T he J ournalofthe A erospace M edicine

Transcription

T h e
J o u r n a l
o f
t h e
A u s t r a l a s i a n
S o c i e t y
o f
A e r o s p a c e
M e d i c i n e
Vo l ume 6 Num ber 1 Decem ber 2011
2 | JASAM Vol 6 No 1, December 2011
Editorial. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Original Articles
What’s wrong with the Age 65 Rule? – The evolution of the Age 60 Rule
Jeff Stephenson OAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Colour perception standards in aviation: Some implications of the AAT decisions regarding
colour perception and aviation
Arthur Pape et al . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Knowledge from the Aviation Industry Adapted for the Management of Victorian Trauma Patients
Melinda Truesdale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
The Advantages of a DAME Database
Dave Baldwin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Implantable Cardiac Devices in the Military Aviation Environment
Paul Kay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Reprint
Frequent users of the Royal Flying Doctor Service primary clinic and aeromedical services
in remote New South Wales: a quality study
David L Garne et al . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2010 DINNER PRESENTATION
How to earn a Golden Caterpillar
AVM Eric Stephenson AO OBE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2012 International Congress of Aviation and Space Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2010 Annual Scientific Meeting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
2011 Annual Scientific Meeting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Honorary Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
ASAM Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
2011 Membership List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Information for Authors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
JASAM (ISSN 1449 – 3764) is the official journal of the Australasian Society of Aerospace Medicine.
© Copyright ASAM 2006
Website: www.asam.org.au
Address: PO Box 4022, BALWYN, VIC, 3103, AUSTRALIA
JASAM Vol 6 No 1, December 2011 | 3
EDITORIAL
The value of annual scientific meetings
Annual scientific meetings (ASM) have been a long standing and integral
feature of the Society’s history over the past six decades. As well as providing
a forum for the essential legal requirements for annual general meetings which
are necessary for all incorporated organisations, the ASM have provided vital
opportunities for formal and informal discussion and exchange of information
on aerospace skills, knowledge and experience. Our society has a fortunate
culture of warmth, support and camaraderie and this results in a large
percentage of members who regularly attend the ASM.
Over the past decade, there has been an increasing demand for evidence
based medicine, as well as increasingly requirements for, and now mandated,
continuing professional development, in a now highly evolved information
technology environment where computer literacy has now become an essential
skill for professionals. Our Society has adapted to these changes and this
is particularly noticeable at the ASM with the increase in the quality of the
presentations. Active involvement in presentations has been enhanced by the
use of wireless remote responders to select answers posed by presenters, and
the Society is greatly appreciative to CASA for the provision of this technology.
The introduction of a theme for the ASM over a decade ago has resulted in
selection speakers to complement the expertise of the John Lane Trust and
Patterson Trust orators. This has provided a benefit of both broadening the
content and depth of current knowledge in clinical areas resulting in review
and revision of the aerospace implications for the wider aerospace community,
and mirrors the process adopted by CASA over recent years in updating the
DAME Handbook.
Selection of a topic for the ASM has focused the energy of organising committees
as well as revealing their creative ingenuity in developing appropriate themes to
encapsulate the topic: the 2005 ASM on fatigue management was held on the
Gold Coast with the theme ‘Asleep in the sun’; mental health was the topic in
Launceston in 2006 ‘ A flight of ideas’; Avian influenza and infectious disease
was the topic in Busselton in 2007 ‘There is something in the air’; the 2008
ASM held in Darwin on commercial space flight had the theme ‘Frontiers of
aerospace medicine’; while cardiac arrhythmias were discussed in Canberra in
2010 with the appropriate theme “The heart of the nation’. The most difficult
challenge was selection of a theme for the 2011 ASM to cover the topics of
ophthalmology and endocrinology. Dr Gordon Cable is acknowledged for his
inspirational idea for the theme ‘Keeping your eye on the ball’!
One of the consequences of these changes is that feedback following the
ASMs has been very positive and frequently accompanied by the comments
‘Best one ever’. This is rewarding to the organisers as well as the committee
as it means that the ASMs are meeting the needs of our members who pursue
excellence and currency in aerospace medicine.
With the emphasis of evidence based medicine, there may be a tendency to
dismiss and devalue the opinions and experiences of individual practitioners,
often disparagingly called ‘eminence based medicine’. Those who only value
observational data are advised to read the article challenging evidence based
medicine detailing where a systematic literature review failed to reveal any
published evidence that parachutes work1. But there remains an important role
for individual experience and opinion. It is through experience that orthodoxy
may be challenged or hypotheses can be developed. There is a richness
and diversity of individual experience in aerospace medicine and this should
continue to be encouraged at ASMs.
In this edition of the journal, four articles are published from presentations
at our ASMs that relate to this concept. Our reviewers were divided on the
controversial article on colour vision in aviation by Arthur Pape, known for
his successful challenge on aviation colour vision policy to the Administrative
Appeals Tribunal2 over two decades ago. In his article, Pape again challenges
the reader and proposes that the presence of colour is neither sufficient nor
necessary for appropriate information processing. He argues his case well and
provides supportive examples. However, readers are invited to challenge the
rejection of the third assumption detailed in the article. A clue is in the ICAO
colour perception standard: “The applicant shall be required to demonstrate the
ability to perceive readily those colours the perception of which is necessary for
the safe performance of duties.”
Melinda Truesdale’s article on “Knowledge from the Aviation Industry Adapted
for the Management of Victorian Trauma Patients” discusses how the highly
successful crew resource management (CRM) developed in the aviation
industry to combat a number of accidents in which poor teamwork in the cockpit
had been identified as a significant contributing factor, can be successfully
migrated to the hospital emergency department. She provides an overview of
training of hospital staff in what she terms ‘Crisis Resource Management’.
In another different paradigm of the practice of aerospace medicine, Dave
Baldwin discusses the use of a database he uses for the conduct of aviation
medical examinations as he travels to aircrew as a flying aviation medical
examiner, as an alternative to aircrew attending his clinic. Finally, our esteemed
and highly respected honorary member, AVM (Ret) Dr Eric Stephenson AO OBE
publishes the after dinner talk he presented at the 2010 ASM at the Australian
War Memorial under the Lancaster bomber ‘G for George’ on how he gained his
‘Golden Caterpillar’. This was an inspiring personal experience of his combat
experience from World War 2 and was appropriately rewarded by a standing
ovation. May our members continue to share their aerospace experiences at
future ASMs.
Warren Harrex
References
1.Smith GCS, Pell JP. Parachute use to prevent death and major trauma related to
gravitational challenge: systematic review of randomised controlled trials. BMJ.
2003 December 20; 327(7429): 1459–1461.
2.Administrative Appeals Tribunal: Re: ARTHUR MARINUS PAPE and SECRETARY,
DEPARTMENT OF AVIATION. No. V87/494 AAT No. 3821 Air Navigation
ORIGINAL ARTICLE
What’s wrong with the Age 65 Rule? – The evolution of the
Age 60 Rule
Jeff Stephenson OAM MBBS MAvMed DipAeroRet
Abstract
For nearly 50 years in the USA, the Age 60 Rule mandated the compulsory
retirement of commercial aviation pilots upon reaching the age of 60 years.
This age-based retirement rule was recently amended to age 65 years.
The reasons behind these rules are discussed. A discussion of ageing and
its effect on the pilot is included. Alternatives to an age-based system are
provided with reference to the literature on ageing and pilot performance.
Acknowledging the role that older pilots have in the aviation environment,
some guidelines are suggested to accommodate their needs and to make the
aviation environment safer.
Introduction
The Age 60 Rule was implemented by the Federal Aviation Administration (FAA)
in 1959. Simply stated it did not permit U.S. based pilots or co-pilots engaged in
commercial passenger transport (Part 121 of the FAA regulations), to continue
flying after their 60th birthday1. This controversial rule was implemented by the
FAA in 1959 and its validity had been hotly debated and challenged ever since.
On 13 December 2007, after nearly half a century, the Age 60 Rule was altered
with the signing of a Bill called the “Fair Treatment for Experienced Pilots Act”.
When President Bush signed this Bill he effectively changed the Age 60 Rule
to the Age 65 Rule.
The reasons for the implementation of the age 60
rule – controversies and debate
The reasons provided for the implementation of the Age 60 Rule range from
the pseudo-scientific, albeit with scant objective evidence, through to the
conspiratorial. Amongst the reasons provided were the difficulties that older
pilots were encountering in transitioning to new turbo-jet aircraft and the
involvement of a 59 year old pilot in a crash of a new-model aircraft. In addition,
there was an increase in the number and percentage of older pilots and also an
increased prevalence of heart disease amongst older individuals. The principle
concerns articulated were related to the risk of sudden pilot incapacitation,
degraded performance and subtle performance decrements due to ageing2.
Amongst other theories explaining the origin of the Age 60 Rule are those
claiming that the rule was instituted to allow airlines to retire more expensive
senior captains and promote the less expensive first officers. In addition, the
airlines were able to age-retire their pilots at age 60 years, which was in
keeping with the 1950’s approach to employee management. Obviously, for
some junior pilots this was seen as a good thing – permitting them to get into
the “left seat” earlier. The main protagonists around this time were the founder
and CEO of American Airlines, C.R. Smith and Gen. E. R. Quesada the first
appointed administrator of the newly created FAA. Amongst the 10,100 web
sites found on a Google search of “Age 60 Rule” are many that allude to the
conspired “smokey back room deals” and “Age-60 Fraud” that is alleged to
have occurred9.
Author details
Dr Jeff Stephenson OAM MBBS MAvMed DipAeroRet,
Senior Medical Advisor, 3EHS, RAAF Richmond, NSW 2755
Correspondence
[email protected]
Other approaches to implementing an age 60 rule
The Joint Aviation Authorities (JAA – a 42 member aviation regulatory body
consisting of member countries from the European Civil Aviation Conference
(ECAC) also prohibits a pilot who has attained the age of 60 years from
engaging in commercial air transport operations. The JAA is slightly more
liberal than the FAA and will allow an exception to the rule for a pilot between
the ages of 60 to 65 to pilot an aircraft, where he or she is the only pilot crew
member who is over 60 years1.
The International Civil Aviation Organisation (ICAO – an international organisation
with 190 contracted states) also limits the age for a pilot and co-pilot to 60 years.
However, many of the member states have notified ICAO of their intention to not
comply with the rule – with some countries raising the limit, several lowering
the limit and some doing away with it altogether5. Australia, Canada and New
Zealand have strong anti-discrimination laws which prohibit discrimination on
age grounds and thus these countries do not implement an Age 60 Rule at all.
Evolution and studies relating to the
implementation of the age 60 rule
Principle reasons for implementing an age rule
The major considerations for implementing an “Age Rule” relate to an ageing pilot:
1.
having subtle and undetected cognitive decline and decreased
psychomotor skills;
2.being at increased risk of sudden incapacitation; and,
3.that medical screening may fail to detect which pilots are at risk for
adverse events6.
Pilot incapacitation
When the Age 60 Rule was first implemented, pilot incapacitation was cited
as one of the major concerns. Proponents of retaining the Age 60 Rule placed
emphasis on pilot incapacitation as a cause of diminished flight safety. However,
when compared to human-factors causes, pilot incapacitation has been shown
to be an uncommon cause of aircraft accidents7-9. Whilst in-flight discomfort
is not an infrequent occurrence, (most commonly due to gastrointestinal
disorders), only a small proportion of such in-flight physiological events were
deemed to be a threat to flight safety6,10.
To gain some perspective on the relative risk of pilot incapacitation, various
authors have calculated the accident rate per number of flying hours where
pilot incapacitation was considered a causative factor11. One author has
derived a figure of approximately one pilot incapacitation associated accident
for every 1010 flying hours (1 in 10-10) – which is many orders of magnitude less
than the accepted accident rate from airframe failure (1 in 10-5)11.
Ageing
Whilst it is almost universally accepted that age-related changes will affect
a pilot’s skills, it should be emphasised that ageing is a non-linear process.
Ageing will occur at different times for different body systems, and proceed at
different rates amongst individuals within a population12. The process of ageing
is progressive and continuous1. Studies have shown that the ageing process
results in a general decrease in working memory (fluid memory) capacity and
central processing speed13. There have been multiple studies documenting
age-related physiological declines in vision, hearing and perceptual motor
skills14-16. Cognitive performance also exhibits a decline with age18, however
time-sharing tasks may not be affected18.
It is generally believed that aviation expertise (crystallised memory) decreases
What’s wrong with the Age 65 Rule?
the effects of age–related decline in memory tasks19, although the results in
some studies do not support this view14. Studies on attention and concentration
have shown similar mixed results with some studies showing age-related
decline18, and others showing the attention performance of older pilots being
equal to that of younger pilots20.
by the same authors which showed a clear decline in pilot performance with
age, although the authors stressed that age only explained 22% or less of the
observed performance variation on different flight tasks28. Another paper from
1989 reported that older pilots exhibited greater deviation from a prescribed
flight path when compared to their younger colleagues29.
Sleep
An area of particular concern when considering the implementation of an
age rule is the evidence obtained from sleep studies. These studies have
documented that older pilots will experience greater sleep loss in long haul
operations, with the increased loss being proportional to increased age15. If
an age rule is not implemented for pilots, due consideration should be given
to the fact that sleep loss has been implicated as a human factor in accidents
and incidents21.
Hearing
Hearing is another important physiological parameter that has been shown to
have an age related decline. The process of presbycusis can be exacerbated by
noise induced hearing loss (NIHL) and there is data suggesting that some older
pilots may not hear higher frequency alarms in the cockpit22.
Vision
Figure 1: A portion of the CogScreen-AE showing a symbol digit coding
task. With all the CogScreen-AE subtests, a practice session precedes
the test itself. The CogScreen-Aeromedical Edition (CogScreen-AE) is
a computer-administered and scored cognitive-screening instrument
designed to rapidly assess deficits or changes in attention, immediate
– and short-term memory, visual perceptual functions, sequencing
functions, logical problem solving, calculation skills, reaction time,
simultaneous information processing abilities and executive functions.
Source: Westerman R, Darby D, Maruff P, Collie A. Computer-assisted
cognitive function testing of pilots – ADF Health April 2001 Vol. 2 No. 1.
http://www.defence.gov.au/health/infocentre/journals/ADFHJ_apr01/
ADFHealthApr01_2_1_29-36.pdf
It is estimated that at least 80 per cent of all information acquired by pilots is
derived through the sense of vision. Pilots gather visual information both from
their instruments within the cockpit and from looking through the windscreen
canopy23. Excellent corrected visual acuity is required for approach and
landing, and for spotting other aircraft24. Good corrected near visual acuity
is required for reading aircraft instruments and maps. Most neonates are
hypermetropic and the magnitude of this increases to a peak at about eight
years of age, when the refraction becomes relatively myopic until about 40
years of age23. With middle age there is increasing hypermetropia due to
the loss of accommodative power. Finally, after the age of about 75 years
the crystalline lens becomes sclerotic, with a higher refractive index and
a tendency back towards myopia.23. The progression through this typical
pattern is variable and unable to be accurately predicted24. Ageing of the
eye leads to sclerosis of the crystalline lens, which leads to gradual loss
of accommodative power. This effect usually becomes marked during the
fifth decade, resulting in the need to wear corrective spectacles for near
vision. In addition to the loss of accommodative power, the ageing eye is
slower to accommodate with older pilots requiring up to ten times as long to
accommodate when compared to younger pilots16.
Whilst some studies show age-related differences in simulator perfomance28,29,
others do not10,14,30. There are several limitations to interpreting simulator
analysis studies of pilot performance. Firstly, most of the studies have been
cross-sectional studies, with the exception of the Yesavage et al. study which
was a longitudinal study conducted on 100 pilots over three years28. A further
limitation of studies is that there are few subjects aged over 60 years-old with
current airline flight time (as they have been retired prior to 13 Dec 2007 due to
the Age 60 Rule). This has dictated that most simulator studies are performed
on small-aircraft flight simulators – airframes that general aviation (GA) pilots
over 60 years retain currency on.
Cognitive skills
Flight performance
Ageing is accompanied by a general decline in cognitive function, although
it is rarely manifest before the age of 70 years14. Fortunately, airline pilots
have been shown to demonstrate superior task performance when compared
to age-matched non-pilots26. However, within the broad area of cognitive
functions analysed there was significant variation, with perceptual-motor skills
and memory tasks being the most affected14.
The evidence supporting the implementation of an Age 60 Rule is not strong
when flight performance is analysed independently. Several studies confirm
there is a decline in accidents as pilots’ age (and experience) increases31,45.
This decline continues to around the age of 65 years when it begins to increase
again31; thus demonstrating a “U-shaped” relationship between accident rates
and pilot age. The total number of accidents involved in air carrier accidents is
small and this gives any study on Age versus Flight Performance (as measured
by accident rates) less power.
Simulator performance
An area that has been used to assess pilot capacity is the flight simulator
environment. There have been concerns expressed that simulator results may
be invalid as insufficient workload can be generated to test whether an impaired
pilot could perform time-sharing tasks at adequate speed1. A study by Taylor
et al demonstrated that the CogScreen – Aeromedical Edition (CogScreenAE) – a cognitive battery of tests to assess pilots in simulated flight – was a
valid method of investigation27. This study followed on from an earlier paper
A study by Kay et al. demonstrated a gradual decline in accident rates for
pilots with a Class II or III licence until the early 60’s followed by a slight
increase from age 65 to 69 years31. Similarly, another study conducted on GA
pilots demonstrated that older pilots were at decreased risk for accidents and
violations when compared to younger pilots32. Other studies do not support any
relationship between pilot age and accident rates33.
operating in a two pilot environment can be considered for a continuation of
flight status by use of the 1% rule. It may be more appropriate to adopt a
functional approach for the aging pilot, rather than adopt a broad ruling of
compulsory age retirement.
The concept of functional age – should it
replace implementation of an age rule?
Figure 2: The Sioux City Crash – where age and pilot experience proved
beneficial Photo: Source unknown.
Prior to 2000, Japan permitted pilots up to age 63 years to fly air-carriers. A
study of the over 60-years pilots in Japan found a zero accident rate over a
three year study interval. As a consequence of this finding, the pilot age limit
was raised to 65 years for Japanese pilots34.
It has been proposed that “functional age” (the equivalent chronological age
that a pilot performs to), rather than biological age should be used to assess
the ability of a pilot to continue to fly40,41,42, although some authors do not
believe this is a viable alternative14. Sophisticated neuropsychological tests,
such as the CogScreen-AE have been validated as demonstrating age-related
performance decrements27,43. Further refinement of this type of testing may
be a method to ascertain a pilot’s flight safety, however it will be an expensive
process to fully validate such a system. The corollary of the adoption of a
functional assessment of a pilot’s safety is that some pilots aged less than 60
years will be deemed unsafe to pilot aircraft.
How implementing an Age 60 Rule leads to
“medical” wastage
DeHart, Stephenson and Kramer examined the aircrew selection program for
RAAF applicants between 1969 and 197335. The term medical wastage was
used to describe that group of unsuccessful applicants who were rejected for
medical reasons, and this terminology was previously used by Bennet and
O’Connor when they examined civil aircrew in Great Britain36. Historically there
is usually a high supply of pilots satisfying demand from the commercial and
military recruiting environment. However, there are times when the number of
applicants decreases, thus lessening the supply. Several studies and papers
describe this fluctuation and comment that a consequence is a need to review,
and to sometimes relax standards35,37. An analogous situation occurs at the end
of a pilot’s flying career. The enforced age-retirement at age 60 of healthy and
experienced pilots is another example of medical wastage and some claim it
wastes the skills of thousands of capable pilots38.
Aeromedical decision making (ADM) and the
implementation of an age rule
The principles of ADM
The aviation clinician makes aeromedical decisions on a regular basis. The
basic principles of ADM involve an acknowledgment that each case is decided
on its merits, a consideration of whether the medical condition has implications
for flying safety and whether the aviation environment will have an effect on the
condition or its treatment39. The implementation of an age rule for retirement
ignores the concept of ADM and replaces it with a compulsory retirement rule.
