®)
(STP), phencyclidine (PCP), and psilocybin. available in the U.S. as a controlled Schedule
They appear in the forms of crystals, powders, II drug. Dronabinol is used for the treatment
and liquids. of nausea and vomiting in chemotherapy
patients. It may also be useful in the treatment
of acute glaucoma, asthma, and nausea and
vomiting from other chronic illnesses.
22-32
The individual response to the recreational Substances in this category include
use of marijuana varies and depends on the adhesives (synthetic glues), paint, wet
dose, the personality and expectation of the markers, lighter fluids, solvents, and
user, and the setting. Unexpected ingestion, propellants in aerosol spray cans, and air
emotional stress, or underlying psychiatric fresheners. Inhalants can be abused by
disorders can increase the possibility of an "sniffing" which is inhaling through the nose
unfavorable reaction. directly over an open container;
“ b a g g i n g ” which is holding an open bag or
After a single inhaled dose of marijuana, a container over the head; o r “ h u f f i n g ”
subjective "high" begins in several minutes and which is pouring or spraying material on a cloth
is gone within four hours. Marijuana causes that is held over the mouth and inhaling through
decreased pupil size and injected conjunctiva the mouth. These methods usually use a bag or
(reddening of the white of the eye). Smoking other container to concentrate and retain the
marijuana can increase the heart rate propellant thereby producing a q u i c k h i g h
(tachycardia) for about two hours. It can for the abuser.
slightly increase systolic blood pressure in low
doses and can lower blood pressure in high Patients who regularly abuse inhalants risk
doses. An increased appetite “munchies” and permanent and severe brain damage and even
dry mouth are common complaints after sudden death. The vapors from these volatile
marijuana use. chemicals can react with the fatty tissues
(myelin) in the brain and literally dissolve
Social setting influences the psychological them. Additionally, inhalants can reduce the
effects associated with "usual doses" of availability and use of oxygen causing brain
marijuana smoking. Smoking in a solitary hypoxia. Acute and chronic damage may also
setting may produce euphoria, relaxation, and occur to the heart, kidneys, liver, peripheral
sleep. In a group setting, increased social nervous system, bone marrow, and other
interaction, friendliness, and laughter or organs. Sudden death can occur from respiratory
giddiness may be produced. Subjectively, time arrest or irregular heart rhythms.
moves slower, images appear more vivid, and
hearing seems keener. High doses can cause Signs and symptoms of inhalant abuse
lethargy, depersonalization (a state of mind in closely resemble a combination of alcohol and
which the self appears unreal), pressured marijuana intoxication. Acute symptoms are
speech, paranoia, hallucinations, and mania very short-lived and are completely gone within
(excited, over-activity and psychomotor two hours. Physical symptoms of withdrawal
agitation often accompanied by impaired from inhalants include hallucinations, nausea,
judgment). excessive sweating, hand tremors, muscle
cramps, headaches, chills, and delirium
Inhalant Intoxication tremens (which is a medical emergency).
22-33
MANAGEMENT OF DRUG- 8. Calm and reassure the excited patient by
INTOXICATED PATIENTS "talking them down" in a quiet, relaxed,
and sympathetic manner. Decrease visual
General priorities of care are outlined below: and auditory stimuli.
1. Observe the ABC + D & E. 9. Gather materials and information to assist
in identifying and treating the suspected
a. Assess the ABC’s.
drug problem.
b. Assess the Drug-induced central nervous
a. Spoons, paper sacks, eyedroppers,
system (CNS) depression.
hypodermic needles, and vials are
c. Expose (undressing/uncovering) the excellent identification clues or
patient for disabilities/injuries to ensure witnesses.
areas of contact or exposure to a
b. The presence of capsules, pills, drug
chemical can be properly visualized and
containers, needle marks (tracks) on the
assessed.
patient’s body, or substances noted
d. Watch for shock! around the mouth and nose, are also
e. Give appropriate treatment. important findings of substance abuse.
2. If the victim cannot be aroused, place them c. A personal history of drug use from the
on the side allowing secretions and vomitus patient or those accompanying the patient
to drain from the mouth and not being is very important and may reveal how
aspirated into the lungs. long the victim has been abusing drugs,
approximate amounts taken, and time
3. All adult patients with an altered mental between doses.
status should receive dextrose (after blood
sugar testing), thiamine, naloxone (i.e. d. Knowledge of past medical problems,
Narcan®), and oxygen. When in doubt give including history of convulsions (with or
patients Oxygen, Narcan® and dextrose. without drugs) is also important.
4. If recommended by the PCC or medical 10. Transport the patient and the materials
officer, place the patient on a cardiac collected to a treatment facility.
monitor and or obtain specimens for 11. Inform treatment facility personnel and
comprehensive laboratory work-up (blood present the materials collected at the scene
and urine). upon arrival at the facility.
5. If recommended by the PCC or medical
officer, decontaminate the stomach: SUMMARY
a. ONLY if the victim is conscious.
This chapter covered the assessment and
AND treatment for poisoning and drug abuse. In the
b. The drug was RECENTLY TAKEN rapidly changing world environment, HMs
ORALLY. must be up to date on the latest changes in
assessment and treatment for these conditions.
6. Cardiac monitor all patients with an altered Corpsmen may stay informed through contact
mental status. with the local Poison Control Center (PCC),
7. Prevent the victim from self-injury while MEDIC releases, or via the World Wide Web
highly excited or lacking coordination. Use on the Internet through credible sites such as
physical restraints only if absolutely the American Association of Poison Control
necessary. Centers.
22-34
CHAPTER 23
23-1
Vapors and droplets of liquids can be
absorbed from the surface of the skin and
mucous membranes. Toxic compounds that are
harmful to the skin can produce their effects in
liquid or solid state. Agents penetrating the skin
may form temporary reservoirs under the skin;
the vapors of some volatile liquids can penetrate
the skin and cause adverse effects. See Table 23-
Figure 23-1.—Clandestine Chemical Lab 1 for a list of common chemical weapons.
23-3
The M256A1 chemical agent detector kit is If there is a known threat of possible
a portable kit that detects nerve gas, mustard chemical, biological, or radiological attack or
gas, and cyanide. The kit contains a package of personal need to enter known contaminated area,
M8 paper, detailed instructions, and a vapor protective measures should be taken. Personal
sampler (12 enzymatic tickets that contain Protective Equipment (PPE) consists of the Joint
laboratory filter paper for detecting chemical Service Lightweight Integrated Suit Technology
agent vapors). The vapor sampler uses wet (JSLIST), Field M-40 Chemical/Biological
chemistry technology, in which ampules Mask with hood, protective gloves, and
containing different substrates are crushed so protective boots.
that the liquids interact with strips of filter paper,
chromatographic media, and glass fiber filter. Dependent upon the threat, forces may adopt
These substrates are exposed to the vapor under a Mission-Orientated Protective Posture
suspicion. The reaction causes a color change, (MOPP) and there are five levels (Table 23-2).
alerting the user to the presence of a chemical MOPP Gear consists of previously mentioned
agent. The reactions typically take 15 minutes PPE to include an individual decontamination
to occur. kit as well as antidotes. MOPP is a flexible
system of protection against chemical, biological
PERSONAL PROTECTION and radiological threats, which is used to
facilitate mission accomplishment. MOPP does
In a chemical attack, the first priority is to give the commander a range of choices
ensure the HM’s survival so that casualties can regarding the level of chemical protection.
be treated. There are several items available to Choices range from no protection at all to full
help HMs survive a chemical attack. Along with protection.
protective clothing, there is a protective mask,
which should be put on at the first indication of
a chemical attack. The mask will filter out all
known chemical agents from the air and allow
HMs to work in a chemically contaminated area.
23-4
Chemical agents penetrate ordinary clothing CHEMICAL AGENTS
rapidly. However, significant absorption
through the skin requires a period of minutes. NERVE AGENTS (VX, GA, GB, GD, GF)
The effects of clothing penetration may be
reduced by quickly removing the contaminated Nerve agents are of greatest concern as
clothing and neutralizing the chemical agent on compared to all chemical agents. They produce
the skin by washing, blotting, or wiping it away. their effect by interfering with normal
A chemical agent on the skin can be removed transmission of nerve impulses in the
effectively by using the M291 skin parasympathetic autonomic nervous system.
decontamination kit (Fig. 23-2) or Pharmacologically, the nerve agents are
decontamination procedures associated with cholinesterase inhibitors (interfering with
each agent. normal transmission of nerve impulses in the
nervous system). Their reaction with
cholinesterase tends to be irreversible, and
reaction time varies with the agent.
Characteristics
23-5
• Liquid The MARK 1 antidote kit (Fig. 23-4)
consists of an autoinjector of Atropine 2mg and
o Small to Moderate Exposure – Localized
an autoinjector of 2-PAM CL 600mg. A new
sweating, nausea, vomiting, and weakness
autoinjector called Autoinjector Treatment;
o Large Exposure Level - Sudden loss of Nerve Agent Antidote (ATNAA) will replace
consciousness; convulsions; apnea (no the MARK 1 kit. The ATNAA is a single
breathing); flaccid paralysis; and copious autoinjector that has two chambers that deliver
secretions from the nose, mouth, and 2.1 mg of Atropine and 600mg of 2-PAM CL in
lungs a single injection. ATNAA is used in the same
manner as a MARK 1 kit.
Treatment
23-6
5. Apply firm and even pressure to the If convulsions continue after 10 minutes of
autoinjector until the needle pushes into the initial injection of CANA (Diazepam), a second
injection site. dose may be administered. Observe patient for 5
to 10 minutes after injection, if the patient is still
6. Hold the injector firmly in place for at least
convulsing a third dose may be administered.
10 seconds.
Medical officers may choose to give more
NOTE: diazepam either IM or IV, if they deem it
Do NOT use a jabbing motion. necessary.
This may result in improper injection of antidote
and/or injury to the patient. Decontamination
23-7
Characteristics The eyes are the most vulnerable part of the
body to mustard gas. Contamination insufficient
Each agent is chemically different and will to cause injury elsewhere may produce eye
cause significant specific symptoms. They are inflammation. The eyes are the most sensitive
all similar in their physical characteristics and part of the body. The first noticeable symptoms
toxicology. H, HD, and HN are oily, colorless of mustard exposure will be pain and a gritting
or pale yellow liquids, sparingly soluble in feeling in the eyes, accompanied by spastic
water. HN (Nitrogen Mustard) is less volatile blinking of the eyelids and photophobia. This
and more persistent than HD (Distilled Mustard) may continue to develop with swelling of the
but has the same blistering qualities. Lewisite eyelids, cornea damage, and moderate to severe
(L) is an arsenical (an arsenic-based compound). pain.
This blistering compound is a light to dark
brown liquid that vaporizes slowly. All blister The skin will develop erythema and blisters
agents have a relatively high vapor density; it is (Fig. 23-6). Typical blister agent cause
more likely to flow to low spots such as valleys, blistering in about 12 hours but may be delayed
ditches, holes, and the ground or deck. for up to 48 hours, while Lewisite (L) causes
intense pain upon contact. Areas affected the
Signs and Symptoms most will be in warm, sweaty areas of the body:
the armpits, groin, and on the face and neck.
Mustards (Fig. 23-5) are particularly
insidious as they do not manifest their symptoms
for several hours after exposure. Blister agents
attack the eyes and respiratory tract as well as
the skin. Patients exposed to mustard may
remember seeing an oily substance and smelling
an odor of garlic, mustard, or horseradish.
Patients exposed to Lewisite (L) may remember
observing puddles of a brown liquid or of
smelling an odor similar to geranium.
23-8
Treatment Cyanides are volatile and evaporate quickly
to become vapors or gases. Hydrogen Cyanide
There is no specific antidotal treatment for (AC) has a bitter almonds smell. Although very
mustard (H, HD, and HN) poisoning. Physically deadly, they are non-persistent agents. Cyanides
removing as much of the mustard as possible as usually dissipate in less than 24 hours. Cyanide
soon as possible, is the only effective method for produces clinical effects by disrupting oxygen
mitigating symptoms before they appear. All uptake by cells.
other treatment is symptomatic and supportive;
the relief of pain and itching, and control of Signs and Symptoms
infection.
• Moderate Exposure (low concentrations)
In cases of systemic involvement, British
Anti-Lewisite (BAL) was developed as an o Symptoms include transient increased rate
antidote for Lewisite (L). BAL is used as a and depth of breathing; dizziness; nausea
chelating agent that combines with the heavy and vomiting; headache; and eye
metal to form a water-soluble, nontoxic complex irritation. Symptoms may progress to
that is excreted. However, BAL is somewhat severe with continued exposure
toxic and an injection of more than 3 mg/kg will
• High Exposure (high concentrations)
cause severe symptoms. Do not use on patients
allergic to peanuts. o The onset is rapid, often within minutes.
Symptoms include transient increased rate
Decontamination and depth of breathing; convulsions
(within 30 seconds); apnea; cardiac arrest
Early decontamination will reduce the affect (within a few minutes)
of blister agents. Decontamination within two
Treatment
minutes will reduce the toxic effects by more
then 50%. Decontamination consists of
Treatment begins with personnel protection
removing all contaminated clothing. A M291 kit
by using a chemical protective mask. Remove
may be used or copiously irrigating the area with
the patient from the agent to fresh air.
water to physically remove agents and then
Treatment of cyanide poisoning is very effective
washing the skin with soap and water or 0.5%
if administered in a timely manner. Antidote
hypochlorite solution (made by diluting
treatment consists of a two step process:
household bleach 1:10) to chemically neutralize
the agent.
1. Initial treatment of cyanides: two amyl
BLOOD AGENTS (AC, CK) nitrite ampules crushed and inhaled (every
few minutes until eight ampules have been
Blood agents or cyanides basic physical used) or intravenous sodium nitrate 300mg
actions disrupt oxygen utilization at the cellular (a 300mg to 600mg dose given).
level causing cellular suffocation. They are
2. Administer intravenous sodium thiosulfate
rapid acting lethal agents that have limited
12.5g (1 to 2 doses given).
military use. Cyanide is a common chemical
and found widespread in chemical synthesis and 3. Follow-up treatment consists of the two
is easy for terrorist to obtain and to potentially antidotes given at half the original dose if
be used in a terrorist attack. there is no response to the first dose.
Characteristics
The key to successful cyanide therapy is
providing treatment early; cyanide acts rapidly
on an essential enzyme system. The antidotes act
rapidly to reverse this action.
23-9
If the specific antidote and artificial Latent symptoms are rapid, shallow, and
respiration are given early enough, the chance of labored breathing; painful cough; cyanosis;
survival is greatly enhanced. frothy sputum; clammy skin; rapid, feeble pulse;
and low blood pressure. Shock may develop,
Decontamination followed by death. Auscultation of the lungs
will reveal crackles and rales, in the lower
Skin decontamination is usually not required lobes initially and progress to be heard
as the agent evaporates quickly. Wet throughout all fields.
contaminate clothing should be removed and
contained to prevent off gassing hazard. Skin Treatment
should be cleaned by copiously irrigating the
area with water to physically remove agents, and Initial treatment is to remove the patient
then washing the skin with soap and water. from the source. There is no antidote for
pulmonary agents. Keep the patient at complete
PULMONARY AGENTS (CG, CL, DP) rest. Even a little exertion can increase the
effects of the agent and speed up the progression
Pulmonary agents damage the membranes in of pulmonary edema. Provide supportive care as
the lungs that separate the alveolar tissue necessary and treat symptomatically. Patients
resulting in fluid from the blood, known as with shortness of breath may require assisted
plasma, to leak into the alveoli and fill them respirations and/or oxygen.
with fluid. This prevents necessary gas
exchange within the alveoli causing hypoxia. Decontamination
This creates a condition known as pulmonary
edema. This group includes phosgene (CG) and
• Vapors
chlorine (Cl); HC Smoke and Ammonia should
also be included as a pulmonary agent. A o Exposure to fresh air or ventilate the area
terrorist threat may come from the release of
• Liquids
chlorine or ammonia.
o Remove contaminated clothing and rinse
Characteristics the affected area with copious amounts of
water
These agents are usually in vapor form,
typically heavier than air, and travel close to the
RIOT-CONTROL/HARASSMENT
ground. They tend to evaporate and disburse
AGENTS (CN, CR, CS, DM, OC)
very quickly, dependent upon temperature and
wind. Chlorine and ammonia have very distinct
"Riot-control agents" is the collective term
smells. Phosgene is a colorless gas with a
used to describe a collection of chemical
distinctive odor similar to that of new-mown hay
compounds, all having similar characteristics
or freshly cut grass.
which, though relatively nontoxic, produce an
immediate but temporary effect in very low
Signs and Symptoms
concentrations. These agents are used to harass
enemy personnel or to discourage riot actions
Early symptoms may be irritation of the
thus the weapon of choice for police when
eyes, nose, and airway. At this stage it may be
managing riots.
difficult to distinguish a pulmonary agent from a
riot agent. Symptoms may progress to
coughing, difficulty breathing, hoarseness
talking, sneezing, wheezing, and a feeling of
tightness in the chest. More often, however,
there will be no symptoms for 2 to 6 hours after
exposure.
23-10
Characteristics While the mask must be worn, it may be
lifted from the face briefly, if necessary, to
Unlike most agents, which are liquids under permit vomiting or to drain saliva from the face
temperate conditions, riot control agents are piece. Carry on duties as vigorously as possible.
crystallized solids that are dispersed as fine This will help to lessen and shorten the
particles or in solution(s). Dispersal devices symptoms.
include small handheld aerosol cans, large tanks,
grenades, and bombs. These agents irritate the Generally, patients require no therapy;
skin, mucosa membranes, and airway, causing removal from the environment is sufficient to
people to become unable to perform their job affect recovery in a short time. Exposure to
due to discomfort. There are two classes of riot- fresh air and letting wind blow into wide-open
control/harassment agents: lacrimators and eyes, held open if necessary, is sufficient for
vomiting agents. recovery in a short time. Talking can relieve
any chest discomfort after CS exposure. Less
• Lacrimators (or tear gases) are essentially
than 1% of people develop severe symptoms.
local irritants that act primarily on the eyes
There is no antidote for these agents. Patients
• Vomiting agents comprise the second class need to be treated according to their symptoms.
of agents in the riot-control category and
cause nausea, vomiting, and general malaise
• Eyes: The eyes should be flushed with water
in victims
or saline and impacted particles should be
removed. General care consists of a topical
Signs and Symptoms solution to relieve the irritation and topical
antibiotics. An ophthalmologist should be
The main effect of riot control agents is pain consulted for further evaluation and care.
burning, and irritation to exposed skin and
• Pulmonary: These agents may exacerbate
mucosa membranes. Other symptoms include
chronic disease or unmask latent disease.
salivation, increased nasal secretions, coughing,
Bronchospasm with wheezing and mild
possible redness of skin, and possible shortness
distress continuing hours after exposure may
of breath. Lacrimators produce intense pain in
occur in latent asthmatic people. More
the eyes with excessive tearing. Vomiting
severe effects and respiratory distress may
agents produce prolong periods of nausea and
occur in one with chronic bronchitis or
vomiting. The symptoms following the most
emphysema. Management includes oxygen
severe exposure to vapors seldom last over 2
administration and bronchodilators if
hours. After moderate exposure, they last only a
bronchospasms are present.
few minutes.
• Skin: The early erythema requires
Treatment reassurance, but no specific therapy is
indicated unless severe and prolonged more
At the first signs of exposure, don than an hour or two. Treat symptoms with
protective mask. It is of the utmost soothing compounds such as calamine.
importance that the mask be worn in spite of Small vesicles should be left intact, but
coughing, sneezing, salivation, and nausea. If larger ones will ultimately break. Large,
the mask is put on following exposure, oozing areas have responded to compresses
symptoms will increase for several minutes in containing substances such as colloidal
spite of adequate protection. As a consequence, oatmeal, Burrow's solution, and other
victims may believe the mask is ineffective and dermatologic preparations.
remove it, further exposing themselves.
23-11
Decontamination Casualty Priorities
Figure 23-7.—Decontamination
23-12
Sentry
- Free Ventilation; some cover. - All cases and records are received
- Remove contaminated clothing and gear. Contaminated Emergency
- Patients are decontaminated in this area
and moved to a clean receiving area or - Area designated for emergency treatment for
contaminated emergency area, dependent contaminated patients.
upon medical status. Treatment Area - Patients are decontaminated when they are
stable.
- Medical Treatment provided in a clean
environment
Evacuation Point
23-13
BIOLOGICAL WARFARE AGENTS33 After reports of flights of Japanese planes
suspected of dropping plague-infected fleas,
plague epidemics broke-out in China and
LEARNING OBJECTIVE:
Manchuria. It was evident the Japanese used
biological agents on civilian populations.
Identify signs and symptoms of a biological
agent exposure and provide appropriate
There has been shift in the use of Biological
medical treatment.
Weapons from a sophisticated biological
program run by other countries to agents used by
HISTORY an individual or terrorist group (Fig. 23-9). The
use of Anthrax in letters used in 2001 was
The use of biological warfare has been believed to have been done by an individual. A
recorded throughout history. Some of the early domestic terrorist group, Rajneesh, used
known uses of biological agents range from Salmonella bacteria to contaminate salad bars, in
using a biological agent in drinking wells to Dalles, Oregon, in order to try and influence the
moving driving infected animals into cities in local county election results in 1984.
hopes of spreading disease. In 1346, plague
broke out in the tartar army during the siege of
Kaffa. The attackers hurled the corpses of
plague victims over the city walls. This caused
an epidemic within the city and forced the
defenders to surrender. It is believed that some
of the infected people from the siege may have
started the Black Death pandemic. The
pandemic spread through Europe and is
responsible for the death of one third (around 25
million people) of the population of Europe.
23-14
The process can be done in a kitchen or Viruses34
bathroom within a house. A terrorist group can
produce the agent and release it before anyone Microorganisms are smaller than bacteria.
knows what happens. Viruses are intracellular parasites that lack a
system for their own metabolism, meaning, they
TYPES OF BIOLOGICAL AGENTS require living cells in order to multiply. Viruses
can infect host cells from humans, animals,
There are three different types of Biological plants, and bacteria. Virus-specific host cells
Agents used as weapons: can be cultivated in synthetic nutrient solutions
and then infected with the virus to be grown. A
Bacteria34 virus typically causes changes in the host cell
that eventually leads to cell death. The best way
Single celled organisms capable of causing a to control viral infections is to prevent them
variety of diseases in animals, plants, and from occurring through the use of vaccines.
humans. Bacteria are living cells that carry Viral Agents can be more expensive and time
many complex metabolic functions. Bacteria consuming to produce when compared to
cause disease in human beings by one of two bacterial and toxin agents.
mechanisms: invading host tissues and
producing toxins. Many bacteria utilize both Toxins34
mechanisms. Bacterial Agents are easy to
produce in significant quantities to cause a threat Harmful substances produced by a variety of
to the community’s health (Fig. 23-10). living organisms, like bacteria, plants, and
Fortunately, the infections they produce often animals (Table 23-3). They are not man-made,
respond to a specific antibiotic therapy. they are non-volatile (i.e. no vapor hazard), and
are usually not dermally active (with exception
to the mycotoxins). Biological toxins are
generally more toxic per weight than the
chemical agents and represent some of the most
toxic substances on Earth. Their lack of
volatility is important to note because it makes
them unlikely to produce either a secondary or
person-to-person exposure. They will not
present a persistent environmental hazard.
Image reprinted with permission from: U. S. Army Table 23-3.—Type of Biological Agents and
Special Programs Division, Dugway Proving Examples of Each Type
Grounds.
23-15
NATURAL OR INTENTIONAL DISEASE With recent advances in diagnostic testing,
OUTBREAK biological agents can be detected in the field. A
first-line presumptive test is the Hand-Held
It is difficult to determine if a disease Assay Panel that can make an indication of the
outbreak is a result of a natural occurrence or an presence of several biological agents within 15
intentional biological attack. An minutes. Portable laboratories have been
epidemiological investigation of a disease developed that can provide field confirmatory
outbreak will assist medical personnel in diagnostics for several biological agents within
identifying the pathogen and use of proper an hour. These labs weigh less than 1,000
medical intervention. This should be done pounds and require three operators to run it.
whether the outbreak is an intentional release or These labs utilize a rapid field detection method
a natural occurrence. incorporating real-time Polymerase Chain
Reaction (rt-PCR) based diagnostics for field
Some attacks may not be apparent and confirmatory testing (Fig. 23-11). These
require a full epidemiological study. Small scale confirmatory assays are based on the unique
outbreaks or those occurring over a long period DNA sequences of potential biological threat
of time require further investigation. Outbreaks agents. The system is excellent for detecting the
occurring in multiple geographical locations presences of the DNA unique to pathogenic
may be either a natural occurrence or an bacteria and viruses. These laboratory tests are
intentional release. An outbreak of a disease extremely accurate.
that is difficult to diagnose or that occurs
naturally or with low mortality rates requires
further studies to determine the cause of the
outbreak.
Some additional indicators of a possible Image reprinted with permission from: Biological
biological agent release: Defense Research Directorate at the Naval Medical
Research Center, Silver Spring, MD.
• Unusual disease for geographic area
• Absence of a competent natural vector PERSONAL PROTECTION
• Restricted geographic distribution, If a suspected biological agent is released in
epidemiological grouping or clustering the field, personnel should don personnel
• High morbidity and mortality compared protective equipment (PPE). This consists of the
with a normal occurrence of the disease Joint Service Lightweight Integrated Suit
Technology (JSLIST), Field M-40 Chemical -
• Dead animals of multiple species are Biological Mask, protective gloves, and boots.
sentinels Personnel should utilize this equipment in an
unknown biological environment and when
conducting decontamination procedures
23-16
BIOLOGICAL AGENTS Signs and Symptoms
23-17
• Gastrointestinal anthrax: The intestinal Prophylaxis
disease form of anthrax may occur 2 - 5
days following the consumption of An FDA approved vaccine can be used for
contaminated meat pre-exposure of high risk personnel. The
vaccine is a series of six 0.5 ml subcutaneous
o Signs and symptoms include fever,
doses at 0, 2, and 4 weeks; then 6, 12, and 18
diffuse abdominal pain, rebound
months followed by a annual booster. A post
abdominal tenderness, vomiting,
exposure prophylaxis antibiotic regimen can be
constipation, and diarrhea
given following the same regimen as the
o The primary lesion is ulcerative, emesis is treatment regimen.
blood-tinged or looks like coffee grounds,
and stool may be blood-tinged or melenic Isolation and Decontamination
(dark)
There is no isolation requirement for
o Bowel perforation can occur
patients; use standard precautions when in
o The oropharyngeal form of the disease is contact with patients. Protective garments and
characterized by local lymphadenopathy, mask are required when handling contaminated
cervical edema, dysphasic, and upper articles. Contaminated materials should be
respiratory tract obstruction bagged and incinerated or autoclaved (121+1
degree C core temperature for 30 min). Spores
o Intestinal anthrax results in death in 25%
are sensitive to 5-10% bleach solutions with a
to 60% of cases
minimum of 10 minutes contact time. Large
scale decontamination is difficult and costly.
Treatment
PLAGUE (YERSINIA PESTIS)
Antibiotics are the primary treatment
required for Anthrax. Supportive care and Plague (Yersinia Pestis) is an infectious
adjunctive care as required for patients. disease that affects animals and humans. It is
caused by the bacterium Yersinia pestis. This
bacterium is found in rodents and their fleas and
• First Line
occurs in many areas of the world, including the
o Ciprofloxacin (500 mg twice daily orally United States. It is a gram-negative rod that is
or 400 mg every 12 hours intravenously) non-motile, and non-sporulating. It is easily
OR destroyed by sunlight and drying. When released
o Doxycycline (100 mg every 12 hours into air, the bacterium will only survive for up to
orally or intravenously) one hour, depending on conditions. Plague is
endemic in many countries in Africa, in the
• Second Line former Soviet Union, the Americas and Asia.
o Amoxicillin (500 mg three times daily As a biological threat, plague was produced and
orally) weaponized in large quantities by the former
Soviet Union. It would not be difficult for a
OR terrorist group to obtain and produce plague.
o Penicillin G (2 mU every 4 hours
intravenously)
• Third Line
o Rifampin, Clindamycin, Clarithromycin,
Erythromycin, Vancomycin, and
Imipenem
23-18
Forms of Disease and Infectious Route • Bubonic: It is characterized by swollen
painful lymph nodes called buboes, high
fever, chills, headache, and malaise. The
• Pneumonic plague: Occurs when Y. pestis
resulting bubo is usually 1 to 10 centimeters
infects the lungs. This type of plague can
in diameter, swollen, painful and warm to
spread from person to person through the
the touch. It can cause so much pain that the
air. Transmission can take place if someone
affected body part cannot be moved. The
breaths in aerosolized bacteria, which could
bubo usually develops in the groin
happen in a bioterrorist attack. Pneumonic
(Fig. 23-12), but may also appear in the
plague is also spread by breathing in Y.
armpit or neck, depending on where the flea
pestis suspended in respiratory droplets from
bite occurred. Bubonic may progress to
a person or animal with pneumonic plague.
either Septicemic or Pneumonic.
• Bubonic plague: This is the most common
form of plague. This occurs when an
infected flea bites a person or when
materials contaminated with Y. pestis enter
through a break in a person's skin. This
occurs in nature with infected fleas and
rodents.
• Septicemic plague: Occurs when plague
bacteria multiply in the blood. It can be a
complication of pneumonic or bubonic
plague, or it can occur by itself.
Incubation Period
23-19
Treatment The Y. pestis bacterium can be inactivated by
heat (greater than 15 minutes at 55°-72°C) or
Treatment should be started immediately direct sunlight (more than 2 hours).
once plague is suspected. Immediate
administration of antibiotics is required to TULAREMIA (FRANCISELLA
reduce mortality. This is especially true with TULARENSIS)
primary pneumonic plague in which the
mortality rate approaches 100% if not initiated Tularemia, also known as “rabbit fever,” is
within 18 – 24 hours. Supportive care should a disease caused by the bacterium Francisella
include hemodynamic monitoring. tularensis. It is typically found in animals,
especially rodents, rabbits, hares, and ticks. It is
• Primary Antibiotics
usually a rural disease and has been reported in
o Streptomycin (1g every 12 hours all U.S. states except Hawaii. It is a gram-
intravenously) negative, non-motile coccobacillus. The
bacterium has several subspecies with varying
o Gentamicin (5mg/kg intravenously or
degrees of virulence. As a biological threat, it is
intramuscular every day or 2mg/kg
rarely fatal (approx. 1-2%), but can be seriously
loading dose, then 1.7 mg/kg every 8
incapacitating. F. tularensis is one of the most
hours intravenously)
infectious pathogenic bacteria, requiring less
• Alternative Antibiotics than 10 organisms for infection. It was used as a
biological weapon during WWII, and engineered
o Doxycycline, Ciprofloxacin, or
to be antibiotic/vaccine resistant by the United
Chloramphenicol
Soviet Socialist Republic (USSR); now Russia.
Post exposure prophylaxis for face-to-face There are two subspecies and several types
contact of patients with pneumonic plague or of the disease that are determined by the route of
personnel exposed to an intentional release infection. Of the subspecies, Jellison type A and
aerosol plague should be given antibiotics for B, Type A is the most virulent. Humans become
the duration of the exposure plus 7 days. There infected through bites from infective arthropods
is currently no approved vaccination (in the (ticks and deer flies), handling infectious animal
United States) for plague. tissues or fluids, direct contact with, or ingestion
of, contaminated matter, or inhalation of
• Primary Prophylaxis
infective aerosols. Tularemia is not spread from
o Doxycycline (100 mg orally twice a day) person to person.
• Alternative Prophylaxis
• Ulceroglandular: is the most common form
o Ciprofloxacin or Chloramphenicol
of tularemia and usually occurs following a
tick or deerfly bite, or after handing of an
Isolation and Decontamination infected animal.
Standard precautions should be used for • Pneumonic and typhoidal: forms of the
bubonic and septicemic plague. Respiratory disease would likely be the predominate
isolation and precautions against airborne spread forms following an intentional aerosol
is required for pneumonic plague. Rid patients release of the agent. Tularemia, in aerosol
and their clothing of fleas. Decontamination can form, is considered a possible bioterrorist
be done with a 1% bleach solution. Patients can agent.
be cleaned with a soap and water solution.
