shipboard injuries and rehabilitation of united states sailors kristin r. hodapp, ms, pt, cscs lcdr,...
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Shipboard Injuries Shipboard Injuries and Rehabilitation of and Rehabilitation of United States SailorsUnited States Sailors
Kristin R. Hodapp, MS, PT, Kristin R. Hodapp, MS, PT, CSCSCSCS
LCDR, MSC, USNLCDR, MSC, USN
Presentation OverviewPresentation Overview
Navy Medicine AssetsNavy Medicine Assets Role of Aircraft Carrier Medical Role of Aircraft Carrier Medical
Department Department Role of Shipboard Physical Role of Shipboard Physical
TherapyTherapy Physical Therapy CasesPhysical Therapy Cases
Navy Medicine Navy Medicine OverviewOverview Medical Treatment Facilities Medical Treatment Facilities
(MTFs): variable level of services (MTFs): variable level of services depending on size. Typically, depending on size. Typically, patients will be medically patients will be medically evacuated to the larger MTFs. evacuated to the larger MTFs. – ““The Big Three”The Big Three”
National Medical Center BethesdaNational Medical Center Bethesda Naval Medical Center San DiegoNaval Medical Center San Diego Naval Hospital PortsmouthNaval Hospital Portsmouth
Navy Medicine Navy Medicine OverviewOverview Forward deployed medical assetsForward deployed medical assets
– Land based: Fleet HospitalLand based: Fleet Hospital– Shipboard: depends on mission/size Shipboard: depends on mission/size
of crewof crew SubmarinesSubmarines Cruisers/Destroyer or “small boys” Cruisers/Destroyer or “small boys” Amphibious Assault ShipAmphibious Assault Ship Hospital ShipHospital Ship Aircraft CarriersAircraft Carriers
Cruiser/Destroyer Cruiser/Destroyer Medical StaffingMedical Staffing
Medical staff: two junior hospital Medical staff: two junior hospital corpsmen and one Independent corpsmen and one Independent Duty Corpsmen.Duty Corpsmen.
Will MEDEVAC patients to either Will MEDEVAC patients to either the amphibious ship or aircraft the amphibious ship or aircraft carrier depending on the carrier depending on the Battlegroup assignment.Battlegroup assignment.
Amphibious Assault Amphibious Assault Ship Medical StaffingShip Medical Staffing Mission: to transport and deploy Mission: to transport and deploy
elements of a Marine landing force elements of a Marine landing force during amphibious assault during amphibious assault operations via helicopter, operations via helicopter, amphibious vehicles, and/or landing amphibious vehicles, and/or landing craft.craft.
Ship’s crew: 100+ officers and Ship’s crew: 100+ officers and 1,000+ enlisted. Marine 1,000+ enlisted. Marine detachment: 1,900 detachment: 1,900
Amphibious Assault Amphibious Assault Ship Ship Largest dental Largest dental
component for component for any combat shipany combat ship
Medical: most Medical: most extensive medical extensive medical support of combat support of combat ship with 600 ship with 600 beds and 6 beds and 6 operating rooms.operating rooms.
Hospital Ships: USNS Hospital Ships: USNS Comfort and MercyComfort and Mercy USNS Mercy is west coast based.USNS Mercy is west coast based. USNS Comfort is east coast USNS Comfort is east coast
based.based. Staff includes all major Staff includes all major
specialties, but will customize specialties, but will customize staffing depending on missionstaffing depending on mission
Hospital Ship MissionHospital Ship Mission
Provide afloat acute surgical care Provide afloat acute surgical care to the U.S. military that is flexible to the U.S. military that is flexible and uniquely adaptable to and uniquely adaptable to support expeditionary forces.support expeditionary forces.
Secondary mission is to provide Secondary mission is to provide medical care for U.S. disaster medical care for U.S. disaster relief and world-wide relief and world-wide humanitarian operations.humanitarian operations.