ADM for retirement age versus an Age Rule
ADM should examine the risk of a sudden incapacitation (such as occurs
for example with severe disabling chest pain), the risk and effect of loss of
function (for example a visual field defect in a stroke) and whether the condition
predisposes to an adverse interaction with the physiological stressors of flight
(for example the increased risk of sleep deprivation in an older pilot conducting
long haul operations). ADM is essentially risk management. Aerospace medicine
has traditionally been conservative and risk averse39, however this must be
tempered with the potential loss of experienced trained pilots. If the principles
of risk management are utilised a pilot with an identified medical problem,
Figure 3: US Airways flight 1549 crash-landed into the Hudson
River on 16 Jan 2009. The captain of the aircraft, Chesley B. ”Sully”
Sullenberger was aged 57 years and had 40 years flight experience.
Lauded by many as an example where the pilot’s experience was
able to prevent a catastrophic outcome. All of the 146 passengers
and five crewmembers aboard the plane survived the water landing.
Photo: Brendan McDermid/Reuters http://www.time.com/time/
photogallery/0,29307,1872172_1826294,00.html Accessed 18 Jan 2010.
Alternatives to retaining the Age 60 Rule
The Aerospace Medical Association in a Position paper from 2004 proposed
several alternatives to the Age 60 Rule1. These included:
1.Abandoning the Age 60 Rule and relying on six-monthly medical and
performance (simulator and actual flight) testing;
2.Replacing the Age 60 Rule with other unspecified tests; or
3.Increasing the Age 60 Rule to Age 65, and examining the results of such a
change in longitudinal studies.
On 13th December 2007 the Age 60 Rule was replaced by option three, and
a Bill was signed effectively changing the Age 60 Rule to the Age 65 Rule43.
The concept of “age-proofing” for older pilots
With the implementation of an Age 65 Rule there would appear to be a
number of relevant safety issues that should be addressed or recognised. By
recognising the limitations that older pilots have, airline regulators may further
promote safety in older pilots by adopting strategies such as those I propose
below. I have termed this concept “age proofing” the cockpit.
Disclaimer
1.It has been documented that cockpit alarms at higher frequencies may
be inaudible to older pilots22. Aircraft design engineers should ensure that
audible alarms are of lower frequencies.
The views, opinions, and/or findings in this report are those of the author and
should not be construed as an official policy of the Royal Australian Air Force or
the Australian Defence Force.
2.Older pilots will inevitably be required to convert onto newer airliners from
time to time. The failure rate for conversion to new aircraft increases with
increasing age45. This fact should be borne in mind by flight trainers and by
examining instructors. The implementation of an Age 65 Rule will lead to an
older pilot cohort. Subsequently consideration should be given to additional
training time for older pilots on conversion courses.
References
1.
Aerospace Medical Association, Aviation Safety Committee, Civil Aviation Safety
Subcommittee. The age 60 rule. Aviat Space Environ Med 2004; 75:708-715. http://
docserver.ingentaconnect.com/deliver/connect/asma/00956562/v75n8/s12.html?ex
pires=1204935536&id=42814302&titleid=8218&accname=Guest+User&checksu
m=AF84F34DDAC45F352DE7A6F83A8139E2 Accessed 2 Mar 2008.
3.The modern “glass cockpit” has increasing amounts of automation contained
within it. Pilots are known to experience problems with automation, and it has
been implicated as a factor in aviation accidents20. Automation is also a key
component of Crew Resource Management (CRM) training20. The older pilot
will have less experience with electronic automation and additional training
with this technology should be given to the older pilot.
2.Airline Pilots Association (ALPA) (1959b). Special report: APLA supplementary brief
submitted to FAA on pilot age limitation question. The Airline Pilot, 28: December
1959, 16-20.
4.Currency of flying time is associated with a lower risk of pilot accident46.
Older pilots should be discouraged from taking lengthy breaks from flying
duty (such as long service leave) between the ages of 60 to 65 years.
It would be more appropriate to take this leave earlier than 60 years or
immediately pre-retirement.
5.Curdt-Christiansen CM. The case for an international upper age limit for airline
pilots. Aviat Space Environ Med 2002; 73:309.
5.
Consideration should be given to giving older pilots additional medical
and neuropsychiatric testing at more frequent intervals. Certainly, in some
countries, the frequency of medical examination for certain areas such as
vision and the resting ECG increases in frequency with the increase in pilot
age47. Neuropsychiatric testing however is not routinely done and would need
to be developed and validated. The cost of these additional and more frequent
medical examinations would be significantly less than the cost of training a
new pilot. However, a problem arises as the US “Fair Treatment for Experienced
Pilots Act”, made law in December 2007, states that a pilot shall not be subject
to different medical standards, or more frequent medical examinations on
account of age43. This would appear to be a flaw in the US regulations as it does
not allow for a more flexible approach to medical or neuropsychiatric testing.
The future of age rule implementation
The recent change from an Age 60 Rule to an Age 65 Rule will effectively
cease the Age 60 debate that has existed for the last 49 years. Within the
next five years, though, the Age 65 Rule will be analysed, criticised and legally
challenged. At this stage the use of a functional assessment has not been fully
investigated or trialled. If a functional assessment was proven to be a valid
method of assessing an aging pilot, then the Age Rule may be discarded. This
is unlikely to occur in the foreseeable future.
Conclusion
Many countries have already discarded the Age 60 Rule. Recent legislative changes
in the USA have led to the passing of the era of the controversial Age 60 Rule
in that country. Intensive investigation by multiple authors, over many years, has
failed to reach consensus on the most appropriate age for a pilot to be retired
form flight duty (if indeed one exists). There is evidence confirming the association
between increasing pilot age and a decline in psychomotor function. On balance,
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ORIGINAL ARTICLE
Colour perception standards in aviation:
Some implications of the AAT decisions regarding
colour perception and aviation
Arthur Pape, MBBS (Melb), Boris Crassini, BA (Hons), PhD
Abstract
The International Civil Aviation Organisation (ICAO) colour perception standard
may be analysed as a form of argument; that is, it may be considered as a
conclusion drawn logically from three assumptions. These assumptions are
(i) that colour is used extensively as a feature of information-presentation
systems in aviation; (ii) that normal colour vision is necessary for safe
information processing from such systems, and consequently, safe
performance of the duties of aviation, and (iii) that defective colour vision
results in unsafe information processing from such displays, and consequently,
unsafe performance of duties in aviation. For the application of the ICAO colour
perception standard to be evidenced-based, the truth or falsity of each of
these assumptions needs to be evaluated using appropriate empirical tests.
An informal demonstration of an empirical test of the second assumption
is presented showing that the presence of colour is neither sufficient nor
necessary for appropriate information processing from one informationpresentation system. The limitations of the kind of evidence provided by the
demonstration are noted, and a proposal for the collection of more appropriate
empirical evidence is proposed. This proposal is possible because of two
landmark decisions made some 20 years ago by the Administrative Appeals
Tribunal (AAT) in Melbourne, Australia, in relation to the aviation colour
perception standard. Because of these decisions, pilots with defective colour
perception were able to gain extensive flying experience commanding modern,
sophisticated aircraft. That is, a group of pilots with defective colour perception
now exists having similar flying experience to the flying experience of pilots
with normal colour perception. These two groups of pilots provide a pool of
possible participants for a more-appropriate empirical test of the assumption
underlying the colour perception standard than had been possible before the
AAT decisions. A proposal for such an empirical test is outlined.
What is assumed in proposing an aviation colour
perception standard?
Assumption 1: There is extensive use of colour-coded information in the
aviation environment.
Assumption 2: The ”safe performance of duties” in the aviation environment
requires ”the ability to perceive readily those colours the perception of
which is necessary for the safe performance of duties.”
Assumption 3: Without ”the ability to perceive readily those colours the
perception of which is necessary for the safe performance of duties”, these
duties will be performed unsafely.
The value of undertaking such a formal logical analysis of the ICAO colour
perception standard is that the analysis makes the assumptions underpinning
the colour standard explicit, and thereby allows the truth or falsity of the
assumptions to be tested. Such tests of the truth or falsity of the assumptions
are needed to determine whether the argument based on these assumptions,
in this case, the colour perception standard, is true or false. That is, such
evaluations of the three assumptions provide an appropriate evidence basis for
the colour perception standard.
Let us consider in turn each of the three assumptions identified above. There
can be little doubt that there is extensive use of colour in systems used to
present information in the aviation environment. This use of colour occurs
inside modern aircraft where, for example, there is extensive use of coloured
displays to present information to pilots. The use of colour also occurs in
the aviation environment external to the aircraft, where, for example, there
is extensive use of colour in runway and taxiway lighting at airports, and in
devices such as PAPI used to help pilots maintain correct glide slope while on
approach to landing. Figure 1 shows examples of this use of colour both inside
the cockpit of a modern aircraft, and in the environment external to aircraft.
More formal support for the truth of this assumption is provided by recent
analyses of the aviation environment by Barbur, Rodriquez-Carmona, Evans,
and Milburn (2009a, b)2 in which they attempted to provide a classification of
the role played by colour in this environment.
The International Civil Aviation Organisation (ICAO) colour perception standard
for those wishing to apply for a pilot’s licence is set out in the July 2001 Annex
1 to the Convention on International Civil Aviation1, and reads in part:
“The applicant shall be required to demonstrate the ability to perceive
readily those colours the perception of which is necessary for the safe
performance of duties.”
The ICAO colour perception standard can be analysed formally as a form
of logical argument. In common language, the word ’argument’ refers to a
situation where there is some opposition or contradiction in two or more points
of view. However, in more formal logical analysis, the word ’argument’ refers
to a situation where a conclusion is drawn from one or more assumptions
or premises. Analysed formally as an argument, the ICAO colour standard is
based on three assumptions, as follows:
Author details
Dr Arthur Pape, MBBS (Melb)
Dr Boris Crassini,
BA (Hons) University of Queensland; PhD University of Queensland;
Honorary Professor of Psychology, Deakin University.
Correspondence
[email protected]
Figure 1. The left panel shows the Pilot Flying Display (PFD) of the
Airbus A330. (With permission, QANTAS Training Material)
The right panel shows a typical runway lighting system with approach
lighting. (www.intertecnica.de)
While there is little doubt about the truth of the first of the three assumptions
identified above, the same cannot be said about the second and third
assumptions. The second assumption underpinning the colour perception
standard is that the ”safe performance of duties” in the aviation environment
requires ”the ability to perceive readily those colours the perception of
which is necessary for the safe performance of duties.” The use of the word
”necessary” makes a strong claim about the role of colour in processing
information in the aviation environment. This strong claim is that the use of
Colour perception standards in aviation
colours in information displays, and the ability of pilots to ”perceive readily”
(to quote the ICAO statement) these colours, is a prerequisite or requirement
for appropriate information processing, and therefore safe ”performance of
duties”. The second assumption, and its strong claim, is problematic. The truth
or falsity of this second assumption is an empirical matter, and the kind of
empirical evidence used to support the truth of the second assumption has
been questioned in the course of the Administrative Appeals Tribunal (AAT)
considerations of the colour perception standard in aviation. The basis of this
questioning is discussed in more detail below.
The third assumption underpinning the ICAO colour perception standard is
that without ”the ability to perceive readily those colours the perception of
which is necessary for the safe performance of duties”, these duties will be
performed unsafely. Implicit in this third assumption is the ’fact’ that there
are individuals who do not ”perceive [colours] readily”. It is more than 200
years since the publication of the first scientific paper on defective colour
vision by the English chemist John Dalton (see Dalton, 1798)3, in which he
described his own misperceptions of colour. Since then, scientific knowledge
of human colour perception, both normal and defective, has increased greatly.
The procedures available to measure colour perception have also improved,
becoming more sophisticated, and enabling more detailed specification of
the nature of defective colour perception. In summary, there is little if any
doubt defective colour perception is a condition that is readily demonstrated
and measured, and is well understood. However, the fact of the occurrence
of defective colour perception has no implication about the truth or falsity of
the assumption that those with defective colour perception will perform duties
in the aviation environment in an unsafe manner. As was the case with the
second assumption, the truth or falsity of the third assumption is an empirical
question. Furthermore, as was the case with the second assumption, the kind of
empirical evidence used to support the truth of the third assumption has been
questioned. Before outlining the problems identified during AAT consideration
of the colour perception standard in aviation, some discussion of the role of
colour in information-presentation systems is warranted.
Is colour sufficient or necessary for
appropriate information processing of displays
in the aviation environment?
The mere use of colour in the aviation environment exemplified in Figure 1 has no
implications for the truth or falsity of the second and third assumptions identified
above. For example, if this use of colour is only for aesthetic reasons, then the
question of the role of colour as an information code does not arise; colour is for
’looks’, not for ’information’. However, if colour is present to serve a functional role,
not merely an aesthetic role, this raises the question of the nature of the functional
role of colour as an information code. Typically in cockpit displays of the type shown
in Figure 1, colour is one of several visual information codes (e.g., a verbal code,
a spatial code, an achromatic luminance/brightness code) used simultaneously. In
such displays, the question of the role of colour as an information code, which is at
the heart of the second and third assumptions, becomes a more-complex question.
Despite this complexity, the empirical test that is proposed later in the paper will
allow appropriate evaluation of the interactions between colour and the other visual
information codes present in multi-coded information displays.
Before discussing the proposed empirical test of the second and third
assumptions, we present an informal demonstration involving the Electronic
Central Aircraft Management (ECAM) display in an Airbus A330 aircraft shown
in Figure 2. As its name suggests, the ECAM display is designed to provide
Airbus A330 pilots with information ”necessary for the safe performance of
their duties” in relation to emergencies that may arise in a flight. During an
emergency, the display presents automatically, on a need-to-know basis,
information about the emergency, the diagnosis of the problem, and the actions
that crew need to undertake to deal with the problem. As is clear from Figure 2,
colour is used extensively in the ECAM display, and is used, in part, as follows:
White colour : Used to show titles on the ECAM display.
Green colour: Used to show normal conditions.
Amber colour:Used to show abnormal conditions requiring some attention,
but no immediate action.
Red colour:Used to show abnormal conditions of a serious nature and
requiring immediate action.
Blue colour:
Used to show actions to be undertaken by aircraft crew.
Figure 2. The ECAM display from an Airbus A330 aircraft showing
the extensive use of colour in the display. (With permission, QANTAS
Training Material)
The question of interest is whether the colours used in the presentation of
these different types of information in the ECAM display are required for the
information to be processed correctly.
There are two ways of considering this question of interest. The first is to ask
whether colour alone is sufficient for the information presented in a coloured
display to be processed correctly. Put simply, is it the case that seeing the
colour is enough to see the information? The second way of considering this
question of interest is to ask whether colour is necessary for the information
presented in a coloured display to be processed. Put simply, is it the case that
not seeing the colour means that the information is not seen?
Figure 3. A version of the lower section of the ECAM display from an
Airbus A330 aircraft with the colour retained, but text replaced by #
marks. (Devised by Author 2)
Figure 3 shows a version of the lower section of the ECAM display shown in
Figure 2 in which the colours used in the original display have been retained,
but the text has been replaced by # marks. Inspection of Figure 3 shows that
the presence of colour alone is not sufficient for meaningful information to be
processed. Without the text, the series of coloured hash marks is meaningless.
Figure 4 shows a different version of the lower section of the ECAM display
shown in Figure 2 in which the colours used in the original display have been
removed, but the text has been retained. Inspection of Figure 4 shows that the
presence of colour is not necessary for meaningful information to be processed.
The colourless display in Figure 4 clearly shows that the emergency is a fire in
engine number 1, and shows also the actions to be undertaken by the crew.
hearings, can now, in theory at least, be gathered. The two cases were: Re:
ARTHUR MARINUS PAPE And: SECRETARY, DEPARTMENT OF AVIATION (DOA)4
and, Re: HUGH JONATHAN DENISON And: CIVIL AVIATION AUTHORITY (CAA)5.
Before commenting specifically on each of the cases, it is instructive to make
two general comments about the AAT appeals overall:
The first comment is to do with the scope and thoroughness of the AAT
process. The two cases, taken together, took up more than 38 days of hearings.
Some 25 witnesses were called to give evidence, including airline pilots, air
traffic controllers, and expert witnesses from the fields of aviation medicine,
optometry, and psychology. In summary, the AAT hearings represented a
wide-ranging and thorough consideration of the evidence of relevance to the
question of whether there should be a colour perception standard in aviation.
Figure 4. A version of the lower section of the ECAM display from an
Airbus A330 aircraft with the text retained, but the colours removed.
(Devised by Author 2)
Taken together, Figures 3 and 4 are compelling demonstrations that colour is
neither sufficient nor necessary for meaningful information to be processed from
the Airbus A330 ECAM display. Despite the compelling nature of this informal
demonstration, we stress that the ’evidence’ it provides is not an appropriate basis
for the evaluation of the second assumption underpinning the colour perception
standard. Before discussing more appropriate evidence, we want to point out
that the Airbus is equipped with an array of devices designed to draw the crew’s
attention to the ECAM display. For example, during a condition requiring attention
but no immediate action (i.e., a caution condition), a loud single auditory signal is
presented, as is a visual display, separated from the ECAM, consisting of the words
’MASTER CAUTION’ in black text on an amber background light. During a serious
condition requiring some immediate action, a loud continuous auditory signal is
presented, as is a different visual display, separated from the ECAM, consisting of
the words ’MASTER WARNING’ in black text on a red background. In summary, in
an actual situation of serious equipment malfunction or of imminent danger (e.g.,
impending stall or dangerous proximity to terrain) information is presented to the
crew using multiple sensory modalities, and from spatially-separated sources.
What are the implications of multiple sources of information of the type
described in the previous paragraph? Whether individuals in the aviation
environment are presented with a single source of information, or with multiple
sources of information, the question of whether they make proper use of such
information so that they engage in ”safe performance of duties” is an empirical
question; that is a question that must be answered using appropriate evidence.
This is the case whether these individuals have normal colour perception or
defective colour perception. But what is the most appropriate evidence that
should be collected to answer the question, and how should this evidence be
collected? These issues are discussed in the remainder of the paper.
AAT decisions in relation to the aviation colour
perception standard
The informal demonstration in Figures 3 and 4 that colour is neither sufficient
nor necessary for appropriate information to be processed from the Airbus
A330 ECAM does not provide the kind of evidence allowing proper assessment
of the ICAO colour perception standard. Before outlining what such evidence
should be, ideally, it is necessary to discuss a more formal and rigorous
examination of the ICAO colour perception standard that was carried out by
the AAT in Melbourne, Australia some 20 years ago in relation to two separate
cases. It is because of the AAT decisions in relation to these cases that moreappropriate evidence, which was not possible to gather at the time of the
The second comment is to do with two aspects of the evidence provided by the
appellants that, on the basis of the AAT’s report, seemed to influence its decisions.
(i)The first aspect was the critique of the nature of the empirical evidence
used by the Department of Aviation (DOA) and the Civil Aviation Authority
(CAA) to support the application of a colour perception standard (e.g., Cole
& MacDonald, 19886; MacDonald & Cole, 19887). The essence of this
critique was that the empirical evidence had very little to do with measuring
the safe performance of the duties involved in flying aircraft, and a lot to do
with measuring colour perception performance. Put simply, the empirical
evidence put forward to support the application of a colour perception
standard in aviation was basically empirical evidence for defective colour
perception, and not empirical evidence for defective, or unsafe, aviation.
Although the empirical evidence involved many experiments and many
different experimental conditions, these experimental conditions could
generally be characterised as variations of standard tests of colour
perception. And since the participants in this empirical research had
all been screened into ’normal’ and ’defective’ groups on the basis of
their performance on tests of colour perception, it was inevitable that
the participants so grouped would perform differently on the alternative
versions of colour vision tests that formed the experimental conditions.
(ii)The second aspect was to do with the theoretical approach that underpinned
the empirical research used to support the application of a colour perception
standard in aviation. This theoretical approach assumed that the information
provided to humans by their senses was impoverished and ambiguous.
Additional processing was needed before accurate information about the
world could be perceived. An alternative theoretical approach to perceptualmotor tasks like flying a plane has been proposed, and was described to the
AAT. This alternative approach was set out by James Gibson8 in his 1979
monograph, The ecological approach to visual perception. This alternative
approach places more emphasis on the richness of the environmental
information available to those engaged in tasks like flying a plane.