23-20
Incubation Period Isolation and Decontamination
Usually 3 to 5 days with a range of 1 to 14 days. Isolation is not recommended for tularemia
patients, given the lack of person-to-person
Signs and Symptoms transmission. Standard precautions are
recommended when treating patients. Clothing
Tularemia presents generally with abrupt or linens contaminated with body fluids of
onset fever, headache, chills, generalized body patients with tularemia should be disinfected.
aches, and nausea begins suddenly. Diagnosis of The agent is rendered harmless when exposed to
tularemia is confirmed by serological testing. heat (55° C for 10 minutes) and susceptible to
1% bleach solution followed by 70% alcohol
solution and standard water chlorination.
• Ulceroglandular: A skin ulcer appears at
the site where the organism entered the
BOTULINUM TOXIN (CLOSTRIDIUM
body. The ulcer is accompanied by regional
BOTULINUM)
lymphadenopathy usually in the armpit or
groin.
Botulinum Toxin is produced by
• Pneumonic and typhoidal: Symptoms Clostridium botulinum, an encapsulated,
include cough, chest pain, and difficulty anaerobic, gram-positive, spore-forming, rod-
breathing. This form results from breathing shaped bacterium. It is a neuroparalytic
dusts or aerosols containing the organism. (muscle-paralyzing) disease blocking the
Develops when other forms of tularemia are acetylcholine release from peripheral nerves.
left untreated and the bacteria spread The toxin is highly lethal and easy to produce
through the blood stream to the lungs. and release. The toxin is the most toxic
substance known and is 10 -15,000 times more
toxic then VX nerve agent by weight. As a
Treatment
biological threat botulinum can be easily
produced and disseminated. It has been used in
The use of antibiotics is necessary for the
former state sponsored bioweapons programs in
treatment of Tularemia.
Japan, Germany, US, USSR, Iran, Iraq, North
• Primary Antibiotics Korea, and Syria.
o Streptomycin (1g every 12 hours
Forms of Disease and Infectious Route
intramuscular) or
o Gentamicin (5mg/kg intravenously or Seven antigen types (A-G) of the toxin exist;
intramuscular every day) only types A, B, E and F are known to cause
illness in humans. There are no reported cases of
• Alternative Antibiotics
person-to-person transmission. There are four
o Doxycycline, Ciprofloxacin, or kinds of botulism:
Chloramphenicol
• Food-borne botulism: Occurs when a
Prophylaxis person ingests pre-formed toxin that leads to
illness within a few hours to days
Post exposure antibiotics should begin
within 24 hours of exposure and continue for 14 • Infant botulism: Occurs in a small number
days. of susceptible infants each year who harbor
C. botulinum in their intestinal tract
• Preferred Prophylaxis
• Wound botulism: Occurs when wounds are
o Doxycycline (100 mg orally twice a day) infected with C. botulinum that secretes the
o Ciprofloxacin (500 mg orally twice a day) toxin
23-21
• Inhalational botulism: Occurs when the C. The toxin is readily inactivated by sunlight
botulinum in aerosol form is inhaled. There (1 to 3 hours) or heat (80°C for 30 minutes,
is no natural occurrence of this type and is 100°C for several minutes) and surfaces may be
feasible to be used as a weapon by a terrorist decontaminated with a 1% bleach solution.
group or another county Clothing and skin should be washed thoroughly
with soap and water.
Incubation Period
RICIN
Neurological symptoms usually appear
Ricin is a potent toxin that has potential to
within 12 to 36 hours. It may take several days
be used as an agent of biological warfare and as
to develop if exposed to a low dose. Time to
a weapon of mass destruction (WMD). It is
onset is does dependent.
derived from the beans of the castor plant
(Ricinus communis) and can be made from the
Signs and Symptoms
waste material left over from processing castor
beans. The toxin blocks protein synthesis at the
The classic symptoms of botulism include
cellular level. The loss of protein synthesis
cranial nerve palsies (double vision, blurred
leads to irreversible cell death and tissue
vision, drooping eyelids, slurred speech),
damage. As a biological threat, it is considered
dysphagia, dry mouth and throat, and muscle
relatively easy to produce and can be delivered
weakness. These are all symptoms of the muscle
by aerosolization, injection, or ingestion.
paralysis caused by the bacterial toxin. If
untreated, these symptoms may progress to
Form of disease and Infectious Route
cause paralysis of the arms, legs, trunk and
respiratory muscles. Laboratory confirmation
Route of exposure is inhaled aerosol,
can be obtained by a bioassay of the patient’s
ingestion, and parenteral (injected). Clinical
blood serum.
manifestations depend on the route of exposure
and amount of absorption. It can be in the form
Treatment
of powder, mist, pellet, or it can be dissolved in
water or weak acid. There is no person to person
Early administration of Trivalent antitoxin
transmission.
(which neutralizes against toxin types A, B, and
E) or Heptavalent antitoxin (for types
Incubation Period
ABCDEFG is held by the US Army).
Respiratory failure is managed with intubation
Symptoms will onset within a few hours by
and mechanical ventilation. Parenteral fluids
ingestion and within 18-24 hours by inhalation.
and supportive care may be required.
If a lethal dose is experienced, time to death is a
matter of a few days.
Prophylaxis
Signs and Symptoms
A Pentavalent (ABCDE) toxoid is
distributed by the CDC to immunize laboratory
workers and protect troops against attack. • Ingestion: Mild exposure can lead to
nausea, vomiting, diarrhea, and abdominal
Isolation and Decontamination pain. Severe poisoning can result in GI tract
symptoms progressing (4-36 hours) to renal
Isolation is not required for botulism and liver failure, and finally death
patients. Use standard precautions when treating
patients and good hand washing after handing
soiled material.
23-22
• Inhalational: Illness within 8 hours If smallpox was intentionally released it
including cough, shortness of breath, fever, would spread rapidly through aerosols or
respiratory distress. This will progress to mucous membrane transmission. The virus has
pulmonary edema, airway necrosis, and been successfully weaponized in long range
death missiles by the former Soviet Union which is
now Russia and various other eastern-block
• Injection: Initial (<6 hours) weakness and countries. There is some question about the
myalgias (muscle pain), progressing (24-36 control of Russian virus stocks.
hours) to vomiting, hypotension, multi-
organ failure, and death Forms and Infectious Route
23-23
A characteristic rash, most prominent on the Isolation and Decontamination
face, arms, and legs, follows 2 to 3 days after the
first symptoms. The rash starts with macules Patients should be considered contagious
and quickly progress to papules (Fig. 23-13). from the onset of the rash until all scabs
After a few days, the lesions become pustular separate. They should be isolated using airborne
vesicles and begin to crust early in the second and droplet precautions during this period. The
week. Scabs develop and then separate and fall aerosolized virus may persist for 24 hours under
off after about 3 weeks. optimal conditions. Extra care must be taken
with infected clothing and bedding as well as
infected scabs and bodily fluids. Contaminated
materials should be bagged and incinerated or
autoclaved. Decontamination can be
accomplished by using standard hospital-grade
disinfectants such as quaternary-ammonia
compounds as these are effective in killing the
virus. They should be used on surfaces to
disinfect hospitalized patients’ rooms or other
contaminated surfaces. A 5-10% bleach solution
with at 10 minute contact time is also
recommended.
HEMORRHAGIC FEVERS
Prophylaxis
23-24
Forms of Disease and Infectious Route Signs and Symptoms
There are four families of VHF: VHF are illnesses that are characterized by
fever and bleeding. Specific signs and symptoms
vary by the type of VHF, but initial signs and
Arenaviruses: Family of viruses whose
symptoms often include marked fever, fatigue,
members are generally associated with rodent-
dizziness, muscle aches, loss of strength, and
transmitted disease in humans via rodent urine
exhaustion. Patients with severe cases of VHF
and excrement. There has also been
often show signs of bleeding under the skin, in
documented person-to-person transmission with
internal organs, or from body orifices like the
close contact in a health care setting. Each virus
mouth, eyes, or ears. However, they may bleed
usually is associated with a particular rodent
from many sites around the body; patients rarely
host species in which it is maintained.
die because of blood loss. Severely ill patient
Arenavirus infections are relatively common in
cases may also show shock, nervous system
humans in some areas of the world and can
malfunction, coma, delirium, and seizures.
cause severe illnesses.
Some types of VHF are associated with renal
Filoviruses: Family of viruses called (kidney) failure. Laboratory diagnosis is
Filoviridae can cause severe hemorrhagic fever required.
in humans and nonhuman primates. So far, only
two members of this virus family have been Treatment
identified: Marburg virus and Ebola virus. Four
species of Ebola virus have been identified: Patients receive supportive therapy, but
Ivory Coast, Sudan, Zaire, and Reston. Ebola- generally speaking, there is no other treatment or
Reston is the only known filovirus that does not established cure for VHFs. Ribavirin, an anti-
cause severe disease in humans. This group of viral drug, has been effective in treating some
viruses is transmitted by persons-to-person individuals with Lassa fever or hemorrhagic
contact. fever with renal syndrome. Treatment with
Bunyaviruses: This group of viruses is convalescent-phase plasma has been used with
vector-borne and transmission occurs via an success in some patients with Argentine
arthropod vector (mosquitos, tick, or sandfly), hemorrhagic fever.
with the exception of Hantaviruses.
Hantaviruses are transmitted through contact Prophylaxis
with deer mice feces. This group includes
Crimean Congo Hemorrhagic Fever, Rift Valley The only approved VHF vaccination is for
fever, and Hantaan. Yellow Fever.
23-25
RADIOLOGICAL WARFARE35 A RDD is any device that causes the
purposeful dissemination of radioactive material
across an area without a nuclear detonation.
LEARNING OBJECTIVE:
Such a weapon can be easily developed and used
by a person with conventional explosives and
Identify medical conditions that occur after due
access to radioactive material (radionuclides;
to radiation exposure and provide appropriate
radioactive isotopes). A radioactive source is
medical treatment.
blown up using conventional explosives and
radioactive material is scattered across the
The principles for medical treatment of targeted area as debris. The material dispersed
casualties, as developed from previous can originate from any location that uses
experiences in conventional warfare, are radioactive sources, such as a nuclear waste
applicable in the treatment of casualties processor, a nuclear power plant, a university
produced by radiological warfare. With the research facility, a medical radiotherapy clinic,
exception of ionizing radiation effects, the type or an industrial complex.
of injuries produced in nuclear warfare are
similar to those of conventional warfare. The use of a RDD type of weapon is likely
Standardized techniques of treatment must be to cause more of a psychological impact than
adopted for all types of casualties so the greatest that of radiation injuries. The resulting blast
number of patients can receive maximum would cause conventional casualties to become
medical care in the shortest period of time with contaminated with radionuclides and would
the greatest economy of medical personnel and complicate medical evacuation within a
equipment. contaminated area.
23-26
TYPES OF RADIATION Beta
23-27
UNITS OF RADIATION Equal doses of different types of radiation
cause different amounts of damage to living
The radiation absorbed dose (rad) is used to tissue. For example, 1 Gy of alpha radiation
measure a quantity of absorbed dose of causes about 20 times as much damage as 1 Gy
radiation. It relates to the amount of energy of x-rays. The energy from x-rays are dispersed
absorbed in material. This does not describe the through the human body, were as the energy
biological effects of different radiation. The from an alpha particle is highly concentrated and
International System of Units (SI) is replacing will kill cells in the immediate vicinity of the
common American terminology; the new particle. Therefore the equivalent dose was
absorbed dose unit for radiation is the gray (Gy). defined to give an approximate measure of the
The unit for dose, gray, is used for all forms of biological effect of radiation. For comparison,
ionizing radiation (Table 23-4). Dose is the total the 'background' dose of natural radiation
amount of energy absorbed per gram of tissue. received by a US citizen is around 3 mSv (300
The exposure could be single or multiple and mrem) per year. A lethal full-body dose of
either short or long in duration. radiation for a human is around 4 - 5 Sv (400 -
500 rem) instantaneously.
SI Unit Old Unit
MEASURMENT DEVICES
1 Gy 1 joule/kg
1 Gy 100 Rad There are special devices used to measure
10 milliGray (mGy) 1 Rad field radiation levels. Some devices are
currently available to conduct radiological
1 Sv 100 rems
10 milliSievert (mSv) 1 rem
surveys and measure radiation levels on
equipment and personnel. They are the
AN/VDR-2 and the AN/UDR-13 for field use
Table 23-4.—SI Conversion Chart and the AN/PDQ-1 for shipboard use. There are
other radiation detection systems available; these
Adapted from Medical Management of Radiological are a few examples of what is in current use.
Casualties 2nd ed.
23-28
Radiac Set AN/VDR-2 Radiac Set AN/PDQ 1
The AN/VDR 2 (Fig. 23-14) is used to The AN/PDQ-1 (Fig. 23-16) is a multi range
perform ground radiological surveys in vehicles Radiac device that detects beta and gamma
or in dismounted mode by individual personnel radiation. The AN/PDQ-1 uses a Geiger-
as a handheld instrument. The device provides a Mueller ionization chamber and has two ranges
quantitative measure of radiation to assist with for radiation levels, mR/hr and R/hr. The probe
the decontamination of personnel, equipment, measures gamma radiation and can also be used
and supplies. The device can be used with to detect beta radiation when the probe shield is
vehicle power or internal batteries. open. It is powered by two D cell batteries and
is used for personnel monitoring and surveys for
hot spots onboard a ship. The device can be
used to detect radiation levels on a patient
during decontamination. The AN/PDQ-1 uses a
Geiger-Mueller ionization chamber and has an
operating range of 0-1000 R/HR. The device
has two ranges for radiation levels, mR/hr and
R/hr. The probe measures gamma radiation and
Figure 23-14.—Radiac Set AN/VDR-2 can be used to detect beta radiation when the
probe shield is open.
Picture from Organizational Maintenance
Manual Radiac Set AN/VDR-2 (NSN 6665-01-
222-1425) (EIC: KYF); U.S. Army
TM 11-6665-251-20.
The more time spent in a contaminated Standard issue chemical protective masks
environment, the higher Gy dose. Limiting the afford excellent protection from inhalation and
time of exposure is essential if total avoidance is ingestion of radioactive material. Radon and
not possible. Rotating personnel entering an tritium gas will pass through the filters, but short
exposure risk area, planning actions to minimize exposures are not medically significant.
time in the area, and prompt decontamination Increasing oral fluids and maintaining sufficient
reduce the total time the individual is exposed, urine output will adequately treat tritium
thereby reducing the dose of radiation absorbed exposures. Vehicle fires produce dangerous
by the body. chemical fumes from burning metals and
plastics and deplete closed-space oxygen; a self-
contained breathing apparatus may be necessary
in such cases.
23-30
Protective Clothing EFFECTS ON PERSONNEL
23-31
Signs and Symptoms The chance of survival for people with ARS
decreases as the radiation dose increases, an
The first symptoms (Prodromal Phase) of inverse relationship. Most people who do not
ARS are typically nausea, vomiting, diarrhea, recover from ARS will die within several
and malaise. These symptoms will start within months of exposure. The cause of death in most
minutes to days after the exposure, will last for cases is the destruction of the person’s bone
minutes up to several days, and may come and marrow, which results in infections and internal
go. bleeding. For the survivors, the recovery process
may last from several weeks up to 2 years.
The second phase or (Latent Phase) results
in the person usually looking and feeling healthy Treatment
for a short time, after which will become sick
again (Latent Period). Time of onset will vary Evaluate ABCs, stabilize any life
between 0 – 15 days dependent upon the degree threatening injuries, and decontaminate. Provide
of ARS. supportive care: Antiemetic, fluids, antibiotics,
pain management, and a clean environment.
Patients may experience loss of appetite, Treat other wounds as necessary. Transfer
fatigue, fever, nausea, vomiting, diarrhea, and patient to a medical treatment facility for
possibly even seizures and coma. This seriously additional care when he/she is decontaminated.
ill stage may last from a few hours up to several
months. CHRONIC RADIATION SYNDROME
(CRS)
The third phase (Manifested Illness) time of
onset ranges from day one (Lethal) to over 2 Chronic Radiation Syndrome (CRS) is a
weeks (Mild). Symptoms are convulsions, medical condition caused by long term exposure
ataxia, tumor, lethargy, severe diarrhea, fever, to low dose radiation. It is highly unlikely to
and electrolyte disturbance for lethal ARS. affect military personnel in an operational
Symptoms for moderate to very severe ARS are setting. It would require prolonged deployments
severe leucopenia (decreased white blood cells), to heavily contaminated areas or long term
purpura (purple colored spots or patches), ingestion of highly contaminated food or water.
hemorrhage, pneumonia, and hair loss after 3 A person may develop this condition after
Gy. Mild ARS is demonstrated by moderate prolonged exposed to a near-ground weapon
leucopenia (decreased total number of white detonation, RDD, or major reactor accident that
blood cells in the circulating blood). creates contamination with high dose rates.
People with ARS typically have some skin Signs and Symptoms
damage. This damage can start to show within a
few hours after exposure and include swelling, Clinical symptoms are diffuse and may
itching, and redness of the skin (resembling a include sleep and/or appetite disturbances,
severe sunburn). Hair loss is common with generalized weakness and easy fatigability,
these patients. The skin may heal for a short increased excitability, loss of concentration,
time, followed by the return of swelling, itching, impaired memory, mood changes, vertigo,
and redness days or weeks later. Complete ataxia, paresthesias, headaches, epistaxis, chills,
healing of the skin may take from several weeks syncope episodes, bone pain, and hot flashes.
up to a few years depending on the radiation
dose received. Clinical findings may include localized bone
or muscle tenderness, mild hypotension,
tachycardia, intention tremor, ataxia, weakness,
hyperreflexia (occasionally hyporeflexia),
delayed menstrual cycles, and underdeveloped
secondary sexual characteristics.
23-32
Laboratory findings include mild to marked Treatment
shortage of all types of blood cells and abnormal
bone growth. The primary treatment is removal of the
radiation source. Removal of contaminated
Treatment clothing and the bare skin, to include the hair,
should be thoroughly washed with soap and
After the patient is removed from the water. Cool compresses and pain medication
radiation environment, clinical symptoms and may be used to control the pain. A topical
findings slowly resolve, and complete recovery moisturizing cream may provide some relief.
has occurred from the lower doses. The patient Transfer patient to a treatment facility when
should receive follow-up care at a treatment possible.
facility when possible.
PSYCHOLOGICAL EFFECTS
RADIATION DERMATITIS36, 37
Radiation illness symptoms in just a few
There are two types of Radiodermatitis, personnel can produce devastating psychological
Acute and Chronic. Acute Radiodermatitis effects on an entire unit that is uninformed about
usually occurs after heavy contamination of bare the physical hazards of radiation. This acute
skin with beta emitting material. This can result anxiety has the potential to become the dominant
from the use of a RDD. It rarely develops in source of stress within a unit.
situations where personnel are fully clothed.
Personnel are more likely to focus on
This condition is best prevented by washing radiation detection and thus increase the
off the contaminated material. Chronic potential of injury from conventional battlefield
Radiodermatitis is a result of long term exposure hazards.
to low levels of radiation (Table 23-6).
OTHER INJURIES
Radiation Dose Effect
6 – 20 sv Erythema only Apart from the ionizing radiation effects,
Acute 20 – 40 Skin breakdown in 2 most of the injuries suffered in a nuclear weapon
sv weeks explosion will not differ greatly from those
> 3000 sv Immediate skin caused by ordinary high explosives and
blistering
incendiary bombs. The types of injuries usually
Chronic >20 sv Dermatitis with
possible cancer risk seen are blast, shock wave, burns, and eye burns
(flash blindness).
23-33
A burn is a burn, regardless of whether it is Radiological decontamination is performed
caused by a nuclear explosion or by napalm, and in an identical manner to chemical
its management remains the same. This is also decontamination. The main difference is in
true of fractures, lacerations, mechanical timing. Chemical decontamination is an
injuries, and shock. In none of these is the emergency. Radiological decontamination is not.
treatment dictated by the cause. For most of the
conventional injuries, standard first-aid Care must be taken to not irritate the skin. If
procedures should be followed. the skin becomes erythematous, some
radionuclides can be absorbed directly through
the skin. Surgical irrigation solutions, normal
NOTE:
saline, should be used in liberal amounts to clean
The following words of caution should be
wounds, the abdomen, and the chest. All such
considered when treating wounds and burns:
solutions should be removed by suction instead
Dressings for wounds and burns should follow a of sponging and wiping. Only copious amounts
of water, normal saline, or eye solutions are
closed-dressed principle, with application of an
recommended for the eye.
adequate sterile dressing using aseptic
techniques.
CERTIFICATION OF
Make no attempt to close the wound, regardless DECONTAMINATION
of its size, unless authorized by a physician.
Careful examination of the body with a
certified radiac, such as the AN/VDR–2, will
If signs of infection and fever develop, give
confirm adequate decontamination. Particular
antibiotics.
attention must be paid to the hands, fingers, face,
hair, and feet. Once safe levels are achieved, the
DECONTAMINATION patient can be certified clean.
23-34
CHAPTER 24
24-1
DISEASES OF THE TISSUES OF THE Treatment
TEETH
• Perform emergency treatment
LEARNING OBJECTIVE: guidelines
• Gently remove all debris from the cavity
Describe the signs, symptoms, and the
with a spoon excavator
emergency treatment for diseases of the tooth
tissues. • Flush the cavity with warm distilled
water, if unavailable use clean tap water
An important part of the HM’s job is the • Isolate the tooth with cotton rolls or
ability to recognize oral diseases and their signs gauze
and symptoms.
• Carefully dry the cavity with cotton
DENTAL CARIES pellets
• Mix a temporary filling (zinc oxide
Dental caries, also known as tooth decay or eugenol, IRM® “Intermediate
cavities, occurs when bacterial processes Restorative Material,” etc.)
damage hard tooth structures (enamel, dentin
and cementum, discussed in Chapter 7). Initially, • Gently fill the cavity with the temporary
it may appear as a small chalky white spot which filling material
may eventually develop into a large cavitation. • Check the occlusion (previously
If the lesion progresses, it will continue into the discussed in Chapter 7). Make sure the
dentin and eventually involve the pulp. temporary restoration does not touch the
opposing tooth
Symptoms
• Instruct the patient to return to the DTF
Once the decay passes through the enamel (dental treatment facility) for definitive
and into the dentinal tubules, it will expose the treatment on the next work day
tooth nerve resulting in pain.
• Pain may worsen with exposure to heat, ACUTE PULPITIS
cold (more often), or sweet foods and
drinks Acute pulpitis is an inflammation of the
pulp usually due to injury from dental caries or
• Pain from an affected tooth can manifest trauma. It is the most frequent cause of severe
in a healthy, noninvolved tooth; this is tooth pain. Pressure from inflammation can
called referred pain cause mild to extreme pain depending upon the
severity of the inflammation.
Signs
Symptoms
• Chalky white spot on the enamel
• Spontaneous, continuous, or intermittent
• Roughness on the surface of the tooth pain that lingers
• Dark, stained cavity • Piercing and pulsating pain in the
• Cavity filled with food or a spongy mass affected area
of decaying dentin • Increased pain when lying down
24-2
Signs
Treatment
24-3
Signs • If drainage still does not occur, apply an
ice pack to the affected area. This may
reduce the patient’s discomfort until the
• Severe pain reaction is experienced
dentist can provide emergency treatment
when light pressure is applied to the
affected tooth • When drainage is established, give the
patient instructions about home care and
• A gumboil
notify the dental officer to see if a
• Facial swelling (general or localized) prescription for antibiotics can be called
into the pharmacy
• Increased tooth mobility
• Instruct the patient to return to the DTF
• An elevated temperature
for definitive treatment as soon as
• Enlarged lymph nodes locally possible
24-4
Symptoms NECROTIZING ULCERATIVE
GINGIVITIS
• Sore or swollen gums
• Bright-red, or purple gums Necrotizing ulcerative gingivitis (NUG)
(Fig. 24-3) is a severe infection of the gingival
• Severe oral odor tissue, commonly referred to as trenchmouth.
• Gums that are tender, or painful to the The condition is caused by an overpopulation of
touch established oral bacteria due to a number of
interacting factors such as poor hygiene, poor
• Gums that bleed easily, even with gentle diet, smoking, stress, lifestyle, and other
brushing, and especially when flossing infections.
Signs
24-5
Signs PERIODONTITIS
24-6
Signs The signs and symptoms for periodontal
abscesses are similar to those for periapical
abscesses.
• Heavy plaque and calculus deposits
• Gingival inflammation, bleeding, or dis- Treatment
coloration (bluish-red)
• Localized or generalized gingival • Perform emergency treatment
bleeding guidelines
• Ulcerated or cratered papilla • Gently probing the affected area with a
scaler (Fig. 24-6) or an explorer to
• Tooth mobility increased establish drainage. Probe the space
between the tooth surface and the
Treatment gingival tissue
PERIODONTAL ABSCESS
24-7
PERICORONITIS Signs
Treatment
Symptoms
24-8
OTHER ORAL DISEASES Treatment
Signs
24-9
Treatment Treatment
Signs
24-10
Symptoms (Type I: Enamel Fracture) Symptoms (Type II: Enamel/Dentin
(Fig. 24-9) Fracture) (Fig. 24-10)
Signs Signs
• A slight chip or fracture of the tooth • Extensive fracture involving the enamel
enamel layer only, or with possible and dentin layers
minimal dentin involvement
• No pulp exposure
• No exposure of the dentin or pulp
Treatment
Treatment
Except in rare cases, the dental officer will
provide emergency treatment. The dental
• Perform the emergency treatment
officer may authorize the assistant to cover the
guidelines
exposed dentin with a temporary type paste or
• Smooth sharp edges of the chipped area place a temporary crown until definitive
with sandpaper strips or disk to treatment is available. Begin with performing
eliminate irritation of the tongue and the emergency treatment guidelines and then
lips going into the remaining treatment steps.
• Carefully dry the chipped area with a
cotton roll or pellets
• Apply small coats of cavity varnish over
the chipped area with cotton forceps and
cotton pellets
• Instruct the patient to eat a bland diet
and avoid extremely hot and cold foods
or liquids and sticky foods
24-11
The procedures for covering a Type II • Remove any excess material from and
fracture with zinc oxide and eugenol (i.e. around the crown with gauze and cotton
IRM®) paste or other temporary paste are as pellets
follows:
• Instruct the patient to eat a bland diet
• Isolate area with cotton rolls and avoid extremely hot and cold foods
or liquids and sticky foods
• Carefully dry the fractured tooth off
with cotton rolls or 2 x 2 gauze (Do not
use direct air with the 3-way syringe) Symptoms (Type III: Enamel/Dentin
Fracture with Pulp Exposure) (Fig. 24-11)
• Coat all exposed dentin with a zinc
oxide and eugenol paste or other
temporary material, including light • Severe, throbbing pain
cured glass ionomer cement
• Very rough or sharp edges
• Advise the patient that this is a
• Severe pain from heat, cold, or air
temporary procedure to relieve pain and
sensitivity. The coat of zinc oxide and • Inability to chew food
eugenol may come off the fracture
• Instruct patient to eat a bland diet and
avoid extremely hot and cold foods,
liquids, or sticky foods, and not to chew
on the fractured tooth
24-12
Treatment • Place the splint so it covers the affected
tooth and the teeth immediately adjacent
In almost all cases of a fracture this severe, to it (Fig. 24-12)
the dental officer will treat the patient. Only in
rare cases would the HM treat the patient. The • Ensure that the mixture is placed well up
following is a treatment plan that the dental on the lingual and facial aspects of the
officer might authorize to treat a Type III gingival tissue
fracture. • Gently compress the splint between a
• Perform the emergency treatment finger and thumb to lock it into the
guidelines interproximal spaces
• Place a crown form over the affected • Trim the splint from the incisal edges of
tooth. Refer back to this procedure the teeth
under the treatment for type II fractures • Check the occlusion to see if the splint
• At times, it may be impossible to place a is interfering with the patient’s bite
crown form over a fractured tooth. The • Advise the patient to let the splint
pressure of the crown form against the harden for several hours before
pulp tissue may cause the patient pain or attempting to eat
there may not be enough tooth structure
left for retention of the crown • Tell the patient to return to dental sick
call ASAP for more definitive care
• If this occurs, a splint rather than a
crown form is placed on the tooth as
shown in Figure 24-12 Symptoms (Type IV: Root Fracture)
(Fig. 24-13)
24-13
Signs
Treatment
FRACTURES OF THE MANDIBLE AND
Because of the severity, almost all cases of MAXILLA
type IV fractures will be treated by the dental
officer. Only in very rare cases, will the HM The dentist will treat this type of injury.
provide treatment. The HM’s responsibility is to prevent further
injury and to lessen the pain while waiting for
• Perform emergency treatment the dentist. A person who has a fractured jaw
guidelines may suffer serious interference with breathing.
One of the most important phases of
• Place a splint in the same way as for the
emergency care is to clear the upper
Type III fracture
respiratory passage of any obstructions.
Fractures are usually the result of a high-
TRAUMATICALLY EXTRACTED TEETH velocity accident (e.g., the face striking the
dashboard of a car). Of all the facial bones, the
If a tooth has been traumatically extracted nasal bones, followed by the mandible, are the
from the socket (Fig. 24-14), notify the dentist most frequently injured (Fig. 24-15).
as soon as possible. The dental officer may
instruct the HM to replace the tooth back in
the socket after rinsing it with sterile saline.
Time is of the essence for the replantation to be
a success. Perform emergency treatment
guidelines and control hemorrhaging until the
dentist arrives.
24-14
Less common is a fracture of the maxilla. It
can be distinguished from a mandibular fracture
because the fractured maxilla will cause severe
malocclusion consisting of an open bite. The
face will also look elongated. Both the
mandible and maxilla fractures are treated in
the same manner until a dentist arrives.
Symptoms
24-15
CHAPTER 25
DECEDENT AFFAIRS
INTRODUCTION For this reason, Hospital Corpsmen (HMs)
should have a working knowledge of decedent
The Navy’s Decedent Affairs Program affairs procedures, which are outlined in
consists of search, recovery, identification, care, OPNAVNST 5360.1 series, Decedent Affairs
and disposition of the remains of deceased Manual.
personnel for whom the Department of the Navy is
responsible. The Decedent Affairs Program is PROGRAMS
considered a highly visible and extremely
sensitive program. Arrangements for the burial
LEARNING OBJECTIVE:
of the deceased should be conducted in an
expedient but dignified manner, and survivors of
Identify the purpose of the Current Death
the deceased should be given the greatest possible
Program, Graves Registration Program,
amount of support and assistance.
Concurrent Return Program, Return of
Remains Program, and the Casualty Assistance
ASSIGNMENT OF Calls Program.
RESPONSIBILITIES
To carry out the various responsibilities of
LEARNING OBJECTIVE: the Decedent Affairs Program, five programs
have been established:
Identify military activities that are responsible for
the management of the Navy and Marine Corps • Current Death Program
Decedent Affairs Program. • Graves Registration Program
• Concurrent Return Program
The overall manager of the Navy and Marine
Corps Decedent Affairs Program is Navy • Return of Remains Program
Casualty, Navy Mortuary Affairs, located in
Millington, TN. At the local level, decedent • Casualty Assistance Calls Program
affairs officers assigned to various naval
hospitals and other naval activities are CURRENT DEATH PROGRAM
responsible for inspecting remains, briefing
escorts, making travel arrangements, selecting The Current Death Program provides
locations, and coordinating the burial at sea of professional mortuary services, supplies, and
casketed and cremated remains via Navy related services incident to the care and
vessels. disposition of remains of persons eligible for
these services. Under this program, remains are
Naval hospitals manage deaths that occur shipped to a place designated by the primary
within the hospital and in their local area of next of kin also known as the Person Authorized
responsibility. At small independent Direct Disposition (PADD), such as a spouse or
operational units and on board naval vessels, the parents, for permanent disposition. The PADD
responsibility for managing the Decedent serves as the person who directs all activities
Affairs Program falls on the Commanding having to do with the deceased. The decedent’s
Officer or Officer-in-Charge, Medical Service personal effects will be shipped to the legal
Corps Officer, and the senior corpsman under the recipient.
guidance of Navy Mortuary Affairs.