Hospital Ship FactsHospital Ship Facts
Total Bed capacity: Total Bed capacity: 10001000
ICU beds: 80ICU beds: 80 Minimal care beds: Minimal care beds:
500500 Recovery Beds: 20Recovery Beds: 20 Intermittent care Intermittent care
beds: 400beds: 400 Operating Rooms: Operating Rooms:
1212
Surgical Capabilities: Surgical Capabilities: – ENTENT– OrthopedicOrthopedic– OB/GYNOB/GYN– OphthalmicOphthalmic– Dental and Dental and
MaxillofacialMaxillofacial– GeneralGeneral– UrologyUrology– NeurosurgeryNeurosurgery– PlasticPlastic– CardiothoracicCardiothoracic
Non-Surgical Non-Surgical CapabilitiesCapabilities Internal MedicineInternal Medicine PediatricsPediatrics DermatologyDermatology Respiratory TherapyRespiratory Therapy Physical TherapyPhysical Therapy
Patient TransportPatient Transport
Patients primarily Patients primarily arrive either by arrive either by helicopter or helicopter or small boatsmall boat
USNS Comfort USNS Comfort Humanitarian MissionHumanitarian Mission• 4 month South4 month South
American TourAmerican Tour
• Training Training Opportunity: Opportunity:
CPR/BLSCPR/BLS
ACLSACLS
intubationsintubations
USNS Comfort USNS Comfort Humanitarian MissionHumanitarian Mission
Physical TherapyPhysical Therapy– Gait trainingGait training– Ergonomics/Ergonomics/
Patient transport Patient transport techniques to techniques to hospital staffhospital staff
– Burns/Wound CareBurns/Wound Care– Splinting Splinting – Typical Typical
Sprains/StrainsSprains/Strains
Aircraft Carrier Aircraft Carrier Medical StaffingMedical Staffing Total Medical/Dental Staff: 97 Total Medical/Dental Staff: 97 Staff:Staff:
– Senior Medical Officer (SMO)Senior Medical Officer (SMO)– General Medical Officer (GMO)General Medical Officer (GMO)– NurseNurse– SurgeonSurgeon– Nurse AnesthetistNurse Anesthetist– Physical TherapistPhysical Therapist
Aircraft Carrier Aircraft Carrier Medical StaffingMedical Staffing Clinical PsychologistClinical Psychologist Physician AssistantPhysician Assistant Radiation Health Officer (nuclear)Radiation Health Officer (nuclear) Medical Administration Officer Medical Administration Officer
(MAO)(MAO) Flight Surgeon (2-3)Flight Surgeon (2-3)
Role of Aircraft Role of Aircraft Carrier Medical Carrier Medical DepartmentDepartment
USS RONALD REAGAN USS RONALD REAGAN CVN-76CVN-76 Peace Thru Strength mottoPeace Thru Strength motto About 4.5 acres of sovereign US About 4.5 acres of sovereign US
territoryterritory One of the most dangerous jobs: One of the most dangerous jobs:
working on the Flight Deck.working on the Flight Deck.
USS RONALD REAGAN USS RONALD REAGAN (CVN-76)(CVN-76) Commissioned on Commissioned on
12 July 200312 July 2003 Ship was built in Ship was built in
Newport News, VANewport News, VA Homeport change Homeport change
“around the horn” “around the horn” cruisecruise
Maiden Deployment Maiden Deployment January-July 2007January-July 2007
Surge DeploymentSurge Deployment
USS RONALD REAGAN USS RONALD REAGAN (CVN 76)(CVN 76)
Crew size: 5300+Crew size: 5300+ As tall as the Empire State BuildingAs tall as the Empire State Building Over 80 aircraft attached to shipOver 80 aircraft attached to ship Can operate 24/7Can operate 24/7
Aircraft Carrier Aircraft Carrier Medical CapabilityMedical Capability Basic Laboratory Basic Laboratory
servicesservices Basic Radiology Basic Radiology
services services – RadiographsRadiographs– UltrasoundUltrasound– Unable to have MRI Unable to have MRI
onboard due to the onboard due to the constant motion on constant motion on ship and metal in ship and metal in shipship
Aircraft Carrier Aircraft Carrier Medical CapabilitiesMedical Capabilities Able to manufacture eye glassesAble to manufacture eye glasses Basic casting and splinting Basic casting and splinting Pharmacy technicianPharmacy technician
USS RONALD REAGAN USS RONALD REAGAN CVN-76CVN-76 Medical resources are primarily Medical resources are primarily
located in the main medical spaces located in the main medical spaces (2(2ndnd deck below the Hangar Bay). deck below the Hangar Bay).
During flight operations, special During flight operations, special manning of the Flight Deck Battle manning of the Flight Deck Battle Dressing Station (BDS) required. Dressing Station (BDS) required.
Flight Deck BDS have special Flight Deck BDS have special communications with Main Medical.communications with Main Medical.