The first case to be discussed is Pape and the DOA. This case was significant
because it was the first time an aviation colour vision standard had been
successfully challenged anywhere in the world. The appellant, an author of this
paper, a deuteranope, and the holder of a commercial pilot licence and command
instrument rating, sought to have removed the limitation placed on his private
pilot licence by the DOA that precluded him from piloting aircraft at night. The AAT
upheld the appeal, and ruled that the appellant be permitted to exercise the private
licence at night with certain extra conditions, namely the carriage of standby
radio apparatus and an increase in IFR approach minima. These extra conditions
were later removed in the decision given in the second appeal. The second case
to be discussed, Denison and the CAA became, by mutual agreement between
the parties, a consideration of wider scope than that of Pape and the DOA. It
involved a wide-ranging investigation of the aviation colour perception standard,
and included all types of defective colour perception. The use of colour in larger
commercial aircraft, including the use of Electronic Flight Instrumentation System
(EFIS) cockpit display equipment was considered, as was the use of colour in
the external aviation environment. It is a matter of record that at the close of the
hearing phase of Denison and the CAA, all parties agreed that all the evidence
available at that point in time had been subjected to exhaustive discussion and
scrutiny. The decision of the AAT was to uphold Denison’s appeal, and in setting
out the bases of this decision, the AAT made clear its view that defective colour
perception did not pose a significant threat to the safe performance of the duties
involved in flying aircraft.
Consequences of the AAT decisions for
an appropriate empirical test of the
assumptions underpinning the ICAO colour
perception standard
A consequence of the AAT decision in the case of Denison and the CAA was
that pilots with defective colour perception were able to increase their flying
experiences beyond the previously restricted range of such experiences
imposed by the aviation colour vision standard. Indeed, pilots with defective
colour vision were now able to embark on careers in aviation involving flying
modern, large and sophisticated aircraft equivalent to the career paths
available to pilots with normal colour perception. Table 1 summarises the
flying experiences of two such pilots. Inspection of Table 1 shows that these
two pilots have each more than 8000 hours flying experience in a range
of sophisticated aircraft. Both have served in command of such aircraft. In
addition to the information provided in Table 1 it is instructive to note that
the regular flight simulator check and training reports that all pilots operating
aircraft at this level of sophistication are required to undertake have been, for
these pilots, completed at a very high standard. There have been no questions
raised regarding the ”safe performance of duties” of these pilots.
80%
60%
40%
20%
0%
Predicted results if argument
underpinning colour perception
standard is ’false’
100%
Performance on flight simulator
Performance on flight simulator
Predicted results if argument
underpinning colour perception
standard is ’true’
100%
Groups
Pilots with normal colour perception
Pilots with defective colour perception
80%
60%
40%
20%
0%
Groups
Figure 5. Predicted results of an ideal empirical test of the argument
underpinning the colour perception standard. The panel on the left
shows the predicted results on the flight simulator if the argument is
’true’; that is, pilots with defective colour perception will perform worse
than will pilots with normal colour perception. The panel on the right
shows the predicted results on the flight simulator if the argument is
’false’; that is, pilots with defective colour perception will perform the
same as will pilots with normal colour perception.
A further consequence of the AAT decision is the possibility of the carrying out
of empirical research that could provide evidence allowing more-appropriate
evaluation of the need for the aviation colour perception standard than had
been possible before the AAT decisions. Paradoxically, this includes the
evaluation of the AAT itself. This statement should not be seen as a criticism of
the AAT, nor of the evidence it considered. Rather, this statement reflects the
limitations of the empirical evidence that was available before the AAT decision.
This empirical evidence was problematic in two ways.
The first problem was that the evidence was not collected from participants
who were pilots who differed only in their colour perception abilities. Instead
the evidence was typically collected from participants who were not pilots
and were selected to take part because they either had normal of defective
colour perception.
The second problem was that the evidence was not based on measuring
the quality of ”performance of duties” involved in piloting aircraft. Instead,
as noted earlier, the empirical evidence was based on comparison of
performance on quasi-tests of colour perception.
The ideal empirical test of the assumptions underpinning the ICAO colour
perception standard involves removal of both the problems identified above.
An ideal evaluation of the assumptions
underpinning the ICAO colour perception standard,
and possible results of such an evaluation
The ideal empirical evaluation of the assumptions underpinning the ICAO colour
perception standard would firstly involve as participants samples of pilots who
were representative of the population of pilots to which any empirical results
could be properly generalised. These samples of pilots would be matched
on some set of variables, but would differ in their colour perception abilities.
This difference is the critical variable of interest. It is beyond the scope of
this paper to provide details of the variables (e.g., health status, age, etc.)
on which the samples of pilots in the proposed research would be matched,
except to say that central to this list of matching variables must be the variable
of amount and quality of flying experience. Until the AAT decisions, there was
little if any opportunity for pilots with defective colour perception to progress
in their aviation careers and flying experiences in ways that paralleled the
career progress of pilots with normal colour perception. Pilots with defective
colour perception were limited in the size and complexity of aircraft they could
command, and the conditions under which such command could be exercised.
However, with the growth of a cohort of pilots of which the two shown in
Table 1 are examples, the possibility now exists for obtaining an appropriate
sample of pilots with defective colour perception that match the range of flying
experiences achieved by pilots with normal colour perception.
In addition to being based on participants that allow proper generalisation of
results to the population of pilots, the ideal empirical evaluation of the assumptions
underpinning the ICAO colour perception standard must be based on experimental
tasks that allow proper generalisation of results to the ”safe performance of
duties” in aviation. Part of the critique of the empirical evidence used to support
colour perception standards discussed earlier was that this evidence involved
experimental tasks that had very little, if anything, to do with the actual task of
piloting aircraft. The obvious reply to this critique would be to replace these artificial
tasks with experimental conditions that involved the actual piloting of aircraft. Such
a proposal is manifestly impractical and inappropriate on numerous grounds.
Collecting data during the actual piloting of aircraft would not only be extremely
expensive, it would involve exposure of participants to such danger that human
research ethics committees would be loath to approve such data collection. What
is needed is a task that approximates, as closely as possible, the ”performance
of duties” actually involved in flying aircraft, and does so relatively inexpensively,
and without danger to participants. Such a task is available, of course. It is the
task of flying an aircraft simulator. This is considered to be so close to what is
involved in actually flying aircraft that pilots who fly modern sophisticated aircraft
such as the Airbus A330 are required to demonstrate their continuing proficiency
and ”safe performance of duties” in aviation by undergoing regular flightsimulator-based assessments. The ideal evaluation of the ICAO colour perception
we propose would involve exposing appropriate samples of pilots to a range of
experimental tests in a flight simulator. As we said earlier, it is beyond the scope
of this paper to provide details of such flight simulator tests and the dependent
variables that could be measured. However, we do point out that flight simulators
are ideal tools for experimental data collection because flight simulators can be
used to expose participants to identical experimental conditions. More importantly,
these experimental conditions can involve unremarkable flying situations, and
also emergencies of different types forcing participants to use all their abilities,
including their colour perception abilities, for the ”safe performance of duties”.
The two panels of Figure 5 show the hypothetical and highly simplified results of
the ideal evaluation of the assumptions underpinning the ICAO colour perception
standard we propose. The results are highly simplified in that the range of
possible measures of ”safe performance of duties” in the flight simulator is
collapsed into a single measure which we have termed ’Performance on flight
simulator’. The panel on the left of Figure 5 shows the predicted results on the
flight simulator task if the assumptions underpinning the ICAO colour perception
standard are true. Participant pilots with defective colour perception will perform
worse than will participant pilots with normal colour perception. The panel on
the right of Figure 5 shows the predicted results on the flight simulator task if
these assumptions are false. Participant pilots with defective colour perception
will perform the same as will pilots with normal colour perception. The pattern of
predicted results if the underpinning assumptions are true or false, that is, if the
colour perception standard is relevant to ”safe performance of duties” in aviation,
are clearly different, enabling a clear evaluation of the need for such a standard.
Table 1. Summary of the flying experience of two pilots with defective
colour perception who have been able to obtain this experience
as an outcome of the AAT decisions relating to the aviation colour
perception standard.
Pilot 1
Age: 42
Colour perception defect: Protanope
References
1.
ICAO International Standards and Recommended Practices. Annex 1 to the
Convention on International Civil Aviation – Personnel Licensing. 9th ed. July 2001.
2.
DOT/FAA/AM-09/11 Office of Aerospace Medicine Washington, DC 20591
“Minimum Color Vision Requirements for Professional Flight Crew, Part III
Recommendations for New Color Vision Standards”
3.Memoirs of the Literary and Philosophical Society of Manchester (1798). Dalton, J
“Extraordinary Facts relating to the Vision of Colours”.
4.Administrative Appeals Tribunal: Re: ARTHUR MARINUS PAPE and SECRETARY,
DEPARTMENT OF AVIATION No. V87/494 AAT No. 3821 Air Navigation (Search at
http://www.austlii.edu.au/au/cases/cth/aat/)
5.Administrative Appeals Tribunal: Re: HUGH JONATHAN DENISON and CIVIL AVIATION
AUTHORITY No. V89/70 AAT No. 5034 Air Navigation (Search at http://www.austlii.
edu.au/au/cases/cth/aat/)
6.Cole, B. L., & MacDonald, W. A. (1988). Defective colour vision can impede
information acquisition from redundantly colour-coded video displays. Ophthalmic
and Physiological Optics, 8, 198-210.
7.MacDonald, W. A., & Cole, B. L. (1988). Evaluating the role of colour in a flight
information cockpit display. Ergonomics, 31, 13-37.
32
8.Gibson, J. J. (1979). The ecological approach to visual perception. Houghton
Mifflin, Boston.
Deuteranope
8800 hours
Flying experience Airbus A320/321
(aircraft flown): Embraer 170
Dash 8 100/200/300
CASA-212
PA-31-350; PA-44
C404, 310/320
Aero Commander 500S
Cresco 750
Beechcraft Duke
C310/320
Baron Travelair
PA44; PA31
Metro 3/23
Saab 340
Boeing 737-300/800
To make clear the assumptions that underpin the ICAO colour perception standard
we set out an analysis of the standard as a logical argument, and identified
three assumptions. We discussed problems with the empirical evidence used to
support the application of the colour perception standard identified during the AAT
consideration of the standard almost 20 years ago. Since these AAT decisions
regarding the standard there has emerged a cohort of pilots with defective colour
perception yet with extensive experience flying modern, large, and sophisticated
aircraft. We argued that these pilots represent a potential pool of participants for
a definitive test of the aviation colour vision standard. We proposed that such a
definitive test should involve comparison of the ”performance of duties” (to quote
the ICAO colour standard) on an appropriate set of flight simulator tasks of two
groups of pilots matched on all relevant variables, and differing on the variable
of colour perception abilities. We appreciate that carrying out the evaluation we
propose would be a complex and expensive undertaking. However, we feel that
the effort is warranted because the results of the kind of evaluation we propose
would provide the strongest possible basis for the need for and continued
application of the colour perception standard, or its removal.
Pilot 2
Total hours flown: 8500 hours
Flying experience 2005-2007
(recent flight crew status): Command Embraer 170
2007-present
First Officer Airbus A320
(preparing for command
training)
Concluding comments
2006-present
Command Boeing
737-800
ORIGINAL ARTICLE
Knowledge from the Aviation Industry Adapted for the
Management of Victorian Trauma Patients.
Melinda Truesdale, MBBS FACEM Grad. Dip. Health Services Management
Abstract
An assumption underscoring good trauma systems is that the survival from
serious injury is enhanced by early recognition of a patient’s risk of early
mortality and morbidity. Hence trauma systems attempt to best match the
facility’s resources with the patients’ needs.
In Victoria, the primary response to a trauma scene is by skilled paramedics. If
a patient is within one hour of one of the two adult Trauma Centres the patient
will be transferred there, bypassing other Emergency Departments. Otherwise,
the patient will be taken to the nearest regional centre, assessed and if major
trauma criteria are met, the patient then will be transferred to a Trauma Centre
using aero-medical retrieval services.
At the receiving Trauma Centre, Trauma Team activation traditionally has been
based on physiological criteria, specific high risk injuries and mechanism of
injury. Many centres are now looking to a tiered response to trauma to enable
them to differentiate between the severely injured patients who have a higher
likelihood of an increased mortality than those with a lower mortality.
Optimal care of the traumatically injured patient relies on a rapid and prioritized
approach to identifying physiological and anatomical derangements that need
urgent intervention. ‘Team Training’ originated from principles of Crew Resource
Management in the Aviation Industry. At The Royal Melbourne Hospital,
Emergency Services regularly run multidisciplinary simulation exercises.
This paper will outline the Victorian Trauma System including patient
transportation decisions, the criteria of major trauma, the Trauma Team
activation and the ‘Team Training’ scenarios.
Introduction
Trauma is the leading cause of death in the under 40 year old age group. Major
trauma is responsible for the loss of more economically productive years of
life than heart disease and cancer combined. A review of the Victorian trauma
system was undertaken during the late 1990s and a number of deficiencies in
the care of trauma patients were identified. The “RoTES Report”1 recommended
the development of an integrated system of trauma care, designed to achieve
optimal outcomes for trauma patients. In essence, to deliver ‘the right patient to
the right hospital in the shortest time’ and ‘to match a facilities resources with
a patient’s medical needs so that optimal and cost effective care is achieved.’
Author details
A.Prof Melinda Truesdale,
MBBS FACEM Grad. Dip. Health Services Management
Director Emergency Services, The Royal Melbourne Hospital
Senior VMO Emergency Physician, The Royal Women’s Hospital
Clinical Associate Professor, University of Melbourne and
Monash University
Correspondence
[email protected]
Acknowledgements
The author wishes to acknowledge Dr. Jonathan Papson, (Emergency
Physician, The Royal Melbourne Hospital) and Ms. Kellie Gumm,
(Trauma Programme Manager, The Royal Melbourne Hospital) for
supplying some data used in this presentation.
An assumption underscoring good trauma systems is that the survival from
serious injury is enhanced by early recognition of a patient’s risk of early
mortality and morbidity.
As a result of the RoTES Report,1 the Victorian State Trauma System
evolved. This meant the designation of two state adult trauma centres, (The
Royal Melbourne Hospital (RMH) and The Alfred Hospital) or in the case of
paediatric patients, The Royal Children’s Hospital. If a patient meets specific
pre-hospital trauma criteria it is deemed that the patient needs the expertise
of a trauma centre. Therefore, if the patient is within 30 minutes (and often
the more liberal time-frame of 1 hour is taken), such a patient will be taken
by the ambulance service to the nearest trauma centre and will bypass other
hospital emergency departments. The pre-hospital major trauma criteria are
summarised as: Glascow Coma Score less than 14; respiratory rate <10
or > 29 per minute; systolic blood pressure < 90 mmHg; Revised Trauma
Score less than 11; penetrating injury, mechanism of injury; pregnancy > 20
weeks with evidence of ruptured membranes or foetal distress. (Pregnancies
are preferentially taken to RMH due to its co-location with The Royal
Women’s Hospital).
The trauma patient is then met by the assembled personnel. It was also
acknowedged in the “RoTES Report”1 that teams have to form and function
efficiently and effectively rapidly. Nearly every time a team involves new
members & a new situation each time. ‘Team Training’ was developed to
enhance the team function and enable high fidelity education for staff at RMH.
Trauma Systems at The Royal Melbourne Hospital
Trauma triage seeks to identify and provide rapid treatment of the most
severely injured patients and ultimately decrease the time to definitive care and
increase the survival rate. Over triage has little impact on the patient, however,
it adds significant strain to hospital resources and the state-wide system by
decreasing efficiency and effectiveness. It has the potential to devalue the
trauma system as a whole due to the “cry wolf syndrome” and unnecessary
trauma team activations divert resources away from other hospital activities
which could potentially compromise patient care. Many hospitals, which provide
trauma care, have developed two-tiered trauma team activation models. These
differentiate between the severely injured patients who have a higher likelihood
of an increased mortality than those who are less severely injured and therefore
usually have a lower morbidity and mortality.
The Royal Melbourne Hospital (RMH) assesses 56,000 emergency
presentations per year of which nearly two thirds are Australasian Triage
System categories one, two, and three.2 There is an even 50:50 split between
the two adult trauma centres with respect to the trauma load. With respect to
the RMH 2009 financial year, there were 2973 trauma admissions of which
799 were major trauma cases. That averages 66 cases per month or two
cases a day. At RMH, Trauma Team activation criteria were developed based on
physiological criteria, specific high risk injuries & mechanism of injury.3 It is a
two tiered system of ‘Trauma Call’ and ‘Trauma Alert.’ The ‘Trauma Call’ is for
the more severely injured patients; involves the full team with a surgeon being
immediately being available.
The Royal Melbourne Hospital’s Trauma Team consists of a team leader who
is either an emergency consultant or senior registrar; a registered nurse (RN)
scribe, two senior RNs; airway doctor – (anesthetic registrar or anesthetist); an
airway RN; two procedure doctors (includes the surgical registrar); a procedure
RN; emergency department assistant (orderly); a radiographer; and, if the
patient is pregnant, an obstetrician and neonatal specialist.
The ‘Trauma Alert’ is for the less severely injured patients. These patients are
Knowledge from the Aviation Industry
managed primarily by the emergency department team and surgical registrar
in consultation with speciality units as needed. Thus the assembled team for
an alert is the team leader (emergency consultant or senior registrar), surgical
registrar, procedural doctor and RN and a scribe nurse. Surgeons are notified
by phone and can attend the department in a short time, should the need arise.
In order to improve this environment and potentially refine the criteria, RMH
undertook a review and reflection of more than 42,000 ambulance cases in
2008. The guidelines at RMH were modified slightly to reflect these findings.
The current ‘Trauma Call’ and ‘Alert’ guidelines are summarised in Tables 1
and 2.
Trauma Team Simulation at The
Royal Melbourne Hospital
The aviation industry learned early on that adverse outcomes occur when
teams don’t work well and pioneered the use of simulation for the training of
their air and cabin crew with a focus on Crew Resource Management (CRM).
Crew Resource Management training was first introduced in the late 1970s
as a means to combating an increased number of accidents in which poor
teamwork in the cockpit had been identified as a significant contributing
factor. Since then, CRM training has expanded beyond the cockpit, for
example, to cabin crews, maintenance crews, health care teams, nuclear
power teams, and offshore oil teams. Not only has CRM expanded across
communities, it has also evolved and benefited from input from multiple
disciplines and over the years.
In both the aviation and medical environment, teams have to form and function
rapidly. This requires team organisation and role clarity. Historically, doctors
and nurses train separately but work together. In-situ simulation training began
at RMH in 2005. There is medium to high fidelity simulation in former trauma
rooms using real equipment. Each course runs for a half day and has between
eight and ten participants. It is multidisciplinary: consultants, registrars &
nurses (ED, anaesthetics and trauma service). The session begins with a
discussion which is titled “Crisis Resource Management”. The aviation context
from ‘cockpit’ to ‘crew’ resource management is noted. Coined in 2001 by
Gaba,4 the key points with respect to Crisis Resource Management were
described as being: the need to know your environment; take a leadership
role; anticipate and plan; communicate effectively; call for help early enough;
allocate attention wisely and to distribute the workload.
The session then moves to discuss the theory of teams, team structure
and the role of a team leader and team member. Role clarity is key so that
each person identifies him/herself and knows his/her role. Specific cards
describing roles are given to the participants to clarify responsibilities.
Communication is a focus and it includes discussion about graded
assertiveness5. The emphasis for the team leader includes: identification
of him/herself as the leader, and introduction and role definitions for other
members. Leadership is perceived as an essential component in trauma
management.5, 6. No differences were found in the outcome of trauma
patients treated by non-surgeon versus surgeon trauma team leaders.
Indeed a more collaborative approach to resuscitative trauma management
with involvement of non-surgeons as trauma team leaders has been
observed.6, 7 The team leader needs to identify and utilise resources;
assign group members to particular tasks; let the team members know
what is expected; decide what should be done and how; use authority
and maintain standards. The leader needs to be able to listen, review and
adapt; maintain situational awareness; maintain noise levels and identify
and endeavour to solve any team problems.
