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.