USS RONALD REAGAN USS RONALD REAGAN CVN 76CVN 76 Medical is staffed 24/7 even when Medical is staffed 24/7 even when
in port.in port. Duty Medical staff in-port: one Duty Medical staff in-port: one
officer and minimum of four officer and minimum of four corpsmencorpsmen
Duty Medical Staff while Duty Medical Staff while deployed: minimum of eight deployed: minimum of eight corpsmen, 2 officers, and one MD.corpsmen, 2 officers, and one MD.
Shipboard 911: Medical Shipboard 911: Medical EmergencyEmergency Over the 1-MC announce location of Over the 1-MC announce location of
casualtycasualty Medical response team launched and Medical response team launched and
main medical sets up triage room.main medical sets up triage room. Communications via radio.Communications via radio. Response team consists of:Response team consists of:
3 corpsmen3 corpsmen One Independent Duty CorpsmenOne Independent Duty Corpsmen
Shipboard Medical Shipboard Medical Emergency Response Emergency Response Underway, all medical staff required to Underway, all medical staff required to
report to main medical to set up.report to main medical to set up. Approximately two minute transit time Approximately two minute transit time
to anywhere in ship.to anywhere in ship. Right of way with ladder wells and Right of way with ladder wells and
passagewayspassageways All crew members are stretcher bearer All crew members are stretcher bearer
and BLS certified. Ship minimum of and BLS certified. Ship minimum of 90% compliance.90% compliance.
Reasons for Actual Reasons for Actual Medical EmergencyMedical Emergency Chest pain/MIChest pain/MI Electrical BurnsElectrical Burns Smoke InhalationSmoke Inhalation Heat StressHeat Stress Fall Fall
– down ladderdown ladder– Flight deckFlight deck
StrokeStroke Drug OverdoseDrug Overdose Steam BurnSteam Burn SyncopeSyncope Ramp strike with Ramp strike with
pilot ejectionpilot ejection Man OverboardMan Overboard
Emergency Medical Emergency Medical Training Training All crew members are to be BLS All crew members are to be BLS
and stretcher bearer certifiedand stretcher bearer certified– Three types of stretchersThree types of stretchers– Reeves sleeve only one safe for Reeves sleeve only one safe for
ladder transportladder transport Unique transportation challenges:Unique transportation challenges:
– Island of shipIsland of ship– Main engineering spacesMain engineering spaces
Emergency Patient Emergency Patient TransportTransport
Mass Casualty Mass Casualty DefinitionDefinition Five or more injuries that taxes Five or more injuries that taxes
medical resourcesmedical resources Most likely scenarios:Most likely scenarios:
– Flight Deck accidentFlight Deck accident Called Mass Casualty by the Air BossCalled Mass Casualty by the Air Boss
– Main space fireMain space fire– Hangar bay explosionHangar bay explosion
Mass Casualty Mass Casualty
Dental officers serve as the initial Dental officers serve as the initial triage officers to sort casualties on triage officers to sort casualties on flight deckflight deck
Senior Medical Officer (SMO) and Senior Medical Officer (SMO) and surgeon divide casualties based on surgeon divide casualties based on acuity.acuity.
““Pods” set up to manage up to 10 Pods” set up to manage up to 10 patients. Staffed by 2-3 corpsmen and patients. Staffed by 2-3 corpsmen and IDC, PA, or MDIDC, PA, or MD
Mass Casualty Mass Casualty
Ancillary services role with Ancillary services role with walking wounded (PT and walking wounded (PT and Psychologist)Psychologist)
Goal to clear all patients off of Goal to clear all patients off of flight deck in 15 minutes and to flight deck in 15 minutes and to resume operationsresume operations
Mass CasualtyMass Casualty
Goal to then clear Goal to then clear hangar bay hangar bay
Overflow area is the Overflow area is the mess decksmess decks
Role of other staff: Role of other staff: – ChaplainsChaplains– Dental after initial Dental after initial
triagetriage– Admin with patient Admin with patient
trackingtracking– SupplySupply– Mess decks staffMess decks staff
Blood bank initiated Blood bank initiated by either the SMO or by either the SMO or surgeonsurgeon
Communication with Communication with Commanding OfficerCommanding Officer
Primary goal is to Primary goal is to “Fight the ship”“Fight the ship”
Mass CasualtyMass Casualty
Mass Casualty TrainingMass Casualty Training
Required to do a Mass Casualty Required to do a Mass Casualty Drill once a quarter.Drill once a quarter.
Once a year, the ship will be Once a year, the ship will be graded by an independent graded by an independent training team.training team.