Following this initial theory, the group is taken to the simulation area, a former
fully equipped trauma room, which is set up with a mannequin and voice over.
The group is introduced to the mannequin and its capabilities (such as the
ability to take blood pressure, to intubate, to hear breath sounds). The vital
signs are able to be set by the session demonstrators and appear on the
monitor. The monitor readings in turn can be superimposed on videorecordings
which are subsequently used in the debriefing.
For the scenario, a case is given to the initial team members present and
the ‘patient’ arrives. Other participants wait in an isolated room until called
in as needed. The exercise is undertaken in real time, (such as putting in an
intravenous line takes a finite time for a particular person). Investigations,
(pathology and radiology) need the required request slips to be written and
calls to relevant personnel are made using a dedicated phone line. The
exercise is videorecorded and the monitor readings are captured on the video
simultaneously. The average exercise lasts around 20 minutes and concludes
at a logical point in the patient’s care, (such as going in to the CT scanner, to
theatre or death of the patient). The group is then taken back to the seminar
room for an assisted debrief of the team performance. The facilitator plays
pertinent sections of the video back for review and there is group discussion
about positive and negative aspects of the patient’s care and the team’s
functioning and dynamics.
Since team training began at RMH, the participants have been surveyed at the
conclusion of each course. The focus of these surveys is on three aspects: the
response to environment; the response to the debriefing and other responses.
These responses are summarized in Table 3.
The advantages of simulation include: routine procedures can be repeated
intensively; participants use actual clinical devices; the same scenario can
be used on different groups to compare performance; errors can be allowed
to occur and be corrected by the participants; simulation can be frozen then
restarted to demonstrate alternate techniques; recording and replay can
occur without the issue of patient confidentiality. The advantages of in-situ
training include learning in one’s own environment which enhances fidelity;
the absence of the need to travel to a separate venue; use of clinical devices
that will be used in actual cases; a reduction in costs by using date-expired
consumables; and the opportunity to test/trial actual systems/new systems);
as well as having minimizing the impact of budget costs. Recommendations
from the RMH team training experience include: keep the training in the home
location (in this case the emergency department); keep it simple; keep it fresh
with new case scenarios; keep it multidisciplinary so all members of the team
get to work together; keep records of who has partaken and which scenarios
were used, and, keep at it!
Conclusions
The major trauma patient should be taken to the most appropriate hospital in
the shortest time. A suitable coordinated & experienced team response should
follow. Team training which takes its origins and teaching format from the
aviation industry is a powerful learning experience.8, 9. The experience at RMH is
consistent with that elsewhere in that participants give strong positive feedback
and agree that it enhances their knowledge, teamwork and experience. There
is a strong perception from participants that team training in practice has a
positive impact on patient care and outcomes.
Knowledge from the Aviation Industry
References:
Table 1: Trauma Call Guidelines:
1.Department of Human Services Victoria: Review of Trauma and Emergency Services
– Victoria, 1999 (RoTES Report). Final report of the Ministerial Taskforce on Trauma
and Emergency Services and the Department Working party on Emergency and
Trauma Services.
Respiratory rate < 12 or ≥ 24/min
O2 Saturation < 90%
Vital Signs
Blood Pressure < 90mmHg
2.Australasian College for Emergency Medicine: Australasian Triage Scale. http://
www.acem.org.au/media/policies_and_guidelines/P06_Aust_Triage_Scale_-_
Nov_2000.pdf.
Pulse Rate >120 beats/min
GCS <9
Penetrating injuries
All penetrating injuries to the neck
Multiple Patients
When 3 or more trauma patients are expected
Pregnancy
Pregnant patient ≥ 20 weeks gestation with
ruptured membranes, PV bleeding, fetal heart
rate < 100 bpm
Table 2: Trauma Alert Guidelines
GCS 9 – 13
4.Gaba DM et al: Simulation-Based Training in Anesthesia Crisis Resource
Management (ACRM): a decade of experience Simulation Gaming (2001) June 32 :
2 175-193.
5.Cummings GE, Mayes DC: A Comparative Study of Designated Trauma Team
Leaders on Trauma Patient Survival and Emergency Department Length-of-Stay
CJEM. 2007 Mar;9 (2):105-10.
6.Hjortdahl M et al : Leadership is the Essential Non-technical Skill in the Trauma
Team – Results of a Qualitative Study Scand J Trauma Resusc Emerg Med. 2009
Sep;26;17(1):48.
Prolonged loss of consciousness
Limb amputation
7.Ahmed JM, Tallon JM, Petrie DA : Trauma Management Outcomes Associated with
Nonsurgeon versus Surgeon on Trauma Team Leaders Ann Emerg Med. 2007
Jul;50(1):7-12, 12.e1. Epub 2006 Nov 15.
Suspected spinal injury
Specific Injuries
3.ATLS. Advanced Trauma Life Support: Program for Doctors. 7th ed. Chicago:
American College of Surgeons; 2008.
Burns> 20% &/or airway burns
Serious crush injuries
Major compound fracture or open dislocation
Fracture of 2 bones of the tibia, femur, humerus
Suspected fractured pelvis
Pregnancy
Pregnant woman > 20 weeks sustaining trauma
Blunt Injuries
Obvious severe blunt injury to head &/or torso
Penetrating Injuries
Penetrating injuries to head &/or torso
Inter-hospital
Transfers
All major trauma transfers to RMH
8.Holzman RS et al: Does team training improve team performance? A meta-analysis.
Human Factors: The Journal of the Human Factors and Ergonomics Society (2008)
Dec;50 : 903-933.
9.Toff NJ: Human factors in anaesthesia: lessons from aviation Br. J. Anaesth. (2010)
105(1): 21-25.
Table 3: Summarised Responses of Participant to Crisis Resource
Management training.
Response to Environment
My responses were realistic
The camera didn’t interfere with my performance
It was easy to treat the mannequin as a human
I felt comfortable in the simulation environment
Debriefing Session
The session enhanced my knowledge
The session added to the learning experience
The session clarified important teamwork issues
The session clarified important issues with scenario
Other Responses
The course will help the team function better
The course will help me act more safely
The course would benefit me as a doctor or nurse
The course helps to put teamwork knowledge into practice
Agree
%*
Strongly
Agree
58
43
48
59
%*
22
46
17
18
50
42
44
38
48
50
58
55
40
50
23
44
60
40
77
55
*The percentages recorded are only those agree or strongly agree and thus will not add
up to 100%
ORIGINAL ARTICLE
THE ADVANTAGES OF A DAME DATABASE
Dave Baldwin, BSc, Dip Obs/Gynae, MB, ChB., Dip Avmed, FRNZCGP
Abstract
Dr Dave Baldwin is a longstanding DAME/AME in New Zealand. He has up to
1800 pilots registered with the Bulls Flying Doctor Service, and has developed
a Personal Pilot Medical Database which provides a simple and effective query
builder to allow the review of pilot demographics and disease profiles of the
pilots registered with his service. A database of this kind has many advantages
for DAMEs and for pilots and is a great resource for aviation medicine research.
The database
The database is based on Borland Delphi™, a relatively simple software
package that can be set up to store demographic data, disease information,
and flight details for each pilot. It is cheap to set up, and doesn’t need expensive
licences and upgrades like larger practice management programs. Figure 1
shows the initial screen.
Background
Dr Dave Baldwin is a longstanding DAME/AME in New Zealand. His core
training is General Practice and Family Medicine, and he practices in the small
town of Bulls, located in the lower half of the North Island of New Zealand and
situated next door to RNZAF Base Ohakea. He works half time as one of five
doctors at the Bulls Medical Centre, a semi-rural General Practice where the
workload includes routine family medicine, screening and preventative health,
minor surgery (such as vasectomies), and some accident and emergency work.
Bulls Medical Centre has been fully computerized for many years, using the
MedTech™ practice-management package. In addition to information related
to appointments and finances, Medtech™ can easily provide a clinician with
data that describes the practice’s patient demographics, disease prevalence,
and an overview of screening and health promotion programmes.
In addition to working in general practice, Dr Baldwin works half time in aviation
medicine. Bulls Flying Doctor Service is based at Palmerston North Airport, and
is located in a purpose-built aviation medicine centre which has consulting
rooms and classroom facilities (for teaching Massey University Students in
aviation medicine, and for various conferences), as well as an administration
area and hangar space for its two aircraft: a Cessna XP2 HAWK and a helicopter.
These aircraft have been equipped to accommodate all the specialist medical
equipment required for an aviation medicine examination.
The Bulls Flying Doctor Service performs aviation medical examinations for
approximately 1700 pilots, 30% of which have their medical examinations performed
at the Palmerston North Airport Aviation Medical Centre. In addition, the Bulls Flying
Doctor Service provides a fly-in aviation medicine service to the remaining 70% of
pilots on its register. These pilots have their aviation medicals performed at outreach
clinics located at regional and rural airports spread across two thirds of New Zealand.
These outreach clinics are visited on a regular monthly schedule.
Figure 1
For each pilot, the database records the ARN or CAA number, basic
demographic data (gender and date of birth), basic aviation data (type of flying,
class of licence), and disease codes. The bottom of the screen displays realtime summary statistics: total number pilots, average age, gender mix, total
flight hours, and average flight time over the last six months.
The disease codes used in the database have been generated by the author.
They are intended to identify clients with specific conditions, in order for the
clinician to get the casenotes and read through the relevant clinical entries.
As such, the disease codes used in this database are not as specific as those
used by other clinical management software packages. For example, Figure 2
shows “dyslipidaemia” is segregated into “treated” and “non treated” groups.
However, the disease codes are flexible – the DAME can easily add, delete,
or modify disease categories as they wish. One drawback to this flexibility in
disease coding is that there may be difficulty sharing or comparing datasets
between different aviation medical practitioners.
The database has very simple but
effective sort and search
functions. Sorting is done by
clicking the heading buttons for
each column. Figure 3 shows the
data sorted by ascending
date of birth.
The outreach clinics give the Bulls Flying Doctor Service the opportunity to “live
the dream” – get out of the surgery, do mountain flying, and practice aviation
medicine in one of the of the most beautiful places in the world.
Unfortunately, in contrast to the fully computerised practice at the Bulls Medical
Centre, the Bulls Flying Doctor Service had no way to track client demographics
or disease prevalence. However, Dr Baldwin has now developed a DAMEspecific database that provides the Bulls Flying Doctor Service with the benefits
he sees in his general practice.
Author details
Dr Dave Baldwin, BSc, Dip Obs/Gynae, MB, ChB., Dip Avmed, FRNZCGP,
Bulls Flying Doctor Service
Correspondence
[email protected]
Figure 2
The Advantages of a Dame Database
in New Zealand, spread across approximately two-thirds of the country. As
a result, the database that he has created could provide significant insight
into the demographic profile and health of New Zealand’s pilots. He intends
to undertake a structured review of the clinical and demographic data he has
collected in order to better understand the health of his pilots. He would be
interested in undertaking collaborative research with other aviation medicine
specialists who would be interested in determining the extent to which the
dataset he has collected could further our appreciation and understanding of
the health of pilots in general, and clinical aviation medicine more broadly.
Figure 3
Searching for relevant demographic or disease information is easily performed
by entering the search term in the window at the top of each column and
clicking the search icon as in Figure 4.
Figure 4
The Advantages of Pilot Databases.
The author considers that using a database to capture relevant demographic
and clinical information for his pilots brings significant advantages, not only to
his clinical practice, but also to the service he is able to provide his pilots as
well as the potential to create a dataset for aviation medicine research.
Advantages for the DAME.
The database provides the DAME with evidence-based insight into their
aviation medicine practice, enabling the DAME to obtain an accurate profile
of their pilot population: the age distribution, gender mix, and the proportion of
pilots who fly fixed- or rotary-wing aircraft. The database also allows the DAME
to determine the prevalence of particular diseases in their pilot population,
and provides them with an understanding of how many of their pilots have
hypertension requiring medication, how many have asthma, and how many
require spectacles. Furthermore, the author’s experience is that his clinical
history and examination has become more meticulous since the introduction of
the database, due in part to his understanding that the quality of the results he
gets out of the database are only as good as the quality of the data he feeds
into it. For example, he would record that a pilot has flown 10560 hours (rather
than “about 10 000 hours”), and he now records the method of fixation for a
pilot who reports a fracture in the previous 12 months.
Figure 5
Advantages for the pilot.
Rather than simply performing routine medical examination for pilots to
gain medical certification to continue flying, the Bulls Flying Doctor Service
provides a “service” to the pilots. The database allows the DAME to provide
pilots with ongoing medical advice tailored to their particular demographic or
clinical profile. The database makes it easy for a DAME to identify pilots with
a particular medical condition, and send them copies of the latest treatment
guidelines relevant to their condition.
Advantages for aviation medicine research
Although New Zealand’s population is relatively small – only 4.3 million people
– its disease demographics are representative of many other western countries.
The author’s aviation medicine practice covers approximately 18% of all pilots
ORIGINAL ARTICLE
Implantable Cardiac Devices in the Military
Aviation Environment
Paul Kay, BEng(Hons), PhD, M.IEEE, M.IE Aust
Abstract
Implantable cardiovascular devices (pacemakers and implantable cardioverter
defibrillators) are electronic devices that are implanted in the human body
in order to ensure correct operation of the patient’s heart. Malfunction of
these devices seriously endangers the patient’s life. In general, electronic
devices can malfunction in the presence of radio frequency signals. The
engineering endeavour to minimise this problem falls within the discipline
known as Electromagnetic Compatibility (EMC). This paper provides an
overview of the approach to achieving electromagnetic compatibility with
general electronic equipment, then looks at the special case of implantable
cardiovascular devices and contrasts the general civilian electromagnetic
environment with the military aviation electromagnetic environment. The
limits for protection of humans from over exposure to radio frequency energy
are compared to the limits for protection of equipment from malfunction
due to radio frequency energy. The analysis concludes with the finding that
implantable cardiovascular devices in the military aviation electromagnetic
environment are at a higher risk of interference than when they are in the
general civilian environment.
Historical Background: Frogs, Dogs and
Electrocardiograms
In 1791, Luigi Galvani published his discovery that metallic contact between
muscle and the crural nerve in a frog’s leg caused twitching of the muscle;
the experiment was replicated by Volta soon afterwards. The ensuing 50 years
brought refinements in the generation of electricity and recording of muscle
movement as other researchers entered the emerging field of electrophysiology.
A laboratory setup of the period is shown in Figure 1.
In 1842, Metteucci was able to demonstrate that electrical current was associated
with human heartbeat. Measurement of the heartbeat was possible from 1872, when
Gabriel Lippmann invented the capillary electrometer; experimenters Sanderson and
Page used the apparatus to record two phases of the heartbeat soon afterwards2.
Introduction: what is EMC?
The International Electrotechnical Committee definition of EMC is “the ability of
equipment to function satisfactorily in its electromagnetic environment without
introducing intolerable disturbances to anything in that environment.” Note that
the definition encompasses the physical properties of the equipment in question
as well as the electromagnetic characteristics of the equipment’s operating
environment. The environment is defined as the totality of electromagnetic
phenomena existing at a given location1. When a piece of electronics can perform
its intended function in its intended environment without causing an interference
problem, we say that electromagnetic compatibility has been achieved.
A familiar example of an electromagnetic interference is the buzzing that is
sometimes heard on a desk telephone when a mobile telephone is close by.
The buzzing arises because the mobile telephone is transmitting a powerful
pulsed signal to the phone tower, and those signals are “picked up” by the desk
telephone’s wires (the electromagnetic field induces a voltage between the
wires). This unwanted voltage makes its way to the desk telephone’s speaker
and an unwanted buzzing occurs, even before the mobile phone rings, because
of transmissions that occur when the call is being set up. In the case of a
desk telephone, the buzzing is nothing more than a minor annoyance and the
interference may be considered to be acceptable – after all, the consequences
are minor, and the problem is easily cured by moving the mobile telephone
further away from the desk telephone.
Figure 1: Galvani’s frog experiment
Technological developments over the following hundred years significantly
refined our ability to measure electrical activity in the heart. Two streams of
research grew: measurement and characterisation of electrical activity in the
heart, and electrical stimulation of the heart.
The capillary electrometer was supplanted by the electrocardiogram, when Einthoven
adapted a galvanometer to the purpose in 1912. The original galvanometer invented
by Deprez and d’Arsonval could not measure the very small voltages associated with
heart activity; Einthoven’s modifications yielded a very sensitive galvanometer that
could respond very quickly to the electrical activity of the heart. An early production
version of Einthoven’s apparatus is shown in Figure 2. The patient has both hands
and one foot in salt water baths to make electrical contact with the apparatus. The
deflections of the moving coil meter must have been very small, evidenced by the
viewfinder and magnification apparatus to the right of the detection stage (above
the control panel at the centre). The final major technological leap for measurement
of the electrical activity in the heart came around 1953 when Dirk Durrer (professor
of cardiology at the University of Amsterdam) collaborated with physicist L. H. van
der Tweel to apply van der Tweel’s oscilloscope to extracellular cardiograms2.
Author details
Dr Paul Kay, BEng(Hons), PhD, M.IEEE, M.IE Aust
Electromagnetic Test Flight
Aerospace Operational Support Group,
Development and Test Wing
RAAF Base Edinburgh, SA 5111
Correspondence
[email protected]
Figure 2: Einthoven’s Galvanometer
Implantable Cardiac Devices
Modern ECG machines are digital refinements of the oscilloscope; digital
signal processing technology is employed to improve the quality and expand
the content of the information gleaned from waveforms present at the ECG’s
interface to the patient. Modern software makes the equipment easier to
operate and the results are easier to record, store and interpret. However,
the measurement philosophy and system architecture of the modern ECG is
strikingly close to van der Tweel’s oscilloscope.
among them was the idea of an implantable pacemaker. Wilson Greatbach,
an electrical engineer, worked with Dr. William Chardack, a surgeon, and
implanted a pacemaker in an animal in 1958. An unsuccessful attempt at
implanting a similar device in a human patient was made by Dr. Ake Senning in
Sweden in the same year, but the device failed after three hours. In 1960, the
first really successful implant was performed, and a further 9 patients received
pacemakers that year, some of whom lived long and active lives4.
Those early devices required a risky surgical procedure in order to attach the
electrode to the heart, and mortality was near 10%. Improvements in lead
design and insertion methodology pioneered by Dr. Seymour Furman gave rise
to a procedure that could be performed under local anaesthetic, without the
need for a thoracotomy. Further improvements were produced in 1964, when
Barouh Berkovits reported a “demand” pacemaker, which sensed heartbeat in
the patient and produced pulses only when necessary. This was a significant
improvement over the initial pacemaker designs, which produced pulses
irrespective of the patient’s needs4.
Figure 3: Modern ECG system
Meantime, the first steps towards therapeutic electrical stimulation of the heart
were taking place, and two further streams emerged: impulse stimulations,
designed to stop fibrillation, and measured low level pacing signals, designed
to address heart block.
In 1899, Prevost and Batelli stopped ventricular fibrillation in a dog by direct
electrostimulation of the exposed heart. In 1947, Beck successfully used the
technique in a human patient, and in 1957, the external defibrillator was
developed by William Kouwenhoven, an electrical engineer at the Johns
Hopkins University in Maryland. This device applied alternating current (AC)
externally, using electrodes on the patient’s chest. Cardiologist Paul Zoll applied
the external AC defibrillation apparatus to a human patient in 1952. While there
was some success with the treatment, the externally applied electrodes caused
burns on the patient’s skin. Lown and Neuman improved on that system with
their direct current (DC) defibrillator in 1962; this system was more reliable and
safer for the patient than the original AC system3.
Electrical technology until the 1950s was almost exclusively valve (vacuum
tube) based. Miniaturisation was restricted to devices that used very small
valves (so-called “peanut valves”, that were approximately the size of a peanut
rather than the typical egg sized devices), but such devices were still physically
large by today’s standards. Also, power consumption was too high for longterm battery operation, due to the need for a heating circuit in each valve. While
it was possible to construct a device as small as a cigarette packet, it was not
possible to provide a long life battery small enough to fit inside it.