25-1
The Current Death Program is normally The Return of Remains Program is activated
operational on a worldwide basis during only upon the enactment of special legislation.
peacetime, but may also be used during major This special legislation may authorize the
conflicts. establishment of one or more permanent
American cemeteries in the overseas area and
GRAVES REGISTRATION PROGRAM may give PADD the option of having the
remains buried therein or shipped to another
The Graves Registration Program (GR or place of their choosing. When the Return of
GRREG) provides for the search, recovery, Remains Program becomes activated, the Chief,
evacuation to a temporary cemetery or a Bureau of Medicine and Surgery (BUMED), is
mortuary, initial identification, disposition of responsible for notifying field activities of its
personal effects found, and burial in the activation.
temporary cemeteries. This program is only
operational when authorized by the responsible CASUALTY ASSISTANCE CALLS
commander during major military operations. PROGRAM
When necessary, the GR program includes the
establishment and maintenance of temporary The Casualty Assistance Calls Program
burial sites. Detailed guidance on graves (CACP) is administered by the Chief of Naval
registration procedures are contained in the Operations Personnel Command, and the
Mortuary Affairs Joint Operations 4-06, Commandant of the Marine Corps (CMC).
05JUN06, and Navy and Marine Corps Although integrally related, the CACP is not
publication NAVMED P-5016/NAVMC part of the Decedent Affairs Program. The
2509A, Handling of Deceased Personnel in CACP details a Casualty Assistance Calls
Theaters of Operation. Officer (CACO), a commissioned officer or
senior enlisted personnel, to personally contact
CONCURRENT RETURN PROGRAM the PADD. The CACO helps the PADD and
SNOK (secondary next of kin) with problems
The Concurrent Return Program combines surrounding the death and provides information
the Current Death Program and Graves regarding:
Registration Program. The program provides
for the search, recovery, and evacuation of • Disposition of remains, to include funeral
remains to a processing point; identification planning
and preparation of remains in a mortuary; and • Death gratuity and unpaid pay and
shipment, for permanent disposition to a final allowances
destination designated by the PADD. The
Concurrent Return Program normally • Shipment of service member’s personal
becomes operational when large numbers of effects, household goods, POV, etc.
military personnel are committed to a • Claim documents to aid in the movement
strategic area. Remains buried in temporary and/or settlement of the decedent’s estate
cemeteries (under the GR program or in (wills, bank accounts, property, savings
emergencies) will normally be disinterred and bonds, commercial insurance, etc.)
evacuated under the Concurrent Return Program
i f conditions and capabilities permit. • Servicemen’s Group Life Insurance
(SGLI), and travel of all eligible dependents
RETURN OF REMAINS PROGRAM to grave site funeral services and final move
to permanent residence
The Return of Remains Program provides
for permanent disposition of remains of persons
buried in temporary cemeteries who could not
be evacuated under the Concurrent Return
Program.
25-2
The Navy and Marine Corps Casualty PERSONNEL CASUALTY REPORT
Assistance Calls Programs are operated
differently. The individual service instructions A personnel casualty report must be
noted below should be consulted for specifics. completed for the following category
incidents:
• NAVPERS 15560, Naval Military
Personnel Manual (MILPERSMAN) • Active Duty Navy
• BUPERSINST 1770.1 series, The Navy • Retired Navy personnel while inpatient at
Casualty Assistance Calls Program Military Treatment Facilities
(CACP) Manual
• Certain former service members, while
• MCO P3040.4 series, Marine Corps inpatient at Military Treatment Facilities
Casualty Procedures Manual
• All active duty and reserve military
(MARCORCASPROCMAN)
dependents
• All active duty members of other Armed
ELIGIBILITY FOR DECEDENT
Forces
AFFAIRS
• Civilians, to include contract employees,
LEARNING OBJECTIVE: serving with or attached to Navy commands
• Others deaths occurring aboard Military
Identify individuals who are eligible for Sealift Command vessels
decedent affairs benefits.
When a member becomes a casualty, the
service member’s Commanding Officer (CO)
Navy and Marine Corps members who die must submit a personnel casualty report. If a
while serving on active duty or active and service member becomes a casualty while away
inactive duties for training are entitled to from his or her command, the command or
Decedent Affairs Program benefits. Generally, activity that learns of the casualty occurring
the following persons under the jurisdiction of should submit the personnel casualty report.
the Department of the Navy are entitled to The member’s command should supplement
some decedent affair benefits: dependents, the personnel casualty report that was
retirees, and c i v i l i a n employees. Refer to previously submitted by another command. If
OPNAVINST 5360.1 series, Decedent Affairs a service member has detached and was en
Manual and U.S. Code, Title 10, Subtitle A, route to the next command, the gaining
Part II, Chapter 75, Subchapter II, 1481, for command is responsible for generating the
detailed guidance. personnel casualty report.
25-3
The appropriate Navy Regional Casualty CONFIRMATION OF THE CASUALTY
Office will be notified concerning a casualty or
death in the coverage area. The Casualty In all cases, notification shall be made in
Assistance Calls Officer/Funeral Honors person. Due to modern technology, casualty
Support (CAC/FHS) Program oversees family reports are forwarded through the region
notification in the area in which the PADD headquarters locations. An initial notification is
and SNOK reside, or the appropriate overseas made by the CACO who schedules a follow-up
CAC/FHS program coordinators. notification to take place within 24 hours. The
purpose of the follow-up notification is to
NOTIFICATION OF NEXT OF KIN complete the paperwork associated with a death.
CONDOLENCE LETTER
LEARNING OBJECTIVE:
COs are required to write a letter to the
Explain notification of the next of kin
appropriate NOK within 48 hours of a
procedures.
casualty. The letter, in addition to expressions
of condolence, should contain appropriate
In cases of death, PADD are personally details of how the casualty died unless the cause
notified by a uniformed Navy or Marine Corps is under investigation (i.e. suicide). No details
representative as appropriate. Personal should be included that are likely to distress
notification of the PADD w i l l normally be made the NOK. A copy of the letter is sent to
between 0500 and 2400, except under unusual NAVPERSCOM and Office of the Judge
circumstances (e.g., the news media is expected Advocate General (OJAG) Investigations
to make a press release; or the member has been Division. Example formats for condolence
hospitalized in serious or very serious condition letters can be found in the Decedent Affairs
within CONUS, and the NOK is already aware Manual.
of the prognosis).
AUTOPSY
When a death occurs within CONUS, it is
the responsibility of the member’s CO to make
sure that personal notification is made. Outside LEARNING OBJECTIVE:
CONUS, individual commands shall follow
standard procedures when reporting a casualty. Identify which circumstances require an
Navy Personnel Command (NAVPERSCOM) autopsy to be performed.
duty watch personnel are available 24 hours a
day to receive message traffic, phone calls, and An autopsy will be performed on the
email traffic from OCONUS commands when a remains of active duty or active duty for
death occurs. NAVPERSCOM will forward the training personnel. It will be performed if the
personnel casualty report to the designated death is considered accidental, intentional,
CACP regional headquarters, where CACO suicide, homicide, or absent care of a
officers will proceed with notification physician. Individuals that are involved in
assignment, and support. CACOs are assigned motorcycle accidents, automobile accidents, or
for a period of 90 days to 9 months depending under the care of a physician, autopsies are at
on the needs of the families. the discretion of the local medical examiner; it
is not a requirement. An autopsy may be
requested when the CO deems it necessary.
The CO’s request may be self-initiated or
based upon the recommendation of an
investigating officer, other fact-finding body, or
a medical officer.
25-4
An autopsy may be necessary to determine PRIVATE AUTOPSY
the true cause of death, to get information for
completing military records, or to protect the If the federal government or local
welfare of the military community. jurisdiction has determined that an autopsy is not
necessary, the PADD may elect a private
AIRCREW AUTOPSY autopsy. Families must be made aware that they
are financially responsible for the movement of
The Manual of the Medical Department the remains and the pathologist’s autopsy fees.
(MANMED), NAVMED P-117, states that A private autopsy costs thousands of dollars.
when an aircrew member dies while serving as Families can seek professional assistance
an aircrew member on a military aircraft, the through the CACO prior to pursuing a private
medical officer will recommend to the CO that autopsy.
an autopsy be performed to determine the cause
of death. The cause of death in these cases is SEARCH, RECOVERY, AND
interpreted to mean any correlation between IDENTIFICATION
pathological evidence and the accident cause
factor.
LEARNING OBJECTIVE:
REQUESTING PERMISSION FOR
Identify procedures used to search, recover,
AUTOPSY
and identify remains.
When an autopsy is desired but not
mandatory, the following sentence will be The search, recovery, and identification of
incorporated in the casualty notification remains shall be accomplished as soon as
message that requests disposition instructions possible and must be coordinated with an
from the PADD: administrative fact-finding body. The need for
these operations results from acts of violence,
"In the interest of medical science and to such as an aircraft accident, fire, explosion, or
confirm medical diagnosis, it is requested that natural disaster. The JAGINST 5800.7 series,
your telegram include whether or not Manual of the Judge Advocate General
permission is granted to accomplish m o rtem ( J A G M A N ) , requires the convening of an
examination." administrative fact-finding body when
in cid en t s of this nature occur. This
NONMILITARY AND RETIRED responsibility is usually delegated to a naval
PERSONNEL AUTOPSY activity with necessary capabilities at or near the
scene of disaster. In establishing identification of
When an autopsy is deemed necessary for remains, search and recovery operations are part
retired personnel or non-military persons who of the fact-find ing functions w i t h technical
die at a naval treatment facility or on a Navy assistance furnished by appropriate medical
installation, written authorization from the authorities.
NOK must be obtained before performing the
autopsy. The request for permission to perform SEARCH AND RECOVERY
an autopsy should be incorporated into the
casualty notification message as noted above. Every effort should be made to recover all
remains. D isasters such as aircraft accidents,
fires, and explosions that result in the death of
naval members and members of other services
must be reported to the Bureau of Medicine
and Surgery (BUMED) and Navy Mortuary
Affairs by priority message.
25-5
This assures immediate interdepartmental Disposition of unidentified remains will be
cooperation and the early dispatch of directed by Navy Mortuary Affairs for Navy
necessary supplies, equipment, medical and personnel or CMC for Marine Corps personnel.
dental records, and technical personnel. The After thorough study of all evidence, final
priority message should include the following conclusions made by Navy Mortuary Affairs
information: will result in one of the following
determinations:
• Name, grade or rate, and social security
number of all personnel believed dead or • Identification of the remains
missing
• Unidentified, but believed to be a specific
• Names of those personnel already identified individual
and method of identification
• Unidentified, unknown
• Names of those personnel tentatively
• Group remains, known individuals
already positively identified, and whether
remains are anatomically intact • Group remains, unknown individuals
• Type and quantity of mortuary supplies,
transfer cases, chemicals, and other When an autopsy of remains is required or
equipment required requested, the identification specialist should
schedule the autopsy to be performed during
• Whether technical help is desired
the identification process or immediately
Do not release information to the NOK, following. This will preclude any delays in
family, or news media unless specific releasing the body for burial and make sure
instructions are received from BUMED and that methods of identification are included in
the Navy Casualty Office to do so. the autopsy report.
25-6
For those cases that are pending ANNUAL CONTRACTS
identification, the personnel casualty report
status shall categorize the service member as Annual contracts are awarded to funeral
Duty Status Whereabouts Unknown directors serving the local area of activities
(DUSTWUN). With advances in science and anticipating three or more deaths per year.
technology, active duty service members that are
killed in theater are identified in short periods of ONE-TIME CONTRACTS
time. There will be exceptions to this case.
One-time contracts (individual purchase
Families will be provided the opportunity to orders) are created through Navy Casualty
receive partially identified remains, primarily for Office, Chief of Naval Operations (OPNAV) to a
funeral purposes. Families that grieve need funeral home when an annual contract is not in
something they can see, feel, and touch. This is a effect.
healthy part of the funeral process and basic
concepts of death and dying. Remains PRIVATE ARRANGEMENTS
identified at a later date (days/weeks/months)
will be delicately processed with services Private arrangements are made by the
coordinated through the CACO as directed by PADD. The PADD should be advised of
the family. The CACO will be contacted by the services, supplies, and reimbursement funding
Navy Casualty Office, Navy Mortuary Affairs available through Navy Mortuary Affairs or the
for the coordination and return of the partial local Naval Hospital Decedent Affairs Office.
remains. All elections (choices) will be Private arrangements are coordinated
determined by the PADD. between the PADD, CACO, Navy Mortuary
Affairs, and the funeral home. When
The Armed Forces Institute of Pathology choosing this option the Statement of
(AFIP) and or local medical examiners may be Disposition, CJMAB 5360/1, is thoroughly
requested to provide an identification specialist briefed by the CACO to the PADD.
to make a complete review to ensure that all Selection of Option 5A or 5B authorizes the
possible techniques, methods, and procedures release of funds to reimburse funeral
have been used to provide a positive providers engaged in the responsibility of
identification. removing, preparing, embalming, dressing,
casketing, and preparing for the funeral.
PROCURING MORTUARY SERVICES Financial limits are updated biannually,
where the services set the allowances. All
mortuary billing questions shall be
LEARNING OBJECTIVE:
forwarded to Navy Casualty Office, Navy
Mortuary Affairs.
Identify mortuary services procurement
methods and recognize both primary and
AUTHORIZED SERVICES
secondary burial expenses.
Annual contracts and one-time contracts
Mortuary services for the remains of cover primary funeral expenses but do not
individuals eligible for Decedent Affairs include secondary expenses. NOK should be
Program benefits outside CONUS are specified tactfully encouraged to allow the Navy to make
in local instructions. Mortuary services within all primary-care arrangements, since greater
CONUS are provided by naval activities through benefits can be furnished. For more information
annual contracts, individual purchase orders, concerning procedures and authorized items,
or by private arrangements. consult OPNAVINST 5360.1 series.
25-7
Primary Expenses Transportation Expenses
25-8
PREPARATION AND PROCESSING a government mortuary or a commercial facility
REMAINS is available or arrange for emergency dispatch of
a qualified embalmer from an overseas
government mortuary to the place of death.
LEARNING OBJECTIVE:
CERTIFICATE OF DEATH (OVERSEAS)
Identify procedures for preparing and
processing remains.
When remains are transferred from an
overseas activity to a CONUS point of entry,
It is imperative that preservative treatment three signed copies of DD Form 2064,
be initiated as soon as possible after death. The Certificate of Death (Overseas), must
naval authority with decedent affairs accompany the remains. Failure to include the
responsibility should maintain close DD Form 2064 may cause delays in providing
coordination with appropriate military or further transfer within CONUS. Additionally,
civilian authorities to ensure the prompt release at least two DD Form 565, Statement of
and delivery of remains to the mortuary Recognition, should be included.
facility. Remains must be prepared under
approved high standards of the mortuary BURIAL CLOTHING
profession and returned to the final destination
i n their most normal and l i f e l i k e appearance. The service dress blue uniform or (if this
uniform is not available for deceased personnel)
INITIAL PREPARATION the appropriate service dress uniform, with
authorized insignia, devices, badges, decorations,
Remains may be refrigerated for short underwear, and hose are the only approved
periods pending arrival of a transportation items for burial, unless other items are
vessel or arrival of the government embalmer. specifically requested by the PADD. Shoes and
To minimize cellular deterioration, remains headgear are not authorized and thus
should be refrigerated above the freezing point at unfunded. It is recommended to obtain these
36° to 40°F (2.2° to 4.4°C). items from the deceased’s personal effects. If
unavailable, contact Navy Mortuary Affairs to
OVERSEAS FACILITIES obtain through Uniform Support Services, Navy
Exchange, Navy Retail Clothing Store, or
Government mortuary facilities are located Marine Corps Exchange. When suitable items
in various overseas areas and have the are not available for personnel who die outside
responsibility to furnish mortuary services for the 48 contiguous United States, the U.S. port
all eligible categories of military and civilian of entry should be contacted and given
personnel. The geographical areas of estimated uniform sizes, as soon as possible, so
r e s p o n s i b i l i t y are o u t l i n e d i n the burial clothing can be obtained.
CINCPACINST 5360.1 series, Geographic
Responsibilities for Mortuary Operations. Also When requested by the PADD, remains may
consu lt OPNAVINST 5360.1 series for be attired i n a white uniform or civilian
locations of overseas mortuaries. clothing consisting of appropriate outer
clothing, underwear, hose, and, i f specifically
When death occurs in overseas areas not requested, shoes. Items of clothing in the
served by one of the designated facilities listed, individual’s possession at the time of death
request assistance from the senior naval may be used i f available and in satisfactory
command. In some areas, Department of State condition.
sources may have the capability to render
advice or assistance. The senior naval
command may also be able to arrange airlift of
remains from the place of death to a point where
25-9
PLACEMENT OF REMAINS IN CASKET CREMATION
OR TRANSFER CASE
LEARNING OBJECTIVE:
Normally, remains are placed in a specified
casket or transfer case in a manner that will
Identify guidelines for requesting cremation of
create an appearance of rest and composure.
remains.
Precautions should be taken to ensure
maintenance of position during transit. The
remains will be returned in a transfer case and When requested in writing, cremation can be
will be wrapped in a white cotton sheet plus a authorized. It is subject to compliance with civil
second wrapping in a polyethylene cover. They regulations. No overt action by naval
will be sealed with pressure-sensitive tape or authorities should be made to encourage the
heat sealed. NOK to elect cremation. Cremation will not be
permitted i f any member of the deceased’s
CASKETS PADD or SNOK objects.
25-10
CEREMONY RECORDS Government Air
Civilians are not normally allowed to attend Government air is not authorized within
ceremonies aboard naval ships or aircrafts. CONUS without approval of the CNO (OP-
Photographs and or video of the ceremony will 414). If the circumstances indicate government
be taken. A letter describing the ceremony, air, Navy Mortuary Affairs should be contacted
photographs and or video will be sent at the for guidance and assistance.
command’s discretion to the NOK.
Commercial Air
CONSIGNMENT AND
TRANSPORTATION OF REMAINS Commercial air may be supplemented by
either rail or funeral coach transportation. An
escort must travel with the remains. I f delays en
LEARNING OBJECTIVE:
route or changes in schedule occur, the escort
must notify the installation arranging the
Identify consignment policies and authorized
transportation and the consignee.
methods of transportation of remains.
Chartered Air Taxi
Activities that arrange transportation for
remains have the responsibility to provide Chartered air taxi service may be authorized
expeditious transportation and a confirmed when commercial air is not available to the
schedule as soon as possible by whatever destination and the use of a funeral vehicle or
methods meet the req u ir e men ts . rail would cause undue delay.
Consideration should be given to any special
desires of the NOK including releasing the Funeral Coach
remains for transportation that they may wish to
provide. The funeral coach method of transportation
may be used under any of the following
CONSIGNMENT circumstances:
Remains may only be consigned (turned • To transfer remains from the place of
over) to a funeral director, the director or preparation to another local funeral home, to
superintendent of a national cemetery, or the a local cemetery, or to a common-carrier
consignee (receiver) designated by the Navy terminal
Mortuary Affairs for unclaimed remains. In • When common-carrier service is not
addition to the above consignees, cremains may available
be consigned to the PADD or person designated
by the PADD. • When a common-carrier is available only
part of the way to the place designated by
AUTHORIZED METHODS OF the PADD
TRANSPORTATION WITHIN THE o Funeral coach service may be used for
UNITED S T A T E S the remaining portion of the
transportation authorized
Authorized methods of transportation
within the United States include government o When the cost is not in excess of the
air, commercial air, chartered air taxi, and common-carrier cost
funeral coach.
25-11
• When the cemetery cannot p r o v i d e When the remains carry communicable or
transportation from the terminal to the contagious disease, make sure that the
cemetery, a funeral coach may be used as a consignment message specifically states that death
continuation of common-carrier service was due to a contagious or communicable
when remains are consigned directly to a disease.
national cemetery, a Navy cemetery, or a
Navy plot AUTHORIZED TRANSPORTATION TO
OR FROM CONUS
• To transfer remains from the common-
carrier t e r m i n a l at d estin ation to the Remains of eligible decedents who die
funeral establishment and to deliver remains outside the 48 contiguous United States will be
to the local cemetery or crematory transported by the most expeditious U.S.
• When requested by the NOK, and the family government means; normally, government airs
member defrays costs in excess of the (Air Mobility Command (AMC) flights) are
method that would have been used by the used. I f such transportation is not available,
government impractical, or would cause undue delay,
commercial air may be authorized by Navy
• When the use of a common-carrier service Casualty.
will involve extended layover and this
method will expedite the arrival OUTSIDE CONUS DESTINATIONS
25-12
Problems concerning arrangements for a SPECIAL ESCORTS
Navy escort that cannot be resolved by the
responsible command should be referred to A special escort is defined as a person
Navy Mortuary Affairs or the area commander requested specifically by the PADD or by his
OCONUS. Problems concerning Marine Corps representative, or a person assigned by an
members should be referred to CMC. appropriate command because unusual
circumstances prevail and such assignment is
INSIDE CONUS ESCORTS/ OUTSIDE considered in the best interest of the naval
CONUS ESCORTS service. All requests for special escorts must
be referred to Navy Mortuary Affairs.
Within CONUS, escorts are detailed to
accompany the remains or cremains of each I f desired by the PADD, a civilian or
Navy and Marine Corps decedent to the final member of another service may be assigned as a
destination. Furnishing escorts is the special escort. An escort in retired or inactive
responsibility of the activity arranging status should be treated as a civilian. A l l
transportation of the remains or cremains. When military special escorts are assigned subject to
selecting an escort for the deceased, the activity availability as determined by their CO and,
arranging transportation is encouraged to unless closely related to the deceased, generally
consult the last duty station of the deceased. are not authorized OCONUS.
SELECTION OF ESCORTS
25-13
DISPOSITION OF PERSONAL Civ il authorities should be consulted to
EFFECTS determine local requirements. When a death
occurs at a naval activity in any state, territory,
or insular possession of the United States, the
LEARNING OBJECTIVE:
CO will report the death to civil authorities
(usually the coroner or medical examiner). It is
Explain disposition of personal effects policies.
a general practice for medical officers to
complete a civil certificate of death for all
A l l personal effects of the deceased are to deaths occurring in naval medical treatment
be collected and inventoried, except where the facilities.
member occupied government or public housing
and the spouse requires no assistance. In the The medical officer or Medical Department
event the spouse dies simultaneously with the Representative (MDR) of the ship or station
service member, the CO cooperates with where the deceased was attached will obtain the
surviving relatives of the deceased and civil certificate from the civil authorities. I f
authorities by providing protection for the requested by the authorities, the civil certificate
property of the deceased. of death may be prepared and signed by a
naval officer. If problems arise in getting a
The CO appoints an inventory board certificate, request assistance from Navy
consisting of two members, of which one Mortuary Affairs. I f death occurs abroad and no
member is normally a Commissioned Officer. naval activity is available, the nearest consulate
The inventory should be recorded on an officer should be requested to get a certificate.
Inventory of Personal Effects Form, NAVSUP The medical o ffi c er or M D R will prepare
Form 29. An original and four copies will be and forward a DD 2064 with the civil
prepared and signed by the board members. The certificate of death, supporting papers, and the
board will send all five copies with the personal closed health record.
effects to the Supply Officer for completion,
disposition, and signature. The Supply Officer In general (except where the state has
returns three signed copies. The inventory board retained concurrent jurisdiction with the United
sends one copy to NAVPERSCOM, files one in States), civil authorities have no jurisdiction
the service record of the deceased, and sends over deaths occurring on naval reservations. A
one to the officer who appointed the board. transit or burial permit must be obtained from
civil authorities to remove the remains from a
naval reservation either for shipment or burial.
CIVIL CERTIFICATES OF DEATH I f death of any person for whom the
Department of the Navy is responsible occurs
LEARNING OBJECTIVE: outside the limits of a naval reservation, the
remains normally will not be moved until
Identify when civil certificates are required and permission has been received from civil
where they should be distributed. authorities.
DISTRIBUTION OF DEATH
A civil certificate of death must be obtained CERTIFICATE FOR DEATHS
i f a death occurs within one of the 50 United OCCURRING IN CONUS
States or the District of Columbia. I f a death
occurs outside these areas, with the exception When a Navy or Marine Corps death occurs
of Guam, a Certificate of Death (Overseas), DD in one of the 50 United States or the District of
2064, should be prepared. This certificate is in Columbia, follow local civil requirements.
addition to the civil certificate of death;
however, the civil certificate of death is not
required in all overseas areas.
25-14
DISTRIBUTION OF DEATH PRIMARY EXPENSES
CERTIFICATE FOR DEATHS
OCCURRING OUTSIDE CONUS I f the NOK makes arrangements for
disposition of remains, rather than using
When a Navy or Marine Corps death services of DoD, or completes funeral
occurs outside the 50 United States or the arrangements before DoD services are offered,
District of Columbia, follow the local civil the NOK will be reimbursed at the current
requirements. I n addition, a DD 2064 is biannually updated amount approved. Consult
prepared and copies are distributed as the latest OPNAVINST 5360.1 series and or
outlined in current instructions and local Navy Mortuary Affairs for the authorized
policies. allowances.
25-15
A claim for reimbursement may be allowed GOVERNMENT SERVICES NOT
i f presented within the approved time frame UTILIZED WITHIN CONUS
after notification of the NOK of the date of
death. The PADD must submit receipted Claims re la t in g to primary expenses and
invoices or a certified claim to Navy Mortuary transportation costs to a common-carrier
Affairs. terminal for transportation to the final
destination w i l l be forwarded to Navy
HEADSTONES AND MARKERS Mortuary Affairs.
Personnel serving on active duty at the time Claims re la tin g to interment (secondary)
of their death are eligible for a headstone or allowances and supplemental transportation
marker provided by the Veterans' costs will be forwarded to Navy Mortuary
Administration (VA). At a national cemetery, Affairs.
the director or superintendent will make the
arrangements. In naval plots and cemeteries, the GOVERNMENT SERVICES NOT
Navy w i l l make the arrangements. I n other UTILIZED OCONUS
cemeteries, an application should be submitted
to the VA. I f a commercial headstone or Area commanders outside CONUS are
marker is procured, a limited reimbursement is authorized to make local payment of expenses
authorized. A memorial marker may be incurred in areas under their jurisdiction.
p r o v i d e d upon request to commemorate the
death of a member whose remains were not Claims in areas outside the jurisdiction of
recovered or were buried at sea. the activities (area commanders) should be
submitted to BUMED for resolution.
REIMBURSEMENT PROCEDURES
GOVERNMENT SERVICES UTILIZED
LEARNING OBJECTIVE:
When the Navy has arranged for primary
services and transportation, submit claims for
Identify procedures for reimbursement of
payment and reimbursement of interment costs
funeral costs.
or supplemental transportation expenses to Navy
Mortuary Affairs.
When the Navy has arranged for primary
services and transportation, a claim for payment REPORTING EXPENSES
of the supplemental transportation charges may
be submitted to Navy Mortuary Affairs by the
funeral director at the final destination. DD LEARNING OBJECTIVE:
Form 1375, Request for Payment of Funeral
and/or Interment Expenses, should be given to Identify reporting procedures for funeral
the PADD (or PADD’s designee) to claim expenses.
reimbursement or payment for primary
expenses, transportation, and secondary Activities incurring expenses in connection
expenses. with disposition of remains of Navy and Marine
Corps personnel do not report these expenses to
BUMED except when indicated on the DD
Form 2062, Record of Preparation and
Disposition of Remains (Outside CONUS), and
DD Form 2063, Record of Preparation and
Disposition of Remains (Within CONUS).
25-16
When arranging for disposition of remains ELIGIBILITY FOR INTERMENT
of other services' deceased personnel using
commercial sources, the activity should Remains of the following naval and
forward a letter report, MED 5360-3, Report of former naval members may be buried in any
Disposition and Expenditures Remains of the open national cemetery except at the National
Dead, to the service obligated for Cemetery at Arlington, Virginia (which has
reimbursement. Costs for which the activity’s separate criteria for acceptance):
funds have been cited should be shown on the
• Navy or Marine Corps member who was
letter report.
serving on active duty at time of death (other
than active duty for training)
NATIONAL CEMETERIES
• Any member of a Navy or Marine Corps
LEARNING OBJECTIVE: Reserve organization whose death
occurred under honorable conditions
Identify services that are available at National while the individual was in one of three
Cemeteries. categories:
o On active duty for training (including
Except for Arlington National Cemetery authorized travel to and from active duty
(which is under the jurisdiction of the training)
Department of the Army) and a few other o On inactive duty training (in cluding
exceptions noted in OPNAVINST 5360.1 authorized travel to and from such
series, national cemeteries are under the training)
jurisdiction of the Chief Memorial Affairs
Director, Department of Memorial Affairs, o Hospitalized or undergoing treatment at
Veterans' Administration, Washington, DC. the expense of the government for
injury or disease incurred or contracted
NATIONAL CEMETERY during the period covered by 1 and 2
CLASSIFICATIONS above
• Former Navy or Marine Corps members
There are three classifications of national who were discharged under conditions
cemeteries: other than dishonorable
• Open (Active): Cemeteries with grave • Members of the Naval Reserve Officers'
spaces available Training Corps whose death occurred
• Closed (Inactive): Cemeteries without under honorable conditions while they
grave spaces available were in one of the following situations:
• New (Inactive): Cemeteries planned but not o Attending an authorized training camp or
yet opened authorized training cruise
o Performing authorized travel to and from
that camp or cruise
o Hospitalized or undergoing treatment at
the expense of the government of the
United States for injury or disease
incurred or contracted during the period
covered by 1 and 2 above
• Surviving spouse and minor children of
individuals covered above
25-17
At the discretion of the Chief Memorial NAVAL PLOTS AND CEMETERIES
Affairs Director, unmarried adult children of
eligible individuals may be buried in any open
LEARNING OBJECTIVE:
national cemetery (except Arlington) i f they
were totally disabled either physically or
Indentify the policy for interment at a Naval
mentally before attaining the age of 21. The
Cemetery.
Chief Memorial Affairs Director may also
authorize the burial of unremarried widows or
widowers; eligible deceased members whose With two exceptions, Navy Mortuary
remains were either lost at sea or buried at sea Affairs exercises technical direction of naval
not at their own volition; or who were plots and cemeteries. Presently, there are only a
officially determined missing or missing i n few active naval cemeteries, so plot availability
action and subsequently administratively is extremely limited. For this reason, decedents
declared dead. who are eligible for interment in national
cemeteries will not normally be authorized
HONORS interment in a naval plot or cemetery. However,
exceptional or unusual circumstances will be
M i l i t a r y honors for interment i n national referred to BUMED for determination.
cemeteries are the responsibility of the
member’s service. Honors for services at GROUP INTERMENTS
Arlington National Cemetery are coordinated by
the superintendent of the cemetery with LEARNING OBJECTIVE:
BUPERS or the CMC.
Identify guidelines for group internments.
VAULTS
A metal, asphalt, or concrete vault may be When remains of two or more individuals
procured at the NOK’s expense i f it is killed in the same incident cannot be
preferred. I f a vault is privately procured, the individually identified, a priority message
superintendent or director must be notified of detailing the circumstances should be sent to
the outside dimensions to ensure the proper Navy Mortuary Affairs who will determine if
preparation of the grave. The contractor there is a need for an identification specialist to
furnishing the vault must also provide necessary be sent. If remains cannot be individually
equipment and personnel for placing the vault identified, the collective remains will be interred
in the grave before the funeral service and for as a group interment. Group interments should
placement of the vault lid after the service. be made in a national cemetery, within the 50
United States, as close to the midpoint of the
two most widely separated homes of record of
VIEWING REMAINS known deceased individuals involved, or as
otherwise directed by the program managers.
National cemeteries no longer have facilities Navy Mortuary Affairs will coordinate with the
for viewing remains. I f the NOK desires a other services as required.
viewing before interment, the remains must be
consigned to a local funeral director.