Mass Casualty training is the Mass Casualty training is the surgeon’s responsibilitysurgeon’s responsibility
Related Occupational Related Occupational Health IssuesHealth Issues Low Back Pain/Injuries tracked by Low Back Pain/Injuries tracked by
Safety department.Safety department. Multiple medical surveillance programsMultiple medical surveillance programs
– RadiationRadiation– FuelsFuels– Heavy MetalsHeavy Metals– HearingHearing– TBTB– STDSTD
Shipboard Physical Shipboard Physical TherapyTherapy
Physical TherapyPhysical Therapy
On average, 60% of sick call was for a On average, 60% of sick call was for a musculoskeletal reason.musculoskeletal reason.
Prior to Physical Therapists onboard, Prior to Physical Therapists onboard, over 20 MEDEVACS/deployment with over 20 MEDEVACS/deployment with an average cost of over $70,000 with an average cost of over $70,000 with the additional loss of staffing.the additional loss of staffing.
Since PTs onboard, average of two Since PTs onboard, average of two MEDEVACs per deployment and MEDEVACs per deployment and average cost of less than $7,000.average cost of less than $7,000.
Shipboard Physical Shipboard Physical TherapyTherapy Neuromuscular expertNeuromuscular expert Casting/splinting skillsCasting/splinting skills Evaluation, treatment, and Evaluation, treatment, and
management for a return to dutymanagement for a return to duty Manual therapy skillsManual therapy skills Health Promotions OfficerHealth Promotions Officer
Neuromuscular Neuromuscular ScreenerScreener Role of Physical Therapists as a Role of Physical Therapists as a
Physician Extender.Physician Extender. Additional training in evaluation Additional training in evaluation
and therapeutic management.and therapeutic management. CredentialsCredentials
Casting/SplintingCasting/Splinting
Physical Therapy AMMAL Physical Therapy AMMAL (supplies) include materials and (supplies) include materials and prefabricated splintsprefabricated splints
Training Training Fracture managementFracture management
Return to Full DutyReturn to Full Duty
Over 90% of patients returned to Over 90% of patients returned to full duty within two weeks.full duty within two weeks.
Manual therapyManual therapy Light duty recommendationsLight duty recommendations Patient educationPatient education Barriers to return to full dutyBarriers to return to full duty
Barriers to Return to Barriers to Return to Full DutyFull Duty PsychosocialPsychosocial CrutchesCrutches SplintsSplints CastsCasts Operational TempoOperational Tempo Patient CompliancePatient Compliance
Psychosocial FactorsPsychosocial Factors
DepressionDepression AnxietyAnxiety StressStress FatigueFatigue Work Center Work Center
DynamicsDynamics
Shipboard Physical Shipboard Physical TherapyTherapy Top Diagnoses:Top Diagnoses:
- Sacroiliac Dysfunction and Low Back Sacroiliac Dysfunction and Low Back PainPain
- Patellofemoral SyndromePatellofemoral Syndrome- Plantar FasciitisPlantar Fasciitis- Shoulder ImpingementShoulder Impingement- Neck PainNeck Pain
Shipboard Physical Shipboard Physical TherapyTherapy Direct Access clinicDirect Access clinic On deployment, clinic averaged On deployment, clinic averaged
456 patient encounters per 456 patient encounters per month.month.
40% of patients were Air Wing 40% of patients were Air Wing (ship’s company approximately (ship’s company approximately 3500 vs. Air wing 1700).3500 vs. Air wing 1700).
Factors that influence Factors that influence the effectiveness of PTthe effectiveness of PT
BootsBoots Steel decksSteel decks Low ceilingsLow ceilings Poor work center ergonomicsPoor work center ergonomics People not screened for certain job People not screened for certain job
requirements (handling lines, etc)requirements (handling lines, etc) Fatigue/Poor sleep hygieneFatigue/Poor sleep hygiene Drills and work center hoursDrills and work center hours
Unique Shipboard JobsUnique Shipboard Jobs
Unique Shipboard JobsUnique Shipboard Jobs
Unique Shipboard JobsUnique Shipboard Jobs
Shipboard Physical Shipboard Physical TherapyTherapy Role of manual therapyRole of manual therapy Patient and supervisor education Patient and supervisor education Prevention programsPrevention programs
Role of Manual Role of Manual TherapyTherapy Key in the treatment of LBP and Key in the treatment of LBP and
SI painSI pain Evidence based Evidence based 45% of all PT patients required 45% of all PT patients required
manual therapy.manual therapy.