In the mid 1950s at the University of Minnesota, Earl Bakken (co-founder of
Medtronic) produced an external pacemaker that used myocardial leads; this
device was located outside the body, so the leads had to penetrate the skin to
reach the heart, increasing the risk of infection4. Also, the device operated from
the AC mains, so was of no use during a power failure. Its main applications
were with patients recovering from open heart surgery.
With development of the semiconductor transistor in the mid 1950s, the way
was opened to many new miniature and low power applications of electronics;
Today, implantable cardiovascular devices exist to provide a regular electrical
pacing signal to the heart in the event of Sinoatrial node failure (pacemakers)
or to apply a defibrillation impulse to the heart in an attempt to stop ventricular
fibrillation (cardioverters). In this paper, these devices are referred to collectively
as implantable cardiovascular devices (ICDs). Modern ICDs have a range of
monitoring and communication functions that allow medical practitioners to
interrogate the device from outside the body, to access data relating to the
status of the device and the performance of the patient’s heart. Transistors are
still used, but not in the discrete form of the late 1950s original transistors;
today, millions of transistors reside on a single wafer of silicon, yielding high
processing and storage capability with very low power requirements.
Electrical Background – Current and Voltage
For the purposes of understanding the electrical terms that are used when
discussing ICDs, the following terms and analogies may be helpful:
Current – this is the movement of charge through a conductor in a circuit. In a
hydraulic analogy this may be compared to water flowing along a pipe, a large
current may be thought of as a large volume of water issuing from a pipe.
Voltage – this is the force that drives a current in an electric circuit; its source
can be an assemblage of electric charges (such as inside a battery) or the
influence of an alternating current (an external radio wave or electrodynamic
field – the effect that allows a radio wave to convert to an electrical signal at an
antenna). To continue the hydraulic analogy water may be thought of as flowing
through a pipe because a reservoir being at a higher point (electrostatic field)
or because of a pump (electrodynamic field).
Resistance – this is the property of a material that opposes the flow of current.
A substance or component with high resistance will not allow a very large
current to flow. In the analogy, a high resistance may be considered to be a
small diameter pipe in series with larger diameter pipes connected to a high
water tank or pump – even though there is good pressure and good flow for
most of the system, the restriction causes a reduction in flow.
The key things to remember are that current flows in (or more accurately, on)
a conductor and that voltage exists between two points in a circuit. Resistance
is a property of materials that opposes current flow – substances with high
resistance are insulators (e.g. wood, plastic) and substances with low resistance
are conductors (e.g. copper, aluminium). In the case of an external defibrillator,
a conductive gel is applied between the skin and the pads to decrease the
resistance of dry skin.
When considering EMC, it is also necessary to remember some important
implications of Maxwell’s Equations:
• A time varying electromagnetic field (“radio wave”) induces a time varying
voltage in a conductor immersed in that field, which then drives a time
varying current in this circuit;
• A time varying current in a conductor induces a time varying electromagnetic
field in the space around it;
• A constant current in a conductor produces a static magnetic field near
the conductor.
Finally, as an aid to understanding mechanisms for radio interference, it is
helpful to have an insight into how some radio receivers work. When electronic
devices are disrupted by radio signals, the mechanism if often similar to AM
radio reception.
A radio transmission, such as AM broadcast, consists of a carrier wave that
has been modified by superposition of an audio programme. The carrier wave
for AM broadcast is around 1000 kHz; numbers such as 729 kHz and 891 kHz
will be familiar to some readers. The audio bandwidth (loosely interpreted as
“fidelity”) for AM radio is restricted approximately to the range 200 – 4000 Hz.
So, the 1000 kHz carrier wave is modified, or modulated, by the much lower
frequency audio signal, to form a composite radio signal that has desirable
long range propagation properties and embodies the desired audio information.
In the radio receiver, it is necessary to capture the radio signal by means of
a suitable antenna, then extract the audio components from the radio signal.
The latter process is called demodulation, and is achieved with a diode or other
non-linear element. The mathematics of a nonlinear operator on the combined
radio signal show how the signal is separated into radio and audio frequency
components. The interested reader can consult Kawamura et al5 for a summary
of the mathematics. Once the composite signal has been broken into its
discrete frequency components and products by the non linear element, the
audio component is filtered, amplified and relayed to a speaker for conversion
into acoustic signals.
processing occurring in the leads – they are just bits of wire, albeit very special
wire), but they act as antennas and pick up unwanted signals if exposed to an
electromagnetic field. The interference arises when wanted signals (i.e. heart
impulses) on the leads are combined with unwanted signals (e.g. mobile phone
signals) in the ICD, and the ICD has insufficient ability to discriminate between
the two.
There are two types of leads used with ICDs. Originally, unipolar leads were
used exclusively, but in more recent times, these have been almost entirely
supplanted by bipolar leads. Bipolar leads are preferred because they make the
ICD far less susceptible to interference than unipolar leads.
The principle of operation of bipolar input leads is shown in Figure 4. The
wanted heart signal is developed between the two parts of the input leads,
and is presented to the input of the device as the potential difference between
the two leads. An external disturbance, represented by the lightning bolt in
the figure, induces more or less the same disturbance on both input leads.
At the input to the ICD, a “difference amplifier” (the triangular symbol in the
diagram) can be used to subtract the voltage on one lead from the voltage on
the other. This has the desirable effect of almost completely cancelling any
disturbance that is present on both leads, and leaving only the signals that
are the difference between the two leads. The figure also shows a filter, which
is a frequency-selective device that allows some frequencies through whilst
rejecting other frequencies. It is common for ICDs to incorporate filters that are
tuned to reject mobile telephones, while allowing the lower frequency signals
associated with the heart to pass through.
Implantable Cardiovascular Devices – Physical
Arrangement and Radio Frequency properties
Implantable cardiovascular devices are embedded in the human body, typically
in the upper area of the chest, close to the surface of the skin. The device
body houses the battery and processing components, and conductive leads
penetrate to the appropriate regions of the heart. The leads, usually around
300mm long, typically perform two functions:
• to monitor the electrical activity of the heart in order to detect pulse rate
problems (sensing pacemakers) or ventricular fibrillation (cardioverters), and
• to deliver the electrical stimulations that are produced inside the device to the
conductive pathways on the heart.
ICDs operate by monitoring the very small voltages that are associated with heart
muscles. Typical sensitivities (that is, detection levels) for ICDs are approximately
0.2 – 3 mV6; the electrical signals that are associated with the heart are
comparatively small, so sensitive electronic circuitry is required to detect them.
Recall that Einthoven went to considerable trouble to produce a moving coil meter
(galvanometer) capable of responding to heart signals. One challenge faced by
ICD designers is making the device sensitive to signals produced in the heart, but
insensitive to other signals that may exist in the environment.
The leads attached to an ICD are the dominant pathway for interference to
enter the ICD. No disruptive interference can occur within the leads themselves,
because they are electrically passive (that is, there is no amplification or
Figure 4: Bipolar lead ICD input stage
While bipolar leads and difference amplifiers make for a more robust system, it
is still possible for strong interfering signals to swamp the system and disrupt
operation. If the incoming signals are strong enough to drive the difference
amplifier into non-linear operation (analogous to turning a stereo up so loud
that it distorts), then the interference cancelling effect is lost, and the amplifier
will demodulate radio frequency signals.
While the human heart rate broadly lies in the range 0 – 200 beats per minute,
which corresponds to something less than 3 beats per second (3 Hz), the ICD’s
operating frequency range is determined by the fastest and slowest rise times
in the waveforms of the heart. Most ICDs try to process signals in the range
10 Hz to several kHz; higher frequencies can be filtered out without loss of
heart signal information. Unfortunately, constructing lightweight, inexpensive
filters that perform well across very wide bandwidths (from around 10 kHz
to 40 GHz) is very difficult. For that reason, some ICDs incorporate filters that
are targeted to the most common, highest risk threats, for example, mobile
telephone handsets.
Interference Mechanisms
Electronic equipment experiences interference when wanted signals are
distorted or otherwise corrupted by external electrical influences. Electronic
equipment, including ICDs, employs diodes and many other non linear
elements to achieve functions that are not associated with radio reception. The
interference problem arises when the following criteria are met:
1.the physical nature of the device and any leads attached to it provides an
antenna-like function that captures RF signals;
2.sufficiently strong signals reach non linear elements, or overdrive linear
elements so that their response is non linear, inside the equipment, and
3.the unwanted demodulated signal in the equipment becomes confused
with wanted signals, leading to incorrect operation of the equipment.
Criterion (1) is satisfied under most conditions, for most equipment, most of
the time. We live in a world where radio frequency signals are ever-present,
and any conductive surface (wires, pipes, brackets, plates, etc.) interacts with
those fields and has radiofrequency currents flowing on it. Recall that a car
radio antenna can be replaced by a wire coat hanger with satisfactory results.
Criterion (2) can be satisfied when powerful enough radio transmitters are in
close enough proximity to the equipment. The intensity of radio frequency fields
can be described by their electric field strength, expressed in Volts per metre
(V/m). Table 1 lists some transmitter types, their power and the field strength
at various ranges from the transmitter. Note that small transmitters at close
range produce higher field strengths than powerful transmitters at long range. To
provide some context for Table 1, consumer devices are sometimes designed to
tolerate 3 V/m field strength, industrial control systems are designed for around
10 V/m, and safety critical and military equipment is expected to withstand 200
V/m. The author has seen some electronic systems malfunction at less than 3
V/m in laboratory tests. Criterion (2) cannot be satisfied in equipment that does
not contain non linear components – so, simple electrical equipment containing
ONLY motors, light globes and heating elements are inherently immune to radio
frequency disturbances.
Table 1: Field Strengths and Distances
Transmitter
Mobile phone handset
VHF aircraft radio
4WD HF
(“flying doctor”) radio
Peak Power
Range
Field
Strength
0.3 m
25 V/m
1m
7.5 V/m
3m
2.5 V/m
100 m
0.08 V/m
1m
27 V/m
3m
9 V/m
100 m
0.3 V/m
1m
55 V/m
3m
18 V/m
100 m
0.5 V/m
2W
25 W
100 W
Finally, interference requires that criterion (3) is satisfied as well. Even if
the item’s wiring and structure lends itself to reception of a particular radio
transmission, and if the field strength is sufficiently strong to bring about
unintentional demodulation in the victim equipment, there may not necessarily
be any observable effects.
An example of this scenario is a car fuel gauge, exposed to a GSM mobile
phone signal (which has a 217 Hz pulse repetition frequency). The property
indicated by the gauge (fuel remaining in the tank) varies quite slowly, and the
circuits between the sensor and the indicator are designed with this in mind. So
slow is the response of the circuit that it may take a minute or more for a gauge
to indicate full after the tank has been filled from empty. If such a circuit was
exposed to a radio frequency field that induced unwanted impulses of around
200 Hz in it, it is highly likely that there would be no observable malfunction
of the indicator. This is because the circuit is incapable of responding to such
a fast set of impulses (which, if they represented real inputs from the sensor,
would represent the tank being alternately filled and emptied 200 times
per second).
However, the same set of disturbances in a computer speaker system generally
leads to a buzzing sound. In this case, the 200 Hz impulses are within the
audio bandwidth that the speakers are designed to reproduce (20 Hz – 16
kHz); the amplifier in the speakers cannot discriminate between wanted and
unwanted pulses.
Finally, in the case of an ICD, 200 Hz impulses can appear as extra heart beats,
possibly causing the ICD to mistake the interference for ventricular tachycardia,
leading to an uncommanded defibrillation pulse.
RF Immunity of ICDs
To reduce the likelihood of EMC problems with ICDs, the US-based Association
for Advancement of Medical Instrumentation (AAMI) produced technical
standard AAMI PC69, “Active implantable medical devices – Electromagnetic
compatibility – EMC test protocols for implantable cardiac pacemakers and
implantable cardioverter defibrillators”. This document provides detailed
and specific EMC test methods, field strength limits and ICD performance
acceptability criteria.
These requirements exist in order to specify minimum EMC robustness for
ICDs, and to ensure consistency of results between different test facilities.
AAMI PC69 was introduced as a draft in 1975, reviewed substantially in 2000,
and the subject of further revision in 20078. Technical standards are usually
produced by teams of qualified and experienced volunteers operating within
the organisational confines of standards production bodies. The AAMI is such
a body, and has more than 100 technical committees and working groups that
produce or contribute to technical standards for hospital sterilisation, dialysis
equipment and general medical electrical equipment (by cooperation with the
global International Electrotechnical Committee).
At the time of publication of the 2007 version of AAMI PC69, the AAMI Cardiac
Rhythm EMC Taskforce of 12 members comprised: Medtronic (4), US FDA (2),
Medical Practitioners (3), and Others (3)
The evolution of PC69 from 1975 to 2007 is shown in Figure 5. The original
version of the standard primarily aimed to protect pacemakers from powerful
ship radar systems that operated near 450 MHz. If these radars were
energised in harbour, considerable interference issues were observed in the
community9. The ensuing 25 years brought new threats in the form of smaller
transmitters that could be brought very close to the body, and the year 2000
amendments significantly refined the method and extended the frequency
range for measurement.
Human Exposure to RF Energy
The preceding discussions about radio reception and interference highlight the
role of non linear elements as accidental demodulators of unwanted signals
in victim equipment. Non linear elements respond to the peak of the radio
frequency waveform.
Figure 5: Evolution of AAMI PC69 1975 – 2007
In 2007, the frequency range for testing was extended again, this time down
to DC (0 Hz). This is an unusual requirement among EMC standards, and
exists to ensure that the ICD will not inadvertently go into maintenance mode
(“magnet mode”). In a clinical environment, a practitioner can use a special
probe placed over the ICD to non-invasively interrogate the ICD or upload new
pacing programmes. This probe head includes an inductive loop antenna to
facilitate data communication with the ICD, and a permanent magnet, whose
presence is sensed by the ICD. On detection of a static magnetic field, the ICD
changes from normal operation to a maintenance mode that presupposes the
presence of the data probe. Unfortunately, the magnetic field produced by a DC
current in a wire cannot be distinguished from the magnetic field produced by
a permanent magnet, so there is a risk that such ICDs could enter maintenance
mode if they are too close to a wire carrying a DC current.
In order to protect humans from deleterious health effects due to overexposure to radio frequency energy, government regulators around the world
have established regulatory regimes with the intention of limiting exposure.
With a few exceptions associated with very high field strength exposure, the
main health concern for human exposure is heating of tissue. The amount of
heat that is absorbed by tissue corresponds to the average amplitude of the
radio frequency source. Figure 6 shows the reference levels for occupational
(RF aware workers) and general public RF electric field exposure. Note that
the peak levels are very much larger than the time averaged levels. The
peak restrictions exist in order to protect against electro-acoustic effects in
the human ear, where pops and clicks can be heard in the presence of very
powerful pulsed sources, to protect against electrostimulation and to protect
against RF shock and burns.
The 2007 amendments to PC69 did not extend the frequency range of
test above 3000 MHz. The standard justifies the omission based on the
following points8:
• Radiated fields above 3000 MHz are mostly directed beams that do not
cause high intensity public exposure;
• Patient and public exposure to such beams is typically low level side-lobes
of the antennas;
• Devices with a metallic enclosure are expected to provide adequate
shielding above 3000 MHz (that is, if a device can meet the lower frequency
requirements, it probably has good enough shielding to be robust at higher
frequencies as well);
• Overlying body tissues have greater shielding effectiveness at
higher frequencies.
However, recent changes in consumer technology, particularly 5800 MHz
cordless telephones and computer networks, are not addressed by the standard
in its present form. These systems spread their energy in all directions, and are
not directed beams. AAMI PC69:2007 notes that these kinds of emitters will be
considered in a future edition of the standard.
Figure 6: ARPANSA (Australian Radiation Protection and Nuclear Safety
Agency) Standard RPS3 reference levels for RF exposure7.
Two very different waveforms can have the same average level, and generate
the same heating effect on tissue - a short duration pulse of high peak
amplitude produces the same amount of heat as a much lower continuous
wave signal.
This is important when considering interference to ICDs. The ICD responds
to the peak of the interfering wave, because of the response of non linear
elements inside it. In contrast, the human body suffers from over exposure
mostly due to heating effects, which are related to the average level of the
RF signal. It follows that the general protection measures for human exposure
are not sufficient to guarantee interference free operation of an ICD – a fact
borne out by the numerous RF precautions recommended to practitioners and
patients by the ICD manufacturers.
To reduce the likelihood of interference to ICDs, device manufacturers provide
guidance on how to avoid exposure to radio frequency energy. A list of warnings
is shown in Table 2, with some supporting explanation by the author.
Table 2: RF exposure warnings for ICD patients
Electrical reset can be caused by exposure to strong electromagnetic fields (programmed settings may be lost).
In this case, the external field couples into the control portions of the device, mimicking a reset command that may be used in a clinical setting, or setting up
a fault condition that causes the device to restart.
Do not loiter near EAS (Electronic Article Surveillance) systems in shops.
This refers to the anti-theft systems that are typically comprised of two loops, one either side of the exit door. The loops transmit a burst of signal intended to
illicit a response from the transponder affixed to merchandise. The burst/impulse nature of the transmission could couple to the ICD leads and be mistaken for
irregular heartbeats, because of the burst nature of the transmission and the close proximity of the loops to the patient.
Do not carry mobile phones in chest pockets and use the ear furthest from the implant when talking.
While mobile phones are low powered transmitters, their proximity to the body makes them a significant risk to ICD malfunction (refer to field strengths in Table 1).
The table shows that increasing the separation between a transmitter and the victim significantly reduces the field strength at the victim.
HF (short wave) diathermy may damage or reset the device.
The intent of diathermy systems is to raise the temperature of tissue, using 13.56 MHz or 27.12 MHz RF energy. The coupling to the tissue is usually via an
inductive loop antenna that directs the energy in the desired direction. If this intense field was inadvertently directed to the ICD, strong coupling to the leads or
the device itself could occur. Damage of semiconductor devices, including ICDs, can occur in cases of extreme overload.
Avoid high voltage power lines.
There are several reasons for this. First, the lines radiate at the power frequency (50 Hz, or 60 Hz in the US and some other countries). Further, various loads
on the supply network bring about harmonic currents which can also radiate, typically up to 350 Hz, but sometimes as high as 2 kHz. Finally, power networks
have many switching transients (“one-off” spikes) that could resemble irregular heartbeat if they coupled to the leads.
Do not use Magnetic Resonance Imaging (MRI) on ICD patients.
The energy levels in this treatment are very high and cannot be selectively directed to one part of the body, so malfunction of the ICD during an MRI process
is likely.
RF Ablation – keep external defibrillator on standby
This process brings high levels of RF energy directly into the heart, in close proximity to the IDC leads. The risk of interference is such that alternate ablation
treatments should be considered for ICD patients.
Ultrasound – patients should advise the physician before undergoing any treatment.
The same comments as HF diathermy apply.
Avoid communications equipment.
This guidance aims to keep the separation high.
Welders and chainsaws are not recommended.
Chainsaws, brush cutters and other small petrol engines produce considerable impulsive spark noise from the ignition system. The physical location of the
motor is quite close to the torso in normal use and the impulsive spikes could couple into the ICD’s leads.
Maintain separation between implantable and electric fences, automotive ignition systems (30 cm) and remote control model transmitters (15 cm).
Electric fences produce high voltage impulses at approximately 1 cycle per second, often using a transformer that is much like a car ignition coil. The high
voltages, coupled with a large radiating structure (fence) give rise to high peak intensity fields, even though the average intensity is very low. The peaks could
appear to the ICD as irregular heartbeats. Modern automotive ignition systems are reasonably well suppressed when in good condition and interference is less
likely. However, in both cases, a shock can be received by touching live wires and this could have serious implications for an ICD patient.
Remote control transmitters are low powered devices and by keeping a modest separation the field strength is expected to remain below the interference
threshold of the ICD. The guidance does not distinguish between the various different types of remote control transmitter now available, but the most powerful
types are comparable to a mobile phone handset.