SCHEDULING
25-18
Procedures followed in group interments are: SUMMARY
1. Unidentified remains should be prepared,
wrapped, and placed into the minimum The Decedent Affairs Program consists of
number of caskets possible without the search, recovery, identification, care, and
overcrowding. Partially segregated but disposition of remains of deceased personnel for
identifiable remains should be wrapped whom the Department of the Navy is
separately. responsible. Large medical treatment facilities
normally manage decedent affairs mattes.
2. One or more escorts should be provided as However, when a death occurs at small
long as the number of escorts does not independent operational units, senior HMs will
exceed the number of deceased persons. be responsible for the proper management of this
3. The PADD and two blood relatives of each program. For further guidance refer to OPNAV
deceased member in a group interment are 5360.1 series, Decedent Affairs Manual or
authorized round-trip transportation to the contact the N135C, Navy Mortuary Affairs,
place of interment at Government expense. Millington, TN.
25-19
APPENDIX I
GLOSSARY
The following terms are explained as used in this manual and as commonly defined.
AI-1
ANESTHETIST ⎯A registered nurse trained in administering anesthetics.
ANISOCORIA⎯U n e q u a l diameter of the pupils.
ANODYNE ⎯A drug that relieves pain.
ANOREXIA⎯Loss of appetite.
ANTHELMINTIC⎯A drug that expels, paralyzes, or kills intestinal worms.
ANTHRAX⎯Disease caused by Bacillus anthracis where infective bacteria form spores and
transmission occurs through contact with contaminated material.
A N T I B I O T I C ⎯A synthetic product or a product of living microorganisms that kills or inhibits the
growth of undesirable microorganisms.
ANTIBODIES⎯The specific defensive proteins produced when an antigen stimulates individual cells.
ANTIDOTE⎯An agent that counteracts a poison.
A N T I G E N ⎯A substance which, under certain conditions, is capable of inducing the formation of
antibodies and reacting specifically with the antibodies in a detectable manner.
ANTIPYRETIC⎯A drug that lowers elevated body temperature.
ANTISEPTIC⎯A drug or chemical that inhibits the growth of microorganisms without necessarily
destroying them.
APNEA⎯A temporary cessation of breathing.
ARENAVIRUSES⎯A family of viruses whose members are generally associated with rodent-
transmitted diseases in humans via rodent urine and excrement that may cause severe illnesses.
ARTICULATION⎯The place of union or junction between two or more bones of the skeleton.
ASEPTIC⎯Clean; free of pathogenic organisms.
ASSISTANT’S ZONE⎯Between 2 and 4 o’clock; for left-handed dentists seated to the right of the
patient, the assistant’s zone is between 8 and 10 o’clock.
ASTRINGENT⎯A drug or preparation that produces shrinkage of body membranes, especially
mucous membranes.
ASYMPTOMATIC⎯Having no symptoms.
ATTRITION⎯The loss of substance of a tooth from a wearing away process caused by teeth against
teeth.
AUSCULTATION⎯The act of listening for sounds within the body, with or without a stethoscope.
AUTOMATED EXTERNAL DEFIBRULLATOR (AED) ⎯A portable electronic device that is
capable of analyzing cardiac rhythms and selecting the appropriate strength of defibrillation or electrical
therapy which stops the arrhythmia allowing the heart to reestablish an organized electrical message to
the heart tissue, all at the touch of a button.
AUTOLYSIS⎯The spontaneous disintegration of tissues or cells by the action of their own serum or
enzymes, such as occurs after death and in some pathological conditions.
AVULSED ⎯A forcible separation; also, a part torn from another.
AXILLARY⎯Pertaining to the area of the armpit.
AI-2
BACTERIA⎯Single celled organisms capable of causing a variety of diseases in
animals, plants, and humans.
BACTERICIDE⎯An agent that destroys bacteria.
BACTERIOSTATIC⎯An agent that inhibits the growth of bacteria.
BAROTRAUMA⎯Damage to tissues caused by a change in ambient pressure.
BATTLE DRESSING⎯A combination compress and bandage in which a sterile gauze pad is fastened
to a gauze, muslin, or adhesive bandage.
BIOBURDEN⎯The number of microorganisms contaminating an object; known as bioload or microbial
load.
BIOLOGICALS⎯Medicinal preparations made from living organisms and their products, including
serums, vaccines, antigens, and antitoxins.
BLANCHING⎯Turning white.
BLEB⎯Blister, bubble.
BLOODBORNE PATHEOGENS⎯Pathogenic organisms present in human blood and capable of
causing disease in humans.
BODY MASS INDEX (BMI)⎯A healthy weight calculated by dividing a person’s weight in kilograms (2.2# =
1 kg) by the person’s height in meters squared (2.54 cm = 1 inch) or kg/m2.
BODY SUBSTANCE ISOLATION (BSI) ⎯The practice of using personal protective equipment in order to
prevent the spread of disease and contagious pathogens.
BRADYCARDIA⎯Abnormally slow heartbeat, evidenced by a pulse rate of 60 or less.
BRADYPNEA⎯Abnormally slow breathing.
BUBO⎯An inflamed swelling of a lymphatic gland, especially in the area of the armpit or groin.
BUCCAL⎯R e f e r r i n g to the cheek.
BUNYAVIRUSES⎯Group of vector-borne viruses that are transmitted through an arthropod vector.
CARBOHYDRATES⎯Molecular chains of carbon and hydrogen atoms bound together with main role
of providing energy to the cells. All carbohydrates contain 4 calories per gram.
CARBUNCLE⎯A painful purulent inflammation of the skin and deeper tissues with multiple openings
for the discharge of pus usually accompanied by necrosis and sloughing of dead tissue.
CARRIER⎯A person or animal that harbors specific infectious agents in the absence of discernible
clinical disease, and serves as a potential source of infection for humans.
CASTS⎯Urinary sediments formed by coagulation of albuminous material in the kidney tubules.
CATABOLISM⎯A destructive process in which the complex compounds are reduced to simpler
substances during the digestive process.
CATHARTICS⎯Drugs that promote bowel movement.
CAVITY⎯A disease where bacterial processes damage the hard tooth structure.
CELLULITIS⎯A diffuse inflammation of connective tissue with severe inflammation of dermal and
subcutaneous layers of the skin.
AI-3
CERVICAL⎯Pertaining to the neck or the neck of any organ or structure.
CHEYNE-STOKES⎯Breathing characterized by alternating periods of apnea and deep
respirations.
CHILLBLAIN⎯Mild cold injury characterized by redness, swelling, tingling, and pain to the affected
skin area, caused by prolonged and repeated exposure for several hours to air temperatures from above
freezing 32°F (0°C) to as high as 60°F (16°C).
CLARK’S RULE⎯The rule governing pediatric doses based upon weight; the child’s weight is the
numerator, and the average adult weight (150) is the denominator. This fraction is multiplied by the adult
dose.
COAGULATION⎯Clotting.
COAPTATION⎯To fit together, as the edges of a wound or the ends of a fractured bone; category of
splint.
COCCYX⎯Tailbone.
CONCURRENT⎯Done or occurring at the same time; i.e. concurrent disinfection while infectious
patient is still in the room.
CONTAMINATED⎯The presence or reasonably expected presence of blood or other potentially
infectious material on an item or surface.
COLATION⎯The process of straining or filtration.
COMMUNICABLE⎯Capable of being transmitted from one person to another.
COMMUNICABLE PERIOD⎯The period of time in which an infectious agent may be passed
from an infected animal or human to a receptive host. There may be more than one such period of time
during the course of disease.
COMMINUTION⎯The process of physical reduction of a substance to fine particle size.
CONTACT⎯A person or animal known to have been associated with an infected person or animal,
or a contaminated environment, and to have had the opportunity to acquire the infection.
CONTAMINATION⎯The presence of an infectious agent or toxin on the surface of a body or
inanimate article, such as clothing, dishes, surgical dressings or instruments, as well as in food or
water.
C O N T R A C T U R E ⎯A condition of muscle shortening and fibrous tissue development that
results in a permanent joint deformity.
CONTUSION⎯A bruise.
CORROSIVE⎯A substance that rapidly destroys or decomposes body tissue at point of contact.
CREPITUS⎯The cracking or grating sound produced by fragments of fractured bones rubbing
together.
CULTURE⎯The reproduction and growth of micro-organisms in living tissue cells or on a nutrient
medium.
CYST⎯An enclosed pouch or sac that contains fluid or semi-solid material.
DEBILITY⎯The state of abnormal bodily weakness.
DEBRIDEMENT⎯The removal of all foreign matter and devitalized tissue in or about a wound.
AI-4
DECANTATION⎯Separating liquids from solids by letting the solids settle to the bottom and
pouring off the liquid.
DECEREBRATE⎯A person with brain damage that produces certain abnormal neurologic signs
with arms extended to the sides.
DECONTAMINATION⎯The process of removing or neutralizing and properly disposing of
contaminants that have accumulated on personnel and equipment.
DECORTICATE⎯Abnormal posturing with arms flexed over the chest.
DECORTICATION⎯Removing portions of the cortical substance of a structure or organ, such as
the brain, kidney, or lung.
DECUBITUS ULCER⎯Bed or pressure sore.
DENTAL CARRIES⎯Also known as cavities, a disease where bacterial processes damage the hard
tooth structure.
DESQUAMATE⎯To shed, peel, or scale off.
DIASTOLE⎯The dilation or period of dilation of the heart, especially of the ventricles.
DIATHERMY⎯The generation of heat in tissue by electric current for medical or surgical purposes.
DISINFECTION⎯The killing of infectious agents outside the body by physical or chemical means
applied directly.
DISINFESTATION⎯A physical or chemical means of destroying animal or insect pests in a particular
area.
DISLOCATION⎯Injury where a bone is forcibly displaced from the normal position of function.
DISTILLATION⎯Converting a liquid to a vapor by applying heat and condensing the vapor back to
liquid by cooling.
DIURESIS⎯Urine excretion in excess of the usual amount.
DIURETICS⎯Drugs that increase the secretion of urine.
DOSAGE⎯The amount of medication to be administered.
DOSAGE RANGE⎯The range between the minimum and the maximum amounts of a given medication
required to produce the desired effect.
DRESSING⎯A sterile pad or compress (usually made of gauze or cotton wrapped gauze) used to cover
wounds, to control bleeding, and to prevent further contamination.
DYSPNEA⎯Labored or difficult breathing.
ECCHYMOSIS⎯A small hemorrhagic spot, larger than a petechia, in the skin or mucous membrane,
forming a non-elevated, rounded or irregular, blue or purplish patch.
EDEMA⎯Swelling.
EFFECT⎯The direct change, result, or consequence caused by an action.
ELECTROLYTE⎯A substance that dissociates into ions in solution or when fused, thereby
becoming capable of conducting electricity.
ELIXIR⎯An aromatic, sweetened, hydro alcoholic solution containing medicinal substances.
AI-5
EMBOLISM⎯When an object in one part of the body migrates and causes blockage of a blood vessel in
another part of a body.
EMBOLUS⎯A clot or other plug brought by the blood from another vessel and forced into a
smaller one, thereby obstructing circulation.
EMETIC⎯A substance that causes vomiting.
EMOLLIENT⎯A drug that softens, soothes, or smoothes the skin or irritated surfaces.
EMPHYSEMA⎯A progressive long-term disease of the lung that primarily causes shortness of breath
and destruction of the lung tissue around the bronchioles over time.
EMULSION⎯A liquid preparation containing two unmixable liquids, such as oil and water, one of
which is dispersed as globules in the other.
ENCAPSULATED⎯Enclosed within a capsule.
ENDEMIC⎯The constant presence of a disease in a given locality.
ENGINEERED CONTROLS⎯Method of managing environment and health by placing a barrier
between contamination and the rest of the site, thus limiting exposure pathways.
ENTERIC⎯Of or within the intestine.
EPIDEMIC⎯The outbreak of disease in a geographic area in excess of normal expectations.
EPIDEMIOLOGY⎯The study of epidemics and epidemic diseases.
EPISTAXIS⎯Nosebleed.
EPIZOOTIC⎯Disease attacking many animals in a region at the same time.
ERADICATE⎯Wipe out; destroy.
EROSION⎯A loss of tooth substances from a chemical process that does not involve bacteria, usually
occurring on the facial surfaces at the gingival third of the crown and often involves the maxillary
incisors.
ERYTHEMMA⎯Redness.
ERYTHROCYTE⎯Red blood cell.
EUPNEA⎯Ordinary, quiet breathing.
EUTAXIA⎯The liquification of solids mixed in a dry state.
EVERSION⎯The extremity is twisted outward.
EXSANGUINATION⎯Fatal process of total blood loss.
EXTENSION⎯Straightening or unbending, as in straightening the forearm, leg, or fingers.
EXTRAVASATION⎯A discharge or escape, such as blood from a vessel into the tissue.
EXTRICATION⎯The process of freeing a victim, such as from a wrecked car or flooded
compartment.
FATS⎯Primary role is to supply energy to the body, 9 calories per gram.
FILOVIRUSES⎯A family of viruses called Filoviridae that can cause severe hemorrhagic fever in
humans and nonhuman primates.
AI-6
FIRST AID⎯Temporary measures to save life, prevent further injury, and preserve resistance to
vitality.
FISTULA⎯An abnormal connection between an organ, vessel, or intestine and another structure,
usually the result of injury or surgery that can lead to infection or inflammation.
FLAVIVIRUSES⎯Group of several viruses that are transmitted by the bite from an infected arthropod.
FLEXION⎯Bending, as in bending an arm or leg.
FOMITE⎯An object, such as a book, wooden object, or an article of clothing, that is not in itself
harmful, but is able to harbor pathogenic microorganisms and thus may serve as an agent of transmission
of an infection.
FRACTURE⎯Break in a bone.
FROSTBITE⎯Occurs when ice crystals form in the skin or deeper tissues (primarily the face and the
extremities) after exposure to a temperature of 32°F (0°C); formation of frost bite may vary from a few
minutes to a few hours.
FUMIGATION⎯The destruction of disease-producing animals or insects by gaseous agents.
FUNGI⎯Plants that lack chlorophyll.
FUNGICIDE⎯A drug that kills fungus.
FURCATION⎯When teeth have more than one root, the regions where the roots separate.
FURUNCLE⎯An abscess in the true skin caused by the entry of microorganisms through a hair follicle
or sweat gland.
FUSION⎯Melting.
GASTROSTOMY⎯A surgical opening from the external surface of the body into the stomach,
usually for inserting a feeding tube.
GAVAGE⎯Introducing a substance into the stomach through a tube.
GERMICIDE⎯An agent that kills germs.
GESTATION⎯The period of carrying developing offspring in the uterus after conception.
GINGIVITIS⎯An inflammation of the gingival tissue usually resulting from the presence of bacterial
plaque buildup due to lack of adequate oral hygiene.
GLYCOSURIA⎯Glucose in the urine.
GRAM-NEGATIVE⎯A micro-organism that does not retain Gram's crystal voile and is stained by the
counter stain.
GRAM-POSITIVE⎯A microorganism that is stained by Gram's crystal violet.
GUMBOIL⎯Swelling that is confined to a small area at the site of a sinus tract.
HAZARDOUS MATERIAL⎯All types of compressed gases and other materials that present a fire
hazard or are otherwise dangerous.
HEMACYTOMETER⎯An instrument for estimating the number of blood cells in a measured
volume of blood.
HEMATEMESIS⎯Vomiting blood.
AI-7
HEMATOCRIT⎯A determination of the volume percentage of red blood cells in whole blood.
HEMATOMA⎯A localized collection of blood that escaped from blood vessels due to trauma.
HEMIPLEGIA⎯Loss of motion and sensation of one side of the body.
HEMOGLOBIN⎯Iron containing red pigment (heme) combined with a protein substance (globin).
HEMOLYSIN⎯Substance that breaks down red blood cells, thereby liberating hemoglobin.
HEMOPTYSIS⎯Coughing up blood.
HEMOSTATICS⎯Drugs that control external bleeding by forming an artificial clot.
HISTOLOGY⎯The microscopic study of tissue structure.
HOST⎯A man or other living animal affording subsistence or lodgment to an infectious agent under
natural conditions.
HYDROPHOBIA⎯Also known as rabies, disease caused by a virus that is present in the saliva of
infected animals.
HYDROTHERAPY⎯The scientific use of water in the treatment of disease.
HYPERGLYCEMIA⎯Abnormally increased content of sugar in the blood.
HYPERPNEA⎯Increased rate and depth of breathing.
HYPERTENSION⎯High blood pressure.
HYPERTHERMIA⎯Abnormally high body temperature, especially that induced for therapeutic
purposes.
HYPOGLYCEMIA⎯Low blood sugar.
HYPOPNEA⎯Abnormal shallowness and rapidity of breathing.
HYPOSTASIS⎯Poor or stagnant circulation in a dependent part of the body or organ, as in venous
insufficiency.
HYPOTENSION⎯Low blood pressure.
HYPOTHERMIA⎯Abnormally low body temperature.
HYPOVOLEMIA⎯Abnormally decreased volume of circulating fluid (plasma) in the body.
HYPOXIA⎯Low oxygen content or tension; deficiency of oxygen in the inspired air.
IMMERSION FOOT⎯Results from prolonged exposure to wet cold at temperatures ranging from just
above freezing to 50°F (10°C); may also occur in the hands.
IMMISCIBLE⎯Incapable of being mixed.
IMMUNE PERSON⎯An individual who does not develop clinical illness when exposed to specific
infectious agents of a disease, due to the presence of specific antibodies or cellular immunity.
IMMUNITY⎯A defense mechanism of the body which renders it resistant to certain organisms.
INAPPARENT INFECTION⎯An infection with no detectable clinical symptoms, even though the
causative infectious agent may be identifiable with laboratory examinations. It is also known as an
asymptomatic or subclinical infection.
AI-8
INCIDENCE RATE⎯The number of specific disease cases diagnosed and reported in a specific
population in a defined period of time. It is usually expressed as cases per 1,000 or 100,000 annually.
INCISION⎯A cut, or a wound produced by cutting with a sharp instrument.
INCOMPATIBLE⎯Not suitable for combination or simultaneous administration.
INCONTINENT⎯Unable to control excretory functions.
INCUBATION PERIOD⎯The period of time between the initial exposure to an infectious agent and
the first clinical symptoms of the disease.
INDURATION⎯An abnormally hard spot or place.
INFECTION⎯A condition resulting when pathogens enter body tissues, multiply, and cause injury
to cells.
INFECTION CONTROL⎯Process in which steps are taken to prevent the spread of infectious agents.
INFECTIOUS AGENT⎯An organism capable of producing infection or disease.
INFECTIOUS DISEASE⎯A disease of man and animal resulting from an infection.
INFECTIOUS WASTE⎯Liquid or solid waste containing pathogens in sufficient numbers and of
sufficient virulence to cause infectious disease in susceptible hosts exposed to the waste.
INFESTATION⎯The establishment and multiplication of small animals or arthropods (especially
insects and rodents) on the body, clothing, or habitat of individuals or animals.
INGUINAL⎯Pertaining to the abdomen.
INSTRUCTION⎯A directive containing authority or information having continued reference value
or requiring continuing action.
INVENTORY⎯The stock on hand.
INTEGUMENTARY (SYSTEM)⎯The skin and its accessory structures, including hair and nails.
INTRADERMAL⎯Into the dermis.
INUNCTION⎯Rubbing in.
INVASIVE PROCEDURES⎯A surgical entry into tissues, cavities, organs, or repair of major traumatic
injuries. This includes the manipulation, cutting, or removal of any oral or perioral tissue during which
bleeding occurs, or the potential for bleeding exists.
INVERSION⎯Injury where the foot is twisted inward.
ISCHEMIA⎯The lack of blood supply to specific areas due to constriction or obstruction in the
blood vessels.
ISOLATION⎯Procedures taken to separate infected persons or animals, dispose of their secretions, and
disinfect or sterilize the supplies, equipment, utensils, etc., used for their care, in order to prevent the
spread of disease to susceptible persons or animals. Different procedures may be required for the specific
infectious agent involved.
ISOTONIC⎯A solution having the same salinity as whole blood.
KERATOLYTIC⎯Removes horny layers of epidermis.
LACERATED⎯Torn.
AI-9
LACERATION⎯A wound made by tearing and resulting in jagged edges.
LACRIMATION⎯The secretion of tears.
LACRIMATORS⎯Tear gases.
LACTATION⎯The production of milk.
LATENT⎯Concealed; not manifest; potential.
LAVAGE⎯The irrigation or washing out of an organ (such as the stomach or bowel).
LESION⎯Any pathological or traumatic discontinuity of tissue or loss of function of a part.
LEUKOCYTE⎯White blood cell.
LEUKOCYTOSIS⎯Abnormally high white blood cell count.
LEUKOPENIA⎯Abnormally low white blood cell count.
LEVIGATION⎯Adding a small amount of liquid to a mortar and pestle while triturating.
LIGAMENT⎯A sheet or band of tough, fibrous tissue connecting two or more bones or cartilages,
or supporting an organ, fascia, or muscle.
LINIMENT⎯Solution or mixture of various substances in oily, alcoholic, or emulsified form,
intended for external application.
LOGISTICS⎯The acquisition, accounting, sustainment, and disposition of assets within the Department
of the Navy.
LUMBAR⎯Pertaining to the part of the back between the thorax and the pelvis.
LYOPHILIZATION⎯The creation of a stable preparation of a biological substance (blood
plasma, serum, etc.) by rapid freezing and dehydration of the frozen product under high vacuum.
MACERATION⎯Softening of a solid by soaking.
MAGMAS⎯Thick, creamy, aqueous suspensions of inorganic substances in a very fine state.
M A L A I S E ⎯A vague feeling of bodily discomfort.
MASTICATION⎯Chewing.
MATERIAL SAFETY DATA SHEETS⎯Sheets that provide information on the hazards of potentially
harmful material and precautions for using such material safety.
MEDICAL ASEPSIS⎯Practices used to prevent the transfer of pathogenic organisms from person to person,
place to place, or person to place.
MEDICAL ASEPTIC TECHNIQUE⎯The practice that prevents the spread of pathogens from
person to person, place to place, or place to person.
MELENA⎯Excretion of black tarry stools.
METABOLISM⎯The sum of all the physical and chemical processes by which living organized
substance is produced and maintained. Also, the transformation by which energy is made available
to the organism.
METAMORPHOSIS⎯Change of shape or structure, particularly a transition from one
development stage to another, as from larva to adult form.
METROLOGY⎯The science of weights and measures.
AI-10
MICRO-ORGANISM⎯A minute, living organism invisible to the naked eye; bacteria, fungi,
viruses, and bacterial spores.
MICTURATION⎯Voiding; urinating.
MINERALS⎯Substances found in the Periodic Chart of Elements that serve critical functions in the
body and can be found in a wide variety of food groups.
MODE OF TRANSMISSION⎯The mechanism by which the infectious agent is transmitted from its
reservoir to a susceptible host. Air, water, food, dust, dirt insects, inanimate objects, and other person are
examples of modes of transmission.
MORBIDITY RATE⎯An incidence rate that includes all persons in a particular population who
become ill during a specific period of time.
MORPHOLOGY⎯The science of forms and structure of organized beings.
MORTALITY RATE⎯The number of deaths, reported in a particular population, over a specific period
of time, divided by the total population, reported as deaths per 1,000 population. If the deaths are from
one cause, then it is known as a disease-specific mortality rate.
MOTTLED⎯Marked with blotches or spots of different colors or shades.
MUCUS⎯A sticky substance secreted by mucous membranes.
MYDRIATIC⎯Any drug that dilates the pupil.
MYELIN⎯A lipid substance that forms a sheath around certain nerve fibers.
MYELINATED⎯Covered with a myelin sheath.
NECROSIS⎯The death of tissue, usually in small, localized areas.
NON-TACTICAL TRIAGE⎯Civilian sector triage with the primary purpose of treating the most
vitally wounded patients first.
NOSOCOMIAL⎯Originating in a hospital.
NOTICE⎯A directive of a one-time or limited nature that has a self-canceling provision and the same
force or effect as an instruction.
NECROSIS⎯The death of living tissue.
NECROTIZING ULCERATIVE GINGIVITIS (NUG)⎯A disease commonly referred to as trench
mouth, or Vincent’s infection, characterized by redness, swelling, pain, accumulation of calculus around
the sulcus of the teeth, and bleeding of the gingival tissues. Usually there is a film of necrotic white or
grayish tissue around the teeth and the ulceration of the gingival crest results in a characteristic punched-
out appearance and loss of the interdental papille.
NUTIRENT⎯A substance that contributes to growth or maintenance of the body.
NUTRITION⎯The total process of providing the body with nutriments, and assimilating and
using them.
OINTMENT⎯A semisolid, fatty, or oily preparation of medicinal substances for external
application.
OLFACTORY⎯Pertaining to the sense of smell.
OLIGEMlA⎯Deficiency in the volume of blood.
AI-11
OPERATING BUDGET⎯The annual budget of an activity is assigned by the Chief of Naval
Operations (CNO), Fiscal Management Division, to major claimants.
OPERATOR’S ZONE⎯Between 8 and 11 o’clock; for left-handed dentists seated to the right of the
patient, the operator’s zone is between 1 and 4 o’clock.
OPHTHALMIC⎯Pertaining to the eye.
ORAL DIASTIMA⎯Area between teeth where there is no contact point and the teeth do not touch.
ORAL LESIONS⎯Any pathological traumatic disorder of tissue that creates a loss of function of the
area affected.
ORAL PATHOLOGY⎯The science that treats the nature, causes, and development of oral diseases;
includes both the clinical and the microscopic study of structural and functional changes that cause, or are
caused by, oral and other diseases.
ORGANISM⎯Any living thing.
OSMOSIS⎯The diffusion of fluids through a membrane or porous partition.
OSSIFICATION⎯Changing or developing into bone.
OXIDATION⎯The union of a substance with oxygen.
PALPABLE⎯Capable of being touched or felt.
PALPITATION⎯An abnormal, rapid, regular or irregular beating of the heart, felt by the patient.
PARAPLEGIA⎯Loss of motion and sensation of the lower half of the body.
PARASITICIDES⎯Drugs that kill parasites.
PARENTERAL⎯Administration of drugs by injection.
PARESIS⎯Slight or partial paralysis.
PAROXYSM⎯A sudden attack, or intensification of the symptoms of a disease, usually recurring
periodically.
PATHOGEN⎯An organism capable of producing disease or causing infections.
PATHOGENIC ORGANISMS⎯Disease producing organisms.
PATHOGENICITY⎯The capability of an infectious agent to cause disease in a susceptible host.
PERCUSSION⎯The act of striking a body part with short, sharp blows as an aid in diagnosing the
condition by evaluating the sound obtained.
PERIAPICAL ABCESS⎯Occurs when an infection of the pulpal tissue causes the pulp to become
necrotic (die).
PERIAPICAL ABSCESS⎯Results when the pulp of the tooth has been inflamed and a small pus-like
abscess forms in the pulpal canal.
PERICORONITIS⎯An inflammation of the gingival around a partially erupted tooth.
PERINEAL⎯The genital area between the vulva and the anus in a woman, and between the scrotum and
the anus in a man.
AI-12
PERIODONTAL ABCESS⎯Abscess caused by an infection of the periodontal tissues, usually resulting
from long-continued irritation by food debris, deep deposits of calculus, or a foreign object packed in the
sulcus or inter-proximal spaces.
PERIODONTAL DISEASE⎯All diseases of the periodontium that affect the tissues around and
supporting the tooth.
PERIODONTITIS⎯Progressive loss of the alveolar bone around the teeth marked by the gradual loss
of attachment of the periodontal tissues, usually resulting from untreated marginal gingivitis.
PERIOSTEUM⎯Pain center of the bone.
PERIPHERAL⎯Outward part or surface.
PERSISTENT⎯Stubborn; persevering.
PERSONAL PROTECTIVE EQUIPMENT (PPE)⎯Protect equipment such as masks, goggles,
gloves, and gowns worn by medical professionals to avoid exposure to infection and disease and prevent
the spread of infection and disease to other patients.
PESTS⎯Undesirable organisms (insects, rodents, snakes, ect.) that adversely affect military operations
and the well-being of man and animal; they attack real property, supplies, and equipment.
PETECHIA (pl. petechiae)⎯Around pinpoint, non-raised, purplish red spot caused by hemorrhage
in the skin.
p H ⎯S c a l e measuring the acidity or alkalinity of a solution.
PHAGOCYTOSIS⎯The ingestion and destruction by phagocytes of cells, microorganisms, and other
foreign matter in the blood or tissue.
PHARMACOGNOSY⎯ The branch of pharmacology dealing with biological, biochemical, and
economic features of natural medications and their constituents.
PHYSIOLOGICAL⎯Characteristic of or appropriate to an organism's functioning.
PLAGUE⎯An infectious disease to humans and animals caused by Yersinia pestis.
PLEXUS⎯Network.
POISON⎯A substance in solid, liquid, or gaseous form that, when introduced to the body through
ingestion, inhalation, absorption, or injection produces a harmful effect on normal body structures or
functions.
PORTAL OF ENTRY⎯The avenue by which the infectious agent enters the susceptible host.
PORTAL OF EXIT⎯The avenue by which the infectious agent leaves its reservoir.
POSOLOGY⎯The study of dosage and the criteria that influences it.
POSTEXTRACTION ALVEOLAR OSTEITIS⎯Commonly referred to as “dry socket,” occurs when
a blood clot fails to form or washes out of the socket of a recently extracted tooth.
PRECIPITATION⎯The quality or state of being separated from solution or suspension by chemical or
physical change, usually as an insoluble amorphous or crystalline solid.
PRIAPISM⎯A painful medical condition in which the penis or clitoris does not return to a normal
flaccid state within four hours.
PRONE⎯Lying face down.
AI-13
PROPHYLACTIC⎯The prevention of disease; preventive treatment.
PROPHYLACTIC IMMUNIZATIONS⎯Vaccines with effective and reliable immunizing agents used
to protect the Navy and Marine Corps personnel against serious diseases prior to exposure.
PROPORTION⎯Two equal ratios considered simultaneously.
PROSTRATION⎯Total exhaustion or weakness.
PROTIENS⎯Commonly referred to as the “building blocks” of the body, 4 calories per gram.
PROTOZOA⎯Single-celled animals without a rigid cell wall that may cause parasitic disease; the
majority are harmless and live on dead organic matter or bacteria.
PRURITIS⎯Intense itching.
PSYCHOLOGICAL⎯Belonging to or of the nature of psychology; the mental process.
PULPALGIA⎯Pain in the dental pulp that commonly occurs after a restoration has been placed in the tooth.
PULPITIS⎯An inflammation of the dental pulp.
PULSE OXIMETER⎯A medical device that measures the oxygen saturation of a patient’s blood and changes
blood volume in the skin, producing a photoplethysmonograph (measured changes in light absorption).
PURULENT⎯Pus filled or containing pus.
PUSTULE⎯A small, inflamed elevation of the skin containing pus.
QUADRAPLEGIA⎯Loss of motion and sensation below the neck.
R A L E S ⎯A n abnormal sound, either moist or dry, classified by location (e.g., bronchial rales, laryngeal
rales).
RATIO⎯The relationship of one quantity to another of like units.
RECURRENT APHTHOUS STOMATITIS⎯Also known as canker sores, or painful ulcerations
found in the vestibular and buccal mucosa, tongue, soft palate, and in the floor of the mouth.
REGULATED WASTE⎯Medical items that should be handled with extreme care to prevent any
unintentional injury or the spread of blood borne diseases.
R E S E R V O I R ⎯A carrier on which an infectious agent depends primarily for survival.
Reservoirs can be man, plant, animal, or soil.
RESISTANCE⎯The sum total of body mechanisms that provide barriers to the invasion of
infectious agents or their toxic products.
RHABDOMYOLYSIS⎯the rapid break down of muscle due to injury of muscle tissue.
RHINORRHEA⎯The free discharge of a thin nasal mucus.
RHONCHUS⎯ (pl. rhoncii) A rattling throat sound due to partial obstruction; a dry coarse rale in the
bronchial tubes.
ROOT CANAL⎯A dental operative procedure performed in order to save a tooth by removing the
contents of its root canal and filing the cavity with a protective substance.
SACRUM⎯Triangular bone just below the lumbar vertebrae.