Patient and Supervisor Patient and Supervisor EducationEducation Crucial in compliance with program Crucial in compliance with program
and successful rehabilitation.and successful rehabilitation. Fine balance between mission and Fine balance between mission and
patient goalspatient goals Use of light duty recommendationsUse of light duty recommendations
– Work restrictions for max of 30-day Work restrictions for max of 30-day intervals and may be extended for intervals and may be extended for three monthsthree months
Prevention ProgramsPrevention Programs
Basic Weight-lifting gym program Basic Weight-lifting gym program and core stabilization programand core stabilization program
Back and Knee SchoolsBack and Knee Schools Running clinicRunning clinic Health Promotion programs Health Promotion programs
Deployment, Physical Deployment, Physical Therapy and Therapy and PsychologyPsychology 32% of all Physical Therapy 32% of all Physical Therapy
patients also seen by Clinical patients also seen by Clinical Psychologist.Psychologist.
Of those patients, 21% were Of those patients, 21% were diagnosed with depression.diagnosed with depression.
About 15% of all Physical Therapy About 15% of all Physical Therapy patients had chronic pain.patients had chronic pain.
Physical Therapy Physical Therapy CasesCases
Physical Therapy Physical Therapy CasesCases 19 y/o Seaman (Deck Department) with 19 y/o Seaman (Deck Department) with
sudden onset of right hand weaknesssudden onset of right hand weakness Was using sandpaper to prep steel for Was using sandpaper to prep steel for
painting the ceilingpainting the ceiling NSAIDs, light duty, wrist and hand NSAIDs, light duty, wrist and hand
bracingbracing Radial Nerve PalsyRadial Nerve Palsy EMG EMG
Physical Therapy Physical Therapy CasesCases
52 y/o active duty male with left UE and 52 y/o active duty male with left UE and LE pain and weaknessLE pain and weakness
Social h/x: occasional cigar and ETOH Social h/x: occasional cigar and ETOH useuse
60 pounds overweight60 pounds overweight Significant medical h/x: HTN and high Significant medical h/x: HTN and high
cholesterolcholesterol Family h/x: MI, hypertensionFamily h/x: MI, hypertension MEDEVAC for suspected CVAMEDEVAC for suspected CVA
Physical Therapy Physical Therapy CasesCases 36 y/o AD male36 y/o AD male Basketball injury with “pop”Basketball injury with “pop” + Thompson, Absent Achilles reflex+ Thompson, Absent Achilles reflex Watershed Achilles tendon ruptureWatershed Achilles tendon rupture Blue water operationsBlue water operations Casted in plantar flexed position Casted in plantar flexed position
before MEDEVAC.before MEDEVAC.
Physical Therapy Physical Therapy CasesCases 39 y/o pilot with right chest/UE pain39 y/o pilot with right chest/UE pain MOI: Bench pressing with sudden MOI: Bench pressing with sudden
weaknessweakness Main complaints: unable to do pushups, Main complaints: unable to do pushups,
open and close watertight doors.open and close watertight doors. Notable muscle defect insertion Notable muscle defect insertion
pectoralis major with associated pectoralis major with associated weakness and deformityweakness and deformity
Pectoralis Major insertion complete tearPectoralis Major insertion complete tear Sling, ice, and ortho consultSling, ice, and ortho consult
Physical Therapy Physical Therapy CasesCases 22 y/o AD male s/p maxilla fracture (hit 22 y/o AD male s/p maxilla fracture (hit
in face with bat)in face with bat) Pain 8/10 with HA. No dizziness.Pain 8/10 with HA. No dizziness. Exam: significant restriction 75% all Exam: significant restriction 75% all
cervical motions. Passive range of cervical motions. Passive range of motion limited due to significant motion limited due to significant guarding. TTP C3-4 spinous processes.guarding. TTP C3-4 spinous processes.
MRI while in port.MRI while in port. Infectious Disease admission for Infectious Disease admission for
epidural abscess.epidural abscess.
Physical Therapy Physical Therapy CasesCases 32 y/o AD EOD technician with neck 32 y/o AD EOD technician with neck
pain, weakness, numbness & tingling.pain, weakness, numbness & tingling. MVA: unrestrained driver and ejected MVA: unrestrained driver and ejected
with head strike. Initially seen in with head strike. Initially seen in civilian ER and released.civilian ER and released.
Abnormal AROM. TTP C3, C4, and C5 Abnormal AROM. TTP C3, C4, and C5 spinous processes. spinous processes.
MEDEVAC for fracture with subluxation MEDEVAC for fracture with subluxation of C3, C4, and C6.of C3, C4, and C6.
Questions?Questions?
Thank you for your time and Thank you for your time and attention.attention.
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