The Military RF Environment
While the assumptions in AAMI PC69 may provide adequate protection in the
general community, the RF profile of a military environment is quite different,
in terms of the frequencies of transmitters, their proximity to humans, and the
peak power. In the military environment, there are numerous radio systems that
do not exist in the civilian community.
It is possible to meet the maximum RF exposure levels for humans whilst in close
proximity to radar transmitters, because the average energy is comparatively
lower than the peak due to the very short radar pulse transmission time. To
protect electronics from malfunction due to EMC problems, safety-critical
military equipment is tested to a very high level (200 V/m) across the range 10
kHz – 40 GHz10. A pictorial representation of the differences between general
electronics EMC requirements, PC69 requirements, and high reliability military
electronics requirements is shown in Figure 7. The approximate frequency
bands of various common transmitters are also shown, but there is no
indication of the relative powers of these transmitters in the figure.
at very close spacing (1.3cm). This setup captures the inductive coupling effect
of a mobile phone close to the body, but is not directly comparable to the free
space field strengths of other standards.
Conclusion
An introduction to interference mechanisms has been provided. Considerable
engineering effort is expended in producing ICDs that are robust in the face
of various radio frequency disturbances, but the challenge is great. Many of
the preferred interference mitigation measures are not practical for a device
that must be implanted in the body. Further, there is a need to balance the
susceptibility of the ICD to interference against the correct therapeutic sensitivity
setting: it has been shown that ICDs are more susceptible to interference at
their most sensitive setting6, but that must be a secondary consideration to
therapeutic efficacy when choosing a level.
The central change in terms of human safety from radiofrequency
disturbances when an ICD is introduced to the body is that the patient’s life
is now susceptible to peaks of radiofrequency energy, because that is the
susceptibility of the electronic circuit that sustains their heart function. Human
exposure to radiofrequency energy in the general community is low compared
to the military environment, but even so, ICD patients must take numerous
precautions to avoid exposing the device to various disturbances, particularly
impulsive ones (mobile phones, spark ignition, commutator electric motors).
Acknowledgment
The author acknowledges the support of the Aerospace Systems Engineering
Squadron and the Institute of Aviation Medicine of the Royal Australian Air
Force’s Aerospace Operational Support Group.
References
1.IEC 61000-1-1 (ed. 1.0) “Electromagnetic compatibility (EMC) Part 1: General
Section 1: Application and interpretation of fundamental definitions and terms”, IEC
Apr. 1992.
2.Rosen MR, Janse MJ. “Electrophysiology: from Galvani’s frog to the implantable
defibrillator”, Dialogues in Cardiovascular Medicine, Vol. 11, No. 2, 2006.
Figure 7: RF environments, sources and EMC test levels
Inspection of Figure 7 shows that the RF immunity test levels for general
consumer and industrial electronics are quite low, at 10 V/m or less. Further,
they are restricted to a comparatively small frequency range, 80 MHz to 2000
MHz, although this requirement is often supplemented by a complementary
test in the range 150 kHz to 80 MHz.
The pink horizontal line is the peak test level in MIL STD 461F for safety critical
military electronics, 200 V/m. This is a very demanding test to perform and
requires a complex laboratory setup. The orange arrow in the figure shows the
shortfall between the MIL STD 461F test level and the maximum peak exposure
allowed for humans. Equipment that has been tested to 200 V/m must be
provided with supplementary shielding in order to tolerate the peak human
exposure environments.
In contrast, the immunity requirements for electronic equipment located inside
the cabin of a passenger aircraft is approximately 5 V/m in the range 100 –
8000 MHz11.
The test levels for PC69 are not shown on the graph because the test
methodology of that document does not provide a field strength level that is
directly comparable to other EMC standards. The PC69 methodology uses a
setup that emulates the effect of a hand-held emitter at a distance of 15cm,
and an optional characterisation in the standard emulates mobile phone devices
3.“Defibrillator and cardioverter – Early defibrillators”, Medical Discoveries, retrieved
from www.discoveriesinmedicine.com/Com-En/Defibrillator_and_Cardioverter.html
on 21st Jan 2011.
4.Greatbach W, Holmes CF. “History of Implantable Devices”, Engineering in Medicine
and Biology Magazine, IEEE, Vol. 10, Issue 3, Sept. 1991, pp 38-41, 99.
5.Kawamura Y, Futatsumori S, Hikage T, Nojima T, Koike B, Fujimoto H, Toyoshima T.
“A Novel Method of Mitigating EMI on Implantable Medical Devices: Experimental
Validation for UHF RFID reader/writers”, IEEE Symposium on Electromagnetic
Compatibility, Austin, Texas, 2009, pp 197 – 202
6.
Hille S, Eichorn KF, Gonschorek K-H. “Interference Voltage and Interference
Threshold in Pacemakers with Unipolar and Bipolar Electrodes”, IEEE Symposium
on Electromagnetic Compatibility, Austin, Texas, 2009, pp 147 – 152
7.Radiation Protection Standard Maximum Exposure to Radiofrequency Fields – 3 kHz
to 300 GHz, Radiation Protection Series No. 3, Australian Radiation Protection and
Nuclear Safety Agency, Commonwealth of Australia, 8th May 2003
8.Active implantable medical devices – Electromagnetic compatibility – EMC test
protocols for implantable cardiac pacemakers and implantable cardioverter
defibrillators, American National Standards Institute, Arlington, VA, 12th April 2007
9.Kay P, Garrett R. “EMC Standards Development in Australia”, IE Aust EMC Society
of Australia Symposium on Electromagnetic Compatibility, Melbourne, Australia,
Sept. 2010.
10.
Department of Defense interface standard requirements for the control of
electromagnetic interference characteristics of subsystems and equipment, MIL
STD 461F, US Dept. of Defense, 10th Dec. 2007
Reprint
R U R A L of
AN D R
EM O T E Royal
H EA L T H
Frequent users
the
Flying Doctor
Service primary clinic and aeromedical services
remote
Wales:
a quality
study
equentin
users
of the New
RoyalSouth
Flying Doctor
Service
primary
clinic and
David Lservices
Garne, MBChB,
MIPH(Hons),
A Perkins,
BA(Hons),
PhD, Frances
T Boreland BA(Biol)(Hons),
eromedical
in DCH,
remote
NewDavid
South
Wales:
a quality
study
MPH(Hons) and David M Lyle MB BS, PhD, FAFPHM
Abstract
David L Garne, David A Perkins, Frances T Boreland and David
Lyle
ThereMare
several different models of general practice in Australia, and one
interesting variant is the Royal Flying Doctor Service of Australia (RFDS), a
Objective:
To examine
patterns of the Royal Flying Doctor Service of
here are several
different
modelsactivity
of ABSTRACT
community-based not-for-profit organisation. The South Eastern Section is one of
general practice
in (RFDS)
Australia,
Australia
in far and
western New South Wales and to determine whether
four operational sections of the RFDS Australia-wide, and the Broken Hill base is this
Objective: To examine activity patterns of the Royal Flying Doctor Service 1of Australia
one interesting
variant
the Royal
frequent
use ofis RFDS
services, (RFDS)
particularly
emergency
evacuations,
is
a
useful
corporate
headquarters.
It employs
a core clinical workforce consisting
in far western New South Wales and tosection’s
determine
whether
frequent use
of RFDS
Doctor Service
of Australia
indicator
of patients(RFDS),
who may benefit
fromparticularly
care planning
and review.
practitioners
flight who
nurses,
as well as child and family nurses,
services,
emergency
evacuations, isofageneral
useful indicator
of and
patients
may
munity-based not-for-profit organisawomen’s health practitioners and mental health workers.2 They run primary care
benefitWe
from
care planning
and review.
Design,Section
setting isand
conducted
a retrospective
audit of
The South Eastern
oneparticipants:
of
clinics,
conduct remoteaudit
telephone
consultations,
respond to medical emergencies
Design,
anddatabase.
participants:
conducted
a retrospective
of the
RFDS South
the RFDS
Eastern
Section’s
Brokensetting
Hill patient
PatientsWe
with
a
perational sections
of South
the RFDS
AusEastern Section’s Broken Hill patient database.and
Patients
with
a residential
address in
theSection works cooperatively with
manage
aeromedical
evacuations.
The
residential
address
in the
study area who had accessed at least one RFDS medical
wide,
and the
Broken
base
isISSN:
this
The
Medical
Journal
of Hill
Australia
study area who had accessed at least one RFDS
medical service
between
July
2000
and
1
state-based
health services
and1the
local
community-controlled
Aboriginal Health
n’s
corporate
headquarters.
It
service
between
1 July
30 June 2005 were included in the study.
025-729X 7/21
December
2009
1912000
11/ and
30 June 2005 were included in the study.
Service
to
provide
a
wide
range
of
primary
health
care
and
specialist
services to
ys a core clinical workforce consist2 602-604 Main outcome measures: Number
Main outcome
measures:
Number of evacuations,
consultations
andsettlements
remote in far western New South Wales and
of evacuations,
clinic consultations
and
remoteclinic
communities
and smaller
f
general
practitioners
and
flight
©The Medicalremote
Journalconsultations;
of Australia 2009
consultations;
usagenumber
by frequent
evacuees; number of primary diagnoses recorded
clinic usage
by frequentclinic
evacuees;
of primary
associated cross-border regions in Queensland and South Australia.
, as well as child and
family nurses,
www.mja.com.au
for evacuees;
frequent evacuees;
frequent
diagnoses
for frequent
number ofnumber
frequentofusers
who users who might benefit from multidisciplinary
n’s health
practitioners
and mental
Rural
and remote
health recorded
care
or
specialist
shared
care.
The question of how the RFDS might evaluate the quality of its clinical care has
might benefit
from multidisciplinary
care or specialist shared care.
workers.2 They
run primary
care
Results: Between July 2000 and June 2005, thebeen
number
of residents
requiring
the subject
of a review
by the evacuation
South Eastern Section.
, conduct remote
telephone
consulResults: Between July 2000orand
Juneconsultations
2005, the number
of by
residents
remote
declined
26% and 19%, respectively, and the number of
, respond to medical emergencies
Onethe
method
examining
quality is toofstudy
requiring evacuation or remote
consultations
declined
by declined
26% andby19%,
residents
accessing
clinics
6%. (Over
samefor
period,
the population
the frequent attenders at a clinic
anage aeromedical evacuations. The
or
service.
This
approach
has
been
applied
study
area fell
by about
24%.)
Of theby786%.
patients who were identified as frequent users of in both general practice and
respectively, and the number of
residents
accessing
clinics
declined
n works cooperatively with state- the evacuation service ( 3 evacuations/year), 34
emergency
department
settings.3-7
We hypothesised that such patients may
had three
or more primary
diagnoses
(Over
same
period,
the population of the study area fell by about 24%.) Of
health services
andthethe
local
commurecorded;
15
were
infrequent
or
non-users
of
the
clinics
(
3
attendances/year);
53 may and may benefit from a care
have
conditions
that
were
not well managed
the
78
patients
who
were
identified
as
frequent
users
of
the
evacuation
service
ontrolled Aboriginal Health Service have benefited from multidisciplinary care, and 41 from specialist shared care.
planning
or
review
process.
Our
aim
was to determine whether frequent use
3 evacuations/year),
34 had three or more primary diagnoses recorded; 15
vide a wide (≥
range
of primary health
Conclusions: Simple, practical clinical review systems
can help
healthevacuations,
care organisations
in as a flag to identify patients
of
services,
particularly
could
serve
infrequent
or non-users
of the clinics (≥ 3 attendances/year); 53 may
nd specialist were
services
to remote
com- rural
and remote communities to achieve better
outcomes
by identifying
patients who
whose
care
should
be
reviewed.
have benefited
from multidisciplinary
care, and
41 from
specialist
es and smaller
settlements
in far may benefit
from
planned
care.shared care.
n New South Wales and associated
We report on the usage patterns of RFDS services in remote NSW, the
Conclusions: Simple, practical clinical review systems can help health care
MJA
2009;
602–604
border regions in Queensland and
characteristics of patients
who
are191:
frequent
users of clinic and aeromedical
Australia. organisations in rural and remote communities to achieve better outcomes by
services,
and
the
implications
for
delivery
of
quality
clinical care.
may benefit from planned care.
question ofidentifying
how thepatients
RFDSwho
might
consisted of residents of remote communi1 Geographic region of the study
te the quality
of2009;
its clinical
care has ties in far western NSW served by the
MJA
191: 602–604
1 Geographic region of the study population (shaded),
population (shaded), showing
he subject of a review by the South Broken Hill RFDS base, who had accessed
showing
relevant
local government
relevant
local government
areasareas
n Section.
at least one RFDS medical service (evacumethod for examining quality is to ation to a hospital, clinic consultation or
frequent attenders at a clinic or remote consultation) between 1 July 2000
Unincorporated Far West
e. This approachAuthor
has beendetails
applied in and 30 June 2005. The area served by the
Bourke
general practice
and
emergency
David L Garne, MBChB, DCH,
MIPH(Hons),
Broken
Hill RFDS base includes all of the
3-7
ment settings.
We hypothesised Central Darling
Shire, all of the UnincorpoDirector
of Clinical Medicine Stream,1 and Senior
uch patients may have conditions that rated Far West
region, and parts of the
Medical Officer (Education and Research)2
r
not well managed and may benefit Bourke, Cobar
3
and Wentworth shires (Box
ve
David
A
Perkins,
BA(Hons),
PhD,
Director
Ri
a care planning or review process. 1). We excluded residents of the city of
g
n
Frances Twhether
Boreland,freBA(Biol)(Hons), MPH(Hons),
rli
im was to determine
Broken Hill and visitors to the region
Da
Officer,evacuPrimary Health Care Research,
Broken Hill
use of services,Research
particularly
Cobar
because the RFDS is not responsible for
Evaluation
Development Program3
could serve as
a flag and
to identify
providing their
primary health care. The
David be
M Lyle,
MB BS, PhD, resident
FAFPHM, population
Head1
ts whose care should
reviewed.
Central Darling
of the study area was
report on the1 D
usage
patterns
epartment
of RuralofHealth,
University of
Sydney,
Hill, NSW.
determined
from
the Broken
2001 and
2006 censervices in remote
NSW,Flying
the charac2 Royal
Doctor Service
Australia
susesof(Box
2).8,9 (South Eastern Section),
cs of patients whoBroken
are frequent
users
Hill, NSW.
Data extracted from the patient database
ic and aeromedical
services,
and theHealth Research, Department of Rural Health,
Wentworth
3 Centre
for Remote
were the patient’s unique identifier, age, sex,
ations for delivery of quality clinical
University of Sydney, Broken
Hill, NSW.
postcode
of residence, date of consultation,
service type (evacuation, clinic consultation
Correspondence or remote consultation) and diagnosis
HODS
(International Classification of Primary Care
[email protected]
nducted a retrospective audit of the [ICPC] code for diagnoses made in the clinic
South Eastern Section’
s Brokenwith
Hill permission
or remote consultation setting, and InternaReproduced
t database. The study population tional Classification of Diseases, 10th reviGame DL et al. Frequent users of the Royal Flying Doctor Service
METHODS
primary clinic and aeromedical services in remote New South Wales:
MJA • Volume 191 Number 11/12 • 7/21 December 2009
We conducted a retrospective audit of the RFDS South Eastern Section’s
a quality study. MJA 2009; 191:602-604. ©Copyright 2009. The
Broken Hill patient database. The study population consisted of residents of
Medical Journal of Australia – reproduced with permission.
remote communities in far western NSW served by the Broken Hill RFDS base,
who had accessed at least one RFDS medical service (evacuation to a hospital,
clinic consultation or remote consultation) between 1 July 2000 and 30 June
Frequent users of the Royal Flying Doctor Service
clinics attended by a frequent evacuee was 34.
2005. The area served by the Broken Hill RFDS base includes all of the Central
Darling Shire, all of the Unincorporated Far West region, and parts of the
Bourke, Cobar and Wentworth shires (Box 1). We excluded residents of the city
of Broken Hill and visitors to the region because the RFDS is not responsible for
providing their primary health care. The resident population of the study area
was determined from the 2001 and 2006 censuses (Box 2).8,9
Almost half the patients who were evacuated three or more times (34/78) were
identified as having three or more primary diagnoses, and the majority of these
were identified as having conditions that could benefit from multidisciplinary
primary care (53/78), specialist shared care (41/78), or both (Box 5). Some
patients with two or more primary diagnoses required multidisciplinary care for
one condition and shared care for another.
2 Population data for the study area,* by local government area
Local government area
2001
2006
Change (%)
census data census data
Central Darling (all)
2385
1937
- 18.8
Unincorporated Far West (all)
1607
1122
- 30.2
Bourke (part)
622
389
- 37.5
Cobar (part)
97
63
- 35.1
Wentworth (part)
621
552
- 11.1
Total
5332
4063
- 23.8
The top five clinic diagnostic categories (ICPC system) for the 23 patients
who attended 13 or more clinics and were evacu•ated three or more times
were circulatory (13), endocrine, metabolic/nutritional (9), psychological (5),
respiratory (5) and diges•tive (4). The top five evacuation diagnostic categories
(ICD-10 system) for this group were circulatory (12), genitourinary (4),
res•piratory (4), neoplasms (3), and mental/behavioural, injury and nervous (2
each, in equal fifth place).
DISCUSSION
In spite of a fall in the population served during the period of the study, demand
for the RFDS remained strong, albeit with an unexplained dip in evacuations
in 2004–05.
* Population within New South Wales served by the Broken Hill base of the Royal Flying
Doctor Service South Eastern Section.
Data extracted from the patient database were the patient’s unique identifier,
age, sex, postcode of residence, date of consultation, service type (evacuation,
clinic consultation or remote consultation) and diagnosis (International
Classification of Primary Care [ICPC] code for diagnoses made in the clinic or
remote consultation setting, and International Classification of Diseases, 10th
revision [ICD-10] code for diagnoses of patients evacuated to a hospital).
The decline in clinic attendances was largely caused by a reduction in attendances
per patient rather than a substantial reduction in the number of patients seen.
The majority of patients who were frequently evacuated had chronic health
conditions and might benefit from living closer to secondary or tertiary health
care. However, by choice or circumstance, they are living in isolated settings.
Given the relative lack of specialist and subspecialist services in rural and
remote Australia,10,11 the RFDS is an important provider of primary health
care to the local population. Other factors such as lower income levels, poorer
socioeconomic conditions, a higher proportion of Indigenous people and the
fact that men in rural communities are less likely than their metropolitan
counterparts to use preventive health services compound these issues.12
The frequency of evacuations for a patient in each 12-month period (July
to June) was grouped as once (one evacuation), twice (two evacuations) or
frequent (three or more evacuations).
The frequency of patients accessing the clinic service in each 12-month period
(July to June) was classified as low usage (1–3 consultations), medium usage
(4–12 consultations) or high usage (13 or more consultations).
RESULTS
Between 2001 and 2006, the estimated resident population decreased by 24%
(Box 2). The number of residents requiring evacuation or remote consultations
between July 2000 and June 2005 declined by 26% and 19%, respectively,
whereas the number of residents accessing clinics remained relatively stable,
declining by only 6% (Box 3).
Most patients requiring frequent evacuation had two or more primary diagnoses
and conditions that would normally require multidisciplinary or specialist shared
care, and some required both. This suggests that those who require frequent
evacuation may have unmet health needs, poorly managed chronic diseases
of the sort usually managed in general practice, or comorbid conditions that
may benefit from shared care between generalist and specialist providers or
multidisciplinary teams.