AI-14
SANITATION⎯The hygienic means of promoting health through prevention of human contact with the
hazards of waste; The process of cleaning with soap and water or boiling to reduce the number of
organisms to a safe level.
SEPSIS⎯The growth of pathogens in living tissue.
SEROLOGY⎯Procedures by which antigens and reacting serum globulin antibodies may be measured
qualitatively and quantitatively.
SERUM⎯ (pl. serums or sera) The watery portion of an animal fluid remaining after coagulation;
plasma minus the clotting proteins and clotting cells.
SHOCK⎯Collapse of the cardiovascular system, characterized by circulatory deficiency and
depression of vital functions.
SIGN⎯What you observe upon examination of the patient.
SMALLPOX⎯A serious, contagious, and sometimes fatal infectious disease caused by variola virus,
that could prove to be an agent of bioterrorism.
SOLUBILITY⎯The ability of a solid to dissolve in a given amount of solvent.
SPIRITS⎯Alcoholic or hydroalcoholic solutions of volatile substances.
SPECIFIC GRAVITY⎯The density of a solution compared to an equal volume of distilled water
which usually varies directly with the amount of solids dissolved in the urine, and normally ranges from
1.015 to 1.030 during a 24-hour period.
SPONSOR⎯The active duty service member ultimately responsible for authorization the care of
dependent family members.
SPORE⎯A microorganism in a resting or dormant state that renders it highly resistant to
destruction.
SPRAIN⎯Injury to the ligaments and soft tissues that support a joint.
STATIC ZONE⎯Between 11 to 2 o’clock; a designated non-traffic area where equipment,
such as nitrous oxide, can be placed with the top extending into the assistant’s zone.
STERILE, STERILITY⎯Free of all living organisms.
STERILE FIELD⎯A specified area, such as within a tray or on a sterile towel that is
considered free of micro-organisms.
STERILIZATION⎯The process of destroying all organisms on a substance or article by exposure
to physical or chemical agents; the process by which all organisms, including spores, are destroyed.
STERNUTATORS⎯Vomiting agents.
STERTOROUS⎯Snoring-type breathing sound.
STOMATITIS⎯Inflammation of the oral mucosa.
STRAIN⎯Forcible overstretching or tearing of a muscle or tendon.
STRIATED⎯Striped or streaked.
STRIDOR⎯A harsh, high-pitched respiratory sound such as the aspiratory sound often heard in acute
laryngeal obstruction.
SUBCUTANEOUS⎯Under the skin.
AI-15
SUBLINGUAL⎯Under the tongue.
SUPERFICIAL⎯Of or pertaining to the surface, lying on, not penetrating below.
SUPINE⎯Lying on the back.
SURGICAL ASEPTIC TECHNIQUE⎯The practice that renders and keeps objects and areas free
from all organisms.
SURGICALLY CLEAN⎯Clean but not sterile.
SUSCEPTIBLE⎯Not resistant. A person or animal who may acquire an infection or disease when
exposed to a specific agent, because his or her resistance to the agent is lacking or reduced.
SUSEPTIBLE HOST⎯Man or another living organism that affords an infectious agent nourishment or
protection to survive and multiply.
SUSPECT⎯A person who may have acquired a communicable disease; it is indicated by the medical
history and clinical presentation.
SUSPENSION⎯A coarse dispersion of finely divided insoluble material suspended in a liquid
medium.
SYMPTOM⎯What the patient tells you about his or her disease or injury upon examination.
SYNCOPE⎯Faintness or actual fainting.
SYNERGIST⎯A medicine that aids or cooperates with another.
SYRUP⎯Concentrated aqueous solutions of sucrose, containing flavoring or medicinal substances.
TACHYCARDlA⎯Excessively rapid heartbeat, usually over 100.
TACHYPNEA⎯Breathing too fast; Abnormally high breathing rate.
TACTICAL COMBAT CASUALTY CARE (TCCC)⎯Care for patients during combat centered
around blunt trauma and tactical variables, primarily based around three definitive phases – care under
fire, tactical field care, and tactical evacuation care.
TACTICAL TRIAGE⎯Military style triage with the primary purpose of keeping the largest number
of patients in battle.
TAENIAFUGE⎯A drug that expels tapeworms without necessarily killing them.
TENDON⎯A fibrous cord by which a muscle is attached to the skeleton.
TERMINAL⎯Done after a patient has been discharged or transferred.
THERAPEUTIC DOSE⎯The normal adult dose, usual dose, or average dose.
THORACIC⎯Pertaining to or affecting the chest.
THROMBUS⎯A plug or clot in a blood vessel or in one of the cavities of the heart, formed by
coagulation of the blood. It remains where it was formed.
TINCTURE⎯Usually an alcoholic solution of animal or vegetable drugs.
TINNITUS⎯Ringing in the ears.
TOXEMIA⎯Poisonous products in the blood.
TOXICOLOGY⎯The science of poisons.
AI-16
TOXINS⎯Poisons; Harmful substances produced by a variety of living organisms, like bacteria, plants,
and animals that are not man-made, non-volatile, and usually not dermally active.
TRACHEOSTOMY⎯Surgically creating an opening into the trachea.
TRANSFER ZONE⎯Between 4 and 8 o’clock; instruments are passed and received in this zone over
the chest and at the chin of the patient.
TRIAGE⎯Sorting casualties to determine priority of treatment.
TRITURATION⎯A process of reducing a solid to a very fine powder by grinding in a mortar and
pestle.
TULAREMIA⎯Also known as “rabbit fever,” a disease caused by the bacterium Francisella tularensis,
typically found in animals, especially rodents, rabbits, hares, and ticks.
ULCER⎯A disruption of the superficial covering of the mucosa or skin.
UNIT DOSE⎯The quality of materials or supplies required to treat a single patient.
UREMIA⎯A condition resulting from waste products not being removed efficiently by the kidneys
so that they remain in the blood.
URTICARIA⎯Hives or welts.
VASCULAR⎯Pertaining to blood vessels.
VASOCONSTRICTOR⎯An agent that constricts the blood vessels.
VASODILATOR⎯An agent that dilates the blood vessels.
VECTOR⎯Any animal capable of transmitting pathogens or producing human or animal discomfort or
injury.
VENIPUNCTURE⎯The puncture of a vein for drawing blood.
VERMICIDE⎯A drug that expels worms without necessarily killing them.
VERTIGO⎯Dizziness.
VESICLES⎯A small elevation that contains fluid.
V E S I C A N T ⎯A blistering drug or agent.
VESICATION⎯The process of blistering.
VESICLE⎯A small blister.
VIRULENCE⎯The degree of pathogenicity of a microorganism or its ability to invade the tissues
of the host.
VIRUSES⎯Disease causing micro-organisms that cannot live long or reproduce outside of a living
body; they are much smaller than bacteria, variable in size, and can usually be cured by immersion in
boiling water and antibiotics.
VITAMINS⎯Essential, non-calorie containing compounds found in food and needed in the body in small
amounts; vitamins mainly act as enzymes or catalysts and they assist in making necessary chemical reactions
occur in the body.
WOUND⎯An injury that causes break in the skin, underlying soft tissue structures, or body membranes.
AI-17
WORK PRACTICE CONTROLS⎯ Controls that reduce the likelihood of exposure by altering the
way one performs a task such as having patients brush their teeth or using antiseptic mouthwash
before beginning a procedure.
YOUNG’S RULE⎯The rule governing pediatric doses based on age; age of the child in years is the
numerator, and the age plus 12 is the denominator. This fraction is then multiplied by the normal adult
dose.
AI-18
APPENDIX II
BAS ............................... Battalion Aid Station CNS .............................. central nervous system
AII-1
DLA .............................. Defense Logistics GMO ............................. General Medical
Agency Officer
DME.............................. diving medical GMT ............................. general military training
examination Gr .................................. grain
DMLSS ......................... Defense Medical gtt/gtts ........................... drop/drops
Logistics Standard
Support GTT .............................. glucose tolerance test
DNA .............................. deoxyribonucleic acid GU ................................ genitourinary
DOB .............................. date of birth h.s.................................. at bedtime (hora somni)
DoD ............................... Department of Defense Hb/Hgb ......................... hemoglobin
DTs................................ delirium tremens HBV .............................. hepatitis B virus
(confusions and HCG .............................. human chorionic
incoherence brought on gonadotropin
by withdrawal from
Hct ................................ hematocrit
alcohol)
Hg ................................. mercury
DTF ............................... Dental Treatment
Facility HHS .............................. Department of Health
and Human Services
DTR .............................. dental treatment room
HIPAA .......................... Health Information
Dx .................................. diagnosis
Portability and
Ea .................................. each Accountability Act
ECG/EKG ..................... electrocardiogram HIV ............................... human
EM ................................ electron microscope immunodeficiency virus
EMF .............................. Expeditionary Medical Hpf ................................ high-power field
Facility (microscope)
ENT ............................... ear, nose, and throat HSV .............................. herpes simplex virus
EPA ............................... Environmental HVE .............................. high-volume excavator
Protection Agency I ..................................... iodine
o
F ................................... Fahrenheit I&O ............................... intake and output
FAC ............................... free available chlorine IAW .............................. in accordance with
FBS ............................... fasting blood sugar ICP ................................ intracranial pressure
FDA .............................. Food and Drug ICU ............................... intensive care unit
Administration
IDC ............................... independent duty
Fe .................................. iron corpsman
FOIA ............................. Freedom of Information IM ................................. intramuscular
Act
IPPB .............................. intermittent positive-
FSC ............................... Federal Supply Catalog pressure breathing
FSH ............................... follicle-stimulating (asthma and
hormone emphysema)
g/gm .............................. gram IUD ............................... intrauterine device
GI .................................. gastrointestinal IV .................................. intravenous
IVP ................................ intravenous pyelogram
AII-2
JAG ............................... Judge Advocate MMART ....................... Mobile Medical
General Augmentation
K.................................... potassium Readiness Team
(MMART)
KUB .............................. kidney, ureter, and
bladder MO ................................ medical officer
AII-3
OBA .............................. oxygen breathing ppb ................................ parts per billion
apparatus ppm ............................... parts per million
OD ................................. right eye (oculus dexter) pre-op ............................ pre-operative
OJT................................ on-the-job training prn ................................. as required (pro re nata)
OPNAV ......................... Office of the Chief of PRT ............................... physical readiness test
Naval Operations
PSD ............................... Personnel Support
OPTAR ......................... operating targets Detachment
OR ................................. operating room PVC .............................. premature ventricular
OS ................................. left eye (oculus sinister) contraction
OSHA............................ Occupational Safety & q4h ................................ every 4 hours
Health Administration q6h ................................ every 6 hours
oz ................................... ounce qd .................................. every day
P .................................... phosphorus qh .................................. every hour
PAYPERSMAN............ Pay and Personnel qid ................................. 4 times a day
Procedures Manual
qns................................. quantity not sufficient
pc ................................... after meals (post cibum)
qt ................................... quart
PDB ............................... paradichlorobenzene
Ra .................................. radium
PDHA............................ pre-deployment health
assessment RBC .............................. red blood cell
PDHRA ......................... post-deployment health RCF............................... root canal filling
re-assessment Rh ................................. Rh factor (antigen in
PDR ............................... Physician’s Desk blood of some
Reference individuals)
pH.................................. percentage of hydrogen RLQ .............................. right lower quadrant
ion concentration RUQ .............................. right upper quadrant
(alkalinity and acidity
Rx .................................. take (prescription)
measurement)
SAVI ............................. Sexual Assault Victim
PHA .............................. periodic health
Intervention
assessment
sc/sub-q ......................... subcutaneous
PHI ................................ protected health
information SECNAV ...................... Secretary of the Navy
PID ................................ pelvic inflammatory SMDR ........................... Senior Medical
disease Department
Representative
PO ................................. orally (per os)
SMO ............................. Senior Medical Officer
Poly ............................... segmented neutrophil
(seg) SOAP notes................... the only accepted
method of medical
post-op .......................... post-operative
record entries for the
ppd ................................ purified protein military. (Subjective;
derivative Objective; Assessment;
PPE................................ personal protective Plan)
equipment SOB .............................. shortness of breath
AII-4
SPRINT ......................... Special Psychiatric TST ............................... tuberculin skin test
Rapid Intervention UCMJ ........................... Uniformed Code
Team Military Justice
Stat ................................ immediately UIC ............................... unit identification code
STD ............................... sexually transmitted URI ............................... upper respiratory
disease infection
T-cells ........................... lymphocytes produced USP-NF ........................ United States
in the thymus gland Pharmopeia-National
TAD/TEMADD ............ temporary additional Formulary
duty UTI ............................... Urinary Tract Infection
TB ................................. tuberculosis VA ................................ Veterans
Tbsp .............................. tablespoon Administration
TJC ................................ The Joint Commission VDRL ........................... Venereal Disease
(formerly known as Research Laboratory
JCAHO) vs................................... vital signs
TID ................................ 3 times a day WBC ............................. white blood cell
TPR ............................... temperature, pulse, and WHO............................. World Health
respiration Organization
TSH ............................... thyroid-stimulating YOB .............................. year of birth
hormone
tsp .................................. teaspoon
AII-5
APPENDIX III
The following are some of the more common prefixes and suffixes used by healthcare providers to
describe body conditions and procedures.
AIII-1
PREFIXES
a-/an- ................................... lacking; absence of chrom/o ................................color
ab- ....................................... away from chron/o .................................time
acr/o .................................... extremities cib/o .....................................meals
ad- ....................................... towards; addition of con- ......................................with; together
adip/o .................................. fat contra ...................................against; opposed to
aer/o .................................... air coron/o .................................heart
amphi .................................. on both sides cortic/o .................................cortex
amyl/o ................................. starch cost/o....................................ribs
andr/o .................................. male crani/o ..................................skull
angi/o .................................. vessel cry/o .....................................cold
ankyl/o ................................ crooked; bent; stiff crypt .....................................hidden
ante- .................................... before cutane/o................................skin
anter/o; anteri/o ................... front cyan/o ..................................blue
anti- ..................................... against cyst/o....................................bladder
aque/o .................................. water cyt/o .....................................cell
arthr/o .................................. joint dacry/o .................................tear
articul/o ............................... joint dactyl/o ................................fingers; toes
atel/o.................................... incomplete de- ........................................lack of
audi/o .................................. hearing dent/i ....................................tooth
aur/i ..................................... ear derm/o; dermat/o..................skin
auto- .................................... self di ..........................................complete
axill/o .................................. armpit dia ........................................complete; through
bacteri/o .............................. bacteria diaphor/o ..............................sweet
bene-.................................... good dist/o ....................................sweat
bi/o ...................................... life dors/o ...................................back (of body)
bi- ........................................ two dys........................................difficult; painful
bil/i ...................................... gall; bile ec-; ecto................................out; outside
brachi/o ............................... arm em ........................................in
brady- .................................. slow en .........................................in; within
bucc/o .................................. cheek encephal/o ............................brain
calc/o ................................... calcium endo .....................................within
capit/o.................................. head enter/o ..................................intestines
carcin/o................................ cancer epi- .......................................above
cardi/o ................................. heart erg/o .....................................work
cata- ..................................... down erythr/o.................................red
caud/o .................................. tail; lower part of eso- ......................................inward
body estr/o ....................................female
caus/o .................................. burn eti/o ......................................cause
cauter/o................................ heat; burn eu- ........................................good
celi/o.................................... belly; abdomen ex- ........................................out
cephal/o ............................... head exo .......................................outside
cerebell/o ............................. cerebellum fibr/o ....................................fiber; fibrous tissue
cerebr/o ............................... brain; cerebrum gastr/o ..................................stomach
cervic/o................................ neck; cervix gen/o ....................................producing;
chem/o ................................. drug; chemical beginning
chol/e ................................... gall germ/o ..................................sprout; seed
chondr/o .............................. cartilage gingiv/o ................................gums
AIII-2
gloss .................................... tongue myel/o ..................................spinal cord; bone
gluc/o;glyc/o ....................... sugar marrow
gnos/o .................................. knowledge myos/o .................................muscle
gravid/o ............................... pregnancy narc/o ...................................stupor; numbness
gynec/o ................................ woman; female nas/o .....................................nose
hem/o;hemat/o..................... blood nat/i ......................................birth
hemi- ................................... half necr/o ...................................death
hepat/o ................................. liver neo- ......................................new
hidr/o ................................... sweet nephr/o .................................kidney
hist/o;histi/o ........................ tissuse neur/o ...................................nerve
home/o ................................ same; constant; ocul/o; ophthalm/o ...............eye
unchanged odont/o .................................tooth
hydr/o .................................. water olig/o ....................................few; scanty
hyper- .................................. above; increase onc/o ....................................mass; tumor
hypn/o ................................. sleep or/o .......................................mouth
hypo .................................... under; below orth/o....................................straight
hyster/o................................ uterus; womb oste/o....................................bone
immune/o ............................ safe; protection ot/o .......................................ear
in- ........................................ not; in ov/o ......................................egg
infra-.................................... below; inferior pachy/o.................................heavy; thick
inter- .................................... between pan .......................................all
intra- .................................... within para ......................................beside; near;
is/o ....................................... same; equal abnormal
kary/o .................................. nucleus path/o ...................................disease
kerat/o ................................. horny; hard; cornea per ........................................through
kinesi/o ................................ movement peri-......................................around
labio/o ................................. lips phag/o ..................................eat; swallow
lacrim/o ............................... tear; tear duct pharyng/o .............................throat
lact/o.................................... milk phil/o ....................................like; love; attraction
lapar/o ................................. abdomen to
laryng/o ............................... larynx; voice box phleb/o .................................vein
later/o .................................. side phob/o ..................................fear
leuk/o .................................. white phot/o ...................................light
lingu/o ................................. tongue physic/o................................nature
lip/o ..................................... fat pne/o ....................................breathing; breath
lumb/o ................................. lower back; loins pneum/o ...............................lung
macro .................................. large poly- .....................................many; much
mal- ..................................... faulty; poor post- .....................................after; behind
mamm/o .............................. breast pre- .......................................before
medi/o ................................. middle proct/o ..................................rectum
melan/o................................ black prot/o....................................first
meso .................................... middle proxim/o...............................near
meta- ................................... beyond; near; pseudo/o ...............................false
change psych/o .................................mind
metr/o;metri/o ..................... uterus py/o ......................................pus
micro/o ................................ small pyr/o .....................................heat; temperature
mit/o .................................... thread re- .........................................back
mon/o .................................. one; single rect/o ....................................rectum
morph/o ............................... shape; form ren/o .....................................kidney
mort/o .................................. death retro- ....................................behind
my/o .................................... muscle rhin/o....................................nose
AIII-3
rib/o ..................................... sugar tachy- ...................................fast
roentgen/o ........................... x-rays tele/o ....................................far; distant
sarc/o ................................... flesh(connective thorac/o ................................chest
tissue) top/o .....................................position; location;
scop/o .................................. examination place
(usually visual) tox/o; toxic/o ........................poison
semi ..................................... half trans- ....................................across
seps/o .................................. infection ultra ......................................beyond; excess
somn/o ................................. sleep vas/o .....................................vessel; duct
son/o .................................... sound ven/o ....................................vein
sphere/o ............................... round; globe-shape ventr/o ..................................belly side of body
sphygm/o ............................. pluse vir/o......................................virus; poison
spondyl/o ............................. vertebrae viscer/o.................................internal organs
(backbones) vit/a;vit/o..............................life
stomat/o ............................... mouth xanth/o .................................yellow
sub-...................................... under; below xer/o .....................................dry
supra .................................... above
sym-;syn- ............................ together; with
AIII-4
SUFFIXES
-ac; -al; -ar; -ary .................. pertaining to -globin; globulin ..................protein
-algia ................................... pain -gram....................................record
-ase ...................................... enzyme -graph ...................................instrument for
-asthenia .............................. lack of strength recording
-blast.................................... immature; -ia .........................................condition; process
embryonic -iasis .....................................condition (of)
-capnia ................................. carbon dioxide -ic .........................................pertaining to
-cele ..................................... tumor; hernia -ist ........................................specialist
-cidal ................................... killing -lith ......................................stone; calculus
-clast .................................... break -lysis ....................................destruction; break
-coccus (pl. –cocci) ............. berry-shaped down
-crine ................................... secrete; separate -lytic .....................................destruction
-crit ...................................... separate -malacia ...............................softening
-cyte .................................... cell -manometer ..........................used to measure
-cytosis ................................ condition of cells pressure
-desis ................................... binding -megaly ................................enlargement
-ectasia; -ectasis .................. dilation; stretching -meter ...................................used to measure
-ectomy ............................... removal of -oid .......................................resembling
-emesis ................................ vomiting -ole .......................................little; small
-emia ................................... blood -ology ...................................study of
-er ........................................ one who -oma .....................................growth; tumor
-esthesia .............................. sensation -opia .....................................vision
-genesis ............................... condition of -opsy ....................................view
producing -or ........................................one who
AIII-5
APPENDIX IV
TRADEMARK COMPANIES
The following is a list of trademarks used in this manual
AIV-1
Haldol® ................................ Ortho-McNeil Mucinex® .............................Reckitt Benckiser
Pharmaceutical Inc.
Hextend® ............................. BioTime, Inc. Bayer® Multistix® ................Bayer Healthcare
Hygroton® ........................... Aventis Mycelex® .............................Bayer Healthcare
Pharmaceuticals Mycifradin® Sulfate .............Pharmacia &
Ilotycin® .............................. Dista Upjohn
Indocin® .............................. Merck Mycostatin® .........................Bristol-Myers
Innovar® .............................. Janssen Squibb
IRM® ................................... Dentists’ Supply Naproxsyn® ..........................Syntex
Company of New Pharmaceuticals
®
York Nebcin ................................Eli Lilly
Isoptin® ............................... Knoll Nembutal® ...........................Abbott Laboratories
Isordil® ................................ Wyeth Neo-Synephrine® .................Bayer Healthcare
Pharmaceuticals Nitro-Bid® ............................Nycomed US Inc.
Keflex® ................................ Middle Brook Nitrostat® .............................Warner Lambert
Pharmaceuticals Company
® ®
Kefzol ................................ Eli Lilly NIX ....................................Insight
Ketalar® ............................... JHP Pharmaceutical
Pharmaceuticals Novocain® ............................Hospira, Inc
KTD™ ................................ Kendrick EMS Nupercainal® ........................Novartis
Lanoxin® ............................. Glaxosmithkline Ophthaine®...........................Bristol-Myers
Lasix® .................................. Aventis Squibb
®
Pharmaceuticals Ophthetic ...........................Allergan Optical
Librium® ............................. Roche Products Orectic® ...............................Abbott Laboratories
Lithonate® ........................... Solovay PCE Dispertab® ...................Abbott Laboratories
Pharmaceuticals Pen-Vee K®..........................Wyeth
Lotrimin® ............................ Scherring-Plough Pharmaceuticals
Luminal® ............................. Hospira, Inc. Persantine®...........................Boehringer
Maalox® .............................. Novartis Consumer Ingleheim
Healther pHisoHex® ...........................Sanofi-Aventis
Marinol® .............................. Loders Croklaan Pitocin® ................................JHP
B.V. Corporation Pharmaceuticals
Netherlands Polycillin® ............................Bristol-Myers
Maxzide®............................. Mylan Squibb
®
Pharmaceuticals Prmaquine Phosphate.........Winthrop
Mellaril® .............................. Novartis Pharmaceuticals
Pharmaceuticals Procan SR® ..........................Parke-Davis
Metamucil® ......................... Proctor & Gamble Pronestyl® ............................Bristol-Myers
Company Squibb
Mitacin® .............................. Wellspring Prozac® ................................Eli Lilly
Pharmaceutical Ritalin® ................................Novartis
Mintezol® ............................ Merck Robaxin® ..............................Wyeth Corporation
Mobic® ................................ Boehringer- Robitussin DM® ...................Wyeth Corporation
Ingleheim Pharma Robitussin AC®....................Wyeth Corporation
Monistat® ............................ Johnson & Johnson Roxanol® ..............................Xanodyne
Monosticon DRI-DOT® ...... Organon Teknika Pharmaceuticals
Corporation Sager Splint........................Sager® Emergency
®
AIV-2
Seconal® .............................. Eli Lillyand Tylenol® ...............................McNeil Consumer
Company Unopette® Microcollection
Corporation System .................................Becton-Dickinson,
®
Septra ................................ Monarch a division of
Pharmaceuticals Becton, Dickinson
Silvadene® Cream ............... Monarch and Company
Pharmaceuticals V-Cillin K® ..........................Eli Lilly
Sodium Sulamyd® ............... Scherring Valium® ...............................Roche Products
Sorbitate® ............................ Astra Zeneca Vancocin® ............................Eli Lilly
Sudafed® ............................. Warner-Lambert Vermox® ..............................Janssen
Co. Vibramycin® ........................Pfizer
Sumycin® ............................ E.R. Squibb Visine Eye Drops® ...............Pfizer
Surfak® ................................ Aventis Visatril® ...............................Pfizer
Pharmaceuticals Wycillin® .............................American Home
Tagamet®............................. Glaxosmithkline Products
Thorazine® .......................... Glaxosmithkline Xanax XR® ..........................©2008 Pfizer Inc.
Tinactin® ............................. Scherring-Plough Xylocaine® ...........................Astra Zeneca
Tranxene® ........................... Etablissements Zantac® ................................Glaxosmithkline
CLIN-BYLA Zithromax® ..........................Glaxosmithkline
Corporation France
AIV-3
APPENDIX V
REFERENCES
The pages contained within this section and throughout the manual include web address reference
links to source information created and maintained by other public and private organizations. The
U.S. Navy does not control or guarantee the accuracy, timeliness, or completeness of any outside
links or information from non U.S. Navy websites. Links to non U.S. Navy websites are not
intended to endorse or recommend any views expressed or products and services offered on these
sites and are provided for reference only. All links were complete and active at time of reference
content update.
AV-1
REFERENCES: CONTENT UPDATE
APPENDIX V-A
2. Thibedeau, G. A., & Patton, K. T. (2006). Anatomy & physiology (6th ed.). St. Louis:
Elsevier Health Sciences.
3. Evangelist, T., Orr, T., & Unrein, J. (2009). McGraw-Hill: Nursing school entrance
exam book. Department of Defense (DoD).
5. Centers for Disease Control and Prevention (CDC). (2008). Centers for Disease
Control and Prevention (CDC) Partnership Matters Newsletter, 30 May 2008.
Retrieved on November 21, 2009 from
http://www.cdc.gov/partners/Archive/ PartnershipMatters/ 2008_05_30.html.
7. Burgess, E. & Alexander A. (1975). Mobility Aids. In atlas of orthopedics. St. Louis,
MO: CV Mosby.
9. Varghese, G. (1980). Crutches, canes, and walkers, JB Redford, ed.: Orthotics etcetera
2nd ed. Baltimore, MD: Williams & Wilkings, 453-463.
10. University of Illinois. (2008). Using crutches. Retrieved on August 21, 2009 from
http://wwwmckinley.illinois.edu/handouts/crutches/crutches.html.
12. Torres & Ehrlich: Bird, D. L. & Robinson, D. S. (2008). Torres and Ehrlich modern
Dental Assisting (9th ed.). St. Louis: Elsevier Health Sciences.
AV-2
13. Food and Drug Administration (FDA). (2009). Food and drug acts.
Retrieved on June 24, 2009 from
http://www.fda.gov; Food and Drug Administration; Food and Drugs Act.
15. United States Nuclear Regulatory Commission. (2009). Information for radiation
workers. Retrieved on November 30, 2009 from
http://www.nrc.gov/about-nrc/radiation/health-effects/info.html#dose.
16. Frank, E. D., Smith, B. J., & Long, B. W. (2007). Merrill’s atlas of radiographic
positioning and procedures: Volume 1 (11th ed.). St Louis: Mosby-Elsevier.
17. Frank, E. D., Smith, B. J., & Long, B. W. (2007). Merrill’s atlas of radiographic
positioning and procedures: Volume 2 (11th ed.). St Louis: Mosby-Elsevier.
18. Forbes, B.A., & Sahm, D.F., & Weissfeld, A.S. (2009). Facts & Comparison
Editorial Advisory Panel. Drug facts and comparisons, 2009 Ed.
St. Louis, MO: Wolters & Kluwer.
19. Ansel, H. C. (2010). Pharmaceutical calculations (13th ed.). St. Louis, MO:
Wolters & Kluwer.
20. Hunt, M. L., Hunt, M., & Tormo, V. J. (Eds.). (1995). Training manual for
intravenous admixture personnel (5th ed.). Santa Monica, CA: Bonus Books, Inc.
23. Department of the Army. (2009). Soldier’s handbook and training guide for MOS
68W STP 8-68W13-SM-TG. https://www.us.army.mil/suite/login/login.
26. Center for Army Lessons Learned. (2006). Army tactical combat casualty
carehandbook 06-18 2006. http://usacac.army.mil/cac2/call/index.asp.
AV-3
27. United States Dept. of Transportation, & Transport Canada, & Secretariat of
Communications and Transportation of Mexico (May 12, 2008) Canada
Emergency Response Guidebook. (2008). Emergency response guide 2008.
Retrieved on August 21, 2009 from
http://wwwapps.tc.gc.ca/saf-sec-sur/3/erg-bmu/erg/toc.aspx.
28. Mosby/JEMS. (2007). Prehospital trauma life support (6th ed.). St. Louis, Mo: Mosby.
29. Department of Defense. (2004). Emergency war surgery (3rd ed.). Department of
Defense. Washington, DC.
30. U.S. Army Medical Research Institute of Chemical Defense (2007). Medical
Management of Chemical Casualties (4th ed.). Aberdeen Proving Ground, MD.
31. U.S. Army Medical Research Institute of Chemical Defense (2007). Field Management
Of Chemical Casualties Handbook (3rd ed.). Aberdeen Proving Ground, MD.
32. Office of the Surgeon General at TMM Publications Borden Institute (1997).
MedicalAspects of Chemical and Biological Warfare. Washington, D.C.
Office of the Surgeon General Department of the Army, TMM Publications
Borden Institute.
33. U.S. Army Medical Research Institute of Infectious Diseases. ( 2005). USAMRID's
Medical management of biological casualties handbook (6th ed.). Fort Detrick,
MD. U.S. Army Medical Research Institute of Infectious Diseases.
34. Ryan, J. R., & Glarun, J. F. (2008). Biosecurity and bioterrorism. Kidlington,
Oxfordshire, OX5 1GB, United Kingdom: Elsevier, Oxford.
36. Center for Disease Control. (n.d.). Cutaneous Radiation Injury: Fact Sheet for
Physicians. Retrived August 18, 2009, from
http://www.bt.cdc.gov/gov/radiation/criphysicianfactsheet.asp.
38. Terezhalmy, G. T., & Batizy, L. G. (Eds.) (1998). Urgent care in the dental office: An
Essential handbook. Carol Stream: Hanover Park, IL: Quintessence.
AV-4
REFERENCES: DIRECTIVES AND INSTRUCTIONS
APPENDIX V-B
13. BUMEDINST 6260.30 series, Mercury Control Program for Dental Treatment
Facilities
AV-5
22. BUMEDINST 6710.62 series, Management and Disposal of Dated Medical and Dental
Materiel
25. BUPERSINST 1770.1 series, The Navy Casualty Assistance Calls Program (CACP)
Manual
28. Confidentiality of Medical Quality Assurance Records, Title 10 U.S.C. Title 10,
Subtitle A, Part II, Chapter 75, Subchapter II, 148., (2004)
29. Defense Logistics Agency. (2009). DLA Customer Assistance Handbook (17th ed.).
Defense Logistics Agency: Fort Belvoir, VA.
30. DoD Directive 6130.3, Physical Standards for Appointment, Enlistment, and Induction
33. DODINST 6130.4 series, Medical Standards for Appointment, Enlistment, or Induction
in the Armed Forces
34. Eaton A. D.: American Public Health Association (2005), Standard Methods for the
Examination of Water and Wastewater. Washington DC.