Data on frequent users of the evacuation service and the number of times
they presented for clinic consultations are shown in Box 4. Of the 78
patients who required frequent evacuation, four did not attend clinics at all,
a further 11 attended 1–3 times, and almost a third (23/78) attended 13 or
more clinics during the year. No patient was recorded as a frequent user of
evacuation services in more than one 12-month cycle. The maximum number
of evacuations required by a patient was seven, and the maximum number of
Almost a fifth of patients requiring frequent evacuation were infrequent users or
non-users of the clinics. The Royal Australian College of General Practitioners
has suggested that one way to target patients requiring preventive health care
is to proactively identify high-risk individuals who may be infrequent users of
primary health care,12 and one of the Australian coordinated care trials showed
that the greatest benefit was experienced by patients who were not previously
linked with services.13
3 Usage pattern of services, by service type, July 2000 to June 2005*
Service type
2000–01
2001–02
2002–03
2003–04
2004–05
Change between
2001 and 2005 (%)
Evacuations
268 (354)
274 (345)
268 (336)
252 (340)
198 (256)
–26.1 (–27.7)
Clinic consultations
2787 (10829)
2756 (10526)
2724 (9943)
2654 (8830)
2612 (8903)
–6.3 (–17.8)
Remote consultations
1782 (3430)
1668 (3252)
1663 (3252)
1557 (2993)
1446 (2564)
–18.9 (–25.3)
3217 (14613)
3201 (14123)
3166 (13531)
3107 (12 163)
3012 (11 723)
–6.4 (–19.8)
Total
†
†
†
†
†
* Figures represent number of patients (number of encounters). †Some patients accessed more than one service type during the designated period.
Frequent users of the Royal Flying Doctor Service
If infrequent clinic users with poorly managed conditions are to receive the
best quality care, the RFDS service model currently operating in far western
NSW will need to be modified. Best-practice, comprehensive and continuous
care implies that the RFDS should adopt care pathways and protocols that
include multidisciplinary assessments by doctors, allied health staff and,
where appropriate, medical specialists.14 These assessments, supported
by case conferences (if necessary), should lead to agreed care plans and
multidisciplinary or shared care with clear responsibilities for implementing,
monitoring and initiating timely reviews.
The evacuation of a patient should act as a trigger for a multidisciplinary
assessment, which may lead to a care plan or shared care arrangement. The
RFDS should also regularly review evacuations and patients with high clinic
attendance to see if the most appropriate service is being provided to those
patients, taking account of the difficulties imposed by location and personal
circumstances.
RFDS patients may need to travel to regional centres or capital cities to access
medical specialists, and waiting times for non-urgent appointments may be a
problem. Travelling to attend a specialist appointment may incur costs such as
lost earnings and may disrupt family or community responsibilities.
Problems of distance and low population density mean the RFDS will have
to continue using a combination of approaches, including face-to-face
consultations, phone calls and videoconferencing, to enable primary and
secondary consultations, care planning and shared care for its patients in remote
areas. The RFDS has already had to redefine its traditional role as a provider
of bush clinics and emergency evacuations to encompass comprehensive
primary health care based on a multidisciplinary workforce, strong partnerships
with other providers and a strong population health perspective.
4 Clinic attendance pattern among frequent users of the evacuation
service, July 2000 to June 2005*
Clinic
2000–01 2001–02 2002–03 2003–04 2004–05
attendances
Total
0
0
0
1
2
1
4
1–3
4
1
3
0
3
11
4–12
11
6
5
11
7
40
>13
6
4
4
5
4
23
Total
21
11
13
18
15
78
*Figures represent number of patients requiring frequent evacuation (>3 evacuations
per year).
5 Number of primary diagnoses recorded for frequent users of the
evacuation service, by number of clinic attendances, and potential
need for multidisciplinary care or specialist shared care, July 2000 to
June 2005*
Clinic
attendances
Three
Needs
or more
multiprimary disciplinary
diagnoses
care
One
primary
diagnosis
Two
primary
diagnoses
0
2
1
1
1
1–3
3
5
3
4–12
10
16
>13
5
Total
20
Needs
specialist
shared
care
CONCLUSION
People living in remote communities generally have less access to health
care and make less use of services. Further development of practical and
manageable assessment, care planning, and multidisciplinary and specialist
shared care delivery systems will help the RFDS to achieve better outcomes
for patients. The frequency of service use, particularly emergency evacuation,
is a simple tool for identifying patients who may benefit from assessment
and review.
ACKNOWLEDGEMENTS
We would like to acknowledge the contributions of Gary Oldman (RFDS
Broken Hill), who assisted with providing patient data, and Robert Williams
(RFDS National Office), who reviewed an earlier draft. The University of
Sydney’s Department of Rural Health at Broken Hill is funded by the Australian
Government Department of Health and Ageing.
COMPETING INTERESTS
None identified.
REFERENCES
1.Royal Flying Doctor Service of Australia. Our divisions. http:/www.flyingdoctor.org.
au/About-Us/Organisation-Structure/(accessed Apr 2009).
2.Royal Flying Doctor Service of Australia. South Eastern Section. Our services. http:/
www.flyingdoctor.org.au/Health-Services/(accessed Apr 2009).
3.Smits FT, Brouwer HJ, van Weert HC, et al. Predictability of persistent frequent
attendance: a historic 3year cohort study. Br J Gen Pract 2009; 59: 114-119.
4.Neal RD, Heywood PL, Morley S, et al. Frequency of patients’ consulting in general
practice and workload generated by frequent attenders: comparisons between
practices. Br J Gen Pract 1998; 48: 895-898.
5.Vedsted P, Christensen MB. Frequent attenders in general practice care: a literature
review with special reference to methodological considerations. Public Health 2005;
119: 118-137.
6.Brandon WR, Chambers R. Reducing emergency department visits among highusing patients. J Fam Pract 2003; 52: 637-640.
7.Hansagi H, Olsson M, Sjöberg S, et al. Frequent use of the hospital emergency
department is indicative of high use of other health care services. Ann Emerg Med
2001; 37: 561-567.
8.Australian Bureau of Statistics. Census of population and housing. Canberra:
ABS, 2001. 9 Australian Bureau of Statistics. Census of population and housing.
Canberra: ABS, 2006.
10.Australian Institute of Health and Welfare. Rural, regional and remote health:
indicators of health system performance. Canberra: AIHW, 2008. (AIHW Cat. No.
PHE 103; Rural Health Series No 10.)
11.
Australian Government Productivity Commission. Australia’s health workforce.
Research report. Melbourne: Productivity Commission, 2005. http://www.pc.gov.
au/projects/study/healthworkforce/docs/finalreport (accessed Jul 2009).
12.Royal Australian College of General Practitioners. Guidelines for preventive activities
in general practice. 7th ed. Melbourne: RACGP, 2009.
13.Battersby MW. Health reform through coordinated care: SA HealthPlus. BMJ 2005;
330: 662-665.
3
14.Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness.
Milbank Q 1996; 74: 511-544.
7†
6†
(Received 17 Apr 2009, accepted 27 Aug 2009)
14
27
†
16†
2
16
18†
16†
24
34
53
41†
†
*Figures represent number of patients requiring frequent evacuation (>3 evacuations
per year). †Some patients with more than one major diagnosis require both
multidisciplinary care and shared care.
2010 DINNER PRESENTATION
How to earn a golden caterpillar
AVM Eric Stephenson AO OBE
As presented by AVM Eric Stephenson at the 2010 Gala
Dinner held at Australian War Memorial, Canberra.
It is very special to be having dinner alongside the venerable ‘G for George’
Lancaster bomber that was never shot down in all its 89 missions over
enemy territory.
It was mainly crewed by Australians and was brought here to be displayed in
Aircraft Hall. I happened to be driving along Northbourne Avenue so of course, I
followed the large trailer with its load of Lancaster into the War Memorial when
Canberra Times photographers were waiting to record the event. (Photo 8).
The crew of ‘G for George’ which changed from night to night never had to bail
out using their Irvin chutes so none of them qualified to join the Caterpillar Club
when flying in ‘G for George’.
The Irvin Parachute Company, originally in the USA, was established in England
in 1920 by Les Irvin and he also started the Caterpillar Club for people who
had jumped from a disabled aircraft and whose life was saved by an Irvin
parachute. He gave a small gold pin in the shape of a caterpillar to every
member and if the member jumped from a burning aircraft his pin has red
eyes. (Photo 9)
There are no meetings or membership fees and there are now about 4000
members of all nationalities. Over the years there have been about 100,000
people whose lives were saved by Irvin parachutes.
Caterpillar refers to the
little creature that spins the
silk threads from which the
original parachutes were
made and the fact that
the caterpillar or silkworm
lets itself down to earth
by a silken thread. This
gave rise to the club motto:
“Life depends on a silken
thread” is the club’s motto.
No, of course, parachutes
are made of nylon.
night of Thursday December 16 1943, the night we have just seen and heard
when a total of 54 Lancasters were lost, 29 of them on the way home or trying
to land in the appalling weather conditions at their home bases (photo 2).
The weather hadn’t been too bad when we left our base at RAF Spilsby in
Lincolnshire that afternoon. Spilsby was a rather dreary base of Nissen huts
and duck boards like the majority of bases in Lincolnshire in the 1940s.
Lancasters had a crew of seven – pilot, navigator, bomb-aimer, flight engineer,
wireless operator, mid-upper gunner and rear gunner. I was the navigator.
(Photo 3) After breakfast on Thursday December 16th we went as usual to the
crew room to see whether operations were on that night. They were. Briefing
was after lunch so the seven of us attended the General Briefing under close
security, discovered Berlin was again the target and were now forbidden to
use a telephone for off base calls and forbidden to go our own quarters. We
attended specialist briefings for individual crew members and, as navigator, I
collected a large bag of instruments and maps.
Then we returned to our crew room to don flying gear. This consisted of long,
warm underwear, battle dress, Mae West flotation jacket, parachute harness
and, of course, a parachute. The two gunners also collected special heated
suits which they could plug into the fuselage of the aircraft to access the
electricity supply that was generated by the four engines. The gunners could
not move about the aircraft like the rest of the crew and it must be remembered
that at an operational height of 20,000 feet or more the temperature could be
-20°C or less.
While we were preparing for our mission our bombs were being load into our
aircraft. (Photo 4)
We also collected ”flying rations” as we would be airborne for six hours or more.
We were then ready to be driven to dispersals for take-off at about 4:30 p.m.
When we arrived at our aircraft (P for Peter) all seven of us climbed up the small
ladder into the rear of the fuselage, the two gunners going into their turrets and
the remaining five of us climbed over the main spar which went from wing tip
to wing tip and which contained all the aviation fuel for the mission.
The pilot, flight engineer and bomb aimer went to the nose of the aircraft and
the wireless operator and I went to our workstations on the port side of the
fuselage. There was a curtain around our area to screen us from the rest of the
aircraft because we had to work with lights. When we were told by the control
tower, ”Start engines” the noise from four Merlin engines was deafening and
the only way for crew members to communicate was by intercom.
Photo 1 – AC2 aircrew cadet Scarborough
March 1942
I became eligible to join
the Caterpillar Club on the
Photo 2 – The author March 1943
Photo 3 – Lancaster bomber crew
I pulled back the curtain screening me from the rest of the cabin and saw the
pilot, Ralph Allen, and the engineer getting ready to go down the stairs into the
bomb aimer’s area to bail out. Ralph saw me and beckoned me furiously to
follow them. His intercom had been shattered I later learned.
I grabbed my parachute, clipped it onto the harness and then realised the
wireless operator, sitting next to me was still attending his radio. I thumped him
on the shoulder, pointed to my ‘chute and yelled ”Bail Out” in his ear.
By this time, our Lancaster was in a spiral dive and it was difficult to move,
let alone walk about, but I managed to get to the aircraft nose, leapt down the
stairs and dived headfirst through the escape hatch into the cold night air. This
was NOT the way we had been told to do it but then we had never actually
practised the procedure.
Photo 4 – Lancaster bomb load with 4000 lb ’cookie’
Once airborne, aircraft from
about 35 bases in Lincolnshire
flew across the North Sea to
rendezvous at a point near the
Dutch coast and then set course
for Berlin.
Our aircraft had a special
mission on this trip. We had
an infrared camera installed to
take photos of the total damage
done to Berlin industries and to
do this, we were located in the
last wave in the bomber stream
with instructions to fly straight
and level for 29 seconds after
dropping our bombs.
Photo 5 – Lancaster loaded
bomb bay
When we reached the target
area, we could see huge areas
of fire. Target markets dropped
by RAF Pathfinder Force showed
the bomb aimer where to drop
our 4000 pound ”Cookie” and
smaller bombs (photo 5). He did
this and called “Bombs gone”
over the intercom. While we were
flying straight and level to take
our photographs, an electronic
device called ”Fishpond” started
beeping indicating there was an
aircraft beneath us.
Then all hell broke loose!
Photo 6 – The author May 1945
My instrument panel exploded,
obviously hit by a shell, and
I was hit on the forehead by
metal which stunned me. Then I
realised that everything was very
bright and the port wing outside
my workstation was on fire.
I rolled onto my back as I had done many times diving from the edge of
swimming pools and then counted five before pulling the Rip Cord. I felt the
opening shock of the chute between my legs and I looked up. I was horrified! I
thought the silk canopy had come off because seemed so small! Then I realised
it was about 30 feet above my head on long risers!
This reminded me of the time I was collecting my parachute and the chap in
front of me asked the little blond WAAF handing them out. ”Do these chutes
ever failed to open?” She coyly replied, ”We’ve never had any complaints, Sir!”
I pulled the riser, the chute responded and I felt better! It was all so comfortably
quiet after the noise and confusion in the Lancaster.
I WAS ALIVE!
I floated down gently and I could see two parachutes of other crew members
below me and I could see the ground was covered in snow before I became
completely enveloped in thick cloud. Then my parachute wrapped itself round
a clock tower and I crashed into it, knocking myself out with a sharp blow to
my head!
I don’t know how long I was unconscious but when I came to I could hear
rumblings and clickings. I thought I must be lying against a clock face because
of these sounds. Then I heard a voice below me calling out and saw a man with
a yellow helmet shining a light up at me.
I lapsed into unconsciousness again. I have no idea how long I was up there or
how they got me down or how I was transported to a medical centre somewhere
in Berlin. I regained consciousness to find my skipper, Ralph Allen, bending over
me and a German doctor stitching my head. Ralph had parachuted into a tree
in someone’s garden.
Next, we were taken to a hospital where all five of us who had escaped from
our Lancaster were in the same room, being looked after by two British Army
medical orderlies who had been captured in France in 1940. Sadly our two
gunners didn’t make it.
While we were in the hospital, it was discovered my right arm and right leg
were broken so they were put in plaster.
We were under guard throughout the two days we were in hospital and also
when we were taken by train to Dulag Luft in Frankfurt am Rhein, the collection
centre for shot down Allied aircrew. Here we were segregated into officers and
NCOs, so Ralph and I never saw our other three crew members again.
We were put into solitary confinement in unheated cells which was pretty
miserable with two still damp plasters. We were interrogated and photographed
(Photo 6) and given a Red Cross postcard to send to our next of kin to let them
know we were alive. The cards took about five weeks to reach them.
Early in January 1944, we were put into a closed cattle truck marked in French
”8 horses/40 men” with 46 other prisoners of war. Our journey took two days
with many stops until we finally arrived at Sagan in Silesia, where we were
driven to Belaria where a brand new extension of the Stalag Luft III POW camp
had been built. The German guards took us into the camp which was covered
in a few inches of snow, they shut and locked the gates behind us and said,
”For you, the war is over!” I was now a Kriegsgefangener!
One of the first people to greet us was the camp doctor, British Army Captain
Norman Monteuuis, who had been a prisoner of war since 1940. He saw me
hobbling through the snow with my bandaged head and plastered arm and leg
and said ”Ah! My first patient! Come with me to the sick quarters”. So I started
prison life having my head wound treated and the plasters removed from my
arm and leg. I was young, only 21, and made a total recovery except i have
never been able to straighten my right arm which doesn’t matter because I am
left handed.
I made application to become a member of the Caterpillar Club while I was in
Stalag Luft III and eventually received my little golden caterpillar with red eyes
of course.
Photo 9 – Golden caterpillar pin
Stalag Luft III grew from the initial handful of us to over 1000 men and our
lives were disciplined but made bearable with Red Cross parcels of food
supplementing the German rations. The Red Cross also provided boots, musical
instruments and sporting equipment.
But in January 1945 our rather orderly life style ended when we were marched
out into the snow at 4.30 one morning and given one Red Cross parcel for
every two men. This was the beginning of an 80 kilometre trek to get us to
another prison camp away from the advancing Russians.
But that is another story.