36. Health Information Portability and Accountability Act (HIPAA) Health Insurance
Portability And Accountability Act Of 1996 Public Law 104-191
37. JAGINST 5800.7 series, Manual of the Judge Advocate General (JAGMAN)
AV-6
41. NAVEDTRA 14504, Military Requirements for Petty Officer Third and Second Class
46. NAVMED P-5132, Bureau of Medicine and Surgery, Equipment Management Manual
51. NAVMEDCOMINST 6320.3 series, Medical and Dental Care for Eligible Persons at
Navy Medical Department Facilities
54. NAVSUP P-409, Military Standard Transaction Reporting and Accounting Procedures
(MILSTRIP/ MILSTRAP) Desk Guide
55. NAVSUP P485, Naval Supply Systems Command (NAVSUP) Manual, Vol’s I, II, & III
57. NEHC-TM89-2, Nosocomial Infection Control Manual for Ambulatory Care Facilities
60. OPNAVINST 1752.1 series, Sexual Assault Victim Intervention (SAVI) Program
AV-7
62. OPNAVINST 4614.1 series, Uniform Material Movement and Issue Priority System
(UMMIPS)
63. OPNAVINST 4790.4 series, Ship's Maintenance and Material Management (3-M)
System Policy
65. OPNAVINST 5100.19 series, NAVOSH Program Manual for Forces Afloat
66. OPNAVINST 5100.23 series, Navy Occupational Safety and Health (NAVOSH)
Program
67. OPNAVINST 5102.1 series, Navy & Marine Corps Mishap and Safety Investigation,
Reporting, and Record Keeping
69. OPNAVINST 5350.4 series, Drug and Alcohol Abuse Prevention and Control
72. OPNAVINST 6320.7 series, Health Care Quality Insurance Policies for Operating
Forces
74. SECNAV M-5510.36 series, Department of the Navy Information Security Program
77. SECNAVINST 1850.4 series, Department of the Navy Disability Evaluation Manual
80. SECNAVINST 5210.11 series, Department of the Navy Standard Subject Identification
Codes
81. SECNAVINST 5210.8 series, Department of the Navy Records Management Program
82. SECNAVINST 5211.5 series, Department of the Navy Privacy Act Program (PAP)
AV-8
83. SECNAVINST 5212.5 series, Navy and Marine Corps Records Disposition Manual
86. SECNAVINST 6120.3 series, Periodic Health Assessment for Individual Medical
Readiness
88. SECNAVINST 7320.10, Department of the Navy (DoN) Personal Property Policies and
Procedures
89. SECNAVNOTE 5211, Systems of Personal Records Authorized for Maintenance Under
the Privacy Act of 1974, 5 U.S.C. 552a (PL 93-579)
90. The Joint Commission (TJC). (2009). Comprehensive Accreditation Manual for
Hospitals: The Official Handbook (CAMH). TJC: Chicago.
92. U.S. Pharmacopeia. (1st ed.). (2008) United States Pharmacopeia and National
Formulary (USP-NF).Rockville, MD.
AV-9
INDEX
A Burns (continued) Dentition periods, 7-10
first degree, 21-88 contact point, 7-15
Abdominal injuries, 21-47 rule of nines, 21-88 dental arches, 7-10
Abrasion, 8-13 second degree, 21-88 dental quadrants, 7-10
Acute pulpits, 24-2 sunburns, 21-91 location of teeth, 7-11
Aids virus (HIV infection), 8-8 thermal, 21-87 surfaces of the teeth, 7-14
Airway, see Breathing Aids third degree, 21-88 types of teeth, 7-12
Amalgam, 16-26 white phosphorus, 21-92 universal numbering system, 7-13
instruments, 16-4 Dental readiness, 2-6
restorations, 16-29 C Diet Therapy, 13-10
Amputations, 21-63 Digestive system, 6-96
Anesthetics, 18-22 Carious lesions, 8-3
accessory organs, 6-103
general, 18-22 Cavity preparation, 16-27
alimentary canal, 6-97
local, 18-22 Cell, 6-4
Directives issuance system, 2-3
regional, 18-22 Charting, 15-5
correspondence, 2-3
Anticoagulants, 18-21 abbreviations/acronyms, 15-5, 15-6
maintaining directives, 2-4
Antiseptics, 18-10 general, 15-6
types and purposes of directives, 2-3
At-sea disposition, 25-10 markings, 15-8
Disposition of personal effects, 25-14
ceremony record forms, 25-11 Chemical warfare, 23-1
Dressings and bandages, 20-1
putrefied remains, 25-10 agents, 23-5
battle dressing, 20-1
Authorized Dental Allowance List (ADAL), decontamination, 23-7, 23-9, 23-10, 23-
definition of a bandage, 20-2
5-30 12, 23-13
definition of a dressing, 20-1
Authorized Medical Allowance List personal protection, 23-4
Drug abuse, 22-28
(AMAL), 5-30 Circulatory system, 6-44
management of drug-intoxicated patients,
Autopsy, 25-4 blood, 6-44
22-34
Avulsions, 21-63 blood vessels, 6-50
Drug and Alcohol Abuse Prevention and
heart, 6-46
Control Program, 3-8
B Cold injuries, 21-95
Contingency supply blocks, 5-29 E
Bacteriology, 19-18 assembling the block, 5-29
bacteria classification, 19-18 managing the block, 5-30 Eligibility of treatment, 3-2
bacteriologic methods, 19-20 – 19-21 Controlled substances, 18-40 Endocrine system, 6-80
common bacteria, 19-20 accountability, 18-40 pancreas, 6-86
Basic dental procedures, 16-22 inventory of, 18-42 pituitary gland, 6-82
Biological warfare, 23-14 regulations/responsibilities, 18-40 thyroid gland, 6-83
agents, 23-17 schedules, 18-40 Environmental hygiene, 12-28
decontamination, 23-18, 23-20 – 23-25 security of, 18-41 aesthetics, 12-28
personal protection, 23-16 survey of, 18-42 concurrent and terminal cleaning, 12-28
Blood collection, 19-4 Cremation, 25-10 climate control, 12-29
finger puncture, 19-5 Cricothyroidotomy, 21-14 lighting, 12-28
universal bloodborne Environmental injuries, 21-87
pathogens/precautions, 19-4 D chemical burns, see Burns
venipuncture (vacutainer method), 19-6 cold exposure injuries, 21-90
Blood count, 19-13 Death certificates, 25-14
electrical burns, see Burns
complete, 19-13 civil, 25-14
sunburn, see Burns
differential white blood cell, 19-15 conus, 25-14
thermal burns, see Burns
hematocrit (packed cell volume) for shipment, 25-14
white phosphorus burns, see Burns
determination, 19-14 oconus, 25-15
Escorts, 25-12
hemoglobin determination, 19-14 Decedent Affairs, 25-1
duties of the escort, 25-13
red blood cell count, 19-13 eligibility, 25-3
inside CONUS escorts, 25-13
total white blood cell count, 19-14 programs, 25-1
outside CONUS escorts, 25-13
Breathing aids, 20-13 Defense Enrollment Eligibility Reporting
selection of escorts, 25-13
artificial airways, 20-18 System (DEERS), 3-2
special escorts, 25-13
bag-valve mask ventilator, 20-17 Dental caries, 8-2, 24-2
pocket face mask, 20-18 Dental classifications, 15-5
suction devices, 20-18 Dental examinations, 15-1
use of oxygen (O2), 20-20 pre-examination duties, 15-1
Burns, 21-87 patient preparation, 15-1
chemical, 21-91 Dental instruments, 16-2
electrical, 21-91
Index-1
F I Medical record (continued)
security and safekeeping, 4-35
Family Advocacy Program, 3-8 Inpatient medical care, 12-1 verification, 4-16
Federal Supply Catalog system, 5-5 orthopedic patient, 12-9 Medication administration, 18-2
Federal supply classification system, 5-5 surgical patient, 12-3 rights of, 18-6
national stock numbers, 5-6 terminally ill patient, 12-23 Medication classifications, 18-7
terminology, 5-7 Integumentary system, 6-11 Medication incompatibilities,
Female reproductive system, 6-117 skin function, 6-11 contraindications and adverse effects,
external accessory organs, 6-120 skin structure, 6-11 18-33
female reproductive cycle, 6-122 Interpersonal relations, 11-4 Microscope, 19-11
internal accessory organs, 6-119 age, 11-6 care of the microscope, 19-13
ovaries, 6-117 culture, 11-5 focusing the microscope, 19-12
Filing health records, 4-12 gender, 11-5 framework, 19-11
First aid equipment and supplies, 20-1 race, 11-5 illumination system, 19-11
Fleet marine force (FMF), 2-6 religion, 11-5 magnification system, 19-12
support to, 2-6 Inventory management, 5-12 Morphine use for pain relief, 21-61
fleet hospitals, 2-7 procedures, 5-13 casualty marking, 21-62
FMF dental support, 2-7 types of inventories, 5-13 morphine administration, 21-61
FMF medical support, 2-7 Mortuary Services, (see Procurring
Forms, 4-3 J Mortuary Services)
Medical/Dental Record, 4-16 Muscles, 6-33
Joints, 6-29
Abstract of Service and Medical History contraction, 6-34
classifications, 6-29
(NAVMED 6150/4), 4-28 contraction and recovery, 6-34
types of joint movements, 6-31
Adult Preventive and Chronic Care Flow extensibility and elasticity, 6-34
Sheet (DD2766), 4-20 L fatigue, 6-34
Chronological Record of Medical Care maintenance of muscle tissue, 6-34
(SF 600), 4-25 Labeling prescriptions, 18-39 major skeletal, 6-35
Consultation sheet (SF 513), 4-29, 15-29 Laceration, 21-62 stimulus for contraction, 6-34
Dental Exam (EZ603), 4-33 Legal implications in medical care, 3-9 tissues, 6-35
Dental Health Questionnaire (NAVMED abuse and neglect, 3-16 tonicity, 6-34
6600/3), 4-31 assault and rape, 3-15
Medical Board Report (NAVMED consent requirements for treatment, 3-9 N
6100/1) 4-29 delivery of a patient under arrest, 3-14
Record of Occupational Exposure to incident reports, 3-11 National cemeteries, 25-17
Ionizing Radiation, (DD Form 1141), prisoner patients, 3-15 eligibility for interment, 25-17
4-28 Lesions, 8-1 honors, 25-18
Report of Medical Examination, (DD types, 8-3 national cemetery classifications, 25-17
2808), 14-9 Liquid disinfectants, 10-2 scheduling, 25-18
Report of Medical History (DD 2807), Lungs, 6-88 vaults, 25-18
14-6 Lymphatic system, 6-56 viewing remains, 25-18
Four-Handed Dentistry, 16-17 lymph nodes, 6-60 Naval plots and cemeteries, 25-18
passing and receiving instruments, 16-18 pathways of the lymphatic system, 6-56 NAVMEDLOGCOM Manuals,
zones and positions, 16-17 Publications, and Directives, 5-3
Fungus test(KOH), 19-23 M NAVSUP Manuals, Publications, and
Directives, 5-3
G Male reproductive system, 6-113 Navy Medicine’s Quality Assurance
external accessory organs, 6-116 Program, 3-5
Group interments, 25-18 internal accessory organs, 6-115 Necrotizing Ulcerative Gingivitis (NUG),
Management of infectious waste, 9-19 8-6
H Management of musculoskeletal injuries, Nervous system, 6-61
21-72 autonomic nervous system, 6-72
Health and wellness, 11-1
Medical conditions and law enforcement central nervous system, 6-65
Health records, 4-1
personnel, 3-13 impulse transmission, 6-64
closing, 4-17
Medical readiness, 2-5 nerves, 6-64
filing, 4-12
Medical record, 4-1 neuron, 6-63
opening, 4-3
closing health records, 4-17 peripheral nervous system, 6-68
verifying, 4-16
cross-servicing health records, 4-36 Notification of death, 25-3
Heat exposure injuries, 21-93
dealing with lost, destroyed, or illegible method of reporting casualties, 25-3
Historical Significance, 1-1
health records, 4-19 personnel casualty report, 25-3
disposing of health records during Notification of next of kin, 25-4
hospitalization, 4-36 condolence letter, 25-4
health record custody, 4-35 confirmation of the casualty, 25-4
primary and secondary, 4-1
Index-2
Nutrients, 13-3 Physical examinations (continued) R
types of, 13-3 – 13-7 routine physical examinations, 14-2
occupational health medical surveillance Radiation, 17-3, 23-26
O examinations, 14-4 dermatitis, 23-33
overseas/operational suitability screening safety, 17-3
Opening health records, 4-3 types, 23-27
examinations, 14-4
active duty enlisted personnel, 4-4 units, 23-28
special duty physical examinations, 14-3
active duty officers, 4-3 Radiological Warfare, 23-26
Physical examination testing procedures and
reservists, 4-4 decontamination, 23-34
equipment, 14-16
Orthopedic devices, 12-13 personal protection, 23-30
audiogram, 14-18
Orthopedic patient, 12-9 Releasing medical information, 3-11, 4-36
color vision testing, 14-17
management of bone injuries, 21-72 Reporting, 2-1
electrocardiogram, 14-18
management of joint and muscle injuries, Reproductive system, 6-113, 6-117
visual acuity, 14-16
21-80 female, 6-117
Physical Readiness Program, 3-9
Poisoning, 22-1 male, 6-113
P reproductive cycle, 6-122
absorbed poisons, 22-9
Patient assessment, 21-26 assessment and treatment of patient, 22-2 Respiratory system, 6-88
anaphylactic reaction, 21-35 diagnosis of poisoning, 22-3 Riot control agent(s), 23-10
cardiac emergencies, 21-34 general treatment, 22-4
cerebrovascular accident, 21-26 ingested poisons, 22-4 S
complications in childbirth, 21-52 inhalation poisons, 22-8 Salivary glands, 6-40
convulsions, 21-27 injected poisons and envenomations, Security medical records, 4-35
dermatologic emergencies, 21-28 22-9 Sensory system, 6-73
diabetic emergencies, 21-40 Position and direction, terms, 6-1 Serology, 19-22
drowning, 21-27 Preparation and processing remains, 25-9 Shock, 21-19
childbirth emergencies, 21-49 burial clothing, 25-9 anaphylactic, 21-36
poisons/drug abuse/hazardous materials, caskets, 25-10 cardiogenic, 21-23
21-38 certificate of death (overseas), 25-9 hypovolemic, 21-20
psychiatric emergencies, 21-27 initial preparation, 25-9 neurogenic, 21-22
scene assessment, 21-25 inspection of remains, 25-10 septic, 21-21
syncope, 21-26 overseas facilities, 25-9 stages, 21-20
Patient Contact Programs, 3-6 placement of remains in casket or transfer Skeletal system, 6-14
Patient education, 11-10 case, 25-10 divisions, 6-16
Patient eligibility for hospitalization and Prescriptions, 18-34 Skin, 6-11
nonfederal care, 3-1 authorized prescribers, 18-37 Smallpox, 23-23
Patient Relations Programs, 3-6 filing prescriptions, 18-38 SOAP note, 11-12
Patient safety, 12-24 parts of the prescription, 18-35 Social Security Number (SSN), 4-5
environmental safety, 12-24 Preventive medicine, 9-1 Soft tissue injuries, 21-62
general safety, 12-27 food-service sanitation, 9-1 management of, 21-63
Patient rights and responsibilities, 11-1 habitability, 9-1 Splinting, see management of
Payments and Collections, 25-15 immunizations and communicable musculoskeletal injuries
headstones and markers, 25-16 diseases, 9-2 Standard precautions, 9-8, 19-4
memorial service for non-recoverable sanitation, 9-1 Sterilization, 10-6
remains, 25-16 vector and pest control, 9-1 area, 9-6
primary expenses, 25-16 wastewater treatment and disposal, 9-4 functional flow, 10-6
secondary (interment) expenses, 25-16 water supply, 9-3 methods, 10-13
transportation expenses, 25-16 Procuring mortuary services, 25-7 processing, 10-7
Personal traits, 11-4 annual contracts, 25-7 storage and issue, 10-7
integrity, 11-4 authorized services, 25-7 Stock, 5-2
personal appearance, 11-4 one-time contracts, 25-7 control, 5-2
Pharmacology, 18-1 private arrangements, 25-7 level, 5-6
Pharmacy calculations, 18-24 Professional ethics, 11-3 objective, 5-7
conversion, 18-27 Professional practice, 11-2 rotation, 5-19
metrology and calculation, 18-24 accountability, 11-2 Suitability screening, 14-4
percentage calculations, 18-28 patient advice, 11-3 Supply, 5-7
ratio and proportion calculations, 18-28 patient behavior, 11-3 BUMED-controlled items, 5-8
Pharmaceutical instruments, 18-30 professional limitations, 11-2 levels of supply, 5-7
Pharmaceutical preparations, 18-29 professional books and publications, 5-9
Physical examinations, 14-1 purchases, 5-11
types of, 14-2 requisitions, 5-9
medical board examinations and reports,
14-4
Index-3
T Transportation of remains, 25-11 W
authorized methods, 25-11
Teeth, 6-40 CONUS, authorized from/to, 25-12 Waste, 9-19
identification, 7-13 expenses, 25-15 infectious waste disposal, 9-22
location of, 7-11’ TRICARE, 3-4 infectious waste storage, 9-21
surfaces, 7-14 Triage, 21-2 infectious waste treatment, 9-22
types of, 7-12 Non-tactical, 21-2 regulated waste disposal, 9-22
Temporal mandibular joint (TMJ), 6-33 Tactical (S.T.A.R.T.), 21-4 Wounds, 21-62
Terminal digit filing system, 4-12 amputation, 21-63
Thermal burns, see Burns U avulsion, 21-63
Tissue(s), 6-6 laceration, 21-62
connective, 6-7 Ultrasonic cleaning, 10-9 puncture, 21-62
epithelial, 6-6 Universal precautions, 19-4
Tissue(s) (continued) Urethra, 6-112 X
muscular, 6-8 Urinalysis, 19-23
preservation, 19-25 X-ray, 17-2
nerve, 6-10
routine, 19-25 dental chair, 17-2
of teeth, 7-5
Urinary system, 6-107 equipment preparation, 17-27
cementum, 7-6
bladder, 6-111 film log, 17-5
dentin, 7-6
kidney, 6-107 film viewer, 17-3
enamel, 7-5
function, 6-110 film processing, 17-37
pulp, 7-6
medical machine, 17-2
of the oral cavity, 7-8
gingiva, 7-9
V of the ankle, 17-24 – 17-26
of the chest, 17-11, 17-12
hard palate, 7-8 Vasoconstrictors, 18-20 of the hand, 17-8 – 17-10
Tooth formation, 7-1 Vitamins, 13-7, 18-21 patient preparation, 17-7
Tooth morphology, 7-18 Viral infection, 8-8 dental procedures, 17-27
Tourniquet, 20-11, 21-64 Virus, 9-7, 23-15
application of, 21-64 Hemorrhagic fever, 23-24 Y
C-A-T®, 20-11 Smallpox, 23-23
Toxicology, 18-1 Young’s rule, 18-2
Traumatically extracted teeth, 24-14
Transfer of medical records, 4-16 Z
Zones and Positions, 16-17
transfer, 16-17
Index-4
ASSIGNMENT 1
Book Assignment: “Heritage of the Hospital Corpsman,” pages 1-1 to 1-9
1-1. Which of the following is the key to 1-6. The first Hospital Corps School for
service with distinction? Women Accepted for Volunteer Emergency
Service was commissioned where?
1. Honor and Courage
2. Customer Service 1. Hospital Corps School, Great
3. Professional ethics Lakes, IL
4. Stellar performance 2. U. S. Naval Hospital Pensacola, FL
3. National Naval Medical Center,
Bethesda, MD
1-2. The importance of having medical care 4. U. S. Naval Hospital , San Diego,
onboard naval vessels was reinforced on CA
____.
1. Secretary of Defense
1-3. The area called the sick bay today was 2. Secretary of War
originally referred to as what? 3. Secretary of the Navy
4. Secretary of State
1. Cockpit
2. Sickcall
3. MTF 1-8. What was the original rating insignia of
4. Ward the Hospital Corps?
1. Caduceus
1-4. The first member of the Hospital Corps 2. Red Cross
to be awarded the Medal of Honor was? 3. Gold Oak Leaf
4. Blue Cross
1. Hospital Apprentice Eugene Soucy
2. Hospital Apprentice Robert Stanley
3. Loblolly Boy Russ 1-9. Shock Trauma Platoons (STP) were first
4. Pharmacist Mate Moore deployed during the Afghanistan phase of
the War on Terror.
1
1-11. The Dental Technician rating was
established ___________.
1. 12 January 1944
2. 02 April 1948
3. 07 December 1941
4. 12 December 1947
1. Wichita Falls, TX
2. San Diego, CA
3. San Antonio, TX
4. Ft. Bragg, NC
1. 50%
2. 20%
3. 40%
4. 65%
2
ASSIGNMENT 2
Book Assignment: “Expeditionary Medicine Administration,” pages 2-1 to 2-9
2-1. The following should be reported to the 2-5. Change transmittals should be filed with
OOD for inclusion into the duty log. ________ on top?
1. True
2. False
1
2-10. Medical and dental personnel must be 2-15. FMF dental units maintain dental
aware of planned operations so they can readiness during all of the following
____. EXCEPT:
2-11. Which element of medical readiness is 2-16. Fleet Hospital mission and personnel
used to correct individual medical readiness requirements are set by _______________.
deficiencies?
1. Chief of Naval Operations (CNO)
1. Dental Readiness 2. Combatant Commander (COCOM)
2. Immunizations 3. Type Commander (TYCOM)
3. Deployment Limiting Conditions 4. Chairman, Joint Chiefs of Staff
4. Periodic Health Assessment (CJCS)
2-12. Personnel in these dental classifications 2-17. Fleet hospitals are used in operations
go to the head of the line for treatment prior that are less than 60 days in duration.
to deployment.
1. True
1. Class 1 and 2 2. False
2. Class 1 and 4
3. Class 3 and 4
4. Class 2 and 3 2-18. Who directs the actions of the Naval
Mobile Construction Battalion when
responding to a natural disaster, i.e.
2-13. A patient in Class 2 dental status means? Hurricane Katrina?
2
ASSIGNMENT 3
Book Assignment: “Healthcare Administration Programs,” pages 3-1 to 3-16
3-1. Which of the following is not a HM 3-5. How many days after receiving
administrative responsibility during the treatment does a patient have to present a
operations of a medical clinic? valid ID card before being billed as a
Civilian Humanitarian Non-indigent?
1. Greeting the patient entering the
clinic or inpatient floor 1. 15
2. Opening the clinic and making 2. 30
coffee 3. 45
3. Providing initial clinical 4. 60
documentation
4. Assisting with the referral process
3-6. Who may delay billing on a patient not
presenting with a valid ID?
3-2. Which system was implemented to
assist in the projection and allocation of 1. Commanding Officer
cost for healthcare programs? 2. Personnel Officer
3. Third Party Collections
1. DEERS 4. Patient Billing
2. DIRS
3. ALHTA
4. DENCAS 3-7. What is the length of time a newborn
can be treated without presenting a valid ID
card?
3-3. Instances where the beneficiary has a
valid ID card and DEERS shows the 1. 60 days
individual ineligible, or not in the database, 2. 90 days
eligibility verification by ID Card overrides 3. 6 months
DEERS. 4. 1 year
1. True
2. False 3-8. Which of the following Foreign Military
Personnel are not eligible for care at Naval
MTF’s?
3-4. In cases where a patient presents
without a valid ID card and does not appear 1. NATO personnel stationed in the
in DEERS, non-emergent care will still be U.S.
rendered. 2. Crew of visiting aircraft
3. Crew of NATO ships in port
1. True 4. Foreign military on vacation in the
2. False U.S.
1
3-9. Which of the following is not a type of 3-14. The Patient Relations Program is the
dental care? only program that strives to enhance
channels of communication between the
1. Routine hospital, staff, and patient populations.
2. Special
3. Emergency 1. True
4. Elective 2. False
3-10. Treatment that is necessary to relieve 3-15. Which program allows patients to voice
pain, control bleeding, and manage septic their satisfactory or unsatisfactory
conditions falls under Special Types of complaints, including those concerning
dental care. treatment?
2
3-18. Physical readiness testing is required to 3-23. Who is recommended to act as a witness
be conducted by subordinate commands, when the patient is consenting to a medical
who’s medical departments are responsible procedure?
for all of the following EXCEPT?
1. Family Member
1. Providing technical assistance to 2. Staff member not involved in the
BUPERS procedure
2. Conducting lifestyle, fitness, and 3. Staff member involved in the
obesity research procedure
3. Assisting in the development of 4. Another medical provider
exercise prescriptions
4. Process waivers for completing the
PRT 3-24. Under the Freedom of Information Act
the Navy must make all documents available
EXCEPT those that are exempt.
3-19. Failure to obtain consent prior to
initiation of medical treatment may result in 1. True
medical malpractice and/or assault and 2. False
battery.
1. True
2. False 3-27. Personal Health Information is required
to be disclosed for all of the following
reasons EXCEPT?
3-22. What legal doctrine serves as the final
authority over and determines the control of 1. Treatment
substitute consent? 2. Security
3. Payment
1. Hospital Rules 4. Health Care Operations
2. Federal Law
3. State Law
4. The Joint Commission
3
3-28. Under what act is it unlawful for the 3-32. All military prisoners with active
United States military to be used as an sentences are allowed to receive medical
enforcer or to assist in the enforcement of care.
federal or state law?
1. True
1. Privacy Act 2. False
2. HIPPA Security Act
3. Freedom of Information Act
4. Posse Comitatus Act 3-33. Where can the HM locate guidance on
care, evaluation, and medico-legal
documentation for a victim alleged of rape
3-29. Who is authorized to deliver an Active or sexual assault?
Duty member to federal law enforcement
authorities and based upon what actions? 1. NCIS
2. OPNAVINST 1752.1
1. Commanding Officer, presentation 3. SECNAVINST 5800.11
of a federal warrant 4. NAVMEDCOMINST 6310.3
2. Medical Officer, presentation of a
federal warrant
3. Executive Officer, presentation of a 3-34. What is the reason many legal battles
federal warrant are lost?
4. Commanding Officer, presentation
of an accusation 1. Victim refuses to speak out
2. Improper documentation of
medical treatment
3-30. Prisoners as patients categorized under 3. Failure to adhere to proper
all of the following categories EXCEPT? administrative procedures
4. The many mistakes made by
1. Family member prisoners Hospital Corpsman, nurses, and
2. Enemy POW and other detained medical providers
personnel
3. Non-military federal prisoners
4. Military prisoners
4
ASSIGNMENT 4
Book Assignment: “Medical Records,” pages 4-1 to 4-38
4-1. Custody of health records is generally 4-5. When a HREC is opened on a service
vested in the medical department. On ships member, the member should be directed
without a medical department representative, to read and sign the Privacy Act Statement
an individual retains custody of the record inside the back cover of the HREC.
until which of the following times, if any?
1. True
1. Transfer 2. False
2. Transfer with verification every 6
months
3. Transfer with annual verification 4-6. Entries to the Chronological Record
4. Never of Medical Care, SF 600, when not
typewritten, should be made in which
color(s) of ink?
4-2. When a member is hospitalized in a
foreign nation and the ship departs port, the 1. Blue
health record is? 2. Black or blue-black
3. Red
1. Retained on board 4. Ink color is irrelevant
2. Turned over to the hospital
3. Forwarded to the nearest U.S.
consulate or embassy 4-7. What is the preferred form on which to
4. Turned over to another U.S. vessel record admission to the hospital?
in port
1. SF 509, Medical Record-Progress
Report
4-3. The health record jacket of PO3 2. SF 600, Chronological Record of
Walter T. Door, 333-44-5555, would Medical Care
be what color? 3. NAVMED 6150/4, Abstract of
Service and Medical History
1. Blue 4. NAVMED 6150/20, Summary of
2. Almond Care
3. Orange
4. Pink
4-8. A health record is opened in which of
the following cases?
4-4. The health jackets of flag or general
officers should be annotated to reflect 1. When a member returns to active
their rank. duty from the retired list
2. When the original record has been
1. True lost
2. False 3. When first becoming a member of
the naval service
4. In all the above cases
1
4-9. A well known research group requests 4-13. A member separated for disability
medical information to use as part of the should receive a copy of the HREC to
basis of a study it is performing. What present to the VA so that the member’s
action, if any, should be taken prior to claim can be processed expeditiously.
release?
1. True
1. None; an individual’s medical 2. False
information may not be released
2. Commanding officer of the MTF
should release information 4-14. Which of the following FMP codes will
immediately be placed in the two diamonds preceding
3. Commanding officer of the MTF the SSN for an active duty member?
should check with the Judge
Advocate General for advice 1. 01
4. Commanding officer of the MTF 2. 20
should forward the request to 3. 30
BUMED for guidance 4. 60
4-10. In which of the following circumstance 4-15. Which of the following phrases is
should the health record be verified? written in the lower portion of the patient’s
identification box for retired 0-7 and above
1. Reporting to a new command personnel?
2. When transferring
3. Annually 1. “VIP”
4. All of the above 2. “ADMIRAL”
3. “FLAG/GENERAL OFFICER”
4. “ATTENTION ON DECK”
4-11. Under which of the following
circumstances would a member’s health
record NOT be closed? 4-16. Which of the following symbols and
which color of felt-tip pen is used in the
1. Transfers to a new duty station alert box if the patient has an allergy or
2. Transfers to the Fleet Reserve sensitivity?
3. Placed on the retired list
4. Declared missing in action 1. “A/S” Black
2. "X” Red
3. “A/S” Red
4-12. On which of the following documents 4. “X” Black
would a notation be made concerning a
member’s status as a deserter?
1. SF600
2. NAVMED 6100/1
3. NAVMED 6150/2
4. Both 1 and 3
2
4-17. Which, if any, of the following color For questions 4-21 through
felt-tip pens is used to mark the annual 4-29, use the following diagram:
verification section on the right-hand side of
the dental record jacket? A. SF 600
1. Red B. PHS-731
2. Blue C. DD 2766
3. Black
4. None of the above D. SF 513
E. DD 771
1. A
4-19. Where is the DD 2005, Privacy Act 2. D
Statement located in the NAVMED 3. E
6150/21-30? 4. H
1. Back cover
2. Back of front page (Part I) 4-22. Routinely used for inpatient admission
3. Back of center page (Part III) and filed in the IREC.
4. Front of center page (Part II)
1. I
2. B
4-20. Where is the Disclosure Accounting 3. F
Record located in the NAVMED 6150/21- 4. H
30?
3
4-24. Adult Preventive and Chronic Care 4-30. Dental Exam Forms should be filed in
Flow Sheet which section of the NAVMED 6150/21-
30?
1. I
2. C 1. Back of center page (Part III)
3. E 2. Front of center page (Part II)
4. F 3. Inside back cover (Part IV)
4. Inside front cover (Part I)
1. A
2. I 4-33. When using the terminal digit filing
3. B system, how many equal sections are the
4. C central files divided into?
1. 100
4-28. Dental Exam Form 2. 200
3. 300
1. F 4. 50
2. G
3. H
4. I 4-34. All forms documenting patient care
placed in the NAVMED 6150-21/30 will
contain which of the following patient
4-29. Dental Treatment Form information?
4
4-35. Which of the following NAVMED
Forms is the Health Record Receipt?
1. NAVMED 6150/1
2. NAVMED 6150/6
3. NAVMED 6150/7
4. NAVMED 6150/8
1. 3 months
2. 6 months
3. 1 year
4. 2 years
5
ASSIGNMENT 5
Book Assignment: “Medical Logistics,” pages 5-1 to 5-30
5-1. Where would the HM locate the policies For questions 5-6 and 5-7 use the following
and guidance for operating and managing diagram:
procedures of supply departments and
activities? 6515 — 00 — 123 — 4567
A B C D
1. NAVSUP 485
2. OPNAVINST P-485
3. NAVMEDCOMINST 4850 Select from the diagram above the numbers that
4. NAVSUP P-485 best fits the classification.
1. Requisitioning objective
5-4. Any item that has an application and 2. Supply Level
appears on APL, SNSL, ISL, or Naval Ship 3. Stockage objective
Systems Command is known as what? 4. Operating level
1. Consumable
2. Non-consumable 5-9. A Controlled Substance Inventory is
3. Repair part conducted how often?
4. Standard stock item
1. Weekly
2. Monthly
5-5. How many digits are included in the 3. Annually
Federal Supply Classification? 4. Bi-annually
1. 4
2. 3
3. 2
4. 1
1
5-10. The end user must complete all of the
following EXCEPT upon receipt of items?