Photo 8 – G for George at Australian War Memorial 2001
Air Vice Marshal Eric Stephenson AO OBE
Annual Scientific Meeting Canberra 2010
Annual Scientific Meeting Canberra 2010
Annual Scientific Meeting Newcastle 2011
Annual Scientific Meeting Newcastle 2011
Honorary members & ASAM Committee
Honorary Members
The ASAM Committee
Year awarded
Dr Jeff Brock
2011
President
Dr Greig Chaffey
0437 496 002
[email protected]
Mrs Jan Chaffey
2010
Dr Greig Chaffey
2010
Dr J B Craig (Foundation Member)
2008
Dr B Costello (Foundation Member)
2008
Dr Graeme Dennerstein
2007
Dr Malcolm Hoare RFD
2007
Dr Michael Lischak
2003
Treasurer
Capt Glenn Todhunter 2003
Dr Richard Williams (Chief Medical Officer NASA)
2003
Dr Jeanette TB Linn OAM
2002
Dr Andrew Marsden
0419 965 115
[email protected]
Vice-President
Dr Barney Cresswell
0403 584 770
[email protected]
Air Vice Marshal Glen W (Bill) Reed
2001
Secretary
Air Vice Marshal Eric Stephenson AO, OBE, QHP
1999
Dr John Colvin OAM
1999
Dr Len Thompson
1999
Dr Heather Parker
0418 715 340
[email protected]
Dr Eric Donaldson OAM
1999
Public Officer
Dr Bert Bailey
1999
Dr Ron Wambeck DFC
1999
Dr Dorothy Herbert OAM
1997
Dr Craig Schramm
0418 239 190
[email protected]
Dr Derek Dawes
1997
Immediate Past President
Dr AW Erenstrom
1987
Mr Doug Patterson
1981
Air Vice Marshal LK (Kiwi) Corbet
1979
Dr Warren Harrex
0409 466 632
[email protected]
Dr JC Lane OAM
1979
Committee
Dr HJ Mail
1978
Dr FS Parle OBE
1975
Air Vice Marshal EA Daley CBE, KHP, QHP
1961
Dr Gordon Cable
0412 658 240
[email protected]
Dr (non-medical) JH Martin,
Director of Physics at the Melbourne Cancer Institute
1956
Dr Ian Cheng
0419 207 111
[email protected]
Dr David Emonson
0419 145 983
[email protected]
Dr Tracy Smart
0458 737 693
[email protected]
Dr Adrian Smith
0413 940 694
[email protected]
2011 Membership List
AUSTRALIAN
CAPITAL TERRITORY
Coote, Dorothy
Doherty, Belinda
Ferguson, Alan
Fitzgerald, David
Gordon, Andrew
Harrex, Eleanor
Harrex, Warren
Henry, Hayden
Howe, John
Jolly, Danielle
Joseph, Vince
Kennealy, Steven
Klar, Danielle
Lee, Doug
Lee, Rob
McGinniss, Elicia
Moller, Graeme
Muthalaly, Rana
Norgrove, John
Pitcher, Andrew
Roantree, Dennis
Ross, James
Schramm, Craig
Seah, Mike
Sham, Tak
Smart, Tracy
Smiles, John
Stephenson AO OBE, Eric
Travers, Tamsin
Van Der Rijt, Carmel
Wilkins MBE, Peter
Williams, Felicity
NEW SOUTH WALES
Lawson, Peter
Abraham, George
Adler, Paul
Affleck, John
Agarwal, Manjul
Allan, Roger
Alterator, Rick
Ambrose, Grahame
Arber, Philip
Arnaudon, Peter
Austin AM, Tony
Bailey, Yvonne
Baker, Eric
Ban, Arthur
Bayliss, Geoff
Bennett, Tom
Beran, Roy
Berry AM, Andrew
Betts, Keith
Bhatt, Priti
Blainey, Chris
Bridger, Diane
Brown, Russell
Brown, Margaret
Bruck, Catherine
Caswell, Gabi
Chara, Asthika
Cheng, Ian
Cheung, Leanne
Coceancig, Paul
Collie, Trish
Cooke, David
David, Timothy
Davies, Gordon
Davis, Jennie
Davis, Peter
Day, Shane
Delaney, Darren
Den, Barry
Duffy, Peter
Duffy, Vincent
Duflou, Johan
Durkin, Dean
Eastman, Creswell
Edwards, Charlie
Elder, John
Evans, John
Fenn, Chris
Fernando, Shiran
Ferris, Joe
Field, Catherine
Fitzgerald, Guy
Flanagan, Izaac
Foong, Jennifer
Forssman, Bradley
Foster, Paul
Frumar, Kim
Game, Justin
Gardner, Trevor
Garne, David
Garrard, Laurie
Gibson, Margaret
Givney, Jane
Hall, Pedita
Hartley, Richard
Harvey-Sutton, Phillipa
Hazell, Luke
Hazelton, Ken
Henderson, Cameron
Heyning, Marc
Higgins, Graham
Hill, Dolores
Hill, Michael
Hopwood, Christopher
Horgan OAM, Terry
Horowitz, Greg
Howle, Stephen
Hughes, Paul
Hughes, Whitney
Hutchins, Ian
Jackman, Kim
Jacobs, Mark
Jambor, Christopher
Jander, Caron
Johnston, Colin
Jongbloed, Larry
Keller, Andrew
Kelly, Bernard
Keys, Phil
Khan, Ijaz
Khan, Jennifer
Khan, Azhar
Khoo, Nee Chen
Kontkanen, Sanna
Kroll, Barry
Kwon, Neville
Lee, Janet
Lehmann, Wayne
Lele, Vinoo
Leppard, Steve
Lewin, Rob
Lewin, Robert
Liebenberg, Albert
Lilienthal, Craig
Lim, Hardy
Livingstone, Elizabeth
Lose, John
Lurie, Eddie
Lye, Philip
MacDonald, Colin
Maclarn, Graeme
Magee, Marion
Mahmood, Javed
Manderson, Kate
Manku, Mehm
Manners, Vincent
Martin, Peter
Massie, Colin
Mathews, David
Maus, Lisa
May, Simon
McGilvray, Steven
McGinty, Mary
McInerney, Peter
Meades, Robyn
Micallef, Robert
Milliken, Andrew
Mills, Ross
Moore, David
Moroney, Kerry
Morrison, Ion
Myers, Phillip
Nerwich, Neil
Ng, David
O’Brien, Peter
Oh, Evan
Ohana, Joseph
O’Kane, Gabrielle
Oswald, Karen
Oxbrow, Doug
Parikh, Jitendra
Parrish, Roger
Pascoe, Glenn
Peterson, Mark
Phillips, David
Phonesouk, Somnuk
Pinkstone, Jeffrey
Pittar, Graham
Porges, Stuart
Price, Eddie
Purches, Peter
Randhawa, Jey
Rankin, Tim
Rao OAM, Balaji
Reppas, Napoleon
Richardson, Brian
Richardson, Natasha
Robertson, Rob
Roby, Howard
Rockman, David
Rowe, George
Ryan, Mark
Saareste, Ain
Sachdev, Darshan
Sagar, Puru
Saunders, Alan
Simpson, Garry
Sinclair, Murray
Singleman, Glenn
Sloane, Rod
Smith, Justin
Smith, Richard
Stephenson OAM, Jeff
Stern, Harry
Stringfellow, Gavin
Summers, Frank
Tang, Derek
Tang, Kong Chan
Taylor, Christopher
Taylor, Giles
Thatcher, Lewis
Thomas, Geoff
Thomas, Michael
Thomas, Vin
Thomson, Clyde
Thorogood, Paul
Tinning, Dick
Tongson, Steven
Tonkin, Alexander
van der Walt, Annemarie
Viljoen, Deon
Webber, Chris
Westphalen, Neil
Wheeldon, Lorraine
Wicks, Leon
Williams, Bruce
Wingate, Richard
Wright, Dean
Wulff, Neville
Zdenkowski, Andrew
Cronin, Sheilagh
Cunningham, Greg
Daniels, Marc
Davies, Ian
NORTHERN TERRITORY Dawbarn, Tim
Dietz, Walter
Brotherton, Michael
Donaldson OAM, Eric
Brummitt, David
Dowd, Peter
Dimond, Greg
Dunn, Tom
Fuller, Margaret
Dunne, Elaine
Giese, Richard
Easton, David
Hardcastle, Doug
Edwards, Norm
Loh, Lawrence
Evans, John
MacDonald, Andrew
Fenner, Peter
Mahasuria, Asha
Fukuzawa, Hiroyoshi
Mahendrarajah,
Gardner, Amanda
Tharmalingam
Gilford, Chris
McCullough, Jamie
Goldston, John
Pettigrew, Bill
Griffin, Jim
Pettigrew, Jill
Hampson, Greg
Rubin, Colin
Harding, Philip
Scott, Hamish
Hardy, Tim
Stacey, Mike
Hashim, Rozi
Thompson, Geoffrey
Hawes, David
QUEENSLAND
Hay, Rosemary
Abrahams, Jim
Herat, Bandu
Adsett, Geoffrey
Hetherington, Ross
Ahmed, Waseem
Hickey, Michael
Ambler, John
Hill, Adrian
Andrews, Christopher
Ho, Lee
Angel, Paul
Hodge, Jon
Apel, Andrew
Holborn, Luke
Beeston, Peter
Holt, Geoff
Bennett, Ann
Horsburgh, Scott
Birchley, Simon
Horwood, Michael
Black, Dan
Hosegood, Ian
Bondeson, Kimberley
House, Diana
Bowley, Don
Housego, Ian
Bradley, David
Howes, Andi
Brock, Jeff
Hudson, John
Bromet, Michael
Jack, Carolyn
Bryant, Andrew
Jenkins, Tony
Byrnes, Patrick
Jennings, Scott
Cameron, John
Joice, Paul
Campbell, Jessica
Joseph, Deep
Carr, Martin
Kearney, John
Castrisos, Edwin
Kearney, Stephen
Chaffey, Greig
Keating, Michael
Chaffey, Jan
Kelly, Simon
Chambers, Aaron
Kennedy, Robert
Chater, Alan
Keyes, Richard
Clem, Peter
Kitchener, Scott
Clements, Michael
Kleinig, Daniel
Collyer, Bill
Koppen, Blair
Cormack, Ian
Lahanas, John
Costigan, Dennis
Lamb, John
Cotter, Margaret
Lanham, Paul
Lawson, Stephen
Cranstoun, Peter
2011 Membership List
Leggat, Peter
Lillicrap, Gary
Litherland, Gary
Little, Simon
Marendy, Peter
Marks, Warwick
Marshall, Ian
Marshall, Jodie
Maxwell, Ian
McAdam, Margaret
McCaldin, Charles
McCombe, Don
McCoy, Jodie
McDonnell, Michael
McPhee, Ewen
Moon, Maria
Munn, Josh
Naidoo, Pat
Nicholson, Geoff
Novakovic OAM, Petar
Oltvolgyi, Csongor
O’Malley-Ford, Judith
O’Toole, Robin
Palmer, Kym
Parker OAM, Heather
Pascoe, Geoff
Peel AM CSC, Graeme
Perera, Shawn
Pietzsch, Tom
Potter, Thomas
Powell, Ben
Read, Michael
Reader, Stuart
Reed, Bill
Rivlin, Ian
Rosewarne, Phil
Rubis, Carl
Ruscoe, Peter
Seckler, Wolfgang
Seliga, Stan
Sharma, Anita
Sharma, Anil
Shumack, Paul
Smith, Shane
Spall, Andrew
Spicer, Paul
Steel, Sue
Stone, John
Sutch, Allan
Swanson, Craig
Talbot, William
Taylor, Dean
Taylor, Ross
Thomas, Bob
Thomas, Dale
Thompson, Richard
Todhunter, Glenn
Tong, Douglas
Turner, John
Ullman, Geoff
Valentine, Matthew
Vogel, Willem
Walker, Nathan
Whitworth, Andrew
Wilson, Chester
Windley, Stephen
Wong, Max
Woodward, Jane
Yantsch, Phil
Yoke Choon Lip, Patrick
Zischke, Kevin
SOUTH AUSTRALIA
Alcorn, Bruce
Ameerjan, Feroz
Anderson, Daniel
Babu, Suresh
Baczyk, Iwona
Barker, Brent
Barker, Tony
Bebb, Edward
Bloom, Martin
Bryant, Geoff
Bulyga, George
Burrough, Timothy
Cable, Gordon
Capps AM RFD, Roger
Chadha, V
Charlton, Peter
Corbett, Mark
Crompton, John
Davies, Glyn
De Sari, Adrian
Del Fante, Peter
Fernando, Colin
Flabouris, Arthas
Fleming, Graham
Forrester, Jackie
Graham, Geoff
Griggs AM, Bill
Heah, Richard
Hume, Clive
Jennings, Reece
Jolly, Richard
Kasauskas, Jonas
Kokar, George
Lewis, Scott
Librarian, The
Linn OAM, Jeanette
Martin, Stewart
Menzies, Geoff
Miller, Alan
Murray, Neil
Nelson-Marshall, Rae
Oo, Htun Htun
Oppermann, Brett
Page, Nicholas
Partridge, Ian
Pike, Lincoln
Ramsey, David
Schultz, Barry
Shivashankaraiah,
Anupama
Singh, Bhupinder
Smith, Adrian
Storey, Adam
Thompson, Bryan
Thorpe, Peter
Trappitt, Andrew
Tucker, Richard
Waite, Chris
Ward, Kym
Watson, Christopher
Wilson, Richard
Wood, Tim
TASMANIA
Ayton, Jeff
Dow, Doug
Emmett, Ian
Farmer, John
Graham, Stewart
McCartney, Paul
Plumley, Noel
Roddick, Ian
Rowan, Pauline
Skinner, Marcus
Tooth, Michael
Treplin, Michael
Tymms, Anthony
Walker, Bob
VICTORIA
Abou-Seif, Nader
Allen, Robert
Alpins, Noel
Amini, Alex
Anderson, Malcolm
Andrade, Simon
Antonenko, Peter
Aouad, Ayman
Atkinson, Peter
Baddeley, Ken
Balnionis, Andrius
Barry, Jim
Bassovitch, Oleg
Baynes, Michael
Bernstein, Allan
Birman, Sam
Black, Rhyll
Bloom, Philip
Boltin, Phillip
Boothby, Graham
Brook, Wilfrid
Buttery, Robert
Cameron, Don
Cartwright, Paul
Cato AM, Alex
Chesney, Christopher
Cheung, Philip
Chew, Denis
Christiansen, Rowena
Clift, Andrew
Connor, Michael
Cooper, Max
Costello, Brian
Daniell, Mark
Davis, Ivor
Day, Geoff
De Clifford, Max
De Sousa, Tony
Demediuk, Nicholas
Dennerstein, Graeme
Devincentis, Fio
Dickman, John
Ding, Yock Seck
Douglas, Ian
Duncan, Colin
Dwyer, Bill
Dyson-Berry, John
Ellis, Greg
El-Sheikh, Khaled
Emonson, David
Farmer, Ian
Farrow, Jeff
Fawcett, Rodney
Ferguson, Malcolm
Fifield, Scott
Forster, Mike
Fuller OAM, John
Galtieri, Vince
Gardiner, Scott
Gaze, Doug
Gee, Murray
Gibson OAM, Tony
Gill, Cecil
Grace, Carl
Green, Catherine
Gunn, Barry
Habersberger, Peter
Hamer, Angas
Handley, Paul
Haralambakis, George
Harris, Andrew
Harris, Phil
Hauptman, Oded
Hince, Monica
Hirschfield, Marcus
Hoare, Julian
Hoffman, Tamaris
Holian, Annette
Homewood, Michael
Homolka, Sue
Hooke, David
Hunt, Campbell
Irvine, Gerald
Jackson, Neil
Jelbart, Stephen
Johnston, Roger
Kefford, Marina
Kemp, Warren
Keppel, Peter
Koniuszko, Miriam
Kudelka, Peter
Kunjidapaadhum, Ganes
Lau, Sonny
Lazarus, Mark
Lazell, Robert
Lee, Rodney
Leow, Priscilla
Lia, David
Ling, Andrew
Loeffler, Mark
Lucca, Luigi
Lunz, Richard
Macaulay, Geoff
MacDonald, Ileene
Mack, Heather
Mackey, Noel
Manolopoulos, John
Martiniello, John
Marty, David
Mazzetti, Julian
McCarthy, Anthony
McDonald, Colin
McInnes, Ian
McKenzie, Doug
McKenzie, Matt
McKnight, David
McLean, John
McLeod, Liz
McMahon, Hal
McMahon, Phyllis
Merrett, Andrew
Miller, Graham
Milne, Peter
Moffitt OAM, Rob
Monash, David
Narendranathan,
Ramanathan
Neath, Adrian
Newman, David
Ng, Weng Toon
Nicolettou, Nick
North, Rob
O’Brien, Karen
O’Day, Justin
O’Gorman, Michael
O’Kane, Chris
Olesen, James
Osman, Stan
Overton, Mark
Pahuja, Om
Pape, Arthur
Papworth, Gregory
Parkes, John
Paterson, Ian
Pattison, Matthew
Peters, Andrew
Phan, David
Pillai, B
Price, Ian
Priest, Christopher
Reed, Melissa
Reid, Ruth
Renehan, Mark
Reynolds, Kath
Robertson, Shelley
Roth, Norman
Sabetghadam, Reza
Samuel, Manojkumar
Sandor, Les
Schneeweiss, Anthony
Searle, Russell
Serong, Roger
Shannon, Meg
Sharma, Rajeev
Sheppard, Colin
Shields, Richard
Shute, Simon
Silver, John
Smith, Michael
Stapleton, Ian
Stewart, Tony
Sullivan, Laurence
Tomkins, Ron
Toogood, Geoff
Tran, Duc Nguc
Truesdale, Melinda
Tunbridge OAM, Raoul
Van Der Spek, Tony
Vandenberg, Rosemary
Vingrys, Algis
Walters, Barry
Ward, Richard
Ward, Salena
Warren, John
Watson, Laurance
Webster, Philip
Weinrich, John
Westerman, Rod
Wolf, Peter
Wolfe, Rick
Wong, William
Workman, David
Worsnop, David
WESTERN AUSTRALIA
Adamson, Stuart
Adeoye, Adegbuyi
Afolabi, Olajumoke
Al Qubaisy, Omar
Andrews, Reg
Aniyi, James
Arthur, Stephen
Barr, Tony
Bateman, John
Benson, Michael
Briggs, Patrick
Cadden, Frances
Catanchin, Andrei
Chandran, Mohan
Christensen, Bernard
Collings, Brian
Collis, David
Craig, John
Cresswell, Bernard
Daniels, Dru
Davies, John
Denz, Chris
Dobson, Ron
Dorkham, Zaki
Dymond, Jane
Foote, Andy
Forgione, Nicholas
Gorman, Paul
Hartill, Graeme
Harvey, Ross
Harwood, Abigail
Henwood, Anthea
Hernaman, Peter
Heyworth, Peter
Hoare, Malcolm
Hochberg, Anthony
Hodge, Matthew
Hodgkinson, Airell
Holt, David
Hutchinson, Allan
Inoue, Yoshi
Junckerstorff, Reimar
Keating, Darren
Khong, Chee-Hoong
Kotai, Frank
Laney, John
Langford, Stephen
Lee, Colin
Liddell, Rob
Marsack, Christine
Marsden, Andrew
Martin, Phillip
McConnell, Christine
Mears, Mike
Mikhaiel, Nazmi
Miller, John
Milligan, Cathryn
Morison, Kent
Noble, Phillip
Perry, Chris
Pleass, Trevor
Ravet, Jan
Robson, Jenny
Rose, Chris
Ryan, Elizabeth
Rynn, Chris
Sim, June
Singh, Harpreet
Sovann, Ritthy
Starling, Doug
Stewart, Andrew
Stott, Barb
Stynes, Paschal
Swemmer, Ebbie
Talbot, Jane
Tan, Hui
Thelander, Charles
Thompson, Larry
Van Ballegooyen, Andrew
van Reenen, Charles
Ward, Olga
Wee, Alvin Hock Peng
White, Craig
Wilson, Glenda
Wong, Yim-Kong
Woods, Tom
Zentner, Adrian
OVERSEAS MEMBERS
CANADA
Sardana, Tarek
Denmark
Lyduch, Steffen
FIJI
Biumaitotoya, Isireli
Goundan, Ravinesh
Hong Kong
Fu, Samuel
Lau, Hay Tung
Lee, Horace Yan Wang
Liew, Michele
Ong, Rose
O’Tremba, Frank
Pei, Benjamin
Searl, Robyn
Iran
Ronaghi, Iman
Malaysia
Kwong, Khiew Siaw
New Zealand
Baldwin, Dave
Blackmore, Robert
Thompson, Len
Visser, Robert
Papua New Guinea
Chelvanathan, Athithan
Kalana, Charles
Mackerell, John
Taunao-Lega, Heni
Singapore
Joang, Kim Soo
Wong, Raymond
Sri Lanka
Herat-Gunaratne, Nimal
Thailand
Banasarnprasit, Sethanai
Muangsillapasart, Viroj
Premmanisakul, Sumait
United Arab
Emirates
Chalkley, John
Chang, Rae-Wen
Lee, Robin
Luna, Eleanor
United Kingdom
Morgan, Dewi
Smith, Thomas
United States
of America
Contiguglia, Joseph
Lischak, Michael
Williams, Richard
Information for authors
Journal of the Australasian Society of
Aerospace Medicine
Information for Authors
JASAM is published annually and contributions are welcome at any time.
JASAM welcomes contributions including letters to the Editor on any aspect of aersopace medicine.
Manuscripts must be offered exclusively to JASAM unless the manuscript is accompanied by a copyright exemption.
All manuscripts and contributions are subject to peer review and to editing.
Contributions are preferred by e-mail to:
[email protected]
Typewritten contributions should be sent to:
The Editor
JASAM
Australasian Society of Aerospace Medicine
PO Box 4022
BALWYN VIC 3103
Requirements for Manuscripts
JASAM follows the agreed conventions for medical journals. Full details of the requirements for manuscript preparation are available on the internet at the site
http://www.icmje.org
An electronic copy (on disc or sent by e-mail) should be submitted. The copy should be able to be read in MS Word and formatted to A4 paper, using Arial or Times
New Roman 10 font. Reviewers will be provided with a copy with the authors’ names, affiliations and acknowledgements removed.
The title page should contain the title, list the names and qualifications of all authors as well as the position and institutional address at the time of submission.
One author should be identified as the correspondent along with his or her postal address, telephone number and email address.
An abstract of no more than 250 words should be included with headings for Aim, Methods, Results and Conclusion.
Abbreviations should be avoided and if used only after they have appeared in brackets after the completed expression – eg, Journal of the Australasian Society
of Aerospace Medicine (JASAM). SI units should be used but altitude may be expressed in feet.
Figures and Tables are encouraged and should be entered on separate pages and numbered sequentially underneath eg Figure 1 or Table 1 with an appropriate
self-explanatory legend. Their preferred location should be indicated in the manuscript.
References should be presented in the “Vancouver” style. References should be numbered consecutively as they appear in the text as superscript numbers (eg,
text1,2). An example of the format for journals and books is given below:
1. Cable GG, MacFarlane A. Is neurological hypobaric decompression illness a more common phenomenon than we think? J Aust Soc Aerospace Med 2006;
2(2):3-11.
2. H
eath D, Williams DR. Man at high altitude, 2nd ed. Edinburgh: Churchill Livingstone, 1981: 56-65
Permission to reprint articles will be granted by the Editor, subject to the author’s agreement, provided that an acknowledgement giving the original date of
publication in JASAM is printed with the article.
Reviewers
All articles will be subject to blind review by at least two reviewers. Members with expertise who are willing to join the panel to review articles for publication are
invited to contact the Editor.
Editor:
Editor Dr Warren Harrex
Dr Adrian Smith has been appointed editor from January 2012
Email: [email protected]
Editorial Assistant for inquiries/and submissions:
Anne Fleming
Tel: 03 9899 1686
Email: [email protected]

T he J ournalofthe A erospace M edicine

Transcription

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