1. Sign
2. Date
3. Circle Amount
4. Place a check by each item
received
1. DD 200
2. DD 1348
3. DD 1348-1
4. DD 1200
1. Discrepancy report
2. DD 365
3. Report of Discrepancy
4. DD 374
1. DD 364
2. NAVMED 3640
3. NAVSUP 364
4. SF 364
1. True
2. False
1. True
2. False
2
ASSIGNMENT 6
Book Assignment: “Human Anatomy and Physiology,” pages 6-1 to 6-122
6-1. When the body is in the anatomical 6-6. That portion of a cell containing all the
position, the thumbs point? genetic material important in the cell’s
reproduction is called the?
1. Medially
2. Laterally 1. Plasma membrane
3. Anteriorly 2. Nucleus
4. Posteriorly 3. Cytoplasm
4. Reticulated endothelium
1
6-11. Bones of the cranium include which of 6-16. The prominence easily felt on the inner
the following? and outer aspects of the ankle are called?
6-12. The axial skeleton is composed of which 6-17. Bones that develop within a tendon are
two regions of the skeletal system? known as which of the following?
6-13. The upper three ribs on each side are 6-18. Moving an extremity away from the
known as which of the following types? body is called?
1. True 1. Flexion
2. False 2. Extension
3. Floating 3. Abduction
4. Sternal 4. Adduction
6-14. The concavity into which the head of the 6-19. The act of straightening a limb in known
humerus articulates is called the? as?
1. Scapula 1. Flexion
2. Acetabulum 2. Extension
3. Glenoid fossa 3. Abduction
4. Epicondyle 4. Adduction
6-15. The innominate bone is composed of 6-20. The primary function of the muscles
three parts that are united in adults to form a includes all of the following EXCEPT?
cuplike structure called the?
1. Providing heat during activity
1. Glenoid fossa 2. Maintaining body posture
2. Acetabelum 3. Producing red blood cells
3. Symphysis pubis 4. Providing movement
4. Obturator Foramen
2
6-21. Which of the following properties 6-25. Intramuscular injections are frequently
describes the ability of muscles to respond given in which of the following muscles?
to a stimulus?
1. Trapezius
1. Contractility 2. Pectoralis majoris
2. Irritability 3. Deltoid
3. Extensibility 4. All of the above
4. Tonicity
3
6-30. In an accident victim suffering from a 6-35. The pulse pressure is the difference
fibrinogen deficiency, the rescuer may have between which of the following
difficulty performing which of the actions measurement?
listed below?
1. Venous and arterial pressure
1. Controlling hemorrhage 2. Resting and active pulse rate
2. Immobilizing a fracture 3. Arterial and ventricle pressure
3. Supporting respiratory function 4. Systole and diastole
4. Reducing a dislocation
4
6-40. Of the following nerves, which, if any, 6-45. Circulation and respiration are
controls the larynx during the process of controlled primarily from what area of the
breathing? brain?
1. Phrenic 1. Medulla
2. Intercostal 2. Pons
3. Vagus 3. Cerebral cortex
4. None of the above 4. Cerebellum
6-41. A nerve, cell, or neuron is composed of 6-46. The meninges, which cover the outer
all of the following EXCEPT a/an? portion of the brain and spinal cord are
composed of all the following EXCEPT?
1. Synapse
2. Axon 1. Dura mater
3. Perikaryon 2. Pia mater
4. Dendrite 3. Arachnoid membrane
4. Foramen magnum
6-42. The impulse receptors of a nerve are
called?
6-47. In what part of the body is cerebral
1. Dendrites spinal fluid produced?
2. Schwann cells
3. Ganglia 1. Central Ventricles
4. Neurons 2. Spinal cord
3. Meninges
4. Medulla Oblongota
6-43. The space through which a nerve
impulse passes from one neuron to another
is called a/an? 6-48. The 12 pairs of cranial and 31 pairs
spinal nerves form what nervous system?
1. Myelin sheath
2. Synapse 1. Peripheral
3. Axon 2. Central
4. Ganglion 3. Autonomic
4. Sympathetic
1. Cerebral cortex
2. Cerebellum
3. Pons
4. Temporal lobe
5
For questions 6-50 through 6-52, use the 6-52. The autonomic nervous system is
following diagram: composed of two main divisions.
6-50. This nerve allows you to stick out your Select the nervous system that is most
tongue. responsible for the symptom or function given.
1. D
2. G 6-54. Increased heart rate.
3. J
4. L 1. A
2. B
3. C
6-51. This nerve receives sensory input from 4. D
the face.
6
6-56. Decreases heart rate to within normal 6-61. An insufficient secretion of thyroxin is
limits characterized by all of the following
EXCEPT?
1. A
2. B 1. Weight gain
3. C 2. Fatigue
4. D 3. Profuse sweating
4. Slowed heart rate
1. Secreted directly into the gland, 6-63. Electrolyte balance is a function of the
tissue, or organ it influences hormone produced by the?
2. Directed to the gland, tissue, or
organ by a duct system 1. Posterior lobe of the pituitary gland
3. Secreted into the circulatory system 2. Anterior lobe of the pituitary gland
4. Typically produced in large 3. Cortex of the adrenal gland
quantities 4. Medulla of the adrenal gland
7
6-66. The cornea is part of the protective outer 6-71. The mechanical transmission of sound
layer of the eye called the? from the tympanic membrane to the inner
ear is a function of which of the following?
1. Sclera
2. Conjunctiva 1. Auditory ossicles
3. Choroid 2. Eustachian tubes
4. Crystalline body 3. Bony labyrinth
4. Organ of corti
8
6-76. Of these listed below, which function as 6-81. Testosterone production is a function of
the accessory organs of digestion for the which of the following glands?
small intestines?
1. Cowper’s
1. Pancreas, liver, and villae 2. Prostate
2. Spleen, liver, and gallbladder 3. Testes
3. Pancreas, pylorus, and spleen 4. Bulbourethral
4. Pancreas, liver, and gallbladder
1. 250 ml
2. 300 ml
3. 600 ml
4. 750 ml
9
ASSIGNMENT 7
Book Assignment: “Oral Anatomy and Physiology,” pages 7-1 to 7-33
7-1. Dental development usually begins in 7-6. The part of the crown that is visible in
which week of prenatal life? the mouth is known by which of the
following terms?
1. Fourth
2. Fifth 1. Clinical crown
3. Sixth 2. Clinical tooth
4. Either 2 or 3 3. Clinical enamel
4. Clinical exposure
1. 32 1. Apex
2. 20 2. Furcation
3. 15 3. Bifurcated
4. 10 4. Trifurcated
7-3. What is the name of the last period of 7-8. The tip of each root is known by which
tooth growth? of the following terms?
1. Histodifferentiation 1. End
2. Morphodifferentiationy 2. Arch
3. Eruptodifferentiation 3. Angle
4. Both 2 and 3 4. Apex
7-4. How many years does it take 7-9. When there is a slight indentation that
permanent teeth to emerge after crown encircles the tooth and marks the junction
completion? of the crown with the root, it is known by
which of the following terms?
1. One
2. Two 1. Bifurcation
3. Three 2. Cervical line
4. Four 3. Clinical line
4. Junction line
1
7-11. What is the chief function of the pulp? 7-16. The hard palate is covered with what
type of mucosa?
1. Provides feeling to the tooth
2. Formation of cementum 1. Masticatory
3. Formation of dentin 2. Specialized
4. Formation of enamel 3. Lining
4. Rugae
2
7-21. How many dental quadrants are in the 7-26. What is the name of the system that is
mouth? used by the armed forces to identify teeth?
7-22. How many primary teeth are there in a 7-27. Primary teeth are identified by which
normal deciduous mouth? letters of the alphabet?
1. 30 1. A to W
2. 20 2. A to V
3. 16 3. A to U
4. 12 4. A to T
7-23. Which of the following reasons affect 7-28. The mesial surface of a tooth is located
how teeth are formed? in which area?
7-24. What type of shape does the lingual 7-29. The distal surface of a tooth is located
surface of an incisor have? in which area?
7-25. Cuspids are designed to perform what 7-30. A tooth has how many proximal
type of function? surfaces?
3
7-31. The inter-proximal space is occupied 7-36. What is the term used to describe the
by what type of anatomy? appearance of a mandibular first bicuspid?
1. Embrane 1. Bell-ringer
2. Interdental klingons 2. Bell-crowned
3. Interdental papilla 3. Bell-cusp
4. Interdental contact 4. Bell-shaped
7-32. The anteroposterior curve is referred to 7-37. What tooth will have a fifth cusp on it?
by what term?
1. Maxillary first molar
1. Curve of Koffax 2. Maxillary second molar
2. Curve of Wilson 3. Mandibular first molar
3. Curve of Splee 4. Mandibular second molar
4. Curve of Spee
1. I 1. Groove
2. II 2. Fossa
3. III 3. Cusp
4. IV 4. Pit
7-34. The mesial margin of a maxillary 7-39. What is the name of the dental anatomy
central incisor meets the incisal edge at that has small, rounded projections of
almost what degree angle? enamel from the incisal edges of newly
erupted anterior teeth?
1. 30
2. 90 1. Oblique ridge
3. 110 2. Cusp ridge
4. 180 3. Groove
4. Mamelons
4
ASSIGNMENT 8
Book Assignment: “Oral Pathology,” pages 8-1 to 8-14
8-1. Which of the following conditions does 8-5. May be caused by biting, denture
the science of Oral Pathology NOT treat? irritation, toothbrush injury, viruses, or other
irritants.
1. Nature of the disease
2. Surgical procedures 1. C
3. Causes of the disease 2. D
4. Development of the disease 3. E
4. G
1. 150 ml 1. A
2. 750 ml 2. E
3. 1500 ml 3. F
4. 1750 ml 4. G
For questions 8-4 through 8-10, use the 8-8. A small elevation that contains fluid.
following diagram:
1. A
A. Abscess 2. B
B. Cyst 3. C
C. Ulcers 4. D
D. Vesicles
E. Hematoma
F. Petechiae 8-9. Large, purplish-red areas caused by
G. Ecchymoses blood under the skin or mucosa.
1. A
8-4. An enclosed pouch or sac that contains 2. E
fluid or semi-solid material. 3. F
4. G
1. A
2. B
3. C
4. E
1
8-10. Commonly caused by a bacterial 8-15. Smooth surface caries develop in what
infection. area of a tooth?
1. A 1. Depressions
2. C 2. Pulp chamber
3. E 3. Incisal third
4. F 4. Proximal surfaces
8-11. When dental caries first appear on 8-16. Pulpalgia commonly occurs after which
enamel, what is that appearance? of the following procedures has been
performed on a tooth?
1. A chalky white spot
2. A small brown spot 1. Extraction
3. A hollowed out hole 2. After a restoration
4. All of the above 3. Before a restoration
4. After placement of gutta-percha
2
8-20. What chronic disease is the most 8-25. The gingiva surrounding a periodontal
prevalent in mankind? abscess will have which of the following
appearances?
1. Periapical
2. Periodontal 1. Red and hard
3. AIDS 2. Hollow and swollen
4. HIV 3. Bleeding and swollen
4. Inflamed and swollen
3
8-30. What are the two types of neoplasms 8-35. Which of the following conditions
that can be diagnosed in oral cancer? causes attrition?
1. Transdermal 1. Erosion
2. Transfusion 2. Attrition
3. Transferism 3. Abrasion
4. Metastasis 4. Impaction
1. At death
2. After birth
3. At birth
4. Before birth
4
ASSIGNMENT 9
Book Assignment: “Preventive Medicine and Infection Control,” pages 9-1 to 9-31
1. True 1. Idophors
2. False 2. Bleach
3. Chlorhexidine Gluconate
4. Chlorine
9-5. ______are instruments that frequently
contact mucous membranes, but cannot be
sterilized because of their design or inability
to withstand heat.
1. Semicritical items
2. Unit Dose
3. Pre Vacuum Sterilizer
4. Critical items
1
9-10. When the HM is preparing for a surgical 9-15. What type of mask should be worn
case, what is the maximum length of the when in contact with a patient diagnosed
fingernail? with Tuberculosis?
1. Airborne
2. Droplet 9-19. What Transmission-based Precaution
3. Contact requires limited transport EXCEPT for
4. All the above essential purposes?
1. Airborne
2. Droplet
3. Contact
4. All the Above
2
9-20. What are daily measures taken to 9-25. While in the process of doing a minor
control the spread of pathogenic organisms? procedure the HM’s glove is punctured by a
suture and it breaks the skin, should the HM
1. Portal of exit report it to occupational health?
2. Concurrent Disinfection
3. Reservoir of infectious agents 1. No, because it’s a minor procedure
4. Susceptible host 2. Yes, any puncture injury with
possible contaminated fluid should
be reported
9-21. In a DTR, at the beginning of the day, 3. No, because the patient says he
the unit water lines and hoses should be doesn’t have anything
flushed for how long? 4. Maybe, if I bleed a lot
1. 5 minutes
2. 1 hour 9-26. Needles, scalpels and sutures should be
3. 1 minute disposed of in what container?
4. 30 seconds
1. Thick red bag with Biohazard
symbol
9-22. For equipment that is difficult to clean, 2. Cardboard box
what should be done before using it on a 3. Linen bag
patient? 4. Rigid, puncture resistant, red
container with a biohazard symbol
1. Spray-Wipe Spray
2. A sterile or clean drape
3. Sterilize 9-27. Bed linens, towels, smocks, trousers,
4. Wet-vac and other protective attire are classified as
what?
1. 3 minutes
2. 1 minute 9-28. What is the term used to describe the
3. 30 seconds sterilization, storage and handling of articles
4. 5 minutes to keep them free of pathogenic organisms?
3
9-29. What gear must be worn to enter a
surgical suite?
1. Scrubs
2. Hair cover
3. Mask
4. All the above
1. Scrub tech
2. Circulator
3. Surgeon
4. All of the above
4
ASSIGNMENT 10
Book Assignment: “Disinfection and Sterilization,” pages 10-1 to 10-22
10-1. Disinfection is a more lethal process 10-6. What level of a disinfectant and sterilant
than sterilization. are glutaraldehyde-based solutions classified?
1. True 1. Medium
2. False 2. High
3. Low
4. Both 2 and 3 above
10-2. Which of the following levels of
disinfectants are classified by the EPA?
10-7. Which of the following is a
1. Low, middle, and high disadvantage when using chlorine dioxide-
2. Low, high, and medium based solutions?
3. Maximum, low, and high
4. Intermediate, high, and low 1. Has a 24-day use life as a sterilant
2. Does not readily penetrate
inorganic debris
10-3. What two types of micro-organisms are 3. Must be discarded daily
killed by all three levels of disinfection? 4. All of the above
10-4. What are the three factors that influence 10-9. The biocidal activity of iodophors is
germicidal procedures? accomplished with how many minutes of
exposure?
1. Bioburden, nature of the material,
and organic debris present 1. 1 to 25
2. Organic debris present, type of 2. 10 to 25
sterilizer, and bioburden 3. 15 to 25
3. Nature of the material, bioburden, 4. 20 to 25
and packaging
4. Bioburden, packaging, and type of
sterilizer 10-10. What level of disinfection are iodophors
and phenolics classified?
1
10-11. All semi-critical category items should 10-16. In what area of the CSR will the HM
receive what level of disinfection? take contaminated instruments after
completion of a patient’s treatment?
1. Intermediate
2. High 1. Issue
3. Middle 2. Receiving
4. Low 3. Processing
4. Sterile storage
1. CRS 1. One
2. SRC 2. Two
3. CSR 3. Three
4. CPR 4. Four
10-14. Which chart tells CSR personnel the 10-19. What type of cleaning effect does an
specific order equipment, instruments, and ultrasonic cleaner provide?
materials are to be processed?
1. Cavitation
1. Figure eight 2. Positive
2. Functional area 3. Gravity
3. Functional flow 4. Ion
4. Functional system
2
10-21. How often must ultrasonic solutions be 10-26. The period during which sterilized items
changed? are considered safe for use is known by
which of the following terms?
1. Daily only
2. When visibly contaminated only 1. Safe zone
3. Both 1 or 2 above 2. Event-rotated shelf life
4. Monthly 3. Expiration date only
4. Both 2 and 3 above
3
10-31. When storing sterilized items, how 10-36. What is the least expensive form of heat
should they be arranged? sterilization?
4
10-41. Instruments being sterilized in the
STERRAD do not need to be completely
dry.
1. True
2. False
1. Prevacuum
2. Gravity
3. Sterris
4. Plasma
1. Internal
2. Incubator type
3. Biological
4. Both 1 and 2
1. Internal
2. External
3. Universal
4. Biological
5
ASSIGNMENT 11
Book Assignment: “Fundamentals of Patient Care,” pages 11-1 to 11-14
11-1. The concepts of health include? 11-5. A patient requests the HM’s advice
concerning the care they are undergoing.
1. The absence of disease or disability Which, if any, of the following is the
2. Soundness of mind, body, and appropriate response?
spirit
3. Both 1 and 2 above 1. Answer honestly, to the best ability
4. A feeling of euphoria possible
2. Refer the patient to the nurse or
physician responsible for the
11-2. Patient rights and responsibilities are care
standards addressed by what organization? 3. Say, “I will ask the supervisor”
4. None of the above
1. Commander, Navy Medical
Command (formerly Bureau of
Medicine and Surgery)
11-6. Personal and medical information
2. American Medical Association learned about a patient as the result of the
(AMA) HM position is privileged and must not be
3. The Joint Commission (TJC) shared with unauthorized individuals.
4. National League of Nursing
(NLN) 1. True
2. False
1
11-8. Culture
11-13. The most common cause of ineffective
1. A communication and the most difficult
2. B obstacle to identify is which of the following
3. C barriers?
4. D
1. Psychological
2. Physical
11-9. Race 3. Psychosocial
4. Spiritual or religious
1. A
2. B
3. C 11-14. In the communication process, listening
4. D is a critical skill and can be improved by
developing which, if any, of the
following attitudes and behaviors?
11-10. A patient who is a professed atheist is
placed on the Very Serious List (VSL) 1. Anticipating what the patient will
with a poor prognosis for recovery. All of say
the following actions by the staff are 2. Managing distractions
considered appropriate and ethical 3. Taking notes
EXCEPT? 4. None of the above
1. True
2. False
1. Hearing impairment
2. Age
3. Education
4. All the above
2
For questions 11-16 through 11-19, use the 11-21. Patient education is the responsibility of
following diagram: ______.
1. A
11-19. Directing the patient to the pharmacy to 2. B
fill a prescription. 3. C
1. A
2. B 11-23. A patient claims to have swallowed
many respiratory problems pills and
complains of sleepiness and nausea.
11-20. Which of the following are goals of
patient health education? 1. A
2. B
1. Promoting patient self-care 3. C
2. Promoting behavior modification
3. Influencing a patient’s attitude
toward health and disease 11-24. A patient complains of chest pain and
4. All the above has difficulty breathing.
1. A
2. B
3. C
3
11-25. When picking up a patient’s dinner tray,
the HM notices that only the liquids have
been consumed at this meal, although the
patient has normally eaten full meals before
this.
1. A
2. B
3. C
1. A
2. B
3. C
4
ASSIGNMENT 12
Book Assignment: “Inpatient Care,” pages 12-1 to 12-29
1
12-9. When caring for a young, otherwise 12-14. When climbing stairs the patient should
healthy orthopedic patient requiring be taught to go “up with the bad and down
immobilization, the HM can anticipate all with the good.”
of the following EXCEPT what?
1. True
1. Symptoms of emotional stress 2. False
2. Frequent complaints of sore or
aching pain
3. Periods of dizziness associated with 12-15. Which of the following are safe to walk
disorientation on with crutches without much thought to
4. A deterioration of skin tone and safety?
function
1. Uneven sidewalk
2. Thick carpet
12-10. Unless otherwise directed by the 3. Hardwood floor with throw rugs
physician, when one is applying a cast to an 4. None of the above
arm, the patient’s wrists is generally in
which of the following positions?
12-16. Which ambulatory device provides the
1. Extended about 10 degrees most stability?
2. In the neutral position
3. Flexed about 30 degrees 1. Walkers
4. In any of the above; specific 2. Canes
position is immaterial 3. Quad Cane
4. Crutches
2
12-19. Patient falls may be avoided by taking 12-23. Environmental hygiene is directed
which of the following preventive toward producing a healthy environment and
measures? includes such practices as maintaining unit
cleanliness and ________ .
1. Proper use of bed/gurney side rails
2. Keeping floors dry and uncluttered 1. Providing for adequate ventilation
3. Instructing patients on the proper 2. Limiting noise levels
use of walking aids (crutches, 3. Proper disposal of soiled articles
canes, etc.) 4. All of the above
4. All of the above
1. True
2. False
3
ASSIGNMENT 13
Book Assignment: “Nutrition and Diet Therapy,” pages 13-1 to 13-15
13-1. What is the leading cause of nutrition 13-6. What is total amount of water that a
related diseases in the environment in which female needs to consume on a daily basis?
humans live?
1. 3 liters
1. Energy balance 2. 3.7 liters
2. Weight gain 3. 2 liters
3. Excess calories 4. 2.7 liters
4. Weight loss
1
13-11. Some polysaccharides are known to 13-16. Glucose
contain up to how many carbon molecules?
1. A
1. 10 2. B
2. Hundreds 3. C
3. Thousands
4. Trillions
13-17. Lactose
A. Monosaccharide
B. Disaccharide 13-19. The recommended fiber intake for
C. Polysaccharide women is?
2
13-22. Proteins contain what amount of calories 13-27. What vitamins are fat soluble?
per gram?
1. A, B, C, and E
1. 2 2. A, D, E, and K
2. 3 3. B6, B12, A, and D
3. 4 4. D, E, K, and B6
4. 5
1. True
13-24. For a person who weighs 185 lbs, what 2. False
is the recommended amount of protein that
should be consumed daily?
13-30. The most common phospholipids is bile;
1. 67 grams where is it produced?
2. 68 grams
3. 69 grams 1. Liver
4. 70 grams 2. Stomach
3. Spleen
4. Pancreas
13-25. Infants and children require a greater
daily protein intake then adults.
13-31. Which of the following is not a water
1. True soluble vitamin?
2. False
1. C
2. B6
13-26. The main role of fats is to? 3. A
4. B12
1. Aid in the absorption of
carbohydrates
2. Collect unused salts 13-32. Which vitamin interferes with anti-
3. Supply energy to the body clotting medications such as warfarin?
4. Fats have no role
1. K
2. A
3. B6
4. Niacin
3
13-33. Surgical patients should eat cantaloupe 13-38. What type of diet is normally ordered
and strawberries containing Vitamin ____ in for an individual who has not eaten for a few
order to support wound healing. days or recovering from surgery?
13-34. Which of the following is not considered 13-39. Which of the following diets is NOT
a major mineral? nutritionally complete?
13-35. Which of the following is not considered 13-40. A dental liquid diet is usually indicated
a trace mineral? for a patient who?
13-36. Infusing too much ______ in an 13-41. Which of the following diets is usually
intravenous line can cause death. lower in fiber?
13-37. Surgical patients who do not consume 13-42. Calorie restricted diets should be at least
enough of _____ mineral found in shellfish how many calories per day?
could have poor wound healing.
1. 1000
1. Iodine 2. 1100
2. Zinc 3. 1200
3. Copper 4. 1300
4. Iron
4
13-43. What type of diet is in indicative of
renal or hepatic disease?
1. None
2. Half
3. 1
4. 2
1. Enteral
2. Parenteral
3. Oral
4. All of the above
1. NG Tube
2. J Tube
3. Both 1 and 2
4. ET Tube
1. Breakfast
2. Lunch
3. Dinner
4. Food Pyramid
5
ASSIGNMENT 14
Book Assignment: “Physical Examinations,” pages 14-1 to 14-20
14-1. What two agencies have established 14-5. A member separating after serving 30 or
uniform physical standards for entry into less consecutive days on active duty, being
military service? found unfit for continued service, which of
following may be appropriate?
1. SECNAV and BUMED
2. DoD and DON 1. Memorandum for Understanding
3. SECDEF and BUPERS 2. Notice of Eligibility
4. DoD and BUMED 3. Letter of Intent
4. Cited MEBR
1
14-9. Who is responsible for reviewing the 14-14. The Armed Forces Vision Tester, is
Abbreviated Medical Board Report for used to for which type of vision test?
accuracy in content and processing time?
1. Distant
1. Patient Administration Officer 2. Near
2. Service Member 3. Binocular
3. MTF 4. Both 1 and 2
4. LIMDU Coordinator
1. DD 2808 1. True
2. NAVMED 6100/5 2. False
3. NAVMED 1300/1
4. DD 2697
14-17. Audiometric testing may be performed
by any uncertified healthcare provider (i.e.
14-12. Patients should be instructed to do all of Hospital Corpsman, Nurse) that is available
the following when they return for a visual to perform the test.
acuity examination EXCEPT?
1. True
1. Arrive 15 minutes early 2. False
2. Don’t wear contact lenses
3. Bring in contact lenses
4. Bring in glasses 14-18. How many leads are used in a 12-lead
EKG?
2
14-19. Along what plane do the precordial
leads record the heart’s electrical
conduction?
1. Vertical
2. Transverse
3. Saggital
4. Horizontal
1. 5th
2. 3rd
3. 4th
4. 7th
3
ASSIGNMENT 15
Book Assignment: “Dental Examinations,” pages 15-1 to 15-30
15-2. When seating the patient for a dental 15-6. Which of the following personnel may
exam, where should the dental light be perform a Type 4 dental screening
positioned to avoid shining the light in the evaluation?
patient’s eye?
1. A dental officer
1. Above the patient’s mouth 2. A dental hygienist
2. Beneath the patient’s chin 3. A qualified dental assistant
3. Above the patient’s forehead 4. All of the above
4. Beneath the patient’s chest
1
15-9. What dental classification indicates that 15-13. When charting the top section of the
the patient’s dental condition, if not treated Forensic Examination form, what symbol
or followed up, could have the potential, but should be used to indicate missing teeth or
is not expected to, result in dental teeth not visible in the patient’s mouth?
emergencies within the next 12 months?
1. O
1. Class 1 2. //
2. Class 2 3. X
3. Class 3 4. =
4. Class 4
2
15-18. When charting a Forensic Examination, 15-22. What number of Angle classifications
what method, if any, should be used to could be used on the Forensic Examination
describe the differences between gold and form?
other alloy restorations?
1. One
1. Indicate in the “Remarks” section 2. Two
the specific restoration alloy 3. Three
2. Inscribe horizontal lines in the 4. Four
chrome alloy
3. Black
4. None of the above 15-23. On the Forensic Examination, what
method should be used to indicate that a
15-19. When charting, how should it be patient does NOT have a soft tissue
indicated that gold material was used in a condition?
fixed partial denture?
1. Write “none” in the Soft Tissue
1. Inscribe vertical lines Remarks section
2. Inscribe horizontal lines 2. Write “none” in the Hard Tissue
3. Inscribe diagonal parallel lines Remarks section
4. Outline each aspect of the FPD 3. Write “no existing conditions” in
the Soft Tissue Remarks section
4. Leave blank if a condition does not
15-20. What procedure should be used to chart exist
the presence of supernumerary teeth?
1. Insert a “D” in the location on the 15-24. Where in the occlusion section of the
tooth number line Forensic Examination should the HM
2. Insert a “S” in the location on the document and record any other occlusal
tooth number line conditions not listed?
3. Draw an outline of the tooth in its
approximate location 1. Section A
4. Both 2 and 3 2. Section B
3. Remarks
4. Hard Tissue Remarks
15-21. The remarks section of the Forensic 15-25. Which of the following non-pathologic
Dental Examination is used to differentiate findings should be annotated in the “Hard
between which of the following types of Tissue Remarks” section on the Forensic
dental materials? Examination form?
1. Sealants 1. Tori
2. Temporaries 2. Rotated teeth
3. Composites 3. Intrinsic staining
4. All of the above 4. All of the above
3
15-26. What procedure should be used when a 15-31. Which dental form provides a record of
patient requires the completion of a new initial accession exam and all subsequent
Current Status form? periodic, annual, recall, and separation
exams?
1. Complete Box 1 of the Current
Status form 1. SF 87
2. Complete Boxes 1 and 2 of the 2. SF 603
Current Status form 3. EZ 603
3. Transfer the information from the 4. EZ 600
previous forms to the new form
4. A patient’s Current Status form
should not need to be replaced 15-32. What part of the S.O.A.P includes the
reason for the visit and a statement of the
chief complaint?
15-27. Which of the following conditions
should be annotated in pencil in Box 1 of the 1. Subjective
Current Status form? 2. Objective
3. Assessment
1. Carious lesions 4. Plan
2. Periridicular lesions
3. Indications for root canal treatment
4. All of the above 15-33. What part of the S.O.A.P is generally
used by the examiner to make a diagnosis?
4
15-36. The back of the EZ 603 may be 15-41. Which form should be used to refer a
overprinted with a command specific patient to another specialist or to medical for
format. further evaluation or treatment?
1. True 1. SF 2808
2. False 2. SF 513
3. SF 515
4. EZ603
15-37. Which of the following forms should be
used to document dental treatment 15-42. Which section of the Consultation Sheet
completed from the treatment plan, dental should be left blank for the person receiving
emergencies, and any other narrative dental the form to document his or her findings?
findings?
1. Reason for request
1. DD 2808 2. Provisional diagnosis
2. SF 513 3. Consultation report
3. EZ600 4. Place of consultation
4. EZ603A
1. Front desk
15-40. Which of the following entries should 2. Operative
be annotated in Box 44 on the report of the 3. Oral surgery
Medical Examination form? 4. Oral diagnosis
1. Dental Classification
2. Type of dental exam
3. Qualified “YES” or “NO”
4. Patient’s dental defects
5
ASSIGNMENT 16
Book Assignment: “Operative Dentistry,” pages 16-1 to 16-33
16-1. Operative dentistry is concerned with 16-6. An amalgam condenser is often referred
the prevention and treatment of defects of to as which of the following instruments?
what tooth surfaces?
1. Carvers
1. Enamel and cementum 2. Burnishers
2. Enamel and dentin 3. Pluggers
3. Dentin and cementum 4. Carriers
4. Cementum only
1
16-11. The working end of a rubber dam punch 16-16. Extensions on the wide #2 matrix bands
is designed with which of the following are known by which term?
mechanisms?
1. Bumps
1. Plunger and spindle 2. Aprons
2. Plunger and wheel 3. Wings
3. Wheel and spindle 4. Circles
4. Spindle and clamp
2
16-21. The transfer zone is located between 16-26. The needle end of a carpule is sealed
which positions? with a rubber membrane held in place by
what type of material?
1. 8 and 11 o’clock
2. 2 and 4 o’clock 1. Metal band
3. 3 and 6 o’clock 2. Rubber band
4. 4 and 8 o’clock 3. Copper band
4. Plastic band
16-24. In what zone will the instrument 16-29. What type of cavity is present when
exchange between the dentist and the three or more surfaces are involved?
assistant take place?
1. Large
1. Operator 2. Small
2. Assistant 3. Medium
3. Transfer 4. Complex
4. Static
3
16-31. What is the last cutting step in the 16-36. What BUMED instruction contains
preparation of a cavity? information of the Mercury Control Program
(MCP)?
1. Finishing the tooth walls
2. Finishing the dentin walls 1. 6260.30
3. Finishing the enamel walls 2. 6260.20
4. Finishing the occlusal walls 3. 6360.30
4. 6360.20
16-33. What two materials are used in a cavity 16-38. Which of the following composite resins
preparation to protect the pulp? is available for use in operative dentistry?
16-34. What material is used to seal the 16-39. What composite shade will appear if the
dentinal tubules to help prevent tooth becomes dehydrated?
microleakage in a cavity preparation?
1. Darker
1. Bases 2. Lighter
2. Cements 3. Transparent
3. Amalgam 4. Chalky white
4. Cavity Varnish
16-40. What type of matrix may be placed on
the tooth before the acid procedure begins?
16-35. What instrument will the dentist use to
bring any excess mercury from the amalgam 1. Wood
to the top of the restoration? 2. Metal
3. Rubber
1. Carver 4. Celluoid
2. Hatchet
3. Burnisher
4. Mouth mirror
4
16-41. Glass ionomer cement will bond directly
with which of the following tooth surfaces?
1. Enamel
2. Dentin
3. Cementum
4. All of the above
5
ASSIGNMENT 17
Book Assignment: “Radiology,” pages 17-1 to 17-47
17-1. Which scientist first discovered X- 17-6. The time setting on the X-Ray machine
Rays? is measured by using which of the following
methods?
1. Wilhelm Konrad Roentgen
2. Doctor H. G. Gama 1. Minutes or impulses
3. Doctor Otto Proton 2. Minutes or milliamperes
4. Raymond Cathode 3. Fractions of a second or
milliamperes
4. Fractions of a second or impulses
17-2. What is the name of the tube that was
discovered in 1895?
17-7. Which of the following instruction is
1. Crooke’s tube most important when ordering radiographs
2. Roentgen’s tube for female patients?
3. Walkoff tube
4. Evacuating tube 1. Have the patient remove her
eyeglasses
2. Have the patient remove her
17-3. Which of the following is NOT a earrings
characteristic property of X-Rays? 3. Ask the patient is she has any type
of denture
1. They travel in straight lines 4. Ask the patient if she is pregnant
2. They travel at the speed of sound
3. They cause irritation to living cells
4. They cause certain substances to 17-8. The film badge should be placed behind
fluoresce the lead-lined barrier at least what number
of feet from the tube head?
17-5. When taking radiographs, always drape 1. Always stand behind a lead screen
the patient with a lead apron. during an exposure
2. Never stand in the path of the
1. True central X-Ray beam during
2. False exposure
3. Never hold the tube head or the
tube head cylinder of the X-Ray
machine during exposure
4. Hold the film packet in the
patient’s mouth during exposure if
necessary
1
17-10. Which of the following personnel are 17-15. Which of the following structures will
authorized to order and diagnostically be seen in the AP projection of the cervical
interpret dental radiographs? spine?
17-11. How often should the surfaces in the 17-16. A patient presenting with chronic
dark room be disinfected? cervical spine pain should be ordered what
type of radiograph?
1. Daily
2. Weekly 1. KUB
3. Bi-weekly 2. AP Cervical Spine
4. Monthly 3. Pelvic
4. Chest PA
2
17-20. The bisecting angle technique is the 17-25. What X-Ray machine settings should
preferred method and recommended for you use when exposing a maxillary occlusal
routine use when taking periapical radiograph on an adult?
radiographs.
1. 10 mA, 87kVp, and 60 impulses
1. True 2. 12 mA, 90kVp, and 60 impulses
2. False 3. 10 mA, 90kVp, and 60 impulses
4. 12 mA, 87kVp, and 40 impulses
1. True 1. True
2. False 2. False
3
17-30. When checking for light leaks in the 17-35. The processing solutions used in the
darkroom, you should leave the penny on automatic processor are the same as those
the X-Ray film for at least what number of used in the manual processing procedure.
minutes?
1. True
1. One 2. False
2. Five
3. Three
4. Seven 17-36. The cleaning of the roller transports and
the solutions in the automatic processor are
accomplished at what minimum intervals?
17-31. Which of the following methods is most
commonly used to process dental 1. Twice a day
radiographs in the Navy? 2. Daily
3. Weekly
1. Laser processing 4. Monthly
2. Manual processing
3. Computer processing
4. Automatic processing 17-37. Which teeth can be identified
radiographically by a large white region
caused by the bone of the nasal septum?
17-32. Which of the following procedures
should be included in the daily maintenance 1. Mandibular incisors
of the X-Ray machine? 2. Mandibular cuspids/bicuspids
3. Maxillary incisors
1. Dusting 4. Maxillary incisors and bicuspids
2. Cleaning with a cloth moistened
with water
3. Both 1 and 2 17-38. When mounting radiographs, the raised
4. Cleaning with a cloth moistened dimple should be facing you.
with solvent
1. True
2. False
17-33. You should wait what number of
seconds between films before inserting
another film into the automatic processor? 17-39. You should attempt to complete all X-
Ray repairs yourself.
1. 10
2. 12 1. True
3. 15 2. False
4. 30
1. Daily
2. Weekly
3. Biweekly
4. Every 3 to 4 weeks
4
ASSIGNMENT 18
Book Assignment: “Pharmacy,” pages 18-1 to 18-42
18-1. Pharmacology is a basic medical science 18-6. What dose refers to the least amount of
that deals with the study of which specialty? a drug that can cause death?
1. Drugs 1. Toxic
2. Diseases 2. Minimum toxic
3. Compounds 3. Minimum lethal
4. Pharmacy operations 4. Maximum lethal
18-2. The branch of pharmacology that deals 18-7. The most common factor influencing the
with the preparation, dispensing, and proper amount of drug given to a patient is?
use of medications is?
1. Weight
1. Toxicology 2. Gender
2. Pharmacy 3. Age
3. Pharmacognosy 4. Route of administration
4. Therapeutics
1
18-11. Determine the appropriate dose in 18-15. What term is used to define a
milligrams of medication for a child medication that is placed under the tongue?
weighing 30 pounds if the average dose for
an adult is 600 mg. 1. Suboral
2. Submandibular
1. 50 3. Subcavity
2. 100 4. Sublingual
3. 120
4. 150
18-16. Which of the following is an example of
a drug injected intradermally?
18-12. In computing the amount of drug to be
given to an underweight female, what 1. Insulin
adjustments to the normal dosage would 2. Procaine hydrochloride
ordinarily be made? 3. Purified protein derivative
4. 2 or 3 above
1. Increase the dosage because of her
weight and further increase because
of her sex 18-17. What technique introduces a drug
2. Increase of dosage because of her directly into a vein?
weight but decrease because of her
sex 1. Intravenous
3. Decrease of dosage because of her 2. Infiltration
sex and further decrease because of 3. Intramuscular
her weight 4. Intradermal
4. Decrease of dosage because of her
sex but an increase because of her
weight 18-18. In what form are medications introduced
into the body through inhalation?
1. Orally
2. Parentally
3. Topically
4. Intravenously
2
18-20. Which of the following is NOT a way in 18-25. In conjunction with antacids, which of
which drugs are grouped? the following is used to treat duodenal
ulcers?
1. By chemical characteristics
2. By their brand names 1. Dimenhydrinate
3. By their source 2. Diphenhydramine hydrochloride
4. By their action on the body 3. Ranitidine
4. Pseudoephedrine hydrochloride
1. Petrolatum 1. Emollient
2. Guaifenesin 2. Laxative
3. Benzoate 3. Demulcent
4. Phenol 4. Astringent
18-23. Which of the following is a 18-28. The standard by which all other
characteristic side effect of antihistamines? antiseptics are measured is?
1. Nausea 1. Povidine-iodine
2. Drowsiness 2. Phenol
3. Uricaria 3. Isopropyl alcohol
4. Tinnitis 4. Hexachlorophene
18-24. Which of the following medications is 18-29. The primary pharmacological action of
administered to control motion sickness? sulfonamides is?
1. Cimetidine 1. Viricidal
2. Meclizine hydrochloride 2. Parasiticidal
3. Chlorpheniramine maleate 3. Bacteriostatic
4. Diphenyhdramine hydrochloride 4. Fungistatic
3
18-30. The most common use for systemic 18-35. Macrolides are effective against which
sulfonamides is in the treatment of which of of the following organisms?
the conditions listed below?
1. Gram-positive cocci
1. Respiratory infections 2. Dermatophytes
2. Urinary tract infections 3. Parasites
3. Viral infections 4. Gram-negative
4. Furunculosis
18-32. The drug of choice for uncomplicated 18-37. Undeclyenic acid is used as a/an?
group A beta-hemolytic streptococcal
pharyngitis is? 1. Disinfectant
2. Antipyretic
1. Penicillin V Potassium 3. Analgesic
2. Nafcillin 4. Antifungal
3. Ampicillin
4. Dicloxicillin
18-38. Supplemental potassium may be
required with which of the following
18-33. Patients sensitive to penicillin may also categories of drugs?
exhibit sensitivity to cephalosporins.
1. Anti-inflammatories
1. True 2. Antidiahrreals
2. False 3. Antipyretics
4. Diuretics
1. Cephalexin (Keflex)
2. Tetracycline hydrochloride
3. Streptomycin sulfate
4. Erthromycin
4
18-39. The drug of choice for the treatment and 18-44. The agent used to treat pernicious
management of grand mal seizures is? anemia is?
18-40. Prochlorperizine is used mainly to? 18-45. Which of the following is the vitamin
involved in absorption and use of calcium
1. Treat symptoms of nausea and and phosphorus?
vomiting
2. Alleviate symptoms of tension, 1. Vitamin A
agitation, and psychosis 2. Vitamin B1
3. Counteract the effects of alcohol 3. Vitamin C
withdrawal 4. Vitamin D
4. Relieve respiratory distress
1. Methocarbamol 1. gr, l, cm
2. Diazepam 2. gr, ml, m
3. Cyclobenzaprine 3. g, l, m
4. Methylphenidate 4. g, l, cm
18-42. Water-soluble vitamins are not excreted 18-47. Which of the following is equal to one
in the urine and are stored in the body in one-hundredth of a liter?
moderate amounts.
1. Dekaliter
1. True 2. Deciliter
2. False 3. Centiliter
4. Milliliter
5
18-49. You have 360 grams of a compound. If 18-54. What chapter of The Manual of the
54 grams of the compound is silver nitrate, Medical Department gives guidance on
what is the percentage strength of silver pharmacy operations and drug control?
nitrate?
1. 6
1. 12.5% 2. 9
2. 15% 3. 15
3. 17.5% 4. 21
4. 20%
6
18-59. Which of the following is a Schedule III
medication?
1. Marijuana
2. An antitussive
3. Amphetamines
4. Nonbarbiturate sedative
1. II
2. III
3. IV
4. V
1. One
2. Three
3. Four
4. Six
1. Annually
2. Bi-annually
3. Quarterly
4. Daily
7
ASSIGNMENT 19
Book Assignment: “Clinical Laboratory,” pages 19-1 to 19-30
19-1. Which of the following is considered the 19-5. A tourniquet is normally applied before
preferred source for blood specimens to aid in the process of venipuncture. At
obtained for clinical examination? what point in the venipuncture procedure
should the tourniquet be removed?
1. Venipuncture
2. Finger puncture 1. Just before needle insertion
3. Arterial puncture 2. Just after needle insertion
4. Antecubital puncture 3. Once blood flows freely into tubes
4. No longer than two minutes
1. Arm
2. Base
3. Frame
4. Mechanical stage
1
19-10. What objective should be used for a 19-15. The normal value for male hemoglobin
detailed study of stained bacterial smears? is?
19-11. A Complete Blood Count includes 19-16. What is the term used for the volume of
which of the following? erythrocytes expressed as a percentage of
the volume of whole blood in a sample?
1. Total RBC count
2. Hematocrit 1. Hematocrit
3. Differential WBC count 2. Hemoglobin
4. All of the above 3. Red Blood Count
4. Complete Blood Count
1. Leukopenia 1. Radiation
2. Anemia 2. Psittacosis
3. Dehydration 3. Anaphylactic shock
4. Uremia 4. Each of the above
2
19-20. Which study within a CBC often 19-25. When performing a WBC differential,
provides the most helpful information in which cell has the large, scattered dark blue
determining the severity and type of granules that are darker than the nucleus?
infection?
1. Lymphoctes
1. Red Cell count 2. Monocytes
2. White Cell count 3. Basophils
3. Hemoglobin 4. Neutrophils
4. WBC differential
1. Pathogen
19-23. Which leukocyte functions by ingesting 2. Virus
invading bacteria? 3. Non-pathogen
4. Flora
1. Neutrophil
2. Eosinophil
3. Lymphocyte 19-29. The difference between anaerobes and
4. Monocyte aerobes is that anaerobes need oxygen to
reproduce.
1. Neutrophil
2. Eosinophil 19-30. What is the term used to define bacteria
3. Lymphocyte that are round in shape?
4. Monocyte
1. Strep
2. Cocci
3. Rods
4. Bacillus
3
19-31. In the Gram’s stain, what is the primary 19-37. The RPR is a specific test to diagnose
stain? syphilis.
19-35. Which bacteria causes tetanus? 19-41. The best urine specimen for screening
purposes is that taken during which of the
1. Staphylococcus aureus following times?
2. Streptococcus pyogenes
3. Neisseria gonorrhoeae 1. First morning
4. Clostridium tetani 2. Random
3. Fasting
4. 24 hour
19-36. What is the term used for a substance
that, when introduced into an individual’s
body, is recognized as foreign to the body, 19-42. What is the desired urine sample volume
and causes a detectable reaction? for routine testing?
1. Pathogen 1. 10 ml
2. Antigen 2. 20 ml
3. Reagin 3. 15 ml
4. Antibody 4. 12 ml
4
19-43. Which of the following colors would be 19-49. Normal specific gravity for routine
considered abnormal in a urine sample? urinalysis is within what range?
19-44. Which urine color is most related with 19-50. The addition of one drop of 2 percent
the presence of blood? acetic acid to urine sediment will
disintegrate which cell?
1. Dark orange
2. Red 1. White blood cells
3. Yellow 2. Mucous threads
4. Olive green 3. Casts
4. Red blood cells
5
ASSIGNMENT 20
Book Assignment: “Emergency Rescue: Supplies, Equipment and Procedures,” pages 20-1 to 20-47
20-1. Why is the spica or figure eight bandage 20-5. Which statement is false concerning
used around the elbow? Normal Saline?
1. True
2. False 20-8. Which of the following is a true
statement concerning oropharyngeal airways?
1
20-9. The oropharyngeal airway is the airway 20-13. Which of the following is not a concern
of choice for patients with a gag reflex. about the distance a casualty can be
carried?
1. True
2. False 1. Weight of the casualty
2. Strength and endurance of the
stretcher bearers
20-10. The effective life of an oxygen 3. Nature of the casualty’s injuries
breathing apparatus (OBA) is? 4. The amount of radiation with
which the victim is contaminated.
1. 45-60 minutes
2. 15-30 minutes
3. 20-45 minutes 20-14. Which of the following is not a phase of
4. The canister never needs changing. Care of Patient en Route?
1. Ensure you have a dosimeter prior 20-16. When establishing a helicopter landing
to entering the area. site, the ground slope can be no more than
2. Be ready to fill out training forms ____ degrees.
prior to entering the scene of the
incident. 1. 7
3. Good judgment is confirmed when 2. 15
stopping medical personnel from 3. 10
performing their duties. 4. Helicopters cannot land on a slope.
4. Treatment of life threatening
injuries takes precedence over
decontamination procedures.
2
For questions 20-16 through 20-19, use the 20-21. In HAZMAT management situations,
following diagram: site control is divided into 3 zones. In
which zone does personnel
A. Indicates the Reactivity decontamination happen?
B. Indicates Health Hazard
C. Indicates Flammability 1. Hot Zone
D. Indicates any Special Hazards 2. Warm Zone
3. Support Zone
The National Fire Protection Association has 4. None of the above
developed a labeling system for indicating the
health, flammability, and reactivity hazards of
chemicals. The labels are made into squares to 20-22. When decontaminating personnel
comprise a diamond-shaped label. contaminated from a HAZMAT situation,
the most frequently appropriate method of
Match the color to the corresponding definition decontamination is?
in the diagram above.
1. Dilution
2. Absorption
20-17. Red 3. Chemical Washes
4. Disposal and Isolation
1. A
2. B
3. C
4. D
20-18. White
1. A
2. B
3. C
4. D
20-19. Blue
1. A
2. B
3. C
4. D
20-20. Yellow
1. A
2. B
3. C
4. D
3
ASSIGNMENT 21
Book Assignment: “Emergency Medical Care Procedures,” pages 21-1 to 21-105
21-1. All of the following are measures first 21-5. What is the method for sorting
aid is intended to address EXCEPT? casualties in a multiple casualty incident
(MCI)?
1. Save Life
2. Prevent further injury 1. F.I.N.I.S.H
3. Replace proper medical diagnosis 2. S.T.O.P
and treatment 3. Stop at the first patient I come to
4. Preserve resistance and vitality and provide for all their needs
4. S.T.A.R.T
1
21-9. Casualties with a total upper airway 21-14. A patient with a skin assessment of pale
obstruction, inhalation burns, or massive and cool and whose blood pressure dropped
maxillofacial trauma who cannot be briefly would be consider to be in what type
ventilated by other means are candidates for of shock?
a King LT® airway.
1. Neurogenic
1. True 2. Psychogenic
2. False 3. Hypovolemic
4. Cardiogenic
21-11. Distributive shock is a loss of 21-16. What is the most common cause of
intravascular volume, which may occur from shock the HM will encounter?
blood, plasma, or fluid loss.
1. Uncontrolled hemorrhage
1. True 2. Syncope
2. False 3. Dehydration
4. Sepsis
2
21-19. The general impression is crucial to 21-23. What is the acronym used when
identifying which of the following? assessing a patient during a rapid physical
exam?
1. Transport decision
2. Patient’s overall systemic condition 1. PASTHAM
3. Obvious significant external 2. ABCDE
problems 3. SAMPLE
4. All of the above 4. DCAP-BTLS
3
21-28. If a patient is hypotensive, then the 21-32. Which of the following signs and
systolic blood pressure is below what? symptoms is considered a late sign of a
hemothorax?
1. 110
2. 100 1. Deviated trachea
3. 90 2. Cyanosis
4. 80 3. Shock
4. Coughing up frothy red blood
21-30. During a patient assessment the HM 21-34. After the baby has delivered and the
notices that the patient seems to have a cord has been cut, which of the following
fruity breath odor, the HM suspects the steps is correct when delivering the
patient is suffering from ______ . placenta?
4
21-36. During Tactical Field Care, what is the 21-41. What is the first step in treating for
best way to control compressible hypovolemic shock?
hemorrhage when a tourniquet is not
amendable? 1. Maintain the Airway
2. Start an IV
1. Use combat gauze as the 3. Elevate the patients feet and keep
hemostatic agent of choice with at warm
least 3 minutes of direct pressure 4. Take BSI precautions
2. Make the tourniquet work
3. Use a large battle dressing
4. All of the above 21-42. Which type of suture material is best
used for surface closures and cause very
little tissue reaction?
21-37. What is the usual dose of morphine for
adult patients in severe pain? 1. Silk
2. Cotton
1. 2-5 mg 3. Catgut
2. 5-10 mg 4. Dermalon
3. 10-15 mg
4. 10-20 mg
21-43. The most common method of anesthesia
used by the HM is the infiltration of the
21-38. Morphine can be given to patients who anesthetizing agent into the nerve trunks that
have suffered a head injury. innervate the fingers or toes.
1. True 1. True
2. False 2. False
21-39. Which of the following steps in bleeding 21-44. For a large, gaping, soft-tissue wound, a
control are no longer utilized? primary closure is acceptable.
5
21-46. Any person who has an acute pain in the 21-51. When applying First Aid for removing
back or neck as well as a significant foreign objects, which statement below is
mechanism of injury, should be treated as NOT correct?
though there is a fractured spine, even if
there are no other symptoms. 1. Remove bullets to aid in stopping
bleeding
1. True 2. Do not attempt to remove
2. False powdered Glass
3. Do not attempt to remove widely
scattered foreign objects or
21-47. When is it acceptable to move a patient materials from the skin
with a suspected pelvic fracture? 4. Do not remove deeply embedded
objects
1. Never
2. When absolutely necessary
regardless of stabilization steps 21-52. When applying aid for animal bites,
taken what should you NEVER do?
3. When absolutely necessary after
MAST garments have been applied 1. Wash the wound and surrounding
to stabilize the pelvic region area
4. All of the above 2. Cover the wound with a clean
sterile dressing
3. Cauterize areas that are bleeding to
21-48. What method should be utilized when aid in transport
opening the airway of a patient who is 4. Transfer to nearest treatment
suspected of having a spinal cord injury? facility for evaluation
6
21-54. The rule of nines assigns what 21-59. The usual treatment for chemical burns
percentage value for burns of the anterior is to flush with copious amounts of water.
chest and anterior neck? The two exceptions to this rule are in the
case of which of the following chemicals?
1. 13
2. 14 1. Phosphoric acid and lye
3. 26 2. White phosphorus and carbolic acid
4. 28 3. Dry lime and carbolic acid
4. Sulfuric acid and carbolic acid
1. Heat Cramps
2. Heat Stroke 21-61. How many additional atmospheres of
3. Heat Exhaustion pressure are applied at a depth of 33 feet in
4. Death sea water?
1. 3
21-57. Which cold injury is a mild cold injury 2. 14.7
that happens from prolonged exposure in 3. 1
temperatures above freezing to as high as 60 4. .445
degrees F?
1. Alcohol
2. Phenol
3. Vinegar
4. Baking soda
7
21-63. A middle ear squeeze is classified under
which type of diving injury?
1. Decongestants
2. NSAIDS for pain and inflammation
3. Administer ear drops for ruptured
ear drum
4. No diving chit
1. Dalton’s Law
2. Henry’s Law
3. Boyle’s Law
4. Nature’s Law
8
ASSIGNMENT 22
Book Assignment: “Poisoning and Drug Abuse,” pages 22-1 to 22-34
22-1. Poisoning is defined as contact with or 22-6. Which of the following is the method of
exposure to a toxic substance. choice for the HM to use to induce
vomiting?
1. True
2. False 1. 15-30 cc of syrup of Ipecac
2. 2 teaspoonfuls of dry mustard in
water
22-2. Toxicology is defined as the science of 3. 2 teaspoonfuls of an active charcoal
poisons. slurry
4. To tickle the back of the victim’s
1. True throat
2. False
1. Narcotic
2. Anticholinergic 22-8. If the HM is unable to reach the poison
3. Withdrawal control center or a physician for specific
4. Non-syndrome syndrome instructions, how should the HM treat a
victim who has ingested turpentine?
1
22-10. Treatment for an inhalation poisoning 22-15. What is the key identifying feature of
victim includes all of the following the North American coral snake that
EXCEPT? distinguishes it from other snakes with
similar markings?
1. Removal from the contaminated
atmosphere 1. The yellow band is always next to
2. Administration of oxygen the red band
3. Administration of stimulants 2. The red band is always next to the
4. Treatment for shock black band
3. It has a distinctive bite pattern
4. It has deep pits below the eyes
22-11. A patient presents exhibiting signs of
anaphylactic reaction to a bee or wasp sting.
Of the following, which is NOT considered 22-16. On patrol, a member of the unit receives
appropriate treatment? a rattlesnake bite just below the elbow.
What first aid treatment should be
1. Removal of patient’s jewelry performed?
2. Subcutaneous injection of
epinephrine 1. Place a tourniquet 1 inch proximal
3. Warm packs over the sting site to the bite site
4. Removal of the stinger by scraping 2. Place a constricting band 2 inches
with a dull knife proximal to the bite site
3. Place a constricting band 2 inches
distal to the bite site below the
22-12. The victim of a scorpion sting may elbow
safely be given any of the following 4. Both 2 and 3 above
pharmaceuticals EXCEPT?
2
22-19. A person suffering from a Venomous 22-24. Which of the following is not a
Fish sting should? symptom of alcohol abuse?
3
22-29. Marijuana falls into which of the
following categories of drugs?
1. Barbiturate
2. Physically addicting
3. Cannabis
4. Harmless
4
ASSIGNMENT 23
Book Assignment: “Medical Aspects of Chemical, Biological, and Radiological Warfare,”
pages 23-1 to 23-34
23-1. When was the first large scale use of 23-6. What MOPP Level affords the most
chemical agents? protection?
1. WW I 1. 1
2. WW II 2. 2
3. Iraq War 3. 3
4. Vietnam 4. 4
23-2. Terrorists will not use chemical agents 23-7. Nerve Agents enhance the nerve
because they are difficult to make. impulses.
1. True 1. True
2. False 2. False
23-3. M9 Chemical Agent Detection Paper 23-8. Nerve agents enter the body through
turns what color if a nerve agent is present? what area.
1. Gold 1. Eyes
2. Green 2. Skin
3. Red 3. Respiratory Tract
4. Yellow 4. All the above
23-4. M8 Chemical Detection Paper turns 23-9. A MARK 1 Kit consists of?
what color when it comes into contact with
VX? 1. Atropine
2. 2-PAM CL
1. Yellow 3. CANA
2. Red 4. Both 1 and 2
3. Purple
4. Green
1. Yellow
2. Red
3. Purple
4. Green
1
23-10. For severe nerve agent symptoms give 23-16. What antidote is used for lewisite?
how many MARK 1 kits in a row?
1. Atropine
1. 1 2. BAL
2. 2 3. 2-PAM CL
3. 3 4. CANA
4. 4
1. True
23-15. Symptoms of mustard agent contact are? 2. False
1. Miosis
2. Paralysis
3. Blisters
4. Dizziness
2
23-22. Lacrimators are also known as? For questions 20-29 through
20-35, use the following diagram:
1. Tear Gas
2. Nerve Gas A. Bacteria
3. Blood Agents B. Virus
4. Chocking Agents C. Toxin
D. Fungus
23-23. Decontamination for harassment agents
Match the following examples to the class of
generally consists of?
Biological Agent.
1. Use of M291
23-27. Anthrax
2. 0.5% Bleach Solution
3. Washing with baby shampoo 1. A
4. Exposure to wind 2. B
3. C
4. D
23-24. The first priority for first aid for a
chemical agent patient is?
23-28. Plague
1. Control massive hemorrhage
2. Decontaminate exposed skin 1. A
3. Treat for shock 2. B
4. Adjust patients mask 3. C
4. D
23-25. Initial management of a chemical agent
casualty is? 23-29. Smallpox
1. Removal of MOPP gear 1. A
2. Decontamination with 0.5% 2. B
hypochlorite solution 3. C
3. Both 1 & 2 4. D
4. None of these
23-30. Ricin
23-26. What are the three types of Biological
Agents? 1. A
2. B
1. Fungus, Bacteria and Viruses 3. C
2. Fungus, Bacteria and Toxins 4. D
3. Bacteria, Viruses, and Toxins
4. Viruses, Toxins, and Fungus
23-31. Marburg
1. A
2. B
3. C
4. D
3
23-32. Botulism 23-37. Viral Hemorrhagic Fevers are susceptible
to?
1. A
2. B 1. Air
3. C 2. Phenolic Disinfectants
4. D 3. 1% Bleach Solution
4. Both 2 & 3
23-33. Ebola
23-38. A dirty bomb could be used by a
1. A terrorist organization.
2. B
3. C 1. True
4. D 2. False
23-34. Biological outbreaks that occur in 23-39. What type of radiation is sometimes
multiple geographical locations are called penetrating radiation?
classified as?
1. Alpha
1. Natural Occurrence 2. Beta
2. Intentional Release 3. Gamma
3. Both 1 and 2 4. None of these
4. Small scale
23-36. Viruses can be treated with the use of 23-42. The time of onset of which symptoms
antibiotics. will give you an estimate of radiation
dose/exposure?
1. True
2. False 1. Diarrhea
2. Nausea and Vomiting
3. Seizures
4. Ataxia
4
23-43. Once a patient is removed from a
radiation source, Chronic Radiation
Syndrome symptoms will resolve.
1. True
2. False
1. True
2. False
1. M256A1
2. M291
3. AN/PQS 2A
4. AN/VDR 2
5
ASSIGNMENT 24
Book Assignment: “Emergency Treatment for Oral Diseases and Injuries,” pages 24-1 to 24-15
24-1. The HM may provide temporary 24-5. When pain from an affected tooth
emergency dental treatment under which of manifests to a healthy, non-involved tooth,
the following conditions? what is the condition called?
1. Sinus abscess
24-3. Which of the following choices best 2. Grape abscess
describes a symptom? 3. Cellulitis
4. Gumboil
1. HM observes bleeding gums
2. HM observes a fractured tooth
3. The patient informs the HM of a 24-8. When performing an emergency
toothache treatment for a periapical abscess, what
4. All of the above instrument will be used to drain the abscess?
1
24-9. A patient with a periapical abscess may 24-14. Which of the following conditions exist
complain of which of the following if a patient complains that their gums are
symptoms? “itching”?
1. Trenchcoat
2. Trenchmouth 24-16. Which of the following solutions should
3. Foul mouth syndrome be used to irrigate the tissue flap if a patient
4. Glowing gums syndrome has pericoronitis?
1. Glycerite of iodine
24-12. What colored membrane will be 2. Warm saline solution
covering the gingiva if a patient has NUG? 3. Hydrogen peroxide
4. Flap conditioner
1. Bluish-grey
2. Reddish-white
3. Bluish-white 24-17. What are the two common types of
4. Gray-white stomatitis found in the oral mucosa?
2
24-18. Bleeding from an extraction site is 24-23. Which of the following dental materials
referred to by which of the following terms? will be used to treat a Type I fracture?
1. 1
2. 2
3. 3
4. 4
3
ASSIGNMENT 25
Book Assignment: “Decedent Affairs,” pages 25-1 to 25-19
25-1. All of the following Decedent Affairs 25-6. The Commanding Officer must write a
Programs are utilized to carry out standard letter of condolence to the appropriate NOK
responsibilities EXCEPT? within what time frame?
25-2. Which program is initiated during major 25-7. When an individual is involved in a
military operations? motorcycle or automobile accident or under
the care of a physician and death occurs,
1. Current Death they must receive an autopsy.
2. Graves Registration
3. Concurrent Return 1. True
4. Return of Remains 2. False
25-3. Which of the following will NOT 25-8. When an autopsy is desired but not
require submission of a Personnel Casualty required permission must be granted from
Report? the PADD.
1. 0600-2300 1. Priority
2. 0500-2400 2. Flash
3. 0700-2300 3. Single Address
4. 0800-2200 4. General
25-5. A CACO is normally assigned to assist 25-10. When a search and recovery operation
the needs of family members for what continues longer than 36 hours how often is
period of time? a report submitted to BUMED?
1. 30 days 1. 72 hours
2. 45 days 2. 48 hours
3. 60 days 3. 24 hours
4. 90 days 4. 12 hours
1
25-11. Which of the following determinations 25-15. Uniform.
is NOT made by Navy Mortuary Affairs?
1. A
1. Unidentifiable 2. B
2. Identification of remains 3. C
3. Unidentified, unknown 4. D
4. Group remains, known
individuals
25-16. Removal from place of death.
1. Private contract
2. Single funeral contract 25-18. Autopsy preparation.
3. Local contract
4. One time contract 1. A
2. B
3. C
For questions 23-15 through 23-19 use the 4. D
following diagram:
2
25-21. Who may be able to provide mortuary 25-26. Which of following is NOT an
services if death occurs in an area not served authorized method of primary transportation
by Navy facilities? for remains?
25-22. What form must accompany the remains 25-27. Cremated remains may be shipped to a
of a member to a CONUS point of entry CONUS point of entry via commercial air.
from OCONUS?
1. True
1. DD 2064 2. False
2. DD 1146
3. DD 771
4. DD 1141 25-28. When transporting remains of death
resulting from a communicable disease,
there is a label placed on the transfer case
25-23. How many copies of the Statement of that states ______ .
Recognition (DD 565) must accompany the
remains? 1. Contagious
2. Warning
1. 1 3. Communicable disease
2. 2 4. Infectious
3. 3
4. 4
25-29. To be selected as an escort of remains
you must meet all of the following criteria
25-24. What are the dimensions of the standard EXCEPT?
and oversized naval caskets?
1. Same branch of service
1. 24x80 and 22x77 2. From the same city
2. 25x80 and 23x77 3. Same pay grade
3. 25x81 and 22x78 4. Same status
4. 25x81 and 23x78
3
25-31. Who is ultimately responsible for
assigning an inventory board for the
personal effects of a deceased member?
1. NAVPERESCOM
2. Commanding Officer
3. Supply Officer
4. BUMED
1. MEDDEN Affairs
2. Mortuary Affairs
3. NAVPERSCOM
4. Veteran Affairs
1. DD 1375
2. DD 2062
3. MED 5360-3
4. DD 2063
1. Open
2. Closed
3. New
4. Planned
1. True
2. False